tips to quit smoking
On tips to quit smoking:
Quit Smoking BenefitBy Juliet Cohen
Smoking is bad for your health. Smoking harms nearly every organ of the body. Smoking is a practice where a substance, most commonly tobacco, is burned and the smoke tasted or inhaled. Smoking not only harms your health but it hurts the health of those around you. Exposure to secondhand smoke (also called environmental tobacco smoke or passive smoking) includes exhaled smoke as well as smoke from burning cigarettes. Cigarette smoking causes 87 percent of lung cancer deaths. It is also responsible for many other cancers and health problems. These include lung disease, heart and blood vessel disease, stroke and cataracts.
Women who smoke have a greater chance of certain pregnancy problems or having a baby die from sudden infant death syndrome (SIDS). Smoking is one of the most common forms of recreational drug use. Tobacco smoking is today by far the most popular form of smoking. Nicotine is a drug found naturally in tobacco. It is highly addictive as addictive as heroin or cocaine. Over time, a person becomes physically and emotionally addicted to, or dependent on, nicotine. Quitting smoking is not easy, but you can do it. When you quit smoking, the benefits begin within minutes of your last cigarette. Some powerful ______continued.
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continued______ reasults for quit smoking.You will know you can succeed at difficult taks and take more control of your life. Quitting helps you believe in yourself. Quitting smoking has major and immediate health benefits for men and women of all ages. Benefits apply to people with and without smoking-related disease. The excess risk of developing heart disease as a result of smoking may be reduced by as much as half in the year or two after quitting. Women who stop smoking before pregnancy or during the first 3 to 4 months of pregnancy reduce their risk of having a low birth-weight baby to that of women who never smoked.
The health benefits of quitting smoking are far greater than any risks from the small weight gain or any emotional or psychological problems that may follow quitting. Women who quit at age 35 increase their life expectancy by 6 to 8 years. It is never too late to gain benefits from quitting. When you 3 - 9 months Coughs, wheezing and breathing problems improve as lung functions are increased by up to 10%. Quitting at age 45 increases life expectancy by 6 or 7 years. Quitting at age 55 increases life expectancy by 3 to 6 years. Quitting at age 65 increases life expectancy by 1.4 to 4 years.
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Historic accreditation announcement delivered at NCAD conference
In a move that some see as opening the door to uniform licensing standards for substance use counselors, a new commission will begin establishing procedures for the first-ever accreditation of addiction studies education programs at the undergraduate and graduate level. Attendees of the inaugural National Conference on Addiction Disorders (NCAD) learned of the formation of the National Addiction Studies Accreditation Commission at a Sept. 8 luncheon meeting led by NAADAC, The Association for Addiction Professionals. Representatives of NAADAC and the International Coalition for Addiction Studies Education (INCASE) signed an agreement that formally launches the commission. In an exclusive interview with Addiction Professional , NAADAC President-Elect Donald Osborn emphasized the financial support of the Substance Abuse and Mental Health Services Administration (SAMHSA) in encouraging a process that would lead to curriculum and scope-of-practice standards for addiction counselors at all levels. A collaborative committee spearheaded by NAADAC and INCASE leadership has worked for more than three years on this initiative. Osborn said of SAMHSA, “They know that for this profession to survive, and not be absorbed into social work, psychology, or something else, we need a curriculum. That will establish an addictions profession.” Osborn said his own involvement in this effort was fueled by comments made to him several years ago by a state legislator in his home state of Indiana. The lawmaker scoffed at the idea of licensing counselors, telling Osborn that addiction counseling could be considered no more than a subspecialty because it did not have a standardized curriculum and scope of practice. “That lit a fire in me,” Osborn said. The new commission’s goals are to establish a national standardized curriculum for counselors at the associate’s, bachelor’s, master’s and doctorate levels. Osborn said he believes it will be about a year before education programs will be able to begin the process of seeking accreditation. He told the NCAD audience, “We’re entering into a new era in the addictions profession.” Osborn added that some of the work that organizers have completed drew from curriculum standards developed in Indiana, which recently adopted a counselor licensure law that is gaining national attention. He said he also closely studied the process of developing scope-of-practice standards for marriage and family therapists, who are now licensed professionals in all 50 states. Osborn considers this week’s announcement a major development in the effort to convince more state legislatures to embrace licensure for addiction counselors. Plenary speakers At the conference’s opening plenary session, the deputy director of the National Institute on Drug Abuse’s (NIDA’s) Office of Science Policy and Communications sought to get attendees “jazzed” about scientific developments that could improve clinical practice. Lucinda Miner, PhD, also may have helped coin a new word for the field in describing an intervention that could assist recovering persons with relapse triggers. Miner said that through use of a GPS system to record the whereabouts of an individual, that person could receive an encouraging message via Twitter when he/she enters an area that could intensify the urge to drink. That, in essence, would constitute “Tweetment.” Miner announced that in November NIDA will sponsor a National Drug Facts Week that builds on a one-day “chat” event for schoolchildren that in its first year attracted 36,000 questions to experts on drug topics. The Nov. 8-14 event is designed to meet a growing appetite for science-based information among young people, she said. “We realize that scare tactics don’t work with kids,” Miner said. “They need a reliable source for science-based information.” H. Westley Clark, director of the federal Center for Substance Abuse Treatment (CSAT), used part of his morning plenary talk to discuss the impact of the new health reform law, at a time when the discussion in Washington has turned largely to whether the law could be repealed after the November mid-term elections. Clark argued that “when the Baby Boomers see the cost of ‘no insurance,’” they may change their mind [about opposing the Affordable Care Act].” Clark discussed the many ways in which the act will lead to integration with primary medicine. He also lamented that the field has much work to do in preparedness, after a disappointing show of hands from questions he posed about how many attendees possess advanced electronic health record capabilities or have established working relationships with community health centers. “We under healthcare reform will no longer have to suffer healthcare apartheid, with mental health and substance abuse somewhere ‘over there,’” separated from the rest of the delivery system, Clark said. The Sept. 8-11 NCAD meeting in Washington, D.C. is being presented by Vendome Group, publisher of Addiction Professional and Behavioral Healthcare magazines, in collaboration with NAADAC, INCASE, the National Association of Addiction Treatment Providers (NAATP) and NALGAP, The Association of Lesbian, Gay, Bisexual and Transgender Addiction Professionals and Their Allies.
Reform shapes physicians' role in addiction treatment
Gathering steam from director of the federal Center for Substance Abuse Treatment (CSAT) Dr. H. Westley Clark's morning plenary on integration, Michael Miller, MD, FASAM, FAPA, gathered with addiction professionals in an afternoon breakout session to discuss the emerging roles of physicians in addiction treatment. Miller, who is the medical director at Rogers Memorial Hospital's Herrington Recovery Center in Wisconsin, agreed with Clark, telling attendees that the specialty care delivery system works for some, but misses much of the population affected by addiction. "As Clark said, [specialty care] is not where doctors practice, and it's part of stigma," Miller said. But healthcare reform aims to change that by investing the majority of funding into federally qualified health centers (FQHCs), which will integrate primary care and addiction services through the co-location of services or consults. "Addiction must be treated in primary care," he said. Physicians face paradigm shift The specialty care delivery system that the majority of addiction professionals work in will be affected by healthcare reform's emphasis on integration, but it's unlikely that they'll be skeptical of its benefits. On the other hand, Miller pointed out, physicians may need more convincing. "The biggest failure of American medicine is to appreciate addiction as a brain disease," he said. "Education has failed doctors in regard to understanding what these issues are all about." However, Miller sees hope in the effectiveness of pharmacotherapies for withdrawal, detox, and addiction, including naltrexone, buprenorphine, methodone, and nicotine replacement therapies. These therapies medicalize the process of addiction treatment and finally “allow doctors to be doctors." "I was in the business of subtraction, and now I'm adding medications," Miller said. "This changes doctors' thinking." New roles, new partnerships With this new attitude toward addiction, physicians will be responsible not only for providing direct treatment to patients, but for implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in their practices as well. Though SAMHSA has funded SBIRT initiatives since 2007, Miller estimated that four out of five doctors still don't recognize or acknowledge addiction. “Some have never heard of case finding by SBIRT,” he added. In addition to screening, physicians working in integrated care will also be responsible for providing what Miller calls the five A's: “ask, advise, assess motivational level, and arrange follow-up.” One attendee pointed out the possibility of physicians hiring addiction professionals to screen patients for addiction, to which Miller responded by citing a study that showed non-physicians achieved better outcomes in similar efforts. Another attendee added that their organization staffs a counselor at a primary care facility part-time just to screen patients, saying that “it works great.” Miller sees these types of multidisciplinary teams as another staple of effective integration in the wake of healthcare reform.
New Suboxone formulation expected to be available in October
Within a month, prescribers of the opioid dependence medication Suboxone will have the option of prescribing a second formulation of the drug that could improve patient compliance. Reckitt Benckiser Pharmaceuticals, Inc. announced Aug. 31 it had received federal approval to market a sublingual film that patients in clinical trials preferred to Suboxone sublingual tablets. The new formulation of the medication that combines buprenorphine and naloxone was developed under an exclusive agreement between Reckitt Benckiser and MonoSol Rx, a company whose PharmFilm technology was first authorized for prescription use with the July approval of the anti-nausea medication Zuplenz (ondansetron) by the Food and Drug Administration (FDA). “During clinical studies, Suboxone sublingual film was shown to be faster dissolving than Suboxone sublingual tablets,” Reckitt Benckiser president Shaun Thaxter said in a statement announcing the film’s approval. “Because of the faster dissolution and the taste profile, patients preferred the film.” Both formulations taken under the tongue now will be available for maintenance treatment of opioid dependence. The manufacturer emphasizes that Suboxone should be used as one element of a comprehensive addiction treatment program that includes counseling and psychosocial support. Officials with MonoSol Rx state that the two drug approvals they have received over the past couple of months confirm federal regulators’ acceptance of their technology as a viable drug delivery option. They have developed PharmFilm in an effort to improve the convenience and compliance associated with new and existing medications. The sublingual film will be packaged in individual doses using child-resistant pouches. Warnings associated with the medication include that it should always be kept out of the reach of children, who can suffer severe respiratory depression if they take the medication.
S.F. agency will close in October, leaving legacy of service
Government funding cuts and uncertain times for private philanthropy have combined to force the planned closing of New Leaf, a San Francisco behavioral health agency specializing in services for the gay and lesbian community. But New Leaf’s imprint will remain noticeable long after its mid-October departure, particularly at the many nonprofit agencies where staff members once received training as New Leaf interns. “We trained thousands of clinicians to work with the LGBT community,” says Thom Lynch, who became interim director of New Leaf 10 months ago. Two years of budget cuts from the city and county of San Francisco, in combination with challenges to maintain needed levels of private fundraising, led to the decision to close New Leaf after 35 years of operation. The organization, which offers both addiction and mental health services, is in the process of ensuring continuity of care for its clients by parceling out its various programs to other service agencies. Lynch believes ongoing funding uncertainties make this a good time for human-services organizations to consider mergers and other consolidation arrangements, although factors such as New Leaf’s debt and union contract obligations made such a move impossible for his agency. “People need to look into becoming leaner machines,” Lynch says. “We probably need a few less executive directors, boards and development directors.” He adds that with so many nonprofit agencies in the San Francisco area, private donors feel challenged in terms of what causes they can reasonably support. “Donors are overwhelmed by the number of requests they receive,” he says. New Leaf is working closely with local government leaders to ensure that the public dollars that supported its programs remain in the community, Lynch says. The agency has seen numerous changes in the human-services arena, having been founded at a time when the American Psychiatric Association (APA) still formally considered homosexuality to be an illness. Lynch says that with many LGBT organizations now funneling their dollars to political causes such as marriage equality, it is a precarious time for agencies that specialize in human services and supports for this population.
AA founders debated approach in original manuscript
Long before word processors gave us the luxury of tracking our text edits for the next reader, Bill Wilson, founder of Alcoholics Anonymous (AA), passed around 400 physical copies of his recovery doctrine for revisions and suggestions. Afterward, he and a few of his colleagues copied the most significant of those contributions onto one manuscript, which would eventually become AA’s Big Book —a text used faithfully by addiction professionals and those in recovery since its first publication in April 1939. The Big Book went on to sell over 20 million copies worldwide, but the original manuscript and its many contributions remained hidden from public view. It was stored in Bill and Lois Wilson’s home until 1978, when Lois passed the manuscript on to friend Barry Leach, who maintained its privacy for 30 more years. The manuscript eventually went up for auction in 2007 and was secured by Ken Roberts for $850,000. Roberts then presented the manuscript to Hazelden, who will release the book in two editions, one cloth and one leather-bound, this October. “It’s arguably one of the most important books of the 20th century as it relates to addiction and recovery,” says Nick Motu, senior vice president of Hazelden and publisher at Hazelden Publishing. “To those that use the Big Book and the 12 Step process as core to their profession, it would be very interesting for them to understand what went into the conceptual beginnings of the 12 Step model of treatment.” The manuscript shows text revisions and comments inked in a variety of colors, indicating the work of four to eight core contributors that Hazelden will identify in its release this fall. “Readers … will see the rejected suggestions, inserts, crossed-out comments, and then last minute changes,” Motu says. Along with the original manuscript, Hazelden’s editions will include: • Comments from leading archivists in the margins; • Two essays by Big Book and AA historians; • Annotated notes on the text; • A publication timeline; and • A 1954 speech by Bill Wilson on the making of the Big Book. Debate over spirituality uncovered Though it’s no secret to the addiction profession, much debate arose over how AA would present its principles, which relied heavily on religion. “Of special interest in the manuscript will be the debates that occurred … over the role of religion and spirituality in AA,” says Motu. “Bill Wilson really was adamant about making AA spiritual rather than religious, and you will see that not only in the comments of those that were accepted but also of those that were rejected.” For example, on the opening page of Chapter 5, one contributor noted that ideas in the text “should be studied from the mold angle.” Fred Holmquist, historian and director of Hazelden’s The Lodge Program, attributes this commentary to the fellowship’s fear of triggering newcomers’ religious prejudices. “It talks about their understanding that religions sometimes pour people into a mold, and it’s a little bit one-size-fits-all,” he says. “Typically, alcoholics had not found relief from alcoholism in their religions, yet some had, but the idea was that they did not want to arouse religious prejudice that already existed in people.” Page 30. Revisions to the first page of Chapter 5: How it Works, featuring Steps 1 through 9, show the internal debate between AA members over the use of religious language and references. To view a larger version of page 30 of the original AA Big Book manuscript, click here. Similarly, another contributor makes a note of “His Divine Consideration” across the bottom of the page near Step 9, which states, “Made direct amends to people wherever possible, except when to do so would injure them or others.” To Holmquist, this reference is still obscure, but he has some speculations. “If it’s referencing Step 9, then the idea of doing what you need to do unless it will injure them or others would be a matter of Divine Consideration,” he says. “They were avoiding the density of religious-sounding language, and that would be an example of somebody maybe noting what spiritual or religious principle it represented, simultaneously written in pragmatic language.” From “prescribing” to “describing” a program of recovery Widespread changes in the manuscript signal AA’s decision to avoid prescriptive language—such as “you should do this”—in favor of descriptive language—such as “we did this.” Holmquist says this typifies AA’s strategy of addressing the newcomer with gentleness and accessibility while maintaining respect for the medical community. “They were respecting the attitude of the newcomer as perhaps being defensive or quick to run,” he says. “Also, to other professionals, it was clear they took out specific references that could make the authors sound like they were prescribing medical or psychiatric or psychological recommendations.” Holmquist attributes the original use of a prescriptive voice as the result of the founding members’ sincerity and seriousness about their program of recovery. “Their heart was right, but they realized in looking at it that it would probably be overwhelming for a newcomer to look at and think, ‘I have to do all of this stuff,’” he says. “So they just reverted to sharing what they did, which is what I think is at the heart of attraction not promotion.” Page 31. Revisions to the page featuring Steps 10, 11, and 12 show a shift from the use of prescriptive to descriptive language. The passage, “If you are not convinced of these vital issues, you ought to re-read the book to this point or else throw it away,” was circled in red and removed from the final version of the Big Book. To view a larger version of page 31 of the original AA Big Book manuscript, click here. This is evident in the paragraph following the final step on page 31, where the original text read: “You may exclaim, what an order! I can’t go through with it!” The contributors changed this to, “Many of us exclaimed,” which allows the newcomer to share in the original AA fellowship’s own experience of feeling overwhelmed by the program’s requirements. “These people realized it was far more pragmatic to … settle for doing a little bit better each day,” Holmquist says. “That’s why the idea of this being both a program of action and a fellowship is so important, because you get so much from the combination of both versus just one.”
Addiction clinicians receive firsthand look at military culture
Especially for soldiers who have endured multiple combat tours, the circle of trusted confidants becomes a select group. The director of special projects at the Tennessee Division of Alcohol and Drug Abuse Services uses a striking comment from a sergeant who lost both legs from service in Iraq to describe the soldier’s mindset. Maggie Throckmorton recalls the veteran telling a group of behavioral health professionals, “There are three people I talk to: my God, my wife, and my battle buddy. If you want to be the fourth, you’ve got to let me know I can trust you.” Deciding that a typical passive training session about military culture wouldn’t be sufficient to develop a more responsive clinical professional, the Tennessee agency teamed up with Department Veterans Affairs (VA) and National Guard leaders two years ago to expose treating professionals more directly to the military culture. OPERATION IMMERSION held two training sessions in 2009 in which Tennessee clinicians lived in barracks, engaged in pre-dawn Physical Training (PT) and heard from presenters with firsthand knowledge of military service and its effects. This month, thanks to financial support from the Substance Abuse and Mental Health Services Administration (SAMHSA), the state will be able to host Access to Recovery (ATR) grantees from 19 states and five tribal organizations at the third OPERATION IMMERSION training. The event will be held in Smyrna, home of the Tennessee National Guard Training Center, from Aug. 30-Sept. 1. “We knew that we had a workforce of behavioral health professionals that did not understand the uniqueness of military culture,” says Throckmorton, whose state agency is part of the Tennessee Department of Mental Health and Developmental Disabilities. “We surveyed our network of providers about what they knew about traumatic brain injury, post-traumatic stress disorder, and deployment, and they did not know a lot.” News event hits home On the first day of its second OPERATION IMMERSION training last fall, the group received a stark reminder of why it had convened. On that day, news broke of the mass shootings at Fort Hood in Texas. “It underscored the importance of why we needed to do this,” Throckmorton says. Counselors and case managers from treatment organizations are the typical attendees at these trainings. The participants awaken at 5 a.m. for PT, they reside in barracks, and their food consists of Meal Ready to Eat (MRE) fare. The name tags they wear during their stay list their last name only. “We don’t let the staff sergeants scream at people,” Throckmorton says, but the military setting and the presentations they hear from soldiers give the clinicians a unique opportunity to relate to military culture. Throckmorton advises professionals who want to reach out to returning veterans in their community to contact their National Guard office, and to make an attempt to learn the military lingo. Most importantly, she warns about working with this population, “Do what you say you’re going to do.” The more often these individuals are sent into service—a common occurrence with today’s citizen-soldier—the more insular their world will become, and the more challenging it will be for a treating professional to play a meaningful role. While initiatives such as OPERATION IMMERSION demonstrate greater attention to soldiers’ behavioral health needs among military leaders, there remains a long way to go. For example, a Defense Department task force reported this week that despite having initiated hundreds of suicide prevention programs at military installations, the federal agency still has several holes in its approach. Problems include a shortage of behavioral health specialists and lingering discrimination against soldiers who seek help.
A film festival benefits members of a professional group
Using the tagline “Every story deserves a great second act,” the nonprofit organization Writers in Treatment is trying to assist professional writers who might need financial help to pursue addiction treatment and recovery services. The two-year-old group’s signature event has become a Los Angeles-based film festival that showcases movies with addiction subject matter. This year’s REEL Recovery Film Festival will be held from Oct. 27-30 in Los Angeles, with plans for a smaller-scale presentation Dec. 13-14 in Nashville, Tenn. Writers in Treatment co-founder Leonard Buschel says last year’s inaugural event, which featured weekly film showings at a rented Hollywood theater, attracted a number of clinicians as well as persons in recovery and non-recovering people. Some treatment centers sent groups of clients to the screenings last year, and the event included some facilitated process group meetings afterwards. Buschel, a former publisher and addiction counselor who has been in recovery for 15 years, recalls his own emotional experience in early sobriety after he watched the film “Leaving Las Vegas” starring Nicolas Cage. “I immediately went to a location where meetings were held and waited for the next meeting to start,” he says. Buschel recalls that while he was aware of other efforts on behalf of specific professional groups, such as musicians, he had never heard of an effort to help writers. People in California often assume the nonprofit was created to assist screenwriters only, but it’s for anyone who derives at least one-quarter of total income from the written word. Scholarships are available to individuals with or without health insurance. Applicants must agree to participate in a relapse prevention program along with the primary treatment they attend, and must submit—what else?—a written essay of up to 750 words about their addiction and treatment history. “We’d like to get at least one person a month into treatment,” Buschel says. Besides the film festival, Writers in Treatment also sponsors educational events featuring authors and field professionals. The group tries to be sensitive to the needs of writers, who like other artists often find it difficult to resume with their craft in early recovery, Buschel says. For more information about the REEL Recovery Film Festival, visit www.writersintreatment.org . Writers in Treatment is seeking corporate sponsors for this fall’s event. In addition, film and video entries for possible screening at the festival are being accepted through midnight on Sept. 17.
Alumni coordinators? group continues to gain momentum
The alumni coordinator who launched an effort to establish an association of professionals who work with treatment programs’ graduates says it is clear to her that more treatment centers are seeing outreach to alumni as central to their service mission and business model. The fledgling Treatment Professionals in Alumni Development (TPAD) already has about 75 members representing 60 treatment centers, and next month some members will participate in a facilitated meeting at the National Conference on Addiction Disorders (NCAD) in Washington, D.C. “It seems like I’m getting more calls from people saying, ‘We now have someone full-time in this role,’” says Lorie Obernauer, alumni coordinator at the Center for Dependency, Addiction and Rehabilitation (CeDAR) at the University of Colorado Hospital. “They are recognizing that this is an important full-time position.” This remains a prominent issue as many treatment centers continue to take criticism for delivering care in an episodic fashion that has not often emphasized ongoing post-treatment monitoring. Sherri Layton, outpatient services administrator at the La Hacienda treatment center in Texas, is scheduled to facilitate a TPAD meeting on Sept. 9 as part of the Sept. 8-11 NCAD conference. NCAD is being produced by Vendome Group, publisher of Addiction Professional , as an event combining treatment, administration, design, technology and other information for addiction professionals. For more information about the conference, visit www.ncad10.com . Obernauer says that the formal meeting is designed both to attract new members and formalize a strategy for next steps for the organization. The group could move in several possible directions, from building a Web site and a resource guide to possibly forming a broad network that would assist alumni in regions of the country where none of their fellow program graduates reside, Obernauer says. Another area that the group is likely to tackle involves promoting research into how treatment programs stay in touch with alumni and which of their efforts appear to be most effective in promoting long-term recovery. Obernauer sees these as important initiatives for the treatment community. “This is about the future of our businesses,” she says. Similar meetings to the facilitated session at NCAD are also planned for two other September conferences: the Cape Cod Symposium on Addictive Disorders and Foundations Associates’ “The Moment of Change” intervention conference. For more information about TPAD, contact Lorie Obernauer at (303) 854-4087 or Lorie.Obernauer@uch.edu .
NCAD speaker: The model for treating addicted doctors can work for all
Gary D. Carr, MD, says no physician treating diabetes would ever tell a patient, “Here’s your insulin. Don’t eat chocolate cake. Have a good life.” So he wonders why it seems acceptable to send a patient with a substance use disorder to a world-class treatment center, only to tell that person at the end of the stay, “Don’t drink. Go to meetings. Have a good life.” “That’s a great failing we’ve had in this field,” says Carr, medical director of a Mississippi nonprofit network that assists physicians who have substance use problems or other impairing illnesses. At next month’s National Conference on Addiction Disorders (NCAD) in Washington, D.C., Carr will suggest in a presentation that a system of treating impaired physicians that emphasizes long-term monitoring can work for individuals from all walks of life. Carr’s Sept. 8 session at the Sept. 8-11 conference will feature research data from Project Blue Print, involving an examination of 36 state “physician health programs” in which physicians receive treatment and ongoing monitoring that allows them to resume practice safely. The research showed that 78 percent of 904 doctors in the studied programs completed an average of 7.2 years of monitoring without relapse. “Those are just over-the-top numbers for a chronic, progressive disease that kills people,” says Carr. A skeptical argument often goes that physicians are a special case because the threat of losing a lucrative profession they have worked so long to pursue gives them extra motivation to stay sober. But Carr believes most everyone has something similar in their life that they value, and that is what the treatment system must identify and tap into. “The plumber has a good job and doesn’t want to lose it,” he says. “Or he’s got a great wife.” Carr says the field needs to analyze what it is providing to groups such as physicians and airline pilots but not to others. Then it can determine how to overcome barriers to a more widespread application of a treatment model that is based on accountability. He believes that post-treatment monitoring needs to involve more than verifying whether a patient has located a sponsor. “We need to ask, ‘Who is your addiction professional?’” he says. He adds that treatment organizations need a dedicated staff for ongoing monitoring. “It’s a full-time job,” he says. The NCAD meeting is being produced by Vendome Group, publisher of Addiction Professional , as an event combining treatment, administration, design, technology and other information for addiction professionals. Participating associations in NCAD are NAADAC, the Association for Addiction Professionals (which will now hold its annual meeting under the NCAD title), the National Association of Addiction Treatment Providers (NAATP) and the International Coalition for Addiction Studies Education (INCASE). For more information about the conference, visit www.ncad10.com .
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Two leading credentialing authorities hint at potential for major collaboration
Signaling a cooperative spirit that has been in evidence for some time, the two leading national credentialing organizations for addiction counselors have announced a mutual interest in exploring collaborations. A July 29 letter to colleagues from the National Certification Commission (NCC) and the International Certification & Reciprocity Consortium (IC&RC) describes common interests and goals outlined at a recent two-day meeting attended by leaders of the two groups. “Both IC&RC and NCC recognize the need to speak with one voice for our profession if we hope to effectively address the needs of our respective constituencies in the current political climate and as U.S. healthcare reform moves forward,” the communication states. “The time is now!” NCC, which is affiliated with NAADAC, The Association for Addiction Professionals, and IC&RC each had three representatives present at the two-day meeting held in Denver late last month. The group identified several common interests between the two credentialing organizations, including ensuring that certified counselors are represented in health reform discussions and regulatory efforts, and agreeing that credentialing services and membership services should be administered by separate entities to avoid conflicts of interest. “Recognizing our common ground, we enjoy a cordial and mutually respectful relationship, and we are excited about exploring additional ways that we can collaborate,” states the communication, signed by NCC chairman James A. Holder III and IC&RC president Rhonda Messamore. The two major voices in credentialing for addiction professionals have not always been so harmonious. About five years ago there were ongoing discussions of a NAADAC-IC&RC merger that would have brought the credentialing role under one authority, but later those talks collapsed. At other times there have been bitter relations between NAADAC and IC&RC. Under the present leadership of the two organizations, lines of communication have reopened. There has been a growing sense in the field that an “alphabet soup” of credentials and certification requirements for addiction counselors has hurt the profession’s standing vis-à-vis other healthcare disciplines. This week’s joint effort gives little indication of what types of collaboration might be on the horizon. Field leaders have talked in recent months about standardizing the educational requirements and examinations that would-be counselors face, regardless of the entity from which they are seeking certification.
California nonprofit provides last line of defense for addicts seeking treatment
The Newport Beach, Calif.-based nonprofit organization REACH does not deliver direct services, but it is becoming a lifeline to addiction treatment for some of Orange County’s neediest residents. The organization has established a “Network of Hope” that through donations from multiple sources will be able to offer qualified individuals a treatment slot within a few hours of their pursuit of services. The organization was founded 12 years ago by Carl and Barbara Mosen, who established the Sober Living by the Sea treatment center in the 1980s and became known for their work in creating niche services for special populations. Their more recent effort stemmed from a desire to give back to the community by assisting a broad population of individuals battling substance use problems. The structure of REACH’s scholarship assistance is designed not only to place an individual in a treatment facility but to monitor that person’s progress and to offer opportunities for meaningful aftercare. “Our Network of Hope is an expansion of the mission of REACH,” says REACH’s Jan Brewer. “We are seeking to expand our network of treatment providers and our presence in the community, as well as expand our sponsorship and funding in order to help more people. The HopeLine will be Orange County’s only resource for comprehensive information about treatment for addiction, sober living, and Welcome Back Scholarships.” The latter are financial aid arrangements in which REACH uses funds raised from individuals, foundations and corporations to finance treatment and sober housing stays. REACH has established a partnership with more than 200 addiction treatment providers in the Orange County area, and refers screened candidates to a facility that offers a good match to the individual’s needs. “Our approach has delivered remarkable results because we place them in the right facility and stay connected to their progress every step of the way,” says REACH board chairman Rial Barnett. Barnett calls the Network of Hope a “last line of defense” for many low-income addicts seeking treatment. For more information about REACH’s approach, visit www.reachoc.org .
What did we miss?
Chronic relapsers often have a hidden problem that is difficult to detect and that leads to continuous relapse. These hidden problems require careful re-evaluation if the client is to move toward a path of recovery. This article outlines seven areas of evaluation for chronic relapsers as well as implications for recovery management. 1. Failure to assess for other addictions We can begin with the number one drug of addiction: nicotine. Nicotine kills more people than alcohol and all illicit drugs combined. In addition, clients who smoke cigarettes are three times more likely to return to their drug of choice than are clients who do not smoke. There are also clients who routinely combine drinking and cigarette smoking. For them, smoking can trigger an urge to drink. For clients using illicit drugs that require the lighting of a match, the smoking of a cigarette can trigger cravings for heroin and cocaine use, for example. 1 There is also a strong link between process addictions (addiction to mood-altering behaviors such as gambling, sex, etc.) and substance use disorders. Many chemically dependent clients who stop using drugs substitute process addictions for their drug use, and vice versa. 2 Clinicians should assess for process addictions with chronic relapsers. 2. A hidden psychiatric disorder Approximately 50 percent of chemically dependent clients have a co-occurring mental illness. Often, psychiatric disorders are difficult to detect and might include phobias, obsessive-compulsive disorder, personality disorders, anxiety disorders and depression. The difficulty in detection results partly from the fact that drug use can mimic many forms of psychiatric disorders, and withdrawal from drug use can mimic symptoms of mental illness. In addition, many professionals working in the addiction field are not routinely trained in assessing co-occurring disorders. In an ideal world, all chemical dependency programs would employ a consulting psychiatrist who routinely screens for psychiatric disorders. This is especially important with chronic relapsers. 3. Unresolved grief There is a strong relationship between unresolved grief and relapse, as many clients medicate the pain of grief with use of alcohol and other drugs. 3 For chronic relapsers, clinicians should regularly assess for unresolved grief. Losses that cause such grief include divorce; death; ambivalent losses; loss of custody of children due to drug use; miscarriages and stillborn births (often exacerbated by drug use); and loss of relationships in active addiction. 4. Addictive and abusive relationships It is important to assess relapse patterns with chronic relapsers. Many clients go from drug use to addictive relationships, involving the use of relationships in a similar fashion to the way they were using drugs—to escape and avoid problems and feelings. Addictive relationships are characterized by extreme jealousy; enmeshment; smothering; abuse; multiple arguments and breakups; and staying in these relationships despite adverse consequences. 4 Domestic violence also should be explored, as there is a strong relationship between domestic violence and substance abuse. Research reveals that it is particularly difficult for chemically dependent women to leave relationships that involve domestic violence, because active addiction makes it difficult for a person to mobilize herself. 5 5. Post-traumatic stress disorder The risk of substance use disorders is common among chemically dependent clients who are female, who were exposed to trauma as children, who have done time in prison, or who are war veterans. There is a strong relationship between post-traumatic stress disorder (PTSD) and relapse. 6 6. Enmeshment in a drug subculture Many clients who use drugs that carry the greatest stigma and legal sanctions, such as crack cocaine, methamphetamine and heroin, often find themselves migrating toward “tribes.” These are groups that use the same drugs, provide social support to the user, and often have been shunned by the rest of society. They often have their own language, rituals, styles of dressing, etc. They include motorcycle gangs that use methamphetamine, street gangs, rave party attendees who use Ecstasy, etc. These groups can sometimes have a stronger hold on clients than the drugs they are using, and clients are more likely to use drugs when they are around the group. 7 7. Recovery support It is often helpful to assess the amount of recovery support for chronic relapsers in their natural environment. This support is particularly important in the first 90 days after the client has been discharged from treatment, because most relapses occur within that window. In addition, for those clients who are linked to 12-Step and other mutual aid groups, the great majority of those who drop out do so within the first 90 days of leaving treatment.8 Many clients relapse because they lack recovery support in their natural environment. Recovery management could offer a solution to this lack of support and also address the aforementioned assessment areas. Recovery management Recovery management is an emerging model geared toward supporting clients’ recovery across the lifespan. There are many chemical dependency programs that treat aftercare as an afterthought; thus, the majority of clients leaving treatment do not get the amount of recovery support they need. 8 Recovery management introduces the field to the unique role of the recovery coach, who works with clients in their natural environment upon discharge from treatment. The coach can be instrumental in helping clients navigate the many challenges they face in early recovery, including awareness and assessment of their possible involvement in subcultures of addiction, disengagement from 12-Step and other mutual aid groups, and support in dealing with the pain of loss of relationships and grief. Recovery coaches also can make referrals to therapists as symptoms of PTSD and other forms of mental illness flare. By fine-tuning our approach to assessment and by providing support to clients in their natural environment, we will help more clients stay on a path toward long-term recovery. Mark Sanders, LCSW, CADC, is a member of the faculty of the Addictions Studies Program at Governors State University. He wrote on decreasing c onflict in group treatment in the November/December 2009 issue of Addiction Professional. His e-mail address is onthemark25@aol.com . References 1. White WL. Alcohol, tobacco and other drug use by addictions professionals: historical reflections and suggested guidelines. Great Lakes ATTC Bulletin 2006 Sept. 2. Carnes P. A Gentle Path Through the 12 Steps: The Classic Guide for All People in the Process of Recovery. Center City, Minn.: Hazelden; 1994. 3. Sanders M. Blending grief therapy and addiction treatment. Counselor 2002 Dec. 4. Sanders M. Relationship Detox: How to Have Healthy Relationships in Recovery. Chicago: Winds of Change; 2001. 5. Walker L. The Battered Woman Syndrome (Focus on Women), 3rd edition. New York City: Springer Publishing Co.; 2009. 6. Friedman MJ, Keane TM, Resick PA. Handbook of PTSD: Science and Practice. New York City: The Guilford Press; 2007. 7. White WL. Pathways From the Culture of Addiction to the Culture of Recovery: A Travel Guide for Addiction Professionals. Center City, Minn.: Hazelden Publishing; 1996. 8. White WL, Kurtz E, Sanders M. Recovery Management. Chicago: Great Lakes ATTC Monograph; 2006.
Bringing research-based practice to fruition
The issue of research’s impact on clinicians and patient care in the helping professions is not a new one. In 1949, at the Boulder Conference on graduate education for clinical psychologists, the concept of the scientist practitioner model was introduced, with the idea that clinicians should model their therapeutic interventions after research findings, or empirical data. Although the conference was directed toward psychologists, its impact spread throughout the therapeutic world. While there has been debate over the pros and cons of this model over the years, it is certain that this topic takes on a new importance in the current healthcare climate. The addiction treatment field is at the forefront of this movement for several key reasons. An increased emphasis from insurance providers, consumers and government agencies on outcomes of treatment as a basis for funding has led to the need for a new look at the role of research in our field. In states such as Oregon, Delaware and North Carolina, more and more funding for addiction treatment is being tied to the provider’s use of research-based practices. 1 The passage of behavioral health parity legislation, achieving the long sought goal of equity with other chronic and in many cases fatal medical conditions, only adds to the need to continue to adapt to the changing healthcare landscape. While this landmark legislation will certainly provide more access to addiction and mental health treatment for millions of Americans, there is no question that funding sources, including insurers, will increase their emphasis on working with providers that can produce clear results from their treatment protocols. Showing outcomes, and evaluating how well we as clinicians do with helping our patients achieve goals such as long-term recovery, is becoming an increasingly important task as our field enters a new era. There are several reasons why our field hasn’t fully adopted this model; however, by changing the way we view the role of research in treatment, providers can continue to flourish by giving clients the necessary foundation to begin their recovery journey. Prominent substance abuse researchers for years have presented the idea of “blending practice,” emphasizing a need for more clinical interventions to be based on empirical evidence, or at the least for clinicians to become better consumers of research findings. 2 The National Institute on Drug Abuse (NIDA) has held a series of conferences over the last several years to promote this concept. However, in the substance abuse treatment community, many still view researchers and clinicians as representing different sides of the coin, with different values and goals. Researchers often are seen as lacking insight into the true impact of the disease of addiction and the severe psychological toll it exacts on the individual battling it; practitioners frequently are seen as reluctant to adapt to new concepts regarding treatment and recovery. 3 Those of us who have worked directly with clients for years know the facts—treatment works, and any methods we can employ to help our patients begin to improve their quality of life are important. Research tells us that comorbidity and other factors play a large role in predicting a client’s quality of life following treatment. It also tells us that support systems, including active 12-Step fellowship involvement, play a large role in creating an atmosphere that will help a client not only survive, but thrive. Changing the mindset Creating a clearer picture of what outcome research really means for clinicians, administrators and clients alike is the first step to changing our way of thinking. Research should work hand in hand with clinical processes, with good outcome measurement supporting and adding to the quality of care. For the purpose of this article, let’s focus on one specific type of research: outcomes measurement. Outcomes measurement can be defined as simply measuring treatment outcomes over a specific time period; the measures (or instruments) can track factors such as reduction in symptoms, overall quality of life, and even a patient’s satisfaction with treatment in general. 4 In short, it is tracking a patient’s progress, and beginning the process of collecting data that can be used, at that time or in the future, to assist in treatment planning and service delivery. In non-technical terms, that means “let’s see how well we do what we do!” While ethical standards must be in place to ensure proper methods are followed, beginning the process is not as daunting as it may seem. Laying the foundation for a treatment culture where research-based ideas can thrive and become a vital part of an organization’s mission can begin with a few simple steps. Despite the challenges in adopting research-based practices into treatment facilities, we have some unique advantages in the addiction field in regard to their application in our day-to-day work. For example, our primary goal as providers is helping our patients achieve long-term recovery. What could be more outcome-based than that? While the argument can be made that many other medical treatments are more easily quantified in terms of their effectiveness through testing and other methods, several studies have highlighted that in terms of adherence to aftercare protocols, success rates in addiction treatment (as measured by sustained abstinence) are no worse than those seen in the treatment of other chronic medical conditions, such as asthma and diabetes. 5 While few insurers would place restrictions on follow-up visits to providers to treat these addictions, this unfortunately is an all too common practice in addiction medicine. This challenge offers practitioners and researchers a golden opportunity to redefine the meaning of success in recovery, and to begin to bring together those with different views on what successful recovery entails. Those who begin to look at addiction from a global or holistic sense will see the benefits in improved patient care as well as greater financial stability. Simple practice-based outcome research, with clearly defined goals, plays a key role in this new way of thinking. As mentioned earlier, we know treatment works when clinician and client work as a team, and we know that quality of life improves after treatment. Failure to measure this progress puts the therapist at a distinct disadvantage in treating the client, as well as placing facilities at a marketing disadvantage in being unable to quantify the positive results of interventions. In short, it is a “win-win” situation for everyone involved in the process when we begin to emphasize this way of thinking. Importance of staff education There are obstacles to continuing progress in this area, and in many ways a lack of understanding of the process of research, data collection and its role in changing the way we provide services is key. The first step in laying this foundation is making education a priority for staff at treatment centers. While continuing education has long been a part of the curriculum for licensed professionals, too often this factor has gone neglected at many facilities. Beginning to stress the critical role of continuing education, not just to satisfy licensure requirements but to gain a better understanding of the nature of our clients, is of utmost importance. Whether it is hosting a brief in-house seminar on new research on treating comorbid conditions or distributing new findings on the factors most closely associated with long-term sobriety, there are relatively simple ways to begin to reinforce the notion that practice should be based on what works. Training should not be offered to licensed clinicians alone; even staff members who have no intention to pursue licensure, including support staff, can attain a much clearer picture of the people we serve, increasing their effectiveness as helpers. The ability to understand the patient from a holistic perspective, including spiritual, emotional and physical needs, can make everyone at a treatment center more effective. Clear, straightforward presentation of research findings can help these become practical tools for clinicians to use in their daily work. Obviously, with financial pressures increasing in all fields right now, there is a trend toward cutting services not seen as “essential.” When this affects the areas of education and research in the field, this can come with costs. By not creating the time for clinicians and other staff to participate in continuing education, we put ourselves at a disadvantage in the changing healthcare picture. While many centers, including some of the best-known providers, emphasize this ideal, more needs to be done. Too many times as clinicians we operate in crisis mode, with pressure from all sides to complete the daily tasks that are part of being in direct service to clients. A renewed push by the administrative bodies of treatment centers to create time for clinicians and others to continue to grow through involvement in research and education can help reduce stress by giving employees new options to pursue in helping their clients on the path to wellness. Professional and personal growth no longer can be seen as just another lofty goal, but a necessary function in today’s treatment arena. Overcoming resistance Of course, there are challenges. Despite the growing need to adapt to this new way of thinking about providing addiction treatment, many researchers and clinicians still harbor reservations about each other’s goals. Resistance is normal when new ideas are introduced, when research calls into question some of our field’s commonly accepted practices, or when clinicians are asked to adopt new ways of thinking based on research findings. The key here, as noted above, is an emphasis on education. The more clinicians are engaged in the process early on, the more willing they are to begin to adopt research into their daily routine. For example, when beginning to collect data at a facility, administrators and supervisors must continue to stress that the therapeutic alliance is the key to good outcomes, and the process of tracking those outcomes is just another hallmark of good clinical practice. Making the research findings or projects that are adopted into the facility practical, directly addressing the problems clinicians see on a daily basis, can reduce resistance and pave the way for improving quality of care. Adopting a more collaborative approach, where each group learns from the other, is the way to begin to recognize similarities instead of highlighting differences. 6 In many cases, beginning the process of research at facilities can be easier than we think. Whether in urban or rural communities, many facilities are within close proximity to academic institutions, full of motivated individuals who would jump at the opportunity to assist in conducting even basic research activities. Clinicians want to find new ways to treat the chronic relapsing patient and those who struggle with comorbid conditions such as depression. And the vast majority of clients are willing to do their part to help us shed light on new ways to help those who fight the disease of chemical dependency. Whether filling out a survey regarding their treatment experience or participating in a clinical trial of a new intervention that helps reduce symptoms of post-traumatic stress or depression, patients feel like they are serving a cause greater than themselves. It is one of the key spiritual elements of the recovery process, and just one small example of how research and practice can work together in providing the best quality of care for those we serve. Emphasizing the common goals we have as addiction treatment providers, and focusing on outcomes, is the best path to take for our clients and ourselves. John W. McIlveen, MEd, is Vice President of McIlveen Associates, LLC, a consulting firm focusing on education, training, research and assessment. He is a former Director of Assessment and Education at a large treatment center in South Florida, and has presented and published frequently on treatment-related issues. His e-mail address is mcilveenj@mindspring.com . References 1. Carey B. Drug rehabilitation or revolving door? New York Times, Dec 23, 2008. 2. McLellan AT. Reconsidering addiction treatment: quality, accountability, and outcomes in a chronic care perspective. Presented at National Institute on Drug Abuse conference “Smart Practice, Practical Science: Blending Treatment and Research,” Miami Beach, Fla., June 2005. 3. Marinelli-Casey PJ, Domier C, Rawson RA. The gap between research and practice in substance abuse treatment. Psychiatric Serv 2002;53:984-7. 4. Sperry L. Treatment outcomes: an overview. Psychiatric Annals 1997;27:95-9. 5. McLellan AT, Lewis DC, O’Brien CP, et al. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000;284:1689-95. 6. Carise D, Cornely W, Gurel O. A successful researcher-practitioner collaboration in substance abuse treatment. J Subst Abuse Treat 2002 Sep;23:157-62.
