A challenge for every residential addiction treatment center is the client that suddenly glazes over and announces to his or her treatment team that it is time for them to go home, despite the fact that it is only Day 9 or day whatever of their 30 day program. Sometimes they are glazed and dazed. Sometimes they are highly agitated. Studies show that the longer the client stays in treatment, the better their outcomes. But how do you help that client who suddenly decides they don’t need treatment?

In the past, the standard reaction to AMAs (leaving against medical advice), was to say, “Susie hasn’t hit bottom yet,” “Joe needs to want recovery more,” and similar statements. The truth is, some of those people might not make it back to treatment because addiction is a powerful, and sometimes deadly, disease. What if there was a way to help these clients focus and overcome the fight/flight response they have while in treatment and in early recovery?

Enter EEG Biofeedback, also known as Neurofeedback. At Promises Treatment Centers, we have made Neurofeedback an elemental part of addiction treatment, and it has been immeasurably helpful for clients who have a tendency to bolt from treatment.

Before we discuss further how Promises uses Neurofeedback, let’s discuss what it is exactly.

EEG biofeedback and neurofeedback are synonymous terms. This treatment modality utilizes audio and visual feedback to guide over and under aroused brainwaves, as well as unstable brainwaves, into a more effective mode of operation. Individuals with symptoms and diagnoses as broad as substance abuse disorders, ADD/ADHD, affective disorders (depression, bipolar, anxiety), insomnia, hypersomnia, chronic pain, and traumatic brain injuries can be effectively and measurably helped with EEG Biofeedback.

There is frequent confusion between EEG Biofeedback and Peripheral Biofeedback. Peripheral Biofeedback teaches people how to make seemingly involuntary bodily processes, such as body temperature, voluntary. For example, an individual with chronically cold extremities can learn to voluntarily warm their hands and feet. In the case of brainwave training, or EEG Biofeedback, making brain functioning voluntary is never the objective since the learning happens in the brain, not the mind. Clients simply need to focus and relax while the software teaches their brain, the organ, how to better self-regulate. The objective is to train your brain to automatically be more effective and efficient for the task at hand.

At Promises, we start Neurofeedback sessions as soon as the client is stabilized after detox. If we see within three sessions atypically heightened alpha amplitude, we know that client is at risk to leave Against Medical Advice. We know before the client is even formulating his or her exit strategy that the flight/fight response is kicking in. With appropriate intervention – peer support, clinical interventions, a 12 step meeting, more biofeedback, meditation, everything we offer – we can help the client relax and focus on treatment. If we can’t get them to complete treatment, we can’t help them.

The importance of this information is far reaching. It proves that old beliefs about needing to hit a worse bottom or needing to want it more are simply not accurate. The addicted brain responds to treatment strategies with heightened alpha amplitude, a fight or flight reflex. The addict wants to use drugs. Treatment is about not using drugs. When an individual chooses to leave treatment prematurely and they appear highly agitated or glazed over, they are often quite literally in an altered state of mind – in fight or flight -and without an intervention that meets them where they are it will prove ineffective almost every time.

A study, “Effects of an EEG Biofeedback Protocol on a Mixed Substance Abusing Population,” by William C. Scott, David Kaiser, et al., and published in the American Journal of Drug and Alcohol Abuse, showed significantly improved treatment outcomes for those clients who received neurofeedback vs. those who did not during a 12-week residential treatment experience.

Why Does EEG Biofeedback work on addictions and prevent fight/flight response? For the addicted brain, the threat of ongoing recovery triggers the survival cortical defensive bypass (“If I don’t get my alcohol/cocaine/Oxy I will die!” might be the false survival message they get), but EEG biofeedback trains the cortex to avoid this reactive state. This causes it to integrate the treatment process more effectively. Essentially, the fight/flight response is soothed. One’s resistance to the principles of recovery becomes closer to the nonresistance one would have in following the instructions to set the clock on a DVD player. The unconscious reactions of “not feeling like” reading recovery literature, going to meetings, etc. resolve and there is a greater enthusiasm for recovery activities. Clients are far less likely to regress into primitive maneuvers in response to effective treatment strategies.

If EEG Biofeedback is evidenced based (It Is) Why isn’t it more prevalent?

Up until 3 years ago, equipment was not user-friendly—now there is equipment on the market, which is fully automated and highly effective. The symptom-based evaluation process was very difficult to learn and operator-dependent, therefore results were not consistent before automation. The QEEG methodology is labor intensive and quite expensive to administer. When a technician would leave it would take months to train a replacement. Now with automated symptom-based neurofeedback systems, a new technician can be trained to hook someone up within hours and can become proficient within weeks.

How many sessions does it take?

The broad answer is that it depends on the symptoms. That having been said: Individuals (children, adolescents and adults) with ADD/ADHD often begin to see results in focus and concentration within 5-7 sessions and will frequently conclude treatment in 25 sessions. Clients with anxiety disorders, unipolar depression and substance use disorders often benefit from a more lengthy course of treatment—often 40—45 sessions show tremendous (and permanent) change.

Bipolar depression, long term, chronic relapsers, migraine sufferers, and individuals with chronic pain will benefit from an even longer course of treatment. Although improvements will typically be experienced throughout the course of treatment, for these
conditions, more really is better. Sometimes as many as 75—100 sessions have been reported to be helpful.

How long is a session?

Each session is approximately 35 minutes, but beginning sessions are sometimes shorter in duration.

Shari Stillman-Corbitt, Psy.D., Senior Executive Director, Promises Treatment Centers, has enjoyed an adventurous career performing both clinical and administrative work. She was most recently Executive Director at TouchStone
Treatment Centers. Her past experience includes Clinical Director of the Indian Health Council, Inc. on the Rincon Indian Reservation in Pauma Valley, CA; Program Director at Casa Palmera, an Eating Disorders and Chronic Pain  Management inpatient treatment facility in San Diego, CA; and Clinical Director at Sierra Tucson. Originally from New York, she earned her Masters and Doctoral degrees from Yeshiva University in New York City. Her areas of specialization include the treatment of addictions, eating disorders, trauma, and personality disorders.

Now there’s help in the form of a guidebook. Written by Earnie Larsen, with Carol Larsen Hegarty (Earnie’s sister), Now That You’re Sober, is a week-by-week guide from “Your Recovery Coach,” as described on the book cover and promotional pages.

In fact, the book is good reading for anyone who’s involved with an individual in recovery – although its primary audience is intended to be the recovering addict.

Why do most relapses occur? According to Larsen, it’s because the addict doesn’t do the work and the basics are forgotten. “Recovery is learned and it needs to be practiced,” Larsen says at the beginning of Week 2. Yes, the book is organized according to weeks, since it is a workbook for the individual in recovery to use week by week for an entire year. And the work is the basics of recovery — what the newly sober learned during treatment or from a Big Book study group in a 12-step program.

In writing the book, Larsen, who has written more than 60 books on recovery and spirituality and is a “grateful member of the Twelve Step family since 1966,” decided to focus on “those who are bravely moving through their first year of recovery – whether for the first or twentieth time.”

It’s also a book for those who are well beyond their first year in recovery but who have found themselves stuck in complacency and realize they need to recommit to the recovery principles that work.

While the guidebook is meant to be used in a progressive fashion, week to week, later on in the book, readers may feel drawn back to an earlier chapter to revisit something that’s been a particular problem or an exercise that they’d like to practice further. Each weekly entry, as a matter of fact, focuses on a motivational essay – what Larsen and others describe as a pep talk – that’s centered on a particular key element of recovery. The essay is followed by practical action steps that help the reader focus more in-depth on the concepts and behaviors necessary to effective long-term recovery.

In week 14, Larsen outlines 10 new values, each of which are covered in following weeks. Here are the 10 values Larsen lists:

·         Endurance: Exercising discipline, not quitting, pressing on.

·         Honesty: Facing, telling, and acting the truth.

·         Patience: Accepting that things happen in their own time – not yours.

·         Caring: Allowing others to matter, resolving to make a difference.

·         Forgiveness: Being at peace with imperfection in self and others.

·         Humility: Accepting that everything is not about you.

·         Teachability: Opening your mind to learning something new.

·         Responsibility: Stop blaming and evading – if you make a mess, clean it up.

·         Generosity: Opening your hand and heart to bring new blessings to others.

·         Courage: Facing your challenges whether or not you feel brave.

Honesty – The slip toward relapse always begins with some form of dishonesty. Secrets that remain hidden turn toxic. Don’t trust everyone, but do trust someone. (p. 76)

Gratitude – Gratitude is the opposite of resentment – and resentments are the number one source of relapse. (p. 79)

Naturally, there’s bound to be resistance. Somewhere along the line, maybe midway through the year, maybe not until near the end, some may be tempted to put the book aside. It’s too much work. I don’t need it anymore. I’ve gotten what I need from it already. It’s not difficult to find a whole slew of excuses to rationalize why you don’t complete the guidebook. Isn’t this a lot like what many in recovery do just before a relapse? They don’t do the work. The result is a quick slide down the slippery slope and right into relapse.

