Therapy Gem: Professionals’ Biases and Misconceptions With Substance Abuse Patients

Table of Contents: Biases and Misconceptions

Introduction and Fundamental Premises

The fundamental biases and their correlated misconceptions

I.      Substance users are not like me.

II.     Drug use always means addiction.

III.    Heavy drinking always means addiction.

IV.   All their problems are caused by their substance use.

V.    Treatment doesn’t work.

VI.   Drug users and heavy drinkers always need detox or intensive care.

VII.  Twelve-step programs are the way to go.

VIII. Any mental health professional should be able to treat such symptoms

Introduction and Fundamental Premises

subst abuse1I received a request to address staff at an HMO about substance abuse.  I was given this question: “What information about substance use and abuse will be most useful for nurse case managers?”

Thinking about that question, I knew the answer lay in one attitude that had troubled me more than any other.  Namely, too many colleagues in the mental health field believed that knowledge of substance use disorders (SUD) was outside their competence and, what’s more, they did not want to become knowledgeable about SUDs and their treatment.

Rather than learn the basics about treating substance use disorders – treatment which does work and which has applicability well beyond the treatment of SUDs — I heard many mental health professionals avoid knowledge of addictions and refer even mild cases to substance abuse professionals.  So the answer to the question “What information will be most useful?” is simply, “Before you can help change patients with substance use disorders, you first change yourself, your own attitudes, biases, and misunderstandings about substance use disorders.”

subst abuse2Over several weeks, I developed lists of such biases.  I also polled some of my colleagues who work in our Dual Disorders Department.  The result is a fairly comprehensive list of biases and misconceptions, each of which is juxtaposed with corrected information.

While I was organizing these biases by category, the list factored into what turned out to be eight domains.  A few crucial premises emerged from these ideas.  These premises summarize the main purpose and point of this presentation.

A.         The persistence of biases and misconceptions often leads to inappropriate, out-dated treatment recommendations and other potentially incorrect clinical decisions.  Accurate information AND attitudes lead to higher quality recommendations, treatments, and clinical decisions.

B.        Resolving our biases, we can connect with the substance using patient rather than distance from the patient or judge that person.  We can believe in and express hope – the foundation of motivation to change – rather than convey disapproval, judgment, or pessimism related to the patient’s lifestyle and distress.  Many of our biases derive from cultural beliefs and attitudes; therapists quite successfully overcome cultural beliefs about mental disorders, so they should easily overcome biases and misconceptions about SUDs and persons with addictions.

C.        If we judge addicts as weak and hopeless, will we do our best to help?  If we see them as people with strengths and abilities as well as with problems, we are more likely to see the best in them and do our best to help.

subst abuse3D.        Furthermore, a common fallacy is that we can cajole, guilt, criticize, admonish, confront, punish, or push a substance abuse patient into changing his or her outlook, attitudes, needs, burdens, pains, or behavior.  What we truly can change is our own outlook and attitudes. Rightly aligning ourselves, we can then better express empathy and help the other to see a hopeful vision of the changes he or she may be able to make.

Professionals’ Biases and Misconceptions With Substance Abuse Patients

Here are the most common biases, misconceptions, and myths regarding drug and alcohol use.  Each bias is underlined. The italics set off those beliefs which Shorehaven’s staff considers the most common and the most damaging to patients.  The Roman numerals are the eight categories of these biases.

I. Substance users are not like me.

Addicts are weak. They have no will-power.  If they had will-power, then the addicts could control use.

*Actually, substance use disorders are the result of powerful chemicals acting upon the brain.  Most people are susceptible to the effects of these chemicals.

*In 1960, the AMA determined alcoholism is a disease.  Addiction is a brain disease.

*Cocaine is one of the most powerful addictive substances known. Rats will seek cocaine drops into the brain over survival.

