An Argument for Harm Reduction to Address Collegiate Drinking

Harm Reduction (HR) and its utility as an approach to address substance use is nothing if not controversial. Although most are aware of HR as regards Methadone maintenance or Needle Exchange, but there is more to this behavioral and public policy objective than these two strategies.

In brief, HR is about considering ways to engage individuals committed to a particular pattern of behavior so as to reduce the likelihood of their doing harm to themselves and/or the community in which they reside and operate.  For a brief overview of HR as it applies to collegiate drinking, visit this article that you may find useful as regards justifying HR techniques and strategies when looking to approach a high-risk community (an indicated population) in a pre-contemplative (not ready) stage of readiness to change.  Visit http://peele.net/lib/reducing.html and scroll down to, Is Harm Reduction a Viable Policy for American Collegiate Drinking?

In brief, our biggest challenge in addressing the concerns related to HR is that arguments against such policies tend to be grounded in moral and/or legal principles while the rationale for HR is steeped in public health and quality of life issues.  Until and unless both sides of the HR debate can find a common ground where they can talk about the issue in neutral terms, there will always be more heat than light generated by this debate.

It seems to me that our challenge is to level the proverbial playing field.  Those advocating HR as one strategy in a comprehensive plan to address collegiate drinking will never trump the moral and legal rhetoric directed against HR with a logic-based appeal that addresses the quality of life of those who choose to use.  You and I can likely appreciate this logic and as the result embrace it, but for those who see drug use as “illegal” and those who use drugs as “criminals”—or its first cousin, “if drugs are bad then those who use them are bad people”—HR is tantamount to “giving in,” “permitting use,” “the first step to legalization,” and/or “pushing current non-users towards use.”

An alternative in this debate is to shift the focus for HR away from the reduction of harm for the user and direct it instead onto the reduction of harm for the community in which the user uses.  In the case of the Greeks, a high-risk community of drinkers on college and university campuses, for example, it is improving the quality of life for the community in which the Greeks live (this is where programs like the Good Neighbor Project at Clarion University in Clarion, PA can be useful – see http://www.clarion.edu/267773/) or reducing costs to the university related to violence and vandalism.  If a case can be made to lower high-risk Greek drinking, its related behaviors, and its negative impact on quality of life issues in general, especially if those quality of life issues affect student decisions to transfer before graduation, then one can argue for HR not so much to benefit to “miscreant drinkers,” but the individual “well-behaved student” in the general university community.

Put another way, if there are “indicated populations” that already manifest indications of problems related to drinking on campus, then the university community as a whole--and not just the errant consumers--is the most likely benefactor of the HR efforts targeting those communities.

What do you think?

Dr. Robert

Providing AOD Services to Students in College

A colleague posed the following questions on an online discussion group to which I subscribe:

I am seeking feedback about how private, Christian colleges provide substance abuse treatment for students.  Specifically, how are referrals from administrative sources such as judicial affairs handled?  Are there separate mandated and voluntary treatments?  How is student confidentiality maintained or addressed in light of community abstinence policies? 

Here is the reply I posted to the list:

These are wonderful questions and ones that get asked all to infrequently, especially by administrators in higher ed. The good news, as the saying goes, is that there are literally thousands of pages written on this general topic and these specific questions…the bad news is, there are literally thousands of pages written on this general topic and these questions J So, where to start…

  

How are referrals from administrative sources such as judicial affairs handled? When student affairs and judicial affairs are walking in sync, this is a relatively easy question to address. When at a small, urban, Catholic university, we negotiated what we called an “alternate sanctions program” for those first-offenders or subsequent offenders where the infractions were minor, e.g., no hospitalization; no injuries. In this program, there were set consequences that would follow specific violations—deferred suspension of housing, probation, etc.—but students were offered the choice between a hefty monetary fine or to participate in an alcohol awareness program modeled on harm reduction and Motivational Interviewing as the last consequence of the violation. This increased the likelihood that students would participate in the educational alternative and do so “voluntarily,” which allowed the practitioner presenting the program to be the “good guy” who allowed the student to save $X, not to mention used choice to more directly involve the student in the process.