Granted, not everyone backslides. But don’t think for a minute that there aren’t plenty of times when it almost happens. It’s only by working the steps – doing the work – that they manage to overcome the challenge and keep on in recovery. The work is certainly not easy. No one who’s being honest will ever say that it is. There are going to be good days and there will also be days when everything seems to go wrong. By using the guidebook, says Larsen, the newly sober will be able to make use of the practical advice and get back on track.

The guidebook is more than just simple reading for one individual. As a matter of fact, Larsen says the guidebook is meant to be shared, to be worked — preferably by two or more people. Larsen notes in his introduction that “It is intended to provide support, insights, and exercises that will do something about the high relapse rate of people starting recovery.”

Along with the weekly chapters, the book is organized into 11 sections. They are:

·         Getting Ready

·         The Nature of Addiction

·         Getting the Problem Right

·         Moving Into the Solution

·         Attitude Adjustment Required

·         The Steps

·         Emotional Management

·         The Toolkit

·         Regarding Relationships

·         Spirituality

·         The Great Endeavor: Moving From Self-Contempt to Self-Compassion

After completing the fifty-two weeks, those in recovery who truly paid attention and actively did the work should feel better about themselves and their ability to move forward with their sobriety. Just as a reminder, however, Larsen closes the book by telling readers that they always have resources – as long as they remain connected. “You are never alone,” Larsen says, repeating a mantra often recited in the rooms. Add to that his final words, “Never, never give up.”

Now That You’re Sober is published by Hazeldon and is available online at Amazon, Border’s and Barnes and Noble, as well as in many bookstores.

Words are Just Words – Let Them Bounce

The power of the human language is such that single words can wound us terribly or lift us up and give our imagination flight. They can lay us low, mourning our plight, or inspire our renewed efforts to push forward in our recovery to the maximum of our abilities.

When you hear someone say something that you know is directed at you or about your dual diagnosis, it will be very helpful if you can adopt the attitude that allows you to let them bounce right off you. Words have no sticking power if you don’t let them. You can be like Teflon, so that hurtful words and phrases, awful names and such have nowhere to latch on.

Granted, this takes a bit of doing. Okay, so a lot of doing. But think of the benefits of not internalizing negative comments.

• By letting harmful comments and names to sail away, you aren’t sidetracked from your current recovery efforts.

• When you’re not distracted by something bad others say about or to you, you have more energy to devote to what’s best for your recovery in the here and now.

• Not allowing negative statements by others access to your thoughts and emotions means you can concentrate more fully on doing the positive activities you’ve set out in your recovery plan.

• Positive overrules negative in all situations – the more positively you can view yourself and your situation, the better you feel about yourself and your situation.

• The sticks and stones of others’ cruelty to you leaves no residue if you refuse it entrance. Be more like an armadillo, with a tough, thickly armored exterior – who’s going to penetrate this superb wall of defense?

Figure Out Who’s in Your Corner – and Who’s Not

Sometimes you don’t have a choice of the people who surround you on a daily basis. If you have a job, you’re pretty much in a status quo relative to your co-workers. And, as anyone with dual diagnosis knows, co-workers can say and do some of the most awful things. Despicable is probably a more accurate description.

And it goes far beyond just water-cooler talk or coffee-room chitchat. When you’re being virtually ostracized by the rest of the office, you start to feel less than valuable. Before long, your work is affected. You miss assignments, bungle tasks, forget due dates, get overstressed, mired in a mixture of conflicting emotions. The boss starts to notice – and not in a good way. This downward cycle has to be stopped. Here’s how.

What you need to do is figure out if there’s anyone in your workplace that’s in your corner. Those that aren’t – well, they are the ones you need to steer clear of. For one thing, they don’t understand what’s going on with you. They probably never will.

First of all, ignorance is the main reason why people cast aspersions at others. This is true in almost every situation, but even moreso when it comes to dual diagnosis. It would be bad enough if people just gossiped about the office alcoholic, but when the individual in question has a co-occurring mental health problem – such as post-traumatic-stress-disorder (PTSD), depression, obsessive-compulsive disorder (OCD), or others – ignorance adds up to a totality of – you guessed it – pretty repulsive comments and behavior by thoughtless others.

Think of the employees you interact with every day. How did they talk and act in your presence before you went for treatment for dual diagnosis? Are they any more or less friendly and helpful now that you’re back to work? Has their demeanor to your face changed dramatically in the intervening time? Have you heard, or has it gotten back to you, that one or another individual has repeatedly cut you down, sabotaged your projects, taken credit for your accomplishments, angled for your job – or to get you fired or demoted?

One word of caution here. Don’t tell everything to everyone – whether it’s at the office, among friends, or people you just meet. Sure, you need support, but you won’t get it from people who just don’t have it in them.

When you’re deciding who’s in your corner and who’s not, take the long view. If someone has repeatedly stabbed you in the back (verbally, not literally), they’re likely not going to change. Don’t invest your time and energy worrying about what they say and do.

Concentrate instead on solidifying your relationship with those who have integrity, do what they say and say what they do. These are the individuals who can be counted on to perform work duties and interact with you on a professional basis. They may never be friends or confidants, but your worklife will be much more tolerable.

By the way, did you know that people with mental health problems – just like those with other disabilities — are protected under federal and state laws?

Find a Role Model

Whatever your dual diagnosis, in your days during treatment or afterward during 12-step meetings, you’ve undoubtedly encountered one or more individuals that struck you as someone whose behavior you wanted to model. It could be how they managed to raise themselves up from a disastrous situation despite herculean odds and went on to become happy, productive, energetic and successful in their long-term recovery.

You need a role model. You need someone who can inspire you. Chances are, it will be someone you meet in the rooms of the fellowship meetings. It may be your 12-step sponsor. This is just a suggestion, of course.

You may not interact that closely with the person you choose as a role model – and there’s nothing that says you have to. Just modeling your behavior after someone who’s made it against the odds or who carries himself or herself as you would like to is a good place to start.

You Are Not Your Illness

Another tip for fighting the stigma of dual diagnosis is how you perceive yourself – including words you yourself use to describe your illness. Instead of saying you are or thinking of yourself as bipolar, say or think that you have bipolar disorder. Similarly, you’re not schizophrenic, but a person with schizophrenia (and substance abuse). You’re not depressed – you have depression.

This is called “people-first” language. It helps reduce the stigma associated with hurtful labels.

The reason this distinction is important is that you are not your illness. You are not chained to a stereotypical image of an alcoholic-schizophrenic or a drug addict-bipolar. When you view yourself as your disease, you limit your ability to envision a future without these constrictions. That you have a dual diagnosis doesn’t mean that you can’t learn how to manage both – with continuing work, support and encouragment.

Keep Taking Your Meds

One way to really slip up is to discontinue taking your prescribed medication for mental health disorder. You might think your prescription isn’t working, or not working to the extent that you’d like. But you can’t just toss it out willy-nilly. Your doctor is the one who’s best suited to figure out the correct course of action. In fact, you should advise your doctor of any noticeable side-effects you experience so that your brand, dose or frequency of medication can be changed.

It’s also true that medication for depression and other psychological conditions takes some time to be fully effective. It may take altering or modifying your medication several times over the course of many months before the right combination can be achieved.

Don’t give up hope. And definitely keep taking your meds. Mental health disorders may not disappear entirely, but they can be managed. You can live a full and productive life and be reasonably happy.

Continue with Counseling

Overcoming dual diagnosis takes more than just initial treatment at a facility that helps you detox from substances and go through a comprehensive, coordinated, and integrated treatment plan that treats substance abuse and mental health disorder simultaneously. Maybe you initially entered treatment just to overcome alcohol or drug addiction, and didn’t mention PTSD.

It likely was soon discovered. Hopefully, you received treatment at a facility staffed and equipped to handle dual diagnosis. If not, and you only received treatment for one – say substance abuse – now it’s time to get help for your mental health disorder.

If you did receive concurrent treatment, while you may have had better success in overcoming substance abuse, you still should continue counseling to get more comfortable in managing the other part of your dual diagnosis – your mental health disorder.

Why is continuing counseling so important? Studies show that people with mental illnesses recover – and many recover completely. But this does take time – and continued support in the form of counseling. Recovery refers to the way in which you are able to live, work, learn and participate fully in your community. For some, recovery means the ability to live a fully productive life. For others, recovery is more a matter of reduction or elimination of symptoms. Integral to your recovery is hope – without hope, there is slim chance of effective recovery.

Counseling can be with therapists, psychiatrists, psychologists, and social workers. You will also learn to make use of self-help strategies and how to benefit from support groups. Combined with some of the most advanced medications now available, recovery from dual diagnosis is not only possible – it’s more likely than ever.