*Crossing the line from use to severe abuse, also known as dependence, which is marked by the symptoms of tolerance, withdrawal, loss of control, and preoccupation, creates a compulsive, chronic, relapsing disorder.

*Also, remember addiction is both psychological AND physiological with alteration of dopamine, serotonin, and other neurotransmitter stocks and pathways in the brain.  So cravings are mostly based upon neuro-psychological changes.

subst abuse4*In addition, chemicals cause powerful conditioning which associates various using situations with urges to use.  Think of smokers willing [actually, compelled by withdrawal symptoms and cravings] to go outside in zero weather to smoke!

*So we should conclude that heredity, the powerful addictive potential of the chemicals, the level of pre-existing tolerance in the person’s biology, the degree of pleasure experienced in early use, and the social environment all contribute powerful forces which take the use out of the realm of “voluntary” and into the realm of compulsion.

subst abuse5Addicts are lowlifes.

*Most substance users are indistinguishable from others, are working effectively, and are managing in day-to-day life.  Addiction does not discriminate.

*Only a small percentage become severely debilitated.  Between these poles of functional and debilitated users, drug users have varying degrees of impairment and impacts due to use.

*Comment: we have had accusations made against SUD patients, such as panhandling near our offices, damage to premises, etc; investigation revealed the damage was sometimes done by customers of other businesses – it’s just presumed addicts do inappropriate behavior more than others do.

*Stigma is the disgrace and subsequent discrimination applied to people with certain characteristics.  People with substance use disorders are often stigmatized.  While some users do commit crimes, panhandle, manipulate, etc., most do not.

Addicts have a character flaw.

Various addictive chemicals each affect neurotransmitters in different ways – stimulating transmission, depleting neurotransmitter stocks, blocking re-uptake, etc.  Prolonged use often suppresses neurotransmitter production, leading to profound effects upon mood, thinking, memory, motor performance, and behavior.  Therefore, the chemical use results in personality changes.  So only then do patients appear to have flaws.  By circular reasoning, the bias is that the way they appear after addiction is how they were before and pre-disposed them to use.  But during recovery, many of these ‘flaws’ often vanish. In Dependency, the drug becomes a central focus in life, often due to the reinforcing effects of use and the alteration of brain functioning.  Any “flaw” is no different from common problems in impulse-control and thinking that many people experience.

Addicts have an addictive personality.

*No such underlying characteristics have been discovered.  Rather, addiction itself leads to common types of behaviors among users.

*Cross-addiction is the phenomenon that dependency upon one chemical causes one easily to become addicted to another related chemical.  Cross-addictions common, but the fact that many people are heavy users of more than one chemical does not mean they have underlying personality characteristics in common.

All drinking kills brain cells.

*This old belief is partly incorrect.  Recent research does not support this assumption.

*However, heavy long-term use seems to harm the brain significantly.  Heavy long-term use of alcohol appears to shrink brain volume.  Methamphetamine use appears to change some brain functioning.  Use of CNS depressant drugs may sensitize persons to pain.  We know that decades of heavy drinking do harm memory and other areas of brain functioning.

Addicts choose to drink or use drugs.

*Early use may be voluntary, but over time use affects the brain and leads to compulsion.

*Some persons become dependent very rapidly after starting to use drugs.  On average, adolescents become addicted in half or less the time it takes an adult.

*Let’s mention TOLERANCE and WITHDRAWAL.  Tolerance is a physiological process in which the dependent person needs more of the chemical in order to get the desired effect or experiences less of a reaction from taking the usual dose of the chemical.  Tolerance leads to increased use, hence more severe dependence.  We see this with pain medications as well.  So tolerance is a physiological process which overcomes the choice to control use and contributes to loss of control.

*Let’s also look at GENETICS.  If one parent is alcohol dependent, the chances of inheriting the tendency to dependence is 16-25%.  If both parents are, the rate is 33-50%.  This ‘genetic; type of drinking often begins as early as between ages 12-14.

