© Dori Digenti. 2021. All rights reserved.
We now shift from exploring personal and collective trauma as a root cause of addiction, to how we deal with addiction itself. How has our understanding of addiction, treatment, and recovery from addiction evolved? This is a very complex story. There are so many different approaches and opinions, not to mention scientific findings, about how to help people with addictions to recover.
From the introduction, we discovered that the first two approaches of Van der Kolk’s trauma treatment model
track well with Debra Rothschild’s groundbreaking model of the “Three Waves of Substance Use Treatment,” as mentioned in the Introduction. We explore now those Three Waves and how the treatment and recovery field has evolved. As our understanding of addiction has increased, the range of approaches has expanded greatly. We are making progress in all the fields impacting addiction: psychology, trauma, physiology, biology, chemistry, brain science, many others. We see through the Three Waves how different disciplines dominate the recovery landscape at different times and through different eras. Each Wave helps us to expand beyond the “one size fits all” treatment formula, to use the combination of approaches that best fits the individual’s circumstances and abilities. First, let’s take a look at addiction treatment to distinguish it from addiction recovery.
There is a commonly accepted dividing line between treatment and recovery. Treatment typically occurs in a facility with skilled medical staff that assist the addicted person with detox, followed by a stabilization period, and possibly other inpatient programs. Most treatment centers will include education on the patterns of addiction, how to avoid relapse, and resources and approaches available after leaving treatment, including recovery resources. A centerpiece of addiction treatment is counseling, combining education and talk therapy.
Addiction counselors and therapists use a range of methods in treatment, including Cognitive (CBT) and Dialectical Behavioral (DBT) therapies, motivational interviewing, family therapy, contingency planning, coaching, and other methods of psychiatric and psychological treatment. The addiction counseling field is dominated by CBT, since it is considered to have the highest scientific evidence base.[i] CBT as a method trains us to control behavior through changing negative and obsessive thinking. As Van der Kolk reminds us, top down therapies are helpful to create a framework for seeing our behavior and thinking patterns more clearly. At the same time, “the part of our brain best able to consciously regulate behavior, the prefrontal cortex [thinking brain], is the first part to go offline when we get stressed.”[ii] We know that stress, when trapped in the body or mind, can lead directly to addiction and substance misuse.
We can think of our current treatment system as what Joanna Macy calls a Holding Action. A Holding Action is an effort “designed to prevent an enemy from attacking, or from moving its position.”[iii] Our enemy is mass and deadly addiction, and our current treatment system can be seen as a holding action. We are engaged in tactical responses, and have not been able to fully prevent the attack or spread of addiction. There is hope to stem the tide of addiction, but we are likely reaching only 1 in 10 addicts with our current treatment methods.[iv]
After treatment, the next step is to enter recovery. Recovery programs are now considered best practice for long-term healing from addiction. To understand the three waves, it helps to start at the beginning with the first wave, developed from the Alcoholics Anonymous method, and now widely known as 12-Step recovery programs.
The first wave of addiction recovery focuses on 12-Step programs and AA. History is a powerful lens for understanding how the creation of 12-Step programs revolutionized, and some would say, founded the recovery movement.
We can trace the founding of Alcoholics Anonymous back to the late 1930s and see it as a turning point toward dealing with the hidden problem of alcoholism. Through the development of the 12 Steps and 12 Traditions, the publication and dissemination of the Big Book, and most significantly the flourishing of “meetings” — fellowships around the country and around the world — millions have found solace from the ravages of alcohol addiction. A key component of the 12-Step approach is the sober sponsor, a peer who can advise and steer the new member toward abstinence. The approach expanded in the later 20th century to include other addictions – drugs, gambling, love & sex, food (“Overeaters”), and others. As well, other fellowship communities and online recovery communities have arisen, such as Dharma Recovery, Smart Recovery, and many more which we won’t review in detail here.
The 12-Step Journey as outlined in the Big Book unfolds in three phases:
The reach of 12-Step programs since they were developed is truly astounding. Prisons, recovery centers, and detox and treatment centers use 12-Step language, offer groups, and emphasize abstinence. Many who become entangled in the criminal justice system for driving under the influence, assault or domestic violence are mandated or diverted into 12-Step programs. In jails and prisons, attendance at 12-Step meetings can add to one’s “good time,” contributing to a shorter sentence. Up to 50% of the scheduled offerings at many treatment or rehab centers are 12-Step-based fellowship meetings.
