Addiction Professional Blogs

Complex Issues Require Complex Treatment

Wed, 11 Nov 2009 16:03:45 EST

I was recently giving a talk about identifying eating disorders in chemically dependent clients and received feedback from members of the audience that made a lot of sense. One woman mentioned she had been in inpatient treatment for alcoholism but remained active in her eating disorder, binging and purging the entire time she was in treatment. She underplayed her eating disorder and her counselors didn’t tackle the problem, as a matter of fact, she felt they avoided it. She quickly relapsed. She entered another treatment center and the clinical team realized they had to treat both the eating disorder and her substance abuse issues concurrently. Fortunately for her, the team was well trained and developed a complex, individualized treatment plan. She said they were tenacious as far the eating disorder was concerned and she did the work she needed to do. She has been in recovery ever since. So how do we treat clients who are diagnosed with more than one disorder? For example, someone who is diagnosed as chemically dependent, depressed, a gambling addict and is struggling with significant trauma? Where do you, as a clinician begin after detox? What do you tackle first? It takes a highly skilled team to work with these issues as a whole and not place clients in “tracks”. I have seen the “non track” approach work very well at several facilities due to the fact that they developed integrated individualized treatment conducted by experienced clinicians. So many treatment centers claim to work with “dual diagnosis”, but often, their programs do little to address all of their client’s issues or their clinicians are not trained in specific therapeutic modalities that are required for complex clients. If centers claim to treat dual diagnosis, I believe their program schedule and clinicians should reflect a high level of clinical sophistication. It’s important treatment management understand the need to provide training for clinicians in order to offer a high standard of care. It’s also crucial for Clinical Directors to construct a program that is updated on regular basis, in order to best serve their client population.

Health Reform Vote Coming Saturday?

Thu, 05 Nov 2009 10:29:10 EST

Health reform is set to take a major step towards passage this Saturday (if they're working on Saturday, something big must be happening!). A quick reminder on the procedural steps that have gotten us to where we are: First, each of the three committees of jurisdiction in the House has to pass a health reform bill. Then those three bills have to be merged into a single bill that the whole House can vote on. That single, merged bill was introduced last week and can be found in its entirety (all 1,990 pages!) here . An in-depth summary of all the bill's addiction-related provisions can be read by clicking here . (Note that the same process has to happen on the Senate side, except they're a little behind; the Senate leadership is still working in merging the committees' separate bills. A combined version is expected some time in the next 2 weeks, which can then be voted on by the full Senate.) What will happen on Saturday's vote? It's unlikely that House leadership would allow the bill to come to the floor without confidence that it would get the majority vote needed. But you never know for sure until the votes are tallied ... Of course, there is still some last minute wrangling to be done. Yesterday, for example, House leaders met to ensure that the bill handled abortion in a way that was acceptable to pro-life Democrats. Fortunately, and thanks largely to the outreach that was done during the push for parity in 2007-08, addiction treatment issues have face no significant opposition. Not-being-talked-about is a great position to be in! A requirement that all health plans cover Screening, Brief Intervention, and Referral to Treatment (SBIRT) had been left out of the merged House bill (it had been included in one of the earlier committee drafts), but it has since been added back. This House bill also differs from earlier House bills in that it includes a large of number of American Indian-related health provisions--essentially, a separate Indian health bill was grafted to the end of the health reform bill. Many aspects of the Indian health bill relate to addiction and mental health treatment, including the creation of a Fetal Alcohol Disorders task force and the creation of new youth treatment sites to provide culturally competent care to Native American youth. These people--Speaker of the House Nancy Pelosi and other Democratic House leaders--have a lot riding on health reform's passage! A vote is expected as early as this Saturday. Photo from Flickr user "Speaker Pelosi," used with a Creative Commons license. No House Republicans have voted for health reform during the committee process, and it's not expected that any GOPers will vote for the bill on Saturday. The Dems hold a 258-177 numerical advantage, however, so they can afford to lose some of their own without jeopardizing the bill. Several Democratic legislators have expressed concern about the bill's cost , for example. It also remains to be seen what effect this week's elections will have on legislators up for re-election in November 2010 (now less than a year away). The first congressional election after a presidential election year (as 2010 will be) is always considered an uphill battle for the president's party, since the out-of-power party is free to lay all the blame for whatever ails the country on the president and his allies. The fact that Republicans won the governorships in New Jersey and Virginia (even though the Democrats actually picked up a House seat by winning a special election in upstate New York) is likely to give extra pause to Democratic members of Congress facing competitive races next year. That's one of the main reasons that health reform advocates want reform passed well as soon as possible--controversial votes will get harder the closer they come to Election Day. If health reform is passed by both the House and Senate, then those two versions will have to be reconciled and both chambers will have to vote--for the last time!--on that final version. Even without any major unexpected disruptions, this process could easily spill into 2010. Once more, detailed information about the addiction-related provisions of the House health reform bill can be found here : http://www.naadac.org/advocacy.