Two California organizations respond to shortage of residential beds
Could the combination of intensive outpatient services plus supervised living in a sober home duplicate the experience of a residential treatment stay? Two Southern California organizations are testing the idea in response to state funding cutbacks that have resulted in severe shortages of affordable residential treatment options. Twin Town Treatment Centers, based in Los Alamitos, and Serene Center Long Beach have established a strategic alliance that to date has served half a dozen clients. The individuals receive IOP services at Twin Town and reside at Serene Center. Because Serene Center is a state-licensed operation by virtue of its transitional-living services component, it can offer to IOP patients a level of supervision (with 24-hour staffing) that cannot be accessed in most typical recovery home settings. “An unforeseen benefit to the patient is that our counseling staffs see the patient at different times of the day, and we can communicate the behavioral changes we see back and forth,” says Andrew Martin, Serene Center’s president. Martin says the arrangement also works because the two organizations have similar missions with respect to client services. “We both believe in a long continuum of care, and a rigid accountability structure,” he says. Martin explains that dramatic cuts to government-supported treatment programs in California have led to wait times of up to four months for county residential treatment beds. “Even ‘tomorrow’ doesn’t work for people who are looking for treatment today,” he says. The two entities are advertising the availability of five months of treatment with supervised living at a cost of $1,540 a month plus food expenses. Martin expects the partnership to be sustained over the long haul, not simply becoming a short-term response to the present budget crisis in California. He adds that while residential treatment in one setting might still be the preferable scenario to many, he believes longer-term treatment that involves support for a longer period than the duration of a residential stay could prove more beneficial.
Texas company sees need for sober-living options for gay community
With a number of factors that increase risk for addiction and undermine prospects for recovery among members of the gay community, a Texas company that operates sober-living homes believes more aftercare options should be tailored to this community’s needs. Eudaimonia Recovery Homes, which operates six sober-living residences, opened its first sober home for gay and bisexual men two years ago. The Scott Daniel Home, an Austin residence named after a successful local attorney and philanthropist who committed suicide, is believed to be one of only three recovery homes for gay men in the United States. “Why are there not more gay sober homes when addiction in the gay community is such a problem?” says house manager Jason Howell, who became involved in the Scott Daniel Home project after a former partner told him how important his sober-living experience had been to sustaining his recovery. Howell says the home offers an attractive option for individuals who often avoid the usual treatment or support programs for fear that they will not be accepted. “Treatment facilities don’t necessarily acknowledge the sexual orientation of males,” he says. “Gay men haven’t been able to share the same experiences with straight men.” The home is located in a section of Austin that is very close to the site of regular 12-Step meetings tailored to the gay community; residents are required to attend at least three support meetings a week. Eudaimonia Recovery Homes director Mathew Gorman says the house rules at the Scott Daniel Home are virtually identical to those at the other homes the company operates. For example, all residents must be involved either in volunteer work, employment or school attendance during their stay. Computer use is allowed on the premises but takes place in common areas of the house and not in residents’ rooms, so as to guard against potentially dangerous uses of the Internet. Residents make a commitment of at least three months at the home, where the rent charge is somewhat below that of similar facilities elsewhere. Howell says his former partner is now an officer on the home’s governing board. “He has said that his struggle with his sexuality was at the heart of his addiction,” Howell says. “We’re glad that we can fill this gap in services.”
NCAD speaker intends not to bash 12-Step, but to enhance it
Harold C. Urschel III, MD’s presentation at this year’s National Conference on Addiction Disorders (NCAD) is entitled “A New Science-Based Model of Alcohol and Drug Addiction Treatment Delivery,” but he wants to make it clear that his talk will not cause dedicated supporters of 12-Step treatment to depart the lecture hall in disgust. “This is not in any way pushing 12-Step to the side,” says Urschel, co-founder of Dallas addiction disease management company Enterhealth and CEO of the Urschel Recovery Science Institute. “This is giving 12-Step additional resources to further turbo-charge its effectiveness.” Urschel, who serves as Enterhealth’s chief medical strategist and oversees a program that combines 12-Step treatment, family therapy, medications and whole-health strategies, will deliver his 90-minute NCAD talk on Wednesday, Sept. 8 at 2 p.m. The Sept. 8-11 conference in Washington, D.C. is being produced by Vendome Group, publisher of Addiction Professional , as an event combining treatment, administration, design, technology and other information for addiction professionals. Urschel received some of his graduate medical training at the University of Pennsylvania and admits being heavily influenced by the research-to-practice orientation of research leaders there such as Charles O’Brien and Tom McLellan, the latter now with the federal Office of National Drug Control Policy (ONDCP). He says much of Enterhealth’s program reflects National Institutes of Health (NIH) findings that point to the need for multiple treatment approaches and individualized treatment plans. “We’ll find out through research in the next few years that there are probably 12 to 15 different types of alcoholics,” says Urschel. “They have different psychiatric components, different family issues, etc. Their treatment requires a multidimensional approach.” The lectures Urschel has presented on this subject have been more theoretical than what he intends to discuss at NCAD, so it is likely that his talk in September will address some of the real-world challenges around implementing a more comprehensive treatment model. In order to offer a more far-reaching and longer-duration treatment program in Dallas, Enterhealth opted to abandon the insurance market for its residential treatment services (it does work with insurance in its outpatient programs). Urschel hopes that addressing these practical issues in his talk will convince NCAD attendees to re-examine their programs when they return home. He acknowledges that an “inertia to change” often plagues professionals’ efforts to apply what they learn in conference settings. NCAD also will feature a number of other presentations that will discuss successes in blending 12-Step treatment with other strategies. Among these are sessions titled “12-Step Recovery, Motivational Interviewing, and Harm Reduction: Natural Partners” and “DBT Meets the 12 Steps.” Participating associations in the NCAD meeting are NAADAC, the Association for Addiction Professionals (which will now hold its annual meeting under the NCAD title), the National Association of Addiction Treatment Providers (NAATP) and the International Coalition for Addiction Studies Education (INCASE). For more information about the conference, including details on early registration discounts, visit www.ncad10.com .
More patients or more competition?
It wasn't too long ago that addiction treatment specialists were the only source of professional help to those suffering from problems with alcohol and drugs. But in recent years, screening, brief intervention and referral to treatment (SBIRT) of patients with potential alcohol- and drug-related problems has increasingly become a part of mainstream medicine. First introduced in the late 1990s, SBIRT addresses the entire spectrum of substance use disorders, from early symptoms that are identified and addressed before the patient has exhibited signs of addiction to addicted patients who need long-term chronic treatment. The approach is evidence-based, and has demonstrated a small but proven impact on daily and weekly alcohol consumption, DUI arrests, injuries, car crashes and other complications associated with alcohol and drug misuse. Now, physicians and healthcare providers of all stripes (those in trauma centers, emergency departments, primary care and college campus health clinics, general surgical and medical wards, and employee assistance programs) increasingly are using formal screening methods to detect the potential harmful use of alcohol, prescription drugs, or illicit drugs. And physicians and other hospital and clinic staff are also counseling patients who screen positive for substance use and are referring some on for treatment by addiction specialists. There is a great deal of other evidence that the momentum for the SBIRT approach continues to grow: A new medical specialty board, the American Board of Addiction Medicine, was established in 2007 and already has certified nearly 3,000 physicians from various disciplines as specialists in addiction medicine. Medicare, and in some states Medicaid, is reimbursing clinicians for these services. New CPT codes for reimbursing brief intervention activities were adopted. Effective in January 2007, the Centers for Medicare and Medicaid Services (CMS) allowed reimbursement for alcohol- and drug-related screening and brief interventions. Barriers to SBIRT are falling. For instance, many states have repealed insurance laws that discourage blood alcohol test screening in emergency departments. A widely adopted state insurance law recommended in 1947 by the National Association of Insurance Commissioners (NAIC) allowed health insurance companies to deny payment to physicians and healthcare providers for medical care to persons injured as a result of being under the influence of alcohol or a non-prescribed narcotic. As a result of these laws, one in four trauma surgeons were experiencing denials of reimbursement and only half of trauma surgeons surveyed were screening patients for blood alcohol content. Fortunately, progress has been made in repealing these laws. In 2001, the NAIC unanimously recommended that states repeal the laws, and since then 14 states and the District of Columbia have done so. The leading question now for “traditional” addiction treatment professionals is how much this trend will affect public health and their livelihoods. Will there be fewer referrals to addiction treatment specialists? Will these specialty providers have to compete with doctors for patients? Or will they receive more referrals and develop closer ties and stronger relationships with physicians? Those are legitimate questions, but first it might be helpful to place this trend into some historical perspective. What's behind the SBIRT trend? The mainstreaming of SBIRT reflects a growing acknowledgement that alcohol and drug use can endanger the health of people who do not have, by definition, an addiction. Although alcohol and other drugs cause or complicate the treatment of at least 70 medical conditions for which patients frequently seek care, medical schools and residency training programs traditionally have provided very little practical training for doctors on how to screen for substance use and intervene when necessary. As a result, in any given year, 22 million Americans are in need of substance use treatment, yet only two million patients each year receive it. Why is that? The main reason is 94 percent of patients simply don't know they need treatment. Four percent know they need treatment but don't want it, and two percent know they need help and are actively seeking it or wanting to engage in it. When it comes to addressing alcohol or drug use problems, one of the most important developments in the past 20 years has been the recognition that only a relatively small fraction of the patients who use alcohol or drugs in quantities that can damage their health meet the criteria for having alcohol dependence syndrome or alcoholism, or are drug addicts. This was shown by the largest study on SBIRT, a 2009 analysis that screened 459,599 patients in general medical settings (including emergency departments, family practice clinics, trauma centers and general medical surgical wards). The study found that 22.7 percent of patients had a positive screen for some type of alcohol or drug problem. The two most commonly identified problems were binge drinking (getting drunk to the point of intoxication) and regular use of alcohol in amounts that might not lead to intoxication, but that over time can cause chronic health problems. These two types of drinking patterns were found in 15.9 percent of patients. However, the severity of the problem was at a level that most patients were judged to need only one skillfully delivered counseling session. The study found that an additional 3.2 percent of patients had problems that were more advanced but still did not meet the definition of addiction or dependence. However, it was felt that these individuals would benefit from more than one counseling session, and should be seen at least two or three more times. The patient's primary physician, regardless of specialty, can provide these sessions if he/she receives the proper training. The SBIRT trial found that only 3.7 percent of patients who present for general medical care-about one in six of those who screened positive-met the definition of addiction, or suffered from the alcohol dependence syndrome. These patients need to be referred to an outpatient or inpatient center for treatment by an addiction treatment specialist or someone with similar professional credentials. Proven value in trauma What addiction professionals have learned is that “the setting” often plays an important role in the effectiveness of the screening and brief intervention. SBIRT has proven to be especially valuable in trauma centers, because nearly 50 percent of the time, alcohol or drugs played a key role in the event that led to the patient's injuries. SBIRT appears to be particularly effective in trauma centers. One study showed that a year after a trauma center intervention, patients reduced their alcohol consumption by an average of nearly 22 drinks per week (a control group that did not have an intervention reduced their drinking by only six drinks per week). 1 Over the following year there was a 48 percent reduction in return visits to an ER for treatment of another major or minor injury. There was still a benefit three years later, as the intervention group had a 47 percent reduction in injuries that were serious enough to require readmission to the hospital. 1 More patients who require the services of addiction treatment professionals will be identified, and referred. Another study showed that by reducing the risk of reinjury, each time it provides an intervention it saves $330 in healthcare costs over the next three years. The return on investment was $3.81 saved for every $1 spent on screening and intervention. 2 The role that SBIRT could play in transforming healthcare was underscored when the American College of Surgeons Committee on Trauma (COT), the primary organization responsible for developing trauma center requirements, added a new criterion for Level 1 trauma center verification. Starting in the spring of 2007 the COT required all Level 1 trauma centers to have a mechanism to screen for substance use problems for all patients who sustained injuries serious enough to require admission to the trauma center. And all Level 1 trauma centers had to have a mechanism in place to provide an intervention to those who screened positive. The American College of Surgeons was the first professional medical society that had regulatory authority to pass a requirement that patients receive treatment for a substance use problem. For that matter, it became the first medical society that mandated any type of mental health benefit for patients receiving medical care. 3 Prior to this mandate, screening for alcohol problems in trauma centers was far from routine. 4 A 1999 study based on a random sampling of 241 members of the American Association for the Surgery of Trauma reported that more than half of trauma surgeons screened fewer than one in four of their patients. 5 Given the rarity of screening, and lack of interventions and referrals prior to the new COT ruling, it is anticipated that the currently required use of SBIRT in trauma centers will increase the number of patients screened. More patients who require the services of addiction treatment professionals will be identified, and referred. However, the big payoff will come when the practice of screening and interventions spreads from trauma centers, and begins to involve hospital settings in general. The trauma center mandate for use of screening and brief intervention has ignited the fuse that we hope will eventually lead to the spread of screening, intervention and referral to specialty care for those who need it, to many other types of general medical practices. What it means for the addiction professional Now that SBIRT has been adopted in trauma centers, it is hoped that screening, intervention and referral will become standard medical care. Studies have shown that SBIRT is one of the most beneficial and cost-effective preventive healthcare measures available (more than screening for cholesterol, cervical cancer, diabetes and depression-preventive measures that already are standard medical practices in many settings). There are reasons to believe that the trend to adopt SBIRT will accelerate. More and more doctors are becoming board-certified in addiction medicine; hospitals are increasingly developing expertise in performing SBIRT; and young, new physicians are beginning to accept that addressing substance use problems is a part of their core responsibilities. There has never been a better opportunity to break down the barriers between mainstream medicine and substance use treatment, and to make sure patients with problematic alcohol or drug use are identified and get the help they need. After all, healthcare reform will now require most Americans to have health insurance coverage, and the new federal Mental Health Parity and Addiction Equity Act will increase accessibility to insurance coverage for treatment of addiction and mental health problems. The bottom line is that SBIRT is a welcome addition in the fight against dangerous use of alcohol and other drugs. It has the potential to alert an increasing portion of the more than 20 million people who may have a potential problem and need to seek help. And while patients with mild problems will receive counseling from their doctor, those with complicated or severe problems will be referred to addiction treatment specialists. As screening becomes routine in general medical care, physicians who identify patients in need of more than brief intervention or counseling will have to have arrangements with addiction treatment specialists who possess the skills and who work at facilities that can provide the more extensive treatment and ongoing care that these patients require. As adoption of SBIRT into medical care increases, early identification and intervention might result in fewer patients developing the need to be seen by an addiction treatment professional. On the other hand, 90 percent of patients who require help don't even know it. The adoption of SBIRT in healthcare settings will identify these patients and result in more , not fewer, patients being referred for the type of addiction treatment that most general medical doctors cannot provide. Society will need more addiction professionals, not fewer. Ultimately, that's good not only for patients, but also for society at large-and for those who treat them. Larry M. Gentilello, MD, FACS, is a Professor of Surgery at the University of Texas, and Adjunct Professor in Management, Policy, and Community Health. He is a director of the American Board of Addiction Medicine. He is a leader in the area of general medical screening and brief intervention for substance use problems and has conducted a number of clinical trials designed to incorporate psychosocial healthcare interventions, especially those involving substance use problems, into the trauma and acute care arena. His e-mail address is lgenti@gmail.com . References Gentilello LM, Rivara FP, Donovan DM, et al. Alcohol interventions in a trauma center as a means of reducing the risk of injury recurrence. Ann Surg 1999 Oct; 230:473-80. Gentilello LM, Ebel BE, Wickizer TM ,et al. Alcohol interventions for trauma patients treated in emergency departments and hospitals: a cost benefit analysis. Ann Surg 2005 Apr; 241:541-50. Mello MJ. Rhode Island Hospital, Injury Prevention Center Translation of Alcohol Screening and Brief Intervention Guidelines to Pediatric Trauma Centers, grant from Injury Control Research Centers. http://www.cdc.gov/injury/erpo/Funding/ICRC2009.html Terrell F, Zatzick DF, Junkovich GJ ,et al. Nationwide survey of alcohol screening and brief intervention practices at US Level I trauma centers. J Am Coll Surg 2008 Nov; 207:630-8. Danielsson PE. Reasons why trauma surgeons fail to screen for alcohol problems. Arch Surg 1999 May; 134:564-8. Addiction Professional 2010 July-August;8(4):10-15
Revising the NAADAC Code of Ethics
Often when one confronts a situation where another person's behavior is questioned, the behavior is described as ethical or unethical. The judgment is being made on the basis of the morals held by the speaker, unless the behavior is being evaluated on the basis of a specific code of ethics. The NAADAC Code of Ethics was written to govern the conduct of members of NAADAC, the Association for Addiction Professionals. The code reflects ideals of NAADAC and its members. Every member of NAADAC has signed a statement that she/he would follow the standards found in the NAADAC Code of Ethics. When an ethics complaint is filed with NAADAC, it is evaluated by consulting the code. A code of ethics serves to guide the professional to maintain personal integrity and honesty, to make decisions that are in the best interest of clients, and to meet the standards established for persons working in the profession. Most written codes are similar in content, and the variations in them result from the needs felt by a particular group. Ethical codes have a number of strengths, including protection of client rights while identifying what is expected of practitioners. In addition, codes encourage the professional group to regulate itself and function autonomously, instead of being regulated by statutory law. In general, a code of ethics increases public trust in the profession's integrity. Ethical standards are used to settle disagreements and to promote organizational stability. If professionals are following the code of ethics, some protection from malpractice suits exists. Codes of ethics tend to be idealistic and are a statement of the behaviors to which a profession aspires. A code of ethics might be general in nature and not answer specific questions. Instead, the code of ethics is a guideline based on values of the organizational members. The code of ethics also can be used as a tool to encourage discussion of values and standards among members. When a problem arises, the code is consulted to determine the degree to which the individual or group has violated the association's standards. NAADAC procedures NAADAC has specified that its Code of Ethics be reviewed every two years to determine whether or not it is meeting the needs of members, the administrative staff and the committees conducting the work of the association. The NAADAC Ethics Committee is currently re-evaluating the Code of Ethics. Work began when NAADAC President-Elect Donald P. Osborn, MS, MA, MAC, pointed out to the Ethics Committee that we have no ethical standards for conducting assessments and mental health evaluations. Other mental health disciplines include such standards in their ethics codes. Standards were written and approved by the Ethics Committee, but have not yet been added. Over the years, the NAADAC Code of Ethics has been issued in several formats, some of which have been fairly detailed and some of which have been very concise. The code currently in use is a shorter version. Members of the Ethics Committee and the National Certification Commission have found on a few occasions that we did not have standards that clearly described the expectations of members. Parts of the code have been found inadequate to guide members questioning the best action to take in a specific circumstance. NAADAC's Shirley Beckett Mikell and the Ethics Committee compared the ethics codes of a number of organizations and found that codes of other mental health professions provided more detailed guidelines for counselors than were found in the NAADAC Code of Ethics. In February, members of the Ethics Committee were assigned specific principles in the current code of ethics to review, in order to determine whether the principle would be more applicable if it were reworded or if major changes were made. Participants are encouraged to bring questions, share ethical dilemmas they have faced or are facing, exchange ideas, make comments, and suggest ways of educating current members and addiction professionals who are new to the certification process. The updated NAADAC Code of Ethics will be published as a longer document to provide addiction professionals with guidelines in specific areas. An abbreviated version that includes the overall principles will also be available for use in conference presentations and client settings. Code sections The Revised Code of Ethics 2010 is divided under major headings, and standards that apply are documented. The sections utilized are: The Counseling Relationship; Confidentiality/Privileged Communication and Privacy; Policy and Politics; Professional Responsibility; Evaluation, Assessment and Interpretation of Client Data; Working in a Culturally Diverse World; Workplace Standards; Supervision and Consultation; and Resolving Ethical Issues. Printed copies of the revised Code of Ethics will become available by the fall National Conference on Addiction Disorders (NCAD), which will be the site of NAADAC's annual meeting and will be held Sept. 8-11 in Washington, D.C. The new document is considerably longer than the previous one, making it comparable to those of other mental health professional groups. Sections related to the expanding duties of addiction professionals/NAADAC members/certified counselors have been added or expanded. More emphasis has been placed on professional standards and competence, cultural competence, and supervision. At the conference, the Code of Ethics will be discussed in four sessions. Each session will address a different section of the code. Case studies and descriptions of challenges facing the Ethics Committee will be used to illustrate the significance of the new and revised standards. Time will be provided for discussion, challenges and questions. Participants are encouraged to bring questions, share ethical dilemmas they have faced or are facing, exchange ideas, make comments, and suggest ways of educating current members and addiction professionals who are new to the certification process. Some states are requiring that an ethics course be taken every two years to maintain certification. Please bring your ideas about how that might work and the best way to reach individuals as well as agencies. If you are unable to attend the conference, please send your ideas to hatchera@mscd.edu so that they can be discussed at the annual conference. Anne Hatcher, EdD, CAC III, NCAC II, is Co-Director of the Center for Addiction Studies at Metropolitan State College of Denver, and chairs the Ethics Committee for NAADAC, the Association for Addiction Professionals. She is a member of the Addiction Professional editorial advisory board. Her e-mail address is hatchera@mscd.edu . Addiction Professional 2010 July-August;8(4):31-32
The McLean Residence at the Brook
Single or double? The configuration of resident bedrooms was one of several questions confronting leaders at McLean Hospital as they conceptualized a transitional-living program for persons in recovery. Their decision to locate at a facility that could accommodate single rooms for all residents diverges slightly from a notion held by many that having a roommate can benefit a client in recovery. “Some people say that a roommate is a great thing and a client should be able to accept whatever it takes to bring about recovery, but we never saw data on that,” says Nancy Merrill, program director for alcohol and drug abuse services. “If we were going to live somewhere for 90 days, how would we feel about having to share space?” The nationally known Massachusetts behavioral health organization drew on its experience in facility renovation in selecting the site for its transitional-living program, which opened in January. McLean had formerly owned the building, which is located about a five-minute drive from its main campus in Belmont, and most recently it had been owned by an organization that ran an adolescent program. McLean discovered at the outset that it should spend some time reassuring neighbors who had apparently grown tired of noisy teens congregating outside the building. “We had an open house just for the neighbors,” explains Merrill. “We also wanted to spruce up the outside, so we put in new landscaping and did some painting of the windows.” The eight-bed coed facility offers a minimum of 90 days of support for those who are transitioning to a life in the community; some but not all residents are referred to the program from primary treatment at McLean. Services are offered on a private-pay basis. The facility specializes in serving individuals who have frequently relapsed or who have mental health issues that complicate long-term recovery. Merrill says every room in the three-story brick colonial structure was renovated, with fresh carpeting installed throughout the facility. The renovations took about four months to complete, she says. McLean worked with LaChance Furniture, a local retailer in Gardner, Mass., to bring in extended-length single beds and other furniture for the facility. Planners of the facility selected a muted color palette to emphasize a soothing atmosphere for recovery. Shades of beige predominate, and are accented with somewhat bolder salmon, rust and red colors. The kitchen presents more of a contrast; it is done in a black-and-white motif with stainless steel appliances and a checkerboard floor pattern. While residents are allowed to make good use of the kitchen, McLean also has entered into an arrangement with a nearby restaurant owner to have catered lunches and dinners brought in-a welcome option for residents who are busy during the day resuming their studies or work-related activities after primary treatment. Residents also attend anywhere from two to five group meetings a day. The Brook's offerings also include wireless Internet access, an off-site health club membership, and support for activity-based rehabilitation through yoga, cooking and other pursuits. So far, the facility has attracted mainly a client population in its early-to-mid 20s, which has surprised its planners to some degree. As of this spring it was not yet operating at full capacity. Merrill has no regrets about the decision to house residents in single bedrooms. This offers residents an opportunity for some needed quiet reflection, she says, adding that one must remember there is an important difference between quiet time (a positive) and isolation (a barrier to recovery). Addiction Professional 2010 July-August;8(4):44-45
Three groups must jointly develop the workforce
“Now is the time for the addiction treatment field to rally our efforts for talent management,” says Kathleen Caggiano-Siino, executive deputy commissioner of the New York State Office of Alcoholism and Substance Abuse Services (OASAS). After a brief review of some relevant statistics, it looks like the time is now or never. Part of the problem is that, compared to the need, there is hardly any talent to manage. For example, Ohio officials estimate that more than one million people in the state need addiction treatment, but the public system is able to serve only 90,000. 1 Studies show that about 30 percent of addiction professionals are eligible to retire, while the demand for addiction professionals and licensed treatment staff with graduate-level degrees is projected to increase by 35 percent in 2010. 2 The research evidence is overwhelming that addiction treatment works. It saves taxpayers millions of dollars over the cost of incarceration, reduces unemployment, prevents many addiction-related illnesses, saves millions in healthcare costs, and reduces violent crime. Addiction workforce development could solve huge problems for patients, addiction treatment programs, addiction counselors and society as a whole. But is the problem too big to solve? Partnering for solutions Caggiano-Siino and her counterparts in several other states believe the problem can be solved. But it will take a partnership that includes government, the provider network and addiction professionals. Government can help by offering loan forgiveness to those who prepare for work in the addiction field. There needs to be support for an addiction treatment infrastructure that ensures the availability of qualified professional staff, accountability, and quality of care. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends federal leadership and partnership with elementary and secondary schools and institutions of higher learning to generate early student interest and to promote opportunities within the field. 3 The provider network needs to hone its talent management skills. This involves careful planning to attract, select, develop and retain staff. Programs should design a career path for the positions that turn over most frequently. 4 This could include salary differentials for Counselor I, II and III positions, as well as administrative options. A career path helps staff members realize they are part of a profession. It validates training, academic credentials, time in the field, and prior experience. 3 Management best practices include: Providing staff development/training; Allowing for flexible work schedules; Rotating staff assignments; Providing staff mentors; Rewarding staff for performance; and Providing supportive supervision and manageable caseloads. 5,6 All staff members should have a professional development plan. This can be co-written by the supervisor and the staff member, and committed to by both. Programs can develop a leadership pool by soliciting external mentors (outside the addiction field), leadership assessments, and “talent audits,” where programs identify who is promotable in the next 6, 12 and 24 months. Succession planning is the end product of a robust leadership program. 4 Programs also could pool resources. Networks can enhance the infrastructure of member agencies by making available specialized staff. For example, nursing, vocational, psychiatric, psychological, clinical social work and other services can be shared through co-location, joint funding, referral or rotation. This sharing of resources allows economies of scale for participating agencies and also makes available critically needed supports that might otherwise be unaffordable. When organizations join together in networks, they benefit from the ability to manage care efficiently across agencies, and those whom they serve benefit from access to a more complete array of services. 3 Addiction professionals can help by sharing their stories. There are many success stories shared about clients, but not as many about the rewards of witnessing the struggles and triumphs of those grappling with addiction. Brush up your public speaking skills. Speak publicly at least three times a year about what you do; practice until you're comfortable enough to share off the top of your head at a moment's notice. You can add your story to the online resource “Stories From the Drug and Alcohol Addiction Front” at http://nationalsubstanceabuseindex.org/articles/APstories-original.php . Stay in the game Finally, as an addiction professional you can also continue your education, regardless of your age, to better prepare yourself for the more and more complicated cases we are seeing. And you can leave the rocking chair on the front porch empty for a few more years. Nicholas A. Roes, PhD, author of Solutions for the ‘Treatment-Resistant’ Addicted Client (Haworth Press, 2002; reviewed in the January 2003 issue of Addiction Professional ), is Executive Director of the New Hope Manor residential treatment facility in upstate New York. His e-mail address is NickARoes@aol.com and his Web site is http://www.nickroes.com . References Kaplan L. Partners for Recovery: Ohio Alcohol and Other Drug Addiction Workforce Development Project. Available at http://pfr.samhsa.gov/docs/OH_approved_web_article_5_1_06.pdf . Addiction Technology Transfer Center Network. Addiction Professionals Like You Are in Demand.Available at http://www.attcnetwork.org/explore/priorityareas/wfd . Substance Abuse and Mental Health Services Administration. Strengthening Professional Identity: Challenges of the Addictions Treatment Workforce: A Framework for Discussion. Rockville, Md.:SAMHSA; 2006. Available at http://www.attcnetwork.org/find/respubs/docs/WorkforceReportFinal.pdf . Caggiano-Siino K. Becoming a profession of choice through talent management and leadership development. In LEADERSHIP: Creating a Profession of Choice. NEATTC; 2008. Annie E. Casey Foundation. The Unsolved Challenge of System Reform: The Condition of the Frontline Human Services Workforce. Baltimore:Annie E. Casey Foundation; 2003. Hager MA, Brudney JL. Volunteer Management Practices and Retention of Volunteers. Washington, D.C.:The Urban Institute; 2004. Addiction Professional 2010 July-August;8(4):42-43
Career-sustaining behaviors of addiction counselors
“First we make our habits, then our habits make us.” - Charles C. Noble Most addiction counselors focus on helping their clients break their habits of addiction. In this article, we suggest that counselors need to pay attention to their own habits-habits of self-care. As students, we had given little thought to the kinds of habits necessary to succeed in an addiction counseling career. But that changed last summer when one of us interned at a recovery center. There, the supervisor was adamant about helping staff develop good habits of self-care, or what some call career-sustaining behaviors (CSB). He demonstrated their importance by structuring our work so that it was refreshing and energizing. He consistently modeled how to integrate CSB into daily life. Sometimes we had staff meetings outside on a sunny day. Other times, he asked what we had done over the weekend. He wanted to be sure we practiced taking care of ourselves. This experience was formative, underscoring the importance of developing good habits of self-care so that we could better serve the needs of others. Since then, we have learned a lot more about CSB. With the help of our professors, we reviewed research on stress, burnout and CSB, and then conducted a national study of the self-care habits of more than 700 addiction counselors. This article reviews some of the research on CSB and describes the results of our study. Burnout among counselors Addiction counseling involves heavy caseloads and clients prone to relapse, which can create high stress levels. The effects of stress on helping professionals can range from depression and emotional exhaustion to loneliness and decreased self-esteem. Moreover, stress can diminish counselors' effectiveness by disrupting decision-making skills, attention and concentration, as well as the ability to generate strong relationships with clients. 1 Unattended stress can lead to burnout, a syndrome involving depersonalization, emotional exhaustion and a sense of low personal accomplishment. 2 Counselors risk significant physical, emotional, spiritual and psychological harm if they force themselves to continue their work and ignore the stressors leading toward burnout. 3 Furthermore, their effectiveness is significantly diminished. The addiction counseling profession requires special attention to burnout. Alcoholics and addicts are noted for being “difficult clients,” often presenting with chronic difficulties, demonstrating slow progress, and regularly relapsing. Many times, addiction professionals are children of alcoholics or are in recovery themselves. While shared experience can initially assist counselors in empathizing and building rapport with clients, it also can increase burnout risk. “Empathy fatigue” occurs when counselors' own past problems resurface as they explore client issues. 4 By continually revisiting their own suffering during counseling sessions, counselors often endure additional emotional turmoil and struggle to work effectively. Of course, counselor stress is not limited to the office. Stress at home also may be related to burnout at work. When counselors do not set adequate boundaries between home and work, personal struggles can affect their work. Value attainment also might play an important role in job satisfaction and stress reduction. 5 Counselors who are able to achieve their personal goals are more likely also to accomplish their professional goals. Yet when counselors feel hindered from achieving their personal ideals, they are likely to experience greater work conflict and frustration. Career-sustaining strategies While little has been done to identify strategies to prevent burnout in addiction counselors, researchers such as Norcross have identified career-sustaining strategies for counselors in general. 6 First, he suggests that professionals openly acknowledge the stress and hazards of their occupation and appreciate the rewards. Second, he recommends activities that are enjoyable and provide stress relief. Third, focusing specifically on the problems related to the stress is important. Often, working to modify the work environment or other procedural aspects of work can serve to reduce stress. Fourth, Norcross suggests that taking advantage of helping relationships, social supports and personal therapy can help to ease ongoing stress. Finally, he advises counselors to avoid wishful thinking and self-blame, and encourages them to diversify clients and counseling techniques. In addition to these general recommendations about managing stress, we found additional practical recommendations from others, 7 including maintaining a leisure mindset, leisure space and a connection to others, and using rewards as self-care strategies. Clinicians' self-care strategies should not be event-based but a “lived experience.” That is, self-care should be an ongoing, rather than compartmentalized, practice. The point of career-sustaining behaviors is not to add another task to a checklist, but to turn them into habits of daily life. CSB are most helpful when they create space in counselors' lives to allow them to be more than clinicians and, consequently, to enrich and lengthen their careers. 7,8 Religion and religious practices also have been found to enhance counselors' well-being. Steger and Frazier found that “meaning in life” mediates between religiosity and well-being. 9 When counselors engage in religious practices, such as going to worship services, praying and reading religious texts, they find meaning in their lives that they may not be able to find elsewhere. This meaning may transfer into one's counseling practice, providing a greater sense of purpose in daily work and in turn contributing to greater well-being. Study background While it is clear that career-sustaining behaviors are important for promoting effective counseling practice, little is known about their use among addiction professionals in particular. Therefore, we invited more than 5,000 members of NAADAC, the Association for Addiction Professionals to complete an online survey of their CSB. 10 A total of 709 members participated. The majority of the sample was female (about 61 percent) and the average age was 50. Geographically, the Southern U.S. had the highest representation with 35 percent of participants. Approximately 68 percent of participants were married or in a significant relationship. In the paragraphs that follow, we explain which addiction counselors are most likely to use CSB and we identify which CSB counselors are practicing. Results We used a variety of statistical analyses to determine what factors were related to the practice of CSB among addiction counselors. We found that certain demographic groups were more or less likely to practice CSB. For example, those who were married or currently divorced reported more frequent practice of CSB. Perhaps it is not surprising that those who had never been married reported lower rates of CSB. It might be that, in order to meet the demands and needs of family and romantic relationships, some counselors intentionally utilize CSB to structure their relational and vocational priorities. We suspect that single individuals might be more prone to focus on their work, and as a result end up maintaining fewer boundaries between work and personal life. Addiction counselors who lived in the West, Northeast or South had similar CSB scores; however, their scores were consistently higher than those reported by counselors from the Midwest. These differences suggest that the practice of CSB might be affected by place. Cultural as well as climate factors might contribute to the different levels of CSB practice across geographic locations. For example, some find an afternoon walk enjoyable and stress-relieving. While those in the South may be able to step outside to practice this CSB, January's weather in the Midwest is less conducive to such activities. Those in colder climates might have to be more creative and intentional to integrate CSB into their daily life. We expected that those who had more years of education, as well as those who had greater work experience, would more frequently practice CSB. While the data did demonstrate positive relationships between CSB and both years of education and years of work experience, the relationships were weak. These weak correlations (r =.12 and .19, respectively) suggest that counselors with more training and education use CSB only marginally more than counselors with less training and education. This might reflect a lack of CSB instruction in addictions counseling academic programs. CSB were unrelated to other demographic factors. Men and women did not differ on CSB scores. Likewise, we found no difference in CSB among those who worked in different practice settings (urban vs. suburban vs. rural). We asked participants to indicate the frequency with which they used a variety of CSB. The most commonly used CSB are listed in Table 1 and those that were used least frequently are reported in Table 2 . Cultivating habits of self-care Addiction counselors' training is predominately other-focused, with less attention given to self-care. Studies on burnout urge educators to alter their curriculum to include career-sustaining behaviors. 11 Yet the novelty of standardized curriculum, limited faculty and scarce resources may interfere with teaching self-care methods. However, in the same way that students learn Motivational Interviewing techniques, students should learn self-care-by practicing. Good habits, whether they are related to counseling skills or self-care, require practice. Educational institutions strive to equip students with the counseling skills necessary to be successful in the addiction field. Yet by neglecting to cultivate good habits of self-care, or CSB, training programs could be missing an essential ingredient for sustained effectiveness. Our addiction counseling faculty have acknowledged the difficulty of adding “one more thing” such as self-care strategies to the addictions counseling curriculum. Faculty members feel pressure to streamline curriculum, and students-responding to financial and other life pressures-move as quickly as they are able through training. These factors challenge the implementation of CSB into the training curriculum. As a result, students do not develop CSB habits, and instead cultivate unhealthy habits that they carry with them into their counseling work. Charles C. Noble reminds us, “First we make our habits, then our habits make us.” Given the demands of addiction counseling, we are reminded of the importance of developing good habits in these formative years. Studying addictive behaviors has taught us that, over time, habits have a way of shaping individuals into certain kinds of people. Likewise, we are realizing that the habits we cultivate now will shape us into certain kinds of professionals. More Online For another perspective on avoiding burnout, visit http://www.addictionpro.com/shulman1207 . Michelle Sobon (pictured above), Ashley Davison and Lauren Bogear are undergraduate students at Indiana Wesleyan University. Sobon is completing her undergraduate majors in psychology and addiction counseling and will be pursuing doctoral training in clinical psychology in the fall. Davison is a psychology major and a member of the John Wesley Honors College; she plans on finishing her undergraduate work in 2011 and pursuing a career in Student Development. Bogear is graduating with majors in psychology and adolescent ministry; she plans to work in a local church with her husband. Tim Steenbergh is Associate Professor of Psychology at Indiana Wesleyan University, and Katti Sneed is Social Work Department Chair and Associate Professor of Addiction Counseling at Indiana Wesleyan University. Steenbergh's e-mail address is Tim.Steenbergh@indwes.edu . References Sherman M, Thelen M. Distress and professional impairment among psychologists in clinical practice. Prof Psychol Res Prac 1998; 29:79-85. Shapiro SL, Brown KW, Biegal GM. Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Train Educ Prof Psychol 2007; 1:105-15. Barnett J. Who needs self-care anyway! Prof Psychol Res Prac 2007; 38:603-7. Stebnicki MA. Empathy fatigue: Healing the mind, body, and spirit of professional counselors. Am J Psych Rehab 2007; 10:317-38. Perrewe PL, Hochwarter WA, Kiewitz C. Value attainment: An explanation for the negative effects of work-family conflict on job and life satisfaction. J Occup Health Psychol 1999; 4:318-26. Norcross J. Psychotherapist self-care: Practitioner-tested, research-informed strategies. Prof Psychol Res Prac 2000; 31:710-13. Grafanaki S, Pearson D, Cini F ,et al. Sources of renewal: A qualitative study on the experience and role of leisure in the life of counselors and psychologists. Couns Psychol Quarterly 2005; 18:31-40. Lawson G, Venart E, Hazler RJ ,et al. Toward a culture of counselor wellness. J Human Couns Educ Devel 2007; 46:5-15. Steger MF, Frazier P. Meaning in life: One link in the chain from religiousness to well-being. J Couns Psychol 2005; 52:574-82. Kramen-Kahn BL. Career-sustaining behaviors for psychotherapists: Relationship to perceived job-related rewards and hazards. Retrieved from Fielding Graduate University, 1995. Turner JA, Edwards LM, Eicken IM ,et al. Intern self-care: An exploratory study into strategy use and effectiveness. Prof Psychol Res Prac 2005; 36:674-80. Addiction Professional 2010 July-August;8(4):25-30
Doctors' role in the prescription abuse crisis
There is general agreement that misuse and abuse of prescription drugs in the U.S. by all age groups has increased significantly in the past decade, with the death rate from overdose now exceeding that from illicit drugs, including heroin, cocaine, hypnotics and stimulants combined. Among teenagers, painkillers are the most commonly abused drugs after tobacco, alcohol and marijuana. Each day, an average of 2,000 youths ages 12 to 17 initiate use of a prescription drug without a doctor's guidance. Prescription drug “abuse” means using a controlled mind-altering substance without a prescription from a physician, or using a prescribed medication for the sole purpose of achieving a pleasurable, mind-altering effect. Medications typically abused include opioid painkillers (Vicodin, OxyContin, etc.), sedative-hypnotics (Valium, Ambien, etc.), selective serotonin reuptake inhibitors (SSRIs) and other antidepressants, and stimulants (Ritalin, Adderall, etc.). Prescription drug “misuse” refers to patients diverting controlled drugs for sale, as well as physicians prescribing a controlled drug for a patient when better pharmacological awareness or a more thorough examination would have suggested that the drug was contraindicated. Patients use a variety of methods to obtain controlled substances illegally. These include doctor-shopping, doctor manipulation, symptom fabrication and prescription forgery, as well as certified and illegal Internet pharmacies, of which about 800,000 were estimated to exist worldwide in 2007. As a consequence of inadequate education about addiction in medical school and residency training, a significant majority of physicians in the U.S. wittingly or unwittingly contribute to the prescription drug epidemic because they lack the skill, knowledge and training to diagnose and treat addictive disease. These deficiencies are exacerbated by prejudice against addicts, radical changes in patterns of clinical practice, substandard reimbursement, and a nihilistic attitude about treatment's efficacy. Deadly impact The dimension of the crisis can be visualized in this way: Currently, there are approximately 780,000 licensed physicians in the United States, with about 15,000 new graduates joining their ranks each year. A survey conducted by the National Center on Addiction and Substance Abuse (CASA) at Columbia University found that 57 percent of doctors believe it is their primary responsibility for preventing prescription drug diversion and abuse. However, two-thirds of these physicians report that they received only two hours or less of training in prescription drug diversion in medical school, residency or continuing medical education. Moreover, CASA has reported that only one-third of physicians rated the training they received in this area as adequate. Doing the math, it is not unreasonable to conclude that at least two-thirds (520,000) of the U.S. physicians currently in practice lack the knowledge and skills to diagnose and manage addictive disease. These undertrained physicians will thus proceed to treat the symptoms of the disease but not the disease itself. Consequently, common symptoms of addictive disease such as depression, anxiety, insomnia, migraine and other conditions tend to be treated as separate disorders, not as frequently encountered concomitants of addiction. Furthermore, many of these symptoms will be treated with controlled medications that might not be appropriate if the primary diagnosis is addictive disease. This prescribing can lead to unwitting abuse and dependence by the patient who will continue to take the medications in good faith without being aware that they may be harmful. This approach leaves the underlying addictive disease alive and undisturbed, thereby postponing indefinitely the opportunity for appropriate treatment and recovery. Defensive prescribing of controlled drugs is also common because of fear of liability arising from allegations of undertreatment. A tragic case involved a 48-year-old patient of mine who had had a liver transplant necessitated by alcohol and other drug-related hepatitis. Although not completely abstinent, he had been doing fairly well in his recovery for three years. After he underwent outpatient surgery for a hernia repair, his surgeon, despite prior awareness of the patient's addiction and recovery, gave him a bottle of 80 Percocet tablets with instructions to take two every four hours if he woke up in the middle of the night with severe pain. According to the patient's father, even though his son attempted to refuse the meds on the grounds that “[his] addiction would not permit him to stop at just two tablets,” the surgeon insisted that he take the bottle home. As predicted, my patient did indeed wake up in the middle of the night with severe pain and, presumably finding no relief after two tablets, swallowed the entire bottle of Percocet. His body was found the next morning. Seeking solutions For too long, the failure of many of the nation's leading medical education institutions to provide their students with the skills to address substance abuse disorders has been allowed to fester as a silent epidemic. What can be done to reverse the tide? For physicians, at least, the answer lies in mandatory education and training in the diagnosis and treatment of addictive disease, including specific reference to abuse and misuse of controlled prescription drugs. As part of its effort to reverse the prescription drug abuse and misuse epidemic in the U.S., the Betty Ford Institute in 2008 held a Critical Issues Consensus Conference entitled Addressing the Crisis: Helping Graduate Medical Education Integrate Addiction Medicine and Science Into Primary Care; The Time Has Come! The conference yielded six recommendations aimed at ensuring that core competencies and the faculty to teach them be mandatorily included in all undergraduate and graduate medical education, including examinations to assess appropriate levels of physician knowledge. One of the conference's conclusions was that despite the fact that the core competencies for diagnosis and treatment of addictive disease have been widely endorsed by prominent medical education groups and specialty societies, the need for improved education in prescribing controlled substances in medical schools remains largely unmet. To address this need, the Betty Ford Center, and now the Institute, since 1986 has offered residential, weeklong, innovative learning opportunities about the science and art of addiction treatment for medical students. Since its inception the program has educated more than 1,500 medical students. In addition to education, policy and regulatory changes are also required: The American Board of Medical Specialties should require that knowledge in identifying, diagnosing and treating substance abuse and the prescribing/administering of controlled drugs be included in its minimum standards of competency. The award of Medicare reimbursement funds to medical schools providing undergraduate and post-graduate education for physicians should be contingent upon the school's ability to demonstrate that its courses follow standard curricula, and that adequately trained faculty are in place to teach them. Failure to meet this standard would lead to withdrawal of federal training funds. All state professional boards should require, as a condition of licensure, that physicians complete training in substance abuse, addiction, pain management and the legal regulations and responsibilities related to the prescribing and dispensing of controlled drugs. The Drug Enforcement Administration (DEA) should require physicians to demonstrate actual competence in prescribing controlled substances as a prerequisite for being awarded a DEA Controlled Substance Prescribing License. Congress should act on a variety of measures related to the prescription drug misuse and abuse epidemic by framing legislation to prohibit sale or purchase of controlled prescription drugs on the Internet and to ban direct-to-consumer (DTC) advertising for a number of mind-altering drugs. Regardless of whether these recommendations are followed, it is the responsibility of each physician, especially those who have not been adequately trained in recognizing and managing addictive disease, to make up for that by any means available, including appropriate workshops and, most importantly, attendance at open meetings of 12-Step programs. Garrett O'Connor, MD, became President of the Betty Ford Institute in 2008. In 2003 he was hired as Chief Psychiatrist for the Betty Ford Center. He is certified in General and Addiction Psychiatry by the American Board of Psychiatry and Neurology, and in Addiction Medicine by the American Society of Adduction Medicine (ASAM). His e-mail address is goconnor@bettyfordinstitute.org . Addiction Professional 2010 July-August;8(4):40-41