Some studies claim that 12- Step success rates (defined by abstinence from drug or alcohol use) are very low, possibly in the 5-10% range.[v] How do we explain the discrepancy between the very widespread popularity and proliferation of 12-Step programs, and the lack of studies that have been able to show its efficacy? Is it that by creating a “fellowship” and a culture of defined behavior, members are freed from their isolation and develop a sense of belonging? These rituals may act to restore our ability to listen, to witness, and to feel empathetic connection – abilities that we may have lost or covered up as addiction set in. By creating a counter-culture and bonding through shared experience, some for the first time find acceptance in their 12-Step “home group.” This in itself may bring relief and mitigate against self-destructive behaviors, even if the program does not always lead to total abstinence.
12-Step programs make the individual the central focus of recovery. Our individual willpower, even as we say and pray that it has been turned over to a Higher Power, is paramount and we are individually responsible for success or failure in the program. If alcohol or drug use reoccurs while we are engaged in the 12 Steps, we are instructed to restart the Steps. It’s hard for some not to see that as a failure that could add to feelings of worthlessness. There are many studies exploring willpower exhaustion, ego depletion, and delayed gratification. When we continually call on willpower to change behavior and resist harmful behaviors, we are calling on a limited resource.[vi] This is where the turning over of will to a Higher Power (“God of My Understanding”) is deemed essential. In the 12-Steps, we must connect both the peer community of those who are trying to abstain and call on a powerful ally external to us.
The evidence for 12-Step programs, then, is that it has helped many, many people to leave harmful addictions behind. How is it that 12-Step programs work?
From the Traditional Knowledge (TK) perspective, the combination of these factors would be the very reason that the 12-Step approach does work for so many. In other words, it is the community of those in recovery and the positive regard and support for each other that make the medicine.
What the 12-Step recovery approach shows us is that science-only based evidence or “proof,” by definition, must isolate factors, must pick apart the levers of the system in order to show the cause and effect mechanisms. Whenever we encounter the meeting of science and faith, however, proof is very hard to come by. If millions of people have benefitted from 12-Step, then we accept it as a TK approach that has shown the test of time. The First Wave of recovery approaches – the 12-Step framework – remains a boon to many. And yet, through the late 20th century, those who struggled with addiction were seen to be damaged, doomed, or broken as compared to those who did not suffer from addiction.
“Twelve-step philosophy stipulates that addiction is a spiritual disease born of defects of character, and that 12-step groups are the only cure, involving faith in a higher power, prayer, confession, and admission of powerlessness. In contrast, the National Institute on Drug Abuse (NIDA) defines addiction as a disease of the brain – a medical condition requiring medical treatment. A spiritual disease concept is not the same as a medical disease concept.” – Laurel Sindewald, The Fix [vii]
“Drugs gave doctors a greater sense of efficacy and provided a tool beyond talk therapy. Drugs also produced income and profits… [and] takes control over people’s fate out of their own hands.” – Bessel Van Der Kolk, The Body Keeps the Score
In the Second Wave, we view addiction as a health condition that can be treated through detox followed by rehabilitation and recovery. In this wave, also called the Disease Model, the medical community is in charge, and holds the view that addiction is a brain disease. [viii] The medical model says that habitual use of addictive substances rewires and damages the reward, impulse-risk-craving, and decision-making areas of the brain over time (and acknowledges that there may be pre-existing brain impairments due to trauma or mental illness). The result is that the brain is hijacked and you focus on drug acquisition and use and whatever you need to support it, despite harm to your health. As a result of the brain changes addiction causes, you under-value risk and over-value and seek only short-term rewards.[ix]
At the far end of the Disease Model view, addiction to drugs is considered equivalent to chronic diseases like diabetes. There is no cure, a daily dose of medication is the best approach, and relapses or worsening of symptoms are very possible. If we see addiction as a chronic disease, then we approach it with a diagnosis and treatment plan. As this diagnosis/treatment approach has continued to grow, and research on drugs to alleviate craving and addictions has developed, the Disease Model has become the dominant paradigm in treatment, since at least the early 2000s. We can see the benefits of this approach, measured by people who have entered a treatment regimen that is allowing them to live more normal lives. We can look at the current focus of recovery efforts – the opioid crisis – as a way to fully understand the shift from the First Wave of Recovery through peer support and calling to a higher power, to the Second Wave’s Recovery through medications.