Solidify Family Ties

It’s critically important that you don’t isolate yourself. No one in recovery does themselves any favors by hiding away from loved ones and friends. In fact, whether you’re in recovery from drug or alcohol abuse or from dual diagnosis, you need people now more than ever.

Start by solidifying your family ties. If you’ve had a falling out with loved ones due to one or both of your illnesses, try to repair and rebuild the relationship. It might be very difficult talking about your illness with loved ones or really close friends, but these are the very people who know you the best and care about you the most. They can give you much-needed support and encouragement as you continue to make progress in your recovery.

It won’t happen if you clam up and keep your distance. You do need to make an effort to reach out and ask for help. Express your appreciation for their encouragement and support and go out of your way to be part of activities with family and close friends.

Final Thoughts on Fighting the Stigma of Dual Diagnosis

You are not alone just because you have a dual diagnosis. Millions of Americans have a problem with substance abuse or addiction to one or more substances. A majority of them also have a co-occurring disorder. It may be caused by drug or alcohol addiction or it may be an underlying condition that’s exacerbated by substance abuse. Some get treatment for the mental health disorder, while many more do not out of fear of the stigma attached to mental illness.

The reality is that mental illnesses are surprisingly common. Almost every family in America has been touched by mental illness. You probably live near or work with or know someone else who has a mental illness – that you’re not even aware of.

Studies by the National Institute of Mental Health (NIMH) and the National Alliance for the Mentally Ill (NAMI) show that there are no differences in productivity when people with mental illnesses are compared to other employees. Employers who have hired people with mental illnesses report good attendance, punctuality, as well as motivation, good work and job tenure on par with – or greater – than other employees.

Sure, your return to work after treatment for dual diagnosis might be stressful. But all jobs can be stressful to one extent or another. The truth is that you – or any employee – will be more productive if there’s a good match between what you need and your working conditions.

Strive to make the changes necessary to better accommodate your life – whether it’s at work or in building better communication with your loved ones and friends.

Resources for More Help

There are a number of agencies and programs support people with mental health problems, just as there are those that support persons in recovery from substance abuse. Wherever you start, you’re likely to find information that’s helpful or links that lead to even more resources.

Vocational Rehabilitation

Veterans Affairs

National Institute of Mental Health

Bring Change 2 Mind – a new anti-stigma project

National Alliance on Mental Illness

SAMHSA Mental Health Services Locator

Carrie Fisher is also an alcoholic, drug addict, and suffers from bipolar disorder.

And she’s gotten her life back together – principally for herself, but also for her daughter, Billie.

Don’t read this book if you’re looking for salacious details of affairs, back-street drug deals, waking up in unfamiliar places with unfamiliar faces – it’s not there. But that’s not to say that Fisher doesn’t take you places you never thought you’d visit, courtesy of her easy ability with words and plucky humor. In fact, Wishful Drinking was also the basis for her stage play, a perfect showcase for an average, plain, somewhat amusing – wait, no, that last part would be Carrie’s brand of self-deprecating humor. Let’s just say that Carrie Fisher knows how to hold an audience, whether in the pages of her book or onstage.

Who could possibly grow up under similar circumstances and not turn out a little wacky? And that’s not a disparaging comment. The reality is that Fisher’s life, while completely out of synch with what most Americans call normal, was normal (sort of) for her. All she knew were celebrities – some of whom married her father, some of whom regularly came to the house to visit her mother, some of whom even visited her. You know, names like Elizabeth Taylor, Mike Todd, Ava Gardner, Cary Grant, George Lucas…

Although she’s clean and sober today, Fisher – just like millions in recovery – takes it day by day. She lives in the present, actively working her recovery. It hasn’t been easy. Fisher admits to four or five slips in twenty-three years, of which she says, “I’m not proud that I wasn’t able to remain sober that entire time – especially in terms of my daughter, who has had to suffer the most from these largely inexcusable forays back down the dark path that is drug use…But ultimately you could say that I don’t have a problem with drugs so much as I have a problem with sobriety.” (p. 119-120)

The book is short, only 163 pages (including photo identifications). Photos and funny? Who knew? Unlike many another book on overcoming addiction by one author or another, Fisher’s book isn’t a classic guide to how to manage your life without booze and/or drugs while, at the same time, trying to combat bipolar disorder. No, it’s uniquely Fisher’s story. Isn’t that the way it is with each person in recovery? Each person has his or her own path to sobriety. Some slip occasionally. Some slip regularly. But the path is littered with challenges, only some of which are recognized as opportunities.

What can readers learn from Wishful Drinking that can help illuminate their own path to being or remaining clean and sober. Well, it’s certainly not a textbook, but it does cause you to think. If you’ve been down that “dark path that is drug use,” you’ll both recognize yourself in some of Fisher’s scenarios — okay, not the crazy Princess Leia hairdo or waking up with a dead gay guy in your bed (what? – you have to read the book) – but reading between the lines, so to speak, to get at the profound heartache and difficult life lessons that come with being an alcoholic drug addict who also suffers from bipolar disorder.

One way Fisher got her life back was to undergo electroconvulsive therapy, or ECT, also known as shock therapy. No, this isn’t a myth or a scene from One Flew Over the Cuckoo’s Nest – although that thought did come into Fisher’s mind when the therapy was first recommended. Her memories were wiped, as she says, and she’s gradually putting her life story back in place.

Nothing has dulled Fisher’s wit, not ECT, not the booze, drugs, or medications she’s had to take at varying times in her life. Now, at fifty-something, she’s quite possibly reaching the point where she’s actually happy with who she is and with life in general. Well, maybe that’s stretching it a bit too far. But then, you be the judge.

If anything, reading Wishful Drinking will make you smile, allow you to forget what it is that’s bothering you, if only for the time it takes to read the book (depending on how fast a reader you are, a couple of hours). It won’t alter your life, but it may give you inspiration. Hey, if a famous person like Fisher can overcome all this misery (self-imposed and not) and come out on the other side even more alive, present, and aware, maybe you can, too.

It’s certainly worth a try.

And the book will only set you back a few bucks (or borrow it from the library for free).

It’s not a pretty picture. But that’s not to say that Dr. Maté – or, Maté, as most of his patients in the skid row clinic where he works call him – words are not hopeful. Indeed, the book is filled with surprises, some delightful, many sad, always profound. In short, it is a book that anyone interested in learning some truths about the real world of addiction can and should read.

What qualifies Maté to write such a book? For one thing, he’s a doctor who has had a family practice, worked as a palliative-care physician, and has most recently devoted his life to working with the addicted men and women who reside in Downtown Eastside Vancouver, British Columbia. Dr. Maté is also the author of Scattered: How Attention Deficit Disorder Originates and What You Can Do About It, and When the Body Says No: Understanding the Stress-Disease Connection. He also co-authored, with Gordon Neufield, Hold On to Your Kids: Why Parents Need to Matter More Than Peers. He is also a former medical columnist in the Globe and Mail, where his bylined articles on health and parenting issues continues today. All in all, Dr. Maté seems more than qualified – by virtue of his credentials, but more so because of his incredible compassion and humanity.

Finding Decency and Goodness in Those Whom Society Shuns

Dr. Maté is certainly not a saint. He is the first one to say so. He is a human being who is sometimes prone to making harsh judgments without benefit of the facts, becoming impatient with patients’ incessant whining and complaining and failure to follow his advice, and, sometimes, just wanting to be alone with his books and his music when the stress and demands of his addictive patients becomes too much.

But these self-described limitations are few and far between. What readers find when they turn the page is anecdote after anecdote that rings true – not because we have any personal experience with addiction or addicts, or even if we do – but because of the true generosity of spirit and willingness to go to extreme lengths to help his patients that Dr. Maté so eloquently displays. He truly believes in human decency and goodness, even – and especially – in those whom society at large generally shuns.

No Other Possible Existence

Dr. Maté makes observations that cut through all the myths and misinterpretations about addicts and how they live. In the very first pages of the book, he says that the addict sees no other possible existence for himself. It’s this inability to see beyond current existence – as incredibly self-harming as it may be – that keeps many addicts firmly ensconsed in their behavior. They seek only relief from the pain that comes when their high wears off, when reality comes crashing in and they are ill-equipped or too soon give up despite repeated promises to come clean.

It isn’t that many don’t want to, but that they cannot bear their existence without the balm of alcohol and drugs. Later on, he comment that a hurt is at the center of all addictive behavior. It’s not simply confined to drug and alcohol addicts. It’s also present in the gambler, compulsive shopper, Internet addict and the workaholic. For the addict, the drug of choice provides the route for feeling really alive again – if only temporarily.

This isn’t a condemnation by Dr. Maté. Far from it. It is a simple declaration of the truth that he sees day in and day out in Downtown Eastside Vancouver.