How is student confidentiality maintained or addressed in light of community abstinence policies? Regarding the issue of confidentiality, students would be told at the first session that everything that went on in the sessions was confidential and nothing, including attendance info, would be released w/o a written consent to do so. That said, students were reminded that it would be in their best interest to allow judicial affairs to at least know about their attendance. NOTE: A written report would be prepared for Judicial Affairs, but again would not be released until (1) the student reviewed the report with the practitioner and (2) provided the written consent. A similar process was used with MANDATED students. NOTE: As a counselor I addressed the “seeing mandated clients” dilemma by ensuring students that I “work for you and not judicial affairs” and for this reason would not release info unless such was indicative of likely harm to oneself or others. For details/copies of forms/etc. please contact me back channel: Chapman.phd@gmail.com

At the end of every semester I would routinely hear from judicial affairs about how students actually found the alcohol sessions interesting if not enjoyable. I would be asked, “What are you doing over there? When we sent him/her your way, he/she went kicking and screaming.” It was this student compliance with the program that allowed judicial affairs to recognize that approaching high-risk student behavior as something done “with a student” rather than “to a student” was actually more productive…a collaborative rather than adversarial approach.

Where the issues you raise become challenging is when senior administration and/or judicial affairs folks see violation of institutional policy as being a hanging offense AND assert their need to know everything that goes on as the result of that violations. In this day and age we tend to see institutions open to my suggestions above regarding alcohol, but closed to them when the violation is for “drugs other than alcohol.”

I suggest that you look at the literature related to (1) environmental management and (2) Brief Alcohol Screening and Intervention with College Students, BASICS. Basic info on both can be found on my web site. I also suggest that looking at my 3-monograph series entitled, When They Drink, especially the first one, which includes invited essays on all aspects of addressing high-risk and dangerous collegiate drinking. Links can be found at http://robertchapman.net/essays.htm

What do you think?

Dr. Robert

Considering Collegiate Drinking; The Rest of the Story

When considering collegiate drinking, it is important to step back from issues such as student AOD use and consider a larger picture.  As a profession, substance use disorder prevention specialists have a tendency to be myopic in our consideration of "the problem."  As accurate as accounts of this problem may be, they are, nonetheless, incomplete.

Lists of strategies to address collegiate drinking generally include several important and proactive suggestions.  Approaches such as social norms marketing, environmental management along with clinical intervention strategies like Brief Alcohol Screening and Intervention for College Students (BASICS) are on the short list and are important steps that need to be considered when addressing the issue of alcohol and other drug use by students.  As important as these approaches are in addressing high-risk and dangerous collegiate drinking, they do not provide access to the "big picture."  If anything, these are “problem-oriented” strategies, but are the metaphorical equivalent of effective strategies for bailing the water from a sinking ship, but do little to solve the problem of taking on the water being removed from the bilge. 

What we need to ask is, when framing the issue of collegiate drinking, "what is just outside the framed shot.”  What would we capture in our picture of collegiate drinking if we used a wide-angle lens?  I suspect that there are several influential factors that heretofore have been overlooked at best or more likely, simply not considered...at all.  As Paul Harvey used to say in his syndicated radio program, what is, “the rest of the story”?

Just like Pluto--before it was demoted to a dwarf planet--was predicted to exist before it was actually discovered by Tombaugh in 1930, its existence was postulated via mathematical calculations.  So do "other forces" exist that affect the use of alcohol and other drugs by students?  Although I focus on this in great detail in the latter 2 monographs in my 3-monograph series on collegiate drinking, When They Drink (links included at the end of this post), here are three invisible, that is to say, "unstudied," forces I suggest affect collegiate substance use:

•                What do "alcohol" as a substance and "drinking" as a behavior mean to students?  This social constructionist view of collegiate drinking has never been seriously investigated.  "How" does alcohol reach its iconic status for students?  "What" affects the meaning ascribed to alcohol and drinking?  "Why" and more importantly, "how" does this meaning change with time...often in 2 to 3 semesters via the "maturing out" phenomenon?  If we better understood the social construction of use, we would be likely to incorporate this into prevention strategies...again, read my monographs.

