THE FUTURE OF HELPING
Dr. Charles H. Frost
Middle Tennessee State University
Presentation to the University of the Philippines, Diliman
Manila, July 30, 2003
Almost all of my adult life I have been fortunate enough to have been a social worker. I cannot imagine what my life would have been like if I had not been fortunate enough to have stumbled into this profession. I grew up not even knowing that such a profession existed and when I went off to college in 1956 they didn’t have accredited undergraduate social work programs---and if they did have them I probably would not have chosen such a profession…at least not at first.
It is a requirement set by the Council on Social Work Education, our accrediting body, that our curriculum be built on a liberal arts foundation. My undergraduate degree was a liberal arts degree---without any real major. I didn’t design it so, it just happened.
Luck has played an important role in my life as it does in just about everyone’s life. I was lucky to have that liberal arts background as no one really wanted to hire me because I didn’t have a major. I was lucky that I stumbled upon social work as that was an area that valued my background.
Why do social work educators value liberal arts as a foundation? Because we are interested in what makes human society and human beings behave the way they do and the arts and sciences of a liberal education provide you with the best background you can obtain for that purpose. It is through reading Shakespeare, more than reading Freud, that you will gain a deep and lasting understanding of human nature. It is through the great spiritual teachers---Abraham, Buddha, Christ, Mohammed, Bahaullah, Lao Tzu---that you will find the wisdom of the soul, more than studying Jung. It is through a study of history that you will find out the way society has oppressed the masses and created excruciating injustices, more than studying current social welfare policies and regulations. If you read Sarah Orne Jewett’s Decoration Day, written in 1892, you will discover that she understood how alcoholism was caused by genetics, sociological events, and emotional reactions to loss long before researchers understood the complex causes of this deadly addiction. If you read Charlotte Perkins Gilman’s The Yellow Wallpaper, also written in 1892, you will see she understood how your brain could turn against you long before modern research began to understand the brain.
I start out my presentation in this manner as we are going to talk about the future. Whatever the future is, it will not be worthwhile, it will lack meaning, it will be hollow if it is not deeply informed by the wisdom of the past as reflected in the liberal arts.
Another way of expressing this need is to remind you that, as a social worker, you are an artist first and foremost. Yes, you are also a professional that needs to understand and effectively utilize science. However, in order for you to do the work you do, you must apply your skills through relationships that require artistry in order for that application to be effective. The skillful, talented, creative artist that you need to be evolves out of the base of experience and wisdom contained in the liberal arts.
Today I am going to focus my comments on addiction. For thousands of years humans have used drugs and alcohol to help them cope with stress and pain. As our ever more complex, demanding, and confusing world society continues to evolve, it tends to increase stress. The reliance on drugs and alcohol and other potentially addictive forms of behavior as ways of dealing with that stress has been growing tremendously. America is a country where that stress is very pronounced and the number of addicted Americans is enormous. No matter what field of social work you are going into, you need to understand addictions. In the time I have with you, I will: 1. Warn you about the stupid way America responds to addiction; 2. Alert you to the fact that Europe is ahead of the United States in developing addiction programs; 3. Explain the best way of treating addiction; and 4. Call your attention to the importance of old ideas that should not be abandoned in our implementation of new models.
HOW STUPID CAN YOU BE?
THE POLITICS AND ECONOMICS OF ADDICTION IN THE UNITED STATES
The United States of America has one of the worst track records when it comes to addiction policies of any modern industrialized country in the world. We are a great example of a model to avoid. Instead of having policies driven by research and what is in the best interests of our citizens, we have consistently let politicians establish policies that are guaranteed to fail. Our policies are driven by ultra-conservative, punitive, and foolish ideologies that are aiding in the self-destruction of our society.
This is nothing new. We have behaved in this irresponsible manner for over a century now. One of the classic examples was our effort to prohibit the consumption of alcohol---the era of Prohibition. This was a disaster! It resulted in a tremendous increase in crime before it was abolished. In fact it helped create other forms of drug addiction. “When prohibition of alcohol spread throughout the country, cola drinks laced with cocaine…stepped in as the savior. Cocaine, in fact, was considered the remedy for addiction to other substances. Coca-Cola contained cocaine until 1903 and, not surprisingly, was an extremely popular ‘pick-me-upper.’” (van Wormer & Davis, p. 45). Our “modern” anti-drug laws have been accomplishing the same. Those policies have resulted in our incarceration of 2,000,000 Americans. (80% of people behind bars were involved with alcohol and other drugs at the time their crimes were committed according to the National Center on Addiction and Substance Abuse at Columbia University.) When you lock up an American it costs approximately $20,000 per year per inmate. A little quick math and you can see that we are spending $40 billion a year just to lock people up. (Roughly 2 trillion pesos!)
