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On October 9, 2010, I had the privilege of sitting down with Dennis McCarty, PhD to discuss drug and alcohol addiction treatment in the US. I have the great fortune of working with Dennis, mostly by turning his printouts into PDFs and booking the conference room for him, and I’ve always been fascinated and heartened by the work he and his team does; I’ve secretly always thought of him as a bit of an unsung superhero – out there fighting the good fight. After reading some posts about drugs, addictions, and treatment here on TNB in recent months, I asked Dennis to share his thoughts on all of it from the angle of policy. Here’s what he had to say.
GH: Hi Dennis!
DM: Hi Gloria.
Thank you for taking the time to answer some questions. Don’t hold back too much! Let it flow, Dennis! Be lyrical and stuff. This is a literary site after all.
As best I can for an old guy.
Okay, to start: I see from your faculty profile that you are the Director of the Substance Abuse Policy Center in the Oregon Health Policy Institute and that you work with state and local policy makers to improve the quality of services and the use of data on substance abuse treatment. What does that mean?
And you want me to be lyrical?
Yes. Make sure you write an a-b rhyme – like The Lorax, only about drugs.
I will try. Addiction treatment is more than patients and counselors and 12 step groups. It’s the organization and financing, structure and delivery of treatment services. My job is to understand the context for addiction treatment.
To what end?
To improve patient care and outcomes. I will tell a story: I was flying from Kansas City to Saint Louis. The last passenger to board took the empty middle seat next to me and announced, “I am a nervous flyer, I need to talk.” I ignored her and she turned to Mr. Window seat. When she exhausted him she turned to me. “I see you are reading medical papers. What do you do?” I responded ‘I study the organization and financing of addiction treatment services.’ That is usually sufficient to inhibit conversation. Not this time. She needed to talk. I proceeded to discuss addiction treatment. As we began to land in St. Louis, Mr. Window seat leaned across and dropped a coin in my hand and said, “I wanted you to know.” It was his sobriety medallion. A number 2 was on the back — two years of sobriety. Mr. Window Seat explained that he had entered treatment 6 years ago but was not ready to stop drinking. His story is not uncommon. But why should we and he blame himself. “I was not ready.” I believe that the treatment program was not ready for Mr. Window Seat. So my work is directed to helping addiction treatment systems do a better job with patients the first time they enter care. Let’s make care more accessible, attractive, and effective. That’s the goal.
Why do you think people take a long time to “be ready” to quit abusing drugs and alcohol? Do you think it has anything to do with their treatment options? I know that there are many factors in a person’s willingness to get sober – psychological, sociological, etc.
Simple answer is because they are addicted — their brain chemistry changes. A longer more complex answer is that treatment services wait for patients to be ready rather than helping patients become ready.
But, you know, if you have diabetes, you can go get treated – get some insulin and voila! Better. It’s not like that with addiction, which is also a disease, isn’t it?
Diabetes is a good example of a chronic disease that can be treated effectively but also requires lifestyle changes. If a diabetic stops exercising and dieting and monitoring their insulin levels, they get sick. Doctors make lots of money treating diabetics for preventable illness.
But as you note they continue to treat them. One strategy we need in addiction treatment is a system of chronic disease management. Currently the system provides acute care rather than chronic care.
What would that look like?
We don’t know actually because the system has not been invented.
You’re a visionary, Dennis! Imagine the future!
It probably includes ongoing contact and leaving medical records open like physicians do. It requires different systems of reimbursement and contracting. Lots of systems changes. Also changes in the type of work for counselors and people in recovery.
So, basically, a reform of the medical system in general, which has been an ongoing discussion and debate. What barriers do drug counselors face in delivering the type of treatment that would be most effective?
Yes. Health care reform and the Affordable Health Care Act create many opportunities for changing systems of care. Counselor barriers are many. Training is the first. Only about half of the US counselor workforce has a graduate degree. Should we allow individuals without graduate training to work as counselors? Reimbursement and salary are another. The counselor workforce has a 25% annual turnover rate. Lack of evidence-based practices is another challenge and counselors who are not trained in the practices that are evidence based.
What do you mean by evidence based?
Evidence-based is based on scientific research.
Your team is also involved in some of that scientific research, is it not?
Yes. We participate in the National Drug Abuse Treatment Clinical Trials Network and test pharmacological and behavioral therapies in community-based addiction treatment programs like CODA, ChangePoint, and NARA (addiction treatment centers in Portland).
Which leads me to my next question: as you know, I asked a few fellow TNB writers what they’d like to ask you, and one question that was repeated several times involved methadone clinics. People are concerned about them. Are they safe in my neighborhood? Why should we let junkies use our social service dollars to get drugs? Etc. What can you say about that?
The problem is not the medication; it is the quality of the treatment service. Opioids and nicotine are probably the two hardest drugs to stop using. The best treatments for both are agonist medications (replacement medications). Most opioid users relapse to opioid use following treatment. And if you are using heroin or pharmacological opioids you are likely to be supporting your use with illegal activity. Patients using methadone have more stable outcomes, reduced criminal involvement, more employment, and better health. What’s bad about that? Of course it’s more complex but that is the goal.
Sure. Let me segue now. The second most asked question was: What alternatives to god-based recovery do we have here in the U.S.? I think one barrier to drinkers quitting drinking is that AA looms large as the only game in town for support and it turns the less religious among us off, I think.