•                Explore the "positive consequences" of abstinence and/or moderate use rather than the "negative consequences" of abuse.  We already know that students respond better to "positive" messages than to negative...and we know that "scare tactics" do not work.  How about investigating what students view as being the "pluses" of abstaining and moderating use rather than always hawking the negatives. 

•                "Bystander Behavior" - This comes in at least 2 forms: (1) "the silent majority," to quote Spiro Agnew, who say nothing when John Jones or Mary Brown act like a jerks at a drinking gathering, and (2) "most of us" when we fail to hold drinkers accountable for their irreverent, inappropriate, or otherwise untoward behavior because we "don't want to hurt his feelings" or "she'll get all Jersey Shore on me" if I say/do something.

We have learned much in the last 15 years regarding how to affect the campus drinking culture; this is very good news.  That said, we have a long way to go and, unfortunately, much of the interest and money that drove discoveries of the past 15 – 20 years has gone other places.  But just as we knew Pluto was there before we were able to "see it," so is it likely that "something else" is there as regards changing the campus drinking and drugging culture.

Solution-Focused counselors suggest asking individuals to consider a time "before" the problem existed or imagine "when" the problem no longer exists.  By doing this, they invite us to explore how we acted before the problem existed or consider what happened or was done to solve the problem in the future.  This becomes the focus of the practitioner's intervention...get us thinking about possible solutions rather than being preoccupied with the consequences of problems.  

We all know the old adage about the glass being half empty or half full.  There is another option, however, when looking at that glass, namely, that it is always "fully full."  Think about it…the glass is half full of water and half full of air!  We need to look at the "air in the glass" in order to appreciate that the glass is, indeed, always full.  So, when considering collegiate drinking, with what is the rest of that glass filled?

What do you think?

         When They Drink:Is Collegiate Drinking the Problem We Think It Is? (PDF)

         When They Drink:Deconstructing Collegiate Alcohol Use (PDF)

NJ Legislature Votes to Permit Sale of Syringes W/O Prescription

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Designed to address the transfer of blood-borne diseases via “dirty needles,” the NJ legislature has passed a bill permitting the sale of up to 10 syringes w/o a prescription.  Interestingly, this will not become law until and unless the governor signs it into law, an outcome that is “up in the air.’  Having opposed “needle exchanges” while a US Attorney, Gov Christie is on record indicating he is open to revisiting that opinion. For more on the story, visit http://bit.ly/sYsLHZ

NOTE: making the sale of “up to 10 syringes w/o a prescription” legal presents an interesting spin on the harm reduction strategy of ‘needle exchange.”

1. 1.     By “purchasing” syringes rather than “exchanging them,” some of the potential stigma of “self-identifying” as a “drug addict” is removed in the effort to put clean needles in the hands of intravenous drug users (those in a pre-contemplative stage of readiness to change)
2. “   Purchasing” needles rather than “exchanging” them is consistent with the old adage that, “Something for something is worth more than something for nothing” 
3. 3.    “Purchasing” needles rather than “exchanging” them may permit those who have historically be opponents of needle exchange programs on the groups that they promote drug use to support the intended purpose of such programs—reduce the spread of blood-borne disease—w/o having to “give users paraphernalia

Of course as with all things, there is a down side.  Potential issues related with this Jersey bill include:

1. 1.     Unless regulating the cost of needles, there is nothing to stop pharmacies from charging whatever they like for “loose needles.”  Although most pharmacies will not want to gouge their customers with “legitimate” reasons to purchase syringes, some may want to gouge “drug users” or discourage “them” from coming in their stores by charging an outrageous price for “loose” needles
2. 2.     What becomes of the “dirty” needles?  In the exchange programs, they were disposed of properly, but in a “purchase” type exchange, the “dirty” needles remain “on the street”

Nothing is ever simple and without its controversy, but a tip of the hat to the jersey legislature for considering a new approach to a perennial problem.  Hopefully Governor Christie will weigh in on this issues based of fact and what is in the best interest of the citizens of NJ and not simply make a political decision.