The Opioid Crisis is now the leading cause of death among Americans under 50, causing 67,000 deaths in 2018.[x] The overprescribing of pain medications set off this deadly chain of addiction. As people became addicted to prescribed opioids and were then cut off from prescriptions by new controls, they moved to cheaper street heroin. Now, we have entered the third, and most deadly, stage of the opioid crisis with the advent of fentanyl. Fentanyl is a highly potent drug that can cause clusters of overdose deaths as it moves through a community.[xi] We must pay attention to the fact that in communities across America, there are daily overdose clusters that have the effect of moving our addiction resources away from treatment to intervening in an epidemic. There is a danger of severe limitations on emerging treatments and recovery approaches, as focus and money goes to the emergency overdose treatments that save lives.
What the Opioid Crisis has forced is a move away from seeking control of addiction through the criminal justice system which disproportionately affected communities of color in the late 20th century. We now live in the historical shadow of the War on Drugs, the Crack Epidemic of the 1980s, and the rapid acceleration toward mass incarceration that resulted.[xii] Even now, our jails and prisons are filled with drug “offenders” – unfairly treated due to racism and/or poverty – who need addiction treatment much more than classic crime rehabilitation.
The move away from enforcement and confinement in the past two decades, and toward treatment and recovery, is laudable. It is through the Second Wave shift to a medical-disease management that we see a more humane approach unfolding, in concert with the expansion of peer support, community-based recovery options and a slow awakening to histories of discrimination and racial profiling. Clinicians and doctors are convinced that the Disease Model of addiction is not only a more humane view, but also means that addiction is treatable the same was as other chronic diseases – by medications. The maintenance medications prescribed are themselves opioids, but allow the person with addiction to return to a life with more options, less risk, and less craving.
The rise of Medication-Assisted Treatment (MAT) is changing the landscape of the opioid crisis and other substance addictions as well, but with it comes the “Business as Usual” limitations of our current economic and healthcare systems. I outline in detail how MAT, a treatment approach so critical to saving lives in our current crisis, is under siege by the types of corruption and profit-seeking that have distorted the effectiveness of this approach in Appendix 3.
On a positive note, we can have confidence that the worst abuses in MAT will be corrected over time. The Second Wave with its Disease Model has brought more solutions to bear on the addiction crises we face. In the next section, we will explore another leap forward with the Third Wave of Recovery, based on the notions of harm reduction and overcoming stigma.
The Third Wave of Recovery is marked by a move toward Harm Reduction and potentially a move away from the insistence on total abstinence. Harm reduction accepts without stigma that people who use illegal drugs deserve respect, assistance, and protection. The harm reduction approach embraces pragmatism toward high-risk behaviors, and a focus on how to enhance a person’s quality of life. Some common harm reduction measures are:
In a harm reduction scenario, for example, if you are an opioid user, and you drink alcohol in order to avoid using street drugs, then that is considered a positive harm reduction, though not an endpoint. A key component of harm reduction is to move us toward solutions to high-risk behaviors, and away from judgment. One other factor that is part of a harm reduction approach is to develop culturally appropriate approaches to addiction treatment. Based on the knowledge that collective and intergenerational trauma can create a fertile ground for addiction, we can be more successful by using harm reduction approaches that are founded on strongly held cultural values.
To engage in harm reduction on a broad scale, coaches, counselors, and treatment programs have focused on reducing the stigma associated with drug abuse. Many programs have adopted a “multiple pathways to recovery”[xiii] approach. Multiple pathways empowers the individual to seek out tools and approaches in managing their own recovery. Those who accept the multiple pathways model believe that there is no cookie-cutter approach to overcoming addiction. Each person’s recovery could draw on any number of approaches that work for them, based on the variables of their age, family, origin, medical history, sexual orientation, learning style, and trauma history. With the growing acceptance of the multiple pathways model, more options are becoming available, and a wider range of needs can be met through existing treatment programs.[xiv]
This concludes our review of the Three Waves of Recovery. Many aspects of the highly complex recovery field were omitted to avoid going too deeply into what is a vast and evolving body of knowledge and practice. The Third Wave paradigm – Harm Reduction — that is emerging in the field is a hopeful sign of more inclusivity, more options, more agency, more cultural relevance, and more public awareness.