I sense a bias in the question. AA is only 75 years old or so. The whole field dates to the mid 1930s and existed without federal or state support until the late 1960s. Addiction treatment is a young science. But about the god thing – AA in the Netherlands does not discuss god and do not include prayers in meetings. AA need not be about god. People seeking recovery can find god-less groups and alternatives to AA.
Is it still called Alcoholics Anonymous in Holland?
Yes, it’s still called AA. But the Dutch are relatively godless.
Can you name some other American-based support systems that are not AA and don’t discuss God or a higher power in their approach?
SMART Recovery is probably the most visible of the alternatives.
Speaking of the Dutch – when I think of the Dutch, I think of three things: windmills, tulips, and marijuana. So, let’s talk about pot for a second. Something that I’ve heard asked many times in my life by many people is: Why is pot illegal and alcohol legal? Can you help answer that question?
It’s the devil’s weed. Being silly. I don’t know if there is a good answer. Technically, marijuana is prohibited because international treaties declare that it has no valid medical use.
Many states disagree. Oregon, for example.
There is scientific debate. But until the international drug control conventions are revised, marijuana is an illegal substance and member nations are required to make marijuana use illicit and to prosecute offenders. The tension between state and federal government does not change federal law where marijuana is illegal.
As I sit here and type, there is an advertisement for Concerta going on in the background. That’s an ADHD medication that uses methamphetamines in its ingredients. And pain is often treated with opioids. I thought it was a widely held understanding that those drugs that are illegal are also used legally.
Yes, drug control policies are an amusing set of contradictions. Legal drugs can be used illegally but illegal drugs cannot be used legally (under federal law).
It sounds like this isn’t just federal (US) law. It sounds like what you’re saying is that our country’s drug laws are also regulated by some sort of international body. Is that right?
Yes. The United Nations now functions in that capacity. Of course, the US tends to have a disproportionate influence. The international conventions (treaties) are marvels of ambiguity so that the Dutch can do their interpretation and the US can have a different opinion.
Why does the US have a greater influence?
Because we have the biggest purse and are the most dogmatic. Dogmatism is a function of US policy. The Regan Bush Bush administration catered to white southern Christians who feared that marijuana was stealing their children.
I see. For the record – for all of posterity, Dennis, where do you stand on the legalization of marijuana?
I am ambivalent. The biggest drugs of abuse are all legal: tobacco, alcohol, prescription opioids and marijuana (which is quasi-legal in many states). From a public health perspective, I think that legalization would increase problems with marijuana. At the same time, I recognize that too many people are in prisons and jails.
What types of problems would it cause?
Drugged driving, neglect of children, health problems.
I’m glad you brought up prisons. As I mentioned, some TNBers sent me some questions they’d like to ask you. Sean Beaudoin asked some really incredible questions, and I think each would be its own essay. In one of his questions, he mentions “…the usage of the penal system to handle addicts, particularly addicts of specific drugs (massive percentage crack), as well as that approach’s colossal failure and the opportunities to institute genuine rehabilitation within the penal system that are missed…” What can you say about the way the US uses the penal system to deal with addictions? I mean, it seems like that’s our real addictions treatment system.
Historically, the US relies on corrections to address addictions. In the 1950s, the county work farm was the primary treatment for alcoholics. Today incarceration is the primary treatment system for heroin, cocaine, and marijuana. The Department of Justice screens arrestees for drug use in 10 communities across the US (Portland is one of the cities) about two thirds of the offenders are positive for drug use at the time of their arrest. The link between crime and drugs is astounding.
Do you have any numbers on how many people go back to using after they’re released from prison?
It’s high. I can find numbers but I guess it’s at least 50% if not 75 to 90%.
So, then, it sounds like the incarceration model of treatment is a colossal failure.
Individuals who receive treatment in prison are less likely to use when they return to the community. Those who continue in treatment when they return to the community have the lowest reincarceration rate. Incarceration is not treatment.
Andrew Nondetti wants to know: What constitutes a “rehabilitative success”? Complete non-recidivism? A reduction in usage to “social levels”? Not seeking further treatment?
Neither a simple question nor a simple answer.
It doesn’t sound like any of this is simple, actually. Probably why you’ve dedicated 35 years of your life to it and still haven’t ironed it all out!
Yes. The complexity becomes compelling. The outcome measure varies depending on your perspective. Another anecdote: if I am taking a medication for high blood pressure and my blood pressure is normal, the drug works. But if I stop taking the medication and my blood pressure is too high no one claims the medication does not work. They say I should be taking my medication. But if someone stops alcohol and drug use while in treatment and relapses to drug use when they leave treatment, treatment is said to have failed. It’s not fair. In both cases treatment should continue at levels required to support behavior change. This brings us back to a chronic care model for addiction treatment.
Which, it seems, is sort of what methadone clinics are for, yeah? What is the chronic care model for alcohol addiction?
Absolutely. Methadone is a chronic care model. The problem with methadone again is the way it’s delivered not the medication. One chronic care model for alcoholism is AA. The question is can we invent additional models?
Can we? Not is it within the realm of possibility, but more are the barriers in place to allow for that so prohibitive that it will never occur?
Sure. Let’s pay for internet counseling. Let’s use text messages and cell phones to support ongoing recovery. Let’s invent other strategies.
Ooh, those are awesome solutions.
Barriers are just problems that need to be solved.
Ha! I love you; you’re so optimistic.
The solutions are often in inventing new systems of care or new rules for care — New rule we pay for chronic care. Just looking at the opposite side of the coin or the glass half full.