Principle 7: Dual Relationships - some considerations

Wed, 28 Oct 2009 17:32:46 EST

A credentialed counselor under NAADAC (A) learns from a femaleclient (C) that she is living with a male NCACII counselor (B) working in another office of the same agency. A is a friend of B and has attended parties at the his home; a comparison of addresses confirmed that they are the same. After gathering the information, A reported the information to her supervisor who then met with the client. The supervisor also compared addresses and asked C to describe the person with whom she lives. All the information gathered indicated that a dual relationship is present. However, the supervisor who does not want to complete the required paper work decided that the information from A and C is hearsay and therefore there is no need to report a breach of the NAADAC Code of Ethics or file a grievance with the state. The NAADAC Code of Ethics specifically states that counselors shall not engage in sexual behavior with current or former clients. Where does living in the same place fit into this principle? Since a female client and male counselor are living at the same address, do we automatically assume that a sexual relationship is present? What is the responsibility of the supervisor who does not want to make the report? What is the responsibility of counselor A in this situation? In the treatment setting, how do we teach new counselors to uphold ethical and legal standards when the supervisors ignore these standards?

Military to Review Tx Services

Thu, 15 Oct 2009 12:32:19 EST

Last week, the Congress approved the $693 billion 2010 National Defense Authorization Act. The NDAA sets spending levels for all the programs in the Department of Defense, the largest area of the U.S. budget after Social Security. The President is expected to sign the bill shortly. In addition to authorizing new equipment purchases, servicemembers' salaries, and a controversial hate crimes provision, the bill requires a comprehensive evaluation of the armed forces' substance use disorder treatment system. U.S. Military Academy graduates celebrate the end of college (but we're sure they're happy about the new substance use disorder provisions of the 2010 NDAA as well). Photo used with a Creative Commons license from the U.S. Army. The legislation is drawn from Missouri Sen. Claire McCaskill 's SUPPORT for Substance Use Disorders Act. (Parochially, one of the biggest differences between the original bill and the one that was included in the NDAA is that the original bill referenced NAADAC by name!) Sen. McCaskill has been a strong supporter of addiction treatment since coming to Congress in 2006, and she used her position on the Senate Armed Services Committee to draw attention to the needs of the military's addiction services system. As passed, the bill requires the Dept. of Defense to conduct a comprehensive review of: The programs and activities of the Dept. of Defense for the prevention, diagnosis, and treatmetn of SUDs in members of the Armed Forces. The policies relating to the disposition of substance abuse offenders in the Armed Forces, including disciplinary action and administrative separation. Of particular interest to addiction professionals is the order to assess "the adequacy and appropriateness of current credentials and other requirements for healthcare professionals treating members of the Armed Forces" and "the advisable ratio of physician and nonphysician care providers for substance use disorders." The bill also requires an assessment of the TRICARE program's coverage, the adequacy of care for families, and the care available for Reservists. (You can read the whole section of the bill by clicking here and going to page 170.) Within 180 days of the bill's enactment, the Dept. of Defense must publish findings, statistics, and recommendations on its addiction services. Three months after that, the military must present Congress with a comprehensive plan to improve those services. Interestingly, the bill also requires a separate, independent study from the Institute of Medicine about the substance use disorder programs for members of the armed forces. It can never hurt to have a second opinion! If you're from Missouri, you can send Sen. McCaskill a thank you e-mail by clicking here . Do our readers have any experiences dealing with TRICARE or treating servicemembers or military families? What's the most important recommendation for the review to include?

The Disease Model

Sat, 10 Oct 2009 21:01:57 EST

I’ve been reading the recent articles on the new cocaine vaccine and was stuck by a comment by Dr. Nora Volkow. Dr. Volkow, the director of the National Institute on Drug Abuse, said “the research exemplifies a transformative perspective on drug addiction. By targeting it (drug addiction) as a medical disease as opposed to a moral dilemma, we’re likely to come up with solutions that have a much longer impact”. This quote made me realize an actual paradigm shift is taking place not only in the way we treat addiction, but how the public perceives this disease. However, to hear that pharmaceutical companies may not be interested in producing this or other “addiction” vaccines is disheartening. My husband, an addiction medicine physician, and I have talked endlessly about the disease model. He works with impaired professionals who are often enrolled in monitored aftercare programs. When his patients are drug tested, he does so because he wants to know if they are still in remission from their disease. If not, what type of treatment do they need? What will best help them recover? He has been open to trying new drug treatments and has found them very helpful. Change is often hard and I think it’s important to keep an open mind when it comes to treating addiction. If the pharmaceutical companies believe the professional addiction community is going to be supportive of new medication or vaccines, then maybe they will consider producing them. If there are new advances in medicine that help our clients, that’s wonderful. It doesn’t mean that 12 Step programs and psychotherapy aren’t valuable therapeutic modalities. If the psychotherapists, addiction specialists and the medical field can find a way to dialogue on a regular basis, the research and development of new treatment options will benefit everyone. Is there a way to start a forum of some sort, so those of us on the front lines can communicate better with medical researchers and show our support for new vaccines and medications? If you have any thoughts, please feel free to comment.