Working Hard to Make Human Connection

Among the many patients who flock to see Dr. Maté is Ralph. Of this man, Dr. Maté observes: “I’ll soon come to know Ralph as one of the most intellectually gifted people I have ever met. He is also profoundly sad – a lost poetic soul with a hopeless, unrequited longing for human connection.” (p. 77)

Addiction recovery experts, treatment specialists, and numerous 12-step publications say that isolation is to be avoided as it is only with people that the addict can recover. No one recovers alone. Yet, to the addict residents of Downtown Eastside Vancouver, isolation is very much their everyday existence. They use alone, fall into a stupor alone, wake up alone, and fight with their ever-present demons alone. Even in the presence of other drug- and alcohol-using acquaintances, each is alone.

Yet each seeks human connection, even if it is the hopeless and unrequited longing that Dr. Maté found so heartbreaking in Ralph.

Spiritual Void at the Core of All Addiction

Another point that Dr. Maté makes that will sound familiar to anyone who has more than just a little knowledge of addiction and what it does to human beings is that there is a spiritual void at the core of all addiction.

How many times have we seen the faces of despair and hopelessness among people who, even in their pursuit of recovery, reflect a spiritual bankruptness that sabotages or severely compromises their sobriety efforts?

Spirituality does not have to imply a belief in a Higher Power or a religious deity. Enriching the spirit can be accomplished through prayer, if that is in a person’s belief set, or through communing with nature, meditation, or other manner.
The power of the spirit, of humanity, of becoming a part of community – all of these can help fill the void that addiction creates.

But filling the void also doesn’t come easy. For some, it never gets filled. Others don’t even dare to dream of such a thing.

Dr. Maté is not deterred.

In the Drug Gulag

In Chapter Eight, “There’s Got to Be Some Light,” Dr. Maté talks about his experiences working in the drug ghetto in the presence of hungry ghosts. He’s not some self-proclaimed martyr or a doctor who sees himself as the savior of the addicts he treats. He is fully cognizant of his patients’ circumstances – when they choose to be truthful. Dr. Maté often has to glean what is truth from what is a falsehood, since many, if not most, of his patients tell elaborate, embroidered tales with only a faint glimmer of veracity.

But what is amazing about this physician’s writing is not the despair and hopelessness and everyday tragedy he sees, but rather the extraordinary humanity and courage he witnesses. Listen to the doctor’s own words: “It is difficult to convey the grace that we witness – we who have the privilege of working down here: the courage, the human connection, the tenacious struggle for human existence and even for dignity. The misery is extraordinary in the drug gulag. But so is the humanity.” (p. 90)

The Rest of the Book

But the journey Dr. Maté takes readers on goes far beyond recounting his daily encounters with the addicts in Downtown Eastside Vancouver. The doctor uses the book as a venue to address the larger societal problem of addiction. Dr. Maté describes addiction, what it is, the different state of the addict’s brain, how the addicted brain develops, and about the addiction process and the addictive personality.

Dr. Maté then dares to imagine a humane reality that’s well beyond the War on Drugs before he takes on the ecology of healing.

There are many nuggets of wisdom and insight throughout the book. Readers can literally pick up the book and leaf to any chapter and begin reading – and learn something valuable. It’s never boring, never condescending, never too much to read. In fact, the pages are so engrossing that you quickly come to the end of a chapter.

Think you know all about addiction and addicts? You haven’t begun to scratch the surface until you’ve read In the Realm of Hungry Ghosts: Close Encounters with Addiction, by Gabor Maté, MD.

It’s a glaring look at a brutal drug that continues to ruin the lives of many thousands of men, women, and children in towns large and small. To tell the story, Reding focuses on the small town of Oelwein, Iowa. Seen from above, from the many planes that traverse the airways coming and going from Chicago’s O’Hare airport west to San Francisco, Oelwein (pronounced Ol-wine) is a tiny speck of a community. In fact, the town’s population is only about 6,126, give or take a few residents. That meth should seize this particular town in a death grip is not unique, but it is instructive. Reding tells the story of the town’s descent into near extinction due to meth’s influence as well as its climb back out of the ashes to seeming prosperity – or the appearance that, at least, things are looking up.

Since it’s impossible to get the right perspective on what meth does to a community without looking at the effects of the drug itself, Reding cleverly introduces readers to some of Oelwein’s inhabitants – the chief characters of the story – in order to show what meth does to individuals and how the fates of those individuals are inextricably tied to the town.
In the proces, we get a sobering glimpse at the horrors of meth.

Key figures in the town’s story include Nathan Lein, Fayette County’s assistant prosecutor, and Larry Murphy, Oelwein’s mayor. There’s Roland Jarvis, a meth lab cook or “batcher” who blew himself up cooking a batch of meth. The explosion took off his nose, melted the skin from numerous parts of his body and took his fingers down to the nubs. Despite his disfiguration and the long-lasting physical effects from the blast, Jarvis continued to smoke meth. Cooks, you see, are often as big of consumers of meth as the rest of the junkies seeking crank’s high. There are cops and bartenders, farmers and waitresses, the heroes, the helpless, the victims, and perpetrators – all of whom are integral to Oelwein’s story.

And Reding tells it all with compassion and an unflinching honesty that makes Methland impossible to put down.
One point that Reding makes implicitly clear is that meth is not at all conquered in America. His chronologue of how meth came to Oelwein and grew to overshadow all that was good and right in the town mirrors what happened in many a small town in America. How the drug got its start, grew and fluorished there in Oelwein is more than just a cautionary tale. It’s also a story of death and rebirth. Oelwein’s fate could have been cast in stone, but for the people – like Nathan Lein and Larry Murphy, to name but two. It’s people that can bring a town up from near death and breathe life back into it. It’s people that have to take back the streets and schools and help its citizens find reason to hope again.

Far from being decimated, Reding says meth is now in the process of reassorting itself, not unlike killer viruses that mutate and become impervious to vaccines. Where once meth was the province of the small Mexican traffickers and grew to become big business of the Mexican drug cartels, and then after federal clampdowns on the source or precursors of meth (ephedrine and pseudoephedrine) and stepped-up law enforcement on both sides of the U.S. and Mexican border, clandestine meth labs proliferated in this country like seeds on a fertile plane – today, the Mexican drug cartels are readying themselves to again take control. They are acquiring pseudoephedrine from many places like Africa and Central America and Canada. They will soon be doing most of their meth manufacturing in the United States.

Reding instructs readers in meth’s history in Oelwein, and of the efforts of legislators and law enforcement and doctors and social workers in town and across the country to combat meth. That lobbyists for the big pharmaceutical companies and distributors of cold medication available over the counter could successfully thwart efforts to severely reduce the supply of cold medications containing pseudoephedrine shouldn’t be a surprise to readers once they get halfway through the book. After all, drugs are big business in this country. When you learn that chemists long ago discovered a way to manufacture cold medications with an ingredient that wouldn’t allow the medication to be used to manufacture meth – but they chose to ignore it – you’ll likely be outraged. Such is the way that things go relative to meth’s rise in this country. That a lot of the heartache and tragedy could have been easily – and inexpensively – prevented by simply substituting pseudoephedrine with something else, is hard to swallow.

Reding credits many sources that helped him in creating Methland. He gives a great deal of thanks to the citizens of Oelwein, without whose stories the book would not have its incredibly human touch. Of course, there was controversy when the book first came out, with some residents decrying Reding’s painting the town and its inhabitants in an unfavorable light. Even Reding’s friendship with Nathan Lein was a bit strained for a bit, but they’ve patched it all up now. It’s hard to spend the months putting such a book together, talking and being with the people so intimately involved in the struggle to kick meth from Oelwein without getting first-hand knowledge of some fairly painful facts.

In the end, Methland: The Death and Life of an American Small Town is a powerful work that deserves to be read by anyone who wants to understand more fully how pervasive and destructive the drug can be – both to the individual user as well as the communities in which they live. As a nation, we live in the small towns and rural areas as well as the big cities. Meth is a factor in the decay of many a locale across the U.S. and will only be defeated with the combined efforts of all.

The author says she wrote the book for a number of different audiences. These include:

• People affected by someone else’s alcoholism, addiction, illness, compulsions, hurtful behaviors, including issues of abuse, rage, and anger management

• Those who are the legitimate caretakers of anyone, whether that be a parent, child, or spouse – who also need to remember to take care of themselves

• Men, women, and children who have been emotionally, physically, or sexually abused

• What Beattie terms as Double Winners, alcoholics or addicts codependency underneath – and especially those who need to forgive themselves for having the disease (of alcoholism or addiction)

• Children (adult and teenage) of alcoholics, addicts, and parents whose problem affected and still affects them

• People who are codependent on codependents

• “Classic codependents,” who are looking for more peace, power, and information, and are ready for an “upgrade” to Codependent No More

• Finally, for people who turned the idea of codependency recovery into just another set of repressive and fundamentalist rules
With such a broad audience, it could be argued that the scope is too large for a single book. This is not the case, as Beattie delivers on all fronts. First, however, let’s look a bit at Beattie’s background, her life experiences, why she’s qualified to write on the subject of codependency.