Because it seems like the barriers are not just on a local level – but international too.
Yes international, national, state, local, and individual.
Where do you see addictions treatment in the US in 20 years?
The addictions treatment system as we know it today may not exist. Addiction treatment should be more fully integrated into health care. However, the addiction treatment system exists because health care does not want to address addiction and addicts so the separate specialty system may persist. Hopefully, the system is using more evidence-based practices, using chronic care strategies for those who need chronic care, and relying on medications to more fully address changes in the neurochemistry.
Why doesn’t healthcare want to address addiction and addicts?
Addicts are disruptive pains that don’t have real health care problems.
Medical professionals believe this?
Physicians and the healthcare system currently have little to offer addiction.
Isn’t it widely accepted that addiction is a disease?
They believe it. Addiction is a disease but most people still believe that it’s a result of weak will.
Even health care providers?
Yes.
What do you believe?
I believe addicts are a pain for the health care system. I also believe that they are real people struggling with an illness and need compassionate care. They deserve better than they are currently given.
Let’s talk about willpower for a second. Where does an addict find the willpower to seek treatment? What can we do differently to see to it that people who are born with the disease of addiction don’t get to a place where they’re addicted in the first place?
Good treatment programs offer hope. Women and men struggling with alcohol and drug problems need confidence in their ability to recover. Good treatment provides hope and structure to guide recovery. Addiction has both genetic and environmental causes. We have more opportunity to create environments that discourage use and support recovery than we have in changing the genetics. Strong policy that supports prevention and treatment is a good strategy.
I would love to talk about the national policy on prevention. I know that the national approach in the 80s was to increase the policing of borders and prosecution of drug traffickers. Is that right? What is it now?
Yes, the Regan Bush Bush regime emphasized supply reduction. The Obama administration is placing more stress on demand reduction — treating addiction.
That sounds like the correct order of things in my opinion. Didn’t DARE come out of the 80s?
DARE is a good example of practice driving policy without the guidance of science. DARE came out of LA in the late 80s as a way to get police involved with schools.
Why do you think DARE is the wrong approach?
Research shows it does not reduce drug use.
I see. Well, I think that’s it. Any final thoughts?
I wasn’t even lyrical in rhyme or song. Thanks for your interest in the issues of treatment and addiction:
The conversation can continue to unfold.
Who knows what stories are yet to be told
During the long walk from infant to old.
Sorry, that’s the best I can do.
It’s perfect. Thank you for your time, Dennis.
Thanks.
Dennis McCarty is head of the Health Services Division of Public Health and Preventive Medicine at Oregon Health and Science University. He’s invested over 35 years into studying addictions and addictions treatment. He works about 34 hours a day, 12 days a week, but does take a few weeks off every year to go bird watching with his wife Sarah in a remote area of the world.
This was a great interview, Gloria.
I love the airplane story that Dennis McCarty told.
Thanks for reading, Irene!
Yeah, it’s a good story. It shows, I think, that people want to connect with someone who understands. I’m sure this isn’t true of just addicts, either.
Okay, well, I bleated my bleat on “God-based” AA already in Toth’s piece. But I’ll re-bleat a summary:
I think the very attitude that it’s “God-based” is largely myth. I’ve never seen anyone in AA claim that they thought the most important part of recovery was making sure someone converted to Christianity or even any type of necessarily metaphysical higher power (certainly any particular religion) at all.
The notion that someone would let that stand in the way of their recovery hints at two things to me: First, a lack of creativity. AA never tells an addict what his/her higher power has to be. If an individual can’t come up with something other than Jesus Christ, AA’s not doing that to him or her. It’s more about humility and acceptance of life’s imperfections than a conversion. If an addict is more interested in maintaining pride and atheist cred than sobriety (the dichotomy is false, but for argument’s sake, let’s roll with it), again, the problem isn’t AA.
Second: It’s tough to suss out the genuine root of God-centered complaints. Addicts are, in large part, interested in making it someone else’s fault when their recovery doesn’t go the way they’d like or as easily as they’d like. I mean, addicts do specialize in blame-shifting. I’m sure it’s not always the case, but “AA’s too God-centered!” seems like a tidy excuse to me.
But one thing AA does do, I should point out, is offer a lifetime support/care/intervention program and stable network that any person can walk into just about anywhere in the world.
I mean, that’s in place. And 100% volunteer. Which is pretty inexpensive.
I’m utterly biased, since my dad is 35 years sober in AA as of this year and I’ve been immersed in that culture, that particular philosophy of addiction and recovery (and life, really) my whole life. Enough to consider myself an expert by proxy (even if from an outsider perspective).
Don’t make me go get my army of old drunks! 😉
“I bleated my bleat…” That’s the funniest phrase. I love it.
I agree with everything you say, Becky. I mean in this comment. Not, like, in the history of the world.
As you and I have discussed, AA gets a couple of things super right – like not shaming recidivism. Practitioners don’t always even offer that.
Interesting interview, Gloria. Very thought-provoking stuff.
The sensitivity of the subject matter is likely such that people who have been through various treatment and recovery programs might be reluctant to chime in, but if this inspires people towards more solution-oriented discussions of the problem, then it can be immensely helpful.
I agree, Joe. That’s what inspired me to want to chat with Dennis in the first place. I’ve had many opportunities to discuss this work with him and his team, and I’ve always walked away feeling that people should know about this! It’s tremendously inspiring. It makes me want to go out and do shit! 🙂
I appreciate you reading.