*Let’s look at PTSD.  The emotional toll of trauma actually reduces hippocampal volume and sets the amygdala to be hypervigilant for negative emotional experiences.  The resulting discomfort is a strong motivator for using chemicals to reduce painful emotional arousal.

Alcoholics can drink socially.

*Dependent users cannot resume moderate drinking.  “Abusers” or “problem drinkers” (substance abuse, mild type) might be able to, but only a minority can switch to stable moderate use. Think of a former smoker having one cigarette without relapsing totally – seems most unlikely.

*Why would someone whose life has been harmed by alcohol wish to have a drink!  It makes no sense other than the power of the addiction.  There is an expression in AA, one drink is too many and a thousand is not enough.  Along these lines, a Moderation Management movement from the 1990s and early 2000s proved to be ineffective.

Addiction is treated behaviorally, so it must be a behavioral problem.

*Behavioral and Cognitive treatment affect the brain in ways similar to some prescribed medications.

*Abstinence allows the brain to recover from long term drug use.

*In addition, we now have medication treatments to augment sobriety – ReVia, Campral, Suboxone.

*Treatment helps the patient stay away from drugs and change the beliefs and attitudes which support use to those which support recovery.  So behavioral treatment is aimed at changing ideas and behaviors which lead to overcoming the temptation to use and urges to use, managing urges, avoiding using situations, and developing a level of health such that using is anathema to the patient’s lifestyle.  But cocaine and nicotine users often report urges after months or years of sobriety.

*If you look at this list of outcomes carefully, you see that behavioral treatment does not mean using is a voluntary behavioral choice – what we are trying to do is help the patient in a number of ways to avoid relapsing and to maintain recovery.

II. Drug use always means addiction.
III. Heavy drinking always means addiction.

Heavy drinking episodes predict addiction.

*Possibly, but most drinkers follow a pattern and so their use is about the same amount most of the time.  The pattern may be continuous or episodic.  The pattern may involve binges. Some may increase the amount of the patterned use over time (say from 3-4 beers to 6), but most do not, although they may experience greater tolerance.

*But other heavy users may stop.  E.g., most heavy college drinkers cut back after college.

*Binges (over 4 standard drinks [.75 oz of alcohol] for females, 5 for males), predict abuse (early mild substance use disorder associated with mounting negative consequences).  But in most people, the pattern does not escalate into full-blown dependence.

*Late in chronic alcohol addiction, tolerance actually decreases due to liver damage, so a severely dependent drinker may be drinking less.

If withdrawal occurs, the person must be addicted.

*Not exactly.  Withdrawal can set in with normal use of prescribed medications (opiates, subst abuse6benzodiazapines), but no desire to get ‘high’ was present and use was not compulsive. The person did not lose control and use more than intended.  So the person may have become dependent upon the medication without having a substance use disorder.

*Even addicted persons sometimes have minimal withdrawal.  Cocaine shows little by way of physiological withdrawal symptoms.  Many patients have no significant withdrawal symptoms when they stop using alcohol.

*If we confine “addicted” to meaning substance use disorder, moderate-to-severe, with loss of control, compulsion, desire to attain the effect of the drug, and a withdrawal syndrome after stopping use, then we have many people who become dependent upon a prescription drug, but who are not addicted in the sense of a substance use disorder.   In fact, dependence upon prescription opiates has been the fastest growing segment of the “dependent” population; though those people are not “addicted” in the sense meant here.

*So the presence or absence of withdrawal does not always indicate an ‘addiction’ marked by the desire to get “high,” compulsion, and loss of control of use.

A high number of children with ADHD and on stimulants will become drug dependent.        

The reverse is true.  Children who take stimulants and have a more adequate developmental course tend to have less addiction later.  Most of the increase in drug use among those with ADHD is in those with concurrent Conduct Disorder.

subst abuse7Abuse inevitably leads to dependence.