Mind you, this is just the tip of the cost iceberg. Approximately 50% of mental health clients will have problems stemming from their own or a family member’s alcoholism. Add to that the other forms of addiction and you will see that most of the mental health costs are related to our failed policies connected to various forms of addiction. What the government doesn’t address in the development of its policies is two very very important things. First, they don’t recognize that Americans have a history of quickly shifting from one drug or addiction to another. For better or worse, Americans are flexible, as long as they can find something to become addicted to. Second, as noted, we are addiction prone; which should obviously raise the question of: “Why?” Our government has stupidly concluded that the answer is that it is due to those foreigners. Following World War I our government began blaming the countries that supplied the drugs---a foolish and ineffective policy avenue that we continue to go down to this day. America’s youth don’t need cocaine to be imported from South America in order to begin a life of addiction. With alcohol to drink, cigarettes to smoke, glue to sniff, and gasoline soaked rags to snuff or breathe, they need no “evil” foreigners to provide them with anything! Tons of the marijuana we smoke is home grown and we are adept at cooking up meth in the back room---if it doesn’t explode and kill us and the neighbors. Our nation does nothing effective to end addiction to alcohol and tobacco and both of these substances are more destructive than all of the illegal drugs put together. Where is the wisdom behind such behavior?
Alcohol is associated with 50% of the homicides, 30% of child abuse cases, around 30% of large urban hospital admissions, 37% of the rapes, 67% of partner assaults, 40% of traffic fatalities, and 36% of all crimes for which there were convictions (as reported by the federal government). So our own government knows clearly how devastating alcohol is and still goes on focusing on a drug war with its principal target of stopping the importing of drugs into America.
In fact, instead of curbing addiction, governmental policies are clearly but incompetently designed to increase addictions! The recent (2001) movie Traffic, starring Michael Douglas as the new American drug czar who discovers his 16-year-old daughter sinking ever more deeply into addiction ends with his realization that the policies he is being asked to implement are worthless. “America’s war on drugs (is) a war that has been driven by moral and political rhetoric but that is clearly racist and classist in practice” (van Wormer & Davis, p. 29). America has between 13 and 16 million addicted citizens in need of treatment and only about 3 million of them get help and often that help is not comprehensive enough to effectively help them. Meanwhile, 70% of the federal expenditure on drug problems is going to law enforcement instead of to treatment where it would do some good.
The cost effectiveness of substance abuse treatment pays for itself 10 times over but “only 37% of all those needing substance abuse treatment receive it, mainly due to its high cost” (van Wormer & Davis, p. 23). Our politicians decided to spend billions locking people up, billions trying without success to stop the flow of drugs into our country, when they could have spent money on treatment programs that would have effectively dealt with the problem. Fortunately, public opinion is changing. “Most Americans (69%) are in favor of treatment over jail for first- and second-time offenders” who we have been foolishly and wastefully locking up on their first offense (van Wormer & Davis, p. 29).
The national budget is burdened with war efforts and balance of payment crunches. The federal government has been paying less and less of the costs for services and the state budgets have had to take up the slack. The result is that states are now unable to meet all of the costs for effective services. So, instead of locking everyone up, government at all levels is starting to be more realistic and less fanatical in its response to addictions. One of the best alternatives that has evolved in recent years is the drug court movement. This movement began in Florida. “These new courts, which divert nonviolent drug offenders from the prison system into treatment, have proved that addicts can be returned to work, family, and ultimately the American mainstream. Today, there are just over 700 drug courts in 50 states. Knowing that jail time awaits them if they begin abusing drugs again can offer a strong incentive to change” (van Wormer & Davis, p. 30).
However, for this type of movement to be successful, we need to ensure that the treatment they offer is the best available. So, what is the best treatment for addiction?
THE BEST TREATMENT FOR ADDICITION
In order to answer this question, you have to examine what is and has been happening not only in the United States but in other industrialized nations because the best policies are not necessarily developed in the country with the greatest addiction problems. Also, you have to be very careful to not assume that what works in one country will be effective in another. Finally, you have to define “best” in terms of what an economy can truly afford to spend. We shall explore all of these issues as we search for an answer to what is “best” treatment.
The most important lesson from Europe is one of attitude. In general their attitudes toward addictions are far more enlightened and far less politicized than American attitudes. “European ideology…is geared toward a pragmatic, public health approach that is clearly at loggerheads with American moralism and inflexibility” (van Wormer & Davis, p. 51).
They have also produced some excellent research and some outstanding treatment programs from which we all can learn. Take Norway, for example, where they accept the concept of alcoholism as a disease---a personal and family disease---and where the government provides complete funding for five weeks of inpatient treatment, including an extensive family-week program along with aftercare. The program utilizes extensive feeling work, communication emphasis, spirituality, and personal sharing like a first rate American program tends to offer to those few who can get into a good program. However, they also borrow from non-Western or Eastern alternatives. They use acupuncture, meditation with music, and a highly nutritious diet to help detoxify and get clients back on the road.
Research from Sweden and Denmark established that high novelty seeking and low harm avoidance (daredevil behavior) predicted early-onset alcoholism. Data from Finland indicated that aggression at age 8 predicted alcoholism in males and female children who cried easily when teased or who were anxious and shy were most apt to develop addiction problems later in their lives.
But what is more important than the research is that Europeans develop rational policies instead of the irrational ones we have in America. Europeans tend to apply a harm reduction model.