“In both cases treatment should continue at levels required to support behavior change. This brings us back to a chronic care model for addiction treatment.”
Exactly. I see those commercials for Passages, the Addiction Cure and I want to throw something at the T.V. They don’t believe in the “disease model” of addiction. It needs to be treated like a chronic condition. Doctors have to deal with patients with chronic illnesses who are non-compliant with their meds and follow up appointments all the time. They don’t give up on them and the continue to treat them. Addicts should be treated the same way.
That said, I admire Mr. McCarty and his passion and resolve. It’s issues like this that test my political leanings and (sorry the election is tomorrow and all this crap is on my mind) makes me angry there are only two major party options. I am fiscally conservative and socially liberal. Where the two meet, welfare and addiction treatment as two examples, well, I’m just glad I’m not someone who has to figure out how to pay for it all, especially given the current state of things economically. But we can’t just brush aside an entire section of the population because they are, as some see, too weak-willed to be contributing members of society.
So much reform and innovation is needed. It’s sad to think that those with the power to green light possible solutions are so jaded and exhausted at money being poured into problems that they probably wouldn’t approve funding. The private sector needs to stand up and take point on social issues like these.
Great interview, Gloria!
Damn. My apologies, Dr. McCarty, not mister.
(Pssst… You can just call him Dennis. I once made the mistake of calling him Dr. McCarty and he said, “Well gee, Ms. Harrison, we’re very formal this morning. 🙂 )
This crap is on my mind, too. Speaking of which – I’d better vote! My ballot is due tomorrow!
The private and the public sector alike need to step up and take point on this issue, imho. And, yes, others as well.
I appreciate your thoughtful comment, Sarah. Thank you so much for reading.
Really great stuff, Gloria. Dennis, if you’re reading, thank you for both the time here and the work, well, everywhere.
Thank you, Anon – for your comment and for your question. I appreciate it.
Okay, I have a question.
Dr. McCarty, you question whether or not we want people without advanced degrees treating addicts, but coming from the background I do, I can’t help but wonder whether or not it matters who addicts want helping them?
Given my upbringing, it will come as no surprise that my impression of addiction recovery at its most successful is that it involves community, and a sense of camaraderie on a level that isn’t particularly necessary with regard to drug-based or even group therapy treatment of other physical or mental illnesses.
There is, of course, something unique about addiction, hence its fruitfulness as an area of expertise and research. It is not quite a physical ailment, and it’s not quite a mental illness. It’s both or neither. Or something. It’s addiction.
Regardless of what a person with an advanced degree might bring to the table at a theoretical level, it strikes me that addicts are more comfortable talking to other addicts, more comfortable accepting the advice of other addicts, etc. That recovering addicts can identify/sympathize/empathize in a way that a person who has never been an addict simply could not. There’s a certain humanity in not being a patient or a formalized object of clinical treatment by a perceived white coat, plainly.
This isn’t necessarily a dichotomous problem, but of course, being an addict has a way of interfering with one’s schooling in many cases. I guess what I’m asking is whether or not there is a necessary or even likely conflict in pressing for advanced degree requirements (and hence, a certain amount of exclusivity) among chemical dependency counselors and giving addicts one of the things they most need to feel comfortable and understood in the recovery process–that is, the presence of trusted, established people in recovery who are also in positions of authority.
Becky
Thanks for your passion and interest.
I agree that it is helpful speaking with others who share the experience of alcohol and drug dependence. I should have added more context. I think that women and men struggling with addiction also need help from the best practitioners available. For too long the field has accepted less. If state regulations require graduate degrees to provide counseling for mental health problems, and medical degrees to provide health care, we should apply the same standards to treatment for alcohol and drug use disorders. To be a bit silly about the issue, Gloria has three children but she isnt an obstetrician. Consumers should demand the best.
I’m not?
**puts away speculum**
Well, of course, she isn’t an obstetrician.
Then again, a lot of women choose midwives and doulas, too, and have all kinds of babies with no obstetrician in sight.
I mean, not all at once or anything. Usually just one baby at a time. Maybe two.
That’s a rhetorical technicality, but all kidding aside, the point remains. What I’m asking, I suppose, is whether you think addicts should have those advanced-degree resources available to them or if they should be the only resources permissible.
For various political reasons, we dare not impede a woman’s right to choose who helps her have a baby, but do addicts get the same choice?
The flip side, of course, is that a lot of addicts’ first impulse upon staying sober for some period of time is to try to help other addicts. I don’t know what the requirements are now, but back when I briefly considered becoming a chem dep counselor, it was a two-year certification with the potential to go on to higher levels of education and with the following unique stipulation:
Minimum two years active sobriety.
I mean, that tells me that a LOT of recovering addicts look to helping other addicts not just as a good deed or means of self-improvement but as a means by which to begin reconstructing their own lives, make something positive out of the time they spent as an addict, head out on a career path in a field they are passionate about, that will be rewarding to them, etc.
These strike me as positive things to do in the course of recovery.
I mean, the more years of school and minimum degree requirements you heap on there, the more inaccessible that kind of constructive potential becomes, except to the most bourgeois of addicts.
(I might as well just say now that higher education is another one of my ideological hang-ups.)
I mean, certainly there are plenty of other career opportunities in the world. It is not as if chem dep counseling is the only thing every recovering addict wants to do, but I sense a bit of a catch-22, damned if you do or don’t scenario.