Using technology to increase retention and revenue
Over the past decade we have seen dramatic changes in the use of digital technology in our field. In fact, when I first wrote about the use of technology in clinical practice for this magazine in 2003, it wasn't uncommon for me to meet practitioners who did not have access to e-mail at work. Today, our field has begun to realize many of the benefits that the new technology promised. Providers are using the Internet to enhance their knowledge and skills. They are leveraging technology to increase organizational capacity and improve their services. Clients have new options to support their recovery, such as online self-help and support groups or specialized “e-therapy” programs. Of course, providers today still face many of the same obstacles to adopting new technology that they did seven years ago. The most pressing concerns are perennial: Providers worry about money, time, lack of computer knowledge, confidentiality/security of patient information, and lack of technical support. There also are fears that using computers will depersonalize services and compromise the engagement process. And there are the challenges of training staff to use the new technology and make procedural changes that they might not welcome. These concerns only have been exacerbated by the economic crisis of the past two years. Many state agency budgets have been cut, and many providers have been seriously challenged to provide the same level of services with fewer resources. To balance the budget, some agencies have chosen to cut programming or reduce staff. Given these circumstances, it might seem like the worst possible time to explore the use of technology in clinical practice. However, there are several good reasons to reconsider. Avoiding reductions First, used judiciously, the right technology could help you avoid program or staff reductions. Laying off staff or cutting programs can destabilize an agency. When you reduce your capacity to serve clients, you could be vulnerable to further revenue loss. Fortunately, projects facilitated by NIATx, the pioneering improvement collaborative, have demonstrated that agencies can increase financial stability using a different approach: process improvement. 1 The approach entails closely examining an agency's procedures to identify those that block access to treatment, increase wait times, drive up no-shows, or reduce staff productivity. Making even small modifications to these procedures, such as systematically reminding clients of their appointments, can positively affect retention rates and revenue. Notably, using technology to support key process changes can be a smart, cost-effective strategy. For example, an agency might choose to purchase an automated phone service for reminder calls. While a phone service represents an investment, it could dramatically reduce no-shows. As NIATx co-deputy director Kim Johnson explains, “We have 50 percent no-show rates in this country. If you're paid on a fee-for-service basis, the no-show costs you what your fee is.” 2 Most agencies that implement reminder calls, Johnson says, will cut no-show rates in half. Improving client engagement Second, by improving your clinical workflow, you might be able to increase client motivation, engagement in treatment, and retention. In any effort to improve agency services, it is extremely important to consider the clinical workflow. When a provider is able to design a workflow that is evidence-based and consumer-friendly, and that leverages technology in a time- and cost-efficient way, it is possible to increase the quality of care while saving time and money. There are plenty of free and low-cost online resources to help providers learn about and implement evidence-based practices. The Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse Treatment (CSAT; http://csat.samhsa.gov ) has continued to publish invaluable treatment improvement protocols (TIPs) and technical assistance publications (TAPs). The Addiction Technology Transfer Centers, or ATTCs ( http://www.attc network.org ), offer extensive learning materials, including a monthly e-newsletter with updates on addiction research, funding and other developments in the field. NIATx ( http://www.niatx.net ) documents “Promising Practices” on its Web site and offers free online webinars. The rise of social media in the past few years has also opened up new avenues for learning. Sites such as Facebook ( http://www.facebook.com ) and LinkedIn ( http://www.linkedin.com ) allow practitioners to connect directly with one another, share relevant information and work through the practical challenges of translating research to action. On LinkedIn, for example, I have joined a number of useful “groups,” such as Addiction Professionals, Friends of SAMHSA, and the ATTC Network, enabling me to follow threaded discussions, post questions and find resources. In these conversations, and in my experience consulting with providers to develop and enhance the ASI-MV Connect, a computer program for client self-administration of the Addiction Severity Index, I have observed that agencies benefit most from implementing evidence-based approaches when they are incorporated in a workflow that makes sense for both clinicians and clients. One example of this can be found at Universal Counseling Services in Baltimore, which followed the NIATx model of process improvement to redesign its workflow. By simplifying intake paperwork and adopting the ASI-MV Connect program as part of the assessment process, the agency was able to cut the time required for intake to one hour (from two to three hours previously), and to double the number of assessments that could be completed per staff member per day. At the same time, the staff introduced motivational incentives for clients, such as awarding a certificate of completion at the end of the intake assessment and other important steps in treatment. In a field study of the impact of these changes, the organization found that it was able to increase retention and revenue significantly, while saving 351 hours of clinician time and more than $6,000 for the agency. 3 Preparing for change Third, integrating technology in your program may help you prepare for the state and federal requirements of the (near) future. Perhaps the most significant development that is likely to affect use of technology in clinical practice is the passage of the American Recovery and Reinvestment Act of 2009, which created new incentives for building critical healthcare infrastructure such as electronic health record (EHR) systems. If these incentives are extended to cover behavioral healthcare providers, we could start to see profound changes in the way addiction treatment is delivered and clinics are managed. Indeed, many providers, anticipating expanded or required use of EHRs, already have begun to implement these systems. This might be the year in which the government moves to support state providers that want to implement EHRs, since these systems can assist providers with gathering data for the National Outcome Measures (NOMs), integrating care by sharing data across systems, and collecting information that can be used for performance-based reimbursement. Behavioral Healthcare magazine provided a useful overview of EHR providers and products last September. 4 These products, along with the Web Infrastructure for Treatment Services (WITS), an open EHR platform developed by SAMHSA, CSAT and state agencies, are valuable tools designed to help providers standardize their operations; reduce duplicative data entry; and gather, sort and report clinical and administrative data in real time. Taken together, these developments suggest that now may be the right time for providers to explore their options for using technology in their clinics. A year from now, small but important changes already may have yielded significant benefits. Albert Villapiano, EdD, a psychologist, is Vice President of Clinical Development at healthcare technology research and development company Inflexxion, Inc. in Newton, Mass. ( http://www.inflexxion.com ), and product lead for the ASI-MV Connect ( http://www.asi-mvconnect.com ), a web-enabled program with scientifically validated assessment tools: the Addiction Severity Index-Multimedia Version (ASI-MV) for adults and the Comprehensive Health Assessment for Teens (CHAT) for adolescents. Villapiano's e-mail address is avillapiano@inflexxion.com . References Quanbeck A. Managing your way to better addiction treatment outcomes. Behavioral Healthcare 2009; 29 (9): 34-5. Knopf A. New phase of NIATx campaign to focus only on bottom line movers. Alcoholism and Drug Abuse Weekly 2009; 21 (34). Schulden T. Increasing retention using motivational incentives. Presented at Research Utilization Committee Dissemination Workshop, National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) Steering Committee meeting, Bethesda, Md., Oct, 20, 2009. Available online at http://ctndisseminationlibrary.org/display/403.htm . The 2009 Behavioral Healthcare IT vendor survey. Behavioral Healthcare 2009; 29 (8): 12-4. Addiction Professional 2010 July-August;8(4):34-36
An advocate finds her place
More than 35 years ago, Laura Elliott-Engel could have benefited from the very same services she has dedicated her career to in the state of New York. With little direction in life, Elliott-Engel-who is now one of the state's leading recovery advocates-found herself bouncing from college to college, her grades reflecting those of an honors student or a dropout, depending on the state of her disease. “My college transcripts are a roadmap into my addiction,” she says. “I went to about four undergraduate schools in 10 years.” Eventually, Elliott-Engel gave up on school and entered the working world, taking on an administrative role at a small business where she was able to “really use my inherent people skills.” But this change of pace did little to help her gain a sense of self, and her addiction ultimately rendered her unemployable. Two years later, in 1975, Elliott-Engel entered treatment. After spending seven weeks at an inpatient facility, she moved into her parents' home, ready to get back to work. “I worked very hard at my recovery,” she says. “But I needed to establish to myself that I had some kind of competence.” Passion discovered While beginning her studies again-this time majoring in social work-Elliott-Engel also began substitute teaching at a local nonprofit agency focused on troubled youth. “Out of that, I really gained some sense of direction,” she says. “I learned what I was interested in, what I was good at.” After completing her bachelor's degree in social work, Elliott-Engel was recruited by a small treatment clinic not far from her home in rural, upstate New York. Having just received a first-time grant, the clinic was looking for a counselor who would work with chemically dependent women in rural, isolated communities. “Part of the reason why I was interested and why they thought I might be a good candidate was my own recovery,” says Elliott-Engel, who had been in recovery for five years by that time. “I think walking the walk and then working with others can complement each other.” Excited to be “part of something that had never been done before,” Elliott-Engel committed herself to her new position. As a counselor, she helped women not only to realize their own potential for recovery, but also to “come out of their homes” and get involved in their communities. Eventually, she worked her way up at the clinic, earning a master's degree in pastoral counseling along the way. She finally had found her passion, but difficult transitions would send Elliott-Engel down a familiar, but more challenging path. A spiritual transition In 2002, Elliott-Engel experienced what she calls “some significant life changes.” After 18 years of marriage, she and her husband divorced, and her two children were ready to head off to college. But rather than “revert to an old way of responding” to such emotional triggers, Elliott-Engel sought out a different kind of satisfaction: She applied to the vacant executive director position at the Council on Addiction Recovery Services, Inc. (CAReS) in Cattaraugus County, N.Y. As the sole provider of chemical dependency treatment in a county of 87,000 residents, CAReS offers the full continuum of care as well as prevention, education and housing assistance services. Elliott-Engel was drawn to CAReS' residential treatment offerings-a level of care that her previous employer did not offer-as well as its focus on keeping families together by treating women and their children in a home purchased especially for this purpose. “In a way, this seemed almost spiritual,” she says. “I had come into the field working to find and help women, and here was this place where they made it a commitment to actively recruit and then work with women with their children.” After accepting the executive director position at CAReS, Elliott-Engel took an even bigger step in her career by transitioning from a countywide provider of addiction services to a statewide advocate for recovery. Two years ago, she helped to found Friends of Recovery-New York (FOR-NY), a representative, grassroots coalition that promotes policies and practices in support of recovery. She is currently the president of FOR-NY's board of directors, representing rural, upstate New York. “Sometimes upstate New York gets left out of the conversation in other forums,” Elliott-Engel says. “But our board is representational of the width, breadth and length of a very large state.” By partnering with other advocacy groups such as Faces and Voices of Recovery and the National Council on Alcoholism and Drug Dependence (NCADD), as well as the state substance abuse agency, FOR-NY is working to break down stigma and give recovering individuals a place at the public policy table. Its first rally in February, held in Albany, attracted 300 attendees. “Going from 15 or 20 of us screaming about this a couple of years ago to 300 people walking the halls of the Capitol and making appointments with legislators was pretty doggone cool,” Elliott-Engel says. Addiction Professional 2010 July-August;8(4):64
Caring for self while caring for others
You can only go halfway into the darkest forest; then you're coming out the other side . - Chinese proverb Caring for others is hard work. Being exposed to others' trauma opens us to our pain. It is important for caregivers to be good stewards of themselves. The Webster's II New Riverside University Dictionary defines stewardship as “the careful and responsible management of something entrusted to one's care.” As counselors, we're entrusted with people's stories and, at times, their lives. This is an incredible honor and a tremendous responsibility. In counseling, we create space for and honor clients' hardship and pain. To be a good steward of this privilege is to remember the sacredness of this relationship, to maintain the highest ethical practices, to act with integrity, and to honor our responsibility. Stewardship of our relationship with clients is not just a good idea you hear about at a conference. It is a daily practice, tending to others' and our pain, suffering and trauma experiences. It entails learning to stay present in our counseling, no matter how difficult the stories we hear might be. It means slowing down what we hear from clients in order to be curious about what is happening within ourselves. It is paying attention on purpose, in the present moment. Counseling involves listening non-judgmentally, suspending our assumptions and biases, and simply being present to another. To be an effective counselor, we need to pay attention to our intention. It doesn't mean putting on a happy face. Instead, we need to embrace the paradox that if you are to be effective as a counselor and experience joy in what you do, you can't afford to close yourself off to the experience of pain. There are many barriers in our daily lives that get in the way of this attentiveness. Some barriers are personal, some societal, and others institutional. Ever say to yourself, “When my boss leaves, I'll feel much better,” or “When we get more funding, things will run more smoothly,” or “If I can attend this conference, I'll learn how to be a better counselor.” One of the most profound influences on our personal stewardship is who we are as individuals-our own history of pain and suffering. Yes, some organizations foster pain when they ration services, operate bureaucratically and focus primarily on the bottom line. Societal forces influence our self-care; these include systematic oppression, racism, ageism, sexism, ethnocentrism, elitism, or heterosexism. Some organizational or societal issues can and should be addressed to seek change; others require regular recitation of the Serenity Prayer, accepting that which we cannot change. ‘I'm OK, but I worry about her’ Most of us do not realize how really tired and burned out we are until we hit the wall, becoming apathetic to clients. But what does the wall look like before we hit it? For some, the elaborate structure we build around our hearts resembles a fortress. We build a moat, we add sharks in the water, we create new weapons to defend ourselves from the pain of clients, and we build higher and stronger defense walls. When we finally hit the wall, we find ourselves locked inside a protective fortress of indifference and apathy (“Who cares? What can I do to change this? I've got to get a better job”). What we did to survive destroys us. The key is rather paradoxical: We need to dismantle the walls, melt down the weapons of our heart and open ourselves to the pain of others. Does any of this sound like something you at times experience? Here are 13 signs of trauma exposure. “I so often feel helpless and hopeless. Why am I getting out of bed today? Why am I bothering to go to work, other than because I need the money?” “I can never do enough.” This leads to a sense of internalized inadequacy. “When I get to work, I feel I have to be hyper-vigilant and attend to everything.” “I don't have any original thoughts anymore. I'm bored with what I'm doing. I can't remember the last time I felt creative.” “The first word out of my mouth lately is ‘no.’ I love the Mom I am treating but I hate the Dad. I always knew the new effort would be a disaster.” “I came home last night and thought, as my daughter told me about her hard day at school, ‘You think you've got problems. You should hear the stories of the kids I saw today.’ I wanted to say to a client, ‘You should be grateful for what you have, in comparison with other patients here.’” Nothing ever seems to engage your empathy. “I can't remember a time when I wasn't tired. My body seems to be keeping score. Been there, done that.” “I want to just turn off the phone and not talk to anyone when I go home-and many times during the day. I pray it will snow today and the agency will be closed (and I live in Miami!). My favorite day of the week is when I don't have to go to work.” “I deserve better pay, a safer work environment, more respect from my boss, and greater resources.” This is a sense of persecution, of “them vs. us.” “I feel guilty because I can leave at the end of the day and go to a safe home.” “I'm not an angry person. Everything is fine at work.” And then the conversation over the water cooler becomes cynical and angry about “them” (whoever the “them” may be). “I feel emotionally asleep. I can't empathize anymore. I feel numb to pain. I don't have any ‘oh my’ moments anymore. My children say I don't play with them anymore. I don't laugh or sing now.” “Who else will do it if I'm not here? I cannot leave; they rely on me.” Creating change If this sounds familiar, here are ways to navigate to a sense of openness and wholeheartedness. The theologian Brother David Stendl-Rast said the antidote for pain is not just rest but wholeheartedness. Here are some questions to ask yourself. Do you find any consistent patterns or themes in how you look at clients? Is what you are doing working for you? Does it edify you and bring joy? The keys to self-care are to develop a sense of personal control, to pursue personally meaningful work, to make healthy lifestyle choices, and to have a solid system of social support. The following are steps to caring for yourself: Come into the present moment. Buddhist nun Pema Chodron says we ought not to get caught up in hopes that we will achieve anything in the future. What we do right now is all that matters. Mae West said, “When in doubt, take a bath.” Buddhist teacher Thich Nhat Hanh calls this to have a spirit of aimlessness. That's contrary to Western culture that tells us to “do, do, do.” “Doing” is only effective when we begin with a stillness within ourselves that comes from being in the present moment. When we are in this precious, present moment, we are able to stop the pattern and return to an awareness of what matters most. Find your passion. Plain and simple, passion is a commitment without conditions. It is directing ourselves to greatness, obeying our priorities and following what calls us. Persian poet and philosopher Rumi wrote, “Let yourself be silently drawn by the pull of what you truly love.” What's in your heart and how do you approach work? Make peace in the space of your own heart before you attempt to do so with others. Ask yourself, “Why am I doing what I'm doing?” Is this working for you? Find a calling that serves you while you serve others. Once you have a “why” you can handle almost any “how.” Consult with someone else about why you're doing what you're doing. Get their feedback about your “why.” Ask yourself, “Where can I best focus my energy today? Why am I focusing on that?” Find a mirror and stand in front of it. Notice three things about yourself. Are they positive, loving and kind things? If not, try again. Focus on the beauty you see. Find a Plan B. What else would you do if you couldn't do what you're currently doing? Your Plan B might be a career change, a new place to live, a new approach to work, or a totally new life. Ask yourself, “If I weren't doing this, what would I love to do?” Build community. What is your personal support system? With whom do you need to reconnect? What would your ancestors and those who raised you have done to heal themselves and others? When they experienced trauma, how did they go on? Practice self-compassion, which is rooted in humility, vulnerability and a sense of interdependence. The Dalai Lama reminds us to practice internal disarmament by being more compassionate to ourselves. You can't take a person to a place you haven't been. Think of someone from your life who showed you compassion. Hold that person in your thoughts while you allow yourself to remember what it felt like to be with that person. Change what you can change. Ask yourself, “What can I do to change the system in which I work?” Find three ways in which you can progress toward positive change at work. Avoid any situations that will leave you feeling bitter or isolated. Offer a shoulder to someone at work who needs a helping hand, even if it's your boss. Find balance in your life. Surround yourself with people who are wholesome, healthy and positive. Make an appointment with sleep. Remember, humor has the ability to help us change perspective quickly. Weave gratitude into your daily life. Justice and unfairness will not disappear overnight. Instead, bring light and wellness with you to work. And when you put your head on the pillow tonight, say, “It was a good day. I did what I could do.” Practice joy! In conclusion, when you go to work, don't ask what the world needs. Ask what brings you alive. Then do that. The addiction field needs people who have come alive. David J. Powell, PhD, is President of the International Center for Health Concerns, Inc. ( http://www.ichc-us.org ). The author expresses his appreciation to Laura van Dernoot Lipsky for her book Trauma Stewardship (Berrett-Joehler Publishers, 2009). His e-mail address is djpowell2@yahoo.com . Addiction Professional 2010 July-August;8(4):37-39
DBT meets the 12 Steps
Dialectical Behavior Therapy (DBT), founded by Marsha Linehan, PhD, was initially developed for women diagnosed with borderline personality disorder. Recently, there have been numerous research articles describing the effectiveness of utilizing DBT in substance abuse treatment. 1,2 In light of this research, many addiction treatment centers have begun implementing DBT programming. Addiction literature also demonstrates the utility of 12-Step programming in supporting recovery, and the 12-Step approach is commonly integrated into addiction treatment programs. 3,4 The Center for Dependency, Addiction and Rehabilitation (CeDAR) at the University of Colorado Hospital has successfully developed programming that integrates DBT and 12-Step philosophy. In DBT, the focus is on creating a dialectical lifestyle that reflects balanced behavioral patterns such as balanced actions, balanced emotions and balanced cognition. Similarly, working the 12 Steps results in creating a balanced lifestyle. Alcoholics Anonymous (AA) offers “the promises of the steps” and Narcotics Anonymous (NA) gives the promise of “freedom from active addiction.” Both of these gifts of working the steps complement DBT's focus. The four stages of DBT move from addressing severe behavioral dyscontrol to creating the capacity for joy and freedom. In addition to describing four stages of treatment, DBT literature also identifies specific targets that must be addressed in the therapeutic process. The targets of DBT can be found throughout 12-Step literature and are an integral part of step work. The table on the following page outlines the similarities between DBT targets and 12-Step philosophy. In 2007, CeDAR committed to providing DBT services to both primary care and extended care patients. In primary care, mindfulness and distress tolerance modules are taught and practiced in DBT skills groups. The extended care program reinforces continued practice of mindfulness and distress tolerance skills, and introduces the “interpersonal effectiveness” module. Primary care groups are gender-specific and are held once a week. Extended care patients participate in mixed-gender skills groups twice a week. Mindfulness Mindfulness is the foundation of DBT practice. It has been described as “moment to moment, nonjudgmental awareness, cultivated by paying attention.” 7 Linehan describes the “States of Mind”: reasonable mind, emotional mind and wise mind. 8 Mindfulness practice supports patients in centering themselves in the wise mind state. One characteristic of an addict is extreme thinking. The addict is able to achieve a balanced state by using mindfulness practice to move from extreme thinking to wise mind. Wise mind is the middle ground; recovery involves finding that middle ground and staying balanced. At CeDAR, mindfulness and the states of mind are emphasized to reinforce the importance of taming the mind and finding the balanced path. 12-Step literature also provides examples of the three States of Mind. The AA Big Book describes emotional mind on page 36: “Suddenly the thought crossed my mind that if I were to put an ounce of whiskey in my milk it couldn't hurt me on a full stomach. I ordered a whiskey and poured it into the milk. I vaguely sensed I was not being any too smart, but felt reassured as I was taking the whiskey on a full stomach. The experiment went so well that I ordered another whiskey and poured it into more milk. That didn't seem to bother me so I tried another.” 6 This reading illustrates how emotional mind can be a “trickster” and will create the illusion of being reasonable. This concept is extremely important in recovery, as it emphasizes how an individual cannot rely on his/her own thinking and willpower for the answers. The NA Basic Text describes meditation as being an important part of building successful recovery. Mindfulness meditation allows for quieting the mind and focusing energy and strength. This type of meditation targets the mental component of addiction, which is obsession of the mind: “Quieting the mind through meditation brings an inner peace that brings us into contact with the God within us… A basic premise of meditation is that it is difficult, if not impossible, to obtain conscious contact unless our mind is still.” 9 The core concepts taught in the mindfulness module are to quiet the mind and to begin trusting one's own perceptions, judgments and decisions. By being judgmental, the addict reinforces negative behaviors. Perceptions and viewpoints change in order to feed the addiction and allow it to play a primary role in the person's life. The skill of “acting non-judgmentally” (from the “how” skills) emphasizes “principles over personalities” and strengthens the concept of open-mindedness: “A new idea cannot be grafted onto a closed mind. Being open-minded allows us to hear something that might save our lives… Open-mindedness leads us to the very insights that have eluded us during our lives…we no longer need to make fools of ourselves by standing up for non-existent virtues. We have learned that it is okay to not know all the answers, for then we are teachable and can learn to live our new life successfully.” 9 Distress tolerance The DBT distress tolerance module includes five groups of skills that teach individuals how to tolerate uncomfortable situations and decrease intense emotional reactions. Prior to recovery, the addict medicates, numbs and avoids experiencing unwanted emotions. In early recovery, the intensity of new emotions may be overwhelming. Practicing distress tolerance provides the individual with skills to get through difficult times. The five groups of skills taught in the distress tolerance module can also be identified in 12-Step literature. For example, the skill of contributing has to do with helping others in order to help oneself. On page 115 of the AA Big Book, Bill describes how going to his old hospital and talking to another alcoholic would move him from self-pity, resentment and despair and would “save the day.” Service work is a vital element in any 12-Step fellowship. Accepting reality is the last of the five skills groups within the distress tolerance module. “Radical acceptance,” “turning the mind” and “willingness vs. willfulness” are the focus of this skills group. The concept of “radical acceptance” has to do with ceasing to fight reality and being tolerant of whatever the situation brings. A central concept of radical acceptance is that pain creates suffering only when we refuse to accept the pain. One 12-Step slogan related to this concept is “pain is inevitable, misery is optional.” The AA Big Book devotes an entire chapter to the concept of acceptance. The Serenity Prayer, said in thousands of 12-Step gatherings, reminds those in the fellowship of the importance of accepting what is and “letting go.” Radical acceptance and the 12-Step concept of surrender are imperative for those moving toward successful recovery. Without either, internal unmanageability and the inability to “let go” will continue to be roadblocks in the process of recovery. Step One emphasizes the essential need for surrender. Individuals must surrender in order to move successfully through the remaining steps. CeDAR has found that providing DBT skills groups complements other aspects of the program. Staff continuously witnesses the benefits of integrating DBT skills into 12-Step programming. By putting these ideas into practice, the foundation of recovery is reinforced and patients begin moving toward a life worth living. More Online For another perspective on DBT's usefulness in addiction treatment, visit http://www.addictionpro.com/roes1108 . Bari K. Platter, MS, RN, CNS, is a Clinical Nurse Specialist/Educator at the Center for Dependency, Addiction and Rehabilitation (CeDAR) at the University of Colorado Hospital. She is a Dialectical Behavior Therapy (DBT) trainer and a certified Crucial Conversations trainer, and has a certificate in transcultural nursing. Her e-mail address is Bari.Platter@uch.edu . Osvaldo “Ozzie” Cabral, MA, CAC III, is CeDAR's Clinical Coordinator for the Residential Extended Care Program. He has worked as a primary therapist for the past eight years in residential, intensive outpatient and DUI/substance abuse programs. “DBT meets the 12 Steps” is a copyrighted title by the University of Colorado Hospital. References Kienast T, Foerster J. Psychotherapy of personality disorders and concomitant substance dependence. Curr Opin Psychiatry 2008 Nov; 21:619-24. Linehan MM, Schmidt H, Dimeff LA ,et al. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. Am J Addict 1999 Fall; 8:279-92. Galanter M. Spirituality and recovery in 12-Step programs: an empirical model. J Subst Abuse Treat 2007; 33:265-72. Piderman KM, Schneekloth TD, Pankratz VS ,et al. Spirituality in alcoholics during treatment. Am J Addict 2007 May-Jun; 16:232-7. Narcotics Anonymous World Services, Inc. The Narcotics Anonymous Step Working Guides. Van Nuys, Calif.:Narcotics Anonymous World Services; 1998. Alcoholics Anonymous World Services, Inc. Alcoholics Anonymous, Fourth Edition. New York City:Alcoholics Anonymous World Services; 2001. Kabat-Zinn J. Arriving at Your Own Door: 108 Lessons in Mindfulness. New York City:Hyperion Books; 2007. Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York City:The Guilford Press; 1993. Narcotics Anonymous World Services, Inc. Narcotics Anonymous, Sixth Edition. Van Nuys, Calif.:Narcotics Anonymous World Services; 2008. Addiction Professional 2010 July-August;8(4):20-24
Doing whatever it takes
Any routine Internet search for behavioral health issues in military veterans turns up scores of discussions and initiatives taking place at the local, state and national levels. While some observers still argue that service coordination and integrated care for complex diagnoses remain elusive, the treatment community clearly is not lacking for enthusiasm in serving this population. Helping returning veterans reintegrate into their communities no longer is seen as the military's problem. Whether because of benefit disputes, a reluctance to access services through the Department of Veterans Affairs (VA), or years of waiting before pursuing addiction and mental health treatment, more individuals with combat histories are walking through the doors of treatment centers at the community level. “For some members of the military, they feel that the Department of Defense got them into this situation and it's hard for them to trust going back to the base for help,” says Larry Harrison, a therapist and Army veteran who works at the community behavioral health organization Centerstone's Frank Luton Center in Nashville, Tenn. Centerstone is part of a growing legion of treatment organizations that have recently established initiatives specifically tailored to the health concerns of veterans. It is partnering with Not Alone ( http://www.NotAlone.com ), an organization supporting veterans dealing with post-traumatic stress disorder (PTSD) and related issues, to offer online support and other services. As part of its overall effort, Centerstone is involved in establishing a network of service providers who identify with veterans' needs by virtue of their own military service or experience with it in their families. “The highest levels of the VA want to work with their community partners,” says Bob Williams, PhD, CEO of Centerstone of Indiana. “The generals want more networks of resources. There are still some barriers and territoriality at the ‘boots on the ground’ level,” he says, where stigma associated with substance use or PTSD still can be prevalent. Clearly this is an issue that is being watched at the highest levels of the military. The director of the Defense Department's leading center for PTSD and TBI recently resigned from the post amid ongoing criticism that the military remains inefficient in detecting conditions that are believed to affect as many as one-third of returning troops. At the community treatment level, lingering frustrations are apparent as well. More than 90 percent of respondents to a June poll on the Addiction Professional Web site said their communities had not yet established enough programs to meet the needs of returning veterans, with some citing a lack of PTSD treatment and a shortage of residential services among the deficiencies. Trauma programming At Twelve Oaks Alcohol and Drug Treatment Center, a CRC Health Group residential treatment facility in Navarre, Fla., the staff has established a PTSD track that serves both members of the military and other individuals with a trauma history. The ASPIRE (Addicted Survivors of PTSD Integrated Recovery Experience) track is designed to meet the needs of individuals who have battled substance abuse and traumatic experiences. The architect of the track, clinician B. Diane Vchulek, explains that it is based on the notion that treating co-occurring substance use problems and PTSD must occur in a comprehensive fashion in which both disorders are treated simultaneously. Much of the work in the track takes place in psychodynamic groups where participants do more sharing than routine talking. “They support and confront one another,” says Twelve Oaks executive director Bob Lehmann. There also is a great deal of individual work in the program, including journaling. The program employs therapeutic strategies ranging from cognitive-behavioral therapy (CBT) to art therapy-essentially, anything that will get patients to open up. Twelve Oaks uses a VA-sanctioned post-traumatic stress checklist to evaluate patients' functioning on a number of dimensions, and Lehmann says the program is seeing patients reduce their scores to non-dysfunctional levels in several of the measured areas. Lehmann adds that one difference he is seeing in today's military is a higher level of concern among military leaders about their personnel's welfare over the long term. “The cooperation from the military has been incredible,” he says. Tackling TBI Treatment programs' can-do spirit in meeting the needs of returning veterans gets challenged in cases where cognitive impairment due to a traumatic brain injury (TBI) is present in the client. “A lot of places don't want a person with a cognitive disability,” says Duane Reynolds, a director at Vinland National Center in Loretto, Minn., one of few treatment facilities in the country that specializes in the treatment of brain-injured patients. “People say, ‘With a brain injury, how can you expect them to learn anything?’ I say, ‘Well, they learned to drink.’” The typical veteran who might be seen in Vinland's program has a primary alcohol problem that likely started as self-medication. “They feel better when they're intoxicated,” Reynolds says. Oftentimes the person has received medical care in the past, but substance use issues have not been addressed or have been underemphasized. “Then maybe 18 months later it rears its ugly head again,” he says. Many of these clients will be in treatment at Vinland for about 45 days, with their services covered either through state funding or veterans benefits. Clinical services for these individuals must employ a slower, more repetitive approach, but Reynolds says success is possible, and the veterans seem to fare better in settings where others have similar problems. In a more traditional treatment setting, a cognitively impaired person might be identified as somehow holding back the rest of the group, Reynolds says. The program's spacious lakeside setting offers great potential for outdoor activities as part of the therapeutic process. The focus of the therapy is to get the client as many types of services as they're eligible for, Reynolds explains. Motivational Interviewing, mindfulness therapies and 12-Step therapies all can be part of the mix, depending on the client. “You don't know what's going to resonate with the client,” he says. Building resilience serves as an important theme of treatment, with the program emphasizing impulse control through a “stop, think, act” strategy, Reynolds says. Some individual therapy is critical for this cognitively impaired group, he believes. “In a group there is so much chatter that they can lose focus,” he says. Soldiers helping soldiers At many of the facilities that have defined a specialization in treating veterans with complex diagnoses, there is a presence of high-level officials in the organization who have a direct military background. At Twelve Oaks, for example, the medical director is a Vietnam combat infantry veteran who received a Purple Heart and a Combat Infantry Badge. A division of the Outreach Project treatment organization in the New York metropolitan area ( http://www.opiny.org ) is trying to do its part toward developing a treatment workforce with a firsthand appreciation of what the soldier experiences. The Outreach Training Institute is offering veterans its 350-hour, 11-month course that makes them eligible for Credentialed Alcoholism and Substance Abuse Counselor (CASAC) training in the state. Honorably discharged veterans within the past nine years are eligible for full scholarships for the training. “If we can train veterans who are not presently suffering, they would be the most appropriate people to treat other veterans,” says David Greenberg, who is leading the Outreach Project's training program. Honorably discharged veterans within the past nine years are eligible for full scholarships for the training. So far, nine veterans have been admitted into the training programs and two have already graduated. Greenberg says the organization plans to step up its marketing of the program's availability to veterans. “We're trying to head off a problem that we know we're going to get,” says Greenberg, referring to communities meeting the complex needs of returning veterans. “It is no mystery that as a country we will have to take care of these people.” Addiction Professional 2010 July-August;8(4):16-19
Feeling spry at 75
Alcoholics Anonymous (AA) turned 75 this year, and in many respects it appears as vibrant and relevant as ever. Certainly its latest International Convention, an event held every five years, hardly sounded like a gathering of a stagnant fellowship. More than 75 countries were represented at the July 1-4 event in San Antonio, with proceedings held in languages ranging from French to Korean to Farsi. Al-Anon Family Groups and Alateen also sponsored activities, and for AA members with more than 40 years of sober living an Old-Timers Meeting took place. Certainly, the spirit of that very first meeting of two men in 1935 is never far removed from the thinking of the organization, even now that it claims an estimated two million-plus members worldwide. As someone who has covered developments in the addiction treatment field for more than 15 years, I am consistently struck by the commitment of AA's true believers to the widespread impact that the message of the 12 Steps continues to have. The late Father Joseph Martin summarized this in a way only he could, when he told me in an interview for our November 2008 cover story that “unlike everything else, the 12 Steps are so complete. These 12 principles cover every phase of the disease and what it does to us.” And many of those who speak most enthusiastically about AA and its associated organizations today, including several CEOs of the nation's most influential treatment centers, embrace the 12 Steps not to exclude other approaches, but to maintain a solid foundation in their organizations as they broaden their vision to incorporate co-occurring disorders, holistic health approaches and, yes, even medication treatments. Perhaps AA and the 12 Steps still seem fresh because many of their proponents “get” that they are-and should be-subject to the same scrutiny as other approaches in this new world of evidence-based treatment. AA's milestone this year reminds me of the article we published just over a year ago (May/June 2009) by Valerie Slaymaker, PhD, executive director of Hazelden's Butler Center for Research, which is helping to build that evidence base. In the article Slaymaker cited the launch of a comprehensive study to enhance Hazelden's understanding of the mechanisms of spiritual change on which its treatment programs are based. She stated in reference to the subject matter the study will examine, “Only by understanding changes in self-centeredness, selfishness, resentment and the development of a desire or longing for closeness with a higher power, and their direct relationship with recovery, will we understand how best to facilitate this process among those who struggle.” Hazelden hopes to be able to pinpoint the stages at which change occurs and for whom, knowledge that would allow it to identify the characteristics of patients who are likely to struggle and thus to be able to tailor treatment earlier on. Of course, for many there always will be aspects to AA that defy documentation in a research paper. Just ask Mel Schulstad, the co-founder and past president of NAADAC, who says he is celebrating 45 years in AA “by the grace of a loving God.” The fellowship has not lost its magic for Schulstad, who recently told me, “AA was first formed in 1935, the year I graduated from high school. So they knew I was coming.”   Gary A. Enos, Editor Addiction Professional 2010 July-August;8(4):6
Letters
Treatment center will explore resiliency I want to compliment Bruce Campbell for an excellent article in the March/April 2010 issue. I will be sharing it with all my staff and will make a discussion of resiliency dynamics a part of one of our in-services. I hope this information can be part of a larger discussion of the dynamics of recovery. Franklin Lisnow, MEd, MAC Executive director Center for Dependency , Addiction and Rehabilitation (CeDAR) Aurora, Colo . Challenging road for recovering counselors I enjoyed Brian Duffy's article on disclosing a counselor's recovery status, in the March/April 2010 issue. Being a past addictions counselor for 30 years and sober in AA for 35 years, I always envied non-recovering counselors because they didn't have to be concerned about relapse and were more objective about addiction recovery than recovering counselors were. Keep up the good work. Ed McDonnell, MS, LCADC, CCS, CSW Faculty member Rutgers Summer School of Alcohol and Drug Studies I enjoyed Brian Duffy's article on counselor self-disclosure. I thought it gave good guidance on how to approach the subject. I'm happy to know that I've been following most of the advice the article gave, but it also helped me to be more conscious of what I am saying and why I am saying it. I've had experiences where disclosure was made and the clients reported being more hopeful. I believe that they figure that since you're being successful in recovery, maybe this can really work for them. Also, if you're not in recovery you don't have to explain to a client if they happen to see you outside of treatment somewhere drinking. Of course, each case has its own particulars and must be evaluated carefully. I thank you for the very valuable reminder. Hakim Rushdan Washington, D.C . Reducing suicide risk among law enforcers The article “Assess routinely for suicide risk” (November/December 2009 issue) caught my attention. It reminded me that some of the people most affected by violence are those who protect us. In 2008 I worked with a retired, formerly addicted police officer, Sean Riley, at an inpatient facility in the Seattle area. He and I supervised patient care at the time. I learned that in 2005 Riley turned himself in to authorities and had since been struggling with the problems associated with having worked as a public safety officer while using. He and his family were to lose a pension, medical insurance, and of course his job. That year, another police officer had solved his drinking problem with a .45 when he could not face what was happening to him and his family. Suicides such as this have been happening for years. In 2009, 48 law enforcement officers were killed in the line of duty by firearms. In that same year more than 150 officers committed suicide. The police suicide rate per 100,000 individuals is double that of the general public. Alcohol is present in 85% of those suicides. Addiction rates among first responders are estimated to be upwards of 25%. Considering the rate of injuries and stress experienced in this line of work it is not all that difficult to believe. The suicide of a fellow officer and friend affected Riley in a major way. With two years of sobriety under his belt he began asking questions and at one point spoke with the federal judge who had ruled on his case. Due to his unrelenting efforts he found himself standing in front of U.S. Rep. Dave Reichert (former King County sheriff and the man responsible for apprehension of the “Green River Killer”) and Washington Lt. Gov. Brad Owen. They came up with a solution at the state level: Substitute Senate Bill 5131, which would be signed into law in April 2009. The bill relates to crisis referral services “that may have an impact on the personal and professional lives of public safety employees, including mental health issues, chemical dependency, domestic violence, financial problems and other personal crises.” It allows the employment of techniques to recognize the need to seek assistance and obtain referral for consultation and possible treatment. It includes a clause stating that all communications shall be confidential, and specifying the conditions under which information can be released. Since April 2009, 57 public safety officers in the state have completed treatment for chemical dependency and have returned to their jobs with nothing more placed in their file than a statement as to having returned from a medical leave. It is also noteworthy that more than 1,100 employees and family members have received assistance for mental health, financial matters, family dysfunction and other crises. Riley travels the U.S. speaking before police and other groups, and presently is working with Reichert to introduce a similar bill in Congress for federal safety workers. Safety leaders in various states have contacted Riley for assistance in bringing about the same relief to their states. The goal is to treat the underlying problem before it results in behavior that could be considered misconduct and/or self-harm. Any Washington safety officer or family member who believes their life is in crisis can make a “Safe Call Now” and talk confidentially to another safety officer, one who has been trained to take the call. For more information, visit http://www.safecallnow.org . Michael Oborn, CDP Advisory Committee Safe Call Now Seattle Addiction Professional 2010 July-August;8(4):8
Alumni coordinators in treatment centers form a new trade group
How do addiction treatment centers track the progress of their program graduates? Can social media be an effective tool for staying in touch with alumni? Can a treatment program identify in advance the clients most likely to remain involved with the center after they leave? Professionals who coordinate alumni activities for some of the highest-profile treatment centers believe it’s time for the field to get a better grasp on the answers to these questions. To that end they are forming a national trade group that will encourage alumni activities and promote professional collaboration and educational opportunities. The group’s name is Treatment Professionals in Alumni Development (TPAD). “In the past I was surprised to learn that many treatment centers don’t have alumni programs, and that includes some of the big names in the field,” says Lorie Obernauer, alumni coordinator at the Center for Dependency, Addiction and Rehabilitation (CeDAR) at the University of Colorado Hospital. Obernauer sees the presence of an active alumni program as significant to clients’ long-term wellness as well as to the financial health of a treatment organization, as many active alumni will become enthusiastic program supporters. Obernauer launched the effort to establish a group of alumni professionals when in a September/October 2009 Addiction Professional article she urged readers to contact her for this purpose. Many expressed interest, and she says at this point about 50 professionals want to be part of the group. Although the association has not been officially formed, it does have some mission statement language and a logo. Facilities represented among those with professionals interested in joining include the Betty Ford Center, Hazelden, Pine Grove, Hanley Center, Father Martin’s Ashley, Brighton Hospital, Caron Treatment Centers, The Right Step and Sierra Tucson. “I’ve heard from several CEOs who have said, ‘I’d like my alumni coordinator involved in this,’” says Obernauer. She says the group already has listed about two dozen topics that it would like to pursue under the auspices of the association. “Quite a few of us recognize that we need to look at what works” in alumni programming activities, she says. “This is a large part of keeping a center going.” In the coming months, the group will discuss opportunities for regular face-to-face meetings, possibly by scheduling sessions as part of larger national conferences in the treatment field. Obernauer still is encouraging alumni coordinators to join the effort; she can be contacted at (303) 854-4087 or via e-mail at Lorie.Obernauer@uch.edu .