The Harm Reduction Model Imported to American from Europe
Professors van Wormer and Davis open their book entitled Addiction Treatment: A Strengths Perspective with the following statement:
“Is cutting down on drinking and drug use a realistic option for alcoholics/addicts? Or is total abstinence the only path to recovery? The moderation versus abstinence controversy is easily the most hotly contested issue in substance abuse treatment today. Each position has its strength, and each carries inherent risks. Addiction counselors who help clients merely moderate their destructive behavior run the risk of giving some of their clients false hopes and setting them up for failure. Proponents of immediate and total abstinence, on the other hand, can rest assured that they will drive away the majority of people who might otherwise come to them for help” (p. xi).
That is a tough nut to crack. Given that the large and influential self-help organization Alcoholics Anonymous is committed to total abstinence as the only “true” path and that many of their “graduates” from AA and NA styled 12 step programs are fixated on abstinence and are frequently involved in various treatment programs, anyone who suggests that another path may have value tends to get attacked. However, even if you are not an AA/NA believer, the issues are complex and the point is that you will inevitably get some who really need abstinence latching on to moderation as an excuse to avoid dealing with their problem. So, what should we do?
The harm reduction model accepts both ways of reaching out to those with addictions. “Harm reduction therapy allows for creativity in the design of treatment strategies. Total abstinence from dangerous drug use is certainly not discouraged, nor is total abstinence from alcoholic beverages by those with a genetic predisposition to get ‘hooked.’ But starting with ‘where the client is’ rather than where we think the client should be---this is the basic principle underlying harm reduction. Placing faith in the client’s ability to make choices is a related concept” (van Wormer & Davis, p. xiv).
The reality is that if you go down the “harm reduction” road several things will inevitably occur. First, if you are an abstinence advocate, you are going to have to learn a lot of new and complicated things. This model is more sophisticated and knowledge rich than the relatively simplistic ones of AA and NA. Change is always challenging, sometimes threatening. But the rewards in this case are tremendous. Currently we are not very effectively reaching out to the millions who are addicted in the United States. Clearly we need a new and better model and the harm reduction one holds great promise for reaching millions that are unwilling to accept the total abstinence approach. Second, you are going to have to be very skilled at assessment so that you don’t encourage moderation for those who really need abstinence, and vice versa.
With the harm reduction model it is recognized that addiction is not a dichotomous either/or problem. Addiction occurs along a continuum. At one end is behavior that is not destructive and at the far other end is behavior that is life threatening---and a lot of those who are addicted fall somewhere in between. Therefore, one task is to understand why people proceed along this continuum and try to move them back in the direction of less harmful behavior. Remember those European studies? For some addicts, it is the thrill of risk taking that gets them going. Therefore, in recognition of this factor, with those clients we are going to help them develop less dangerous but thrilling forms of risk taking. We are not going to say to most of them, STOP entirely taking your drug of choice. Instead we will be saying to them: “How about trying another method of getting your thrills?”
The harm reduction method of treatment relies on two basics that are inherent in all of the best forms of psychotherapy. Those basics are a strengths perspective and client empowerment. Instead of seeing the addicted person as only a person with a profound problem, we are examining him or her in terms of strengths. What strengths do they bring with them that we can effectively help them employ to build a less addictive lifestyle? The empowerment principle is based on a recognition that the client is the one that will make the decisions. Yes, they may temporarily be court ordered to undergo treatment and we may be monitoring that treatment with urine analysis to increase their motivation to abstain; however, they will at some point leave our service and be on their own. If they have not been empowered, then their potential for relapse soars at that point. The two most powerful forces against relapse in the future are strengths utilization and empowerment in the present treatment process.
I have been a social worker now for over 40 years. When I started it was been clear to me and others that when you try to help someone that you use their strengths and you try to empower them. The most important aspects of the most advanced forms of help have these principles as their foundation. No matter what new techniques arrive on the scene tomorrow or a hundred years from now, I am convinced that these two principles will continue to be the foundation. Any “new” or “great” advance will be ineffective without them. That doesn’t mean we should not value the new, but it does mean that we should continue to honor what has been time tested as basic and very effective.
You can find these principles built into all of the great religions and into the great literature of the world. They go back thousands of years in these two bodies of knowledge and wisdom. Why do they continue to be so valid and effective over time? Because they touch upon what the human condition is all about. We are an amazing and wondrously evolving creature. When we fully appreciate that fact, then our potential for growth is tremendously magnified. That is what Carl Rogers did over 50 years ago when he created client-centered therapy. His ideas have now been incorporated into the basic concepts of every effective type of psychotherapy that exists.
Rogers’ three principles on which effective therapy are based are related to relationship factors in the client-therapist interactions. They are: genuineness, empathy, and unconditional positive regard. He established how important our attitude toward the client was and helped codify what great writers and spiritual leaders have long been telling us.
So why do I get into this? What does this have to do with addictions? Everything! As you will see when we get to the discussion of what is most effective in the modern world of therapy, these old concepts are necessary to the effective utilization of the new. “Given the horrendous grip of addiction for certain individuals, the self-defeating behavior, guilt feelings, busted relationships, it is clear that whatever treatment modality is used it would have to offer hope, a way out of the morass of the addiction cycle” (p. van Wormer & Davis, p. 17). The relationship you form with the client is the power that drives their willingness to change; it is the most important element in their motivation.