*Then why call it “abuse” instead of “prodromal dependence?”  *While the abuse often precedes dependence, that is mild SUD predicts later severe SUD will occur, most users remain at the abuse level, what is now termed “substance use disorder, mild.”  *Some users jump from initial use directly to dependence.  That is more characteristic of cocaine, methamphetamine, and heroin.

*This topic is about the steady increase in use, quantitatively, but another side of this question refers to the “Gateway Drug” phenomenon.  The question is asked whether adolescent use of marijuana, tobacco, or alcohol inevitably leads to using crystal meth, heroin, cocaine, or other drugs.  The findings on Gateway Drugs are controversial and the topic is more complex and undetermined than a simple correspondence between mild substance use and future severe substance use disorder.

Use has to be every day in order to become a problem.          

Actually, many addicted users are binge or episodic users.  But once they start, they lose control and use compulsively for a day up to several days.  For example, a cocaine binge may last 8-24 hours until one runs out of money.

All heroin or cocaine users are addicts.

Some people use either of these drugs without becoming addicted.

Marijuana is not addicting.

Marijuana has significant impact upon attention, learning, memory, and performance of responsible behavior.  Marijuana use undermines motivation to accomplish goals.  Some users become psychologically and physically dependent.

Crack is no more addicting than snorted cocaine. Coke is coke.

Physiologically, they are the same.  However, injected or smoked drugs tend to produce dependence more quickly than ingested drugs.  The reason is that they arrive at the brain faster and with more impact.

There is a high risk of dependence with pain meds.

*This is a bit complicated.  While those with a history of drug dependence should be not be given opiates generally, as they are at risk of relapse, most people with severe pain do not become dependent because they gain no euphoria, “buzz,” or enjoyment from these drugs.  They are more prone to attending to the unpleasant side effects rather than euphoria. They may have some tolerance or withdrawal effects, but they do not seek or want these drugs once the pain subsides.

*One complication is that some pain patients do take more than the prescribed amount of medication and do develop higher tolerance.  So there is a risk of dependence on opiate pain medications for some patients.  In general, the use of these medications should be monitored.

It’s only beer.

Of course, a 12 oz beer has the same alcohol content as a shot of whiskey or a glass of wine.  Many people consider a beer to be a 16 oz can or they drink from pitchers or 40 oz containers, so they are unaware of how very much they have consumed.  Further, those who pour their own vodka, gin, whiskey, or Scotch usually don’t measure and so they consume the equivalent of 3-4 mixed drinks in a single ‘drink.’  Many drinkers are not aware of how very much alcohol is in some drinks, such as, specialty margaritas, Long Island iced tea, or specialty martinis.  The important thing is to try to get a sense of the actual amount of alcohol consumed overall regardless of the type of drink.

 subst abuse8To be addicting, the object of interest must be a chemical.

There is some controversy about whether pathological gambling, sexual behavior, spending, or Internet use are ‘addictions.’  They can be compulsive, can involve loss of control, preoccupation, tolerance, a high, mounting consequences, and even withdrawal.   In addition, brain pathways, dopamine secretion, and dopamine receptor deficiencies are almost identical in pathological gambling and cocaine dependence. So it is useful to consider activity or process addictions to be like other addictions for the purpose of treatment.  In DSM-V, gambling disorder is now classified as an addiction.

IV. All their problems are caused by their substance use.

All the addict’s problems in life are caused by drug use.

*This is an outdated belief.  Sometimes, however, depression and other problems do clear up after a few weeks of sobriety.  So we see many symptoms may be an effect of prolonged use.

*But often, other disorders are co-occurring and need to be treated simultaneously.  Some common problems we see co-occurring with addiction are depression, anxiety disorders, personality disorders, bipolar disorder, post traumatic stress disorder, and schizophrenia, amongst others.

*Furthermore, drug use leaves in its wake severe consequences which require rehabilitation, job retraining, working through debt, repairing relationships, attending to health, and other long-term efforts.

