sociopathic blackguards or innocent lost lambs?

the mark of maturity and courage is not to let one feeling cancel out the other, to give people their humanity –Ta-Nehisi Coates

3934-a-foolish-consistency-is-the-hobgoblin-of-little-minds-adored_380x280_width_thumb[7]Keith Humphreys has a new post on the human tendency toward “affective consistency”, our tendency to avoid conflicting feelings by choosing one and eliminating the other. He argues that this tendency dominates discussions about how to respond to the bad behavior of addicts and alcoholics.

People have a range of strong feelings about addicted offenders: rage, fear, pity, compassion and disgust. Those emotions may drive stereotyped, over-simplified views of this population and what to do about them. If you are scared and angry, addicted criminal offenders may seem like thoroughgoing monsters who belong in prison. If you feel pity and compassion, the same individuals may seem like misunderstood martyrs who couldn’t possibly pose a threat to anyone. If you feel both such feelings, you may be driven to edit out the subset of facts that complicate your emotions.

I understand the desire for emotional simplicity because I have struggled with it myself. In interacting with addicted people, I have at times felt angry at them, disappointed in them, caring of them and sorry for them at the same moment. It’s a challenging emotional swirl that even after many years in the addiction field, I have never come to enjoy. I try hard to help my students accept the emotional contradictions, rather than seeing addicted people either as sociopathic blackguards or innocent lost lambs. But I recognize that I am asking a lot of my mentees, as I am advising them to voluntarily maintain an unpleasant emotional state when a simpler view would be more satisfying (if inaccurate).

If we fail to deal with this complexity, we’ll be stuck in the same cycle of bad arguments and inadequate responses:

. . . without some ability to tolerate the dual nature of addicted offenders and the emotional complexity that brings, we will keep lurching back and forth between destructively draconian and laughably lax responses to this troubled and troubling population.

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Urban myths exposed

1242257784-vaillantPoints blog is back with a great interview with George Vaillant.

Here’s one of the questions and his response:

2. What do you think a bunch of alcohol and drug historians might find particularly interesting about your book?

The value of the Grant study to the history of alcoholism is the number of urban myths that it exposes, and for this reason it received the biennial Jellinek prize for the best research in alcoholism in the world.

The first urban myth exposed is that depression causes alcoholism. Our prospective study shows beyond a doubt that alcoholism causes depression.

Second, alcoholics have unhappy childhoods due to their parents’ alcoholism; unhappy childhoods without a history of alcoholism do not lead to alcoholism. Therefore, the relationship between childhood and alcoholism appears to be genetic.

The third urban myth exposed is that AA is only for a few alcoholics and drugs are more useful. There are no two-year or longer studies of Naltrexone, Antabuse, or Acamprosate that have been shown to be effective, nor has long-term follow-up of cognitive behavioral therapy proved to be effective. On the other hand, when we followed, over 60 years, our sample of roughly 150 alcoholics, the men who made complete recovery—that’s an average of 19 years of abstinence—as contrasted to those men who remained chronically alcoholic until they died, the men who “recovered” went to 30 times more AA meetings than the men who remained chronically ill. Like outgrowing adolescence, it takes a long time to learn to put up with AA, but when you do, it works.

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Does it matter whether it’s viewed as a disease?

We are all one by JohnnyRokkit

The maker on The Anonymous People recently wrote:

“Is addiction a disorder, a matter of human frailty or something else?”

This debate about whether addiction is a disease or a matter of choice continues to garner headlines and direct our collective discussion away from the only thing that really matters: “How do people enter recovery from addiction and stay well?”

He points to the fact that addicts are dying and there are “23.5 million people in recovery.”

About that number, I’ve written about it before. Now, Young People in Recovery throw a little cold water on it:

“There are 23 million people in long-term recovery in the United States.” This widely cited statistic, sourced from a 2012 survey conducted by the Partnership at Drugfree.org and the New York Office on Alcoholism and Substance Abuse Services (OASAS), is often used to justify the need for increased recovery support services in the United States. However, in fact, what this survey actually asked to adults (ages 18 and over) was, “Did you once have a problem with drugs or alcohol, and no longer do?” Each respondent who answered “Yes” to this survey question has subsequently been labeled by the recovery community as a person in “long term recovery.” This begs the question: if a person has struggled with drugs or alcohol at one point in their life, is he or she automatically “in recovery”?