Many credit Beattie with coining the word codependent back in 1985-1986 – when she published her first book, Codependent No More. Readers of this latest work will discover in its pages the four decades of learning life lessons that Beattie reveals. These, more than anything else, show that she knows what she’s talking about. Beattie grew up in an alcoholic family, was abused as a child, placed for adoption, abused by a spouse, lost someone to suicide, and had a serious illness. She started drinking at 12, using drugs at 18, robbing drugstores and shooting narcotics at 20, ran out of veins and faced five years in jail by 24. But perhaps the most powerful words leap out on the first page of Section One, “Crossing Lines and Getting Back over Them Again”:
“I know what it’s like to lose yourself so badly that you don’t know if there’s a you or ever was one. I spent thirty years not knowing what boundaries were and another ten learning to set them. I gave until I was depleted and needed someone to take care of me. I threatened, begged, hinted, and manipulated to get what I wanted. I was convinced that I knew what was best for other people. I got so busy teaching them their lessons that I forgot to learn mine.”

Although she’s written four books on the subject of codependency, Beattie says she realizes that’s not enough. This most recent work is intended to clear up confusion, reveal new information, show how codependency has mutated over the years, give various support options, and remind us of the lessons we’ve learned. And, lest anyone think that codependency can just vanish, never to surface again, Beattie tells us that she sometimes will still “step in codependency puddles.” She may get hooked into someone’s stuff, and allow their problems to control her. Then she may over-engage or start reacting instead of taking the right action. That’s when she comes to an abrupt halt, and reminds herself that she needs to take care of herself.

An important concept is that when people sometimes resort to survival mode, it’s not relapse. Beattie says that when we care about someone and feel victimized when they betray us, give everything to those we love, or want to control others because we see them destroying themselves and hurt us – this doesn’t mean we’re sick. These are normal human reactions. According to Beattie, codependency is about normal behaviors taken too far – or crossing lines.

Here are some important points Beattie makes in the book:

• Alcoholism and other addictions are diseases. Codependency is a problem.

• Most recovering addicts and alcoholics have codependency underneath.

• If you’re in the codependent zone, you need to do whatever it takes to get back across the line. The goal of recovering from codependency is looking to and trusting yourself – not doing what someone else tells you to do.

• Excessive and unreasonable guilt is a common codependent trait.

• The biggest codependency issue many of us have is our need to control. Underneath that is fear, and under that is lack of trust.

• Codependency issues either cause us to be among the living dead or drain the life out of us slowly, tortuously. Codependents – like addicts – need to work recovery as though our lives depend on it, because they do.

• Taking care of ourselves can’t be reduced to a list of rules. Don’t’ let anyone tell you it can.

• Boundaries concern our behavior – what we will and will not do. It isn’t a boundary if we can’t enforce it. Expect people to test your boundaries. The more they have to lose, the harder they’ll push. They won’t stop pushing until they know you mean what you say.

• If we’re being manipulated time and time again by the same person or the same thing, we may have crossed into the codependent zone where we’re living in denial, dependency, or not trusting ourselves again. Healthy behavior means taking care of ourselves as soon as we recognized manipulation.

• We may never be happy certain events happened in our lives, but we can be happy again.

Fear, obsession, control, manipulation, denial, guilt, and resistance – Beattie deals with each of these. She also shows us how to make a conscious connection with ourselves and how to “catch and release” feelings so they don’t overwhelm us and drop us into the codependency zone.

There’s also a section on troubleshooting or what to do when we find ourselves in situations where we’re unsure of the right direction or action to take.

Who should read this book? The answer to that is easy: just about everyone. It’s likely that you or someone you know or love is codependent or affected by someone who is. Consider Beattie’s book an owner’s manual, of sorts, helping all of us to learn who we are and giving us tools to overcome unhealthy behaviors and reclaim our lives.

If you currently abuse substances (alcohol, illicit drugs or prescription drugs used nonmedically), and have suffered trauma (early childhood physical, sexual and/or emotional abuse, PTSD, or other trauma type), there is hope for you to heal. You can’t do this on your own. No matter how strong and self-reliant you are, there are some things that you can’t sort out without professional help. Fortunately, there are treatment programs that are currently available – and more are being developed – to help you overcome trauma and substance abuse.

PTSD-Targeted Treatment

Several recent studies with homeless addicted women with substance abuse and significant history of early and subsequent trauma point to the effectiveness of the Seeking Safety targeted treatment program. Seeking Safety is an integrated cognitive behavioral approach that actively links PTSD symptoms with unsafe substance use behaviors. Its effectiveness has been widely demonstrated with active substance users.

When used to treat dual-diagnosis patients (those with PTSD and substance abuse), the Seeking Safety approach is generally modified from the standard 25 core sessions to 12 to better fit standard substance abuse treatment duration. The following is an example of the modification of the Seeking Safety approach when used in a research study.

Sessions included:

• Basic education on substance use disorders and PTSD
• Skill-building to prevent drug use and manage PTSD
• Cognitive restructuring with attention to maladaptive thoughts linked to substance use and trauma symptoms
• A focus on developing effective communication skills to build healthy support networks

Each session used the same format:

• Initial check-in, including brief reports of good coping skills or any “unsafe” behaviors
• Session quotation – a brief inspirational point to engage participants and link to the topic of the session
• Relating of material to patients’ lives (including hand-outs to facilitate discussion and skill practice)
• Check out – including a commitment by the patients to specific practice of skills between sessions

Researchers concluded that when the comorbidity between PTSD and substance use was examined during active study intervention, PTSD changes were found to impact outcomes of substance use. Reductions in PTSD severity were associated with improvement in substance use disorder, specifically among women with severe baseline substance use. Researchers, however, found minimal evidence of substance use reduction improving PTSD symptoms. These findings support the self-medication model (people use substances to cope with PTSD) for persons with comorbid PTSD and addictive disorders.

While research studies have control groups and specific study limitations (i.e., obtaining their pool of volunteers from patients in substance abuse treatment facilities who are already abstinent), the positive results obtained here with women will undoubtedly lead to additional studies with men to see if the same benefits (i.e., reduction of PTSD and reduction in substance use) occur. And such studies included assessment at 1-week, 3, 6, and 12-month post treatment. In any event, use of such targeted and integrated treatment programs at the onset of treatment in residential treatment facilities may prove to be an effective way to let the healing begin.

Eye Movement Desensitization and Reprocessing (EMDR)

Eye movement desensitization and reprocessing (EMDR) is a psychological methodology that is being applied to a wide variety of psychological disorders and to the treatment of substance abuse. EMDR is a structured, client-centered treatment modality that integrates key elements of several different approaches: behavioral, cognitive, body-oriented, intrapsychic, and interactional.

EMDR should only be administered by a trained clinician who is both experienced and educated in this approach. Use of EMDR requires a comprehensive client history and extensive preparation so that the client is able to deal with the high levels of disturbance the treatment often engenders. EMDR uses horizontal eye movements or other repetitive or bi-lateral (which means both eyes, or ears, receive the same) stimulation such as tapping or auditory tones during the session.

How does EMDR work? According to the EMDR International Association (http://www.emdria.org/displaycommon.cfm?an=1&subarticlenbr=2), EMDR seems to have a direct effect on the way the human brain processes information. After a successful EMDR session, normal information processing resumes. The patient no longer relives the images, sounds, and feelings when the traumatic event is brought to mind. It isn’t that you don’t remember what happened, but the memory is less upsetting. While many therapies have similar goals, EMDR seems to be similar to what occurs during rapid eye movement (REM) sleep or day dreaming. Think of EMDR as a psychological-based therapy that helps you see disturbing things in a new, different and less upsetting way.

A typical EMDR session lasts between 60 and 90 minutes. The treatment is conducted in phases in order to identify traumatic experiences (or memories), desensitize the patient to those experiences or memories so they’re no longer disturbing from an emotional standpoint, and help the patient form positive feelings about themselves and their experiences. EMDR may be used within a standard “talk” therapy, as an adjunct therapy with a separate therapist, or as a standalone treatment. The type of problem, life circumstances, and amount of previous trauma will determine how many treatment sessions are necessary.

Studies have shown that 78 percent of veterans who have undergone EMDR treatment no longer met the criteria for PTSD after 12 sessions. The EMDR Institute website cites studies reporting 77 to 90 percent of civilians who underwent the treatment no longer suffered from the symptoms meeting PTSD diagnosis after 3 to 7 sessions. Some drug rehabs offer EMDR as part of the drug addiction treatment program.

Treatment for Adolescents

A considerable body of literature points to the fact that youth who have been traumatized do not do well with treatment that focuses only on substance abuse. Several treatment approaches have been developed for complex trauma specific to adolescents. These use group therapy to address skills development, affect regulation, competence, resiliency building, and interpersonal connections. All these interventions emphasize the relationship between symptoms and the traumatic experience, how to develop concrete coping skills to manage symptoms, and use of peer support groups to help increase normalization, develop healthy interpersonal skills, and establish strong social supports.