Drug dependence is a just a symptom of  underlying problems which must be treated first.

*This is also an outdated belief derived from psychoanalytic thinking some years ago.  Most often, use began in the first place due to underlying problems with depression, anxiety, trauma, self-esteem, pain, etc.  But, eventually, people drink because they drink.  They do cocaine because they do cocaine.  In other words, the drug and the world surrounding use become motivators on their own.  The avoidance of withdrawal eventually dominates behavior (something easily demonstrated with smokers).

*Underlying emotional problems do need to be addressed at some point, however, in order to ensure long-term treatment success.  During EARLY RECOVERY, a period marked by Post-Acute Withdrawal, on the one hand, and the need for major lifestyle change on the other, intensive specialized care is needed so the person can work on underlying problems while working on staying sober.

subst abuse9Treat the chemical dependence first and all the other problems will be cleared up.

Again, the majority of patients today have dual disorders.  Other disorders and problems will still need to be resolved even with sobriety.  The current approach is to treat all the problems with chemical use, mental health, physical health, and lifestyle concurrently in integrated care.

The person has to stop using ALL drugs and medications..

This too is an outdated belief held by some in AA.  They view all chemicals as promoting an unhealthy dependence upon the use of substances to modify moods and improve lives.  By contrast, we now know some medications improve the chances of sobriety (e.g., ReVia, Suboxone, Campral).  We also know that mental disorders do not clear up with sobriety alone and require concurrent treatment, often with psychotropic medications.subst abuse7

Addicts are in DENIAL about the reality of their use, the extent of the use, and the harm their use causes.

*Modern treatment centers de-emphasize the notion of “denial,” which is a remnant of an older way of thinking.  It turns out much of what passed for denial was defensiveness caused by confrontive treatment methods.

*Much of denial is also the result of stigmatization of drug users.  Who would be ready to admit a problem knowing he or she will be judged and looked down upon?

*Modern methods accept the powerful effect of these chemicals upon vulnerable individuals.  So we can see that quitting is a hard road.  In order to quit, most addicts need to realize they have something more valuable to lose and more to gain, on the one hand, than the value which the substance may have, on the other.

*Denial is a real phenomenon.  One can deny doing drugs at all. Adolescents are more likely to cover up using. Adults tend on average to be more revealing.  One can deny that use has an effect or impact or harm.  For instance, it’s common to say marijuana doesn’t affect anyone or to be blind to the effect drinking has on others in the family.  One can deny the amount of use, minimizing the degree of use.  But direct confrontation of denial is not always the best way to reduce it.  Research in Motivational Interviewing demonstrates that confrontive and prescriptive interventions promote more denial, minimization, and self-justification.  A better way to move beyond denial is to validate the difficulties of stopping and empathy.

V. Treatment doesn’t work.
VI. Drug users and heavy drinkers always need detox or intensive care and then should be recovered.

subst abuse10Note: In a survey of my staff, the bias that treatment does not work ranked as the #1 most troubling bias.

We can’t treat addiction effectively, It doesn’t work.

*Addiction is a chronic, relapsing disorder with a potentially fatal course. Therefore, like any chronic disorder, remissions occur and a lifelong course of treatment may be necessary.  Think of hypertension, insulin-dependent diabetes, or asthma — the treatment for these conditions must take place one or more times per day every day for the rest of one’s life.

The treatment of addiction is similar.  Given this view, drug treatment methods have proven more effective than methods for the treatment of hypertension and diabetes. Treatment works.

*State-of-the-art treatment involves evidence-informed methods:

A) Motivational Interviewing and Stages of Change Interviewing

B) Cognitive Behavioral Therapy

C) Relapse Prevention

D) Involvement of the family

E) Use of medications which mitigate cravings

Too many people have too pessimistic a view of the possibilities of a successful treatment process.

Addiction is an acute condition.