Survey Finds Public Support for Treatment in Health Reform

Thu, 08 Oct 2009 16:10:04 EST

Scottish poet Robert Burns 's most quoted line reads, O would some Power the gift to give us To see ourselves as others see us! Advocates on all issues make a similar plea: What does the public already know, or think they know, and how can I tailor my message to them so that it's as effective as possible? In answering these questions, there's no substitute for survey data. Thanks to the Closing the Addiction Treatment Gap initiative, addiction prevention, treatment, and recovery advocates are the beneficiaries of a newly released poll that quantifies public opinion on addiction's place in health reform. On the whole, the survey's results are extremely encouraging. For example: 77% of Americans support including addiction treatment in health reform. 69% would be willing to pay $2 more per month in premiums to ensure that treatment is accessible and affordable. 88% of people think that treatment is important in helping people with addictions get better, and 76% say that long-term recovery is unlikely without support. 87% of people see treatment as an ongoing process rather than a one-time occurrence. The study also shows that there is a lack of knowledge in some areas. For example, 27% of people admit that they don't know whether their community offers affordable, accessible treatment services (26% say there are already enough such services where they live). Groups more likely to see a treatment gap include African Americans, people in recovery, people without insurance, and people who have had family members with addictions. Similarly, two-thirds of Americans with insurance don't know whether their health plan covers addiction treatment. (October 3 was the one-year anniversary of the Wellstone-Domenici Parity Act being signed into law--it's hoped that regulations will be released some time before Jan. 1, 2010.) Half of people don't think that they or someone in their family could afford treatment if needed. There seem to be a few takeaways from this report (produced by Lake Research Partners) that are immediately helpful to advocates. Firstly, we need to shake off any lingering defensiveness when we're talking about the importance of ensuring access to treatment. The public, by large numbers, agrees that addiction is an important issue that needs to be addressed in our health care system. Secondly, the public agrees that addiction can be treated and managed like other chronic health conditions such as diabetes. Despite any ongoing debates or uncertainty about the disease model of addiction, it doesn't matter to people when you're talking about how to make sure that people with addictions get the care they need to be well. If we adopt a problem-solving posture (there are 20 million people with untreated addiction; treatment works; how do we get those people the care they need?), we can avoid getting bogged down in complex questions about the causes of addiction where there is less public certitude. Thirdly, it seems like education of the public (and, by extension, policymakers) is still a priority. Although this survey shows strong public support for treatment and closing the treatment gap, there remains a knowledge gap in some key areas. One very practical area, as mentioned before, is whether you have insurance coverage. With the parity law going into effect in 2010 and health reform in the news, early next year is looking to be the ideal time to do outreach to help people understand their rights to addiction services (unfortunately, it's difficult to do this in detail before we have parity regulations or a final health reform bill ... but it's something to prepare for now). I was also surprised that "only" 71% of people ranked addiction as a serious problem. That might be due to varying standards of "seriousness," but considering the staggering costs in lost productivity, criminal justice, social services, broken families, illness and early death, traffic accidents, etc., I can't help but think that that number would be higher if people had more information. A related area for education would be the cost savings and other benefits that would be expected from specific policy interventions. In addition to commissioning this survey, the folks at Closing the Addiction Treatment Gap have also been working to make sure that this data is put to use in real health reform debates--among other things, they co-sponsored a very helpful briefing on behavioral health in health reform back in July ( video, PowerPoints, and resources here ). For an update on the status of addiction-related provisions of the health reform bills, please click here .

NM Human Services Department Official Nominated as SAMHSA Administrator

Fri, 02 Oct 2009 16:51:42 EST

We're hearing reports that Pamela Hyde, J.D., will be nominated by President Obama to serve as the next Administrator of SAMHSA. SAMHSA has been led by Rear Admiral Eric Broderick since its former administrator, Terry Cline from Oklahoma, resigned in Aug. 2008 to assist in establishing the health system in Iraq. Ms. Hyde currently serves as Cabinet Secretary to the New Mexico Human Services Department. She has formerly served as New Mexico's state mental health director and the state's Medicaid director. She is also a former CEO of a non-profit behavioral health care organization. Pamela Hyde's biography can be found here . Congratulations to Administrator-nominee Hyde!

New Problem Gambling Bill Makes Its Play

Fri, 18 Sep 2009 15:23:33 EST

With an unprecedented 48 states facing budget shortfalls in fiscal year 2010, legislators are desperate to find revenue sources that save them from the rock-and-hard-place of unpopular tax hikes and unpopular cuts in services. It's not surprising then that state legislators are allured by the revenue promised by expanding legal gambling. Gamblers want the chance to voluntarily give away their money, and state governments can rake in healthy profits--it's win-win! The federal government alone pockets well over $5 billion in tax revenue annually from the gaming industry. As state fiscal problems continue, it's likely that we'll see gambling operations increase. Photo from Flickr user morburg; used with a Creative Commons license. The gaming sector is huge and growing (the word "gaming" is preferred by industry proponents, since "games" are harmless fun, whereas "gambling" is risky). Excluding online and sports betting, annual legal gambling revenue is over $90 billion and growing rapidly--as a point of comparison, the entire U.S. brewing industry's revenues are about $18 billion . Of course, that $90 billion is also the measure of individual gamblers' annual losses. The costs of problem gambling are significant and under-recognized (see Addiction Professional's recent article about research about gambling). It's estimated that about 1% of adults are pathological gamblers, and about 3% are problem gamblers. About twice that many are considered "at risk." As with substance use disorders, however, the number of people affected by problem gambling extends to spouses, children, employers, neighbors, and beyond. Problem gambling is estimated to cost society about $7 billion each year, including bankruptcies, divorces, crime, and job losses. Only 34 states provide public problem gambling services of any kind (and many of these services are extremely modest), more than 40 operate state lotteries . The intersection of problem gambling and substance use disorders is enormous--over three-in-four problem gamblers have an alcohol or other substance use disorder. They are at heightened risk for co-occurring depression, anxiety disorders, and other mental health conditions as well. The National Council on Problem Gambling operates a national hotline, 800-255-4700, which may be a helpful resource for any clients you suspect might be problem gamblers. Gamblers Anonymous meetings are held in many areas as well. These issues were highlighted yesterday at a Capitol Hill briefing about a recently introduced bill, the Comprehensive Problem Gambling Act of 2009 (HR 2906). Representatives Jim Moran (D-Va.), Frank Wolf (R-Va.), and Patrick Kennedy (D-R.I.) spoke about their support for the bill, which would give the Substance Abuse and Mental Health Services Administration (SAMHSA) authority and funding to address problem gambling (problem gambling currently falls through the cracks, with no federal agency bearing responsibility). It would allow SAMHSA to conduct research, expand treatment and training for addiction professionals, and support public awareness campaigns. The bill can be read, and its progress tracked, here .