That is, to an addict who wants to make a career out of helping other addicts, an advanced degree mandate could be considered a roadblock.
I’m no obstetrician, nor a midwife, but I’ve attended a LOT of births.
One thing you have to stop and consider in the comparison, is that when I attend a birth, I am in no danger whatsoever of becoming pregnant or miscarrying.
When you put a newly-sober/clean/dry addict with only the BEST intentions into the position of trying to help other addicts, you face the very real danger that the counselor will find him/herself sucked right back in.
Instead of medical practitioner, use the analogy of two exhausted, drowning swimmers. Better for the one who reaches the boat first to let one of the fresh and rested crew jump back in after his brother, than to immediately throw himself back into the water.
Not every recovering addict is an “exhausted, drowning swimmer.”
My dad has been sober 35 years, sponsored dozens of individuals, and never slipped once.
So have countless people, including those who go into recovery professions.
I don’t know where you get the notion that recovering addicts are so feeble and fragile. In a lot of cases, they’re remarkably strong individuals, even more so for having gone through recovery.
They have to be vigilant, sure, but it doesn’t mean they’re going to catch a relapse from talking to another drunk. If that were the case AA would NEVER work.
It’s not the flu, for godssake.
Like, look. I get what you’re saying. Fresh-on-the-wagon, still-floundering individuals should not be saddled with the responsibility of helping to ensure others’ sobriety as well as their own.
But if at 4 years sober you can’t offer a little helpful advice to a fellow addict without immediately relapsing, your problems are bigger than your addiction.
The social, aspect, however, is worth mentioning, particularly in advocacy of community models of recovery.
Because of course, when you get pregnant or get cancer or are diagnosed with schizophrenia, you’re not generally encouraged to quit hanging out with most of the people you know and quit doing almost everything you used to do in all of the places you used to do it in. You don’t have to re-learn every single aspect of your life.
When you’re a drunk, for example, you tend to hang out with people who drink. When you decide to sober up, you’re encouraged to leave those people behind. So there you are, potentially with no one who doesn’t drink or use still talking to you, which has the potential to cause both loneliness and boredom, two big triggers for relapse. So at least if you have a social community of non-drinkers, there is some salve for the cure. A cure which stings on more levels than just the discomfort of wanting a drink. The social aspect is indeed what sets addiction apart from physiological or mental illnesses, but I think it’s an argument for, not against, getting people with similar goals and challenges in the same room.
People who are compulsive, addictive personalities can offer the empathy of personal experience.
And while that’s possibly quite valuable, it’s also the crux of the worst problem with it.
Part of being a caregiver is being able to abstract YOURSELF out of the situation. That is, if you are going to be doing it for more than, say, a year.
The folks that can’t, burn out of it like bottle rockets. And that doesn’t really add to the positive balance, in the overall sense. Sure, they might help one or two people, but they lose it.
The other part of highly compulsive, addictive personalities is that the desire to help so easily turns into zealotry. It’s simply the next higher expression of their disorder.
Does that argue against ever letting addicts talk to one another, lean on each other a little, etc? No, of course not, but you will attempt to paint it that way.
Please try not to stretch my point like a bit of soft taffy, to an extreme, until it inevitably breaks. Obviously there are as many exceptions to the rule as there are exemplars of the rule. Other folks have drunk dads too. I was burying mine when you were in diapers.
There are other career choices for a recovering addict. Author, for instance.
I’m not sure it’s entirely a caregiver situation.
Even people who sponsor others in 12-step programs don’t interact with them constantly. The go about their lives, do their things, offer to pick up the person they sponsor for meeting on Thursday. It’s not hospice.
And sure, it’s not for everybody. Not every addict is alike. But the nice thing about a situation like AA is that even the sponsor has a sponsor.
No one is an island. Everyone has someone watching their back.
The person that has been in the program so long that s/he no longer has a sponsor–like, their sponsor has died–is probably sober long enough to be at significantly reduced risk for relapse.
Don’t try to predict what I’m going to do, dwoz. I amended/extended my response to indicate that I understood what you were saying and explain more closely what I meant. Without editorial capabilities it was the best I could do to soften my initial response.
The fact that we have alcoholic fathers in common is just that. If you want to pretend it’s a competition, go for it, but I’m not really interested in playing.
there’s a role for everybody. As you say, a community of caregivers. And I really have no interest in playing the “my father died a more pathetic and meaningless death than yours did” pissing contest. Its boring. I cannot muster even a shred of inspiration to write about it.
My dad is still alive.
He just went back to school for CAD drafting. At 68. His life has been about as far from meaningless as it gets, in large part because of AA. He got help, and then devoted his life to helping other people. I’ve been talking about that the whole time, I’m pretty sure.
That’s not pathetic dwoz. It’s admirable. And kind and brave.
I don’t know why you say a community of caregivers like it’s such an awful thing. No more so than any community that cares for and watches out for one another.
I think that this is a very sensitive area in which many people have experience and maybe we should all be a little compassionate towards each other.
I think there is room for all opinions here. Nobody knows for sure what works for one person and why it doesn’t work for each other.
Dwoz and Becky – I’m sorry that you both had to experience this.
My heart goes out to you both.
Thank you, Zara. Well said. I agree.
Dennis is available to answer questions. He’s not an AA expert at all (which he is quick to tell you), but if you have a specific question about treatment and successes, he may be able to answer that!
Okay, well, I have failed to be clear, I guess.