*This bias leads to severely inappropriate expectations for substance users and treatments. Actually, addiction is a chronic condition prone to relapses.  So, repeated treatment is often necessary.  Furthermore, to reduce the likelihood of relapses, someone in recovery often needs to stay connected to a treatment facility or self-help group for a long time.

*I like to say it this way: “Over time, one has to put in as much time and energy in working on recovery as one put in working on addiction.”


The prognosis is poor.  Most will resume addiction rapidly after treatment.

*The prognosis is not poor at all.  The problem is that patients and professionals don’t always know the elements which increase success rates.  One-shot detox or brief intervention leads to about a 10% rate of sobriety after 2 years.  But add in Recovery Case Managers, spousal or partner involvement, drugs which control cravings, and, most important of all, involvement with the treatment center for an extended period of time (2-4x/month for a year or more), and realistic expectations (i.e., addicts may lapse during the treatment period) and the success rate tops 50-70%.

*Also, treatment should be viewed as promoting improvement in a range of dimensions rather than in the one domain of sobriety.  These are some domains for improvement in recovery:

1. Drug use

2. Alcohol use

3. Medical and health status

4. Employment/Schooling

5. Family and interpersonal life

6. Psychological health

7. Legal

8. Recreation, leisure

When we view improvement as progress along dimensions, rather than as a black-and-white factor of abstinence, then the great majority of patients are making progress on these important dimensions.

*Can we predict prognosis?  To some extent we can.  Looking at these eight dimensions, those with the fewer problems along fewer dimensions will on average do better than those with more problems along more dimensions.  So we see that it is not merely the kind of drug and the degree of compulsive use, but the totality of the patient’s world which must be considered in the prognosis and treatment.

subst abuse11A single intensive therapy should be enough treatment.

*Sadly, detox is the modal “treatment.”  The relapse rate after detox alone is high.  The follow-through rate for treatment after detox is very low!  So we conclude Detox is NOT recovery treatment.  But we no longer have 28-day treatment centers – those went out more than a decade ago.  Thus, Detox and inpatient centers should give the strong message that the outpatient treatment is the actual long-term recovery treatment and the inpatient setting is preparation, helping the patient be physically and neuro-psychologically ready for the outpatient treatment.

*Comment: There are residential treatment programs, 30-90-day intensive residential programs for those who cannot maintain improvement after 2 or more intensive outpatient programs. There are also Intensive Outpatient Programs, sometimes called Day Treatment or Partial Hospitalization, which last 4-12 weeks and can be effective. However, follow-up care helps maintain recovery which begins in those programs.

*If the condition is chronic, acute treatment of an exacerbation can’t be expected to cure it.  Detox cleanses the body of the substance(s), but it does not bring about recovery of the underlying condition which is neuro-psychological and has caused changes in the interpersonal, occupational, and health lives of the patient, changes which must be rehabilitated.

Primary care physicians have little to offer except to admonish the patient to stop drinking.

Actually, they should not admonish the patient.  The Brief Intervention movement has demonstrated that physicians have a significant impact upon use when they:

A) Do a brief screen for alcohol problems.

B) Tell the patient physical findings which are related to drinking.

C) Encourage the patient to stop drinking.  Provide hope for recovery.

D) Tell the patient the office will follow up in a few days.

E) Have a nurse or medical technician call the patient for a brief check-in after a few days
and again a week later.

This method has shown consistent results in reducing use in those with mild-to-moderate use disorder.

They will just relapse and that means they failed in treatment. It’s hopeless.

*Relapse is a symptom of addiction, not an indictment of the dependent person or a sign of total failure. *Furthermore, total abstinence is not the only measure that improvement is taking place.  We need to look at the variables around sobriety – self-care, relationships, financial status, legal status, health, work – so if we see improvement in those factors, the outcome is positive.

*In the HARM REDUCTION approach to treatment, we do not immediately seek abstinence; instead we work to reduce the harm from use.  Good progress can be made by reducing consequences and difficulties which arise from use.