How Do We Define Treatment?

Fri, 04 Sep 2009 13:13:08 EST

This posting relates to a previous one on how much recovery time an individual should have prior to becoming a counselor. As our profession moves towards using more medications to control addictive behaviors and substance abuse, we might find persons who are on those medications wishing to be certified as counselors. If the abstinence standard is applied, the decision must be made about the use of medications that aid recovery as well as those that are essential for health reasons. Is the person not abstinent when taking any medication? Is a person who chooses to continue counseling to work on personal issues still in treatment and thus not eligible for certification as an addiction counselor? A lively discussion on this topic occurred among counselors and in some addiction studies classes. Is a person taking a medication for depression as prescribed in treatment and then not eligible for certification? One example that made the discussion particularly lively was a case study in which someone abused opiate analgesics for 15 years, participated in methadone treatment for 3 years and continued on maintenance doses of methadone. Does methadone maintenance for 6 years mean the person is still in treatment and thus not eligible for certification? Another possible scenario is the addiction professional experiencing pain who elected to use medical marijuana and does so under the supervision of an MD, is that grounds for suspending the counselor’s certification? The standard that might apply to these situations is found in Principle 4: Trustworthiness . “I understand the effect of impairment on professional performance and shall be willing to seek appropriate treatment for myself or for a colleague.” If the persons described in the previous paragraph are evaluated by an addiction professional/clinical supervisor found to be competent to practice as certified addiction professionals, can other persons object to certification on the basis of medication or continued counseling? The underlying question is “What constitutes treatment, when does it begin and when does it end?

Not Just CEU's, but an Adventure

Sat, 22 Aug 2009 15:59:19 EST

My passion is helping those who suffer from eating disorders. I am a Certified Eating Disorder Specialist and have spent years learning as much as I can about this complex disorder. As soon as I received my graduate degree, I realized I needed specific training in the field, so I got in my car and drove to Malibu to meet with Carolyn Costin, LMFT,CEDS. Carolyn is the founder of Monte Nido Treatment Center , The Eating Disorder Center of California and the author of many books, including The Eating Disorder Sourcebook, To this day; I think Carolyn’s book is one of the best books ever written about eating disorders for both professionals and those interested in the subject Carolyn was nice enough to spend time with me and urged me to attend a week long workshop that she and Francie White, a Registered Dietician were co-facilitating in of all places, Orcas Island . What kind of conference takes place on Orcas Island ? Certainly, not one where you sit in a hotel ballroom, under florescent lights, watching a power point presentation. Just getting there was an adventure, riding a ferry through the beautiful San Juan Islands . That week was one of the highlights of my professional life. I began to understand the complexity of eating disorders and how best to work with my clients. But more importantly, I was able to get in touch with some of my own unresolved issues that were getting in the way of my work. I realized it wasn’t about just collecting CEU’s to renew your license and it wasn’t about just the latest research. It’s about slowing down and getting in touch with yourself. The week was spent working in the morning, hiking or kayaking in the afternoon and in the evening, Francie and Carolyn told a myth and we were challenged to see how that myth resonated in our own lives. I returned from Orcas Island not only a better clinician, but a more insightful person. Ten years after I attended that life changing workshop, I’m heading to Hawaii in September, to join Carolyn Costin, Francie White, Dr. Anita Johnston and eating disorder professionals from around the world for another week long training. I’m up for a new adventure, meeting new people in the field, and learning something new about myself. It’s the best way I can think of to get those CEU’s… Look for my blog from the workshop in September.

Health Reform Debate Plays Out in Town Halls

Sat, 15 Aug 2009 17:28:32 EST

(Note: For a newly updated analysis of how the health care bills affect addiction professionals, click here. ) There was the easy way, and there was the hard way. President Obama and Democratic leaders in Congress wanted the easy way. That's why they set August as a deadline for passing health care reform. They came close--all three House committees of jurisdiction passed nearly identical health reform bills, and one of the two Senate committees with health reform oversight passed a bill. But not close enough. The Senate Finance Committee (or, rather, a bipartisan coterie of six senators from the committee representing states whose combined population is less than New Jersey's) couldn't make a deal, and August came without a final (or near-final) bill. August was far from an arbitrary deadline for reformers. Members of Congress spend their August "recess" back in their districts, talking with constituents and holding public events. It's unpredictable and risks throwing even the most carefully orchestrated political plan off track. And thus the president and health reform advocates find themselves doing things "the hard way." There's been extensive media coverage of town hall meetings that devolved into shouting matches between members of Congress and attendees . (Many others were civil, but they didn't receive the same kind of news coverage.) In order to reclaim the town hall as a forum that might actually strengthen calls for reform, President Obama himself began hosting a series of town halls, traveling from New Hampshire to Montana to Colorado over the last few days. It remains to be seen whether Obama's take-back-the-town-hall strategy will pay off (it's also being accompanied by a shift in terminology away from emphasizing reform's long-term cost savings and towards an emphasis on modifications to the "insurance industry"). Why not take part in the debate by attending a town hall? Some talking points and tips for successful town halls can be downloaded from NAADAC's website . Town halls are often listed in local newspapers, or you can call your member of Congress 's office to ask if there are any upcoming public events (some previously scheduled town halls have been canceled because crowds have been out of control). If you make it to a town hall, please let us know how it goes in the comments. If you aren't able to make it, what would you say to your member of Congress about health reform if you had just two sentences to get out your message?