My dad has been sober for 35 years. I am only 32. I didn’t go through much of anything with regard to his actual drinking. My dad was sober before I was born. I was born, arguably, because he got sober.
What I have experience with is AA culture. My dad’s been very active in it my whole life. Talked openly about it to his kids, what it was, what it entailed, answered questions when we asked. I heard him talk on the phone for hours with people he sponsored, went to meetings with him here and there if they couldn’t find a babysitter.
I mean, just immersion in that community as a child of a person in recovery. I picked up a lot by osmosis.
Wait a minute.
Y’all thought I was older than 35?
I would like to state for the record that I, at no time, accused Becky of being 35. Which, as we all know, is the true mark of the beginning of the end (youth) or the beginning of the beginning (middle age) – and I should know, as I will be 35 in six months. **hobbles off to find cane**
I have to get off the comp because my knee is swelling and I have to put my leg up. According to the screws in my tibia and femur, the weather is fixin’ to change. *hobbles off in other direction*
@Zara…
not to worry, my dear. That whole father thing, for me, has been put to bed for years and years.
@Becky – No! I did not think you were older than 35! I am just very very bad at maths. I think your dad is amazingly strong. Well done him!
@Dwoz – I’m glad to hear. It’s still hard though and I’m sorry you had to live through it.
I’m not taking sides in the “been there done that” therapists versus the “extensive training” therapists, but for me it raises some issues.
I had a couple of friends on the alcohol counseling business. One had a graduate social work degree of some kind, and the other had only an BA. The guy with the BA had personal experience with being an alcoholic, and the grad degree person did not. They worked for the same County detox center. I was never a client of either, so I can’t say anything about their abilities and how effective they were as therapists, but I do know that neither ever criticized the other, in my presence anyway.
My friend with the advanced degree was a great supporter of a third counselor, a guy I never met. He didn’t even have a college degree. He was very good, she said, but dropped out of the program in fear of a certification test that he didn’t think he could pass. She thought it was a great loss.
Dennis, I don’t propose arguing the merits of these three kinds of counselors, but I’m interested in hearing how a situation like this would look from an administrator’s perspective. In the real world of regulations, civil services, and public images (fair or unfair), do you think an agency could ever hire counselors on a case-by-case basis? Or do you think that it’s just not something that can happen? Maybe there’s so much state-by-state variation that there’s no general answer to my question.
But I’d still like to know what you think.
Don
As you can tell from the discussion, there are no simple answers. From an administration and policy perspective the issue isnt who is a better therapist. You can have a doctoral degree and be a poor therapist. You can be a person in recovery and have natural talent for helping others.
Regulators dont have a measure of natural talent so they rely on training. The value of training is that individuals learn about standards of practice, record keeping, ethics, and more importantly addiction counseling is placed in the broader framework of science.
Graduate school expects therapists to understand the science of addiction treatment. The science has evolved substantially since the early 1970s. Research documents that confrontation (“You are an addict and you are going to die an addict if you dont change!) is less effective than showing empathy and drawing out the individual with motivational interviewing. Therapists with more education are more supportive of the use of medications to treat alcohol and drug use disorders and more open to the use of contingency management to support early recovery. Consumers (patients and their families) should be demanding the best treatment based on the latest science.
One more dimension is important from an advocacy perspective. A 2006 paper (Kerwin et al. Journal of Substance Abuse Treatment, 30, 173 – 181) found that 47 states required a master’s degree to provide mental health counseling services compared to 3 states for addiction treatment and four states had no degree requirement. Is the implication that addiction is simple to treat and does not require training? I think the real message is that addicts are beyond help and it doesnt matter if you have training. For me, that standard (addicts are beyond help) is unacceptable. Addicts and alcoholics need highly skilled therapists.
By accepting untrained therapists the field also creates an unstable workforce. A national study just reported that addiction counseling centers average a 25% turnover in counselors. The primary reason for turnover is low pay. As advocates and consumers, we need to demand better trained counselors with better salaries so the good ones continue to work in the field.
Finally, there is one more twist. If national health care reform continues, the primary payer for addiction treatment will be Medicaid. Most Medicaid plans will only pay for services delivered by licensed therapist with master’s degrees.
Graduate training should be the expectation for the field. Women and men in recovery can complete graduate school and be both in recovery and have a master’s degree.
The expectation is not reality but its what I advocate for.
I take your point about how regulators don’t have a measure of natural talent.
” . . . found that 47 states required a master’s degree to provide mental health counseling services compared to 3 states for addiction treatment and four states had no degree requirement.”
I’m reading this as “only 3 states required a master’s degree for addiction treatment.” Is that right? I couldn’t get access to the article online, unfortunately.
Even though I’m coming from ignorance about what’s required/permitted, I’m surprised — and I can see why you’re pushing for it.
I’m very surprised about that 25% turnover rate. I can’t imagine trying to run a center with that kind of turnover, never mind being a client who’s doing well with a particular therapist only to learn that he or she has left.
Well-done. Good to see your writing again, Gloria 🙂
Mama Carol!!! So nice to see you, lady. 😀
This is a fantastic interview. Great job to Gloria for the thorough questions and to Dr. McCarty for his thorough and engaging answers. I don’t have a lot of background or experience to draw from with regard to addiction treatment, but I’ve been interested to read Paul A. Toth’s points and now this.
I didn’t know there were international guidelines to what constitutes an illegal substance. I’ve never considered the likelihood of increased addiction problems if marijuana were made illegal, but even if that were true I still wonder if the crime and violence associated with selling pot on the street aren’t still worse for society overall.