One program for sexually-exploited teens emphasizes how important it is for youth to make the connection between their physical symptoms and their mental health. The blending of mental health and other strategies, such as music, art and equine therapy, have proven to be especially promising in treating adolescents with trauma and substance abuse.
Adolescents in treatment for trauma and substance abuse also benefit from therapy that helps them engage in decision making, develop valued social roles, and participate in leadership opportunities.

Alternatives to Traditional Therapies

Besides the therapies already mentioned, many residential treatment facilities specializing in treating dual-diagnosis disorders use nontraditional approaches in conjunction with traditional ones. Alternative methods that help build self-esteem, improve connection with self, and increase empowerment are important adjuncts to traditional therapies. Some examples of alternative approaches include journaling, drama, poetry, song writing, outdoor physical activities, yoga, meditation, acupuncture, massage, healing touch, and body work.

Given the fact that trauma survivors have great difficulties with self-soothing, it is not surprising that many treatment facilities use music as an alternative approach. In addition, some programs offer organized religious or spiritual activities as a way to help patients connect to something that will last beyond the timeframe of the treatment program.

How to Find Treatment

You can start by talking with your doctor and asking for a referral to a treatment facility that specializes in trauma treatment or dual diagnosis treatment.

Once you find several treatment facilities you wish to explore further, go to their website and do some in-depth research. Make a list of any questions you have that aren’t answered on their website and then call for information. Be sure to inquire if the treatment facility accepts your insurance and what type of service is covered. If your insurance doesn’t cover the treatment (or the facility doesn’t accept your insurance), ask about sliding-pay scale, payment assistance, grants, or financial loans. Don’t let money concerns keep you from seeking treatment for trauma and substance abuse. Many treatment facilities and centers will be willing to work with you to help you find appropriate funding for treatment, or will refer you to a federal, state or local agency for assistance.

There is also a listing of state substance abuse agencies at the SAMHSA website (http://findtreatment.samhsa.gov/ufds/abusedirectors). Contact them and find out how they may be able to help you find treatment.
What to Keep in Mind about Treatment for Trauma and Substance Abuse

Chances are that you’ve lived with the effects of trauma for quite some time. You most likely use alcohol or drugs as a coping mechanism to deal with the pain of the frightful memories, to forget or numb out for a while. But, as you well know, the memories are still there, working their havoc on your ability to live a normal life.

Why suffer through the humiliation, shame, depression, anxiety, acting out, and all the physical and psychological symptoms associated with addiction to substances? There is a way out of this. You can be healed from the trauma, and you can overcome your addiction.

Will it be easy? No, and to say otherwise would be counter-productive. If someone tells you they got treatment for trauma and substance abuse and it was a piece of cake, would you believe it? Either they’re telling you that so they can look heroic, or to somehow be elevated in your mind, or they need to reassure themselves somehow that they’re okay. Hopefully, they are. But the truth of the matter is that treatment is different for each individual. What one person finds difficult to face (a particularly painful memory) may be less stressful for another person with a similar memory or experience.

Sometimes it depends on how far along you are in treatment. When you have some time in the program (which will be individually tailored to your particular needs), you will find that you can address certain issues with greater clarity and focus and less fear than you could initially. This is progress. But it takes time. And you have to allow yourself the time and trust in the integrity of your therapists and other treatment professionals to help you achieve the stability and safety and self-esteem you deserve.

During treatment, you will meet other people who have similar backgrounds, possibly even shared traumatic experiences (others with PTSD, rape, incest or childhood abuse victims, etc.). In group therapy sessions, you may begin to understand that you are not alone, that others have the same types of issues, and that there are solutions – coping skills – that you can use to help manage your symptoms and reduce cravings. This is all part of effective treatment.

You will also be introduced to the 12-step group concept and will likely be required to participate in regular 12-step meetings while you are in the active treatment phase. Your therapists will recommend that you continue to attend 12-step meetings when you are in recovery, as this is a strong support network that can help you immensely during your early recovery (the first 6 to 9 months after conclusion of treatment).

Family and close friends also play an important part in your treatment and subsequent recovery. The more supportive they are for your healing process, the more they take an active part in family treatment, lectures, discussions, and family component 12-step group meetings, the greater the likelihood that you will succeed in your recovery.

Think of the journey toward being whole and complete as a process that you can and will be able to undertake. Then, let the healing from trauma and substance abuse begin.

Addiction is a Complex Disease

According to the National Institute on Drug Abuse (NIDA), a body of scientific research since the mid-1970s shows that appropriate treatment can help patients who are addicted to alcohol, drugs, or other addictive behavior to stop using, avoid relapse, and successfully regain their lives. NIDA states that based on this research, key principles (http://www.nida.nih.gov/Infofacts/TreatMeth.html) have been identified that should form the basis for any effective addiction treatment programs:

• Addiction is a complex and treatable disease that affects both brain function and behavior.

• Treatment must be readily available.

• No single treatment approach is appropriate for all individuals.

• To be effective, addiction treatment must attend to the individual’s multiple needs, not just the drug abuse that caused the individual to enter treatment.

• It is critical that the patient remain in treatment for an adequate period of time.

• Both counseling – individual and/or group – and other behavioral therapies are the most commonly used forms of addiction treatment.

• For many patients, medications are an important part of their treatment program, especially when used in conjunction with counseling and other behavioral therapies.

• Treatment and services plan for the individual must be continually assessed in order to ensure the patient’s changing needs are being taken into account and treatment and services modified accordingly.

• Besides addiction to drugs and other behaviors, many patients also have other mental disorders.

• Medically assisted detoxification is only the first step in an overall treatment program for addicted patients. By itself, detoxification does little to curb long-term drug use and abuse.

• Treatment doesn’t need to be voluntary in order to prove effective for the patient.

• Treatment programs should assess the patient for the presence of diseases such as HIV/AIDS, tuberculosis, and hepatitis B and C, and other infectious diseases, and also provide targeted risk-reduction counseling to help patients change or modify their behaviors that put them at risk for spreading or contracting such diseases.

• Treatment professionals must monitor patients’ drug use during treatment, as relapses often occur.

Use Resources to Help in Your Decision

Many times the best place to start is to speak with your doctor about getting treatment for your addiction. He or she can probably give you a referral or point you in the right direction, having assisted other patients with such requests in the past.
At some point, if you have private health insurance, you will need to speak with your insurer to find out what types and duration of addiction treatment your policy covers. You definitely don’t want to decide you want to go to a certain residential treatment facility only to find out that your insurance doesn’t cover this treatment or the facility doesn’t accept your insurance. If you’d rather wait until you’ve got a better idea of which facility or treatment center you want to go to before you talk with your insurance company, you can go through your health insurer’s benefits booklet or go on your company’s website (go to employee benefits section and check out your healthcare coverage). You can get a lot of answers going this route without making a phone call.

You may also wish to contact your employer’s Human Resources department to inquire if your company’s employee assistance program includes addiction counseling.

When you’re ready to find a referral to a treatment facility, use the resources of the Substance Abuse and Mental Health Services Administration (SAMHSA), which maintains a Treatment Facility Locator (http://findtreatment.samhsa.gov/). SAMHSA is part of the U.S. Department of Health and Human Services, and offers an extensive listing of licensed, certified drug and alcohol facilities throughout the United States. You can also call their toll-free referral helpline at 1-800-662-HELP.

Another place to look for treatment facilities for addiction is your State Substance Abuse Agency, available through the SAMHSA site (http://findtreatment.samhsa.gov/ufds/abusedirectors). States often have their own separate listings and toll-free hotlines, and information about accreditation.

Look for Substance Abuse Treatment Programs Specializing in Your Addiction

When you start investigating various substance abuse treatment programs, it’s easy to get lost. Avoid brain fatigue by using the advanced search locator to narrow down the types of substance abuse you require treatment for. If you have an alcohol addiction, look for treatment facilities that treat alcohol dependence and addiction.

If you have a dependence on drugs, such as heroin, cocaine, methamphetamine, ecstasy, or prescription drugs used nonmedically, look for facilities that specialize in substance abuse. You may have multiple addictions, in which case you need treatment at a facility that is equipped to handle your treatment needs for all your addictions. If you have co-occurring disorder (substance abuse and mental health disorder), you need a facility that can handle treatment of both simultaneously.

Types of Addiction Treatment Programs

There are several different types of treatment programs for addiction. Which one is best for you will depend on a variety of different factors. We’ll cover some of those later. First, let’s look at the general types of addiction treatment programs:

• Residential Addiction Treatment – Residential treatment involves living at a treatment facility while undergoing intensive addiction treatment during the day. Duration of residential treatment is generally between 30 and 90 days, although some residential treatment facilities have longer-duration programs for patients who require it.