From San Antonio to Great Falls

Sat, 08 Aug 2009 22:24:46 EST

I was privileged to have the chance to speak about health care reform last weekend to addiction professionals at the Texas Association of Addiction Professionals (TAAP) annual conference in San Antonio (a pared down copy of my presentation can be found here ). It was a wonderful conference and very energizing to spend time with professionals from all across the huge state of Texas who were so dedicated to advocacy. TAAP has long history of organized and effective advocacy on behalf of Texas addiction professionals, and it was wonderful to hear more about what they've been working on recently. San Antonio, Texas. Photo from Flickr by Corey Leopold, used with a Creative Commons license. The conference also gave me the chance to catch up with Eric Newhouse , who was giving a training about PTSD in vets returning from Iraq and Afghanistan. Eric, who's a journalist for the Great Falls Tribune in Montana, has a recently released book on the issue, and it was clear from the eager questions and comments from the people in his training that this is an issue near and dear to a lot of hearts in Texas. The long plane ride back to D.C. from San Antonio--plus an hourlong Amtrak delay--gave me the chance to read through much of one of Eric's earlier books, Alcohol: Cradle to Grave . The book is a lightly edited and expanded version of a yearlong series of articles Eric wrote for the Great Falls Tribune that won the 2000 Pulitzer Prize for Explanatory Journalism. The original series of articles is available online here , and each month the articles examine a different aspect of Great Falls society touched by alcohol (for example, one month focuses on Native American reservations, another on drunk driving, a third on fetal alcohol syndrome, etc.). The Missouri River outside Great Falls, Mont. Photo from Flickr by ThreadedThoughts, used with a Creative Commons license. The articles interview experts and quote research quantifying alcohol's effects, but they go beyond statistics by including "on the record" interviews with people affected by (in every sense of those words) alcohol. The story is animated in particular by a chronic alcoholic named Bill Broderson whom Eric befriends in the course of his reporting. You can't help but think about Bill--a charming, unflappable man who is unable to stop drinking despite countless treatment episodes, medical interventions, and attempts by others to help--as the stories trace the effects of alcohol through Montana society. The unlikely friendship between Eric and Bill, as it unfolds through the year, reminds the reader that every statistic can be broken down to real people and real lives (oftentimes frustratingly, inscrutably, painfully real lives). There's no way to change statistics in the abstract--they can only be changed by the cumulative effects that come from working with real people and in real lives, one by one. That's an important fact for advocates to keep in mind, especially as the nation debates an issue as massive and complex as national health care reform.

Applying Our Ethical Principles I

Sat, 08 Aug 2009 15:43:25 EST

When we hear about what another counselor did and make a judgment based on our emotional reaction, there is a tendency to say that the counselor did something unethical. Often if we look at it carefully, we find that we object to the behavior on the basis of our own standards of conduct or morals. Taken to the next step, when compared to the NAADAC Code of Ethics there might not be a principle that describes the behavior. An attorney recently said that Codes of Ethics and laws are written because someone did something that caused problems and an ethical standard or law was written to hopefully prevent another person doing the same thing. When an ethical complaint is sent to NAADAC, the counselor’s behavior is evaluated by the Code of Ethics. Beginning with this post, each principle from the NAADAC Code of Ethics will be reviewed. A situation will be described for the reader's consideration. Please read the scenario and decide whether or not the cited principle applies. Principle 1: Non Discrimination. I shall affirm diversity among colleagues or clients regardless of age, gender, sexual orientation, ethnic/racial background, religious/spiritual beliefs, marital status, political beliefs or mental/physical disability. This statement includes many of the characteristics exhibited by clients and co-workers. Under this standard, do we also include freedom of choice? Do we honor the right to participate or not participate in an activity? A situation which made some of us think about this principle was a supervisor’s requirement for all counselors in an agency to participate in a therapy group led by her. Two counselors refused to participate because they thought an in house therapy group for counselors was a breach of boundaries. If a counselor who worked in this agency consulted you, how would you approach the problem?

Is the Health Care Reform Glass Half Empty, or Half Full?