Karlin will step down as chief executive of CRC Health Group
An administrator who admitted he knew nothing about chemical dependency when he acquired his first treatment facility 15 years ago, then just a few years later was running the largest for-profit provider of addiction treatment services, announced this week that he will leave his executive post. Barry W. Karlin, PhD, will stay on as CEO of Cupertino, Calif.-based CRC Health Group until a successor is named, likely by the end of this year. “After devoting 15 years to building CRC, I feel now is the right time for a new CEO to take the reins and bring our company to the next level,” Karlin said in a statement released June 28, referring to his “personal decision” to step down. CRC’s founder will remain as board chair for the organization after departing as CEO. Karlin, an accomplished but restless high-tech entrepreneur in the 1990s, often tells the story of his initial response to a colleague’s telling him at that time that a Northern California chemical dependency facility might be on the market. “I asked him, ‘What kind of chemicals do they manufacture?’” He would purchase the facility (The Camp) in what he thought would be a one-time investment in the field, but what he would learn later about the treatment gap and other challenges facing the field and its clients would fuel a greater commitment, building a company with a national presence and strong venture capital backing. Today CRC owns about 30 residential treatment facilities specializing in substance use treatment, but also has become a leader in the treatment of eating disorders, obesity, chronic pain and learning disabilities. In all, the company operates 150 treatment facilities in 25 states, Canada and the United Kingdom. Barry W. Karlin, PhD While the CRC name has national recognition in addiction treatment, many of the facilities it has acquired over the years have retained their own brand identity locally and nationally as well. These include Sierra Tucson in Arizona, Bayside Marin and Sober Living by the Sea in California, Twelve Oaks Recovery in Florida, Bowling Green Brandywine in Pennsylvania and Passages to Recovery in Utah. Much of CRC’s early growth strategy focused on acquiring facilities that had strong records of clinical success but needed a new business vision and in some cases were facing imminent retirement of longtime leaders. The company was seen as seeking to capture a market somewhere between that of the private-pay facilities that are among the biggest national names in treatment and the centers that depend largely on public funding to treat the lowest-income clients. Karlin could not be reached by Addiction Professional this week to discuss his announcement; a CRC spokesperson said he is on a two-week vacation. Karlin said in the statement released this week, “My confidence in CRC has never been higher, and I believe the company is well-positioned to continue to be a leader and innovator in delivering the best quality care to our patients and students for many years to come.”
Field inches toward a medication treatment for stimulant addiction
The “fast track” is a relative term in the world of medication approvals. The GABA aminotransferase inhibitor known as vigabatrin has held that status with the Food and Drug Administration (FDA) for the treatment of cocaine addiction since February 2006, but more than four years later it remains unclear as to how close an official approval for that indication might be. Still, significant progress in this effort might not be far off. Florida-based Catalyst Pharmaceutical Partners, Inc. is about to embark on a $10 million Phase 2B study that is being financed primarily by the National Institute on Drug Abuse (NIDA) and the Department of Veterans Affairs (VA). Company CEO Patrick McEnany says the 200-patient study will examine the effectiveness of vigabatrin vis-à-vis placebo at a number of outpatient sites that will employ observed dosing of the oral medication three times a week. Vigabatrin is indicated for the adjunctive treatment of treatment-resistant complex partial seizures, and as primary treatment for infantile spasms in West syndrome. McEnany explains that the medication’s effects on GABA and dopamine are thought to block the euphoric effects associated with cocaine exposure. At this month’s annual meeting of the College on Problems of Drug Dependence, company officials presented an overview of the data they have collected from vigabatrin trials conducted to date. “We’ve learned a great deal about use of vigabatrin for addiction and about the proper clinical trial design,” McEnany says. He acknowledges a host of challenges associated with arriving at an effective medication treatment for stimulant addiction, ranging from questions about the mechanisms associated with this addiction to concerns over achieving medication compliance in this population. He reiterates the often-cited point that “big pharma” has steered clear of this patient population in its drug development plans, but he adds with confidence, “I really think that that’ll change.” As have many pharmaceutical executives before him, McEnany emphasizes that his company does not see this medication as a magic bullet for cocaine addiction. It would hope eventually to market the drug as a therapy to be used in conjunction with 12-Step or other treatment. Still, any significant breakthrough in a subset of addiction treatment that has not seen one would be a dramatic event for the field, even if it is one that still may be years away.
Blending schooling with treatment
Receive life-changing treatment or stay on course to graduate? It's not a decision a family should have to make when considering what's best for a daughter dealing with an addiction or an eating disorder. Yet this is the situation in which many families find themselves when considering treatment. With National Association of Anorexia Nervosa and Associated Disorders data showing that age of onset is between 11 and 20 for about 76 percent of individuals with eating disorders, it is clear that schooling is a fact of daily life and a top priority for many of these individuals. The stay at a residential treatment center can last almost as long as an entire semester of school, putting an already struggling young woman behind in her studies and behind her peers. Given that many young women with eating disorders are driven and high achievers, this added perceived “failure” can cause significant stress. This is hardly the foundation for beginning a life of recovery. At Timberline Knolls Residential Treatment Center, a facility for young women outside of Chicago, we have always felt that as much as possible, schooling should be available to-and in fact, incorporated into the treatment plans of-our residents. We combine clinical services, expressive therapies, and education to enhance the continuum of care, always with an eye to treating the whole person. In my experience, which parallels the philosophy at Timberline Knolls, the educational component delivered at Timberline Knolls Academy (TK Academy) on the treatment campus is just as important to a young woman's recovery as the clinical component. The educational programs at TK Academy are designed not just to ensure that young women who come to Timberline Knolls for treatment maintain their education. They're developed so student-residents actually excel in their educational goals while healing themselves. Our plan is to keep a strong focus on healing the whole girl and move forward so neither students nor their parents worry about what they are missing while away from home. While continuing to access academic growth, the girls also participate in a comprehensive, integrated approach that includes primary and group therapy. We work with each student-resident so she is not discharged only to realize she has fallen behind in school, at which point a whole new source of anxiety emerges. School procedures When Timberline Knolls opened as a residential treatment center in 2005, TK Academy operated with teachers who provided educational assistance to its residents. In September 2007, just as a new school year began, TK Academy received approval as an Illinois State Board of Education residential school, following a quarter-based academic calendar and offering a six-week summer school program-all in accordance with the state board's learning standards. Providing five hours a day of instruction, the school's certified teachers, certified teacher's aides and academic coordinator partner with students and home school districts to create individualized education plans aligned with state and national standards, grade-level promotion and the exit criteria required for graduation. By building school spirit among the students, TK Academy also seeks to provide student-residents with a sense of community and pride, both of which are critical in achieving recovery. The students celebrate the community and take pride in being part of something bigger than themselves, and that provides the student-residents with the opportunity to celebrate success with one another. Timberline Knolls also offers school districts and mental health providers consultation and liaison services to assess their clients' needs and help make informed treatment decisions. Social worker Aida Maravillas, who has a long history of working with students at Eisenhower High School in Blue Island, Ill., has seen firsthand the success that comes about when combining clinical and educational support. While Maravillas's students during their time at TK Academy received the necessary one-on-one attention unavailable in their home school, she was also allowed to be part of the clinical treatment and educational routine. She says she received progress updates in a timely manner and was quickly notified when issues arose, so that she would be included in decision-making processes. Discharge planning While achieving academic success at Timberline Knolls is important, it is just as important to ensure that students are able to continue their success once discharged. Prior to a resident's discharge, in many cases 30 to 60 days before, TK Academy staff begins working with the student-resident, the parents and the student-resident's home school to ensure continued academic success. The academic program at TK Academy is embedded in residents' overall treatment and recovery plan. Each resident receives an individualized academic program, just as each received an individualized treatment plan. Because each student is different, we assess and then develop a specific plan for each, considering the individual's current level of achievement and ability to learn, as well as the requirements of her home school district. As TK Academy offers residents an opportunity to achieve recovery, it also helps them cope in the world around them. By making TK Academy part of the overall solution for each resident, Timberline Knolls offers the needed real-world environment that gives residents a true sense of familiarity and normalcy, says Timberline Knolls medical director Kimberly Dennis, MD. Dennis and her clinical staff tailor for each individual the programs that immediately create a dynamic, therapeutic and structured community where students learn, achieve and even take responsibility. At Timberline Knolls, the school environment is necessary for our adolescent residents. By focusing on a program of education, treatment and supervision in a healthy environment, our medical team believes residents have a greater chance of leading successful lives of recovery. Carrie Finazzo is the Principal for TK Academy at Timberline Knolls Residential Treatment Center, located on 43 acres outside Chicago and offering a nurturing environment of recovery for women ages 12 and older struggling to overcome eating disorders, substance abuse, mood disorders and co-occurring disorders. Her e-mail address is CFinazzo@timberlineknolls.com . Addiction Professional 2010 May-June;8(3):32-33
Dependence vs. abuse: more than semantics
Carlton K. Erickson, PhD, ac-knowledges that today's conference attendees in the addiction professional community respond more positively to neurobiological clues about addiction than they did a generation ago, when his lectures tended to provoke arguments. Still, he wonders whether clinicians who today will nod their heads when presented with scientific data are effectively applying that knowledge in their everyday work with patients. “Most catch on quickly now, but whether they actually practice it, I don't know, because no one has measured this,” says Erickson, director of the Addiction Science Research and Education Center at the University of Texas College of Pharmacy. Erickson will devote his keynote address at this September's inaugural National Conference on Addiction Disorders (NCAD) to a discussion of neurobiological factors that can inform excellent treatment. Part of the talk will focus on the clinical criteria for a diagnosis of substance dependence vs. a diagnosis of substance abuse, as Erickson believes this important distinction must continue to be reinforced in the field. “It's extremely important to talk about this difference, because one's a brain disease and one is not,” Erickson says. “We know that the good centers are assessing for this difference and are generally admitting people who are dependent. They want their treatment to focus on the people who are the most ill-they feel that's the best use of their limited resources.” NCAD, to be held Sept. 8-11 in Washington, D.C., is being produced by Vendome Group, publisher of Addiction Professional , as an event combining treatment, administration, design, technology and other information for the addiction treatment community. Vendome has founded the event in conjunction with NAADAC, the Association for Addiction Professionals and the National Association of Addiction Treatment Providers (NAATP). NAADAC's annual meeting now will be held under the NCAD title going forward. Also participating as an organizer of this year's conference is the International Coalition for Addiction Studies Education (INCASE). Targeted audiences for the conference include counselors, physicians, nurses and addiction treatment program executives. Erickson concerned Erickson believes many treatment programs might be treating a large number of individuals who do not meet clinical criteria for the disease of addiction (i.e., for dependence). “All they see is this general sense that a person has a drug problem, and all they want to do is help,” he says. Erickson thinks others might actually target non-dependent individuals. He believes, for instance, that treatment centers that emphasize to potential clients their spa-like services have to be treating a non-addicted population if they are showing much success. “You can't change a brain disease with better food and more relaxation,” he says. He is particularly troubled by the removal of the specific distinction between dependence and abuse in the draft of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. The draft's combining of the DSM-IV categories of substance dependence and substance abuse into a “substance use disorder” category is being seen by some as easing insurance requirements for providers, but Erickson thinks it will complicate the case for convincing the public that addiction is a disease. “I happen to think this is a horribly egregious mistake,” Erickson says of the proposed change. “The public won't understand that you don't treat every person the same.” During his NCAD address, Erickson will convey his enthusiasm for neurobiological research during what he considers an exciting time for the addiction profession. He sees important developments on the horizon, from genetic validations for the disease of addiction to the development of a generation of more effective medications. While Erickson sees the time gap between addiction research discoveries and their application in practice as shortening, he still believes there are deficiencies in this regard. And he lays at least part of the responsibility on a research community that has not fully appreciated how the end user of services can benefit from its discoveries. “I think that in cancer research, when researchers are looking for a particular gene, they already will have a vision of what this will mean for treatment,” Erickson says. “In the alcohol and drug area, a scientist may never have talked to a person with a drug problem.” He adds that many of these scientists possibly are motivated more by intellectual curiosity alone than about what the discoveries will actually accomplish for the person with a substance use problem. “A lot still believe that this problem is a willpower problem,” Erickson says. Erickson has authored and edited several books, including the acclaimed 2007 title The Science of Addiction: From Neurobiology to Treatment , and was a regular contributor of commentaries in Addiction Professional . He is an associate editor of the journal Alcoholism: Clinical and Experimental Research . Other presenters As this issue of Addiction Professional was going to press, another confirmed keynote speaker for the NCAD meeting was David E. Smith, MD, FASAM, a leading national figure in addiction treatment since his founding of the Haight Ashbury Free Clinics in the 1960s. Smith is medical director of Center Point in San Rafael, Calif., as well as chair of adolescent addiction treatment at Newport Academy in Newport Beach, Calif. Also at NCAD, a Sept. 7 pre-conference workshop will explore the use of motivational enhancement approaches to assist clients in the process of change. The session will run from 8:30 a.m. to 3 p.m. and will be led by Carlo C. DiClemente, PhD, psychology professor at the University of Maryland-Baltimore County and co-developer of the Transtheoretical Model of Change. For more information about the NCAD conference, which will offer attendees opportunities for up to 30 continuing education units, visit http://www.ncad10.com . Addiction Professional 2010 May-June;8(3):30-31
Researcher whose work defines addiction as lifespan illness earns accolades
The signature research project of Robert Zucker, PhD, has been going on since the 1980s, when many of its now young-adult subjects were small children. And Zucker says of his research that there’s “no end in sight,” not with so many questions about the risk and protective factors associated with addiction still unanswered. The substance use disorder longitudinal study that Zucker spearheads at the University of Michigan Addiction Research Center represents one of several accomplishments for which he is being honored by the Research Society on Alcoholism. The organization later this month will present Zucker, director of the university center, with its 31st annual Distinguished Researcher Award, two days after he delivers a keynote address at the society’s national meeting. Zucker discusses the impact of the award not in personal terms, but with respect to how it might call greater attention to research that he still says has gone largely unnoticed in much of the treatment and prevention community. “We’ve strongly pushed the importance of looking at [substance abuse] risk developmentally,” he says. “It’s not a question of ‘you have it or you don’t have it.’ It unfolds over time.” As does the longitudinal study, one of several in the field that resemble more commonly referenced long-term studies of heart disease risk and other medical risks over the lifespan. Zucker’s research originally identified at-risk families by looking at those where the father had a drunk-driving offense involving a particularly high blood alcohol concentration. The study has generated more than 150 papers over the years and has informed a wealth of topics, from the tendency for behavioral disorders to be “nested” in certain neighborhoods to the large number of variables of health, social and family functioning that substance use disorders touch. The research also has uncovered details about the relationship between genetic and environmental factors associated with substance use, with Zucker making the case that the link plays out as a “two-way street” in which each set of factors affects the other. Zucker’s colleagues also credit him with mentoring a generation of fledgling researchers both in the United States and in Europe. He launched and still directs a training program supported by the National Institutes of Health (NIH) that develops substance abuse research capability in Central and Eastern Europe. That program currently has a presence in Poland, Slovakia, Latvia and the Ukraine.
The disease concept of addiction revisited
Despite the fact that The Disease Concept of Alcoholism by E.M. Jellinek was published 50 years ago, and although the idea that addiction is a disease is now widely accepted, it remains poorly understood. The latest contribution to the confusion is a book published last June called Addiction: A Disorder of Choice by Gene M. Heyman of Harvard University. It’s an ironic recapitulation of history—20 years earlier, Herbert Fingarette of the University of California advanced essentially the same argument in his book Heavy Drinking: The Myth of Alcoholism as a Disease . Both men based their conclusions on epidemiologic studies and surveys. Fingarette, a philosopher, argued solely from his reading of the scientific literature. Heyman, an academic psychologist, based his conclusions on epidemiologic surveys and laboratory research on the psychology of choice. It seems that neither writer spent much time in the clinical trenches, actually listening to alcoholics and drug addicts describe their lives. It seems a fitting moment to re-examine the disease concept of alcoholism and other addictions. To start, scientific data can no more “prove” that addiction is a disease than it can “prove” that the sky is blue. Either we all agree that the color of the sky is sufficiently like everything else we call “blue,” or we agree to call it something else. In the same way, asserting that addiction is a disease cannot be proven by scientific data. A disease concept is really a theory of addiction—a way of showing that addiction is like all the other things we generally accept as diseases. Although it may sound strange, when we say that alcoholism or drug addiction is a disease, we are not talking about the behavior of drinking or using. Behavior might signify the presence of a disease, but behavior itself cannot be a disease. A disease isn’t something you do (voluntarily or otherwise); it’s something you have . The common sense inherent in our language reflects this same idea. We don’t speak of someone “high blood pressure-ing” or “pneumonia-ing.” We say a person has high blood pressure or has pneumonia. This is true for all diseases. The behavior we call a “seizure,” for example, might indicate an infection, a hemorrhage or a tumor in the brain. The seizure is the sign of a disease, not the disease itself. If the behavior of drinking or using drugs is only the sign of addiction, then it is no surprise that measuring drinking or using behavior brings no uniform picture of the disorder. In virtually all illnesses, especially early in their course, signs and symptoms are remarkably variable. Just as fevers may be high or low, pain severe or mild, alcoholic drinking or addictive drug use may be heavy or light, intermittent or continuous, boisterous or quiet—all depending on biological, social and psychological factors influencing the individual with the disorder. So if by calling addiction a disease we mean that sometimes drinking or using is a sign of something else, a result of something a person has , then we need to be clear about what that something is. Without a simple conception of what an addiction is (on par, for example, with what an infection is), we have no strong argument for the disease concept of addiction. The experience of ‘powerlessness’ Part of the difficulty in establishing the disease concept of addiction is that the essence of the condition is known to us primarily through the reported experience of the person who has it. Although advances in brain imaging have begun to show us the disordered biochemistry underlying addiction, diagnosis is still based mostly on what patients tell us about their experience. As a result, the data are largely subjective and can be quantified “objectively” only indirectly. That’s why it is so important to listen carefully to the stories of alcoholics and addicts themselves—to hear what they say about what’s going on inside them. When we do that, we learn that they describe their experience as “powerlessness.” But the idea of powerlessness is paradoxical. After all, many alcoholics and addicts do quit drinking and using for good. What happened to powerlessness, then? Choosing, “one day at a time,” not to drink or use sounds like having power, not like having lost it. More than 100 years ago, in describing his own struggles with tobacco, Mark Twain gave us the solution to this puzzle when he said: “To cease smoking is the easiest thing I ever did. I ought to know because I’ve done it a thousand times.” Twain put his finger directly on the essential experience of addiction—when it is fully developed, it is an all-or-nothing experience. Although addictive behavior is remarkably varied, in the end virtually all addicts discover that abstinence is the only reliable foundation for recovery. “Quitting,” it turns out, is hard, but it isn’t the major problem. The bigger problem, brilliantly expressed in AA, is “staying quit”—not starting again. Like many other illnesses, addictions progress. The beginning is marked by the struggle for control (“never before 5 p.m.,” “only on weekends,” and so on). But as time goes on, control becomes increasingly difficult to achieve. Eventually, it is attained only by quitting. Indeed, episodes of quitting and relapsing are almost an unmistakable indication of the diagnosis of addiction (as opposed to mere abuse or misuse). At this stage, if people begin again, they spend increasing amounts of time and effort trying to maintain “control,” but in the end it is lost. This is what AA’s founders described as having become “powerless” over alcohol—not just for a particular episode of drinking, but repeatedly and inevitably for all drinking. In the end, all addicts discover that there is just no such thing as one. Now comes another paradox. I call it the “control conundrum.” Non-alcoholics don’t have to work at controlling their drinking. Whether they are stronger or better people (as they sometimes like to think) is a matter of opinion. The fact remains that a normal drinker doesn’t have to struggle to control it. So here’s the puzzle: How can an illness be characterized by the loss of control when the healthy state of affairs is experienced as not needing control? How can an alcoholic lose what a non-alcoholic doesn’t have in the first place? The answer is that an addiction isn’t so much a loss of something as it is the development of something that has a life of its own, that takes control for itself. That something is an “automatism.” Automaticity: toward a theory of addiction The answer to all the confusion over the disease concept of addiction lies in conceiving of addictions as “automatisms,” or disorders of automaticity. Automatisms are permanent developments in the central nervous system. Some are instinctive (the control of breathing and heart rate, for example), and belong to what we call the autonomic nervous system. But others are acquired as we mature (standing, walking, talking) and become permanent parts of the voluntary nervous system. All such automatisms have two things in common. First, they are irreversible. Second, once they have been initiated, they function outside conscious control. Swimming offers an excellent example of a common automatism. Once you “get” swimming, you can never go back to being a non-swimmer. Stay out of the water for 50 years, fall off the end of a boat dock, and watch what happens. Automatically, whether you intend to or not, you’ll swim. Of course, since you don’t want to drown, that’s a good thing. But suppose that for some reason it became extremely important for you never to swim again (dangerous currents, sharks, motor boats). What choice do you actually have? Since you cannot forget or “unlearn” being a swimmer, you literally cannot choose not to swim. Your only choice is to stay out of the water. True, a swimmer might try to enjoy the water but avoid swimming by staying in the shallows. This would be analogous to the “setting limits” stage of an addiction. The problem is that it just isn’t going to work in the long run. Sooner or later, whether or not the swimmer intended to, if he’s back in the water, his feet will leave the bottom and he’ll be swimming again—automatically. As long as he doesn’t drift out into the deep water, there may well be no problems. But that isn’t the point. The point is that despite having resolved not to swim again, he is. In order to succeed in controlling an automatism, one must become abstinent. For a swimmer, that means staying out of the water. For an alcoholic or drug addict, it means not drinking or using. I am not saying that all automatisms are necessarily harmful. On the contrary, our lives are filled with, and indeed made possible by, automaticity. Complex automatisms—coordinated physical movements and speech, for example—free our attention for higher levels of consciousness and choice. But that freedom comes at a cost—the loss of choice at a lower level of consciousness—experienced as powerlessness. Again, an example will be more useful than more description: DO NOT READ THIS! In order to experience the meaning of the phrase (and the humor), you have sacrificed choice at the level of recognition—if you look at it, you cannot not read it. Had I written instead, “ Ne olvasd ezt! ”, chances are pretty good you wouldn’t have understood what a Hungarian would have found so amusing. You don’t have that automatism. In that case, you would be rather like a non-alcoholic drinker who doesn’t “get” why alcoholics simply don’t control themselves better. Addictions, then, are complex automatisms, involving the progressive automatization of feelings (urges), thoughts (obsessions) and actions (behavior). In the end, an addiction becomes Mark Twain’s all-or-nothing experience of loss of control or powerlessness. Something inside has acquired a life of its own. When that something threatens the well-being of the whole (just like runaway blood pressure), then it is rightly considered a disease. Is addiction like other diseases? If this conception of addictive disease fits the class of events called “illness,” it shouldn't have to be forced into place. It should fit in the same the way other, well-accepted conditions do (the “Is the sky blue?” test). Does it? In every disease, there is an agent of harm: a hostile germ, a defective protein, an abnormal growth that disrupts the harmonious balance of physiologic and psychological functions. Alcohol, cocaine, heroin, nicotine, etc., certainly fit that definition. They are neurotoxins—nerve poisons. But mere exposure to an agent of harm doesn’t always lead to illness. Most of us are exposed to potentially harmful germs all the time. We don’t become sick because our immune systems fight those germs off. Similarly, many people are exposed to alcohol and drugs, but many of them have resistance to becoming addicted. Many different factors combine to provide this protection, and, as with other illnesses, some people are more vulnerable to developing the disease when exposed to an agent of harm of this kind. Just as the failure of resistance to a germ is a consequence of biological (hereditary and acquired), social and psychological factors, so too is the development of an addiction shaped by heredity, biochemical effects of the toxin, social conditions (availability, cultural expectations), and co-existing psychopathology. What about recovery and treatment? Is addiction like other diseases? The argument has been made that because many people recover from addictions without professional help, these problems should not be called diseases. The word “disease,” it is said, should be reserved for conditions that require medical treatment. But this is a narrow view. First, we recover from all kinds of illnesses (mild and serious) without professional help. Second, and equally important, an enormous proportion of modern healthcare services result at least in part from drug and alcohol use (cirrhosis, trauma, emphysema, AIDS, etc.). To treat only the consequences of addictions without attending to the underlying cause is very short-sighted. Where addictions are different from other illnesses is in the degree of effort required for recovery. In this respect, all illnesses are on a spectrum. At one end (an infection, for example), the degree to which the patient has to work at recovery is relatively small. The body more or less does the work on its own. In the middle of the spectrum is something like having broken a leg. Unless there are complications, the body will heal the fracture, but if the patient will not work at rehabilitation, full function of the limb may not be restored. Addictions are at the other end of the spectrum, the end where almost no recovery takes place by itself. Here, long-term recovery requires the willingness to remain abstinent no matter what. That’s hard work. Dangers of the disease concept Are there dangers in the disease model of addiction? Yes, and in this, valid criticism of the medical perspective must be acknowledged. Addictions are chronic conditions in which the capacity for and exercise of choice play the major role in recovery. Like other patients who have lost control of a part of themselves (e.g., becoming paralyzed after a stroke), alcoholics and addicts must not only want to recover, they must be willing and able to work at recovery and rehabilitation. After 30 years of clinical experience with alcoholics and addicts, I believe that is best accomplished if they will become a dedicated, active member of a 12-Step group. Indeed, I conceive of my role and the role of treatment programs as helping people overcome obstacles to doing just that. There are many different kinds of obstacles: physiologic (withdrawal), psychological (denial, co-existing psychopathology), social (family dysfunction, unemployment), and treatment needs to address all of them. But the ultimate goal, to my way of thinking, is to help our patients find their way to a 12-Step group—not to substitute for it. If the disease concept of addiction gives alcoholics and addicts the message that treatment providers are somehow going to do the work of rehabilitation for them, then it does them great harm. On the other hand, if the concept of addictions as disorders of automaticity clarifies the question of who is responsible for what, then it can be very helpful. The whole question can be summed up pretty simply, and the summary is consistent with illness in general: No one is responsible for having become sick, but everyone who has an illness is responsible for doing what they can to recover from it. It is an error, and a potentially harmful one, to call addiction a “chronic, relapsing brain disease.” Addictions do not relapse of themselves. People who have addictions relapse. That’s why they also can recover. The terrible problem for the recovering addict is revealed in the first noble truth of Buddhism: “Life is suffering.” Put simply, none of us, recovering addict or “normie,” wants to suffer. Nevertheless, some suffering is inevitable. All of us strive to avoid it when we can and to escape it as quickly as possible when we cannot. But alcoholics and drug addicts have the extra burden of knowing precisely how to get rid of pain—drink or use. After a lifetime of changing their state of consciousness at the drop of a hat, the alcoholic or drug addict must become willing to experience “life on life’s terms”—not because it’s morally better, but because it’s the only viable alternative to a path that leads to relapse. This is why participation in one of the 12-Step groups, with their emphasis on spirituality, is so important. However one conceives of a Higher Power (the group, humanity, nature, God, whatever), without a sense of something greater than myself to which I am responsible, there is simply no reason to endure the pain inherent in living, let alone recovery. In this also, addiction is just like other illnesses. As the great French surgeon Ambroise Paré said nearly 500 years ago, “I merely dress the wound. God heals it.” There’s something in that lesson for all of us. Richard S. Sandor, MD, practices psychiatry and addiction medicine in Santa Monica, Calif. He is a past president of the California Society of Addiction Medicine and is the author of Thinking Simply About Addiction (March 2009, Tarcher/Penguin). His e-mail address is rssandor@gmail.com .
An award-winning DVD elevates the conversation about addiction
When Kevin McCauley was sent to a military prison for a year, he decided to immerse himself in learning about the disease that had held a grip on him. Half the books he read during his incarceration were from the addiction field’s historian, William White. So McCauley couldn’t help being moved over White’s writing in Alcoholism Treatment Quarterly this year that McCauley’s latest project “may prove to be one of the most effective educational tools ever developed on addiction and will serve as an invaluable aid in the treatment of individuals and families affected by addiction.” “Bill is the clearest and most moral voice in this industry,” says a humbled McCauley, host of the 70-minute documentary “Pleasure Unwoven.” The DVD, which was released last November and for which about 3,000 copies are in circulation, again received accolades last month when the National Association of Addiction Treatment Providers (NAATP) honored it with its Michael Q. Ford Journalism Award for 2010. The film uses the stunning backdrop of Utah’s national and state parks to illustrate the brain mechanisms at work in addiction, seeking to gently but thoroughly debunk the notion that addiction is a choice and not a disease. White stated in his review that the presentation “synthesizes very complex neuroscience in the clearest language to date,” complimenting the use of vivid illustration to engage the viewer. McCauley says he can’t fully explain how he arrived at the idea of using the park settings to illustrate regions of the brain. But he was looking for a context that would be less threatening and emotionally charged than the spiritual or political constructs under which the disease/no disease arguments often occur. McCauley, whose career as a flight surgeon was cut short by his addiction, had been lecturing on the disease topic for years but had never made a film before. The project took place under the auspices of The Institute for Addiction Study, a Utah-based organization (for more information, visit www.instituteforaddictionstudy.com ). Potential audiences for the film and for McCauley’s lectures range from physicians to justice officials to specialty treatment providers to the general public. McCauley indicates he is mindful that every media presentation on addiction is serving to tip the balance toward either a more professional, sensitively delivered depiction or toward the more exploitative approach that he sees in today’s cable television shows. He says of the latter, “They’re showing the person at the worst point in his life. That person can’t consent to anything.” McCauley casts the situation as akin to a battle for the hearts and minds of the public, and he sees “Pleasure Unwoven” and similar efforts as an advance against stigma.
Methadone provider with operations in 18 states sued over lack of services
An Alabama methadone clinic owned by a company that does business in 18 states does not offer the therapy and other support it promises in its marketing, leaving its patients hopelessly dependent on the replacement medication, alleges a Circuit Court lawsuit filed last month. Attorneys for patient Lisa Cheek Temple are seeking class status for patients who they say have been harmed by the actions of Colonial Management Group, a company headquartered in Orlando, Fla. Temple was a patient from November 2004 until last month at Montgomery Metro Treatment Center in Montgomery, one of several clinic sites that Colonial Management Group operates in Alabama. “She is now as hooked on methadone as she was on painkillers,” says Temple’s attorney, J.P. Sawyer. “Her primary care physician became concerned about some health problems she was having, including venous problems in her lower extremities. She is now out of the clinic and taking methadone through her primary care doctor.” Among the allegations cited in the lawsuit are that Colonial Management Group and the medical director of the Montgomery clinic, Gilberto Sanchez, MD, failed to advise Temple of long-term adverse effects of methadone use, neglected to offer her adequate supervision and counseling, and did not keep complete and adequate clinical records. “Colonial Management Group, L.P. and its subsidiaries take great pride in providing the best care they can to their patients and fully complying with all applicable laws and regulations,” company director of operations Jamie Lovern said in a written response delivered to Addiction Professional via e-mail. “That having been said, we are still in the process of looking into these allegations and it would be premature to offer a comment at this time.” Sawyer insists that the lawsuit does not represent an indictment of methadone treatment in general, but targets a particular provider that promises a variety of supports to end an addiction but that delivers only a daily dose of medication. “We’re not being critical of folks out there who are legitimately helping people and providing this treatment as an alternative,” he says. The lawsuit states, “The Defendants have failed and/or refused to provide counseling and other treatment services necessary for Plaintiff to address her chemical dependence. Temple and the Class Members pay for these services as part of the ‘fee’ paid to the Defendants.” Plaintiffs have requested a jury trial in the case and are seeking unspecified compensatory and punitive damages.
Research examines the benefits of exercise for preventing relapse
Could a regular regimen of aerobic exercise play a significant role in preventing relapse to drug abuse? Researchers at two Georgia universities will be looking into the mechanisms of a brain chemical that is associated with exercise activity, thanks to a $1.9 million grant from the National Institutes of Health (NIH). The five-year project, involving researchers from the University of Georgia and Emory University, will measure exercise-induced increases in the chemical galanin in the brains of rats. Galanin decreases norepinephrine, which is activated in stress response and in turn stimulates dopamine, which can induce cravings for substances of abuse. The researchers hypothesize that exercise-induced regulation of galanin can prevent drug use that occurs in response to stress, through this protective effect against activation of the norepinephrine system. “This research will provide new insight into how regular exercise may attenuate drug abuse in humans,” says David Weinshenker, associate professor of human genetics at Emory University’s School of Medicine. “More importantly, it may reveal a neural mechanism through which exercise may prevent the relapse into drug-seeking behavior.” While the results of this research could point to the value of certain exercise programs as part of recovery support, they also could create momentum for developing medications that increase galanin in the brain.
NAATP board recounts Hunsicker investigation
At an hour-long “town hall meeting” at this week’s National Association of Addiction Treatment Providers (NAATP) annual conference in San Antonio, NAATP board chair Cathy Palm and the organization’s attorney answered questions from dozens of association members about circumstances surrounding the March 31 suspension and subsequent firing of longtime NAATP President and CEO Ronald J. Hunsicker, DMin, for misappropriation of some $500,000 of the organization’s funds over a five-year period. In an opening statement at the session, Palm asked the group’s first, and obvious, question, saying, “What did Ron do?” and answered, “He made NAATP payments on credit cards for personal expenses that were recorded as business expenses.” She explained that payments were made on amounts charged to “in excess of 20 credit cards associated with NAATP” that, according to the Pennsylvania Attorney General’s office, “had been extensively used over a several-year period for what appeared to be both personal and business charges.” The NAATP board had never authorized the CEO’s use of a corporate credit card, said Palm, executive director of Tully Hill Corporation in New York. As to how the misappropriations could have occurred, Palm stated, “NAATP’s books are on a cash basis and that’s how he could do it. The activity was off-balance sheet. We’re talking about credit cards over here—not authorized by NAATP—and cash statements recording activity over here. The payments were then charged to business expenses. So, when we saw financial statements and saw business expenses allocated there ... they never got out of line with what our budget was. There was nothing glaring for us at one time.” Hunsicker was hired in 1997 as NAATP president and CEO at a time when Palm says the organization “was nearly defunct” and “running on a shoestring.” At the time, she says that “Ron ran the business out of his basement and did everything,” including maintaining financial records. Because of the dollar amount of NAATP’s budget, Palm says audits weren’t required. Instead, the board relied on regular compilations of financial information, subject to the opinion of an auditor, but not to a detailed auditing procedure. This changed around 2009, when board members asked whether internal NAATP staff could take over financial management responsibilities to free Hunsicker to devote more time to NAATP’s growing membership. Following a training period, that’s what happened. Palm said that until early 2010, few had reason to doubt Hunsicker’s abilities. “As board members rotated in and out, they came to see Ron as a guy who was pretty accomplished and getting things done. So, we did trust him,” she said. But she acknowledged that she and predecessor board members “had a responsibility to put in place internal controls to prevent bad things from happening. The board takes responsibility—we didn’t do that. We are a group of volunteers who meet three times per year, including this conference, and it was our mistake.” In a communication sent to NAATP members on May 17 to explain the board’s decision the previous week to fire Hunsicker, Palm stated that NAATP is entering into an “Assurance of Voluntary Compliance” with the state Attorney General’s office “that will acknowledge that, due to the level of trust that existed, there were inadequate internal controls in place. It will also document our commitments to remedy the situation.” The communication adds that the Attorney General’s office also had initiated a look into NAATP’s attempt to establish a nonprofit foundation, but that this effort was “easily explained to the Attorney General.” The Attorney General’s office has never officially confirmed publicly the existence of an investigation into NAATP, and it remains unknown as to whether it will pursue any official action on the matter. Timeline of events According to Palm, the trust that existed between Hunsicker and the NAATP board was shattered this Jan. 26, when Palm received a call from the Attorney General’s office stating that for a year it had been investigating possible financial irregularities at NAATP. Palm said she asked for a written summary, which arrived on Feb. 3. The next day, she brought in accountants and launched an internal investigation. On Feb. 13, she brought in outside legal counsel Nancy Armatas and convened a series of executive committee and board meetings that culminated in Hunsicker’s March 31 suspension, she said. As the investigation detailed the amount and circumstances involved, the board made the decision to fire Hunsicker. Restitution sought Armatas, a Chicago-based attorney specializing in healthcare and substance abuse work, explained that the board’s primary goal is to get “restitution in full” from Hunsicker. “We believe that the assets exist,” she said. “We will pursue it as long as it takes. It will be a long process and there’s no guarantee that we will get all of the funds, but we are pursuing it.” At present, she said that “a voluntary agreement is being pursued. But if that does not happen, we can bring a civil lawsuit to force restitution, or pursue a criminal prosecution.” Armatas noted that because Hunsicker was acting in a fiduciary capacity at the time of the misappropriation, “This debt is not dischargeable,” so a bankruptcy filing could not be used to evade restitution. And, because Hunsicker obtained the credit cards without board authorization, he, not NAATP, is their guarantor. “The $500,000 in charges made on those credit cards are ‘his,’” Palm emphasized. Tough questions During a subsequent question-and-answer period, Palm and Armatas responded to comments and questions from members. While many members expressed support for the board’s actions in the matter, a number of members raised questions about actions being taken to protect NAATP assets while the voluntary restitution agreement was being hammered out. Still others expressed incredulity at the apparent laxity of financial controls in their organization. Palm could do little but agree. “In hindsight, it’s easy to be a Monday morning quarterback,” she said. “If we’d have asked for an audit, we would have seen it.” To date, NAATP has spent approximately $40,000 on the Hunsicker investigation, including outside accounting, legal, and crisis-consulting fees. While NAATP’s board and members await the outcome of the misappropriation crisis, other significant, but more routine, challenges lie ahead. Under the direction of Palm and interim chief executive Dennis Gilhousen, the former CEO of Valley Hope Association, NAATP plans to complete amended 2009 and 2010 financial reports, develop a new strategic plan, search for a new CEO, build its year-old political action committee, and plan the association’s 2011 conference.
Speakers at NCAD will demonstrate that smoking cessation is possible in treatment programs
Of all disciplines in healthcare, the substance abuse professional is seen by many as best situated to help a patient quit smoking, given the professional’s understanding of addictive processes. Yet the effort to engage the substance abuse professional on this subject never has been particularly easy. “Once they decide they want to do this, they’re really good at it,” says Connie Revell, deputy director of the Smoking Cessation Leadership Center at the University of California, San Francisco. At this September’s National Conference on Addiction Disorders (NCAD) in Washington, D.C., Revell will be one of several presenters who will carry the message that many addiction treatment programs are addressing client smoking head-on without compromising other clinical goals. “We’ve found that the real heavy-duty core of remaining smokers are people with behavioral health issues,” says Revell. This is why the Smoking Cessation Leadership Center, which started seven years ago as a national program office of the Robert Wood Johnson Foundation, has focused a great deal on initiatives with both the addiction and mental health treatment communities. Revell explains that the project works mainly with national associations, often providing seed money for member surveys that drive interest in smoking cessation efforts. She says the center, which also receives funding from the American Legacy Foundation, has worked with the National Association of State Alcohol and Drug Abuse Directors (NASADAD), Faces and Voices of Recovery, and NAADAC, the Association for Addiction Professionals, among other field groups. Revell’s session at the Sept. 8-11 NCAD ’10 conference is titled “Tobacco-Free for Recovery” and will take place on Sept. 10. Revell says that contrary to a once-held belief among addiction professionals, studies have shown that individuals with behavioral health disorders want to quit smoking as much as or more than individuals without behavioral health problems do. In addition, research has indicated that simultaneous efforts to address all of a patient’s substance use issues are likely to prove more effective than relegating smoking cessation to the back burner during primary drug or alcohol treatment. “Many well-meaning people said tobacco was these patients’ best friend, or the only thing they had,” Revell says. “But it’s not a friend—it’s an enemy. This is the number one killer.” Other tobacco-related presentations at NCAD will look at the use of technology and collaborative partnerships to perform a needs assessment in tobacco control, as well how New York state initiatives have built professionals’ motivation and competency for integrating tobacco cessation into substance use treatment services. NCAD is being produced by Vendome Group, publisher of Addiction Professional , as an event combining treatment, administration, design, technology and other information for addiction professionals. Participating associations are NAADAC (which will now hold its annual meeting under the NCAD title), the National Association of Addiction Treatment Providers (NAATP) and the International Coalition for Addiction Studies Education (INCASE). For more information about the conference, visit www.ncad10.com .
UPDATE: Hunsicker dismissed as CEO of treatment providers association
The tenure of the administrator who rebuilt the National Association of Addiction Treatment Providers (NAATP) from plummeting membership into a vibrant national voice for the country’s most prominent treatment centers ended with a termination vote last week. NAATP members learned this week that president and CEO Ronald J. Hunsicker, DMin, has been dismissed and that former Valley Hope Association CEO Dennis Gilhousen has agreed to serve as NAATP chief executive during a transition period. The NAATP board’s May 6 termination vote comes just over a month after Hunsicker was suspended from his position amid the launch of a review of NAATP by the Pennsylvania Attorney General’s Office. A statement received this week by NAATP members and obtained by Addiction Professional says that according to NAATP board chair Cathy Palm, “this change in leadership was made at the conclusion of an investigation initiated by the NAATP Board, as a result of findings of an independent accounting firm and further discussion with the office of the Attorney General of the Commonwealth of Pennsylvania.” Palm has declined to comment in recent weeks on the nature of the events that led to Hunsicker’s suspension and ultimate firing. Yet the mention of an independent accounting review in the NAATP statement dated May 10 appears to be the first official confirmation that the issues are of a financial nature. The state Attorney General’s office has not confirmed or denied that it is investigating the Pennsylvania-based association. Although this week’s e-mail communication to NAATP members is labeled a “press release,” the announcement as of mid-week was not posted in the news and press section of NAATP’s Web site. Hunsicker’s name has been removed from the roster of NAATP leaders on the site and has been replaced with that of Gilhousen, a nationally known treatment leader who served for more than a decade as chief executive of Valley Hope, a Kansas-based organization now operating treatment facilities in seven Plains and Southwest states. Before retiring from Valley Hope, Gilhousen had served for many years on the NAATP board and is a former board chair for the association. “With this change in leadership completed, we confidently look forward to devoting all of our energy and resources to the important work of the NAATP,” Palm said in the statement. The association’s annual conference in San Antonio begins on May 22. Hunsicker’s departure ends a period in which he became a leading national commentator on policy and programmatic issues affecting the addiction treatment community. His efforts to grow NAATP and to work in cooperation with other field groups have been widely praised, and the news of recent weeks has stung for many longtime leaders in the addiction treatment arena.
Caron honors three board leaders for exemplary volunteer service
Caron Treatment Centers is honoring three individuals from other treatment organizations for their leadership roles in philanthropy, advocacy and other volunteer activities that have advanced the cause of treatment. Board members from New Jersey-based Seabrook House, Tennessee-based Cumberland Heights and Indiana-based Fairbanks will receive the Jasper G. Chen See, MD Award at this month’s National Association of Addiction Treatment Providers (NAATP) annual conference in San Antonio. The award winners, who will receive their honors at a May 22 NAATP board function, are Ann M. Budde, who chairs Seabrook House’s board of directors; Robert Masters Crichton Jr., a longtime officer of the Cumberland Heights Foundation; and Christopher Stack, a Fairbanks director and the first board chairman for the Indianapolis treatment organization Hope Academy high school. The late Dr. Chen See was Caron’s board president for 12 years and was a past president of the American Society of Addiction Medicine (ASAM). Among Caron’s criteria for the award selections are length of service and participation in board meetings and related organizational activity, on a volunteer basis. “These volunteer leaders have had a tremendous impact on the treatment industry,” said Caron president and CEO Doug Tieman. Besides her work at Seabrook House, Budde also serves on the board of South Jersey Hospital and the Cumberland County Board of Health. Crichton has chaired several fundraising campaigns at Cumberland Heights and volunteers his time several days a week in the center’s development office. Stack was instrumental in efforts to convince Indianapolis officials to authorize Hope Academy’s operation as a charter school. A statement from Caron refers to Dr. Chen See as “the tower of strength in Caron’s transition from a family cause to a nationally recognized leader in the field of addiction treatment,” through board service that spanned more than 20 years.