I think it does matter that it’s a disease and I think it matters that we distinguish between those with the chronic, impairing illness of addiction. I tend to believe that failing to distinguish will actually add to stigma. It will perpetuate the conversations that sound something like, “Greg, when your Uncle Tom was in the Navy, he drank too much and got into some trouble. Then he had kids and knocked it off. Why can’t you just do the same?” The reason they can’t do the same was that Uncle Tom was a problem drinker and Greg is an alcoholic.

Non-alcoholics using the drinking experience of non-alcoholics (themselves or others) to understand the experience of alcoholics only increases stigma.

It’s not a different degree of the same thing. It’s a different kind of thing.

In my experience, it’s only when people understand that it’s a different kind of thing—that the experience of the alcoholic cannot be understood by reflecting on your own experience of drinking too much in college—that stigma can be challenged.

So, to me, it’s a political fiction and reasonable people can disagree on whether it’s a useful political fiction. It reminded me of this old post.

Recovering community as political fiction

Ta-Nehisi Coates explores the challenges and political fiction of political movements by unpacking this passage from a feminist:

“She, who is so different from myself, is really like me in fundamental ways, because we are both”: This is the feminist habit of universalizing extravagantly–making wild, improbable leaps across chasms of class and race, poverty and affluence, leisured lives and lives of toil to draw basic similarities that stem from the shared condition of sex…

Inevitably, the imagined Woman fell short of the actualities of the actual woman it was supposed to describe, and inevitably, the identification between the feminist who spoke and the woman she spoke for turned out to be wishful, once those other women spoke up…

But although the Woman at the heart of feminism has been a fiction like any political fiction (“workers of the world,” “we the people”), it has been a useful fiction, and sometimes a splendid one. Extravagant universalizing created an imaginative space into which otherwise powerless women could project themselves onto an unresponsive political culture….

I’ve sometimes struggled with the recovery advocacy movement suffering from the same thing. I think you could substitute “woman”, “feminist”, etc with recovering people and it would be pretty accurate.

We often struggle with how inclusive to make definitions of recovery, who we include in the “community”, etc.

This push to universalize recovery has, I think, been helpful. It’s pushed many people in the recovering community to think of themselves as something larger than their small group and how more people might be helped. (It’s worth noting that Bill Wilson has been described as obsessed with how to reach and bring more people into recovery.) But, it has its limits and, at some point, I suspect it could be harmful. The same walls that inhibit inclusiveness also serve as a container for shared identities, concerns, sentiments, etc. So, I think some caution is probably a good thing.

Ta-Nehisi offers this thought:

But what I like about her analysis is that it doesn’t stop at noting the very obvious point, that political fictions don’t live up to realities.Instead she pushes on to assert that people create political fictions for actual reasons, and often those fictions have actual positive results.

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Cannabis Sense

culture-warA study finding brain changes in casual users of marijuana got a lot of press last week.

There were people seizing upon it as proof of marijuana’s danger and other attacking or debunking the study. Those who attacked the study seemed to react to the inferences people were drawing from the study’s findings, rather than dealing with the actual findings.

I held back because there seemed to be much more heat than light.

Now, finally, we hear from a dispassionate voice of reason that examines the actual findings. The U.K. National Health Service provided this analysis of the findings:

This study found differences between young recreational cannabis users and non-users in the volume and structure of the nucleus accumbens and amygdala, which have a role in the brain’s reward system, pleasure response, emotion and decision making.

However, as this was only a cross sectional study taking one-off brain scans of cannabis users and non-users, it cannot prove that cannabis use was the cause of any of the differences seen. It is not known whether cannabis use could have caused these changes in regular users.

Or conversely whether the cannabis users in this study had this brain structure to start with, and that this may have made them more likely to become regular users of cannabis.

Also, this is a small study comparing the brain structure of only 20 users and 20 non-users. With such a small sample of people, it is possible that any differences in brain structure could have been due to chance. These changes may not have been evident had a larger number of people been examined.

Examination of different samples of people, and in different age groups, may have given different results.

Similarly, examining the extent of brain structural change was related to factors such as age at first use, and frequency or duration of use, are less reliable when based on such a small sample of people.

Confirmation of these tentative findings through study of other groups of cannabis users is now needed.

It would also be of value to see whether the structural differences observed actually correlated with any demonstrable differences in thought processes and decision making behaviour.

It’s a shame that this has, somehow, turned into a front in the culture wars.