The old also becomes a test of the new. By that I mean, if anyone tells you that they have a wonderful new technique that will help a client, the first thing you should do is to ask if it fits the old Rogerian model. If it doesn’t, then most likely they are peddling something that may look good but doesn’t really work. In the United States the most influential and widely used diagnostic tool is the DSM---the Diagnostic Statistical Manual. It currently is called DSM-IV-TR because it has gone through changes over time. However, it really doesn’t meet our test of efficacy. It labels individuals, which violates how we should relate to another human being. No human is a label. We are all more complex than any label will ever capture. It says that you can understand a person by a label that describes what the problem is---which is a violation of our strengths perspective. Such labeling also does the opposite of empowering the individual. You are going to stick a label on them and expect them to behave accordingly. The DSM also is dichotomous---you are either 1 or not 1. You are an alcoholic or you are not an alcoholic. It doesn’t appreciate the diversity of humans, the fact that alcohol use and abuse is on a continuum and therefore, limits the way you are going to think about that individual and the type of treatment you are going to provide.
More Details on the Harm Reduction Model
On the other hand, the harm reduction model easily fits into the Rogerian model. So let us take a more in-depth look at the harm reduction model. “Harm reduction models, much more commonly used in Europe than in the United States, measure success simply by whether or not harm was reduced” (van Wormer & Davis, p. 25).
“What is the harm reduction approach? To define harm reduction, we need to take into account the two aspects of the term that are often poorly differentiated in the literature---policy and practice. As policy, harm reduction is an outgrowth of the international public health movement, a philosophy that opposes the criminalization of drug use and views substance misuse as a public health rather than a criminal justice concern. The goal of the harm reduction movement is to reduce the harm to users and misusers and to the communities in which they live, including the harm caused by the criminalization of the substances. Punitive laws against drinking by young adults under age 21 and possession of or using certain substances are opposed as a new form of Prohibition. The war on drugs is seen as exacting a toll in terms of deaths generated by: use of contaminated, unregulated chemicals; the spread of hepatitis, tuberculosis, and AIDS through the sharing of dirty needles; and the social breakdown in America’s inner cities; and political corruption elsewhere. In Europe, in fact, it was the AIDS epidemic of the 1980s that catapulted harm reduction policies into prominence in several countries. Drug use was medicalized and the behavior of drug use closely monitored at methadone and other clinics, where a safe drug supply was provided under medical supervision. Several U.S. cities, including Baltimore, have moved in the direction of such progressive policies.
“At the practitioner level, harm reduction is an umbrella term for a set of practical strategies based on motivational interviewing and other strengths-based approaches to help people help themselves by moving from safer use, to managed use, to abstinence, if so desired. The labeling of clients, as is the custom in mental health circles (‘He has an antisocial personality,’ ‘She is borderline’) or in treatment circles (‘He’s an alcoholic,’ ‘She has an eating disorder’), is avoided; clients provide the definition of the situation as they see it. Clients who wish it are given advice on how to reduce the harm in drug use, such as, ‘Don’t drink on an empty stomach,’ or ‘Always make sure to use a clean needle.’ Consistent with the strengths perspective, the counselor and client collaborate to consider a broad range of solutions to the client-defined problem; resources are gathered or located to meet the individual needs of the client. Above all, clients are viewed as amendable to change.
“The harm reduction approach recognizes the importance of giving equal emphasis to each of the biopsychosocial factors in drug use. Together, in collaboration, the counselor and client consider a broad range of solutions to the consequences of drug misuse, abstinence being only one. Forcing the client to admit to addiction to a substance as a way of breaking through ‘denial,’ according to proponents of this approach, can lead to resistance and a battle of wills between worker and client. When the focus of the professional relationship, however, is on promoting healthy lifestyles and on reducing problems that the client defines as important rather than on the substance use per se, many clients can be reached who would otherwise stay away. Seeking help is rare among substance misusers until the problems are overwhelming, probably due to the stringent and off-putting requirements of traditional substance abuse treatment” (van Wormer & Davis, pp. 27-28).
Pain and Pleasure
One of the forces that frequently confuses therapists is: How in the world can a person inflict so much pain on themselves through their addiction and continue to put all their energies into continuing the addiction? Whenever you find yourself asking this question, then you need to begin looking for the pleasure that the client is receiving from their addiction. It is there! It is just easy to overlook because of the problem. Remember, we are looking for strengths even in the depth of the problem. Your client is getting pleasure from their addiction. Until you locate and appreciate the pleasure factor, you will not be effective in dealing with their addiction. However, that is never enough, it is only the start of what you have to appreciate. More than anything else, if you are going to understand the addictive personality, you are going to have to understand that their brain functions differently than your brain---unless you are an active addict!
The Brain of the Addict
One of the things that is tricky about our efforts to help addicts is that they are engaged in activities that we are familiar with for the most part. We eat---but we don’t have any food addiction. We may drink in moderation recognizing that to do so is actually good for our health. (Alcohol in moderation---no more than two drinks per day---reduces coronary heart disease a major killer in the United States and helps prevent colds. It also protects the stomach from tainted or unsanitary food.) We shop without becoming shopaholics or shoplifters. We may occasionally gamble without becoming addicted to it. We may take a variety of drugs---both legal and illegal, without becoming addicted to them. So, when we are confronted by the addicted client, we can easily fall into the trap of thinking that his or her brain is like mine. The following thoughts enter our brain: “I can do these things in moderation and so can he. All he needs is the will power. If he fails to stop it’s because he is weak and has a flawed character.” Such is simply not the case.