If you are from Jersey or have connections with others who are, you may want to consider contacting the Governor and voicing your opinion.

What do you think?

Dr. Robert

Energy Drinks and Their Potential for Risk

A sharp increase in ER visits by individuals having consumed “energy drinks” is noted between 2005 and 2009; the status of this trend between 2009and 22011 remains to be seen. 

As may be expected by those familiar with substance use disorders, “other substance use” frequently exacerbates the potential for energy drinks to facilitate these ER visits, but interestingly, “which” other substances seems to vary by gender.  To read more, visit http://www.nlm.nih.gov/medlineplus/news/fullstory_118979.html

For different perspectives (similar details) on this topic, see  http://bit.ly/uA3E8H, http://bit.ly/uVOxqs, and http://www.rodale.com/research-feed/side-effects-energy-drinks  

Popular Media and Preventing Substance Use Disorders

A colleague contacted me earlier today asking if I and other on a discussion list had seen a video clip on "weed bracelets" - see http://www.blackmediascoop.com/2011/11/02/is-your-kid-wearing-a-weed-bracelet/

My response follows:

Thank you J; very interesting.

A couple thoughts:

1.     “It is always gonna be somethin'"

2.     News media that sensationalize things such as this not only make adults/parents aware of such things—in a sensationalistic and therefore questionably responsible (ethical? moral?) way—but romanticize, glamorize, and otherwise proselytize items such as this in the eyes of adolescents à how many adolescents saw this and thought, “Damn, how do I get me one of them?” “Oh…there’s a website? Cool.”

3.     What is the “call to arms” the media are sounding by making this a focal point for parents? Namely, your kids are pulling a fast one and you are oblivious to it, that is, “you are failing as parents.”

4.     This is reactive journalism at best, not proactive…note the parental interviews that were selected to punctuate the piece, especially the guy who is particularly interesting in his passionate plea to send anyone selling these things directly to jail.

This leads to my last point…

5.     This is “problem oriented” prevention rather than solution oriented. It is scare tactics, but not to get high-risk users to lower risk…rather to inflame fears in the population most likely to demand immediate action (reaction?) in the form of more $ for interdiction, punishment, and other like efforts to ‘win the war on drug.’

Remember Carl Jung’s famous quote: What your resist, persists. See http://www.youtube.com/watch?v=95EH9G1c_4o

What do you think?

Dr. Robert

Does Optimism—or a Lack of It—Affect Collegiate Drinking?

An article published recently in Nature Neuroscience entitled, “How unrealistic optimism is maintained in the face of reality” (see http://www.nature.com/neuro/journal/vaop/ncurrent/full/nn.2949.html for abstract and full citation) suggests one mitigating factors that may shed light on the apparent intransience of collegiate drinking behavior – optimism.

Although neither the article nor the BBC report on it (see http://www.bbc.co.uk/news/health-15214080) speak of collegiate drinking per se, one cannot help but wonder if there is a connection.

“If” a natural propensity to remain optimistic out weighs risk-related information made available to collegiate drinkers via prevention program, PSAs, and/or direct observation of peers and their experiences, then this could be an important factor for those focused on preventing high-risk and dangerous collegiate drinking to consider as they think about the next step in proactive programming targeting collegians.

This may also be a further argument for considering a suggestion I have been advocating, namely that better understanding of the “maturing out” or “aging out” phenomenon that seems to result in third and fourth-year students viewing alcohol as a substance and drinking as a behavior differently than they did when first and second-year students may be the next logical step in prevention efforts. This may be an important step in addressing the apparent intractability of collegiate drinking – see my 2nd and 3rd monographs in the When They Drink series - #2 - “When They Drink: Deconstructing Collegiate Alcohol Use” http://www.robertchapman.net/essays/When_They_Drink2.pdf  and #3 - “When They Drink: Is Collegiate Drinking the Problem We Think It Is?” http://www.robertchapman.net/essays/When_They_Drink3.pdf