Thanks for reading, Richard. I’ll see if I can get Dennis to touch on the last part of your comment. You make a great point.
Richard:
Will legalization of marijuana reduce crime? That’s a good research question. The hypothesis has not been tested. I am not aware of any definitive research.
The Dutch stuggle with the issue. They have effectively decriminalized possession by not enforcing current prohibitions. But the consequence is a growth in organized crime in the production and distribution. The Netherlands (according to the police officer I spoke with this summer) is now the leading supplier of marijuana to Europe. They are also concerned about increased use of marijuana among adolescents (rates are now above other European countries).
This is an imperfect example because the Dutch have not legalized marijuana but I think it helps illustrate the complexities. Crime is not going to stop. It will shift. The criminal enterprise is very entreprenurial and creative.
Nonetheless, I also concur that too many individuals are incarcerated and many need treatment. Policy makers struggle to find a balance.
Yes, I agree with Richard this is a fantastic interview.
I love that you tell him you love him in one of your questions.
“Yes, I agree with Richard…”
Jessica Anya Blau is awesome.
Thanks, Jessica. Yes, I love Dennis. Not only is he an amazing research scientist but, as a person, I think he’s fairly neat-o.
By the way, NOTHING would make me happier than to see the D.A.R.E. program fade away. As I saw the program, it had a primary goal (one of several) to place the police in a position of eliciting actionable testimony from children against the activities of the parents in their own homes. Aside from all the fifth amendment problems there, it pre-empted any chance that you could design a meaningful and reasonable dialog on substance use with your kids.
My own anecdote on the subject is my school friend who’s dad was a state cop. Kid goes to college, and goes NUTS, because he just never got any real, reasonable education about drugs and alcohol. He never understood boundaries, personal or social, he never internalized a sense of normalcy about the presence of drugs and/or alcohol in his environment, and so he utterly lacked the personal tools to deal with these things when he finally had to. Myself, and a large number of my cohorts by contrast, had a “normalized” relationship to these things, and so I understood WHY I shouldn’t drink 3/4 of the bottle of bad vodka at one pop. I understood WHY I had to practice moderation and situational awareness of substance use.
D.A.R.E. takes all that away. its just like abstinence as sex education. Sexual Abstinence Education seems like a good idea that unfortunately happens to produce LOTS of teen mothers.
dwoz – I agree with all your points about DARE. I’m not sure I agree that we should “normalize” drug use, but we should, maybe, show kids that it does exist and teaching moderation in all things is a good idea.
Thanks for your thoughts!
Just to make sure I’m not misunderstood. I don’t mean normalize, as in, make it part of our daily lives, but normalize, as in, make our understanding of it normal.
An analogy would be to “normalize” driving on icy roads. Meaning that I take my new student driver out into a big icy parking lot, and let them feel what “the car is letting go” is like, and develop their ability to cope with a sudden loss of control. Teach how to steer through and recover. Show them how the brakes become useless AFTER you’re already out on the ice.
Same with substance use. Just because I’ve “normalized” myself to driving on ice, I certainly don’t go looking for ice to drive on. But when I find myself in that situation, (and I WILL…) I have tools to deal with it.
What a great interview Gloria!
Dennis, you did a wonderful job and I admire your passion.
I agree that a lot has to be done to change the way America views drugs and addiction but it has to start somewhere and you, Dennis, are doing fantastic work!
Thank you, sweetpea. I appreciate your thoughts and comments. You know this, though.
I loved this. Especially the thoughts on a chronic disease management approach to helping people in recovery. Great interview.
Thanks, T-money!
I’m glad to see this came together so well, Gloria. Your suggestion of adopting a Dr. Seuss methodology was just this side of genius. It’s interesting to me, and I’ve seen this happen numerous times, when a group has the opportunity to ask questions of an addiction specialist, we seem to expect answers when we might more realistically expect further-honed questions. Why do we use the penal system to warehouse addicts instead of attempting to treat them? Well, I dunno, why do we have a century of faith-based public policy borne on the back of political cowardice and propaganda? Fascinating stuff that could be debated endlessly. Thanks to you and Dennis to an intelligent discussion.
I was going to suggest iambic pentameter, but there was no way I was going to edit that! 🙂
Why do we have a century of faith-based public policy borne on the back of political cowardice and propaganda? I mean, I know some of the answers, but this is a topic I can discuss endlessly. Epistemology of anything gets my fires burning.
Your question(s) was good, though, Sean. Really thoughtful and thought provoking. It’s the type of thing I’d love to sit around with you and Dennis drinking beers and discussing. The irony of the beers alone would make it fun. (For the record, I’m pretty sure Dennis doesn’t drink beer. He calls my morning coffee my “drugs.” 🙂 )
Thank you so much for your comments.
I’ve seen a few treatises on why cannabis is illegal. There seem to be several emerging themes, a few economic, a few racial/racist, and not a whole lot medical.
First off, hemp is a serious competitor to cotton. The southern textiles industry saw it as a threat.
Secondly, as a commonly-available intoxicant, it was a direct competitor for distillery/brewery products. Again, a threat to an entrenched market.
Thirdly, there was an up-swelling of puritanical political will against all manner of intoxicants at the turn of the century. (drugs like laudanum, cannabis, alcohol.)