• Therapeutic Communities – Long-term residential treatment typically occurs in therapeutic communities, where patients may reside for 6 to 12 months. Therapeutic communities differ from other treatment programs in that they use treatment staff and those in recovery as agents of change to influence the patients’ attitudes, perceptions and behaviors that are associated with drug use. Patients in therapeutic communities typically have had a long history of drug addiction, may have been involved in the criminal justice system, and/or have seriously impaired social functioning. According to NIDA, therapeutic communities are now being designed to accommodate the needs of women who are pregnant or who have children. The goal of therapeutic communities is to get the patient to a point where they can live a drug-free and crime-free lifestyle.

• Treatment within the Criminal Justice System – With the vast numbers of prisoner population who are addicted, treatment during incarceration can prove an effective way of helping to prevent the individual’s return to criminal activity upon release. Treatment has been shown to be most effective when it continues as the person is being transitioned back into the community. This treatment does not have to be voluntary in order to be effective.

• Partial Hospitalization – This type of addiction treatment is for people who require medical monitoring but have a stable living situation. Partial hospitalization treatment programs usually involve the patient meeting at the hospital 3 to 5 days a week for 4 to 6 hours at a time.

• Intensive Outpatient Program – As the name implies, intensive outpatient program (IOP), while not hospitalization, does involve a major time commitment on the part of the patient. Such programs usually meet 3 to 4 days a week for 2 to 4 hours at a time. Often scheduled around work or school hours, intensive outpatient programs have a major focus on relapse prevention. Outpatient behavioral counseling includes treatment such as cognitive-behavioral therapy, multidimensional family therapy, motivational interviewing, and use of motivational incentives.

• Counseling – Various types of counseling (individual, group, and family) usually work best when utilized in conjunction with other types of treatment and follow-up support after treatment is concluded. Through counseling, therapists can help patients discover the root causes for their addiction, repair relationships, and learn healthier skills for coping with triggers.

• Sober Living Homes – After completing addiction treatment (generally residential treatment), many in recovery are still not
ready to return to their home environment. Sober living homes provide for a transition period during which the person in recovery lives with other recovering alcoholics and addicts in a clean and sober environment.

• Brief Intervention – This is only appropriate for those who are at risk for developing alcohol abuse or addiction, and not those who already have the problem. Brief intervention consists of several visits to healthcare professionals to discuss the reasons for alcohol or drug abuse and strategies for cutting back or eliminating such behavior.

Factors to Consider Before Choosing a Treatment Facility

Think about your own circumstance. Do you want to get treatment in a facility that’s close to your home so that family can visit you when permitted, and/or participate in family therapy? Or are you more concerned about making a clean break and being as far away from negative influences and your everyday environment that you are interested in an out-of-state facility or one several hours away?

What appeals more to you, a residential treatment program or an intensive outpatient one? That’s if you have the freedom to make the choice. You may find out that your insurance coverage won’t pay for the residential program, since these are almost always the most expensive option. Still, you may feel that the residential treatment facility offers you the best chance to overcome your addiction. If so, explore residential facilities that have a sliding-scale payment plan or offer payment assistance through scholarships or grants. Many residential treatment facilities have loan programs that you may qualify for to pay for a portion of your treatment program. It’s certainly worth looking into. All things considered, you should never let price alone stand in the way of your choice of addiction treatment facility.

Things to Check in the Facility You Select

You will get to the point where you have several addiction treatment facilities or centers that you like. Now you need to do a little more legwork to make sure these facilities meet the appropriate requirements – even before you pay them a visit.

• Accreditation and Licensing – Be sure that the facility has been accredited in the state where it is located. In addition, ensure that the facility is run by licensed and well-trained addiction specialists and mental health professionals.

• Effectiveness of the Program – While statistics don’t tell the entire story, they do carry a great deal of weight in terms of overall program effectiveness. Find out how well the addiction treatment facility has done in terms of numbers of patients served who have remained in the program and are drug- and alcohol-free.

• Availability of Aftercare Services – You don’t want to be discharged from treatment after going through the entire program only to be left on your own to manage your own recovery. Inquire about the availability and duration of aftercare services, often called continuum of care. Statistics show that those who regularly attend aftercare, counseling, and 12-step group meetings are significantly less likely to return to their previous addictive behaviors than those who do only one of these things. The purpose of aftercare programs is to ensure patients are able to re-integrate into their home environments with the support of others in recovery in their aftercare community. Aftercare may include a “Buddy” system, pairing someone new to recovery with another individual with more long-term sobriety, weekly group meetings, access to a large alumni support network, alumni social events and recreational activities, free recovery workshops, referrals for counseling and other adjunctive services, relapse prevention plan, and referrals to 12-step fellowship groups.

Visit the Treatment Facility before Signing Up

Naturally, you wouldn’t buy a car without taking a test drive first. You wouldn’t normally get married without thoroughly knowing your prospective partner – not if you expect to have a long-lasting union. The same principle holds true in pretty much everything that’s really important in life. And this is especially valid when it comes to entering a treatment facility for the purpose of obtaining addiction treatment. You simply must check it out as thoroughly as you can.
Points to consider include the following:

• Driving up to the facility, do you get the visual impression that it is well-maintained, offering pleasant surroundings, and appears to be a solid establishment?

• Pay attention to how you are greeted upon entry to the treatment facility? Look at the interaction of staff and patients? Is everyone respectful and cordial? Does staff appear willing to assist patients with any problems that you can observe?

• What sense do you get of the helpfulness of the staff?

• What is the ratio of staff to patients?

• How safe is the facility?

• How will your privacy be safeguarded?

• What types of living quarters are available?

• What are the amenities available to you and which ones are at additional cost?

• How often and when is family allowed to visit?

• Is family treatment available?

• Does the treatment facility offer modalities and approaches that suit your particular needs?

• Do you think you will feel comfortable here – given that you will be undertaking a rigorous and intensive treatment regimen?

• Do you receive satisfactory answers to all your questions?

Of course, you may have additional areas that you’d like to explore further, and you should feel free to do so. After all, you will be making a significant commitment of time and money in order to attend treatment here. You want to ensure that you have the best possible chance of achieving your goal of overcoming your addiction.

Resist the Urge to Go It Alone

It may be tempting to weigh the option of foregoing treatment and attempting to overcome addiction on your own. This is an understandable but often misguided decision. While you may sincerely want to beat your addiction to alcohol, drugs, or other addictive behavior, the fact is that it is very difficult for an individual to accomplish on his or her own. Physical dependency requires detoxification that is medically supervised. Long-term alcoholics and those addicted to certain drugs put themselves in significant danger of life-threatening complications when attempting to quit cold turkey. Even if you do get the drugs or alcohol out of your system on your own, detoxification alone does nothing to help you with your underlying need to use, nor give you coping mechanisms to deal with cravings.

Attending 12-step meetings, while a crucial component in overall recovery, cannot do the job by itself. You need a combination of treatment, 12-step group attendance, and continuing care in order to have the best likelihood of a positive outcome – recovery.
Weighing your treatment options for addiction takes a little time and careful thought. But the ultimate goal of recovery can only begin when you take this first step and embark on the path to chart your new future in sobriety.

Americans with mental health problems represent an estimated 44.3 percent of the U.S. tobacco market. And half of all deaths from smoking occur among patients with mental illnesses or substance use disorders.

Clearly, smoking cessation programs could benefit people with mental health problems. In fact, these individuals express a desire to quit smoking just as much as smokers in the general population. Let’s look a bit closer into this area.

Alarming Statistics

Consider the following statistics, which should be alarming to anyone:

• At least 1 in 5 people has a diagnosable behavioral health disorder during the course of any given year
• Individuals with behavioral health disorders die up to 25 years earlier than those in the general population
• People with mental health problems and addictions are nicotine-dependent at a rate 2 to 3 times higher than the general population, represent over 44 percent of the U.S. tobacco market, and consume over 34 percent of all cigarettes smoked in the U. S.

Tobacco Use by Diagnosis

Researchers have determined the following tobacco use by diagnosis:

• Schizophrenia – 62 to 90 percent
• Bipolar Disorder – 51 to 70 percent
• Major Depression – 36 to 80 percent
• Anxiety Disorders – 32 to 60 percent
• Post-Traumatic Stress Disorder (PTSD) – 45 to 60 percent
• Attention Deficit Hyperactivity Disorder (ADHD) – 38 to 42 percent
• Alcohol Abuse – 34 to 80 percent
• Other Addictions – 49 to 98 percent

Barriers to Smoking Cessation

Significant barriers to smoking cessation exist among people with mental health problems, just as they exist for smokers in the general population. While the barriers may be the same, for persons with mental health problems, some of these barriers are particularly vexing. Included are:

• Nicotine addiction
• Socially-reinforced habits
• Expectation of failure
• Lack of motivation
• Lack of adequate support to quit
• Lack of hope that quitting will be successful
• Fear of gaining weight
• Fear of the side effects of withdrawal
• Difficulty in coping with anticipated increase in anxiety and tension
• Loss of pleasure
• Loss of the social reinforcements for smoking

Suspected Targeting by Tobacco Industry Revealed

A 2007 study by Prochaska, Hall, and Bero analyzed previously secret documents from the tobacco industry. They found that the tobacco industry monitored or directly funded research supporting the idea that people with schizophrenia were less susceptible to the harmful effects of tobacco or needed tobacco as a means of self-medication.