National eating disorders conference will have neurochemical focus
While environmental triggers for eating disorders maintain a significant presence in society, research is uncovering genetic links to eating behaviors that offer a more nuanced picture of these disorders’ causes and possible treatments. Clinical professionals will gather in Las Vegas this month to explore advanced treatment strategies reflecting a more balanced perspective on the factors connected to eating disorders. Remuda Ranch Programs for Eating and Anxiety Disorders, a treatment organization with operations in Arizona and Virginia, will host “Clinical Recipes for Success—Advanced Treatment for Eating Disorders” May 13-16 at the Green Valley Ranch Resort and Spa. Dena Cabrera, PsyD, a psychologist at Remuda and a member of the organization’s national speakers’ bureau, says these meetings tend to attract counselors, psychologists and other professionals involved in the clinical care of patients with eating disorders. Cabrera says significant research in genetics is allowing clinicians to tell families that “this is more than your child wanting attention, or trying to lose weight, or dealing with bullying. There is a chemical aspect to the way we approach food and deal with these problems.” Cabrera adds that family influences also are capturing a great deal of research attention in eating disorders. Treatment programs in turn are responding by enlisting families as partners/assets in treatment, not as a contributing problem that needs to be “fixed,” she says. Topics to be covered at this year’s conference include evidence-based nutrition strategies; food and the brain; mindfulness approaches; and eating disorders in males. National eating disorders and exercise physiology expert Ralph Carson, MD, will deliver a talk highlighting a brain model of how mood and cravings are linked and what can be done to alter this. Remuda Ranch also has announced that this speaker for the presentation “Food & Mood: When Food and Eating Is a Problem in Life” has entered into a partnership with the treatment organization for training of staff and other professionals in treatment innovations. According to a statement from Remuda about Carson’s ongoing work with the organization, “Dr. Carson’s training will focus on physiological recovery from eating disorders using a brain atlas. He will discuss utilizing psychotherapy in order to stimulate the brain to rewire itself; nutrition and diet to nourish the brain so that repair, growth and modification take place; and sleep therapy to heal the brain.” For more information about this month’s conference, visit www.bfisummit.com .
Addiction Professional wins Gold Award from ASHPE
The American Society of Healthcare Publication Editors (ASHPE) has honored Addiction Professional with a first-place Gold Award in its 2010 Awards Competition. Addiction Professional won the award in the “Best How-To Article” category for “ Treating the High-Functioning Alcoholic ,” published in the magazine’s March/April 2009 issue. The article was written by Sarah Allen Benton, a licensed mental health counselor at the Emmanuel College Counseling Center in Boston and author of Understanding the High-Functioning Alcoholic: Professional Views and Personal Insights . The article opened with a typical case report for an individual who is able to maintain an outside life while drinking to alcoholic levels, then outlined high-functioning alcoholics’ common characteristics and how clinicians can use this knowledge to improve treatment for these individuals. In the article, Benton stated that even in early recovery, high-functioning alcoholics pose clinical challenges unlike those presented by other clients. She wrote that “they might report feeling worse emotionally and physically during early sobriety. They also might report not being able to handle their professional or personal responsibilities as well as they could while they were drinking.” Three other magazines published by Vendome Group— Behavioral Healthcare , Long-Term Living and Healthcare Design —have been honored in ASHPE’s 2010 Awards Competition. Behavioral Healthcare won a Gold Award in the Special Report/Section category for “ States of Despair ,” an October 2009 issue analysis of steep state budget cuts for community mental health programs.
He shares the good news
David Fine's 64 years of life have been part Boston Common hippie, part Jimmy Buffett clone, but mostly person of service-the latter supported but not solely driven by his recovery. “I don't believe I'm an alcoholic first,” says Fine. “I'm a person first and an alcoholic second. I can't make my addiction my identity.” So even though much of Fine's work since finding recovery via the 12 Steps in 1977 has been situated in addiction treatment and human services, he says he always insisted on venturing away from time to time just to avoid burnout. On one of those journeys in the early 1990s in South Florida, after reading favorite author Emmet Fox's essay “Your Heart's Desire” while lying in a hammock (the Jimmy Buffett part), he would decide to start a newsletter for individuals in recovery. “South Florida was becoming the treatment center capital of America,” Fine says. The Solution News would be born, with the first eight-page issue published in 1992 thanks to support from a handful of friends whose ads weren't all that related to treatment or recovery. “I got enough money for a quickie print job, and I cut and pasted the ads,” Fine says. Later, the treatment and recovery communities would begin to notice Fine's effort; he says support at the time from the organization then known as Hanley-Hazelden proved to be a critical turning point. This eventually led to Fine's decision to make the publication his main work, converting it to a full color newspaper that is published bimonthly. Today, numerous individuals are launching publications directly targeted to the burgeoning recovery community, but Fine stands out as having long-standing credibility in the community-first acquired in South Florida and then spreading beyond the region. Now thanks to the Internet, he can boast of readers from as far as Iraq and Italy. Fine likes presenting what he considers a middle ground between the more professionally targeted publications and the louder voices that seem to focus mainly on landing the hottest celebrity-in-recovery story. “I think there's a place for everything,” Fine says. “I'm a little uncomfortable with what I'd say is the sensationalism out there,” citing television programming such as “Intervention” and “Celebrity Rehab With Dr. Drew.” Yet he adds, “If someone sees that and they have a problem and they do something as a result, I know that God works in many ways.” He adds, “I believe people recover because they get a connection to another human being. I don't really care how it's done.” Enlightened thinking Fine grew up in Massachusetts and started college in the 1960s (the Boston Common hippie part). The failure of his marriage after six years led to a severe decline, but he would find recovery in his early 30s. Much as he has come to accept the role of the more headline-seeking voices out there, he has also come to realize the many paths to recovery that differ from his own. “There is a world of addiction recovery resources that is so broad and wonderful,” he says. “Ten years ago I would have thought that 12-Step was the only approach.” Fine therefore tries to present in his newspaper the full variety of possibilities for people seeking recovery, calling the purpose of his venture “love and service through recovery and community.” The publication is available at no cost; the tagline Fine uses for the newspaper is “Happy, Joyous, and Always Free.” Back to his roots In another sign of the changing times in media, Fine now communicates with his core South Florida audience from afar. He relocated to New England last year, having met and married another native New Englander in Florida. He and his wife, an artist, live in New Hampshire. And Fine remains involved in direct human-services work, serving in a mentoring role at the New Hampshire addiction and mental health services organization WestBridge. Still, he is living his dream by being self-employed in the areas he enjoys most: writing, photography and music. Writing runs deep in his psyche. He recalls his first venture in that area, responsible for creating a newsletter for executives in the electronics company where he worked, distilling information for the board of directors. “I had to learn a lot to do a publication,” he says. Fine remains active in both his work and his recovery, although he still finds time for simpler pleasures such as hiking and fishing as well. “It's very, very important for all people who work in this area to do that,” he says. “You need to step out of this whole arena from time to time.” Addiction Professional 2010 May-June;8(3):48
Hone your skills in intervention
A new year is always a time of re-evaluation and planning. It offers an opportunity to address what works and what doesn't in our lives, and inspires us to chart improved courses for the coming year. In the spirit of Oliver Wendell Holmes, who said, “Man's mind stretched to a new idea never goes back to its original dimensions,” I offer a call to arms for all those in the intervention, addiction and behavioral health professions to embrace the new year by making a commitment to advance ourselves personally and professionally by investing in continuing education. One way to begin is to learn about the power of intervention. It's no surprise that at this time in history, addiction and related behavioral health issues have rocketed to epidemic proportions worldwide. Those of us in the healing arts will inevitably come across individuals and families derailed by the disease of addiction. The pervasive nature of this illness will undoubtedly challenge professionals in every related and adjunct field. Identification, opinion on states of readiness and the willingness to interrupt the progression of the disease are complicated by misunderstandings about the pervasive nature of addiction and are further compounded by uneducated perspectives of the general population, professionals and paraprofessionals alike. Myths are disguised as facts and insidious co-dependence on both personal and professional levels often prevent the sick and suffering from getting the help they need. The truth is that as well-intentioned as we might be, many of us are hobbled in our efforts to help the addicted if we have non-current skill sets. In fact, many practitioners may unintentionally cause even greater harm by relying on medical and therapeutic ideologies that are out of alignment with current treatment strategies. Medical, legal, therapeutic and spiritual professionals come into daily contact with individuals and family members afflicted by this disease. Yet, the untreated addict runs roughshod over the people, places and things in his/her life. With this in mind, a fundamental problem in professional awareness exists in that addiction education and more specifically intervention strategies are not currently taught in mainstream medical, counseling and higher educational curricula. Millions of people suffer from addictive issues and walk among us every day. Some are obviously afflicted while others are harder to detect. But the truth is that an individual who suffers from addiction rarely goes unnoticed. Employing any intervention strategies at earlier stages of the addiction continuum would change inevitably dark outcomes for many. Anyone, be it a layperson or a professional, with even cursory knowledge of intervention can make a significant difference. Few will become interventionists but many can become part of a large pool of people armed with new knowledge and resources. Collectively, the most powerful tool we can have is knowledge executed in skilled and ethical practice. No longer can we afford to ignore these problems because they are not our direct responsibility. A higher human ethic that is involved here must be addressed. Elements of intervention With this in mind let's consider the hallmark features of the acute and complex intervention client. Intervention clients, by the very nature of the fact that they are typically at imminent risk of hurting themselves or others, are earmarked as clinically complex. Simply put, they would not be intervention clients if they were at any earlier stage of their illness. They have slipped through many cracks and have artfully evaded all outreach efforts from the people who care about them. Without a well-orchestrated professional rescue plan their outcomes are often grim and the people who are in their sphere of influence remain at risk. Untreated, these individuals, many of whom come from families with addiction histories, cannot help but influence the next generation (their children) by grooming them to become the next wave of addicts or adult children of addicts. Each such designation carries with it medical, psychological, behavioral and spiritual burdens. Furthermore, the entire family system becomes toxic, and without treatment or good counsel they cannot help passing along to the next generation the collateral damage of untreated co-dependence, enmeshment, poor boundaries and unhealthy communication practices. A great majority of intervention clients are dually diagnosed. They have addiction issues compounded by features of or actual diagnosed mental illness. Their early developmental histories often include elements of neglect, trauma, grief and loss. The scope of their derailment can be evidenced by significant drama in nearly every area of their lives. Most untreated addicts come with legal complications, damaged interpersonal relationships, financial wreckage, employment trouble, and family unhappiness and chaos. In spite of the real, indisputable evidence before them they will vehemently and self-righteously defend their disease and deny its power over them. They often cannot empathetically connect to the ripple effect their behavior has on their families, friends and society. Even the threat of irreversible medical problems, incarceration, divorce, death and banishment from work and family might not be enough to engage an addict in a solution-oriented recovery plan. Intervention, on any level, moves dysfunctional people and their families from illness to wellness. It is a change-oriented process that serves to free the trapped individuals and their families held hostage by this dark force. It is a strategy that empowers families to save their own and it reconnects them with the fact that they too are worthy of being saved and are entitled to live healthy, happy lives. The message of love, hope and help to the addict is delivered in one voice via a powerful, loving, well-orchestrated family meeting. Once the intervention process is initiated, nothing remains the same. It is a game changer for the entire family system. While trained interventionists ultimately adopt their own styles and practice divergent methodologies, most would agree that comprehensive intervention strategies include elements of: An initial phone triage assessment followed by a more comprehensive dialogue that serves to educate and inform families about the process of intervention and the nature of the disease; Collection of collateral assessment information; Suggestions for appropriate treatment referrals for both the addict and the family; Establishment of date, times, travel plans; Pre-intervention/rehearsal training; The intervention; The transport; Case management through completion of treatment; and Ongoing case management and monitoring through the first year of recovery and in many cases beyond. In order to best serve intervention clients and their families, every element of this process must be executed or we run the risk of underserving this population, which could lead to recidivism, ongoing family trauma and tragic outcomes. Professional status There are approximately 200 Board Registered Interventionists that are members of the Association of Intervention Specialists (AIS). In order to receive the BRI distinction an individual must minimally possess specified training, certifications in addiction and/or advanced education. There is a mentoring/supervision period and biannual meetings that are designed to bring this group together and provide them with educational programming and social/professional supports. The individuals who are members are a committed group who want to serve this population with absolute professionalism. They have voluntarily jumped through the necessary hoops to be part of the effort to elevate quality. Once the intervention process is initiated, nothing remains the same. It is a game changer for the entire family system. Yet there are hundreds more who are practicing intervention with no training, ethical accountability or supervisory support, which has created a “wild, wild west” culture within the field of intervention. Additionally, the lure of money entices droves of individuals influenced by reality TV shows, among other things, to throw their hat into the ring. Many believe their sobriety and good intentions alone qualify them to deal with the most problematic and reactive group of people within the addiction field. This puts vulnerable families at great risk, and that is simply unacceptable. For years we have railed about the recidivism of the disease and poor outcome statistics. It is time we looked to ourselves as individuals and institutions and honestly asked, “What is our part in this equation? Are we truly the best we can be?” Certainly, in terms of the intervention world we need to continue all efforts to raise the bar for interventionists currently in the field as well as individuals wishing to enter the field. Organizations such as AIS and the International Interventionists Credentialing Board (IICB) have made great strides to create structure, accountability, camaraderie and support for interventionists. AIS is the only credible membership-driven organization currently available to intervention specialists; it has worked hard to create a professional standard and a code of ethics for interventionists. One suggested way of addressing the “wild, wild west” of untrained and unsupervised interventionists would be to refer only to a BRI. Further, based on the clinical complexities of a case that would include significant mental health disorders, eating disorders and other process addictions compounded by chemical addictions, a referent might want to consider using an interventionist who has a clinical license or is a master's- or PhD-level clinician also trained in intervention. The reality is until interventionists are required to become nationally and internationally certified or licensed, not just Board Registered, we will have no way of standardizing and holding the intervention field to the highest practice standards. Until then, we rely on the good-faith efforts of those paraprofessionals wanting to be counted as credible intervention specialists. The field evolves The intervention field is in a growth spurt in terms of defining itself. In order to stabilize the current culture of intervention and ensure its responsible growth going forward, there is much to be done in terms of training and education, organizational development and political and professional outreach. This industry must raise the level of sophistication of our credentialing and mentoring processes, must model itself after other credentialed and licensed specialties, and must continue to lobby in Washington for essential healthcare reform. Ultimately, the solution will lie in diverse, accessible clinical and method-based curricula, both traditional and online, that produce licensed intervention specialists. The obvious net benefit to an individual who chooses to pursue any educational endeavor is increased competency, relevance and viability. The field of intervention is one of the fastest-growing subspecialties within the addiction and counseling fields. If we are to serve this most complex population we had better be competent. We must not only maintain current skill sets within our own areas of interest but also endeavor to expand our awareness to include other relevant clinical areas. By investing our time in our own education we ensure our professional relevance in this dynamic field. In these turbulent times, continuing education can only additionally serve to increase one's viability in the workplace. Each of us, in our own way, runs the risk of becoming complacent in our lives and our work. Without knowing it, we can drift into the procedure of our work and slowly lose our connection to the joy, creativity and passion of our craft. To buy into the belief that we know enough or have done enough is substandard thinking. It is our responsibility to make sure we stay enthusiastic and engaged, not only with our clients but with our peers and most importantly ourselves. We must adopt the mindset that nothing less than exceeding our own expectations will do. A concerted effort to fuel ourselves with new ideas is paramount to our professional and personal development. After all, passion creates dialogue. Dialogue creates ideas. Ideas create change. Change affects outcomes and restores hope. Hope can inspire and heal future generations. The decision to commit to growth through education and training will undoubtedly invigorate not only us as professionals but the industry as a whole. The upside of holding ourselves to these higher standards is that the trickle-down effect to the people we serve is positively immeasurable. The flip side of that coin is that if we do not commit to improving ourselves and we choose complacency and the status quo over being proactive, we become antiquated, ineffective and possibly dangerous to the people who trust in us to guide them through the worst times of their lives. Upgrading ourselves educationally should be treated as reverently as our commitment to our individual spiritual care and development. With this in mind, I would like to suggest that one way to begin this evolution might be by learning about intervention or actually adopting an intervention skill set. It is a crisis methodology that not only saves lives but also is guaranteed to increase your personal and professional firepower for 2010 and beyond. Jane Eigner Mintz is an internationally known speaker and trainer on the topic of crisis intervention and the complex and comorbid client. She is a Diplomate member of the American Psychotherapy Association, a Board Registered Interventionist (BRI-II), a board member of the Association of Intervention Specialists (AIS) and a member of NAADAC, The Association for Addiction Professionals. Her e-mail address is jane.mintz@realifeinterventions.com . Addiction Professional 2010 May-June;8(3):20-24
Questions remain about health reform's impact
After that initial burst of enthusiasm following the enactment of health reform legislation in March, has the addiction profession's reaction to the landmark law's adoption seemed a little muted? In the weeks following President Obama's signing of the Patient Protection and Affordable Care Act, field professionals with whom I spoke indicated at least some unrest along with the excitement over the law's passage. Much of this appears to reflect uncertainty about how addiction services will be structured in a healthcare system destined to become more integrated. One consultant in April even used the phrase “in the dark” when describing how addiction professionals were reacting to the new law's adoption. He believes care providers will have to place a renewed emphasis on their programs' results in order for their funding to continue. And few observers believe that the combination of health reform and parity laws will simply eliminate all payer restrictions on the scope of addiction treatment. It isn't difficult to understand why thoughts of a more unified, coordinated healthcare system tend to generate anxiety among addiction professionals and the agencies that employ them. Consider the contrast with the mental health provider community. Leading national organizations in mental health for years have emphasized integration with general medicine in their outreach to members. Motivated by data showing improved outcomes when mental health needs are identified as part of managing chronic disease, segments of that field have aggressively tested models for integration with primary care. So for many professionals in the mental health community, today's discussion of a “medical home” that will serve as consumers' access point for integrated care already resonates. Yet in the addiction arena, the specialty treatment sector hasn't embraced the language of integration to as great an extent. Topics such as primary care screening for substance use problems have been talked about, but there remains uncertainty over whether those initiatives will expand or shrink service opportunities for specialty addiction treatment providers. None of this, of course, diminishes the many positives we have conveyed about health reform. The law's inclusion of equitable addiction services in the required benefit packages for new Medicaid enrollees and new private insurance customers is an accomplishment that cannot be underemphasized. Other initiatives in areas such as behavioral workforce development incentives and support for prevention programming also could lift the field. So it is not that the initial euphoria has given way to cynicism, but just to a sense that we aren't close to answering all the questions about how this will play out. Just as one of the first observations after parity took effect was that addiction benefits in some health plans actually were reduced to fall in line with comparable provisions in general health, there could be plenty of unexpected consequences from the implementation of health reform-a process that will take years to unfold. As part of our continued coverage of this topic in print and at http://www.addictionpro.com , we'd like to hear from you about your expectations for the new law and where addiction treatment fits into the overall picture. As always, you can reach me by phone at (401) 353-1316 or by e-mail at the address below.   Gary A. Enos, Editor Addiction Professional 2010 May-June;8(3):6
Testing's role in buprenorphine treatment programs
Since its introduction in 2002, buprenorphine has proven to be a powerful tool in the treatment of opiate addictions. Buprenorphine curbs the craving for opiates, and can send addictive behaviors into remission. Because of the medication's success, outpatient treatment programs that utilize buprenorphine have been opening at a rapid rate. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), the nation currently has more than 11,000 physicians qualified to dispense buprenorphine, and more than 1,800 buprenorphine treatment locations. Drug testing is an essential part of the buprenorphine treatment process for a variety of reasons. Most obviously, it is a valuable tool for physicians and clinicians as they gauge program compliance. It demonstrates that the client is taking the medication as prescribed, while refraining from “supplementing” with other drugs or alcohol. This information can be used to benefit both the client and the treatment center: Drug testing can identify a client's need for additional support, while protecting the center's exposure to liability risk through awareness of a patient's possible prescription misuse. Equally important, drug testing supports the patient's ongoing abstinence. In our former practices as drug and alcohol treatment professionals, we witnessed that clients who receive random drug testing are held accountable for their actions, and thus have more incentive to refrain from substance use. In fact, the observations made in our respective practices motivated us to develop the drug testing protocols currently found in our Vermont-based company, Burlington Laboratories. Clinician Charles Scott Earisman, MA, LCMHC, LADC, notes, “I think that carefully negotiated agreement to use drug testing as part of therapy helps the client feel that their ambivalence is acceptable and understood, and helps the therapist develop a trust in the client. Testing, ultimately, is a tool in developing the therapeutic relationship.” Vital elements Detailed drug testing can be critical in determining the “big picture” for a client in treatment, offering information about use of other drugs or alcohol. For example, without a specific test for oxycodone, its use may go undetected, as lower doses of oxycodone will not trigger a general opiate positive. Alcohol metabolite (EtG) testing also has proven to be a critical tool for buprenorphine treatment centers. Where a standard alcohol (ETOH) screen tests only for alcohol currently in the client's system, the EtG test is an indicator that is able to detect alcohol use up to three days post-consumption. In buprenorphine treatment, alcohol testing is vital. Buprenorphine is highly contraindicated with alcohol; the combination can be dangerous. If alcohol use goes undetected, the client is placing himself and the community at risk. Additionally, studies show that alcohol use during any treatment program can dramatically reduce success rates. From our experience running outpatient programs, we know that invariably there are clients who truly believe that they are able to limit their addiction successfully. They may think, “I'm a heroin addict. I don't have a problem with alcohol.” But in our experience, patients who maintain this attitude never completely give themselves over to the abstinence model. They will experiment with “controlled using.” This behavior more often than not ends up with the client relapsing back into old using behaviors. Unfortunately, EtG testing still is seen by many to be prohibitively expensive and impractical as a treatment tool, therefore making access to the testing limited. Because alcohol is available legally in so many outlets, we believe people in recovery can only benefit from EtG monitoring. We believe it so strongly that our company includes free EtG results with any other tests. Synergy Counseling Group, an outpatient drug treatment center focused on the use of buprenorphine, considers drug testing to be one of the most valuable tools it has at its disposal for tracking the compliance of its clients. Synergy CEO James Hamel, LADC, CADC, ICADC, explains, “Alcohol use was difficult to track prior to our EtG test, and we could only catch them sporadically with an alco-sensor test.” He goes on to say, “When we enhanced the drug testing we do, and added an EtG test at no cost, we discovered that there were a significant number of clients drinking while in the program. It became a major treatment issue for us that we were previously unaware of. We were able to take immediate action to address the situation.” Confirmation testing provides further information for the physician or clinician in the treatment setting, as it can indicate potential prescription misuse and/or buprenorphine diversion. The standard initial screening tests for buprenorphine will show only the undigested buprenorphine that is passed through into the urine. Confirmation testing will show the total buprenorphine un-metabolized and metabolized buprenorphine (nor-buprenorphine). If a client is tampering with the urine by spiking it with buprenorphine powder, it will test positive on the screening test but not on the confirmation test because nor-buprenorphine would not be present. If the client is compliant and taking buprenorphine as directed, the ratio between metabolized and un-metabolized buprenorphine will remain stable. The ratio will drop if the client skips one or more doses. Hamel says, “The bup/norbup ratio reports we receive have been of invaluable importance to us. That has been the biggest boost to our processes since the EtG tests.” There are no false positives with confirmation testing, so both practitioner and client can be confident in the results. Conclusion Drug testing results offer indispensable information, and when combined with other indicators can strongly influence the creation of more effective treatment options. While drug testing should never stand alone in treatment, it is an extremely valuable tool for clinicians as they support and guide their clients toward recovery. In buprenorphine treatment, regular drug testing means higher success rates for clients. And the greater the success for each client, the greater the reward for not only that client, but also for families, friends and the community at large. Michael Casarico and Jodie Casarico are a husband-and-wife team who founded Burlington Laboratories, Inc. ( http://www.burlingtonlabs.com ) in 2006. Both have extensive backgrounds working with and in the substance abuse treatment community, with decades of combined experience. Michael Casarico's e-mail address is mcasarico@burlingtonlabs.com . Addiction Professional 2010 May-June;8(3):44-45
Innate temperament and eating disorder treatment
In the last 50 years, the treatment community has made significant strides in the understanding of anorexia nervosa and bulimia nervosa. Although a stronger grasp of these behavioral illnesses has led to advances in therapeutic methodology, a substantial number of patients still do not respond to standard treatment. 1 In these patients, traditional treatments such as cognitive-behavioral therapy (CBT), which aims to change mental content, are met with ambivalence and resistance. These methodologies simply will not spur lasting behavioral change in treatment-resistant patients. CBT's explicit cognitive processing approach might not work in an eating-disordered mind that is incapable of implicit processing. 2 Another traditional approach-focusing on the cause of the eating disorder-will also have little impact. The fact is, what maintains an eating disorder may be quite different from what caused it. When we instead take the time to comprehend the underlying temperament and neurocognitive processing deficits of an eating-disordered patient, and understand how they help the patient maintain an eating disorder, we can grasp the limitations of many current treatments and turn our focus to newer therapeutic methods addressing these maintaining factors. Patient characteristics Temperament and deficits in neurocognitive processing not only can set the stage for an eating disorder to manifest, but they also will act as catalysts for its maintenance. Temperament refers to those aspects of an individual's personality, such as introversion or extroversion, that are regarded as innate rather than learned. Individuals with different temperaments see the world through different lenses. These innate personality traits can play a significant role not only in an individual's predisposition to an eating disorder, but also in his/her maintenance of an eating disorder. By understanding the specific temperamental traits that are common among individuals with eating disorders, clinicians can form a more targeted, informed approach to treatment. Adapted from C. Robert Cloninger's Temperament Character Inventory, 3 the four key temperament dimensions associated with eating disorders are described below. The harm avoidance dimension of temperament, often intense in eating-disordered persons, is an expression of the brain's behavioral inhibition system. Those who are high in this temperament trait tend to overestimate the risk of hurt. They feel the somatic aspects of anxiety more intensely than the average person does. Consequently, they are more cautious, fearful, tense, timid, apprehensive, doubtful, passive, negative or pessimistic in situations that do not worry others. They tend to be inhibited in social situations. Their cautious nature has an adaptive advantage when there are real risks but can be an impediment to healthy change in treatment due to excessive avoidance of new experiences. High harm avoidance contributes to a life centered on anxiety management by way of an eating disorder. Eating-disordered patients often report that they spend a major portion of their waking existence thinking about controlling their anxiety about eating, shape and weight. The eating disorder becomes the main tactic for mentally avoiding life's anxieties. Novelty seeking is a pre-conceptual bias in the brain that relates to behavioral activation. Those who are high novelty seeking are drawn to the new and stimulating. Such individuals are quick-tempered, excitable, exploratory, enthusiastic, exuberant, curious, easily bored, impulsive and disorderly. It is not surprising that high novelty seeking is associated with binge/purge behavior. Higher novelty seeking is seen in bulimia nervosa cases and in anorexia nervosa cases with binge/purge behaviors, and is also associated with diagnostic cross-over from anorexia to bulimia. On the other hand, individuals with low novelty seeking temperaments are slow-tempered, non-inquisitive, unenthusiastic, stoical, reflective, frugal, reserved, tolerant of monotony, systematic and orderly. In eating-disordered patients, low novelty seeking is seen in restricting anorexic patients. Such individuals tend to be slaves to routines and rituals because they like things to be orderly. The behavioral maintenance system of the brain is represented by the temperament trait of reward dependence . The reward dependence trait is manifested by individual differences in response to social reward. Those who are high in this trait are tender-hearted, sensitive, socially dependent, warm and sociable. They easily form emotional attachments. High reward dependence can be advantageous when sensitivity to social cues is needed and the capacity to understand the feelings of others is beneficial. A disadvantage of high reward dependence ensues from being easily influenced by emotional appeals. Reward dependence is not consistently associated with diagnosis but can significantly affect treatment issues, such as therapeutic alliance. Finally, persistence is a bias in the brain that concerns maintenance of behavior in the face of frustration, punishment, fatigue and intermittent reward. Highly persistent individuals tend to be hard-working and ambitious overachievers. High persistence is associated with anorexia nervosa and consistent with these individuals' well-known perfectionism and inability to shift mental sets to a more healthy orientation. As genetic research informs us, temperament has significant heritable components. Therefore, psychotherapy is forced to take a different approach. When temperament-a subconscious outlook-drives eating disorder persistence, traditional therapies that aim to change conscious mental content are less useful. One such traditional therapy, CBT, seeks to replace a set of thoughts considered dysfunctional with another set of thoughts considered by rational analysis to be functional. When the neurocognitive processing deficits commonly seen in individuals with eating disorders are taken into account, one can understand why therapies such as CBT may be ineffective: Weak set shifting. Set shifting is the mental process of redirecting one's focus of attention away from one task, operation or mental set toward another. Related to a deficit in reinforcement learning, a set shifting impairment leads patients to compensate by an overreliance on models. Rule-boundness becomes the rule; flexibility training is needed. Weak central coherence. Individuals with eating disorders have an excessive attention to detail and an inability to “see the big picture.” Focused on minutiae, they “can't see the forest for the trees” and are constantly caught up in trivial and useless struggles, without seeing a broader context. When the eating disorder is maintained by subconscious outlook, traditional therapeutic activities such as changing the content of thoughts are nearly impossible to achieve. Maintaining factors There are a number of theories about what maintains eating disorders so persistently, including psychodynamic, cognitive-behavioral, psychosocial, functional contextual and psychobiological factors, among others. I subscribe to-and utilize in my treatment approach-the psychobiological model of eating disorder maintenance. This model does not exclude the other models, which have useful aspects, but extends them. The psychobiological model purports that eating disorders are maintained by an unconscious outlook. This outlook-driven by temperament and deficits in neurocognitive processing-undermines the self-directed behavior that normally serves personal intrinsic values. The temperamental traits common in eating-disordered individuals bias them toward a preponderance of negative emotions. Individuals with these genetically elevated emotional drives typically deal with negative emotions by engaging in experiential avoidance strategies, such as an eating disorder. The eating disorder behaviors then become increasingly persistent when the genetically determined information processing biases of weak set shifting and weak central coherence cause the individual to be rigid, inflexible and rule-bound. When an individual's genetic makeup is what is causing his/her eating disorder to continue, treatment professionals must take a significantly different approach to treatment. Treatment When genetically determined factors, such as temperament and deficits in neuroprocessing, are taken into account, treatment will be much more effective and will spur lasting behavioral change. Cognitive remediation, which treats the processes of thinking rather than the content, becomes the focus. Motivational Interviewing should center on helping the patient understand his/her own biological nature and making that nature work with the world in which he/she happens to live. It is a treatment approach that starts from examining one's emotional drives and conditioning, which may be outside of one's immediate awareness. At Eating Recovery Center, a behavioral hospital I co-founded in Denver, cognitive remediation therapy focuses on three key areas. Building values awareness is vital to lasting recovery. When patients understand their own intrinsic values, they are more able to see the big picture and make choices that align with their valued life direction. Values provide the context for actions and feelings, and make negative feelings significantly more tolerable. In an individual who is genetically conditioned to avoid negative feelings and, in the case of an eating-disordered individual, uses disordered eating as an avoidance tactic, this is an important distinction. Values awareness helps patients behave in accordance with an overarching long-term valued direction, and helps patients have a willingness to be present and to persist in the face of difficulty when taking steps in the valued life direction. Self-directed behavior is dependent on clear identification of intrinsic values and their related goals and purposes. Without values awareness, behavior is largely driven by likes or dislikes, moods or reactive impulses. Mindsight is the ability to see the mind in ourselves and others. It is about helping the patient understand his/her intrinsic temperamental traits, and about looking at the pros and cons of holding on to those traits in different contexts, such as academic life or career, family life, relationships and other valued areas. For example, detail focus is a pertinent trait for an individual to have if he/she is a professional proofreader, but the same trait does not necessarily have value in the big picture. Through mindsight, patients also can recognize the patterns that maintain eating-disordered behaviors and ask themselves if those behaviors are aligned with their intrinsic values. Finally, by practicing flexibility in the therapeutic setting, patients learn how to “stretch their minds” and maneuver around their innate rule-boundness and need for control. Buy-in is important in this process: Treatment professionals work with patients to explore the pros and cons of cognitive rigidity vs. flexibility. Flexibility exercises are then determined by taking into account the patient's valued directions. Flexibility exercises can include completing tasks in a different order than usual, flipping a coin to make decisions, varying mealtimes or meal content, sitting in different chairs when entering a room, or letting sealed envelopes determine what activities the patient will engage in next. Relating to real life Throughout the treatment process, a discussion of the ways in which exercises relate to the patient's real life is vital. By practicing mindsight, adherence to values and flexibility outside the purview of treatment, patients will learn to work with their innate temperaments rather than fighting against them. Values are central to this work. Without awareness of valued directions, people are often swayed by their emotional responses, which might or might not serve their long-range goals and purposes. When patients understand and align their behaviors with their valued directions, when they make room in their lives for flexibility, and when they become conscious of their thoughts and behaviors, eating disorders as coping mechanisms are no longer needed. Emmett R. Bishop, Jr., MD, CEDS, is Founding Partner and Medical Director of Eating Recovery Center, a behavioral hospital in Denver that provides comprehensive treatment and lasting recovery for eating disorders. With more than 30 years of experience in the treatment of eating disorders, Bishop designed the multilevel Clarke Center Eating Disorder Program and has completed systematic research in the field. His e-mail address is ebishop@eatingrecoverycenter.com . References Ben-Tovim DI. Outcome in patients with eating disorders: a 5-year study. Lancet 2001 Apr 21; 357:1254-7. Steinglas W. Habit learning and anorexia nervosa: a cognitive neuroscience hypothesis. Int J Eat Disord 2006 May; 39:267-75. Cloninger C. Feeling Good: Th e Science of Well-Being. New York City:Oxford University Press USA; 2004. Addiction Professional 2010 May-June;8(3):14-19
Marlowe House (Rosecrance Health Network) Rockford, Illinois
The residences that make up Rosecrance Health Network's Monarch Recovery Homes had traditionally been mansion-style homes acquired for use as an aftercare setting. Of course, those types of projects can bring on challenges, from location concerns to worries that the old plumbing might not be able to accommodate a quadrupling of the house's population. Rosecrance erased some of those anxieties and worries in deciding to relocate its recovery home for adolescent girls onto its main adolescent campus and to construct a new home on the site. The prairie-style Marlowe House offers its residents some modern conveniences along with access to calming features on the Rosecrance main campus, all while providing enough separation from other activity to convey a safe environment for the girls. That is an important consideration as these young people remain in an early and somewhat precarious stage of their recovery. “These girls need a safe environment to be able to talk about the triggers that take place,” says Denita Lynde, director of the Monarch programs. “Recovery is supposed to get easier, but it is actually easier to keep people clean in an inpatient setting.” The young women, ages 15 to 19, stay at least 90 days at Marlowe House after having completed primary inpatient treatment or intensive outpatient treatment. The house has five bedrooms, each with its own private bath, and a total capacity of 14. Lynde says the residents are surprised by the comfortable surroundings when they enter the program; many hear beforehand that sober homes tend to be located in older sections of a community. They are expected to maintain that appearance of a comfortable environment, Lynde insists. “They are expected to participate in the upkeep,” she says. “Recovery starts with self-care. To have a good foundation in recovery, you need to take care of what's around you.” She adds, “We focus on the need to give back.” The fully equipped kitchen becomes a locus of activity at the house, and the installation of two of most of the major appliances allows the program to conduct formalized life skills activities in the kitchen. As Rosecrance mapped out the construction project, it paid attention to details involving physical accommodation and environmental awareness. One bedroom was situated on the main floor of the two-story house in order to accommodate future residents' mobility-related needs, says Brad Carlson, Rosecrance's director of facilities. Planners also opted to install bamboo flooring and energy-efficient lighting. “We were trying to be green but still have a home-like setting,” Carlson says. A local design firm in the Rockford area, Larson and Darby Group, assisted Rosecrance with the Marlowe House project, including with the identification of sources of durable but attractive furniture. Marlowe House has become an effective complement to the Monarch Recovery Homes' site for adolescent boys, the restored Hillman House site located on the east side of Rockford. That renovation project took place in 2009. With the girls on the Rosecrance adolescent campus, they are able to enjoy some of the more soothing features of the campus setting, such as the serenity garden built on six acres and featuring natural stone waterfalls and ponds filled with colorful koi and other fish. “They can go down the nearby pathways, and woods separate their house from the main building on campus,” Carlson adds. Addiction Professional 2010 May-June;8(3):40-42
Centers explore advances in financial software
When a clinician at the nonprofit Huther-Doyle addiction treatment organization in Rochester, N.Y., creates a progress note, the action automatically generates a file in the billing system with all the information that has been gathered for clinical purposes populating fields in the billing system. “There used to be much greater room for error and inefficiency,” says Sharon DeLeo, Huther-Doyle's director of client accounts. While generally acknowledged as lagging behind the rest of the healthcare industry in technology adoption, addiction treatment centers are starting to take advantage of electronic health records to automate some steps on the clinical side of their operations. Perhaps getting less attention are the gradual but important advances addiction professionals also are making on the financial and billing side to match their software to staff workflow in order to reduce coding errors, speed insurance billing and ease regulatory reporting. Many treatment centers also are taking advantage of the integration between clinical and financial systems to cut down on data entry and to use quality-reporting tools to analyze their trends and improve business processes. The transition to new systems can be painful, and the goal of an entirely paper-free system an elusive one. Nevertheless, the following stories of efficiencies gained could inspire others just starting down the path. Huther-Doyle, which has four locations in the Rochester area and sees about 750 clients per day, began working with software vendor Sequest Technologies in 2003 on electronic billing. But the agency only recently upgraded its Sequest TIER (Totally Integrated Electronic Record) software to tie the patient medical record and billing modules in a workflow process. “Previously nothing was connected,” DeLeo explains. “A progress note was entered, then the medical records department would have to go through those records and re-enter data by hand into the billing system. It was a huge job. Now all those systems are connected.” The integration also helps when the state licensure authority conducts an audit. “They are able to look at charges and see the clinical documents directly attached to them,” says Joyce Mitchell, Huther-Doyle's director of health information and data management. “Those audits now go much quicker. In the old days, they would pore over lots of paper documents.” The agency is planning to take advantage of a few more features the software offers, including electronic download of insurance payments and batch eligibility checks for Medicaid. “Currently we have to do those one at a time,” DeLeo says, “and we do several hundred a week.” Mitchell notes that Huther-Doyle is not yet 100 percent paperless. “We are working toward getting signature pads to get electronic signatures from clients and clinicians, so we won't have to store any paper records at all,” she explains. “And we will have document scanning, so that if people bring paper records from other providers, those can be scanned in and made part of the records we keep.” The need for customization The biggest challenge for treatment centers is that private insurers, Medicaid and Medicare all require a facility to bill differently, says Brad Ewalt, president and founder of software vendor ClaimTrak Systems Inc. in Gilbert, Ariz. “If you are moving to automation, you have to understand how the billing is taking place and translate that into a system that follows that workflow about documenting what the insurers want,” says Ewalt, who started out as a consultant with a handful of behavioral health customers and then saw a need for customizable claims processing and client management software. The biggest challenge for treatment centers is that private insurers, Medicaid and Medicare all require a facility to bill differently. Vendors such as ClaimTrak build core systems but as they move from state to state, they need the flexibility to customize for customers' needs. “For instance, in Rhode Island, there are certain treatment programs in which providers can charge per-diems if they meet certain thresholds in a given month and if not, they have to bill fee for service,” Ewalt says. “They even have to look over a three-month period to make some of the determinations. So we develop a rule-based program that makes that determination for them about which way to bill.” Ewalt sees many treatment centers that are still completely paper-based, and others that are electronic on the billing side but still use paper charts on the clinical side. “Some of those are now moving to a complete system,” he says, “because they realize they are losing efficiency because all that data has to be re-entered.” Web-based solutions Some smaller operations are finding that web-based “software-as-a-service” solutions fit their needs. The Center for Solutions is a 24-bed residential facility in a rural setting in Cando, N.D. As chief of operations Bob Spencer explains, the center was founded as a subsidiary of a nearby nonprofit medical center, which handled the billing. “Addiction treatment billing requires some additional expertise they did not have,” he says. “Things were not being billed appropriately, and the follow-up was not being handled properly.” In October 2008, as the center sought another billing solution, it also separated from the medical center and became an independent, for-profit business. After interviewing several software vendors, Spencer chose an application service provider (ASP) solution from Valley Hope Association, the nationally known nonprofit addiction treatment service organization with facilities in seven states. “We liked Valley Hope's approach that is to build a longer-term relationship and really hold your hand. As the transition took place, they had the depth and experience to help us,” Spencer recalls. “If we had tried to do that transition ourselves with software we had purchased, I think we would have failed miserably.” The center is responsible for entering all billing information and keeping patient information current and correct, while Valley Hope submits claims to third-party payers and maintains the center's accounts. “They double-check our work and can catch it if we forget a charge,” Spencer says. “We are able to handle the billing now with only one staff person.” The Center for Solutions pays monthly fees for the billing and EHR software and another fee for Valley Hope to handle the billing services. When the medical center did the billing, Spencer knew he was losing out on revenue. “With the conversion to Valley Hope, we are capturing revenue that was leaking out, so it has more than paid for the expense involved.” Customization also is important to Tarzana Treatment Centers in California, according to director of information technology Jim Sorg. His organization has used the RADplus (Rapid Application Development) feature of Netsmart Solutions' Avatar product suite to build customized screens. “We have sought to push for better collection of co-pays and deductibles,” Sorg says. In Los Angeles County, providers can collect a therapeutic admission fee for public-sector patients, so Tarzana has developed a series of screens to help staff in the collections. “We are also able to generate automated e-mail reminders to staff to pursue collections,” Sorg adds. “It is quite flexible in allowing us to generate e-mail notifications to particular staff, for instance about billing Medi-Cal for patients who enter a detox unit.” The agency is now working on implementing a patient portal called ConsumerConnect that will eventually include a way for patients to see and pay bills online. The next step for many providers is to take advantage of quality-reporting features both internally and externally. “I am convinced that data can be the key to the success of a facility,” ClaimTrak's Ewalt says. “Agencies that can take data to payers about their outcomes and their spending often get more money and more contracts because they can justify their productivity levels.” David Raths is a freelance writer based in Pennsylvania. Addiction Professional 2010 May-June;8(3):26-28
Ethically responsible recovery