The brain of the addict is profoundly different than your brain. It functioned differently most likely from the day the person was born and after becoming addicted their brain is altered in ways that make resistance to their addiction very difficult. Without an appreciation of that profound fact, you will not be able to have the empathy you need to effectively help the addict.
Note that two differences between their brain and yours exist. Let us look at both of these important areas of difference.
The Addicts Brain is Different from Birth
Not everyone becomes an addict. I know that that sounds obvious. But it is very important. Why doesn’t everyone become addicted? Only about 10% of those who drink alcohol become addicted to it. Only about 30% of cocaine and heroin users become addicted. The most powerfully addictive drug of all is nicotine where the majority of its users become addicted. Why so? Well some of the reasons relate to psychological and sociological factors; however, a very important part of the answer is related to genetics, to how their brain functions.
Everyone’s brain is fundamentally the same. Your brain and spinal cord together make up the central nervous system and they are basically hollow structures filled with cerebral-spinal fluid. In that brain you have nerve cells and each is separated from the next by a narrow gap called a synapse. The nerve cells communicate with one another via chemical messengers called neurotransmitters. It is the neurotransmitters that allow you to have memory and make it possible for you to learn. Every thought and emotion is determined by those neurotransmitters functioning a certain way.
All brains are unique just as all DNA is unique and all fingerprints are unique. Each human being is wondrously and almost magically endowed with their own special wiring in their brains. That should be seen as a blessing, not as a problem. We should develop society to be accepting of all types of brains. We tragically don’t. We tend to say that one type of wiring is better than another. We say that in order to fit into society, we need to have your brain function in a particular manner. The way we expect your brain to function varies according to your sex, race, and culture. American brains are supposed to operate differently than Filipino brains---not because the brains are really different, they are fundamentally the same. Every culture creates its norms and wants everyone to live up to those norms. The fact that we now understand that brains vary has had little impact on the continuing drive of all cultures to bind citizens to one type of acceptable brain determined behavior.
This gets us back to liberal arts. “Different cultures and historical eras have written into their drama, fiction, poetry, and nonfictional prose their sexual/social codes: what it means to be a woman, what it means to be a man, what behavior is appropriate and permissible for each gender, who men and women are expected to meet and marry or not, and how women and men form bonds with members of their own sex” (Annas & Rosen, p. 385). In many ways the greatest work of art protesting this mindless way of viewing the mind is Aldous Huxley’s Brave New World. In this novel, set in the future, the World State’s motto is COMMUNITY, IDENTITY, STABILITY. They manufacture humans so that they are as alike as possible. Infant nurseries run by the government have Neo-Pavlovian conditioning rooms to ensure that certain brains are made to fit one type of task, other brains are designed to fit other tasks set by the state for its citizens.
Until we get to that horrific future where brains are specifically trained by the state to accomplish certain tasks, then we are stuck with brains that vary widely and don’t comfortably fit into certain patterns desired by a culturally driven effort to have everyone conform to a non-existent mythical model of perfection. That inevitable mismatch creates tension and stress. Brains respond to that tension and stress by adopting behaviors that will reduce the stress.
For example, your personality to a large extent is determined by your genetic makeup. The study of twins clearly shows the power of genetics in relationship to behavior, especially those studies where the twins were separated at birth and raised by different adoptive parents. “A gene that relates to risk taking and impulsiveness, for example, is found to vary along a continuum from healthy behavior to high risk taking to extremes, with heroin addicts having the gene for extreme novelty-seeking behavior” (van Wormer & Davis, p. 126).
Although it is clear that psychological and sociological forces are at work in determining addictive behavior, it is also clear that you inherit a brain that is more or less likely to become addicted. A study in Denmark where they controlled for environment by studying adopted children established that biological sons of alcoholics were four times as likely to have alcohol problems as the children of nonalcoholics.
This genetic connection has also been shown in studies of lab rats that have been raised, much like in Huxley’s novel, to have a certain type of brain that gets excited when mildly intoxicated whereas the nonalcoholic strains of rats do not.
The Addicts Brain is Altered Due to their Addiction
It is clear that brains are different and that some people have brains that are more likely to become engaged in certain repetitive behaviors because their brain has a greater need and finds greater pleasure in that behavior than your brain does. But that does not make them an addict. The alteration of the brain due to this repetitive behavior is what creates the addict.
To better understand this alteration, let us examine the impact of cocaine on the brain. “Cocaine’s chief biological activity is in preventing the reuptake (reabsorption) of the neurochemical transmitter dopamine. Drug-addicted laboratory rats will ignore food and sex and tolerate electric shocks for the opportunity to ingest cocaine. A depletion of dopamine following cocaine use probably accounts for cocaine binges, tolerance, craving, and the obsessive behavior of cocaine users. And, as researchers and the general public are increasingly aware, nicotine behaves remarkably like cocaine, causing a surge of dopamine in addicts’ brains. Dopamine is the ‘feel good’ neurotransmitter; too little dopamine is implicated in the tremors of Parkinson’s disease, while too much causes the bizarre thoughts of schizophrenia. This drug-generated surge in dopamine is what triggers a drug user’s high” (van Wormer & Davis, p. 121).