In these two monographs I argue that a student’s understanding of alcohol as a substance and drinking as a behavior is a function of how these symbols of contemporary collegiate life come to be understood by students. That understanding, born in middle and high school, drives collegiate behavior upon arrival at college only to be modified over the first 3 to 4 semester by experience and interaction with upperclassmen, resulting in a more moderate approach to alcohol and its use. This “social constructionist” view of collegiate drinking suggests that if we, as prevention specialists, were to study and better understand the process by which meaning is ascribed to alcohol as a substance and drinking as a behavior, then we would be in a position to affect this process in such a way as to hasten this maturing out process. This could result in expediting the passage from “high-risk use” to social or at least “lower-risk” use in months rather than semester, thereby closing the window of risk out of which so many contemporary collegians see to fall while trying to glean a better view of “the wonder of the college years” they have heard so much about from parents, older siblings, the popular media, etc.

In short, “if” we have a predilection to optimism and “if” this results in down-grading if not ignoring negative information or risk associated with personal behavior, “then” it is likely the prevention field will not move much past the gains it has made in recent years as the result of using current evidence-based strategies. It also means that efforts like BASICS (Brief Alcohol Screening and Intervention for College Students) may be successful, in part, because students exposed to such programs have the opportunity to revisit the meaning they had ascribed to “alcohol” and “drinking” moderate the meaning for this icons of contemporary collegiate life and hasten the very maturing out phenomenon that researchers have noted in collegians for years.

What do you think?

Do Scare tactics Work in Preventing Substance Use?

A reader recently asked what I thought about a scare tactics campaign initiated by a sheriff in Oregon – see http://www.facesofmeth.us/drugs_to_mugs.html

The literature tells us—and has consistently done so now for years—that scare tactics do not work. This, however, does not mean that there is not a place for such campaigns in what we do as prevention specialists.

First, when the literature tells us that scare tactics do not work, what they report in the discussion of the findings on which the article is based is that individuals who engage in the high-risk behavior to which the scare tactic refers do not change their behavior as a result of the scare tactic. So whether it is a “mug shots” campaign referenced above or, my personal favorite, “this is your brain on drugs” (see http://www.youtube.com/watch?v=qyXFN4ocN_o) neither results in someone doing things differently on Friday night simply because of having watch/seen the PSA on Thursday.

We know that many (most?) high-risk viewers of such PSA find it easy to disconnect. They either mistakenly believe, “Oh, that will never happen to me because…” or “Well he/she/they were just stupid and not careful” or “that is just a stupid video.” Interestingly, the key element in such campaigns is their ability to get folks who watch who are not the subject of the PSA in order to get them to react, which is to say, these are the real intended audience for such PSAs…in the readers note to me, he included the statement, “(It) may be scare tactic – but it sure got my attention sent me.

We, the viewers, are the audience, not the drug users in society. When parents/concerned citizens/conservatives/law abiding adults/victims of drug-related crime/etc. view such PSAs, we are galvanized and tend to demand that something be done. Frequently this “something” is more related to the “supply side” of the drug issue (interdiction) than the “demand” side (prevention and treatment). Yet there is a role for such PSAs to play in the work that we as prevention specialists and concerned professionals do to address the alcohol and other drug problem that exists in our culture.

The literature also tells us that people proceed towards change by passing along a continuum of readiness to make that change. When a high-risk user is in the earlier stages of readiness to change—in the literature this is called a pre-contemplative stage—and exposed to such PSAs, they DO NOT change because of the PSA message. What they may do, however, is take notice and add the information to an archive of stored info on AOD use and perhaps eventually move to the next stage on the continuum…contemplation.

If pre-contemplation is the capital “D” Denial stage, the “I-don’t-have-a-drug-problem-but-a-drug-solution” stage, then contemplation is the small “d” denial stage, a stage where one begins to question if what I am doing might just be presenting a problem. From here individuals work through the successive stages of change until they reach a point of “action” and it is here that the user essentially says, “The war is over, I lost; give me the articles of surrender and I will sign.” I will not bore you with the details of how to get from “pre-contemplation to action,” but suffice it to say that scare tactics may, and I emphasize MAY, play a role.