Many professionals in the field of addiction counseling have struggled with their own addiction issues and are now in a position of serving others in addiction treatment. In May 2009, Anne Hatcher, EdD, chair of the ethics committee at NAADAC, The Association for Addiction Professionals and co-chair of the Addiction Studies program at Metropolitan State College of Denver, posted a blog on the Addiction Professional Web site ( http://www.addictionpro.com ) entitled “What is our standard?” Hatcher noted, as credentialing requirements for certification are progressively being altered across the country, “An issue that keeps coming up in discussions as addiction counselors become more active members of the mental health counseling arena is whether or not addiction counselors should be held to a higher standard on behaviors relating to substance use/abuse/dependence than professionals in other mental health disciplines.” This issue led to a discussion addressing the pros and cons of establishing a specific number of years of sobriety required for a counselor in recovery to be eligible for certification. Respondents generally opposed any arbitrary abstinence limits, arguing that demonstrated sobriety requirements would be discriminatory if the standard were not applied across the board for all mental health disciplines. Furthermore, respondents argued that sobriety alone does not equal recovery, or sound emotional health for that matter. A person can be sober for many years and still not be fit to counsel others in a professional capacity. Consensus in the blog discussion emerged on one important point. All respondents think addiction counselors have a moral and ethical obligation to seek continued counseling, consultation and supervision for their own therapeutic issues as long as they work with others in a clinical setting. For recovering addiction professionals this ethical responsibility extends to include a sound program of recovery. Seen in this light, length of sobriety might not be the only indicator of a person's fitness for duty as an addiction counselor. Inferences drawn from this discussion became the basis of this article, which attempts to explore the idea of ethically responsible recovery. What constitutes recovery? The current addiction treatment model focuses on brief biopsychosocial stabilization and often generates sustainable abstinence, but not long-term recovery. 1 This generalized outcome equally applies to addiction professionals who have completed treatment to arrest their own addictions. The current acute care treatment model might initiate recovery, but sustainable recovery is an individual responsibility following treatment, and for the recovering addiction professional an ethical one. What is required to sustain sobriety is qualitatively different from what is required to sustain recovery. Recovery is the presumed goal of treatment, yet the term has remained somewhat ambiguous. An expert consensus panel convened at the Betty Ford Institute in 2006 to propose a definition of recovery; the issue was revisited in 2009. Expert panelists included a number of nationally prominent leaders from the treatment and research communities. The panel's consensus resulted in this statement: “Recovery is the best word to summarize all the positive benefits to physical, mental, and social health that can happen when alcohol- and other drug-dependent individuals get the help they need.” More specifically, the panel stated that addiction recovery is “a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.” The panel noted that while sobriety is a necessary part of recovery, the two are not synonymous. The panel refrained from prescribing a recovery process, stating, “Recovery is not synonymous with a specific method of attaining it.” Although it would be easiest to define recovery as “abstinence attained through adherence to 12-Step principles,” such an approach would limit a description of recovery to the most familiar method of achieving it, confining it to a single strategy. 2 Counseling others in addiction treatment in no way qualifies as working a sound program of recovery. It is interesting to note, however, that when professionals in other health-related fields (social workers, doctors, nurses, psychologists, etc.) are identified as impaired due to alcohol or drug problems, specific criteria must be adhered to following treatment in order to retain licensure and resume practice. Across the board, attending a self-help program is a professionally mandated requirement. 3,4 William L. White, senior research consultant at Chestnut Health Systems, who has practiced and taught in the addiction field since 1969, defines recovery as “the experience (a process and sustained status) through which individuals, families, and communities impacted by severe alcohol and other drug (AOD) use and related problems mobilize internal and external resources to voluntarily resolve these problems, heal the wounds inflicted by these problems, actively manage their continued vulnerability to such problems, and develop a healthy, productive, and meaningful life.” 1 The components of personal (mental) health and the healing of wounds contained within these definitions imply that recovery includes working through one's therapeutic issues. The underlying causes of addiction cannot be fully resolved in treatment, and susceptibility to relapse is often due to failure to make the transition into recovery maintenance. 5 Recovery occurs on a continuum and the despair, grief/loss, resentment, blame, guilt and shame associated with surviving addiction requires continued professional clinical guidance, especially for the recovering addiction professional working with others. Counselors' obligations While exploring what constitutes the concept of ethically responsible recovery for recovering addiction professionals, it is helpful to clarify what it is not. In the course of researching this topic, an interview was conducted with Donald R. Hays, behavioral health counselor at the Center for Dependency, Addiction and Rehabilitation (CeDAR) in Colorado. Hays is a former criminal defense attorney and has worked as an addiction counselor for the past 27 years. He stated emphatically, “I have worked with several counselors who have relapsed and sought treatment at a facility where I was working. In each case we had them self-report as part of their treatment. The underlying problem for all of them was they tried to use their job as their recovery program. It does not work and is unethical.” Clinical work with others does not safeguard a recovering counselor's sobriety. Addiction is a “disease of denial,” and using clinical work with clients as one's program of recovery substantially increases a recovering counselor's chances to minimize his/her own disease. 6 White offers the following suggestion: “If you are in recovery, cultivate and sustain mechanisms of recovery maintenance separate from your professional life. Working in service roles within the addictions field is not a viable program of personal recovery and may even undermine defense structures that have previously served to maintain sobriety.” Counseling others in addiction treatment in no way qualifies as working a sound program of recovery. Worse, it potentially puts clients in harm's way. Substance abuse counselors operate within an extremely complex environment, and the services they provide may have a profound impact on a client's life. 7 Addiction counselors need to be professionally accountable and they owe it to their agencies, organizations, profession and, most importantly, their clients to act within a framework of professional values and integrity. Ultimately, they need to practice what they preach. Recovering counselors who use their clinical work as their program of recovery are not only putting themselves at risk for relapse, but are using their clients for their own self-interest and are violating ethical principles. The NAADAC ethical standard that applies to this issue is found in Principle 9, Duty of Care: “ I shall operate under the principle of Duty of Care and shall maintain a working/therapeutic environment in which clients, colleagues and employees can be safe from the threat of physical, emotional, or intellectual harm .” Although this article primarily addresses the idea of ethically responsible recovery for the recovering addiction counselor, Principle 8 (Preventing Harm) of the NAADAC code of ethics implies an ethical obligation for all addiction counselors to work through their therapeutic issues. The principle states, “ I understand that every decision and action has ethical implication leading either to benefit or harm and I shall carefully consider whether any of my decisions or actions has the potential to produce harm of a physical, psychological, financial, legal or spiritual nature… ” Susan Tzankow is a graduating senior from the Addiction Studies program at Metropolitan State College of Denver and is currently a counselor intern at a women's-specific outpatient treatment facility within the University of Colorado Addiction Research and Treatment Services program. Her e-mail address is stzankow@mscd.edu . References White WL. Recovery: Old wine, flavor of the month or new organizing paradigm? Subst Use Misuse 2008; 43:1987-2000. Betty Ford Institute Consensus Panel. What is recovery? Revisiting the Betty Ford Institute Consensus Panel defi nition. Int J Mental Health Addiction. Retrieved Sept. 10, 2009 from www.springerlink.com/content/119974/?p=55aa4dc755134a94af46d51a39170 528andpi=0 . Boisaubin EU, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci 2001 Jul; 322:31-6. Clark C, Farnsworth J. Program for recovering nurses: an evaluation. MedSurg Nurs 2006 Aug; 15:223-30. White WL. The mobilization of community resources to support longterm addiction recovery. J Subst Abuse Treat 2009 Mar; 36:146-58. White WL. Alcohol, tobacco and other drug use by addictions professionals: historical refl ections and suggested guidelines. Alcoholism Treat Q 2008; 26:500-35. Toriello PJ, Benshoff JJ. Substance abuse counselors and ethical dilemmas: the influence of recovery and education level. J Addictions Off ender Couns 2003 Apr; 23:83-98. Krystal H, Moore R. Who is qualifi ed to treat an alcoholic? A discussion. Q J Stud Alcohol 1963; 27:449-59. Addiction Professional 2010 May-June;8(3):34-37
Product/Service Center
Privacy/Security IT Solutions TheraQuick TheraQuick is a state-of-the-art practice management program for mental health practitioners who want an easy-to-use program without sacrificing power and flexibility. TheraQuick offers a rich and comprehensive feature set with unparalleled ease of use. TheraQuick allows users to track client sessions and accounts, perform billing with professional custom statements, prepare paper or electronic insurance claims, process credit cards, and more-all with automation and simplicity. For more information, visit http://www.TheraQuick.com . UNI/CARE Systems, Inc. UNI/CARE is the partner for progressive, technology-astute Health and Human Services organizations. UNI/CARE's Pro-Filer is a Microsoft .NET certified Electronic Health Record enabling organizations to service multiple domains within a connected continuum of care environment. Pro-Filer seamlessly converts the consumer paper record and diverse HHS functions into an enterprise solution supporting clinical data management (CCD/CCR), revenue cycles, CPOE, PHRs, and HIE. Aligning with Microsoft's Connected HHS Framework, Pro-Filer uses a Service Oriented Architecture. Visit http://www.unicaresys.com . Adolescent Treatment Centers Aspen Education Group Aspen Education Group is a provider of therapeutic education programs for adolescents struggling with behavioral and emotional issues that interfere with their performance in school, at home, and in life. Aspen's services range from short-term intervention programs to residential treatment, and include a variety of therapeutic settings such as boarding schools and outdoor behavioral health programs. Aspen is a member of CRC Health Group, a comprehensive network of specialized behavioral healthcare services. Learn more at http://www.aspeneducation.com . Chestnut Health Systems Chestnut's nationally recognized youth treatment programs continually work to improve service outcomes through collaborations with Lighthouse Institute, Chestnut's applied behavioral research division. Since 1985, Chestnut has offered a full continuum of substance abuse treatment services for adolescents ages 13 through 18. Outpatient, intensive outpatient and gender-specific inpatient services are available at Chestnut's 54-bed facility in Bloomington, Illinois, or its 42-bed facility in Maryville, Illinois. For more information, please call (888) 924-3786 or visit http://www.chestnut.org . The Right Step With 20 years of experience, The Right Step is one of the country's greatest values in addiction treatment. Its adolescent residential program, located in its DFW center, was developed to provide for the specific needs of youths ranging from 13 to 17 years. The Adolescent IOP program (offered at 12 locations) is a clinically proven eight-week session during which adolescents spend 9 to 10 hours each week under the supervision and guidance of licensed counselors. Visit http://www.rightstep.com . Willow Springs Center Willow Springs Center is a residential treatment center for children and adolescents ages 5 to 17, currently with 20 beds dedicated to primary chemical dependency for ages 13 to 17. The Ascent Program at Willow Springs Center is a newly redesigned, Matrix-trained, substance abuse residential treatment program to help patients in a safe, therapeutic and dedicated environment. Patients live in a specific unit under the care of a multidimensional treatment team and a 24-hour medical staff. Visit http://www.willowspringsmediapsi.com . The next issue's product/service center will focus on drug testing and online assessment and treatment tools. To participate in these sections, e-mail lbarba@vendomegrp.com . Addiction Professional 2010 May-June;8(3):47
A changed payment system causes disruption
For decades, federal block grants have funded drug treatment at a variety of levels of care. Historically, most of this funding has come down by way of state contracts and grants for a dedicated number of treatment beds or slots. Programs such as Integrity House in New Jersey have received guaranteed advance funding, whether or not our beds or slots were full. We have always been close to 100 percent of our capacity-with a waiting list that numbers in the hundreds. Yet with federal and state cuts recently extending to direct services, the funding mechanism has changed from guaranteed advance pay to payment only for slots occupied, and only after the pay period or the following month. This is smart management and makes sense in a climate of diminishing state revenue. But at the same time, it creates a challenge for treatment programs to keep all beds full and to bill for these beds in a timely manner. This is complicated by the fact that we have little control over filling our beds, and the bureacracy of referring agents often causes a delay. The traditional funding system of advance pay has helped to overcome the chronically low per diem reimbursement rate offered by our state. The initial impact of the pay switch on Integrity House and all programs in New Jersey produced a major cash flow problem last year. And while most of us survived, virtually all of us had to increase our line of credit, or try to find money from other sources. A fee-for-service funding mechanism for addiction treatment brings our “industry” in line with other service providers. The problem is that our infrastructure has been established over decades on the basis of full funding for all of our beds, and Integrity House will take a loss despite the fact that we are at 98 percent utilization. Benefits of advance pay The traditional funding system of advance pay has helped to overcome the chronically low per diem reimbursement rate offered by our state. Also, through no fault of our own, there are often delays in referrals from our funding sources and a bed will stay open one more day while unfinished paperwork, warrants or other issues are resolved. If three or four prospective clients waiting to be admitted experience even one day of delay, it becomes very costly for us, since under fee for service we do not receive funds until the bed is full. In Integrity House's case this can cause a reduction of funds of as much as a quarter of a million dollars if we dip to 90 percent utilization for a length of time. Recently the state reviewed our utilization report and erroneously came up with a 90 percent rate. In all fairness, we submitted our utilization report in the incorrect format. However, we corrected the report and advised the state, with our data, that we in fact were at 98 percent utilization. The state's response was, “Too late,” as the budget already had been submitted to Trenton. As a result, we are now facing a $230,000 funding cut. We are still hopeful that our appeal will be reviewed favorably based on our correct utilization rate. The 208 people on our waiting list can ill afford a reduction in our services. It is a life-threatening issue for many of them. Policy options With this in mind, I am recommending that New Jersey officials consider two possible alternatives: Phasing fee for service in over a two-year period, which will guarantee funding as long as programs maintain 95 percent utilization. A per diem funding increase based on our actual costs and/or comparable rates with other states and/or insurance industry rates. These two simple steps would help to mitigate the potentially drastic funding crisis that we and agencies like us face, while enabling us to maintain continuity of care to achieve the best possible outcomes for our student members (clients) and for the state as a whole. David H. Kerr is Founder and President of Integrity House, a substance abuse rehabilitation center with locations in Newark and Secaucus, New Jersey that treats more than 1,400 individuals per year. He wrote in the January/February 2009 issue on Integrity House's program to treat gang-affiliated individuals. His e-mail address is dkerr@integrityhouse.org . Addiction Professional 2010 May-June;8(3):38
Raising the bar for recovery residences
Recovery residences today suffer a similar dilemma faced a generation ago in professional counseling. Anyone with a house or a room to rent can hang a shingle and call themselves “recovery housing,” “sober living,” “halfway house,” “three-quarter way housing,” “transition housing,” or various other names. The name variations are as diverse as the services provided, from a nightly place to eat, sleep and attend a mutual-help meeting to multiple-year intensive treatment programs provided by licensed professionals. The critical question is, “How do consumers, recovery professionals and other organizations know if a facility provides alcohol or other drug users and people with mental health needs with a safe, healthy environment for recovery?” A common challenge in the addiction treatment field is “what's next?” for patients stabilized at primary treatment centers who have low recovery capital, are at high risk for relapse, and whose recovery was not sustained during previous outpatient treatment. As a vital component of today's recovery care continuum, recovery residences can be an affordable and effective option as managed care creates shorter treatment stays. Professionally operated, recovery-oriented residential programs that enmesh residents in appropriate services in the local recovery community fill the service gap in a way that is not only economical, but also highly conducive to sustainable recovery. The Georgia Association of Recovery Residences (GARR) is joining other leading voices in calling for high-quality services across the emerging recovery-oriented systems of care continuum for individuals and their recovery allies. Metro Atlanta Recovery Residence townhomes - Women's Program, Lawrenceville, GA GARR is a unique 501(c)3 organization that serves as a professional, volunteer accrediting body for recovery residence organizations in Georgia. Our members encompass varied demographics, for-profit and non-profit providers, and a range of service levels-from long-term treatment to what traditionally has been called a “sober home.” Operationally, we are a diverse group of organizations large and small. Our commonality is a shared commitment to professional standards of operation and recovery services supported by accountability to our local communities and to one another. History and evolution GARR was founded in 1987 in Atlanta by seven demographically diverse recovery residences that came together for the purpose of support, accountability and idea sharing. Doug Brush, Past President of GARR and Men's Director of the Metro Atlanta Recovery Residences, says GARR's history “began as support meetings, particularly around issues of interfacing with the people and communities in which our facilities were located. Soon we established standards that would enhance the recovery programs of our organizations, and developed written criteria for recovery residence operations. We then created a peer review system and opened our organization for membership. Over time, GARR's monthly meetings have evolved to include offering CEU trainings as an additional benefit to our members, as well as the professional community. Though the organization has grown tremendously, the founding principals of idea sharing, peer support, professional accountability, and most importantly quality operational standards remain essential to the GARR mission.” Under the leadership of Joel Bagley, Immediate Past President of GARR and Executive Director of Purple, Inc., membership has grown to 53 organizations at varying levels of care, serving approximately 2,000 men and women in Georgia. This represents 17 percent of total residential recovery services provided in our state. Common living area at Hope Homes, Inc., Atlanta GARR's Executive Committee meets monthly for action planning, and membership meetings occur bimonthly for information sharing, fellowship and CEU trainings. Staff from member facilities volunteer for a variety of roles. Those who complete accreditation training conduct site visits with existing and prospective members. The accreditation and re-accreditation process is a time of training and mentoring. Often newcomers have a passion for helping others but are unaware of the need for such essentials as a written policy and procedure manual, a business license, or even an understanding of local zoning requirements. The accreditation process helps the newcomer define “who we want to be” along the continuum from residential treatment to supportive living. If treatment groups and counseling services are offered in a residence, the new organization is also guided toward obtaining the necessary state licensure to provide these services. Guiding principles Five cornerstone principles guide GARR's work: Promoting professionalism and quality standards for recovery residences . GARR standards are extensive and address the core areas of operations, facilities, and services provided. Reviewers are longtime recovery residence operators. Each prospective member is reviewed carefully and brought to committee for final approval. Organizations that do not evidence professional operating practices or a minimum of recovery support services and programming are not granted accreditation. All GARR members demonstrate professionalism through their record keeping, staffing and safety protocol (i.e., drug screening, emergency procedures). Each residential program must provide evidence of written policy and procedures that meet the GARR standards, as well as appropriate staffing (such as adequate resident-to-staff ratios, adequate qualifications for specific positions, etc.). Clear, ethical financial protocols must also be evidenced. All member facilities provide some type of programming to support and develop resident recovery skills. Treatment programs offer a varying number of clinical counseling hours each week, while extended care programs offer life skills classes. Members are professionally accountable . Re-accreditation site visits occur every two years to ensure that the organizations are following GARR standards. Also, the GARR Ethics Committee reviews and resolves written concerns or complaints regarding a member residence. Barbara Sickmon, the Ethics Committee Chair throughout GARR's history, continues to resolve ethics complaints through collaborative action plans that typically do not result in sanctions. Members value GARR accreditation as it becomes more widely recognized as a stamp of quality in the state of Georgia; if there are issues cited, most facilities will take quick corrective action in order to maintain their status. Our collective membership is a source of support, idea sharing and mentoring for each other and prospective members . GARR's bimonthly membership meetings are well attended. The spirit of non-competitive camaraderie recognizes each program's niche-and acknowledges that need far exceeds capacity. New members are welcomed and helped in addressing the inevitable challenges they will face. Invariably, mentoring begins with more experienced programs, a parallel process to working the program of recovery that we espouse. Continuing education trainings provided for a nominal fee at each GARR membership meeting provide opportunities to develop skills, maintain individual credentials and expand networks with the professional community. Active collaboration with all levels of care in the professional community GARR members recognize that there is a “continuum of care” and that successful programs assist their residents in moving fluidly through it. We partner with primary treatment centers, the legal system, mental health providers, vocational and employment resources, and the 12-Step community to assist our residents in developing living skills to sustain ongoing recovery. GARR member meetings provide a forum for sharing these resources-everything from alcohol and drug testing to liability insurance. Additionally, GARR collaborates with other professional organizations to sponsor an annual Recovery Networking Fair and conference each September during Recovery Month. Partnering with community resources to promote alcohol and other drug recovery Every year, GARR along with other professional recovery organizations in Georgia, including the Georgia Council on Substance Abuse (GCSA), host a Recovery Awareness day at the state Capitol. This year official proclamations supporting alcohol and other drug recovery were read in each chamber of the legislature, where the galleys were packed with people in recovery and their allies who wore “Recovery Happens!” T-shirts. Neil Kaltenecker, GARR's Secretary and the Executive Director of the GCSA, organized recovery advocacy training that delivered a consistent message to many legislators who received personal testimonies from people carrying a message of “Replace Stigma with Recovery Resources.” GARR is also an active partner with the State Board of Pardons and Paroles and the Department of Corrections. Recovery residence services provide an important alternative to incarceration, and GARR members fulfill an equally vital role in successful community reentry. George Braucht, GARR Executive Committee member and Program Specialist with the Georgia Parole Board, describes GARR's role in harnessing “the emergent power of wellness and recovery from alcohol and drug use and criminal behavior. This most often develops through long-term, albeit sometimes intermittent, involvement in indigenous social support systems and activities.” He adds, “I expect that empirical research will show that these recovery services produced unprecedented improvements in personal health and community safety early in the 21st century.” Occasionally a local government will attempt to impose housing restrictions that unknowingly violate the Americans With Disabilities Act (ADA) and fair housing statues. J. Scott Maddox, GARR's Legislative and Community Affairs Committee Chair and Executive Director of Alpha Recovery, assists the local member in responding by providing thorough documentation of the relevant federal statutes along with recent case law. GARR works with local governments to ensure that the rights of people in recovery are recognized while promoting community safety and health. Elevating the field GARR is developing a database of service outcomes that will assist in establishing the efficacy of recovery residences . What is found to be effective is spread throughout member organizations via the GARR standards, which are periodically reviewed and updated. On the basis of this experience, GARR is beginning an important national dialogue on standardizing operations and terminology pertinent to residential levels of care. We seek to define universal levels of care for recovery residences (preferred term) while dispensing with the archaic, nebulous and stigma-laden terms “halfway” and “three-quarter way” house. GARR members are beginning discussions with thought leaders utilizing language from the American Society of Addiction Medicine (ASAM) Patient Placement Criteria manual. Rather than reinvent the wheel, we can hone ASAM-PPC terminology to better apply to freestanding recovery residences. In particular, PPC levels III (clinically managed residential) and II (less intensive service provision) require finer granularity to better apply to residential service providers. There are many advantages to using the ASAM criteria, but most important for the patient will be a vastly improved fluidity and collaboration along the continuum of care. By utilizing a universally understood language and level of care, the patient can be effectively placed at the level of care appropriate to clinical needs. More will be forthcoming in the professional literature about this, and your thoughts and input are welcome in these discussions. Finally, perhaps the recovery field is in need of a cohesive national association for recovery residences. Oxford Houses have been around since 1975 as a model for peer-owned and -operated recovery residences. The Connecticut Community for Addiction Recovery has an unprecedented Internet presence for locating “recovery housing.” CARF accredits a variety of recovery residence programs. GARR, a member of the National Association of Addiction Treatment Providers (NAATP), is unique as a statewide, peer-to-peer accrediting body for recovery residences. A national association involving all of these organizations could increase our professional legitimacy and the strength of our advocacy. In today's changing healthcare market, creating a nationally accepted nomenclature and corresponding standards for recovery residences is paramount to our survival. I invite you to join in the developing discussions regarding recovery residences. Working together we can ensure that appropriate, professional care and sufficient funding are readily available for the individuals and communities we serve. Beth Fisher, LCSW, MAC, CCS, is President of the Georgia Association of Recovery Residences ( http://www.garronline.org ). She also is the Founder and Executive Director of Hope Homes, Inc., an extended care recovery residence in Atlanta. Her e-mail address is beth.fisher@hopehomesrecovery.org . Addiction Professional 2010 May-June;8(3):8-13
Calif. treatment center sees unexpected cohort of obesity surgery patients
An unusual pattern has emerged in recent months at the New Dawn Recovery Centers addiction treatment operations near Sacramento, Calif.: A steady number of patients who have undergone gastric bypass surgery, many with little more than a social drinking history, are presenting with serious alcohol-related problems. The facility’s medical director, David Smith, MD, says many individuals who have had the obesity treatment procedure report difficulty controlling their drinking post-surgery. He says some describe a scenario of becoming intoxicated more quickly than they did before the surgery, while others will drink large amounts and receive no warning of problems before getting “clobbered.” Medical literature lists an ongoing problem with alcohol as a factor that could eliminate an obese person from consideration for gastric bypass surgery, a procedure that is generally considered only for severely overweight individuals who have already tried a number of other weight-loss measures. But Smith says some of the problems New Dawn has seen involve people who have engaged in social drinking, which might mean that broader warnings targeting candidates for the surgery should be implemented. “If alcohol abuse is in someone’s past and now they’re a moderate user, they shouldn’t drink at all,” Smith says. “If someone is at the two-to-three drinks a day level, these folks really need to not be drinking.” Smith points out that research has described a more rapid peak of alcohol absorption in individuals who have had the surgery, in which a plastic band or surgical staples are used to create a pouch at the top of the stomach to reduce its size. But he adds that he is not familiar with any medical descriptions of what many patients have described as “the lid coming off” when they try to resume moderate levels of drinking post-surgery. Once these patients enter treatment, they present with a variety of complicating issues, including issues around body image as they have begun to lose significant weight, Smith says. New Dawn is in the process of organizing an August meeting in its community, where it hopes to educate centers that perform the obesity surgery to be aware of a subject that they might want to discuss in advance with their patients. “They need to give patients a full education that this could be a consequence of the surgery,” Smith says. “This is potentially a completely preventable form of alcoholism.”
As NAATP conference approaches, no word on suspended association director
Less than a month before the National Association of Addiction Treatment Providers’ (NAATP’s) annual conference in San Antonio, members of the association do not know whether their chief executive will be actively serving in that position when the meeting convenes. There has been no further word on the NAATP board of directors’ investigation announced to members March 31 in the wake of a review of NAATP by the Pennsylvania Attorney General’s office. The board that day suspended Ronald J. Hunsicker, DMin, from his position as president and CEO and told members that the association’s everyday work would continue while it sought to learn more about the substance of the state’s review. NAATP’s staff offices are based in Lancaster, Pa. Over the past several weeks, NAATP board members have deferred all questions about the matter to board chair Cathy Palm, executive director of Tully Hill Corporation in New York. Palm has not replied to questions from Addiction Professional about the investigation or the ongoing activities of NAATP in Hunsicker’s absence. Likewise, the Pennsylvania Attorney General’s office has issued no public comments in regard to the matter. It will not confirm that any ongoing investigation is even under way. NAATP has continued to send out regular communications to members and the field at large about subjects not related to the suspension of its chief executive. In recent days, it has extended to April 30 the group-rate deadline for room reservations at its May 22-25 annual Addiction Treatment Leadership Conference. It also has extended to May 15 its deadline for members to complete the 2010 NAATP Benchmark Survey, which offers an annual snapshot of treatment center programs and practices. The ongoing investigation at NAATP also has not had an effect on planning for the inaugural National Conference on Addiction Disorders (NCAD) in September, an event founded by Vendome Group (publisher of Addiction Professional ) and co-hosted by NAATP and NAADAC, the Association for Addiction Professionals.
Recovery communities are thriving at more college campuses
About 60 educators and researchers this month attended a three-day conference at Texas Tech University to discuss how to promote the establishment and growth of recovery communities on college campuses. The number of attendees in this case was less important than the momentum being seen in the recovery movement at colleges and universities nationwide, including on the half dozen campuses that have replicated a model established at Texas Tech in the mid-1980s. Kitty Harris-Wilkes, director of the Center for the Study of Addiction and Recovery at Texas Tech, says the federal government in 2005 began to give funding support to the university for efforts to disseminate its Collegiate Recovery Community model. Texas Tech offers a variety of recovery support services to about 70 to 80 of its students each semester; there is no requirement as to the type of treatment a recovering student must have received before entering the program, or even that a student received formal treatment at all. While many colleges across the country have regular 12-Step meetings somewhere on campus, Harris-Wilkes’ center sees that as a good starting point but not a full recovery support program. She says that two critical elements to a successful campus program are a designated space on campus that helps nurture a community of recovering students, and an integration of support staff (mentors, recovery coaches) with students. “Colleges need to make available a designated space, so that students in recovery don’t feel shunned, so that they’re told, ‘We value your presence here,’” Harris-Wilkes says. In Texas Tech’s case, that space remarkably took the form of a 17,000-square-foot building that houses both the Center for the Study of Addiction and Recovery and a basement area with space for pool tables, a study area, a TV room and a meditation room. Harris-Wilkes adds that while some schools think about a space for students in terms of recovery housing, she does not consider a housing component to be a necessity for a campus’s plan. Schools that have adopted Texas Tech’s Collegiate Recovery Community model include the University of Texas at Austin, Vanderbilt University, Georgia Southern University and Kennesaw State University, Harris-Wilkes says. Limited resources at universities do continue to pose an obstacle toward wider adoption of recovery community models on campus, Harris-Wilkes says. Stigma against recovering addicts also creates barriers, although she says many students have become increasingly willing to be part of an open recovering community on campus. Conservative estimates have pegged the recovering population on college campuses across the country at 50,000. “Recovery is becoming an accepted part of the campus community,” Harris-Wilkes says.
Hallmark drama profiles Al-Anon founder
With over 24,000 groups across the world, Al-Anon has become an international support tool for families and friends of alcoholics since its beginning in 1951. But the story of its founder—Lois Wilson, the wife of Alcoholics Anonymous co-founder Bill Wilson—is little known. Thankfully, that will all change this weekend when Hallmark’s latest film in its Hall of Fame series, The Lois Wilson Story: When Love Is Not Enough, debuts on CBS. Lois’ story is told by personal friend William Borchert, who co-wrote the screenplay based upon his book by the same name. He also wrote the screenplay for the Emmy-winning film My Name is Bill W. “This is an incredible movie about the woman who really is responsible for everything; without Lois Wilson there would have been no AA, because there would have been no Bill Wilson—he would have died,” Borchert says. “Finally, Lois Wilson is getting her due and the world is coming to know what she has done for millions and millions of families.” Borchert became acquainted with Wilson after his wife met her at a local picnic. Living not far away from her Bedford Hills, N.Y. home, Borchert paid a visit to Wilson. “She showed me around the house and upstairs in her home, she had photographs and replicas and all kinds of awards she and Bill Wilson got from traveling the world,” Borchert recalls. “What I saw was a fantastic movie laid out in front of me.” William Borchert walks Lois Wilson to the podium to address guests at an Al-Anon family picnic in 1986. Photo from The Stepping Stones Foundation. Wilson was skeptical at first, but Borchert’s wife assured her of his writing talents. “I then spent a great deal of time with her with a tape recorder,” he says. “She shared her whole life with me.” From these conversations with Wilson, as well as meetings with friends of Bill Wilson, Borchert developed the screenplay for My Name is Bill W. “But I felt bad because there wasn’t time in the movie to tell much of Lois’ story, which was extraordinarily important because she co-founded Al-Anon,” he adds. Wilson’s anonymous status, as required by Al-Anon tradition, prevented Borchert from producing a film exclusively about her and her efforts in the recovery community. But after her death in 1988, he decided to put all of his archived material to good use and write her biography, which would eventually be published by Hazelden Publishing in 2005. The basis of Borchert’s story is the deep bond between Bill and Lois Wilson—but the real message lies in the fact that this love is not enough to help Bill overcome his alcoholism. “I believe this could be a very important support tool because it so clearly shows how alcoholism develops in a family and how Lois didn’t understand what was going on,” Borchert says. “She thought that her love for him would be enough to cure him and get him to stop drinking. A lot of families believe that—how often have we heard a wife say to her husband, ‘If you really loved me, you wouldn’t drink like that.’” Even after Bill Wilson achieved recovery through the co-founding of AA and the 12 Steps alongside Dr. Bob, Lois Wilson continued to be affected by his disease. It was at this point in Bill’s recovery, in fact, that Lois was most distraught. “She thought once he stopped drinking—and this is what families go through, too—everything would be fine,” Borchert says. “But when he got sober, she found that she was angry, resentful, and couldn’t understand why. She also had lost a lot of her spirituality; she had stopped praying, she had given up hope, and she didn’t realize any of this until he got sober.” After an argument during one of Bill’s AA meetings at their home, Wilson stepped outside to clear her head and noticed a line of cars outside her house—each with a woman waiting inside. “She found out that these women had been driving their husbands to the meetings to make sure they got there and were driving them home to make sure they got home sober,” Borchert says. “So she invited these ladies into her kitchen for a cup of tea, and as they sat around the kitchen table talking, she began to hear from them what she was feeling inside of herself—despair, hopelessness, resentment, anger.” After this impromptu meeting, Wilson “adapted” the 12 Steps that her husband had written to guide his recovery from alcoholism to fit with her own journey toward recovery. These adapted 12 Steps would become the foundation of Al-Anon, “a fellowship of relatives and friends of alcoholics who share their experience, strength, and hope in order to solve their common problems.” Borchert is a recovering alcoholic himself, having been sober for 48 years, and he knows firsthand how widely the effects of alcoholism are felt. “There are somewhere around 35 to 40 million alcoholics in the U.S. alone, and each one of them affects at least five to seven other people. So that means there’s over 200 million people in this country impacted by the disease of alcoholism and so many of them don’t know what to do or where to go,” he says. “Lois Wilson shows the way. She had the answers, and it comes across in this movie. She found her way out and started a 12-Step program to help families do the same thing.” Aside from being a support tool for families of those in recovery, Borchert hopes that his films will also help raise awareness of alcoholism and other addictions as chronic diseases. “It’s not a moral lapse and it’s not a criminal thing—it’s an actual disease,” he says. “The American Medical Association said that back in 1951, but there is still a stigma attached to it and people still look upon alcohol and drug addicts as weak-willed or criminal or bad because it’s a difficult disease to understand.” To commemorate the film’s premiere, Hazelden Publishing has released a movie edition of the book. The film will air Sunday, April 25th, on CBS and stars Winona Ryder as Lois Wilson and Barry Pepper as Bill Wilson.
SAMHSA organizes gathering of substance use and primary care professionals
An effort to encourage linkages between the addiction treatment and primary care service systems is at the heart of a one-day gathering to be held this June prior to the 72nd College on Problems of Drug Dependence. The Substance Abuse and Mental Health Services Administration (SAMHSA) is sponsoring the all-day satellite session, “Linking Health Care and Substance Use Disorders Services: Supporting Health and Wellness,” on June 12 in Scottsdale, Ariz. Free registration is being offered for the session, and free continuing education units are being provided by NAADAC, the Association for Addiction Professionals and the National Board for Certified Counselors (NBCC). SAMHSA’s Center for Substance Abuse Treatment (CSAT) is the sponsoring unit, with the center’s H. Westley Clark, MD, MPH, scheduled to deliver the keynote presentation for the satellite session. The list of scheduled speakers and panel discussion participants represents a diversity of experts from both the specialty addiction treatment and general medical worlds. Included on the schedule are Ira J. Marion, director of government and community relations at the Albert Einstein College of Medicine’s Department of Psychiatry and Behavioral Sciences; Larry Gentilello, MD, professor of surgery at the University of Texas Southwestern Medical Center and a leader in the area of general medical screening and brief intervention for substance use problems; Sue Griffith, supervisor of behavioral health at Providence Regional Medical Center Everett; and Kyu Rhee, MD, chief public health officer at the Health Resources and Services Administration (HRSA). According to a statement from SAMHSA about the process of bringing the substance use treatment and primary care communities together, “Such collaboration is expected to enhance integrated care for individuals and families. Improved health and well-being is the ultimate goal.” Online registration is available through May 16, by visiting http://conferences.jbsinternational.com/cpdd2010 . For more information, contact Peter Edwards at (240) 645-4130 or pedwards@jbsinternational.com .
Conference lineup demonstrates that holistic care has arrived
John Giordano recalls a time not long ago when addiction professionals would chuckle upon hearing a colleague talk of providing “holistic” treatment. Today, it would appear that some of the most prestigious treatment centers can’t move fast enough to be associated with the term, now that more are seeing how complementary therapies can help improve upon the success of traditional treatment strategies. “Fifteen years ago, people didn’t know what the term meant,” says Giordano, co-founder and president of the G&G Holistic Addiction Treatment Program in Dade County, Florida. “Holistic treatment means to treat someone globally.” Using more blunt language, Giordano scoffs at those who claim to use a medical model for treating addictions but who never assess key biomarkers that could be a major source or exacerbating factor for patients’ problems. “They call addiction treatment a medical model, but if it’s a medical model then everyone should be sued for malpractice,” Giordano said. Later this month, close to 1,000 professionals are expected to attend a conference in Las Vegas that is being called “Holistic Treatment: Changing the Way We Look at Recovery—Body, Mind & Spirit.” The April 28-30 event is being hosted by Giordano’s center along with the Alliance for Addiction Solutions (a group of integrative medicine experts) and Foundations Recovery Network, a leading voice nationally on effective treatment of co-occurring addiction and mental health disorders. Other prominent co-hosts and sponsoring organizations read like a who’s who of well-regarded addiction treatment facilities. The list includes CRC Health Group, Crossroads Centre Antigua, Hanley Center, The Meadows, Memorial-Hermann Prevention & Recovery Center, Pine Grove Behavioral Health, Promises Treatment Centers and Spirit Lodge. “Everyone’s looking at what we’re doing,” Giordano says. Conference materials state that the target audience includes clinicians of various roles, including chemical dependency counselors and psychologists. Giordano says organizers want attendees to leave the meeting with “a bigger tool bag,” so that they “can stop looking at what they do from just one angle.” Attendees will have firsthand exposure to some of the types of treatment and other services that come under the large umbrella of holistic care. There will be acupuncturists in attendance, as well as people well-versed in amino acid therapies, nutritional aids and hyperbaric therapies. It is important to remember several factors related to these and other complementary therapies, Giordano says: They enhance but don’t replace 12-Step and other effective treatments; their users can never make claims that they “cure” a disease; and they need to be carried out in accordance with voluminous research that illustrates best practices for their use. “The studies say that for acupuncture to be effective it needs to be done four or five times a week, but some programs offer it once a week and say they are holistic,” Giordano says. “Other programs say they have gym facilities, but then you find out that it’s three machines in a room.” For registration information or other details surrounding the conference, visit www.foundationsevents.com .
BREAKING NEWS: Longtime CEO of National Association of Addiction Treatment Providers suspended
Members of the National Association of Addiction Treatment Providers (NAATP) were informed this week that the executive who helped rebuild the association after sagging membership more than a decade ago has been suspended amid an investigation by the Pennsylvania Attorney General’s office. Addiction Professional on April 2 confirmed through multiple sources that members of the association representing most of the country’s largest addiction treatment centers received a communication this week about president and CEO Ronald J. Hunsicker, DMin. The message from NAATP board chairperson Cathy Palm (see full text below) stated that Hunsicker was suspended effective March 31 and that the NAATP board of directors also has initiated its own investigation. The communication from Palm does not specify the nature of either investigation or of any alleged actions by Hunsicker. NAATP’s staff office is based in Lancaster, Pa. A spokesperson for the state Attorney General’s office could not be reached this week. Contacted via e-mail for a comment on the morning of April 2, board chair Palm reported that she would be unavailable for much of the day. Palm is executive director of Tully Hill Corporation in Tully, N.Y. Some leaders in the addiction treatment community this week expressed support and concern for Hunsicker, with one stating the hope that what is being looked into is a mistake and another expressing the desire that the matter be resolved quickly. Hunsicker has received numerous accolades and honors for his work as an association executive and as an advocate for public policy initiatives related to substance use treatment. These honors have included the prestigious Father Joseph C. Martin Professional Excellence Award from the Father Martin’s Ashley treatment facility in Maryland. Here is the full text of the communication from Palm that was delivered to NAATP members: “Effective today, Wednesday, March 31, 2010, Dr. Ron Hunsicker has been suspended from his position as President/CEO of the National Association of Addiction Treatment Providers. This action has been taken as a result of a review of NAATP by the Attorney General of the Commonwealth of Pennsylvania that is currently underway. In light of this review, the Board of Directors of NAATP has initiated its own investigation and felt that it would be inappropriate for Dr. Hunsicker to continue in his position while his actions are being examined. “As Chair of the Board, I want to assure you that the important and vital work of our organization will continue and we will keep all affected parties informed as we learn more about the direction and scope of the Attorney General’s review.” (Check the Addiction Professional Web site for further information on the NAATP situation as it becomes available.)
Michigan company seeks to create community around medical marijuana
Adoption of medical marijuana initiatives at the state level has established communities of legal growers and caregivers supporting this newly authorized use of the drug. It also has created some new ventures in publishing, first surfacing in California and now under way in Michigan. A group of editors this week was putting the finishing touches on the fifth issue of the monthly Michigan Medical Marijuana Magazine , a publication featuring regular contributions from a physician, a legal advocate and a gardener, among others. Contributing editor Rick Thompson says the magazine is intended to connect medical marijuana patients and caregivers in his state and does not focus much on broader marijuana legalization, although he leaves no doubt about his views on that subject. “Once the baby step of decriminalizing medical marijuana nationally occurs, the legality issue will fall into place,” Thompson says. Thompson co-founded the magazine with Rick Ferris, a former construction worker whose landscaping business has been transformed since Michigan voters approved a medical marijuana ballot item in November 2008. Ferris and his wife are medical marijuana patients, with the debilitating pain that caused Ferris to leave construction work being the reason for his marijuana use, Thompson says. Ferris’s Big Daddy’s Management Group in Oak Park now manufactures hydroponic growing systems and publishes the magazine. Thompson says the 40-plus page magazine is meeting its expenses through a combination of paid advertising and a $5 per issue subscription price. “Our goal is to make the process easier for patients to access,” he says. “We include a lot of information about non-smoked varieties of marijuana.” Thompson is critical of aspects of the state’s medical marijuana program, saying patients are being required to wait four to five months to receive the identification cards that document their enrollment. In addition, he believes the state has been slow to expand the overall number of medical conditions that can allow someone to use marijuana legally—leaving out illnesses such as multiple sclerosis for the time being. Also, Thompson says some police officials around the state have maintained a blanket law-and-order mindset around marijuana. “One sheriff refuses to accept paperwork and wants to see the [identification] card,” even after the period in which paperwork is allowed as documentation in the law, Thompson says. “Some are still resisting the new laws.”
Health reform: Addiction no longer left on the outside
The days when the addiction treatment community would have to wait years for their stake in landmark national legislation (remember the “limited parity” law in the 1990s?) might seem centuries away to those who have examined the newly adopted health reform legislation. Numerous references to addiction services and professionals in the Patient Protection and Affordable Care Act indicate an inclusiveness that the substance use provider and patient communities had not come to expect less than a generation ago. As State Associations of Addiction Services (SAAS) proclaimed in a news update on the day President Obama signed the bill into law, “When the law is fully implemented, 32 million Americans who are uninsured today will have access to health insurance coverage that includes mental health and substance use disorder treatment services at parity.” New Medicaid eligibles under the law will see addiction services as a mandated benefit in the minimum benefits package, while all health plans in the individual and small group markets will be required to offer addiction and mental health benefits under terms that reflect the comprehensive federal parity act. Much of the change in the healthcare marketplace will not take shape for four years, and that might be the amount of time the field will need to understand all the implications of this sweeping new law, especially in less-publicized areas such as preventive services and healthcare workforce development. There also are ample opportunities for further refinements, to say nothing about how the public will react and how it will treat both supporters and opponents of the law in this fall’s elections. Yet this week, addiction field leaders were proclaiming a full turning of the corner in terms of how policy leaders are viewing substance abuse services vis-à-vis the rest of healthcare. “Today’s historic bill signing ceremony capped a 17-year effort to bring treatment of diseases of the brain in line with the treatment of diseases of the body and built on the foundation laid by the field’s historic parity victory,” SAAS stated in its alert. An area that has received relatively little attention to date, but one that is bound to resonate with the leading professional groups in the addiction field, involves the new law’s multiple provisions on development of the behavioral health workforce. The law’s section on substance use and mental health workforce development includes: • A loan repayment program that in part targets professionals choosing to practice in the underserved areas of child and adolescent behavioral services. • Priority funding status for institutions that emphasize the needs of vulnerable populations and that embrace evidence-based approaches to treatment and prevention services. • A $10 million authorization for developing the behavioral health workforce in child and adolescent services.