*Also, POST-ACUTE WITHDRAWAL SYNDROME [PAW] appears in many patients recovering from opioid or benzodiazepine dependence, many who are recovering from alcohol dependence, and many who used amphetamines or cocaine.  PAW includes persisting mood swings, anhedonia, insomnia, craving, anxiety, intense guilt, and cognitive impairment.  Hyper-excitability of neuronal pathways, depletion of GABA, and adaptation to life through drug use rather than the build-up of effective coping skills are among the causative factors.  Trained AODA counselors are familiar with how to work with PAW symptoms.

*Research into addictions, mental disorders, hypertension, and diabetes identify the factors most predictive of poor prognosis, that is, higher rates of relapse. Some of those factors include lower socio-economic (i.e., education + income) status, limited family support, co-morbid mental health disorders.

*Among the family and social support factors, high expressed emotion (EE) is a relapse factor.  EE signifies a high level of negative criticism and hostility.

*In summary, relapse is not inherent in addicted persons.  It is inherent in SUDs and is an outcome of many factors, many of which are environmental and some of which arise from symptoms of substance use disorders per se.

There is a ‘magic bullet’ cure.

Just as there is no one-shot cure, there is no one-type of cure.  People have so many different motives and patterns to using, so many underlying emotional problems and co-occurring disorders, that ALL TREATMENT MUST BE INDIVIDUALIZED.

Those patients must be Confronted.

We’ve learned that confrontation usually makes people defensive and drives some patients away.  The Scared Straight approach does not produce lasting change.  It is disrespectful in that it presumes the patient does not want to change, is in denial, and is too foolish to know there are consequences to using.

All patients need detox.

The minority need detox.  Many alcohol dependent persons do not have significant withdrawal symptoms.  Cocaine and marijuana users generally do not need intensive medical management.  With all CNS depressants, medical supervision is important.  Again, the bulk of the work of recovery happens after detox.

Patients must hit bottom or they won’t go for help.

This is another outdated belief.  People are coming earlier for help, which means fewer cases of subst abuse12severe brain syndromes and more effective, rapid care.  A well-trained professional can help motivate a patient – we just need the patient to show up and participate. Another way to think about it is that every patient has a different bottom line.

The patient has to want to change.

The reverse is often the case when people come for help.

*A) Strong, consistent external pressure can keep the person coming long enough to get the message about change.  Many people are motivated to keep a job or relationship, to avoid jail, or to respond to pressure.  While Intrinsic Motivation helps people stay in recovery, Extrinsic Motivation can get them started.

*B) Motivational Interviewing is a method for locating and strengthening what internal motivation the patient already may possess.

*C) In the group process, social behavior can take over – group norms, normalization of the behavior, relating to sober peers, feeling empathic connection – and creates early motivation.

*In sum, motivation is most often the result of the process of treatment rather than the starting point.

Patients who relapse are just not ever going to change.

We now treat lapses as an expectation, that we can learn from them, that we want to keep them short and celebrate that the patient has not gone all the way back to their old patterns.  Why should we expect that patterns of using reinforcing substances for many years, substances associated with many of the person’s friends and relatives, which have replaced healthy coping mechanisms, which have been often the person’s truly best friend, should just stop because of a short treatment?  Relapse is the norm, but consistent treatment will make a difference.  In AA, the belief is that recovery is a journey, not a destination.  To support this position, consider how hard it is to be a perfect dieter; that will demonstrate what the patient is up against to be a perfect sober person – an unrealistic expectation.  Modern professionals see relapse as a learning opportunity.

Addiction is addiction. Men and women should do equally well.

Some parts of treatment need to be gender-specific.  Women suffer more trauma during their using career.  Women have some different life pressures which can interfere with completing treatment.

Women addicts have a poorer prognosis.