Mark Kleiman  questions the motives criticized the unjustified implications* (but not the data) of the researchers:

Overall then, if you were that neuroscientist, you’d write a paper saying “We studied cannabis users and non-users and found the following brain differences. Here’s the next study we plan to do, addressing the questions of causation and possible impact.”

That’s assuming that your goal was informing your readers about the content of your findings. If instead you wanted to score points in the culture wars, push your political agenda, and perhaps please your sponsors at the National Institute on Drug Abuse and the Office of National Drug Control policy, you’d behave differently.

He also challenges the users be framed as “casual users”:

Pretending that the findings to “casual” cannabis user would require that you gloss over how extreme your sample was: an average age of onset of just over 15 (very young exposure is known to be correlated with higher risks) and cannabis use of a minimum of a joint a week and an average of 11 joints a week. (The median cannabis user consumes once a month; once a week – the minimum in this study – puts someone in the top quartile, while 11 joints a week would put someone in the top 15%.) Instead, you’d describe your findings as applying to “recreational” or “light-to-moderate” cannabis use.

The then ends with a point that will disappoint some people who’d been cheering him on:

It’s entirely possible, though not yet demonstrated, that chronic heavy cannabis use causes undesirable changes in brain structure and function. Even if it doesn’t, spending a good chunk of your waking hours zonked seems to me like a bad idea no matter what the zonking agent is, and that’s true in spades for adolescents, who may be unable to make up missed opportunities for both formal and social learning.

[* updated to reflect Kleiman's comment below]

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Recovery Management extends therapeutic reach

Lambert's PieYesterday’s post on addiction counseling as community organization got me thinking about something I’d heard from a Scott Miller presentation.

Miller argued that treatment outcomes are sue to the following factors in the following proportions:

  • 40%: client and extratherapeutic factors (such as ego strength, social support, etc.)
  • 30%: therapeutic relationship (such as empathy, warmth, and encouragement of risk-taking)
  • 15%: expectancy and placebo effects
  • 15%: techniques unique to specific therapies

Part of his argument was that we can’t control that 40% related to client and external factors, and we spend tons of time and capital arguing about the 15% related to specific therapies. He argues that we should spend much more time on the 45% we have more control over, hope and the alliance.

Here’s what I was thinking—that recovery management attends to that 45% plus the 40% Miller says is out of our hands. Bill White calls on us to shape those external factors. The attention to family, community, social, vocational, educational and other factors extends our reach.

Its worth noting that Physician Health Programs do this too, by creating social peer support (caduceus groups) and support within the workplace.

 

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Addiction Counseling as Community Organization

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A few recent posts have put Bill White’s paper on Addiction Counseling as Community Organization on my mind.

First, was a post where I wondered if we were at risk for recovery capital becoming a proxy for class. I worried that this could lower expectations for people with lower socioeconomic status and be used as a justification for different standards of care.

Then, a study on the power of access to transportation as a factor in exiting poverty. This got my gears turning about the impact of these kinds of external factors on addiction treatment outcomes.

Next was a post with a rather heated exchange in the comments that discussed socioeconomic class differences in responses to treatment and what to do about them.

And then, a friend shared this study on racial disparities in treatment outcomes:

More than one-third of the approximately two million people entering publicly funded substance abuse treatment in the United States do not complete treatment. Additionally, racial and ethnic minorities with addiction disorders, who constitute approximately 40 percent of the admissions in publicly funded substance abuse treatment programs, may be particularly at risk for poor outcomes. Using national data, we found that blacks and Hispanics were 3.5–8.1 percentage points less likely than whites to complete treatment for alcohol and drugs, and Native Americans were 4.7 percentage points less likely to complete alcohol treatment. Only Asian Americans fared better than whites for both types of treatment. Completion disparities for blacks and Hispanics were largely explained by differences in socioeconomic status and, in particular, greater unemployment and housing instability.

And, of course, addiction treatment isn’t the only aspect of health that’s affected by class. Just today, The Atlantic posted the following:

Brookings economist Barry Bosworth crunches the data on income and lifespans for the Wall Street Journal, and the numbers tell three clear stories.<

  1. Rich people live longer.
  2. Richer people’s lifespans are growing at a faster rate.
  3. The problem is worse for women than for men.

What do we do about this? Do we lower our hopes and expectations for people with lower socioeconomic status?