No one has ever moved from pre-contemplation to action and on to maintenance (maintaining the change once made) without coming to a point of realizing that “to go on doing what I have been doing is more of a hassle than to change.” Our challenge as prevention specialists is to expedite that movement through these stages…and scare tactics may be able to play a (small) role in this movement. What scare tactics cannot do, however, is move someone from pre-contemplation—or even contemplation—to action…it is just too easy to find countless examples of individuals who are not experiencing the “problem” the PSA rails against and to point to them as proof of the PSA’s spurious message.

In closing, I am not “against” scare tactics so much a I do not believe they change behavior. I believe we must first recognize the limitations of scare tactics PSA before even considering their utility.  Second, we need to accept that they are at least as focused on upsetting you and me as they are in trying to influence the behavior of high-risk users—do they intend to get users to stop or “everyone else” to be upset? Third, we need to accept that no PSA or campaign based on scare tactics is ever going to keep someone with a substance use disorder, in and of itself,  from using. There is no “silver-bullet” that will bring down the werewolf of addiction. There is, however, hope that we can affect change and help move someone along the continuum of readiness to change.

To learn more about the stages of readiness to change, visit: http://www.aafp.org/afp/20000301/1409.html

To read more about a comprehensive plan to address high-risk collegiate drinking, which may serve as a model for affecting any high-risk behavior, visit: http://www.robertchapman.net/essays/when_they_drink1.pdf

To read more on my views regarding a more comprehensive understanding of collegiate drinking and my thoughts on what is missing from a comprehensive plan to address such, visit: http://www.robertchapman.net/essays/When_They_Drink2.pdf

What do you think?

Dr. Robert

The Power of Presence:

Self-Involving Statements in Therapeutic Relationships

 

 

While corresponding with a former student who is in her first professional position post-bachelor's degree, the topic of using self-disclosure came up. Although discussed in classes, the issue took on greater significance for the student, given her recovery from a substance use disorder, her position in a SUD treatment program, and her recent experience with a client. I thought sharing the gist of this correspondence as a post might interest followers of this blog.

 

 

Congratulations on the offer to go full-time. Such an offer speaks to both the quality of your work as a practitioner and your value to the program as a team member; I am not surprised. My experience has always been that as individuals with substance use disorders recover, they do not just get well; they get really, REALLY well :) Over the years, as I have come to watch those individuals who find recovery in 12-step programs, some of whom seem to thrive and truly blossom, I have come to realize that people with addictive disorders tend to be among the more sensitive and, therefore empathetic people I have met—when using, that was a big part of the problem. As you know, this is not, in and of itself, sufficient to make an effective counselor. Still, when harnessed, in tandem with training and education in counseling technique and practice, these individuals can mature into, to quote folks of your generation, 'awesome' practitioners. I do not doubt that you have the potential to be one of them.

 

Your comment about the young gentleman who seems to have confided in you when learning that you have "walked the walk" is not uncommon. The challenge for you as a professional contemplating the use of this type of disclosure, however, is to be sure you know (1) why you are self-disclosing and for what purpose and (2) realize that for self-disclosure to enhance the counseling relationship and benefit the client, it is essential to ensure its use benefits the client and not the counselor. For this reason, it is generally a good idea to self-disclose "later" rather than "sooner" in the counseling relationship, perhaps as the response to a client's inquiry if you are in recovery, having watched you and come to suspect you may be by your actions rather than wearing it like a badge of honor. As the old saying goes, let your actions speak for you. When you "act like" a recovering person, people will notice, and one "acts like" a recovering person by doing what they need to do to stay clean and sober "one day at a time." As the slogan in the program suggests, "do the next right thing."