“If cocaine is present, it attaches to the dopamine transporter and blocks the normal recycling process, resulting in a build-up of dopamine in the synapse that contributes to the pleasurable effects of cocaine” (van Wormer & Davis, p. 123).
We know a lot of this because we can actually see it happening! With “sophisticated technology such as functional magnetic resonance imaging (MRI), scientists can observe the dynamic changes that occur in the brain as an individual takes a drug. They can even identify parts of the brain, the pleasure circuits, that become active when a cocaine addict sees stimuli such as drug paraphernalia that trigger the craving for the drug. The memories of drug use are so enduring and so powerful that even seeing a bare arm beneath a rolled-up sleeve reawakens the cue-induced craving. The situation is similar to Pavlov’s dog salivating when it heard the bell ring, a bell associated with food. Relapse occurs, as every AA member knows, from visiting the old haunts from drinking days. Now there is scientific proof for this folk wisdom about the importance of avoiding people, places, and things associated with past drug use” (p. van Wormer & Davis, p. 123).
“The addicted brain…is significantly different from the normally functioning brain. Through long-term drug misuse, the depletion of the brain’s natural opiates creates a condition ripe for the kind of relentless craving that is known to all ‘who have been there.’ Compounding the problem of molecular alterations in the brain (experienced as a general malaise) is the fact that each time a neurotransmitter such as dopamine floods a synapse through the introduction of a powerful drug like crack or meth into the body, circuits that trigger pleasure are indelibly imprinted in the brain. So when the smells, sights, and sounds associated with the memory are experienced, these feeling memories are aroused as well” (van Wormer & Davis, p. 140).
To compound our problems further, we have to take into consideration that addiction trains the brain to adapt over time so that the addict tends to need to increase the behavior---drug taking, compulsive eating, smoking---to get the results they received from when they initially started this behavior.
Addiction is a brain injury…”even though the initial drug taking is a voluntary act…once neurochemical changes have occurred with prolonged use, the compulsion to return to drug taking or drinking is no longer voluntary…As with other injuries, healing can occur when the source of the injury has been eliminated…The craving that can preoccupy an addict’s mind and very being involves the irresistible urge to get another rush. The memory of past euphoria, coupled with dopamine deficit related to long-term use, means the addict seeks out drugs in order not to feel low. Due to neuronal damage caused by extensive drug use, the individual can no longer feel pleasure normally. Traditionally it was thought that the reason addicts continue to drink and use was to ward off withdrawal symptoms…however, study of various drugs of addiction reveals this is not the case…The drive to return to drug use…(is) associated with memory as well as with the changes in brain chemistry.” (van Wormer & Davis, p. 125).
Fortunately, the brain can recover from the effects of addiction. “Following a year or two of recovery, the brain, as far as we know, replenishes itself. Perhaps this is why long-term treatment has been found more successful than the short-term variety” (van Wormer & Davis, p. 126).
Given what we now know about the brain and the forces of addiction, if we are going to have effective treatment we must build it consistent with our knowledge.
Therefore, we need to think about how to change the addict’s brain. In the dark past we use to take the brains of the mentally ill and do prefrontal lobotomies where we damaged the brain and reduced the person’s ability to feel certain emotions. Shock therapy also use to be much more common than it is now. Today we are moving in the same direction using prescription drugs. Due to the power of the pharmaceutical industry and the desire on the part of the major corporations that control medical care and want to have quick fixes, we are developing all kinds of quick-fix drugs.
We have long used Antibuse, which tends to cause nausea and intense vomiting if an alcoholic taking it tries to drink. However, we now have more effective medications such as Nalrexone and Acamprosate which work by blocking alcohol-brain interactions that produce a high. Prozac and Zoloft are prescribed to treat a wide range of disorders such as binge drinking and eating as well as a range of non-addictive disorders. They work especially well for those who are depressed and an addict who is depressed tends to lose their motivation to stop their addictive behavior. For those addicted to nicotine Zyban (the brand name for bupropion) can help them get past those first weeks or months of intense craving. We have long used Methodone for heroin addicts. More such drugs are in the process of being developed and tested every day because the pharmaceutical companies have a huge segment of our society that is in need of help. However, is this the type of help they need?
Yes, it is better to use prescription drugs to change the brain chemistry and to effectively help those with addictions than to let them remain addicted. However, I want a cautionary note here that we don’t want to go down that road without taking with us all the humanistic desire to develop effective therapeutic relationships with our clients. Also, we must not fall into that type of dichotomous thinking. It is not either/or---either prescription drugs or no help in terms of changing brain chemistry. We can change brain chemistry internally, without the use of externally imposed prescription drugs. Psychological counseling can actually alter brain chemistry restoring more normal functioning. You can help the client substitute healthy for unhealthy thoughts every time an obsessive urge comes over them. You can effectively use acupuncture, massage, and hypnosis to help your client change their brain chemistry.
More importantly we can dramatically reduce addiction by creating a society that doesn’t encourage addiction. If you want youth, for example, to smoke less, then all you really have to do is get them involved in a strenuous exercise program. If you want the excitement prone youth to not become action junkies involved in a variety of harmful addictions, then you are going to need to create exciting alternatives for them. Most of them now are bored to death by marginally competent teachers who themselves are not leading very interesting lives.