Wed, 22 Jul 2009 16:45:15 EST

Health care reform has dominated the American political scene for the past few months. The original White House-imposed deadline (the August recess) for bills to be passed by both the House and Senate is rapidly approaching. Tonight, President Obama will hold a press conference in which he's expected to reinforce the importance of passing health care reform as soon as possible. Here's where we stand: In the Senate: There are two committees in the Senate that have jurisdiction over health care reform, the Finance Committee and the Health, Education, Labor & Pensions (HELP) Committee. These committees have been running on parallel but separate tracks--each has been writing its own bill (focusing on the specific areas over which it has jurisdiction, but there's significant overlap) which will have to be merged later on. The HELP Committee introduced its comprehensive health care reform bill back in June and passed it out of the committee on July 15 . This was a huge step towards successfully passing health care reform. In the end, no Republicans voted for the bill. Sen. Chris Dodd (D-Conn.) managed the legislative process in the absence of Chairman Ted Kennedy, who has been receiving treatment for brain cancer through most of the process. The Senate Finance Committee, on the other hand, has been pursuing a very deliberate and less formal process to try and ensure that they have a bill that (1) has bipartisan support and (2) controls costs (the Finance Committee is ultimately responsible for finding the money to pay for most of health care reform). Despite releasing its first " white paper " on health care reform shortly after the elections last November, the Finance Committee has yet to introduce a bill. Private discussions among committee members are ongoing, though progress seems to come in fits and starts. Because there is no bill yet, however, there's no doubt that the Finance Committee is an area of special concern to the White House and other health reform advocates. A 60 vote supermajority will be needed to overcome an inevitable filibuster against health care reform. There are 60 Democrats in the Senate (and a few potential GOP cross-overs), but every vote will be needed and there's no margin for error ... potential Democratic hold-outs hold significant power. In the House of Representatives: Rather than pursuing separate, parallel tracks like the committees of jurisdiction in the Senate, the House committees with health care reform oversight (there are three) worked together to introduce a single bill. That bill was then divvied up among the three committees so they could "mark up" (amend) the particular provisions over which they have jurisdiction. Two of the three committees have since passed the bill. The third committee (Energy & Commerce, chaired by Rep. Henry Waxman from Ca.) is still working to balance the demands of moderate Democrats (so-called " Blue Dogs ") to reduce the bill's overall costs and find non-tax ways to pay for it. The House ultimately only needs a simple majority to pass its bill. There are enough Blue Dogs, however, to throw passage in doubt if their concerns aren't met. --- Once (if?) both chambers pass a health care reform bill, then the differences between the bills will be negotiated by House and Senate leaders (with input from the White House) in a conference committee. Then both plans will have to be voted on again. But that--relatively speaking--is the easy part. The real challenge is getting the initial bills passed by the House and Senate. The White House and congressional leaders are concerned that if the bills languish over the August recess that they will lose needed momentum. Health care reform skeptics, however, counter that there's no reason to rush such a far-reaching bill. The key question among policy watchers is whether health care is going " according to plan ." The answer, not surprisingly, is that it's hard to say. There's no way to pass a bill like health care reform painlessly, but it's hard to know just how high your pain threshold is (to push the metaphor a to its limits ... ). I realize that this post hasn't even mentioned any of the policy provision in health care reform--I promise to get to those soon!--but the bottom line is that the politics of health care reform will determine the final product as much, if not more, than the policies themselves. Understanding the process and procedure is essential to understanding President Obama's comments tonight, as well as the twists and turns that are sure to come over the next week and a half. For more information on NAADAC's response to health care reform, please visit www.naadac.org/advocacy.

Meaning-Centered Therapy

Sun, 19 Jul 2009 16:28:36 EST

Meaning-Centered Therapy Last week there was an interesting article in The Wall Street Journal about an experimental group therapy study for terminal cancer patients conducted at Memorial Sloan-Kettering. Using meaning-centered therapy, based on the writings of Viktor Frankl, the groups explored things that give meaning to life, such as love, family, work and personal history. The preliminary findings of the study have been “encouraging”, according to the article. Viktor Frankl believed if a person’s life had meaning, he or she could endure any suffering. I began to think of how meaning-centered therapy could be applied to the treatment of addiction. Recently, I’ve spoken with several clinical directors who are integrating specific forms of positive psychology into their treatment programs. Positive psychology has been around for some time, but is often overlooked in our field. I remember, years ago, as an intern at one of the premier treatment centers in the country, I was struck by the fact that only negative or traumatic events were listed by clients on their “timeline”. Of course, many of these clients had suffered severe trauma, but did we as clinicians, underplay or ignore some of the good things that might have occurred? Did we even explore it? Do we place too much emphasis on consequences and not enough on finding meaning and purpose in life, especially a sober life? As one of my friends, a brilliant clinician said the other day, “If my client hated their work when they were using, then they are REALLY going to hate it when they get sober. My job is to help them find meaning and purpose in life. It’s hard to stay in recovery when that’s missing.” I think she has a good point.

Fame, Fortune and Addiction

Sat, 11 Jul 2009 15:27:49 EST

As a clinician, I’ve been watching the endless coverage of Michael Jackson’s death from a different viewpoint. I’ve trained in sexual addiction issues and kept thinking, “here is more than likely, a sexual predator, who is being praised as a fabulous human being”. Then, I realized, my empathy had been replaced by cynicism. No matter how famous, how talented, how rich, everyone on the planet has core issues that drive our emotions and behavior. It made me think of what an effect our family of origin issues have on all our lives and if there is severe untreated trauma, how difficult life can be. When you look back at what we know of Michael’s life, he was emotionally and physically abused as a child, appeared to have been emotionally arrested at the age of 8 or 9, may or may not have been a sexual predator, and more than likely, died of an overdose. Add the media spotlight, the fame, and the pressure and I believe he lived a truly torturous life. Instead of receiving substantial treatment for trauma, chemical dependence and who know what else, he was “enabled” by professionals who were seduced by power, money and fame. I found his death to be profoundly sad, not because we lost the “King of Pop”, but because he was a person who suffered and died, caught up in the web of addiction. In the end, he is just another person, lost to this devastating disease.