 

Remember from our classes the difference between self-involving and self-disclosing statements a counselor can make. Both can convey a personal connection and allow the client to relate more easily to the counselor. The self-disclosing statement, however, necessitates having to place the focus on you to enter the client's space and demonstrate the ability to connect. The self-involving statement, however, maintains the focus on the client and allows the counselor to meet the client personally and demonstrate the ability to empathize. A self-disclosing statement is something like, "I know what you mean because, in my early recovery, I felt alone and afraid most of the time too." Notice all the "I" statements...the focus is on the counselor, not the client. 

 

 

The self-involving statement goes, "You seem to be struggling with the fear that feeling isolated and alone tends to create - (this is an empathic reflection, as you learned in class). Your willingness to share this with me in our session and accept my suggestion to take it to the group shows the progress you have made in your recovery. 6-weeks ago, you would have just said 'screw it' and got high; today, you shared it with me and are ready to work on it; I am proud of you" - (this is the heart of the self-involving part of the statement).

 

Remember, 'you do best what you do most.' The more you do what you learned in school and continue to learn on the job and in supervision, the better you will become at doing it. You are a better counselor today, 'student's name,' than you were yesterday, and nowhere near the counselor you will become tomorrow :) Your progress is evident, and I have full confidence in your potential.

 

 

Self-disclosure is easy and seems like an effective way to help someone feel comfortable and trusting, but it can be a double-edged sword. Although you may intend it as a means of connecting with your client, they may take it as you implying how they should address their problem. It is better to engage the client by entering their experience, as a parent might do with a young child, than by expecting them to join yours.

What do you think?


Dr. Robert

1. What Causes a Problem Is a Problem if It Causes a Problem

With the publicity surrounding the recent publication of the ASAM (American Society of Addiction Medicine) update on the definition of addiction, it is likely useful to review some of the “indicators of a problem” to which non-professionals can better relate and therefore more quickly use to recognize a problem with substance use. First a quick review of the new ASAM definition:

Short Definition of Addiction: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. To review this in more detail, visit http://www.asam.org/DefinitionofAddiction-LongVersion.html

As precise as this definition is for professionals, my experience when working with individuals in earlier stages of readiness to change their drinking and other drug use has been that such definitions present easy targets for those looking to deny their problem. Because defining addiction for professionals and for “consumers” can yield wildly different responses, this post will focus creating a “short list” of indicators that may suggest one’s use is not so much use as it is reason for concern.

In no specific order, here is a short list of indicators. Having but one of these does not necessarily suggest a problem, but as the number of indicators increases, so does the likelihood that one’s use is problematic if not indicative of addiction:

1. “What causes a problem is a problem if it causes a problem.” This ‘bumper-sticker’ wisdom comes from a well know lecturer in the alcoholism field, Fr. Joseph Martin. What it means is, if I am wondering if my substance use is becoming a problem for me or if I wonder if my significant other’s use is becoming a problem, guess what...it is becoming a problem.
2. Increasing time spent thinking about using, planning to use, or finding the economic means to support that use. For the professional this suggests “compulsion”; for the consumer it is rationalized as “preoccupation with an enjoyable activity.”
3. Similar to #2, my use has become an increasingly important determinant of how I budget my time. For example, previously enjoyed or favored past times are bypassed to make time to use. Drinks with friends rather than ball games with kids; smoking-up in the basement rather than watching TV with the family;
4. Protecting the supply. Although most people have some beer, wine and/or spirits in the house they do not have “cases” of their favorite beverage stockpiled. NOTE: The well stocked wine cellar does not necessarily mean the “oenophilist” or connoisseur of fine wines has a drinking problem. Related to this is the need to use more to gain the desired effect...which increases the importance of protecting the supply.
5. Changes in the people with whom I use. To change the people I socialize with and/or the places I socialize in in order to accommodate changes in my use pattern can foreshadow a movement towards a problem. To spend less time with John and Mary who go home after 2 in order to hang with Bill and Flo who “really know how to party,” signals a change worth noting.
6. A shift from 2 beers/sours on Fridays to 3 or 4 shots and beers “a couple nights a week” warrants consideration. Likewise, when “splitting a bowl” a couple times a month morphs into finishing a blunt a couple times a week, or Tylenol-III 2X/day for 3 days becomes Oxycodone PRN.
   

