[acb-hsp] Addiction Is a Mental Illness

[peter altschul]

Addiction Is a Mental Illness -- Treat It That Way
  Scott Kellogg March 3, 2013
  The recent suicide of country singer Mindy McCready brings the 
death toll of patients who were treated onCelebrity Rehab to 
five.  On Monday, Fix columnist Maia Szalavitz questioned the 
effectiveness and ethics of Dr.  Drew's specific approach.  But 
McCreadybs death also calls for us to reflect more generally on 
the nature of addiction and its treatment.  In addition, the loss 
of these five entertainers and public figures speaks to how 
devastating both addiction and mental illness remain as well as 
how our society conceives of addiction.
  The DSM-IV-TR and the upcoming revision, DSM-V, due out in May, 
define addictions to alcohol and drugs as psychiatric disorders.  
Nora Volkow, MD, the director of the National Institute on Drug 
Abuseeaagrees, saying, "We need to first recognize that drug 
addiction is a mental illness." This focus on mental health also 
conforms to research increasingly revealing the many ways that 
addiction is a brain disease.
  By contrast, Alcoholics Anonymous has been centered on a model 
of alcoholism established before the development of this kind of 
disease paradigm, and it has not espoused clinically complex 
models of psychological motivation.  As AA cofounder Dr.  Bob 
told attendees at a 1950 AA convention: "There are two or three 
things that flashed into my mind on which it would be fitting to 
lay a little emphasis; one is the simplicity of our program.  
Let's not louse it up with Freudian complexes and things that are 
interesting to the scientific mind, but have very little to do 
with our actual AA work."
  Our own approach to addiction, which we call Integrative 
Addiction Psychotherapy, is based on the following assumptions:
  Addictions are psychiatric/mental health disorders.
  Many, if not most, addicts also have additional psychiatric 
issues such as PTSAID, depression, anxiety disorders, psychosis, 
ADHD, and various personality disorders.
  With or without a diagnosable condition, people use substances 
for reasons that need to be respected and addressed.
  The treatment of addictions require professionals trained in 
mental health, skilled in psychotherapy, knowledgeable about the 
full range of psychological treatments, and fluent in the use of 
both addiction and psychiatric medications.  Passion and 
dedication are important, but they do not make up for deep skill 
and knowledge.
  What does an Integrative Addiction Psychotherapy based on these 
assumptions look like? Building on themes that were addressed in 
a previous Fix article and a related article on addiction 
treatment reform, we believe there are seven essential 
components:
  1.  Individual Psychotherapy: Each patient is unique and 
treatment must be individualized to address their specific needs, 
history, biology, pain, dreams and desires.  While group 
experiences may be very powerful, even life changing, the 
integrity and depth of the individual psychotherapy session 
remains a uniquely curative experience-and the cornerstone of 
this approach.
  2.  Therapeutic Alliance: The connection between the patient 
and the therapist is of vital importance as it is at the heart of 
treatment.  Good therapists will demonstrate love for their 
patients and will work with authenticity, optimism, courage and 
determination.  Research in both addiction treatment and 
psychotherapy show the positive benefits of patients having a 
good relationship with their therapists.
  3.  Drug Use Is Meaningful: As noted earlier, people use 
substances for complex and deep-seated reasons that may need to 
be addressed before the individual will be willing to make 
changes in their use.  Drugs may serve as a pathway to pleasure, 
as a way to reduce inner pain and suffering, as a method for 
coping with medical problems, as a vehicle for making and 
affirming social connection, and as a response to social 
oppression and poverty.
  4.  Multiplicity of Self: People who use drugs often have 
conflicting motivational forces at workbsome of which support the 
continued use, others that fight for change.  The motivations for 
change might include concerns about the family, anxiety related 
to economic or prestige threats, existential or spiritual 
concerns, health issues and legal problems.  This inner conflict 
can be usefully re-conceptualized as a community of voices, 
modes, selves or parts.  In this way, each of these energies can 
be respected and given a chance to speak, and dialogues can be 
created among the different parts to address their needs and 
desires.
  5.  Strengthening the Inner Leader: Identifying, connecting 
with and empowering the Inner Leader-sometimes called the healthy 
adult mode or the strong and healthy ego-can work to rebalance 
the inner forces.  The individual can then make positive 
connections with others and take assertive, effective and 
meaningful action in the world.  The Inner Leader of addicted 
patients is often underdeveloped or severely damaged, so 
strengthening it will remain an ongoing concern.  To be clear, 
the healthy mode will be distinguished by its use of existential 
language such as "I want," "I am deciding to," "I am choosing 
to," "I will," "I say yes," and "I say no"-rather than the use of 
phrases like "I have to," "I need to," and "I should."
  6.  Working on Two Dimensions: Complex models of treatment, 
like Integrated Harm Reduction Psychotherapy, require therapists 
to work on two dimensions: both the use itself and the underlying 
pain and desires that drive it.  Sometimes one will take 
precedence; sometimes both need to be addressed concurrently.  
Given this, it can be helpful to conceive of the work as 
involving both Horizontal and Vertical interventions.?)
  Horizontal Interventions are techniques and strategies 
specifically focused on such issues as safer use, reduced use, 
moderation, nonaddictive use and abstinence, including Harm 
ReductionstSubstance Use Management, Relapse Prevention and 
Contingency Management.  The goal is to empower the patient to be 
able to control their use in a way that makes sense for them.  
For many, if not most, this will ultimately be abstinence.
  Vertical Interventions are those involved in treating the 
patient's pain and underlying psychopathology.  Addicts may 
suffer from problems connected to the past (trauma, grief and 
moral failure), the present (depression, anxiety disorders, lack 
of assertiveness and personality disorders) or the future (life 
decisions, identity creation, the project of recovery and the 
need to embark on the Hero's Journey).  The therapist will want 
to be able to skillfully draw upon the full range of 
psychotherapeutic techniques to help the patient make 
connections, restructure cognitions, face feared experiences, 
work through traumas, mitigate the impact of the inner critic, 
claim power, clarify values, take heroic action, and learn to 
meditate and self-soothe.
  7.  Identity Transformation: While a great deal of addiction 
treatment is, understandably, focused on the present and the near 
future, long-term recovery depends on the ability of the 
individual to create and maintain identities that are viable, 
meaningful and reinforcing.  The Addict Identity, which is 
central during active addiction, must be replaced with identities 
based on some connection to family, work, recovery, spirituality 
or other activities that provide a self-definition that is 
incompatible with problematic drug use.  (For example, being a 
father takes precedence over using cocaine.) Most stories of 
successful recovery and life transformation involve some sort of 
identity reorganization or creation.
  Mindy McCready was ultimately overwhelmed and destroyed by the 
pain inside of her.  While psychiatrists and psychologists made 
occasional appearances on Celebrity Rehab, none of the major 
protagonists were mental health providers or had extensive formal 
training in psychotherapy.  We believe that Dr.  Drew Pinsky 
cares deeply about his patients and is dedicated to helping them 
achieve healing and recovery; nonetheless, his training is in 
addiction medicine and, while naturally skilled, he is not a 
trained psychotherapist.
  It is our hope that the leaders and practitioners in our field 
will embrace the future by working to fully integrate mental 
health and addiction treatment-both in the therapy we do and in 
the paradigms we create-so that we can understand and work with 
the complex interplay that exists between inner suffering and 
addictive behavior.  Addiction is a mental illness.