Fourth, a racial aspect. Cannabis was common in the Mexican population (California, Texas, and most of the southwest were only recently parted from sovereignty to Mexico at the time), and the black ex-slave population, because it was dirt cheap. Criminalizing it put a law enforcement tool into the quiver of the anti-assimilation movement.
I was going to write “fascinating stuff,” but Sean beat me to it. Between this and the education system the country has a lot of work to do in the years ahead…
Great job, Gloria.
Thanks, Greg. I debated whether I should follow your interview with an interview, but I’d finally finished it! You know the time-sink interviews are. (But so worth it in the end, in my opinion.)
I appreciate your thoughts, sir.
Great interview, G. And thank you, Dennis, for your insight into a topic that is fraught with all sorts of socio-political-religious-emotional baggage, not much of which is useful.
I wish I had something more intelligent to say on the subject, but at this point I am at a loss. I think the policy approach is interesting, and I’m all for evidence-based practice, but I am not optimistic at this point for any rational policy-making in the field of addiction treatment. Post-mid-term election blues, maybe. Living in Texas, where the majority of school districts still teach abstinence-only sex ed (then they bother to teach it all – I heard of one rural school board member in a ranching community who responded to a Freedom of Information Request regarding sex ed that they didn’t need to teach it because the kids around here can just watch the cattle do it and “they’ll get the idea”), the entire concept of a rational approach to either drug treatment policy or incarceration issues seems like a distant dream. Keep fighting the good fight and hopefully some of that common sense will trickle down to TX.
I get that you’re not optimistic, Cheryl. I get why, I mean. You and I once had a conversation about the good work scientists and researchers are doing – the counter-curses. Lovemongers.
There is a good fight.
Thanks for reading and for your comment.
So sorry that Austin is in Texas. 🙂
Oh stupid Texas – and yet I love this state. You know my work – I’m in the fight. Every day I work to promote rational approaches to all kinds of complicated issues. The mid-terms took a bit of the wind out of my sails, so I was licking my wounds the day I commented. Texas’ returns were even more dire than predicted, at the state level. And now the lege is filled with more of the same kinds of people who hijacked the state board of education last year. The same board that passed a resolution requiring that there be more positive mentions of Christianity than Islam in textbooks. And made Thomas Jefferson a footnote in Texas history books. And… and… and… frustrationcakes.
Lovemongers!
LOVEMONGERS!
Gloria and Dennis, this interview tells me more, concisely and straightforwardly, about addiction and treatments than I’ve ever read or heard. You two hit a humane, informed, entertaining and seamless stride of ask/answer/respond, not wasting a word or a beat. I’m so grateful to you both.
Let us stimulate President Obama to name Dennis McCarty to head a national alcohol and drug rehabilitation and treatment research/action group.
Thank you for your comment, Judy, and for your suggestion, which I passed on to Dennis. He said something to the effect of: I wouldn’t live in D.C. if it were the last… I can’t remember the exact quote. 😉 I agree, though. He’d be good.
😉
One can hardly blame him, Gloria.
However, please mention to Dennis that since he has dedicated 35 years to the cause, he can dedicate a couple years to spearheading it in Power City, which, as it happens, has no incessant rainfall such as he has grown accustomed to, and it has, as well, the marvelous advantage of horrid humid heat each summer and sudden inundations of traffic-stopping snowfall in winter. These are perks that come with the assignment.
If that information fails to move him, do tell him that he “owes it to us” (letting him figure out who “us” is)!
Lucky you, knowing Dennis!
I appreciate this article coming at this time. I work with a guy whose family are in Humboldt county and he really opened my eyes to a side of the cannabis issue I hadn’t thought about before. For what it’s worth, it has all made me a more thoughtful voter.
It’s worth a lot, actually. I’d be interested in hearing your new found perspective – here, preferably, but if not, off the board then.
Hi Elaine!!
Hi Gloria/Dennis,
My personal experience with addiction is primarily nicotine, and I’ve gone through a number of modalities in my attempts to quit – it’s a horrible, insidious thing, nicotine addiction, and it’s something I’ve seen in myself and in others close to me. I’ve seen and known people with alcohol and drug related addictions, and a number of my friends are in the psychological community here in Australia, on point, as it were, with some fairly damaging situations, and we often talk about their frustrations with the lack of a system that engages with, supports, and provides ongoing treatment to addicts and those suffering the consequences of addiction. Thank you for this interview, and for your work.
I agree that nicotine addiction is a horrible, insidious thing. I do well, I do well, I do well… then I fall off the cliff. 🙁 Sorry it’s been such a struggle for you.
Thanks for your thoughts, Simon. Here’s to hoping for and working toward “a system that engages with, supports, and provides ongoing treatment to addicts and those suffering the consequences of addiction!”
Great interview, Gloria! Just now getting around to reading it. Instead of gaining an hour, it feels like I’ve been losing an hour every day for at least the last two weeks 😉
You know, Cynthia – I get it. This is the worst time of year. It feels like a timewarp. It’s just a jump to the left…
Thanks for reading, lady.
Finally read. I do like the part about chronic management. Particularly where 28 day rehab and off you go are the norm.
Interesting interview, Gloria! (Sorry so late to comment – I’m not sure where I was in early November. Possibly in an institute?) MMJ is quite the issue here in CO, as well. And actually, we have a town nearby us (Nederland) in which marijuana (medical or not) is considered legal. To sell, to smoke… Anyhow, I like his emphasis on addiction recovery. It gives me hope for this medical system of ours..
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nicotine and alcohol addiction can make them sick physically and mentally.