An overseas view of addiction
Thomas Friedman of The New York Times writes in Hot, Flat and Crowded that nothing from our past will adequately prepare us for the world we now face; this is especially true in the field of addictions. The United States has much to learn from how the rest of the world faces its addiction issues, and vice versa. This is especially the case in Asia and the Middle East, where addiction problems are rapidly growing—as are treatment and prevention approaches. It would be absurd to speak of “Asia” or “the Middle East” as a single entity, even as it would be difficult to encapsulate what is happening in each of our 50 states by speaking of an “American approach.” Therefore, broad statements about the prevalence of drug and alcohol abuse in various continents need to be somewhat limited. Also, it is important to understand that many nations separate alcohol problems from drug abuse and dependence. The public in many Asian and Middle Eastern countries views alcohol abuse as a “bad habit,” certainly not as a disease. For example, in China, the general public thinks it is a matter of will power—easily overcome if one sets one’s mind to do so. Alcohol abuse is not viewed either by the public or by policy leaders as a disease. On the other hand, drug abuse is seen as an evil of society and is not tolerated, and draconian policies have been attempted to control the problem. It is clear that alcohol and drug abuse is on the rise in much of the Middle East and Asia. Over the past five years, alcohol abuse and dependence has become a bigger problem in the Middle East, as have heroin, cannabis and prescription drug use and abuse. Throughout the region, the age of starting drug use is decreasing, IV drug use is increasing, women are using drugs more often, and most drug abusers are not seeking treatment, either because of limited resources or social stigma. All of these factors are contributing to the spread of HIV/AIDS throughout the Middle East. UNAIDS (The Joint United Nations Programme on HIV/AIDS) and UNODC (the United Nations Office on Drugs and Crime) have made significant efforts to address this growing problem. According to the 2007 World Drug Report, production and distribution of illicit drugs continues to be a worrisome trend in the Middle East and North Africa. In China, Korea and Japan, alcohol abuse and alcoholism are rising at startling rates. If the current trends continue in alcohol consumption, in the next 15 to 20 years China will have the world’s highest per capita consumption of alcohol. China already is the largest manufacturer of beer and spirits. Policy response To address these issues, many nations are developing or have developed national drug policies; have sought to increase their understanding of causation, consequences, and care of the addict; and have increased the range of community services available for prevention and treatment. Sadly, this is not the case in China, where environmental, financial and growth-oriented issues are atop leaders’ agendas. Healthcare, and especially behavioral health problems such as substance abuse, are relatively low on their list. The general attitude of the government is “we’ll get to those issues later. We’re on an economic tear and that’s all that matters.” Other Asian countries are addressing substance use issues, however. Vietnam, for example, with the assistance of the U.S. Centers for Disease Control and Prevention, the White House and the U.S. Agency for International Development, is directing considerable attention to the rapid spread of drug abuse and a startling rise in the number of HIV/AIDS cases, mostly related to IV drug use. Methadone maintenance is being used at increasing rates throughout Vietnam. The same is true for other Asian nations, as the public’s attitudes about drug abuse continue to change. Generally, the public in Vietnam and other Asian nations sees alcohol abuse and alcohol dependence much as China does. Overall, there are significant efforts to promote a sense of psychosocial well-being and prevention. In Morocco, among street children ages 8 to 13, 65 percent are inhalant users and 20 percent are cannabis users. A number of substance abuse-related problems have arisen in addition to HIV/AIDS: hepatitis, legal and criminal consequences, traffic accidents, domestic violence, and comorbidity of psychiatric disorders. In Iran, nearly four million people use opioids, and 2.5 million fit the DSM-IV diagnostic profile for opioid abuse, with 1.2 million meeting criteria for opioid dependence. Alcohol abuse is less common, with 250,000 alcohol abusers. Annually, 1,000 tons of heroin and morphine are consumed, with Afghanistan being the primary source of opioids. Sixteen percent of drug abusers in Iran are IV drug users; the mean starting age for that group is 26. Over the past 15 years, Iran has made a major investment in detoxification centers (100 government and 600 private centers), inpatient care (approximately 500 beds nationwide), therapeutic communities (at more than 35 centers) and Narcotics Anonymous (NA) groups (more than 12,000 NA members). In fact, Iran is the nation with the fastest-growing number of NA groups. Palestine territory presents different challenges. Drug injection is a moderate problem, especially for heroin, cocaine and morphine derivatives. Clean needles are available but are not free. The most urgent substance-related problems include hepatitis, comorbidity and adolescent drug use. In Iraq, there has been a significant increase in drug abuse among children and youth. The main reason given for this rise is the psychological effects of violence and the loss of family members. Author’s experience In Turkey, the country where I have spent much of the past two years, there is a dramatic increase in the number of street children and youths using drugs, including inhalants, stimulants, heroin and cannabis. There remain few treatment resources available to address these issues, with the Oya Bahadir Yuksel Sokak Cocuklari Rehabilitation center as the lead agency in the country; it has the capacity to treat up to 60 adolescents. Established in 2008, this center has become the premier adolescent substance abuse treatment program in Turkey and for much of the Middle East. Clearly, the drug abuse issue is a global trend that must be approached with international solutions. For more information, contact me at djpowell2@yahoo.com , or contact the International Network of Treatment and Rehabilitation Centers via rrawson@mednet.icla.edu . David J. Powell, PhD, is President of the International Center for Health Concerns, Inc. ( www.ichc-us.org ). His e-mail address is djpowell2@yahoo.com .
For alcohol dependence with depression, two meds may be better than one
The latest research to bolster the argument for combination treatments could offer hope to professionals treating co-occurring alcohol dependence and depression. A study published March 15 in the online advance edition of the American Journal of Psychiatry found that patients taking both the opioid antagonist naltrexone and the antidepressant sertraline were able to maintain abstinence from alcohol more effectively than were individuals on just one of the medications or no medication. Another interesting facet to the study was that all study groups also received weekly cognitive-behavioral therapy (CBT) as part of study treatment; that appeared to generate reductions in depressive symptoms among study participants. The research team led by Helen M. Pettinati, PhD, of the University of Pennsylvania, emphasized the importance of identifying and managing both disorders in patients with co-occurring problems, in that the persistence of one disorder can worsen symptoms of the other. The study examined 170 alcohol-dependent adults with depression, randomly assigning them to 14 weeks of treatment with naltrexone alone, sertraline alone, both medications, or two placebos. The selective serotonin reuptake inhibitor (SSRI) sertraline is sold under the brand name Zoloft. The researchers selected daily doses for both medications that are in excess of federally approved standards, based on their desire to see maximum therapeutic benefits in subjects. The researchers found that 53.7 percent of the group receiving both medications remained abstinent from alcohol use during the 14-week study period. By contrast, the combined abstinence rate in the other three treatment groups was only 23.8 percent. Also, the mean duration of time before relapse to heavy drinking was longer in the group receiving both medications (63.6 days) than in the other groups in the aggregate (42.4 days). Study authors wrote, “There were also fewer serious adverse event reports in the medication combination group, essentially indicating that fewer patients in this group required hospitalization for alcohol detoxification or rehabilitation.” The researchers pointed out that the study’s findings on these specific medications cannot be generalized to other medications for alcohol dependence or depression. They added that these findings need to be replicated before specific changes in current clinical practice could be recommended.
Sober-living center looks at what keeps people in recovery
Three years ago, the Long Beach, California, sober-living residence Serene Center published Point of Return, 15 stories focusing on the one factor most responsible for helping individuals maintain their recovery. The organization’s founder and chief executive considers the book’s main benefit that of offering a lifeline to the struggling addict losing hope, and now believes it’s time to gather more stories of inspiration. “Many of these people in the first book shouldn’t even be alive,” says Serene Center’s Andrew Martin. “They had a low bottom, and then it got even worse than that. They were dealing with chronic relapsing, and now they have 15 years in recovery under their belt and a fulfilling life.” Unlike with the first book, where Martin himself went out to identify the subjects who would be featured, this time Serene Center is sending out a broad invitation for individuals to submit their stories. Information is available at www.serenecenter.com/self-help.php ; authors of stories selected for the book will receive $100 and will be eligible to be chosen as the honorary donor for a scholarship for transitional living services at Serene Center. Martin says the first book offered a confirmation of the many paths individuals take in sustaining recovery. For example, one writer talked about the Native American rituals that kept him in balance. Another talked about staying sober for the sake of children—not his own that he lost because of addiction, but those he chose to work with post-treatment. Martin says he is similarly open to all stories for the second book, covering both substance and process addictions. He says he will not automatically exclude accounts that deviate from the philosophy of his organization. “Three of the stories in the first book were not 12-Step based. That’s fine with me,” he says. Serene Center is seeking stories of 4,000 to 6,000 words, with half of the text covering one’s addiction and half discussing the point at which long-term recovery was entered and what has sustained it. Martin says the short-story format works for the book’s targeted readers. “Their attention span is not great,” he says of those struggling with an addiction. “The stories can be read in 10 to 15 minutes.”
Research reveals parallels between gambling and substance treatments
As more research delves into the manifestations of pathological gambling, many similarities to substance addiction are beginning to emerge. Some of the latest research points to the potential value of anti-craving medications in controlling gambling behavior. Research presented last December at the annual meeting of the American College of Neuropsychopharmacology found that gamblers who are driven by urges respond well to medications that block the opioid system in the brain or that block receptors for the neurotransmitter glutamate. Jon Grant, MD, MPH, associate professor of psychiatry at the University of Minnesota, says the research points to promise for use of the medication naltrexone or the amino acid N-acetylcysteine as part of treatment for pathological gambling. Grant urges professionals to “keep an open mind about the issue of medication,” adding, “Referral to Gamblers Anonymous, although helpful to many, doesn’t have to be the only thing one does.” Grant believes that what might emerge in treatment of pathological gambling will resemble an emerging mindset about substance addiction, regarding the value of combination treatments that incorporate both therapy and medication. “There are promising medications, but they don’t work for everyone,” he says. In another parallel to substance addiction, certain genetic factors appear to be coming into play in the study of pathological gambling. In the recent research on the effects of opioid blockers, investigators found a better overall response to the medications among individuals with a family history of addiction—alcoholism in particular. This suggests that some genetic factors are involved in the development of and response to gambling addiction. Grant says current research offers hope to families devastated by pathological gambling behavior, but warns that this should be tempered by an understanding of medications’ limitations. He adds that future research will need to offer a clearer perspective on which treatments might work best for which individuals, so that treatment can be administered on something more than a trial-and-error basis.
A group approach to family therapy
In today’s environment of limited time resources for treatment of chemically dependent adults and the need for more economically advantageous treatment that is empirically proven effective, treatment providers should consider using multifamily therapy groups as opposed to individual family therapy sessions. Using multifamily therapy groups is one concept that has not been applied much to the treatment of chemically dependent adults. 1,2 However, it has been used for some time with chemically dependent adolescents. 3 It also has been used in the treatment of other adult populations for addictive behaviors such as eating disorders. 4,5 Multifamily therapy groups are more cost-effective than individual family therapy sessions, which are often limited or not offered in many facilities because of cost or lack of time. Individual family therapy sessions also can represent a cost that insurance plans might not pay. Multifamily therapy groups can include a number of families and require less time resources than those for individual family therapy sessions. Because this is not an additional service since the chemically dependent person would be in group during that time anyway, insurance companies are more likely to pay for it. For the purpose of clarity, some explanation of terms follows. In modern American society the term “family” has taken on a much broader definition. The American family is no longer seen as only an adult male, an adult female and their biological children. Today’s American family as seen in chemically dependent adults could include spouses, common-law spouses, stepparents, biological parents, homosexual or cohabitating adults and/or their parents. For the purpose of this article the term “family” to participate in multifamily groups would mean any adults living with the chemically dependent client or who provide social or financial support to that person. The term “chemically dependent” refers to any chemical substance to which a person might become addicted. “Multifamily therapy group” refers to two or more families who meet for the purpose of being led in a group therapy session by a trained therapist. Limited services Because of limited time resources, treatment for chemically dependent adults often has been reduced to 90 hours followed by 90 minutes of aftercare or continuing care once a week for a minimum of six months. This treatment also includes only the individual who is chemically dependent. This occurs even though research has shown that the involvement of the spouse, significant other and/or parents in the treatment process increases the chances of sustained recovery. Many treatment providers lack the time even to include individual family therapy sessions for their clients except in the most resistant or difficult cases where sustained recovery is impossible without family support. As an example, the following is the chemical dependency treatment program at a small private-practice clinic, with services paid for by insurance. The clinic has two programs: a daytime partial hospitalization program (PHP) for six hours a day for 15 days, and a nighttime intensive outpatient program (IOP) for three hours a day for 30 days. Each program employs one master’s-level therapist. The daytime therapist receives a salary for 42.5 hours a week and the evening therapist receives a salary for 40 hours a week. This is the breakout of each therapist’s time, if each therapist has 10 clients: PHP Therapist IOP Therapist Group Time 25 hours 23 hours Individual Therapy 10 hours 10 hours Paperwork 7.5 hours 7 hours *This therapist does one hour a day of group for the PHP therapist and the three-hour multifamily group for both programs. **Paperwork includes daily progress notes, admission paperwork, treatment plans and weekly staffing summaries for each client. Also included in these programs is a one-hour individual session each week for each client. It is clear that there is not sufficient time for any attempt to include one family session a week for each client. Utilizing multifamily therapy groups takes only three hours a week as opposed to 20 hours for individual family therapy sessions. The one three-hour multifamily therapy group is presented for all clients. Facilities with larger caseloads and more therapists could adjust their programs accordingly. Family education These groups also are used to provide family education sessions. One of the factors involved in the treatment of chemical dependency from a family systems standpoint is that the family is often as unaware of chemical dependency and its effect on the family system as the chemically dependent individual is. Family members also are often unaware that behaviors on their part have resulted in reinforcing the use of addictive substances by the chemically dependent individual. Therefore, education on various aspects of chemical dependency’s effect on the family system, and actions they can take to help them and the chemically dependent individual, could be presented to all families through this process. During the three hours of the multifamily therapy group the first hour is spent processing any difficulties that have arisen with the family member(s) during the previous week. The chemically dependent individuals would have a daily opportunity to process any difficulties they have experienced. The remaining two hours would be used to educate the family members on some aspect of chemical dependency in the family system, such as poor family communication, family roles, codependency, enabling, detachment, dysfunctional families, process of chemical dependency, process of recovery, and adult children of alcoholics/addicts. The first hour is modeled after the typical daily process group in which group members process any problems that have occurred during the previous week. The group leader would use these discussions as an opportunity to reinforce through modeling previously learned material, such as improving communication, problem solving, or conflict resolution skills. The second hour of group would be used for psychoeducation on topics relevant to addiction. A possible six-week topic schedule follows: • Family communication skills—correcting maladaptive patterns; • Family conflict resolution/problem solving skills; • Family systems theory (attachment, developmental and family life stages); • Family adaptation to chemical dependency (family roles, enabling, codependency); • Overcoming addictive adaptations (detachment, letting go of control, recovery encouragement vs. nagging); and • Adult children of alcoholics/addicts (using Al-Anon, Alateen and other family support groups). The family also would be given the opportunity to attend the aftercare/continuing care group once a month for a minimum of six months. In conclusion, an effective method of providing therapy to the family members of chemically dependent individuals as well as the individual would be to conduct multifamily therapy/education groups once a week for individuals in an inpatient or outpatient treatment program. Multifamily therapy is a proven therapy technique in the treatment of not only chemically dependent adolescents, but also chemically dependent adults. These therapy groups also would be cost-effective and would require minimal resources of the treatment provider. Sharon Cowan, LCSW, MAC, is a licensed clinical social worker with 25 years in recovery and 15 years of experience working in the chemical dependency field. She currently engages in individual, group and family treatment for a private clinic’s chemical dependency intensive outpatient program. Her e-mail address is s.cowan4738@hotmail.com . References 1. Boylin WM, Doucette J, Jean M F. Multifamily therapy in substance abuse treatment with women. Am J Family Therapy 1997;25:39-47. 2. McFarlane WR. Multifamily Groups in the Treatment of Severe Psychiatric Disorders. New York City: The Guilford Press; 2002. 3. Springer DW, Orsbon SH. Families helping families: implementing a multifamily therapy group with substance-abusing adolescents. Health Soc Work 2002 Aug;27:204-7. 4. Garner DM, Vitousek KM, Pike KM. Cognitive-behavioral therapy for anorexia nervosa. In Garner DM and Garfinkel PE (eds.). Handbook of Treatment for Eating Disorders. New York City: The Guilford Press; 1997. 5. Tantillo M. Eating disorders multifamily therapy group: capitalizing on the healing power of relationships. In Eating Disorders Today. Carlsbad, Calif.: Gurze Books; 2003.
Blake Recovery Center at Carrier Clinic
It might surprise some to learn that New Jersey ranks second only to California in the number of solar energy installations across a state. One also might not assume that the largest solar array on a New Jersey campus would be situated at a 100-year-old clinical campus that has not seen significant building renovations since the 1980s. “It's paradoxical—people are very surprised to see it,” says Mary Pawlikowski, chief operating officer of Carrier Clinic, a nonprofit behavioral health center in Somerset County that includes the Blake Recovery Center addiction treatment facility. “Patients and families think it's a cool thing.” While to some a photovoltaic installation on a century-old hospital campus might seem out of place, its appearance on the Carrier Clinic campus was no misplaced priority. Pawlikowski explains that it constitutes an ideal fit for an organization seeking to improve the efficiency of an aging physical plant. Having become operational at the close of 2009, the solar array situated on 14 acres of the 350-acre campus will meet 50 percent of Carrier Clinic's electrical needs. The projected annual savings are around $150,000, Pawlikowski says. A vendor originally approached the organization with a proposal to install the solar system. Carrier Clinic would end up researching other vendors and selecting the company enXco, an EDF Energies Nouvelles Company that besides its solar projects is the leading third-party operations provider of wind farms in North America. The arrangement enXco has with Carrier Clinic essentially allowed the behavioral health facility to participate in this project with little initial investment outside of legal costs. Under a 25-year power purchase agreement, enXco owns and operates the system and is eligible to collect state rebates that are available to it but not to an entity such as Carrier Clinic. Officials at Carrier Clinic, which this year celebrates its 100th anniversary, sought to ensure that the solar panels would not detract from the campus's overall aesthetic. They surrounded the site with a fence that blends with the environment and they arranged for landscaping in front of the installation. The patients at Blake have a bird's-eye view of the solar array, as it is situated almost directly behind the addiction treatment facility. The location inspired Carrier Clinic to develop a courtyard for the back of the Blake building. While it would be difficult to contend that the energy source contributes directly to patients' wellness, it clearly reflects a mindset at Carrier Clinic that tries to be sensitive to the little quality-of-life issues that can affect a treatment stay. “Things such as the HVAC system are items that you don't see but are important,” Pawlikowski says. “They have an impact on customer service. People will complain about the water temperature in the showers, or that in one room it's 90 degrees but in another room it's 60.” As part of a master planning process, facility officials are now looking to see what kinds of additions or renovations could improve the treatment experience at Blake. “We're redefining what we feel we need to create a more welcoming environment,” Pawlikowski says. “We want to make the lounges more atrium-like, and take advantage of the natural light.” One area that already benefits from plentiful outdoor light is a community group room that houses a mural completed by an artist in tribute to a deceased former patient. In an unexpected development, the solar energy project actually has served to boost staff morale. “The staff is excited to be part of an organization that is thinking this way,” Pawlikowski says. She adds, “We may be 100 years old, but we're not old-clinically or environmentally.” Photos by Heather Steel and David Holey/enXco Addiction Professional 2010 March-April;8(2):34-36
He had the family doctor's touch
Approachable. Collaborative. Down to earth. Committed. In many ways James Mulligan, MD, shattered stereotypes about the “almighty doc,” which is why former boss Ed Diehl of Seabrook House took little time to rattle off that series of praiseworthy adjectives to describe his facility's former medical director. When we learned that Mulligan retired from field service as of Jan. 1, we were delighted to add him to our list of 2010 Outstanding Clinicians Award winners (the other three winners were profiled in the January/February issue). The award to Mulligan was formally announced on Feb. 22 at the SECAD '10 conference in Nashville, Tennessee. Ironically, as is the case with many of Mulligan's contemporaries in medicine, a full understanding of the plight of the addict didn't come early in this physician's career. He describes the extent of addiction-related information he received in his initial medical training as “zero, zip.” Even the experience of losing a brother to addiction at a young age had left him and his family with numerous questions. Mulligan would build his career in family practice in Pennsylvania, and eventually would gain experience working with addicts in inner-city programs and would obtain his American Society of Addiction Medicine (ASAM) certification in the early 1990s. By the time he arrived at Seabrook House in 2001, he had become adept at translating the science of addiction to a patient and family audience. “He came on board with an excited commitment to the science of addiction,” Diehl recalls. “Jim had mastered the brain disease information that explains so much about what we treat today.” A factor that attracted Mulligan to the medical director's job from the outset was Seabrook's groundbreaking work in treatment of addicted mothers. It was not easy to find a place where a woman who had given up her children could be reunited with them in the treatment setting after showing signs of progress-it still isn't. Now 66, Mulligan firmly believes that addiction constitutes a physiologic issue in the brain, and at the same time he strongly adheres to the 12-Step approach to treatment. He says of the client's perspective on AA and its brethren, “You don't have to like it, but in the first 90 days when you're going every day you're a little more likely not to pick up a substance for that 24 hours. And you may even start liking the people you're going to meetings with.” He says patients with whom he worked came to appreciate the information they learned in his science-based lectures. “Patients like to learn the characteristics of this illness. They'd thank me and say that it did feel like that.” Diehl says Mulligan made a significant impact on Seabrook's family program. He often was accompanied in his talks by his wife Terri, a registered nurse who Diehl says also served as Seabrook's massage therapist. As a staff colleague, Mulligan was credited with being a consensus-builder and never an autocrat, according to Seabrook's chief administrator. “His way was to be an opinion in a discussion, not to be the overbearing point of view to drown out other ideas,” Diehl says. Diehl believes most of the top addiction treatment centers are looking for this kind of presence from a caring and informed physician in their facilities. As of press time for this issue, Seabrook still had not named Mulligan's replacement-it wisely was being extremely selective. Gary A. Enos, Editor Addiction Professional 2010 March-April;8(2):6
Should two research institutes become one?
When Congress adopted the NIH (National Institutes of Health) Reform Act of 2006, it created a Scientific Management Review Board (SMRB) charged with making recommendations about establishing or abolishing institutes under NIH. Two institutes of great importance to the addiction treatment community—he National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA)—re presently under close scrutiny. During four meetings held last year, and another meeting with the NIAAA council that took place Feb. 3, the Substance Use, Abuse, and Addiction Working Group of the SMRB heard presentations from stakeholders on a possible merger of NIDA and NIAAA. The working group was to present a full range of options to the SMRB on March 10, and in May there will be a recommendation for a final decision, which ultimately will be made by NIH director Francis S. Collins, MD, PhD. Not far beneath that landscape of facts lies a wellspring of emotion and fear. Alcohol researchers and the NIAAA community are deeply worried that in any merger, NIAAA would be the loser and NIDA would be the winner. As one observer put it: “To NIAAA, it's a merger. To NIDA, it's an acquisition.” Not only are alcohol researchers worried about losing money, but they also are troubled by the possible loss of alcohol's unique identity as the primary drug of abuse, and a pervasive sense that the value of their work is not being recognized. Basically, those in favor of the merger ask, “Why not?” and say “The science is the same,” and those opposed ask, with anguish, “Why?” and say “The science is not the same!” The discussion has led to divisiveness, putting long-time colleagues and friends on opposite sides of the issue. And while current employees of NIDA and NIAAA will not discuss this sensitive topic publicly, former ones do-none more eloquently than Enoch Gordis, MD. “This is clearly not a time to bury the NIAAA,” wrote Gordis, former NIAAA director for 15 years, in written closed testimony to the Substance Use, Abuse, and Addiction Working Group last December. “That would be a terrible message to the American public and to the global community,” he wrote, adding that the World Health Organization has found that alcohol is the fifth leading cause of premature death and disability worldwide. “I ask this committee and the NIH: please don't take the sign off the door.” Alcohol is unique in its actions and in the scale of the problems it causes, wrote Gordis. “The statement regarding both institutes that ‘the science is the same,’ which comes so trippingly off the tongue, is a serious misrepresentation of the scientific reality, and results from a very narrow perspective of the universe in which alcohol issues, problems and science play out.” Most alcohol abusers and alcoholics are not drug abusers, Gordis points out-of the 18 million adults with an alcohol use disorder, only 13 percent also have a drug abuse disorder. Recovering alcoholics Another key participant in the discussion is the recovering community, which traditionally has had a close connection with NIAAA. The late U.S. Sen. Harold E. Hughes, a recovering alcoholic, helped created the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970, legislation that established NIAAA. Hughes believed that alcohol research needed its own “highly visible agency,” recalled Gordis. And Bill Wilson, the founder of Alcoholics Anonymous (AA), broke his anonymity to testify before Congress on behalf of establishing NIAAA. Slide from Mary Jeanne Kreek, MD Invoking the name of Bill Wilson is a sign of some of the unspoken differences between NIDA and NIAAA-many people who want NIAAA to remain a separate institute are recovering alcoholics, with all of the personal investment that entails. Gordis's letter, along with one from Ting-Kai Li, MD, NIAAA director from 2002 to 2008, was made public by the Research Society on Alcoholism on Jan. 28. Yet it's not only researchers who are concerned about a merger. The National Association of Addiction Treatment Providers (NAATP) officially opposed the merger around the time of the SMRB working group's first meeting last April. According to NAATP president and CEO Ronald J. Hunsicker, it is only the existence of NIAAA that has prevented alcohol, the most commonly abused substance, from being ignored amid a growing focus on drug abuse issues and treatments. With a focus on pharmaceutical cures for addiction, there will not be as much “personal transformation,” says Hunsicker. “We would have people who are perhaps not using, but they would not be having any major changes taking place,” he said. “Do we work to get people to make lifestyle changes, or is it just chemistry development?” Hunsicker would like to see more of a focus on addiction as a primary disease, with recovery measured not by “fewer drinking days” but by “long-term recovery.” He would like to see both NIDA and NIAAA have a focus on recovery that goes beyond biochemical concerns, even taking into consideration the spiritual. Arguing the science On the other side of the argument are some of the top names in addiction research. “The science on use, abuse and addiction clearly belongs together,” says Mary Jeanne Kreek, MD, head of the Laboratory of the Biology of Addictive Diseases at Rockefeller University in New York City. Kreek, who helped to discover methadone as a treatment for opioid addiction, says both NIAAA and NIDA “do a fine job of looking at various health consequences” of abuse and addiction. Put together, she says, they could do even better. “Alcohol and drugs are the two biggest public health problems out there.” Kreek thinks a combined NIDA-NIAAA could be “bigger and wealthier” than the two institutes are individually. Kreek's top concern is that the merger not be used to cut costs-a message that both NIDA and NIAAA supporters emphasize. “The total pool needs to go up,” she says. Her final slide at her September 2009 presentation before the working group won fans at NIAAA and NIDA both. It reads: “NIH-and Congress-must see any merger of NIH-NIDA and NIH-NIAAA as a move to enhance science and thus, ultimately, healthcare in the very costly areas of the addictive diseases, and not as a ‘cost saving’ strategy.” Herbert D. Kleber, MD, professor of psychiatry and director of the division on substance abuse at Columbia University, says NIDA's clinical trials would benefit from more emphasis on alcohol, just as NIAAA's clinical trials would benefit by including polydrug abusers. Kleber is a former deputy director for demand reduction at the Office of National Drug Control Policy (ONDCP). Another benefit of a combined institute would be a focus on relapse prevention, says Kleber, adding that “the role that alcohol and other substances play in relapse for each disorder has been inadequately studied.” ‘Interdisciplinary’ grants So far there has been no discussion of reducing the budget for either of the institutes, and “no discussion whatsoever” of reducing the total pool of money, says Amy P. Patterson, MD, executive director of the SMRB and acting director of NIH's Office of Science Policy. But there may be more of a “cross-cutting” approach to making grant awards, instead of keeping a certain amount of money in alcohol research and a certain amount in drug research. “It may be redistributed, reflecting a more interdisciplinary approach,” Patterson says. Noting that NIH is looking at the restructuring of other institutes as well as NIDA and NIAAA, Patterson says “this isn't just about moving boxes on paper.” A NIDA-NIAAA merger is one possibility, but there are other possible changes as well. “If one is to take a truly scientific approach, one needs to take a broad look at addiction-and it's not simply drugs and alcohol,” says Patterson. If a merger occurs, there would be a new mission statement, and a search for a director, says Patterson, who acknowledges that there is “a lot of anxiety about what will change and what won't change.” There is currently no NIAAA director. The director of NIDA, Nora D. Volkow, MD, would not automatically be the director of the new institute. ‘A lot of angst’ Whenever anyone talks about a merger, there are concerns about what will be saved and what will be lost, says Patterson. “I think this is a particularly poignant case,” she says of the NIDA-NIAAA discussion. The SMRB is “trying to be very careful and understanding of the anxieties that are swirling about,” she says. “There's a lot of angst associated with the deliberation of this topic,” both in the patient community and the research community. “There will be great interest at NIH to bring it to as quick a conclusion as possible.” Key players in merger discussions Non-federal members of the Substance Use, Abuse, and Addiction Working Group of the SMRB are William Roper, MD (chair); Eugene Washington, MD; Deborah Powell, MD; Huda Zoghbi, MD; and Norman Augustine. Federal members are Josephine P. Briggs, MD; Richard Hodes, MD; Griffin Rodgers, MD; Lawrence Tabak, DDS, PhD; and NIH Director Francis S. Collins, MD, PhD. For more information, including PowerPoint presentations and videocasts, visit the SMRB website at http://smrb.od.nih.gov . Alison Knopf is a freelance writer based in New York. Addiction Professional 2010 March-April;8(2):8-12
Should counselors disclose?
Let's get one thing straight: Some of the best addiction and mental health counselors I know do not identify themselves as people in recovery. They might or might not be in recovery, but they've managed to make it a non-issue. For example, I once worked with a wonderful lady, Elizabeth, who would respond to the “Are you in recovery?” question in the following way. She'd simply say, “Honey, I'm recovering from life.” Her response made it clear she wasn't going to disclose, one way or the other. It also reminded her client that we all have our demons, that life is hard, and that addictions come in all sizes and shapes. The setting makes a difference To be fair, one of the reasons Elizabeth didn't disclose was that she was working in a hospital inpatient detox unit. She was part of a treatment team consisting of doctors, nurses, social workers and addiction counselors. Hospital policy dictated that no one disclose whether he/she was in recovery-and for good reason. The treatment team needed to speak with one voice and avoid “staff splitting,” a favorite pastime among more experienced patients. If some of the staff identifies as being in recovery, a patient might say, “I'll speak with her but not with him.” In an outpatient setting, or where it is less likely that clients will play staff members against each other, the need for staff anonymity is less pronounced. So let's talk about reasons for self-disclosure. In support of self-disclosure It's no secret that self-disclosure can create an instant bond with clients. The fact is that many clients think counselors must be in recovery in order to be of any value. For sure it's a fallacy, but it's a perception, and counselors in recovery can use that perception to establish an immediate and effective connection with a client. Further, counselors in recovery are able to tell stories they've heard at recovery meetings (or perhaps their own stories) to show a client that he's not the only person to have “those” feelings or to have done “those” things. Storytelling is an important foundation of 12-Step recovery. The stories have a ring of truth. They demonstrate the denial of the active addict, they reveal the insanity of embarrassing behaviors, and they shed light on the maddening mix of emotions one finds in early recovery. Lastly, the self-disclosing counselor is sometimes able to guide the client through the confusing and intimidating task of making connections with safe, sober people at recovery meetings. Providing tips on getting the most out of one's 12-Step experience can go a long way toward fortifying the relapse prevention plan. Pitfalls of self-disclosure Despite assumptions to the contrary, the simple act of revealing one's status as a recovering addict will not buy instant and ongoing credibility. We all know counselors in recovery who are fairly ineffective in their jobs. Very often, they talk too much (read: preach) and never really understand the client's perspective. Sometimes these counselors use individual or group sessions as an AA meeting, showing off their knowledge of the AA literature as well as their oratory skills. And what of the counselor who discloses his long battle with cocaine addiction, only to encounter a client who says, “Yeah, but you've never done heroin. You can't understand me.” One of the most difficult skills we must master involves giving the client time to recognize the discrepancy between his words and his actions. This Motivational Interviewing technique is not enhanced when the counselor is talking. For counselors not in recovery My first paragraph alluded to my colleagues not in recovery, or at least not disclosing their status. One of the reasons they are such effective counselors is they made a point of learning the language of recovery, particularly 12-Step recovery. These professionals went to AA meetings, read the literature, listened to the stories, watched the fellowship in action, asked questions, studied the steps of recovery, and grew completely comfortable with the program's jargon and spiritual aspects. This is not something we can absorb from a book. It's more “organic.” It takes time and effort-and people who want to be addiction professionals must do their homework. Clients will quickly recognize the clinician who speaks their language and will become more trusting, more willing to participate openly in treatment. I was interested in Addiction Professional 's online poll last fall on the topic of self-disclosure. Asked whether it is generally a good idea for addiction counselors to self-disclose their recovery status to patients, 57 percent of respondents said yes. Yet judging from the accompanying written comments by many participants, there was general agreement that any decision about whether to disclose one's status should be made on a case-by-case basis. Many respondents said clinicians must know why they are disclosing, and that the motive must be for the client's benefit. Some poll respondents wisely guarded against using the individual or group sessions as their own session. It's a trap that can ensnare even the most experienced addiction counselor. Our constant mantra should be, “What am I saying and why am I saying it?” Conclusion There is no simple answer regarding self-disclosure. It depends upon the setting, the client, and the reasons for the disclosure. Those of us in recovery should remain judicious regarding when (and how) to disclose. We must be ready to say to clients: “I'm your counselor, not your sponsor.” We must keep our session from becoming just an extension of AA. We must keep the focus on the client, his triggers and his coping skills. And we must downplay the importance of a counselor's recovery status by asking, “Does the dentist need a hole in his tooth in order to repair yours?” For Brian Duffy's perspective on the questions counselors can ask to achieve productive treatment sessions, visit http://www.addictionpro.com/duffy0509 . Brian Duffy, LMHC, LADC-I, is a mental health counselor at SMOC (South Middlesex Opportunity Council) Behavioral Health Services in Framingham, Massachusetts. His e-mail address is briand@smoc.org . Addiction Professional 2010 March-April;8(2):14-15
Women's wellness: It's about relationships
The eye-catching titles in the bookstore's “relationships” aisle have it right, believe the experts in women's addiction treatment: Women indeed are wired differently from men, and in some respects the differences can pose an advantage for their recovery. “Women's communication center in the brain is bigger,” says Brenda Iliff, formerly clinical director of Hazelden's Women's Recovery Center in Minnesota. “This plays out throughout our life. Recovery's a natural for women. We're wired for relationships, and recovery is about relationships.” Getting to that recovery goal can prove challenging at times, of course, for women and men alike. Iliff, who this spring assumes the role of clinical director for Hazelden's new treatment facility in southwest Florida, recalls that when women in Hazelden's programs would be asked to tell their “stories” they would tend to focus solely on aspects of their relationships and not delve into their substance-using behaviors at all. This scenario prevailed so often that the program changed the name of what it was looking for in this narrative from “stories” to “usage history,” Iliff says. In interviews with staff members at Hazelden and at New Directions for Women in Costa Mesa, Calif., it becomes clear that both partner and parenting relationships are seen as critical in how some women end up in treatment, how they fare when they get there, and whether their recovery can be sustained afterwards. It is not that some of these same factors don't come into play for men in treatment as well, but leaders at the two organizations tend to rank relationship factors as somewhat less of a driving force in men's illness and recovery progression. “A woman in treatment might say, ‘If the people in my life changed, I wouldn't use,’” says Rebecca Flood, New Directions for Women's executive director. “Men are less likely to blame their relationships than women are.” Adds Flood, “For women, their relationships, as a wife or a sister or a mother, are more relevant in their day-to-day healing. For men, it is often more about what they need to do to get back to work, or into their routines.” Partner dynamics The program supervisor for Hazelden's women's extended care program says she has added to the program's assessment phase an internally generated sexual and romantic relationship questionnaire. To Sheila Hermes, obtaining this history carries importance in offering an opportunity to normalize any and all behaviors in which the client might have engaged, from same-sex relationships to terminated pregnancies. “If we don't ask, it's not volunteered,” says Hermes. “And if we don't talk about it, we keep it under the veil of shame.” For the clinician, detaching this process and the client answers that ensue from one's own values remains a paramount objective. Ironically, Hermes says the sexual history part of the assessment has generally seemed more threatening to clinicians than to patients, the latter of which have not resisted participating to any great degree. “Professionals often don't ask these questions because of their own discomfort,” Hermes says. In evaluating the factors in women's lives that she considers most critical to a healthy and lasting recovery, Hermes places relationships second, behind only a primary focus on the addiction itself and ahead of self-esteem/a feeling of belonging. “It's hard to give women good addiction treatment without invoking the primary relationship in their lives,” she says. As such, Hazelden makes a concerted effort to engage women's partners in treatment, although Iliff says there are times when that engagement can be too intensely focused as well. “A partner's wanting to have written reports daily about the person in treatment-that's a poor boundary,” she says. Iliff adds that sexuality often serves as a problematic relapse trigger for women, even after they have made significant progress in their recovery. “I've heard women tell me they've used after a strong recovery,” she says. “They got a life, which is just what we want to see, and they started dating. They didn't want the other person to know they were an alcoholic, so instead they took a drink.” At New Directions for Women, staff conducts a family assessment for each patient within two weeks of admission. Every significant person in the woman's life receives a bio-psycho-social evaluation, Flood explains. Trauma issues serve as a major focus of the staff's exploration; the federal government research sources that Flood examines state that about 80 percent of female addicts have suffered some form of trauma in their life. Family functioning after a treatment stay (women with children at New Directions tend to stay in treatment for an extended period of about six months) plays a significant role in long-term outcome. Flood says the family system becomes destabilized during the woman's active addiction, and if the family doesn't somehow get redefined after treatment, relapse almost inevitably will occur. “The woman can work a good program but the family can still be codependent and be stuck behind,” she says. She adds that the kinds of issues that can harm the relationship between a woman in recovery and her partner aren't all that different from the issues nonrecovering couples grapple with: money, sex, children-all affected by the need to improve communication. Parenting considerations Hazelden's Hermes says parenting represents the issue that triggers the most shame in the clients with whom she works. “They have the knowledge that they have negatively impacted their children,” she says. “We try to tell them that it's not about ‘good mom’ or ‘bad mom.’ It's ‘an addicted mom.’” Clinicians need to remind clients that they will encounter barriers to their effort to reassume parenting duties after an absence. Whether from an older child who might have taken over adult responsibilities or from a spouse who has assumed both parental roles for a while, Hermes says other family members aren't going to relinquish those duties easily, at least at first. Hermes says she tries to emphasize to mothers in recovery that they need to depersonalize their children's behavior and place it in an age-relevant context. Most importantly, “They can't go home thinking that they're going to make it up to the people in their lives, because they can't. They can go forward, but they can't make up for things.” Wanting to go to every sporting event because you missed all the previous ones offers an easy setup for failure. Similarly, Iliff says, programs shouldn't expect that mothers will be able to achieve overly intensive aftercare goals, given the other roles to which they are returning. “Ninety [meetings] in 90 [days], for a woman who's going home to three kids? Shame on us if we're recommending that,” Iliff says. Programs need to embrace effective but also realistic options for recovery support, such as online meetings, according to Iliff. A couple of AA meetings a week supplemented by a continuing care group run by the treatment program stands a much greater chance of success, she says. Addiction Professional 2010 March-April;8(2):16-17
What resiliency research teaches us
In 2008, the Bangor Area Recovering Community Coalition (BARCC) in Maine held its first summit on addiction recovery, entitled “Broadening the Base for Recovery: Promoting Pathways to Recovery in the 21 st Century.” The conference provided a framework for viewing recovery from research in the field of resiliency developed over the past 20 years. While information abounds regarding the brain chemistry of addiction, resiliency research describes the “brain chemistry of recovery.” The recovering community is inherently equipped to foster resiliency in individuals seeking recovery from addiction. As recovery advocates call for a shift from chronic disease management to recovery management via recovery-oriented systems of care, resiliency research provides the architecture that builds a bridge linking prevention, treatment and recovery. It provides a framework for environmental supports that enhance all aspects of clinical interventions. From its origins in prevention, resiliency research is applicable to any group supporting the recovery process. In an economic climate of constricted resources, with an underfunded system often at odds with itself, the recovering community stands in the gap as an underutilized resource. Resiliency provides the language that speaks across divisions as we progress through the 21 st century. What is resiliency? Rooted in anthropological study, the term “resiliency” emerged in the early 1990s. Bonnie Benard's Fostering Resilience in Kids: Protective Factors in the Family, School, and Community first codified what resiliency looked like and how it could be achieved. 1 Since then, a significant body of research has been developed on the subject, mostly in relation to prevention and youth development. The brain dynamics of recovery are found in the literature of resiliency. Environmental strategies influence an individual's capacity for sustained recovery. Resiliency is independent of any particular treatment modality, yet is applicable to all of them. Some common definitions of resilience include: An occurrence of rebounding or springing back; That property of a strained body that enables it to recover its size and shape as it is unloaded after some initial deformation; and Increased probability of school and life success despite adversities caused by early characteristics, conditions and experiences. Resiliency literature points to the brain as being hard-wired for resilience. It is an inborn capacity for adaptation and survival. 2 A “resilient” person is someone who demonstrates social competency, problem-solving skills, a sense of autonomy, and hope for the future . The ability to foster this type of brain development is best achieved when individuals belong to social groups with specific characteristics. Researchers identify three primary elements necessary to develop a resilient individual: high expectations, caring and support, and opportunities for participation. 2 These “environmental protective factors” can be found at the family, school, workplace, organizational, or community levels. When exposed to such an environment, particularly when in relation with a caring adult or peer, an individual who otherwise might be at high risk for problems can “turn around.” Mentors become “turnaround people” and schools become “turnaround places.” 3 Counselors, treatment centers, peer groups, facilitators, sponsors, home groups and fellowships all offer examples of potential turnaround opportunities. The recovering community is an alternate culture that provides environmental protective factors for individuals seeking recovery. A resilient person's attributes The irony of resiliency research is that it simply rediscovers what is natural in a healthy, close-knit community. It is precisely this that makes the recovering community a resilient community comprising resilient individuals. Based in the common experience of individuals recovering from addiction, the recovering community is intentional; it has a unique purpose. Resiliency is spoken in the language of recovery. The Substance Abuse and Mental Health Services Administration's (SAMHSA's) 2005 National Summit on Recovery defined recovery from alcohol and drug problems as a process of change through which an individual achieves abstinence and improved health, wellness and quality of life. 4 Resiliency tenets are embodied in the guiding principles articulated from that summit and reflect the constructs of resiliency research. These principles are paraphrased in these characteristics of a resilient person in recovery: Social competence . Learning to re-socialize without drugs and alcohol is an essential skill of early recovery. Learning to work and have fun in recovery requires developing interpersonal skills, relationship skills and functional work habits. These are essential developmental tasks that must be mastered to some degree to ensure lasting recovery. It is like learning how to ride a bike: At first it feels awkward and is often clumsy, but with practice and skill it becomes easier and, in time, automatic. As Benard quotes Goleman in his discussion of the brain, “…the finding that the brain and nervous system generate new cells as learning or repeated experiences dictate has put the theme of plasticity at the front and center of neuroscience.” 2 Relearning social skills in recovery is literally retraining the brain in how to respond to social situations. The recovering brain creates new neural pathways to accommodate life experiences without alcohol and other drugs. Problem-solving skills . Problem-solving skills are imbedded in many slogans in the recovering community, often in direct opposition to societal norms and specifically to addiction-oriented subcultures. Avoiding brain-related impulses and compulsive behaviors that can lead to relapse requires individuals to avoid instant gratification, learn how to think things through, and develop decision-making skills supporting their recovery. Learning personal relapse dynamics and prevention strategies are essential recovery skills. In essence, sustained recovery is the mastery of relapse prevention. Bruce A. Campbell, LCSW, LADC, CCS A sense of autonomy . While the recovering community accepts the premise that one is not to be blamed for having an addiction, it embraces the principle of personal responsibility for recovery. Recovery is self-directed and empowering. At various times on the pathway to recovery, individuals may seek professional help and guidance. But recovery is fundamentally a self-directed process. The person in recovery is the “agent of recovery” and has the authority to exercise choices based on his/her recovery goals. The process of recovery leads individuals toward the highest level of autonomy of which they are capable. Through self-empowerment, individuals become optimistic about life goals. A sense of purpose and hope for the future . Recovery emerges from hope and gratitude. Individuals in or seeking recovery often gain hope from those who share their search for or experience of recovery. They see that people can and do overcome the obstacles that confront them, and they cultivate gratitude for the opportunities each day of recovery offers. Recovery involves (re)joining and (re)building a life in the community. Recovery is building or rebuilding healthy family, social and personal relationships. Those in recovery often achieve improvements in quality of life, such as obtaining education, employment and housing. They also increasingly become involved in constructive roles in the community through helping others and engaging in productive acts. Purpose is further supported by the rituals and celebrations of recovery, done in part to acknowledge the success of those celebrating, but also to serve as inspiration and hope to those who are following the same path. How recovering communities foster resiliency Three primary environmental protective factors promote resiliency in individuals: high expectations, caring and support, and opportunities for meaningful participation. These can be found in virtually any environment, whether in the family, school, workplace, organization, or community. They are linked to the brain's capacity for adaptation and survival and meet basic developmental needs for safety; love and belonging; respect; autonomy and personal power; meaning; challenge; and mastery. With basic developmental needs met, an individual develops the aforementioned resiliency characteristics. These attributes are expressions of, not caused by, resilience. 3 Increased resiliency reduces health risk behaviors and improves social, health and academic behaviors. 2 The outcome is an individual with greater capacity for “bouncing back” from adverse events or circumstances-one with an enhanced capacity to achieve and sustain recovery. Recovering communities can provide these necessary ingredients for fostering resiliency. Members of recovering communities provide positive models of personal identification, building important environmental factors of competence, connection and contribution. BARCC uses these guidelines for its local coalition efforts: High expectations . Citing the Summit on Recovery, BARCC defines recovery from addiction as a process of change through which an individual achieves abstinence and improved health, wellness and quality of life. For a person addicted to alcohol and other drugs, learning to live without substances is a daunting prospect. Yet within the recovering community, these individuals encounter peers who have done just that. More importantly, recovering individuals convey their deep belief that addicts do have the capacity to recover, and they mirror that possibility through their own recovery. The recovering community holds this expectation for the journey of recovery. To do otherwise would be disempowering, because as the adage affirms, “People rise to their level of expectation.” Maintaining abstinence one day at a time constitutes an example of a high expectation packaged in an attainable goal. Caring and support . Treatment professionals and members of the recovering community forge connections by showing compassion-non-judgmental support that looks beneath addictive behavior and sees the suffering of the individual seeking help. This rapport and engagement often serves as the critical motivational foundation for successful recovery. Peers and allies support recovery; it is a hallmark of the recovery process. A common denominator in the recovery process is the presence and involvement of people who contribute hope and suggest strategies and resources for change. Peers, as well as family members and other allies, form vital support networks for people in recovery. Opportunities for meaningful participation . Providing outlets for personal contribution is a tradition and expectation in recovering communities, but it is also a natural outgrowth of the strengths perspective. Helping others through service and peer support is fundamental to the recovering community. Individuals are ultimately responsible for their own recovery; this involves a personal recognition of the need for change. Individuals must accept that a problem exists and be willing to take steps to address it. The process of change can involve physical, emotional, intellectual and spiritual aspects of the person's life. Recovery is self-directed and empowering. Conclusion Treatment agencies, community organizations, peer support groups and self-help organizations can increase their capacity to foster resiliency. It is an attitude, a belief, a frame of mind. Some steps that may be taken to do so, either formally or informally, include: Reflecting on and discussing as a group your beliefs about innate resilience; Forming a resiliency study group; Creating a climate for resiliency; and Most of all, relaxing, having fun and trusting the process! As efforts continue to develop recovery-oriented systems of care, resiliency points to common ground among prevention specialists, treatment providers and the recovering community. Its greatest power lies in its simplicity. But little effort has been directed to the subject of resiliency in treatment and recovery, and there is a call for such study. One can easily speculate that treatment and recovery outcomes can be positively influenced by the strength of environmental protective factors. It also takes a village to recover. Bruce A. Campbell, LCSW, LADC, CCS, is the Program Director at Wellspring's Men's Residential Services in Bangor, Maine. An individual in long-term recovery, he helped organize and is the current Chair of the Bangor Area Recovering Community Coalition. His e-mail address is bacampbell@wellspringsa.org . References Benard B. Fostering Resiliency in Kids: Protective Factors in the Family, School, and Community. Portland, Ore.: Northwest Regional Educational Laboratory; 1991. Benard B. Resiliency: What We Have Learned. San Francisco: WestEd; 2004. Benard B. How to Be a Turnaround Teacher/Mentor. Reprinted with permission from Reaching Today's Youth, Spring 1998. Retrieved July 20, 2009 from http://resiliency.com/htm/turnaround.htm . Center for Substance Abuse Treatment. National Summit on Recovery: Conference Report. DHHS Publication No. (SMA) 07-4276. Rockville, Md.: Substance Abuse and Mental Health Services Administration; 2007. Addiction Professional 2010 March-April;8(2):18-21