Yes, inevitably, if we want to really do something about addiction, we are going to have to create wonderful, meaningful, exciting, spiritually based alternatives for our adults as well as our youth. “In order to ensure sobriety, alcoholics must achieve a level that is ‘weller than well.’ Spiritual well-being is considered to be the epitome of health. It may come from a sense of unity with the cosmos, from a personal closeness to God or to nature. The experience of wholeness and integration are not dependent on religious belief or affiliation. Fulfillment of the spiritual dimension is important in providing a sense of meaning in life…spiritual practices such as prayer, contemplation, yoga, and Zen and transcendental meditation have measurable effect on physiological processes in the brain. Without imposing their own religious and spiritual beliefs on their clients, professionals in this field should help clients in their search for spiritual truth” (p. van Wormer & Davis, pp. 206-7).
My Family and the Future
I have two sons who are now in their 30s. Back when they were small children I realized that American society was toxic and that I needed to bring them up in a more sane environment than any of our major metropolitan cities provided. I moved them to a small mountain community of only 350 people where they grew up healthy and strong breathing unpolluted air, drinking clean water, knowing who their neighbors were, feeling a sense of community, and communing with nature. Both of them finished college. My eldest now works for NASA as an aeronautical engineer as this was his life long desire. My youngest boy is an artist and lives in Europe because for him that is a more sane society.
Why do I use words such as “toxic” when describing America? One of the most honest and important ways we should judge a society is the way they treat their children. Let us take a brief statistical glimpse at America’s children. In terms of mental health, 21% of 9 to 17-year-old children have diagnosable disorders. Four million children, representing 11% of the population, have significant impairment, and another 4 percent have extreme impairment. 28% of high school children feel blue or hopeless, 19% have considered suicide and 8% have made at attempt at killing themselves. “One of the clear correlates of increasing childhood problems is the declining quality of children’s environments…family resources for coping with these problems have diminished. Almost a quarter of children live in families with incomes below the poverty line…and…between 3 and 10 million children experience domestic violence yearly” (Allen-Meares & Fraser, p. 9). Remember also that children of color are far more likely to suffer these toxic effects than are white children because America continues to be a racist society. If you want to understand racism in American read Battle Royal, the first chapter of Ralph Ellison’s book Invisible Man or read Merle Woo’s Letter to Ma, or John Fante’s The Odyssey of a Wop, or R.T. Smith’s Red Anger. And that is just a small beginning of how our literature dramatically describes the pain we inflict upon our children of color in America. Yes, how we treat our children should be the way our country is judged.
American children, “when asked about substance use in the past month, at least one in three twelfth-graders report having been drunk or engaging in binge drinking (i.e., five or more drinks in a single occasion), one in three report smoking cigarettes, and one in four report using marijuana…over half of twelfth-graders reported using marijuana in their lifetimes…Ecstasy, methamphetamines, cocaine (including crack cocaine, rohypnol, LSD, GHB, and heroin have seen increased use among adolescents in the past decade…Furthermore, the perceived risk of harm from substance use has been falling among teens in recent years. Taken together, higher potency and availability of drugs combined with lower perceived risk of use indicate that drug abuse and dependence is a serious threat among youth” (Allen-Meares & Fraser, pp. 335-336). When you consider all of the stress in the lives of our children, the poverty, the peer pressures, the abuse and violence, the lack of effective parenting, the media pressures, it should not surprise anyone how addictions are a way of life for many of our children. Many of our “youth may view substance use as a way to attract attention or impress others, or alternatively, as a way to alleviate feelings of distress, meaninglessness, or failure” (Allen-Meares & Fraser, p. 339). The threat of drug abuse in my culture is enough to make me fear for both my children and all other American children.
I now have a daughter, age 7, as I remarried 12 years ago to a Filipina. Our second child is due in January. After very careful consideration, we decided, just like 30 years ago, America is too toxic an environment in which to raise a child. My daughter is being raised bi-culturally. I continue to maintain a home in the United States because I love my job there as a social work professor. However, except for her visit to the United States when her summer vacation arrives, she lives in our home in Mindoro. I fly back and forth twice a year spending my summer and winter breaks with them. We also keep in touch daily via e-mail, webcam and phone connections.
What is it about the Philippines that convinces me that this is a healthier and less addictive society?
Yes, I am well aware of the problems that plague the Philippines just as I am aware of the problems that plague America. However, I elect to readily take yours over mine.
In conclusion, I hope that you will learn to appreciate all that you have and avoid addictions. Remember, “all addiction---chemical or otherwise---arises from the same neurobiological processes, processes located deep inside the brain and not in the cerebral cortex, which is the rational, thinking part of the brain. Recent research shows, for example that compulsive gambling may hijack the reward and pleasure pathways of the brain in the same way that psychoactive drugs do…the gambler and the sexaholic, the compulsive shopper, and the man or woman who insists on skiing uncharted glaciers are all looking for the same hit of dopamine and endorphins that the ingestion of substances give the drug addict” (van Wormer & Davis, pp. 213-214).