The study further found that the tobacco industry promoted smoking in psychiatric settings by providing cigarettes to patients and by supporting efforts to block hospital smoking bans.

Smoking Cessation Concurrent with Mental Health or Addiction Treatment

Results of several studies from 2005 to 2008 show that smoking cessation has no negative impact on psychiatric symptoms. Rather, quitting smoking may lead to better mental health and overall functioning.

Numerous studies (from 1993 through 2004) show that participation in smoking cessation efforts while engaged in other substance abuse treatment has been associated with a 25 percent greater likelihood of long-term abstinence from alcohol and other drugs. In other words, treating the primary addiction concurrent with tobacco addiction, patients actually may do better.
Responding to the clinical needs of patients requires programs that hit both the physical and the behavioral side of interventions. On the physical side, addictions and biology mean treatment that involves medications and medical procedures, monitoring, follow-up. The behavioral side involves a person’s habits and environment and treatment that include a program to change behavior.

Smoking Cessation Programs Work

The facts are indisputable. Some 70 percent of smokers say that they want to quit, while about 40 percent attempt to quit. But it’s not a simple matter to just say you want to quit or attempt to quit. Quitting smoking is a difficult process, but it is feasible – if the individual has help to quit.

Consider these statistics:

• Willpower alone accounts for quit rates of about 4 percent
• Nicotine replacement therapy (NRT) alone accounts for quit rates of 22 percent
• Quit line counseling in conjunction with NRT accounts for quit rates of 36 percent
• Medication (Varenicline) accounts for quit rates of 44 percent

Interestingly, smokers who have insurance coverage are more than twice as likely to quit.

Results of smoking cessation programs among people with mental health problems show that most combine medications and psychoeducation and/or cognitive behavioral therapy (CBT). Eight studies of patients with schizophrenia who were smokers attempting to quit showed quit rates of 35 to 56 percent post-treatment, and 12 percent at 6 months. Another eight studies of patients with depression who smoked and tried to quit showed quit rates of 31 to 72 percent post-treatment, and 12 to 46 percent at 12 months.

Advice Helps Reinforce Quitting

People with mental health problems who want to quit smoking have a better chance of successfully doing so if they receive advice as part of their smoking cessation program. Compared to people who smoke who do not get help from a clinician, those who do receive help are 1.7 to 2.2 times as likely to successfully quit smoking for 5 months or more.

Wellness Resources and Tools

There are a number of wellness resources and tools available to help people with mental health problems in their quest to quit smoking. These include:

• Medications and medical interventions
• Cognitive behavioral therapy (CBT)
• Motivational enhancement therapy (MET)
• Individual counseling
• Group meetings
• Individualized treatments based on diagnoses
• Family-based strategies
• Peer-to-peer support
• Referrals – such as a quitline

FDA-Approved Smoking Cessation Products

With smoking so prevalent in the U.S., it’s not at all unusual to see the progression of medications and products approved by the Food and Drug Administration (FDA) over the years. The first tobacco cessation product approved by the FDA was prescription nicotine gum in 1984. A prescription transdermal nicotine patch got the go-ahead in 1991. In 1996, a trio of products was approved: an over-the-counter (OTC) nicotine gum and patch, and a prescription nicotine nasal spray.

In 1997, a prescription nicotine inhaler was approved, along with the prescription medication, bupropion SR. A nicotine lozenge reached the marketplace in 2002 and in 2006, the prescription drug, varenicline. Drugs currently in development include rimonabant and a nicotine vaccine known as NicVAX (currently in a second FDA Phase III clinical study).

Smoking Cessation Program – NYC

The New York City Department of Health and Mental Hygiene instituted a campaign for mental health providers to assist their patients to stop smoking. The program began in 2003 and was modeled after the pharmaceutical sales approach. This approach sells the benefits of good health and promotes public health interventions. It consists of brief, one-on-one interactions with health care providers and staff.

The goals of the detailing program are to promote preventive health interventions to mental health providers in the primary care practice setting, to promote use of clinical systems so that opportunities for care are not overlooked, and to develop relationships and serve as a resource to the staff of the mental health practice.

After visits to 400 mental health sites in January and February 2009 and follow-up visits in July and August 2009, the following key recommendations were made for mental health providers:

• Assess smoking status and readiness to quit at intake and at least every 3 months thereafter
• Provide smoking cessation medications and treatments to assist people in becoming free of tobacco
• Provide education and raise awareness about how to become and remain tobacco-free

Smoking Cessation Action Kits were provided to mental health providers which included clinical tools, provider resources, patient education, medications, health bulletins, and incentives (such as post-it pads and pens). Provider resources included peer-reviewed articles and clinical guidelines on evidence-based care, vital statistics, and information on smoking interventions.
Materials available to patients through the NYC smoking cessation program include Still Smoking. The brochure, targeted to all literacy levels and available in multiple languages, provides key patient messages and prompts discussion with a health care provider.

Sites involved in the initial and follow-up visits received copies of “Smoke Alarm: the truth about smoking and mental illness,” for consumer use in waiting rooms.

What were the lessons learned? By every measure, the campaign proved to be a success. Programs assessing smoking status at every treatment review increased from 21.2 percent to 58 percent. Programs providing smoking cessation education, medication, and counseling, increased from 34.9 percent to 49.5 percent. Willingness to use clinical tools and/or adopt key recommendations increased from 5 to 52 percent. Sites are also requesting additional support and assistance from the NYC
Department of Health and Mental Hygiene.

Successful Strategies

Among other lessons learned are those involving successful strategies. These include:

• Holding regular group sessions
• Addressing smoking at intake and regular reassessments
• Including smoking cessation in treatment planning
• Educating and counseling clients on health benefits and the expense of smoking
• Providing medication
• Providing one-on-one counseling
• Shifting the focus from quitting to reducing amount smoked
• Educating the staff
• Providing a smoke-free facility

Peer-to-Peer Support for Smoking Cessation

One organization has had considerable success in peer-to-peer support for smoking cessation. This group is CHOICES, or Consumers Helping Others Improve their Condition by Ending Smoking. CHOICES employs mental health peer educators and consumer tobacco cessation advocates to deliver two messages to smokers with mental illnesses:

• Addressing tobacco use is important and can improve their quality of life in numerous ways
• Seeking tobacco treatment will increase their chances of successfully quitting

In essence, what CHOICES personnel do is to provide information and support and motivate individuals who smoke to seek treatment. They do not attempt to “force” the individual to quit, nor is this a formal stop-smoking treatment. Each CHOICES member receives 30 hours of tobacco education prior to going out into the field to work with smokers. They also are involved with advocacy, organizing events with agencies, and have ongoing supervision.

This approach, peer-to-peer support, has several advantages. First, it involves shared experiences. Second, there’s increased trust. Third, the interaction is relaxed and non-structured. Fourth, there is no element of judgment. Fifth, consumers find such peer-to-peer support empowering. And, finally, consumers rate the approach as highly satisfactory.

Why do mental health consumers say they want to quit? The answers may or may not be surprising, dovetailing quite a bit with answers from the general population. These consumers want to quit smoking for reasons of health, cost, smell, children, and relationship to other addictive behavior.

The barriers these consumers list to their ability to stop smoking also mirror that of consumers in the general population. The barriers include:

• Stress
• Weight gain
• What else is there?
• What if everyone around me smokes?
• What if I don’t have the willpower?
• Where can I get free treatment?

What Else Is Required to Stop Smoking?

Smoking cessation, in order to be effective, also requires accurate information, support, self-discipline, motivation, and a determination to live a healthier lifestyle. Whether a person has a mental health illness and/or substance abuse, the desire to quit smoking is similar to that voiced by smokers in the general population. The barriers to quitting are similar, and the tools and resources available are also similar in nature.

The fact that there are smoking cessation programs that are tailored to individuals with mental health problems is encouraging. The fact that mental health providers are getting on board is even more encouraging.

Resources

The following resources may prove helpful in understanding smoking cessation programs for people with mental health problems.

• CHOICES, available at http://www.njchoices.org
• Bringing Everyone Along, available at http://www.tcln.org/bea/
• Rx for Change: Clinician-assisted Tobacco Cessation, available at http://rxforchange.ucsf.edu/curricula/
• Smoking Cessation for Persons with Mental Health Illnesses: A Toolkit for Mental Health Providers, available at http://smokingcessationleadership.ucsf.edu/Downloads/MH/Toolkit/Quit_MHToolkit.pdf
• Tobacco-Free Living in Psychiatric Settings, available at http://www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated90707.pdf