Mixing advocacy with treatment
In recent years a growing appreciation has formed about the importance of involving recovering individuals in activities that promote civic engagement. The 2008 election season's “Recovery Voices Count” campaign of Faces and Voices of Recovery offers an example of this trend to bring a recovery voice into national and local electoral politics through policy advocacy. Similarly, the Recovery Community Services Program of the federal Center for Substance Abuse Treatment (CSAT) attempts to organize local networks of recovery advocates to work on policy change and create more recovery-friendly communities. We have come a long way from the late 1980s when former U.S. Sen. Harold Hughes created the Society of Americans for Recovery (SOAR). According to an obituary of Hughes by Gerrit DenHartog, Hughes believed that the voices of recovering people could become a potent force to make recovery “an American priority.” SOAR described itself as the voice of the nation's grassroots recovery community-“those in recovery or in hope of recovery from alcoholism and drug addiction, as well as their families, and other concerned citizens.” A concept ahead of its time, SOAR never counted more than a few thousand members. A number of national advocacy organizations have emerged recently to challenge ingrained public attitudes about individuals in recovery ( http://www.facesandvoicesofrecovery.org ), medication-assisted treatment ( http://www.aatod.org ; http://www.methadone.org ) and national drug policy ( http://www.drugpolicy.org ). These efforts are an integral component of what historian William White and others have termed The New Recovery Movement. Our society continues to marginalize people actively addicted to illicit drugs and alcohol, as well as those in recovery. This “second-class” status is the driving force behind advocacy efforts, and underlines the importance of demonstrating that the “faces and voices of recovery” are also the faces and voices of mainstream America. Traditionally, activities aimed at recruiting recovery advocates have focused on identifying individuals in long-term recovery and convincing them to become active in self- and societal advocacy efforts. In San Diego, a new program exposes residential and outpatient treatment clients to advocacy as a component of their addiction treatment regime. Stepping up at Stepping Stone Founded in 1976, Stepping Stone of San Diego (SSSD) is a nonprofit alcohol and drug treatment and recovery agency that creates and delivers alcohol/drug treatment, HIV and other health interventions, recovery, education and prevention services focused primarily but not exclusively on the gay, lesbian, bisexual and transgender communities of the greater San Diego region. The organization is known for its progressive and innovative response to client needs. At the beginning of the methamphetamine epidemic it developed a harm reduction philosophy that was reflected in a media campaign as well as its service portfolio. More recently, Stepping Stone's Discovering Sexual Health in Recovery program was profiled in the July/August 2009 issue of Addiction Professional . Stepping Stone clients are both challenging and challenged. Besides drug recovery status, the SSSD client often shares other characteristics that add to societal marginalization, including HIV/AIDS and lesbian/gay/bisexual/transgender sexual orientation. In 2009, with funding from the Drug Policy Alliance's Advocacy Grants Program and help from an outside consultant, SSSD staff created and field-tested an advocacy training curriculum for clients called Stepping Up. 1 The curriculum's objectives are to expose clients to organizations seeking to change societal attitudes and to “integrate concepts of self and community empowerment and advocacy into all services for clients at Stepping Stone.” The rationale for the Stepping Up training states: Empowerment and self-advocacy are goals of behavioral health interventions. Stepping Up's facilitating principles including that individuals: have power; are responsible; have some degree of autonomy; can take initiative; and can make choices to provide a base for improved consciousness about one's physical and emotional health. Empowerment and advocacy, however, do not occur in a vacuum. Individuals are empowered and advocate in a social context. That context can enhance or detract from an individual's well-being . The need to advocate and become empowered arises from the inequalities of our society and the discrimination that these inequalities engender. Thus, self-advocacy connects directly to efforts to change society and reduce the marginalization of our clients due to their status as gay, lesbian, transgender, bisexual, HIV+, and former drug user. Therefore, the Stepping Up curriculum also includes information about societal change and the importance of social justice activism . Self-advocacy As defined at Stepping Stone, “ Self-advocacy is standing up for yourself, and whether you are trying to change the world or your own life, advocacy means finding your voice. If you are asking for something, you need to be clear about what it is and why you want it.” Seeking additional services, applying for employment and taking care of one's health all require the ability to assert oneself. Stepping Up participants are taught six steps to self-advocacy: Get educated. “Know your rights.” Define your goals. Have a clear, consistent message and understand the difference between “wants and needs.” Understand the chain of command and the process. Ask for support from others. Document. You should always document your experiences. This can also serve as “proof” for others that your problem exists (e.g., save e-mails, write down dates of correspondence and occurrences, etc.). Be persistent. Stand up for what you believe in and believe that change is possible. Remember: It is not what you say, but how you say it. Societal advocacy Societal advocacy is the pursuit of outcomes including public policy and resource allocation decisions within political, economic and social systems institutions that directly affect people's lives. Unlike self-advocacy, which is learning how to act effectively on behalf of oneself, societal advocacy is focused on causes or particular constituent groups. Last year SSSD clients drew on their experience with the Stepping Up advocacy training to initiate a petition drive to prevent California Gov. Arnold Schwarzenegger from enacting draconian cuts to HIV/AIDS services. For several weeks during the state budget approval process, clients were gathering signatures at local Gay Pride activities and sending e-mails to family and friends encouraging them to call and write the governor to express their views. SSSD clients also have been actively engaged in advocating same-sex marriage, fighting discrimination aimed at transgender individuals, supporting community re-entry for ex-offenders, and reducing stigma experienced by people in recovery from drug and alcohol addiction. The New Recovery Movement seeks to change public and policymaker attitudes about addiction and recovery by creating an army of advocates. Clients in treatment can be exposed to advocacy opportunities that can have direct benefits on the quality of their life, as well as providing large numbers of foot soldiers for this advocacy army. John de Miranda, EdM Kevin McGirr, RN, MS, MPH John de Miranda is President and CEO of Stepping Stone of San Diego ( http://www.steppingstonesd.org ) and the California-Arizona regional representative to the board of directors of Faces and Voices of Recovery. His e-mail address is johnd@steppingstonesd.org . Kevin McGirr, RN, MS, MPH, is on the faculty of the University of California, San Francisco. He is a member of the board of directors of the Harm Reduction Therapy Center and the California chapter of the American Psychiatric Nurses Association. Reference de Miranda J. Training your patients to become advocates for themselves and for systems change. Alcoholism and Drug Abuse Weekly 2008; Nov 3. Addiction Professional 2010 March-April;8(2):22-24
Discuss healthy sex and relationships
It happens all too often at the all-female residential substance abuse treatment facility where I work. A woman who has worked hard for 18 months or more to raise her level of self-awareness, improve her self-esteem, become employable, secure adequate housing and build a recovery support network makes an impulsive decision that just about wipes out all these gains. More often than not, the impulsive decision involves an old boyfriend, past lover, or someone with similar characteristics. Intimate relationships pose a relapse risk for both sexes, and a focus on this area during treatment can make a major contribution to long-term, quality sobriety. We often discuss how a drug of choice can make someone more comfortable in a social situation, but we might be reluctant to open a deeper discussion into more personal and sensitive areas: Did the drug of choice heighten sexual pleasure for the client? Did drug or alcohol use contribute to decisions involving sexual behaviors or sexual partners that would be different when sober? Did the client trade sex for drugs? Was loss of sexual pleasure a result of using? Is substance use a trigger for sex? Is sex a trigger for substance use? Intake is the place to open up this area for discussion, since treatment planning is often based on areas of concern identified at admission. Questions about intimate relationships should be part of the intake process. Psychosocial histories usually address childhood trauma and sexual abuse, but the quality of intimate relationships less often. Treatment too often addresses HIV, STDs, birth control and safe sex practices without enough focus on intimacy issues. Treatment planning and ongoing treatment need to address intimate relationships, so that clients throughout the continuum of care understand the specific interaction-unique to each of them-among sex, intimate relationships and substance abuse. Some clients might fear that their sex drive has permanently disappeared, while others might be concerned that the quality of their relationships will decline without drugs. Aftercare plans should address the lifelong goal of working to continually strengthen our relationships. Clients who have the self-awareness to seek professional help before a relapse to drug use often report relationships as their main area of concern. Relapse prevention plans need to include specific information in this area. As in all other areas of counseling, care needs to be taken so you don't press your clients to make the exact same choices in their lives that you have made in yours. With some clients we'll be working on refusal skills, assertiveness and ways to avoid feeling pressured into sex. With others we might be working on ways to make better connections and to make sex more satisfying. Challenges counselors face To address this area adequately, we need to overcome several obstacles. We might become uncomfortable when clients use street terms instead of the more clinical words we might use to describe sex acts or sex organs. Identifying problems in this important area is a higher priority than using appropriate language. With graduated exposure to this situation we can find a balance between modeling more appropriate language and encouraging discussion by allowing clients to use whatever words are most comfortable for them. Many substance abuse specialists feel outside the area of their expertise when dealing with issues of intimacy or sex. It's important to listen at least long enough to make appropriate referrals. It's likely there will be times when client choices-past, present, or future-will make a counselor too uncomfortable to be helpful, and counselors should identify in-house or community resources to which to refer these clients. An agenda for programs and practitioners who would like to set up training in this area is offered in the article “Addressing Sexual Issues in Addiction Treatment.” 1 Educate your clients Based on their past histories, our clients might have unrealistically low standards for relationships. The ways we relate to our clients can contribute to a higher expectation for other relationships, but this modeling in itself is not enough. Client education is also important. Many people who get deeply involved in addiction have had mostly unhelpful and unsatisfying relationships. It's important for them to get a grasp on what positive relationships look like, and to understand some warning signs that a certain relationship is not helpful. Healthy relationships are mutually satisfying and rewarding. During the course of a long-term, loving relationship there may be periods of time when it seems as if one party or the other is doing the most work. But good relationships are good for both parties and not one-sided. Healthy relationships are respectful and not exploitative. In a good relationship, both parties feel they have made a choice to participate. In unfulfilling relationships, either or both parties might feel as if they have an obligation to participate. Healthy sex can be an expression of true love, but never a condition of love. Persons in a healthy relationship feel more in touch with themselves, more confident, and more self-aware than in other relationships where they feel shameful, disrespected, or shortchanged. Healthy relationships have helpful boundaries, where each person's sense of self is completely intact. Healthy relationships are mutually respectful in that they are private. But healthy relationships are never a secret. For example, the details of an intimate spousal relationship are generally kept private. In the case of sexual abuse or incest, the abuser often insists that the existence of the relationship be kept secret. However creative or passionate the lovemaking, healthy sex is safe-both physically and emotionally. It reflects, rather than compromises, one's values. Healthy intimate relationships are empowering. Some helpful resources for counselors include Time Out! for Men: A Communication Skills and Sexuality Workshop for Men (accessible for free download at http://www.ibr.tcu.edu/pubs/trtmanual/tofmen.html ) and Time Out! for Me: An Assertiveness and Sexuality Workshop for Women (accessible for free download at http://www.ibr.tcu.edu/pubs/trtmanual/tofm.html ), created by the Institute of Behavioral Health at Texas Christian University. For more information on discussing sexual issues openly with clients, visit http://www.addictionpro.com/demiranda0709 . Nicholas A. Roes, PhD, author of Solutions for the ‘Treatment-Resistant’ Addicted Client (Haworth Press, 2002; reviewed in the January 2003 issue of Addiction Professional ), is Executive Director of the New Hope Manor residential treatment facility in upstate New York. His e-mail address is NickARoes@aol.com and his Web site is http://www.nickroes.com . Reference Haynes L, Calsyn DA, Tross S. Addressing sexual issues in addiction treatment. Counselor 2008 Aug;9:28-36. Addiction Professional 2010 March-April;8(2):30-31
Easing anxiety about technology
While larger addiction treatment organizations certainly face their share of challenges in implementing technology to improve practice and administration, individual or small-group providers arguably deal with even steeper odds in upgrading technology. A wealth of products tailored to the individual or small-agency provider exists in today's market, but professionals have to do careful research and then take the time to learn new systems after procurement, say technology experts who work with the behavioral health field. Charles Klein, PhD, vice president of clinical services and e-prescribing options at Netsmart Technologies, says smaller agencies need especially to understand staff capabilities and make the necessary adjustments. “Most places at least have technology for billing. But if you don't use technology much, jumping right into an electronic record could be challenging,” Klein says. On the back end, a program's staff will have to be allowed to take hours away from billable time to learn what new technology for practice management can do for them, insists Klein, who works out of Netsmart's San Diego office. “You've got to give yourself time to learn it,” he says. “The more you want the new application to do, the more time it will take for you to learn how to use it.” Avoid mistakes Klein says he sees several areas in which smaller clients run the risk of missteps in their effort to introduce technological solutions. He finds that when some potential clients are looking into an electronic medical record (EMR), they immediately assume they want to have a system with every possible feature imaginable. “It may be better to start with something that is basic and easy to use but that contains what you need,” Klein says. “That will keep costs down as well.” Clients often want their EMR to interface with other applications in their office operation, but that process can be extremely costly and isn't always necessary for sound practice, Klein says. It might still be worth it to engage in double data entry for certain functions. For example, to this point an interface with lab results is not a standard feature of EMR systems, Klein says, although eventually it will be. Klein also believes that addiction professionals should not start calling vendors to see specific products until they have researched what products and applications their colleagues are using. “A lot of EMRs are designed specifically for specific practitioners,” he says. At Netsmart alone, various products are tailored to the therapist, large agency, outpatient opiate and public health markets. Professionals' trade associations can serve as a fruitful resource for learning about various applications and what current users like about them, Klein says. In what might be the most surprising mistake some professionals will make, Klein says there actually are instances where a professional or a group practice will purchase a technology solution without ever having witnessed in advance how it works. “I don't think anyone should buy without seeing a demo,” he says flatly. Potential buyers should directly ask how a vendor would perform specifically cited functions using the technology, and should have the vendor walk through each process. If an office manager is coordinating the purchase for a small agency, it would be wise after receiving the first demo to arrange another one for clinical staff before an acquisition, Klein believes. “I don't know of any companies that charge for demos,” Klein says. “Customers should ask for more than one.” Process of change To the founder of the practice management solution TheraQuick, getting small providers to embrace technology does not differ greatly from clinicians' own efforts to facilitate their clients' embrace of change. TheraQuick's Dale Stuart, PhD, says asking a potential customer about current use of technology can resemble some of the questions a clinician might ask of a patient: What part of what you're doing right now don't you like? How does what you're doing now not meet your needs? “We have to determine, ‘Where's the pain? Where are the shortcomings?’” Stuart says. “Is it in time? Errors? Searchability? The ability to issue reports?” She says it remains challenging to work with potential customers who aren't familiar with the way software works beyond the most basic functions. “Some will say, ‘I know one way how to do this, and that's good enough,” she says. Netsmart's Klein adds that office managers need to distinguish in their operations between sincere uneasiness in working with new technology (that can be addressed) and stubborn resistance that simply mirrors a negative reaction to any change (that cannot be allowed to derail progress). Stuart's practice management product grew out of her own examination of the options that were available five years ago and her conclusions about how they could be improved upon. In a sense, customers can conduct a similar analysis in their attempt to find the product best suited to their practice. “If I can imagine in my mind that something can be done, then probably there is already a solution that at least approaches part of that problem,” Stuart says. Much as she finds variation in the degree to which treatment providers will do front-end research (“some people will call five to 10 times before they buy the product,” she says), she sees much variability in their post-purchase behavior as well. “About half will call in and ask questions, and about half will never call again after purchasing,” Stuart says. Addiction Professional 2010 March-April;8(2):26-27
Freed from his past
The brawl that landed Michael Daluz behind bars was not the Connecticut man's first brush with trouble, but it would end up affecting him in ways that the self-described street kid never could have envisioned at the time. The resulting assault conviction would keep his dreams out of reach long after his time behind bars ended. However, during his relatively short incarceration, he experienced what he calls a spiritual awakening that would move him away from a life of crack cocaine use and drug dealing and open a different path. Today, the 44-year-old Daluz has a director's title with the services agency New Connections, Inc. in New Haven, running a children's program that he says combines mentoring with therapeutic intervention. Working with the city youth of today fits him perfectly. “The street is the same as it was years ago,” Daluz says. “It's all about failure, and the notion that you can never make it.” That seemed to be what played out on a December night in 1987, when the then-Connecticut College student who had served a stint in the Army was attacked by a group of young people as he and two classmates walked back toward campus from a club. During the melee that ensued, Daluz pulled a gun and shot one of the young men. He would be convicted of first-degree assault and would serve 18 months behind bars. The crime would make headlines in Connecticut two decades later because of controversy over the procedures leading to Daluz's being considered for a pardon, essentially an affirmation that a perpetrator of a crime has reformed. Although the state's failure to notify Daluz's victim of a potential pardon led to calls for reviewing the state's system for granting pardons, Daluz's pardon did become official last summer, after months of waiting. He calls the turn of events a blessing. “The system held this against me for a long time,” Daluz says. “Now doors have opened for me, and I can take care of my daughter better.” He adds that the pardon helped confirm after all these years that others also bore some responsibility for what happened that fateful night. “For years they never acknowledged that I was beaten,” he says. “I'm not saying I was right for what I did. I was wrong. I had no business carrying a gun.” Will to succeed While Daluz says he did attend 12-Step meetings at various times, including while living in a halfway house post-release, his recovery more closely fits that of an individual who succeeds without formal treatment participation. “I did go to meetings to educate myself about the disease,” he says. He considers his recovery a combination of willpower and the grace of a Higher Power. Friends persuaded Daluz to put his story to words, which resulted in publication of the book You Gotta Dance (Universe Publishing Co.; http://www.yougottadancect.com ). He calls the book less of a story about his life (he admits that reliving some events for the project was difficult) and more an inspirational reminder to others. “I want people to know that anybody can do this,” Daluz says, referring to transforming a broken life. A book reviewer wrote last September for the African Americans on the Move Book Club, “The pain Michael felt when he couldn't see his daughter and when he was disowned by his parents was riveting. Undoubtedly, this is a story of disappointment that is all too common for minority males. The author is commended for presenting a male perspective that is so often overlooked and disregarded.” Life's bounty Daluz says life's “at its best” for him right now, with doors seemingly opening everywhere. He worked as a clinician at the Community Renewal Team in Hartford prior to his current job. The agency where he presently works recently entered the nonprofit world and is seeking ongoing Department of Children and Families funding support. Daluz, who has a daughter in college and one in high school, is spending a great deal of quality time with his seven-year-old daughter these days. He also is on track to receive a PhD in counseling studies from Capella University this fall. His dissertation focuses on the impact of afterschool programs for African-American children in single-parent households. “At one time, I never believed that I could succeed at anything but hustling,” Daluz says. He adds that the praise he now receives for his clinical work humbles him, and he tries to remind others of the enviable place counselors find themselves in as they help to transform lives. To those who sometimes fret about the counselor's overall working conditions, he says, “We're going to get paid on the back end, so give it your all.” Addiction Professional 2010 March-April;8(2):48
Out to change attitudes about buprenorphine
The contradictions in the practice world that Jeffrey T. Junig, MD, PhD, inhabits offer a sharp reminder of the addiction community's divisions over medication treatments. In his private medical practice in Wisconsin, Fond du Lac Psychiatry, Junig has remained right at the 100-patient federal limit for buprenorphine patients ever since the maximum was increased, and he says demand for the medication is so great that at any time he could easily maintain a 50-patient waiting list. Yet at the residential and outpatient addiction treatment facility where he serves as medical director, Nova Counseling Services in Oshkosh, buprenorphine treatment is not being used at all, and the center's counselors look warily at the medication. “Our counselors do not like Suboxone,” says Junig. “They don't know anything about its good side.” While he says these professionals equate buprenorphine to a second long-term dependence for the opiate addict, they don't harbor a similar attitude toward a drug such as the anti-alcohol medication naltrexone, which he says they see as a safety device. Believing a few years ago that buprenorphine would prove to be a “huge medication” in the field, Junig set out to educate others about this tool in the fight against opiate misuse. He originally wanted to target practitioners with his information, but ultimately decided to communicate with patients and their families directly. For the past three years he has produced a blog at http://www.suboxonetalkzone.com and has sponsored a discussion site at http://www.suboxforum.com ; he comments on research and practice developments and reminds readers not to engage in “which is better” debates about treatment options. His posts are frank, engaging and often humorous, and make no secret of Junig's firsthand experience with opiate addiction. He became addicted to codeine as a young physician in 1993, then relapsed after seven years of sobriety. He says that both times the 12 Steps helped saved his life, but he doesn't believe 12-Step treatment works for everyone and says some counselors can tend to sabotage life-saving efforts. Junig says, “Sometimes the main topic the counselor wants to discuss with the patient is, ‘When are we going to get you off Suboxone?’” Need for education Junig believes education about buprenorphine and about opiate addiction in general is most critical at a time when more physicians are promising in contracts with health systems not to prescribe any opiates at all, because of concerns over abuse. He makes sure to point out that his sites are in no way affiliated with the manufacturer of Suboxone and the other buprenorphine formulation, Subutex. He actually prefers citing “bupe” instead of the brand name as the keyword for his sites, but he also knows that on the street, individuals look under the name “Suboxone” in Internet searches. Junig says he conducted a few educational sessions for Suboxone manufacturer Reckitt Benckiser in the past, mostly for non-physicians, but says he has found it difficult to establish a rapport with the company. A look at some of his online writings might offer a clue as to why. Junig hardly could be called “corporate” in the way he presents his topics. In a recent post about drug testing to detect buprenorphine, he recalled an uncomfortable moment he experienced with an employer before his relapse. Every two years in his reappointment review he routinely would be asked if he had a chronic illness that affected his ability to care for patients. “I knew what the question was getting at-but to my way of thinking, as a person who had been clean for several years and who was never planning on using again, the correct answer was clearly no, I had no illness that affected my care of patients,” Junig wrote. “But when I relapsed in the year 2000 the hospital made much of my answers to that question, reporting to the board that among my other (much more significant) transgressions, I lied on my reappointment packets. I was going to defend myself by saying it depends on what the meaning of ‘is’ is, but someone else used that excuse before I could use it!” In a recent comment to counteract talk that addicts move to a second addiction when using buprenorphine, Junig wrote, “An addict who is properly treated with buprenorphine loses the obsession for opiates-something that is amazing to witness at the first follow-up appointment, when the addict sometimes cries over how wonderful it is to be freed from the obsession to use.” For those who still bemoan the need for long-term maintenance with the medication, he says the medication should be long-term, adding, “It beats death.” In fact, Junig believes the field also should see 12-Step treatment or other non-medication options as long-term maintenance therapies as well, in that the conventional wisdom states that a recovering addict who stops attending meetings is likely heading to relapse. What has Junig believing in long-term use of buprenorphine are the disappointing outcomes in general for opiate addicts in other forms of treatment, in terms of return to use. In his own practice, he often sees that the best option for the patient is to stay on buprenorphine indefinitely, and he asks in his forums for examples of individuals who were able to taper off long-term use of the drug and subsequently stay clean. He states bluntly in a written description of his practice's protocol, “There may be some value in tapering a properly motivated patient off buprenorphine and seeing if the person can remain clean. It must be recognized, though, that a certain proportion of patients will die as a consequence of relapse during these efforts.” He adds that because he finds it difficult to locate like-minded counselors who could work with him on a treatment team, he himself counsels patients as part of their buprenorphine management. One of the points he stresses to them is that the anxiety they often report is in many cases a manifestation of the cravings that can persist for long periods in opiate addicts. Making progress Junig says he has found in general that his patients in their 30s and 40s have done better with buprenorphine than younger patients have, although he believes that even for the younger group the medication can be useful until something else can take hold. He says none of the four patients in his practice who have died from an opiate overdose or a suicide were on Suboxone. “I wish I had put them all on Suboxone,” he now says. His forum site received more than 52,000 page impressions in January, and about one-third of that number of impressions were registered at the blog site. He subsidizes his efforts through sales of relatively inexpensive education aids. A popular selection at present is the $9.99 recording “How Long Are You Going to Take That Stuff?”, which patients have described as a useful tool for opening communication with their loved ones. Junig hopes that little by little he is helping to change attitudes about what he considers a productive medication. “There are people out there who really get angry about Suboxone,” he says. “Some call me a drug pusher.” Addiction Professional 2010 March-April;8(2):28-29
Speed: The key to EHR implementations
Thousands of addiction and mental health treatment providers across the country soon will be required to adopt an electronic health record (EHR) to satisfy business, clinical, and regulatory requirements. Faced with budget cuts, overextended staff, and limited IT expertise, these organizations might see successful implementation of an EHR as a daunting challenge, but it doesn't have to be. One of the most important (yet most often underappreciated) aspects of running a successful EHR project is speed. For a traditionally resource-constrained organization such as an addiction treatment provider, the ability to dedicate one's best resources to a project that can be quickly completed increases the likelihood of a successful implementation, and in turn better long-term results post-implementation. The reality for providers Every behavioral health provider executive planning to implement an EHR has heard the disheartening odds: An estimated 70 percent of the agencies that made the commitment to move to enterprise EHR and billing systems, whether commercial or “home-grown,” over the past 20 years have failed to fully operationalize their chosen system. Why has the success rate been so low? The primary reason is that behavioral health and human service providers have been historically underfunded and understaffed, particularly for IT projects. These statistics from the 2009 Behavioral Health/Human Services Information Systems Survey, conducted under the direction of several behavioral health provider associations and the Software and Technology Vendors' Association (SATVA), tell the story. Behavioral health providers: Spend only half as much as primary care providers on health information technology (HIT); Employ only about one-third as many IT professionals as primary care providers do; Expect to spend even less on HIT in 2010 because of budget cuts, reduced reimbursements, and higher patient volume; and Would increase overall HIT spending if resources were made available. Also, the traditional software model has the wrong goal-alignment from the start. Traditional software implementations (whereby the provider purchases licenses, hardware, and services from the vendor up front) create little incentive for the vendor to conserve an agency's time or money. Prepayment front-loads the provider's expense, to the vendor's benefit. Furthermore, on-premise software vendors stand to gain when projects run over budget despite the fact that these same overruns put the project at risk for the provider. On-premise vendors lack the motivation to quickly deliver a system that users can skillfully utilize. And what happens to providers when EHR implementations go over budget and behind schedule? Agency resources-already stretched thin-are taxed to the breaking point, and another addiction/mental health agency joins the 70 percent of providers that fail to operationalize their EHR system. Given today's economic environment and forthcoming EHR requirements, providers do not have the appetite or the budget for multi-year projects and hundreds of thousands of dollars in custom software. Agencies need to see value from their system investments as quickly as possible. Case example InterCommunity, Inc., an East Hartford, Connecticut-based behavioral health provider, struggled for three years with an on-premise (client/server) EHR implementation. It changed course in favor of Qualifacts Systems, Inc.'s EHR system, and 90 days after kicking off the new project went live on its new integrated EHR and billing platform. InterCommunity's previous negative experiences lent its officials a new perspective-that a fast implementation was essential. The InterCommunity team set a three-month implementation timeframe. InterCommunity's senior director of quality improvement and human resources, Tyler Philips, was the lead project manager for the implementation. Early on in the process Philips decided to avoid traditional implementation models that included large committees and complicated communication structures. Because the short implementation timeline offered more flexibility on staffing the project, there was a focus on selecting an elite team from across the agency. Chris Bair InterCommunity's four-person implementation team was charged with creating, developing, improving, and implementing all aspects of the organization's service delivery through the new EHR system. The positions and roles were as follows: Project Manager -Acted as the main liaison with the EHR vendor; documented and configured the EHR system to reflect the agency's operational structure, workflow, and state reporting configuration; worked with IT to ensure that only clean client data were brought into the new system; and developed standard operating procedures (SOPs) to reflect the new system's capabilities. Senior Director Clinical Operations -Completed review and modification of service documents/client documentation based on medical necessity and fluidity of service information; managed feedback from a clinical/medical perspective and provided this feedback to the individuals performing EHR system development; and developed SOPs for clinical operations. IT Administrator -Completed inventory, purchase, and installation of computers, electronic signature pads (to capture client signatures), and redundant Internet network connections; cleaned/validated all legacy client data prior to upload into the new system; and prepared the system for the Connecticut state reporting configuration and requirements. Billing -Completed review, modification, and configuration of all billing codes, payer plans, and 837/835 billing processes. Conclusion One of the biggest obstacles related to a complex EHR project is figuring out how to dedicate a significant amount of time and energy from some of the agency's best people to the implementation process. It is likely that these talented and knowledgeable employees are already among the busiest people in the organization. However, with a shortened project timeline, it was possible for InterCommunity to dedicate a higher percentage of key staff members' time to ensure project success and high quality for the system-as the best leaders helped create it. Chris Bair is Vice President of Sales and Marketing at Qualifacts Systems, Inc. He has extensive experience in the information technology services, software, and telecommunications industries, specializing in sales, marketing, operations, and service delivery. His e-mail address is chris.bair@qualifacts.com . Addiction Professional 2010 March-April;8(2):38-39
Tomorrow's leaders need mentoring
For the past few years at the annual conference of the National Association of Addiction Treatment Providers (NAATP), there has been a lot of discussion about the future of the treatment industry. Some of the most important questions have included: “Where is the next generation of leaders in the industry? What's going to happen as the ‘old guard’ retires? Who is going to continue the work of helping people battle the disease of addiction as we lose some of the great experts?” Maybe the important question is not where the next generation of leaders is, but what industry experts are doing today to help develop new executive directors, clinical directors and directors of business development. Has much time and thought been given to mentoring this next generation? More than likely, our future leaders are currently in the trenches, facilitating groups, developing marketing relationships, answering intake calls or working in administration. There are some incredibly bright, dedicated and hard-working young people in this field with tremendous potential. Quite possibly, the next CEO or clinical director currently resides just down the hall from your office. The question is: What can management do to help mentor this next generation, and how can an ambitious, smart employee find someone to help further his/her career? As president of a consulting company that does a great deal of executive recruitment in the addiction treatment field, I am constantly on the lookout for true potential, for someone with the ability and the ambition to lead. What I'm finding is a lack of management training from within organizations or a lack of assertiveness on the part of employees to seek specific training. In graduate school, clinicians don't learn business skills, don't take classes in basic marketing principles, and don't learn to develop and manage a yearly budget. On the other hand, some administrators don't understand the work and years of training that go into becoming a clinician. Too often, there is a lack of understanding on both sides of the field. In executive recruiting, finding someone who has both strong clinical and business expertise is like striking gold. It's what we look for. There's clinical director, executive director, or even CEO potential in that combination. A plan for facilities How can treatment facilities and corporations develop future leaders? Here are a few ideas: Identify employees who often go beyond the call of duty. Look for those who will step in and help out, even if it isn't “their job”-those who are passionate about their work and want to learn as much as they can. Develop a formal management training program. Appoint a group of department heads to work with employees who have shown an interest in learning and are willing to spend the extra time required to learn new skills. Management training programs take effort to design and execute, but will help identify future industry leaders. If you are an executive at a facility, make it a point to mentor someone who you believe has potential. This can be an informal agreement, but it helps to schedule time on a weekly or biweekly basis to work with that person. Send a deserving employee to a training program or help pay for further education if possible. This constitutes an investment in the future of your company and our profession. Employee strategies If you are an employee who is eager to move into a management position, here are some suggestions in seeking a mentor: If you are inspired by or admire an industry expert, don't be afraid to pick up the phone and speak with that person. Once you establish a relationship, ask the person if he/she would be interested in mentoring your career. Research company policy or talk with upper management about available education or training. If no management training is offered, find out what is available outside the company and write a formal report, requesting that the company invest in you and describing how that would benefit the facility. Determine the specific position toward which you would like to work, and talk with other managers around the country currently in that position. Learn their career paths and how they achieved their goals. Don't be afraid to speak with a recruiter. At my company, everything discussed is confidential and the more we get to know you, the better your chance of our calling you when something opens up. Be assertive. You, not your managers, are responsible for your career advancement. Lynn Sucher, MC, LPC, CEDS Mentoring, training and encouraging the next generation of addiction professionals is an important part of this generation's work. We must make sure our industry continues to save lives and provide the very best treatment available to those who need our help in fighting the disease of addiction. Lynn Sucher, MC, LPC, CEDS, is President of Treatment Consultants ( http://www.treatmentconsultants.com ). She has served as an administrator for several treatment facilities, and she specializes in eating disorders and treatment of impaired professionals. Her e-mail address is lynn-s1@cox.net . Addiction Professional 2010 March-April;8(2):32-33
Product/Service Center
Insurance/Risk Management Services American Professional Agency American Professional Agency offers a comprehensive product line that focuses on professional liability insurance with special emphasis on the mental health field. It covers professionals in psychiatry and psychology, pastoral and school counseling, and marriage and family therapy. APA offers plans for social workers, students and faculty, and more. Since 1940, APA has become one of the largest writers of mental health professional liability insurance, with more than 100,000 policyholders. Please call 800-421-6694 or visit http://www.americanprofessional.com . Irwin Siegel Agency, Inc. Irwin Siegel Agency, Inc. is a provider of insurance programs for addiction treatment facilities. Insurance packages address your specific liability needs and include an extensive library of risk management resources to support your mission, enhance training, promote safety, and ensure the longevity of your program for years to come. Explore the various insurance options available to your program by calling ISA today at 800-622-8272 or visiting http://www.siegelagency.com . Professional Risk Management Services, Inc. Endorsed by the APA, The Psychiatrists' Program specializes in medical malpractice insurance programs and services, specifically designed for psychiatrists and behavioral healthcare professionals. Their individual and group coverage includes forensic psychiatric services and administrative and governmental defense benefits. Discounts are available for child/adolescent, early career, groups, part-time, and moonlighting residents. Program participants have access to and receive quality risk management consultation and top-notch legal representation. Unemployment Services Trust The Unemployment Services Trust (UST) works to help nonprofits reduce unemployment costs by offering a safe, cost-effective alternative to payment into the state unemployment system. The average nonprofit that opts out of its state UI system will see a savings of 30 to 60 percent. With many states imposing triple-digit UI rate increases to employers, nonprofits need to take advantage of the federal “opt out” option granted to them in the 1970s. Learn more at http://www.chooseust.org . Clinical Decision Support AccuCare Web-based Clinical Management System The AccuCare Web-based Clinical Man-agement System was designed specifically for the addictions field to support evidence-based treatment. From intake/assessment to discharge/outcomes, AccuCare can provide solutions to the clinical, financial, technological, and administrative elements of any organization, freeing clinicians to focus on building relationships with their clients. To view a free demo, please visit http://www.MyAccuCare.com or call 800-324-7966. Celerity LLC Celerity's electronic medical record, CAM, guides clinicians in making appropriate clinical decisions through integrated psychosocial information gathering and proper level of care tools. CAM focuses not only on problems but on abilities, strengths, and client preferences leading to a person-centered approach to treatment, further aiding in proper clinical decision making. Clinical decision support as well as significant time saving, compliance, and custom features continue to make CAM an attractive choice for treatment providers. Electronic Behavioral Health Record Electronic Behavioral Health Record (EBHR) is an integrated electronic health record system created to aid organizations that treat both chemical dependency and mental health disorders. The system helps practitioners concentrate on providing quality patient care through the streamlining and consolidation of patient records in real time. The program supports every aspect of service delivery, is cost-effective, completely customizable, user-friendly, easily updated, and ultimately licensing is owned by the purchaser. It is also hospital tested. KIT Solutions, LLC KIT Solutions provides real-time, data-driven decision support service with Knowledge-based Information Technology to health and human service agencies. KIT delivers Software as a Service, enabling clients to effectively manage social service programs by helping them better measure impact and performance outcomes, improve decision making, implement best practices, and track funding and satisfy grant reporting. KIT has more than 70 employees and its clients include several federal agencies and state and local agencies in 17 states. My Clients Plus My Clients Plus ( http://www.myclientsplus.com ) is the first billing and practice management software designed to operate exclusively within a web browser. Client information is available whenever and wherever it is needed. Enjoy the option of automatically submitting insurance claims to the insurance company for rapid reimbursement, or print claim forms and mail them personally. In partnership with Healthconnx, its web-based scheduling provides the ability to share calendars with colleagues and access schedules from virtually anywhere. The next issue's product/service center will focus on privacy/security IT solutions and adolescent treatment centers. To participate in these sections, e-mail lbarba@vendomegrp.com . Addiction Professional 2010 March-April;8(2):46-47
Discussions at vibrant SECAD conference reflect hope for future
While pressure on privately funded treatment centers and frustration over a lack of progress on health reform clearly have taken a toll on the addiction field’s collective psyche, attendees at this week’s SECAD ’10 conference appeared undeterred by recent setbacks. In what arguably was one of the most vibrant clinically focused meetings in years, more than 600 participants eagerly jumped into learning about opportunities ranging from science-based analysis of treatment interventions to treatment of families affected by sex addiction. Bookending the conference material were keynote presentations in which two prominent leaders called for a recovery-focused treatment approach and a blend of today’s science and traditional 12-Step philosophy. David Mee-Lee, MD, senior vice president of The Change Companies, assumed a familiar role of challenging attendees not to force clients into rigid treatment models that emphasize symptom control over long-term wellness. Internationally known clinical trainer Cardwell C. Nuckols, PhD, reminded his audience that current research in neuroscience doesn’t supplant the spiritually based approach of 12-Step treatment, but rather confirms much of that tradition. Although several attendees and exhibitors remarked on recent struggles in which even facilities that attract the highest-income clients have seen an erosion in census, the diverse SECAD curriculum clearly helped attract an enrollment increase and a full exhibit hall for this year’s meeting in Nashville, Tenn. Technology and drug testing firms both had a strong presence among exhibitors, and many attendees appeared open to topics not always prominent at clinical addiction conferences, from restructuring outpatient care to defining the needs of men in treatment. One attendee even remarked to conference organizers that more sessions on sex addiction should be scheduled, reflecting a departure from purely a substance use focus. Renowned author Claudia Black, PhD, presented a keynote address that outlined strategies for working with partners of individuals with sex addiction. Black also was one of two 2010 inductees into the prestigious Conway Hunter Society that honors the founding principles behind SECAD, as part of an award ceremony that also featured honors sponsored by Addiction Professional and Behavioral Healthcare magazines. SECAD was produced by Vendome Group, publisher of the magazines. Visit www.addictionpro.com for a roundup of content from conference proceedings, as well as slide presentations from the meeting. The SECAD meeting will merge into a larger national conference that will debut in the Washington, D.C. area this September. The National Conference on Addiction Disorders (NCAD), to be held Sept. 8-11, will also incorporate the annual meeting of NAADAC, The Association for Addiction Professionals, and thus will bring together input from NAADAC and the National Association of Addiction Treatment Providers (NAATP). For more information, visit www.NCAD10.com .
Winter?s fury doesn?t slow daily dosing in methadone program
Edward J. Higgins, the longtime executive director of JSAS Healthcare, Inc. and a board member of the American Association for the Treatment of Opioid Dependence (AATOD), owns several titles and much recognition in the opiate treatment community. Yet each winter in his home state of New Jersey, Higgins also takes on what would seem to be a more pedestrian role: He’s his agency’s chief weather watcher. For an agency that processes about 400 visits a day to its Asbury Park clinic site for administered daily doses of methadone, anticipating what Mother Nature might deliver in any given week becomes a critical role. During a winter when East Coast snowstorms have been frequent but also unpredictable in their path, the challenge of being accurate has intensified. “I’m on with the local stations, the New York weather, the Philadelphia weather,” says Higgins. “Our obligation to patients is our number one priority, and we also have to be sensitive to our staff.” Programs such as Higgins’ have standing orders from regulators to distribute take-home doses of methadone when they anticipate that a patient won’t be able to visit the clinic. Yet they operate cautiously in this regard, weighing any risks of not administering the doses themselves against the possibility that a patient could miss one or more doses and experience severe withdrawal. “Sometimes a patient will miss a dose and just say their stomach was a little off or they had trouble sleeping; it’s nothing they can’t handle,” Higgins says. “But someone with extreme withdrawal might go to the hospital, and the hospital might not give out methadone. But we have a 24-hour answering service that can provide any information that a facility might need for a patient.” In a particularly stormy week earlier this month, Higgins twice had to make advance decisions about take-home dosing. On a Monday morning, with significant snow in the forecast for Tuesday into Wednesday, he ordered that take-home doses for Wednesday be distributed. As the week progressed and the forecast had become even more ominous, the take-home order was expanded to include Thursday. Higgins says the decision-making about take-home doses tends to be based on the anticipated worst-case scenario with weather. He adds that based on staff members’ role and their level of comfort with driving in hazardous conditions, the staff is divided into three groups in terms of how essential it is for them to make it to work on a stormy day. “We take on the responsibility to be on top of things,” he says. Despite its location in an area threatened by winter blizzards and summer hurricanes, JSAS Healthcare never has had to close operations for an entire day, Higgins says. It is a seven-day business in which patients vis