The Health Affairs article on disparities calls for more services:

States could also offer providers incentives to address barriers to completion of outpatient treatment. For example, homelessness and low education are particularly prevalent among blacks and Hispanics and are contributors to lower completion rates in these groups. Future research might explore whether broadened access to resources such as supported housing and vocational training are cost-effective strategies for improving outcomes and reducing disparities. Efforts to improve the tracking of individual patients could increase retention and improve outcomes, particularly for homeless populations.

Bill’s emphasis is a little different. He calls on us to raise our expectations of ourselves and the system while focusing on recovery and the community as the locus of healing. (Rather than emphasizing treatment at the expense of wellness and glorifying ourselves.) [emphasis mine]

Addiction treatment must always adapt to the evolving context in which it finds itself. Such redefinition may push treatment toward the experience of retreat and sanctuary in one period and toward the experience of deep involvement in the community in another. I would suggest that the focus of addiction counseling today should not be on addiction recovery-that process occurs for most people through maturation, an accumulation of consequences, developmental windows of opportunity for transformative or evolutionary change, and through involvement with other recovering people within the larger community. The focus of addiction counseling today should instead be on eliminating the barriers that keep people from being able to utilize these natural experiences and resources. Our interventions need to shift from an almost exclusive focus on intervening in the addict’s cells, thoughts and feelings to surrounding and involving the addict in a recovering community.

6a00d8351b273153ef01156f302741970c-800wiIn another paper. Bill White identified 4 tasks of treatment and recovery:

  1. Recovery from the other genetic, biochemical, social, psychological, or familial influences which initially contributed to the development and trajectory substance problems
  2. Recovery from the adverse psychosocial consequences of the substance use
  3. Recovery from the pharmacologic effects of the substances themselves
  4. Recovery from an addictive culture

When I saw this list for the first time, I was struck by the intuitive truth it organized and articulated. I was also struck by how it illuminated the scope of the treatment and early recovery—”social, psychological, familial . . . psychosocial consequences . . . addictive culture”.

That paper on Addiction Counseling as Community Organization was really an early step in the development of his concept of Recovery Management, which is explained more fully here. In this paper, Bill shifts the language to “community renewal.”

A major focus of RM (Recovery Management) is to create the physical, psychological, and social space within local communities in which recovery can flourish. The ultimate goal is not to create larger treatment organizations, but to expand each community’s natural recovery support resources. The RM focus on the community and the relationship between the individual and the community are illustrated by such activities as:

  • initiating or expanding local community recovery resources, e.g., working with A.A./N.A. Intergroup and service structures (Hospital and Institution Committees) to expand meetings and other service activities; African American churches “adopting” recovering inmates returning from prison and creating community outreach teams; educating contemporary recovery support communities about the history of such structures within their own cultures, e.g., Native American recovery “Circles,” the Danshukai in Japan;
  • introducing individuals and families to local communities of recovery;
  • resolving environmental obstacles to recovery;
  • conducting recovery-focused family and community education;
  • advocating pro-recovery social policies at local, state, and national levels;
  • seeding local communities with visible recovery role models;
  • recognizing and utilizing cultural frameworks of recovery, e.g., the Southeast Asian community in Chicago training and utilizing monks to provide post-treatment recovery support services; and
  • advocating for recovery community representation within AOD-related policy and planning venues.

It can be overwhelming. But, the alternative is despair.

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Should we lower the bar?

Lowering_The_Bar_Cover_2010.09.22USA Today ran a story about problems in the monitoring of impaired physicians.

Many states lack rules to ensure that medical facilities alert law enforcement or regulatory agencies if they catch employees abusing or diverting drugs, so those staffers often are turned loose to find new jobs without treatment or supervision. Disciplinary action for drug abuse by health care providers, such as suspension of a license to practice, is rare and often doesn’t occur until a practitioner has committed multiple transgressions.

“We certainly see gaps in the system; the examples are many,” says Joseph Perz, an epidemiologist at the U.S. Centers for Disease Control and Prevention.

The challenge in addressing the problem is finding a “balanced approach,” Perz adds. “We recognize that addiction is a disease and we recognize the value in … (rehabilitating) a provider. At the same time, we need to be thinking about the potential harm to patients. That balance is difficult.”

One disappointing part of the story is that they failed to discuss the fact that, once they get into physician recovery programs, physicians have extraordinary treatmet outcomes.

The paper posted the following question on twitter: “Thousands of drug-addicted doctors, nurses escape notice, endangering patients, report reveals. What should be done?”

Thank goodness this isn’t actually the approach we take with addicted doctors:

Too bad it is the approach we’ve taken with other patients.

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