There is no gender-specific difference in prognosis.  What is quite different and which affects recovery is that women in treatment have a much higher rate of trauma, have family demands which may get in the way of full participation in treatment, may be inhibited in group therapy dominated by males.  Women are more vulnerable to the impact of heavy drinking.  Female substance users are also more stigmatized.  Husbands are more likely to leave a female alcoholic than wives are to leave a male alcoholic.  Given these considerations, female-specific therapy may be helpful to give women the additional help needed to achieve the best results.  The issue is one for the treatment facility to consider, not a characteristic of females.

subst abuse13Addiction is solely an individual problem.

*Addiction is also a family problem.

*Often there are abuse problems in more than one generation.

*Many members of a family are impacted by one person’s addiction.

*High levels of familial Expressed Emotion predict higher relapse rates [i.e., criticism, hostility, excessive expectations].

*Also, some studies show couple treatment and family involvement can help motivate an addict to get help and can increase the percentage of addicts in recovery who will significantly improve.

Now that you are clean and sober, you need to be told all the things you did wrong.

While those in the person’s life feel justified in telling the recovering addict about the acts for which he or she should feel guilty or make amends, addicts mostly feel a great deal of guilt.  Early in recovery, their health and sobriety is fragile and PAW symptoms are usually occurring; such pressures could make it more difficult for the person to maintain recovery. So family healing, which is also a process over time which can benefit from wise guidance, includes a period in which repair of the harm to the family will need to occur.

VII. Twelve-step programs are the only way to go.

Alcoholics can stop drinking – all they have to do is attend AA. The same for cocaine addicts and CA or narcotic users and NA, gamblers and GA.   

Spiritually-based and group approaches are not for everyone.  Generic approaches – one-size fits all– are also not for everyone.  For those who relate to this approach, it can work very well.  A great many patients find the generic approach, the spiritual focus, the simplification of complex problems, and the group element to be more problematic than helpful.  AA, CA, NA, GA, etc can be part of a comprehensive approach which includes treatment, family support, spiritual or religious practices, and medical care, but in which step groups are not mandatory.

VIII. Any mental health professional should be able to treat such symptoms.

The patient needs to be referred to any psychiatrist (psychologist, therapist, etc.).  They will know what to do. OR,

just refer to a mental health person who is a good therapist and         he/she will know what to do.

*Actually, this is very mistaken! SUD work is specialized care.  Only a small percentage of all mental health workers have solid training/experience in state-of-the-art methods for treating SUDs and even for doing thorough assessments.

*Also, many programs for mental health services often exclude SUD patients.
*And also, many psychiatrists choose not to work with this population.

*Many graduate schools do not teach how to work with addictions or co-occurring disorders.

*Licensure rules prohibit those who are not certified in SUD from treating addictions. 

*The referrals should go to professionals you know have the requisite training.  Ideal is when the practitioner is trained in both mental health and substance use disorders.

*That said, milder cases can be treated effectively by mental health professionals who have worked through their attitudes and biases and have learned the basics of SUD assessment, Motivational Interviewing, Relapse Prevention, and fundamental substance counseling.

In summary, two general biases explain many of the propositions above:

1. It is essential to hold non-judgmental, hopeful beliefs about SUD treatment. It is not permissible to harbor judgmental beliefs, often very pejorative, or discouraging ideas, about people who use chemicals.

2. Many of us have ideas connected with old notions and intuitions, including general cultural beliefs about SUDs, not with recent research.

These propositions may be subsumed under the topic of STIGMA.  Stigma and bias fly in the face of research.  They persist despite research. Those who suffer from substance abuse stigmatize themselves as well. 

 Would you accept help which you felt was disrespectful, patronizing, shaming, over-simplified, pejorative, confrontive, critical, and not matched to your experiences?  Then, would you really try for recovery?  What about help that is well-informed, respectful, supportive, empathic, guiding, and hopeful!

subst abuse14

© Don Rosenberg, 2013





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