These indicators are more environmental or behavioral; personal indicators include:

1. Minimizing reported use or using secretively. Social users have too much and say, “Boy, did I over do it last night; I’m going to have to be more careful in the future.” The problem user says nothing about the overdose and deftly changes the subject if someone brings it up.
2. When considering how to budget money or time, use moves from being a “want” to becoming a “need”; from being a luxury to a necessity.
3. Changing other factors in my life in order to accommodate the use...I eat less so I can drink more (concern about weight); I switch from “good stuff I like” to “less good stuff I can afford” to consume more on the same budget; spending less on clothes or entertainment to accommodate expanded patterns of use.
4. Becoming a different person when using or the “Dr. Jekyll (the accomplished, “nice guy when sober”) / Mr. Hyde (“bestial” ghoul when using) syndrome – young kids are particularly adept at both noting this and commenting on it.
5. Sincere pledges, to self or others, regarding change are easily overturned. NOTE: The true mark of control is not saying “no” to “a” drink or drug—anyone can do this; it is saying “no” to a drink or drug I want.
6. A questionable ability to predict when I will next use and/or once starting, when I will stop.
   

There are numerous screening check lists and indicators available online (for example, see http://www.ncadd.org/). Likewise, any bookstore has numerous publications in the “self-help” section. Some are good, others, not so much. Irrespective of what you read, hear, or listen to, the bottom line regarding one’s use is, what do I tell myself? This reflects back to the first item on the first list noted above: What causes a problem is a problem if it causes a problem.

Substance use disorders are bona fide health care issues, a brain disease if you will. We have stigmatized these disorders in our culture and these stigmas have prevented individuals from recognizing that something is amiss until what was amiss becomes “a mess.” If you think something is amiss regarding your pattern of use, speak with someone who can help you step back, revisit the facts in your life, and consider an objective albeit candid new perspective from which to view these facts.

What do you think?

Dr. Robert

Can a Significant Other Provide Therapy to The Other?                                                   

Not being an ethicist I cannot speak to this question with any authority. I can, however, reflect on it as it does raise at least one intriguing clinical issue: Is it possible for a former “significant," that is to suggest intimate, "other” to be viewed objectively by either the practitioner or the client or one seeking therapy? If the answer is yes, it is feasible, does this possibility assume this objectivity is simultaneous for both parties, that is to say that both parties will be equally objective and detached from the previous relationship at the moment of their reintroduction as practitioner and client? If the answer remains yes, does this necessitate a quantifiable period of time between one’s status as significant other and becoming either practitioner or client in order for this objectivity to be realized? Assuming the answer to all these question continues to be yes and that objectivity is indeed possible, are there other implications raised by the fact that one or both parties have specific intimate knowledge regarding the other that may impact judgment as regards treatment planning and/or follow-through irrespective of objectivity? 

Just as the admiral and captain on a naval flagship dine separately from each other as well as from the crew at large—they literally dine alone so as to discourage the development of close friendships and emotional ties that could affect personal judgment regarding command decisions that necessitate the sending of one's subordinates into harm’s way—can a practitioner every truly detach him or herself from “what once was” in order to thoroughly engage in the pursuit of “what might become”?

Please know that I do not doubt the sincerity of my colleagues who suggest seeing former significant other's professionally is possible and I recognize that the vast majority of us would never intentionally jeopardize the clinical outcome of work with a client if thinking that previous knowledge of said client could result in providing subjective treatment, but we all know what we have learned and learned what we were taught, be it in the classroom, home, or previous intimate relationships. AA has a saying that is somewhat apropos here: You can always turn a cucumber into a pickle, but you can never change a pickle back into a cucumber. Albeit a bit folksy, it is nonetheless a poignant statement that speaks to the clinical issues raised in my initial ethical question: If I had been your lover, could you ever see me as other than that former lover? I am not sure I could see you as otherwise.


What do you think?
Dr.Robert