New Book Reignites Disease Model Debate

Mon, 06 Jul 2009 16:55:42 EST

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The argument about whether or not addiction is a "disease" has been raging for years, but it was recently rekindled by the release of a hotly debated book by Harvard psychiatrist Gene Heyman. Heyman proposes that ongoing addiction is fundamentally a choice that can be changed with the development of motivation, new knowledge and value systems. An interview with him can be read here , and a chapter from his book, Addiction: A Disorder of Choice , can be read here . Other arguments support Heyman’s assertions, such as those who believe that “free will” is what leads to addiction. Since the addict is choosing to use the drug repeatedly, whether or not the end result is physiological dependence does not matter. Still others argue that it cannot be considered a medical illness because addiction, unlike Parkinson’s, cancer, or the flu, requires that you consciously decide to take a pill or pick up a needle in order for it to come to fruition. Heyman’s book seeks to add epidemiological data to support the addiction-is-a-choice argument. He suggests that addiction is more a long the lines of dieting or going to the gym: you can be successful if you want to, and if you make the choice to do so. Heyman believes that people naturally want to consume too much of everything, whether it be food, television programming, or even drugs. He makes the point that most people who don’t become addicted to drugs do so based on the fact that they don’t want to become a drug addict. So, as an addiction professional, I have to ask myself, does this imply that those who are addicted are that way because they--at some level--want to be? Heyman does not dispute existing scientific evidence that drug use alters the brain’s functioning. What Heyman wants to demonstrate is the fact that drug use (even addictive drug use), does not alter our underlying ability to think. Heyman believes that addicts can consider the consequences of their actions, and therefore stop using once they do a rational cost/benefit analysis. He seemingly agrees that the physiological changes involved with addiction--especially withdrawal--make it extraordinarily difficult for many people to do a cost/benefit analysis without some help. Many addicted people I have interacted with are fully able to recognize the consequences of their actions (“If I spend my check on heroin, I won’t be able to pay rent, and will lose my housing”), but yet even with this recognition in mind, they cannot seem to end their drug use. It is true that at some point, those who successfully stop using become able to step back and look at the costs of what they have done for their addiction, but, as is pointed out in this Toronto Star article, there can also be varying levels of addiction. Whether or not addiction is, at its heart, best modeled as a disease or a choice, there's no question that many people with substance use disorders need professional help as they walk the bumpy road to recovery. Yet one can't help but wonder if Heyman gives sufficient weight to the physiological changes that drugs cause in the brain and the rest of the body. One very recent study by NIDA and the Brookhaven National Laboratory involving cocaine users points to evidence that drug abuse can change the brain physiology enough so that the user cannot suppress the “craving” for a drug. Combined with lower ability to monitor behavior, this can indicate why some people are actually more vulnerable to taking drugs. This is because cocaine use alters the function of the anterior cingulate cortex (ACC), which is in charge of emotional regulation and behavior monitoring. Compared to those without cocaine use disorder, the cocaine users performed equally well on most tasks except tasks that require the regulation of behaviors or emotions. This indicates that variance in brain activity is not due to lack of cognitive ability or lack of motivation, one of the points Heyman offers in his book as a reason for why some people become addicted. This study actually contradicts one of Heyman’s points, which is that the addicted person can still regulate their behavior and emotion. The study indicates that, at least in some cases, people who are addicted cannot do so. You can read the full study here . Other evidence supports the brain physiology changing as well. A study done in 2007 and published in the American Journal of Psychiatry (see reference below) illustrates that chronic cocaine use actually changes the reward pathways in the brain. Every time a drug is used, it releases “pleasure chemicals” that make the user feel that “high” they get from using. After a period of consistent use, the brain adapts to having the pleasure chemicals present, and will function normally in this way. However, when the users attempts to stop using the drug, stress chemicals are released, and this causes panic in the user, which makes them want to use again in order to feel “calm”. This process also causes withdrawal as once the brain has adapted to functioning on the drug, taking it away causes the brain to lose its ability to function normally. To the extent that it seeks to move the disease/choice debate in a data-based direction, Gene Heyman’s book has the potential to help advance this longstanding discussion. Ultimately, most people with substance use disorders will benefit from both motivational and medical interventions, and so we need models and knowledge of both. Without having read the entire book, I want to be careful not to make any conclusions beyond that for risk of misrepresenting Heyman's arguments--if anyone has read it already (it came out in June), please leave comments letting us know what you thought. Reference: Koob, George & Kreek, Mary Jean (2007). Stress, dysregulation of drug reward pathways, and the transition to drug dependence. The American Journal of Psychiatry, 164 (8), 1149-59. Retrieved June 1, 2009, from Research Library Database. (Document ID: 1314241921).

Is Health Care Reform D.O.A.?