My hope in this review was to highlight that what we have available has evolved in concert with the social progress we have seen (though not complete) in reducing inequality and the stigma toward those who struggle with addiction. In the best-case scenario, a range of recovery options over multiple years for an individual are available, and relief from addiction is possible for ever more people. And yet, individuals and communities continue to suffer the ravages of addiction, racial profiling, poverty, and generational criminal justice system involvement. How will we end these intractable systems? How will we move millions from narrow lives of addiction and craving to life-sustaining work with joy and satisfaction? How will we transform our divided and segregated communities to life-sustaining economic and social systems that bring healing?
We must be driven to resolve these questions for those who have not found their way out of addiction, and for all of us. There is no one answer, no magic bullet.
The Fourth Wave of Recovery shows us another path – an embodied journey to healing our separation-based addiction crises. The Fourth Wave builds on all the knowledge accumulated in the 70+ years of addiction treatment and recovery. There is no need to throw out the foundations that have led to where we are now, even as some practices are replaced or fade as we understand more fully how the individual recovers in community and in nature.
[i] McHugh, R Kathryn et al. “Cognitive behavioral therapy for substance use disorders.” The Psychiatric clinics of North America vol. 33,3 (2010): 511-25. doi:10.1016/j.psc.2010.04.012
[ii] Brewer, Judson. The Craving Mind.
[iii] Macy and Brown.
[v] Glaser, Gabrielle. The Irrationality of Alcoholics Anonymous. The Atlantic Magazine. April 2015. https://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/.
[vi] The primary source on this effect is Roy E Baumeister, Ellen Bratslavsky, Mark Muraven, and Dianne M. Tice (1998). Ego Depletion: Is the Active Self a Limited Resource? Journal of Personality and Social Psychology, 1998, Vol. 74, No. 5, 1252-1265.
[vii] Sindewald, Laurel. AA Is Not Evidence-Based Treatment. The Fix. Website. March 16, 2017.
[ix] Nora D. Volkow, Gene-Jack Wang, Joanna S. Fowler, Dardo Tomasi, Frank Telang, and Ruben Baler. “Addiction: Decreased reward sensitivity and increased expectation sensitivity conspire to overwhelm the brain’s control circuit,” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2948245/
[x] https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. This is death from all drug overdoses, including both prescription and street drugs. Experts agree that a very high percentage of these deaths are from opioids alone, or in combination with other drugs.
[xi] Vestal, Christine. How Fentanyl Changes the Opioid Equation. Stateline. October 17, 2018. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2018/10/17/how-fentanyl-changes-the-opioid-equation/.
[xii] We should understand that the Opioid Crisis, while deadly, has brought a new-found awareness and focus on addiction. This attention stands in sharp contrast to the “Crack Epidemic” of the 1980s. We now, in hindsight, understand that the War on Drugs of that era was linked to the criminalization of African American communities.[xii] The response to this prior addiction crisis was to reinforce racial stereotypes about street crime, crack babies, and more destructive labeling. With mandatory sentencing under the Controlled Substances Act, the Crack Epidemic resulted in Black and Brown men (and women, but fewer) being incarcerated unjustly, and this is when mass incarceration really took off. To understand this history thoroughly, refer to The New Jim Crow, by Michelle Alexander (New York: The New Press, 2010). Inequities in access to addiction treatment continue to the present day, albeit with some progress in treatment access through the Affordable Care Act.
[xiii] White, William A. “Multiple Pathways and Styles of Addiction Recovery,” CCAR Multiple Pathways of Recovery Conference Keynote, May 2, 2016 Presentation Outline & Reference http://www.williamwhitepapers.com/pr/Multiple%20Pathways%20and%20Styles%20of%20Recovery%20CCAR%20Conference%20Keynote%20Outline.pdf.