I am going to attach to this presentation a list of helpful websites for you to continue your studies on addiction. However, remember, one of the growing forms of addiction is Internet addiction. So stop trying to relate to a computer and go out and get involved in positive relationships with other human beings. That is one of the most effective forms of behavior if you are trying to avoid addiction. Being human is all about being able to enjoy meaningful relationships and to give to others through those relationships. I am positive that this is what life is about for many reasons. One of those reasons is that your brain loves to love. If you engage in positive relationships, if you reach out and give to others, your brain rewards you with a natural chemical high. This is the type of cognitive training we should invest in throughout our schools, throughout our businesses, throughout our personal and professional lives. This is the alternative that every addict desperately needs you to help them develop. If you are going to effectively help them, then you first must begin to apply this idea to your own personal life. You get a rush from the endorphins that your brain releases when you behave in this way. If we encourage this type of habit, the helping, caring, loving habit, then we will get addicted to enjoying our endorphins and building a better world for both ourselves and others.
The future of helping will be based on a better understanding of how the brain functions. The future of helping will also be based on the great literature of the past.
The future of helping will be more about relationship development than it will be about what prescription drugs a client should take.
The future of helping will focus on training your own brain so that it is not vulnerable to addiction and utilizing your own wondrous brain chemistry to your advantage.
The future of helping rests on the shoulders of the past but is going to be determined by the professionals of the future such as you.
The future of helping is not about high-tech modern devices, it is very low-tech.
The future of helping is about you relating effectively with another person, which is cost effective for developing countries as well as developed countries.
I wish you all well as you take charge of helping those in need in the future.
When Bill Clinton was first elected to the Presidency, I became excited about the future of American for the first time in many years. Here was a bright charismatic leader who could make a difference and to top it off he had an equally wonderful Vice President in Al Gore---plus the wives of both of these men were equally talented and wonderful people. When Clinton was through with his two terms, Gore would be able to carry on the good work for two more years of a Gore Presidency. Wow! That was exciting to me.
But then when the scandals started, I couldn’t even begin to imagine why anyone with so much going for them, with all those wonderful opportunities, why, why, why would they undermine it all?
But what I didn’t understand was that Clinton is a sex-addict. Eventually it all came out. The allegations of multiple sexual transgressions, his being prone to lying, that he had an insatiable need to be loved, that he grew up in an alcoholic and violent household, that he learned to use sex as an escape and that he would risk all for reckless sexual intrigues. A sex addicted action junkie who ended up self-destructing and destroying all the promise that he held for our country.
It was indeed tragic. But it also stands as a great example of how addiction runs the person because addiction runs the brain. No matter how smart you think you are, if you are addicted, your brain is injured. So before you do anything else, you need to repair that brain.
Allen-Meares, Paula & Fraser, Mark W. Intervention with Children and Adolescents. Allyn & Bacon: S.F., 2004.
Annas, Pamela J. & Rosen, Robert C. Literature and Society. Prentice Hall: Englewood Cliffs, N.J., 1990.
Ellison, Ralph. Invisible Man. Random House: N.Y., 1952.
Fante, John. The Odyssey of a Wop. McIntosh & Otis, 1933.
Gilman, Charlotte Perkins. The Yellow Wallpaper. In Annas, P.J. & Rosen, R.C. Literature and Society. Prentice Hall: Englewood Cliffs, N.J., 1990, pp. 388-400.
Huxley, Aldous. Brave New World. Harper & Row: N.Y., 1932.
Jewett, Sarah Orne. Decoration Day. In Annas, P.J. & Rosen, R.C. Literature and Society. Prentice Hall: Englewood Cliffs, N.J., 1990, pp. 944-954.
Smith, R.T. Red Anger. In New Worlds of Literature by Jerome Beaty and J. Paul Hunter, W.W.Norton: N.Y., 1989, p. 332-343.
Van Wormer, Katherine & Davis, Diane Rae. Addiction Treatment: A Strengths Perspective. Brooks/Cole: Pacific Grove, CA, 2003.
Woo, Merle. Letter to Ma. From This Bridge Called My Back: Writings by Radical Women of Color. Kitchen Table Press: N.Y., 1983.
Internet Based Resources
Harm Reduction Coalition www.harmreduction.org
American Council for Drug Education www.acde.org
Center for Alcohol and Addiction Studies www.center.butler.brown.edu
Center for Drug Abuse Research www.pitt.edu~cedar/navigat.htm
Drug Abuse Research Center at UCLA www.medsch.ucla.edusom/npi/DARC
Moderation Management www.moderation.org
National Center on Addiction and Substance Abuse at Columbia University www.casacolumbia.org
Self Management and Recovery Training www.smartrecovery.org
National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gove
National Institute on Drug Abuse www.nida.nih.gov
National Institute of Mental Health www.nimh.nih.gov
Help for smokers www.quitnet.org
Alcoholics Anonymous www.alcoholics-anonymous.org
Cocaine Anonymous www.ca.org
Families of Compulsive gamblers www.gam-anon.org
Families of Drug Addicts www.narcanon.org
Gamblers Anonymous www.gamblersanonymous.org
Narcotics Anonymous www.na.org
National Organization on Fetal Alcohol Syndrome www.nofas.org
Students Against Destructive Decisions www.saddonline.com
Dr. Charles Frost www.mtsu.edu/~socwork/frost