Thu, 18 Jun 2009 14:01:49 EST

Since before his inauguration, President Obama has made it clear that health care reform would be a top priority for 2009. And for the last few months, it looked like the stars might all align for a comprehensive re-vamp of America's health care system: Obama's election mandate, along with the Democrats' pick-up of a significant number of seats in the House and Senate, was tied to promises of health care reform. The economic crisis highlighted the high cost of health care for both individuals and families. The White House's strategy of providing broad, general direction on health care reform while leaving the details to Congress seemed to get members of Congress engaged and excited about the policy and process (this is in stark contrast to the Clinton health care reform push in 1993-4, where many observers accused the Administration from shutting Congress out of the process). There had been a successful White House kick-off event that garnered bipartisan support and brought all the key stakeholders together (hospitals, pharmaceutical manufacturers, insurance companies, etc.). There had been reports of very productive meetings between stakeholder groups, Democratic Senate staff, and Republican Senate staff in so-called "workhorse groups," each focusing on a specific aspect of the health care system. Senator Ted Kennedy's waivering health gave extra impetus to quickly address health care reform legislation, the crowning achievement of what has already been one of the most remarkable political careers in American history.(7) An ambitious schedule, with the goal of passing health care reform legislation before the August congressional recess, seemed able to keep everyone focused and the process moving forward. Photo Credit: Donovan Kuehn About a week ago, all the momentum still seemed to favor health care reform being adopted in 2009. Since then, however, the prospects for easy health care reform seem to have sunken markedly . A few things explain the change: The nitty gritty. The Senate Health, Education, Labor & Pensions (HELP) Committee released its 615-page partial health care reform bill . It's no surprise that it was easier to get agreement on general principles than on specific language--(almost) everyone supports universal coverage in the abstract, but agreeing on a specific plan to get there is much more dicey. Hundreds of amendments were submitted. Partisanship's resurgence. Yesterday, the "mark-up" of the HELP bill began--in other words, the process by which amendments to the bill are considered. All the Republican members of the HELP Committee complained that the bill under consideration was written solely by Democratic staffers who didn't take their concerns into account (and all this even though the most controversial aspects of health care reform--like a universal mandate to have coverage and a public insurance plan option--were left out of the draft bill so negotiations could continue). In his opening comments, Sen. Orrin Hatch (R-Utah), a 30+ year Senate veteran, said that this process was one of the least bipartisan he'd ever seen. Accusations that the process has been too rushed were frequently echoed as well. One has to wonder what effect Sen. Kennedy's absence from Washington as he receives medical treatment for cancer is having on these discussions ... The cost, oh the cost! Nearly everyone on the HELP Committee agreed in their opening remarks yesterday that Americans pay too much for health care. The challenge is to lower those costs without simply shifting them from individuals to the government. The Congressional Budget Office, on Monday, released a partial cost estimate of the HELP bill--a sobering $1 trillion over 10 years. Nearly as devastating, CBO estimated that "only" 16 million of the over 40 million uninsured would get insurance under the bill. Republican Senators hammered home the high cost to cover not even half the number of uninsured. As the HELP Committee pursues its process, the Senate Finance Committee, which also has major jurisdiction over health care reform, got an estimate Wednesday of its not-yet-released draft proposal. The cost? About $1.6 trillion over 10 years. Yikes! The Senate Finance Committee was originally scheduled to release its bill yesterday, but Chairman Max Baucus (D-Mont.) has decided to explore significant revisions to reduce the price tag. The bill might not be released until after July 4. Plan proliferation. Now that we've moved from the "general principles" stage to the "specific proposals" stage, we've seen a flood of new plans released. This isn't necessarily a bad thing, but it risks fracturing supporters of reform. There are already the three proposals from the relevant congressional committees of jursidiction (HELP plan, Finance plan, and the House of Representatives plan, due to be released tomorrow). Then there's the Wyden-Bennett plan (which has gained some traction recently because it's budget neutral), the Kent Conrad public plan option, the Daschle-Dole plan , the House GOP Solutions Group plan , the Coburn-Burr plan ... Obviously not all of these are equally influential (Republican plans won't get too far this year), but the sheer number risks diverting much-needed attention (and public support). We were supposed to be moving passed the "let's throw out new ideas" point by now, but perhaps that wasn't a realistic timetable. Has the last week--the divisive HELP Committee markup, the tough CBO estimates, the Finance Committee's delay, the near-daily release of new plans--doomed health care reform? Certainly not. But it certainly was a stark corrective to those who thought that we'd just slide smoothly towards comprehensive health care reform. This is going to be the most complex political task of the decade. Dozens of questions remain: Will the bill be bipartisan, or will the Democrats rely on their numbers and try to force legislation through? Will unexpected news events distract policymakers? Will the Obama Administration begin to play a more active role in creating legislation? Will public support (or opposition) prove overwhelming? How will the ongoing financial crisis affect discussions? The stakes couldn't be higher--health care reform affects every American directly. We have a long way to go. Stay tuned ...

Mass. State Senator Calls Attention to Costs of Addiction

Thu, 21 May 2009 16:12:50 EST

Drug Courts Are Highly Successful, But ...

Fri, 15 May 2009 14:39:00 EST

The National Association of Drug Court Professionals (NADCP) today held an early-morning press conference in Miami to commemorate the 20th anniversary of a movement that started in Dade County and has seen formidable growth. At today's event, former ONDCP director Gen. Barry McCaffrey was expected to call for enough drug court programs so that one would be within reach of every American in need. Over the course of the day, drug court program participants in 33 states were to be named graduates, in ceremonies filled with family pride as well as more than a few pats on the back for policy-makers who embrace the drug court's tough but treatment-focused model. The impact of drug courts on the justice and treatment systems over the past two decades cannot be diminished. But today's events also make me wonder: Shouldn't prominent, respected leaders in drug treatment and policy extend McCaffrey's argument and simply call for an available treatment slot for anyone who needs it, regardless of whether the person ever has had contact with law enforcement and the courts? And if the nation could muster the will to do that, would we need a drug court around every corner?