Substance Use and Eating Disorders
Winter 2007, Vol 6, Issue 1
A. David Wall, PhD, Marian Eberly, RN, MSW, LCSW, DAPA, and Kevin Wandler, MD
Remuda Ranch Programs for Eating Disorders
In Romans 7, the Apostle Paul said: “I have the desire to do what is good, but I cannot carry it out. For what I do is not the good I want to do; no, the evil I do not want to do—this I keep on doing.” This summarizes the experience of many who fight addictions. Indeed, addiction is a common human experience.
Twenty years ago, addiction meant alcohol or drugs. Now the literature describes addictions to sex, gambling, shopping, food, exercise, the internet, anger, and work. Ten years ago, dual diagnosis usually referred to someone with alcohol or substance use who also had depression or anxiety. Today we talk about co-occurring diagnoses, where many psychiatric disorders occur simultaneously.
Blinder et al. (1998) reported that 26% of eating disorder (ED) patients have co-occurring substance use disorders (SUDs). At Remuda, where acuity is high, 40% of ED inpatients have SUD. Nearly 90% of Remuda’s ED patients also have co-occurring depressive and 50% anxiety disorders. One might think that patients with anorexia would more likely use stimulants to reduce appetite, while those with bulimia would more likely use alcohol and marijuana to deal with emotional chaos. But data show almost equivalent drug choices among patients with anorexia, bulimia, and ED not otherwise specified (EDNOS). This suggests that ED patients are choosing drugs for reasons beyond the ED itself—likely the same range of reasons that drive most people to addictions.
Substance abuse and dependence diagnoses differ. DSM-IV defines substance abuse as a maladaptive pattern of substance use within a 12-month period that leads to clinically significant impairment or distress. The criteria include: any failure to fulfill major role obligations, such as work; use of the substance in ways that are physically hazardous, such as driving under the influence; legal problems; and/or continued substance use despite persistent and recurring problems, such as family conflict surrounding the use of substances.
According to DSM-IV, substance dependence involves the same 12-month timeframe as substance abuse, but more extreme impairment. For example, important activities are given up or reduced, and/or significant time is spent obtaining the substance or recovering from its use. With dependence there are also criteria reflecting loss of control: e.g., larger amounts used over a longer period than intended, persistent desire or unsuccessful efforts to reduce or control use. When tolerance or withdrawal symptoms occur, the diagnostic specifier, with physiolo-gical dependence, is added. Tolerance means needing a significant increase in consumption to achieve intoxica-tion or desired effects. Withdrawal involves a syndrome of physical and psychological symptoms following abrupt discontinuation or rapid decrease in substance intake.
The American Society of Addiction Medicine and American Psychiatric Association agree that therapies need to be individualized to specific patient needs and adjusted based on patients’ responses to treatment. Detoxification is not a substitute for treatment, but is one component of a comprehensive treatment strategy. According to the American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Substance Use Disorders (American Psychiatric Association, 2006), SUD treatment programs should diagnose and treat associated psychiatric disorders. As such, many SUD programs are prepared to treat co-occurring depression, anxiety, trauma, Axis II, and certain other issues that frequently occur in SUD populations. However, many SUD programs are not equipped to offer the intensive monitoring needed by patients with anorexia and bulimia. Often, when patients with co-occurring SUD and ED begin SUD treatment and stop using substances, their ED intensifies. Most SUD programs are not set up to manage these patients, who begin bingeing, purging, and restricting food. Similarly, when patients with SUD and ED enter ED programs and reduce their ED behaviors, their cravings for substances intensify. Yet according to the American Psychiatric Association’s Practice Guide-line for the Treatment of Patients with Eating Disorders (Yager et al., 2006), concurrent treatment for ED and SUD should be attempted, since these patients they have a range of medical complications, require longer inpatient stays, and are less compliant with treatment.
Because of ED’s complexities and significant medical sequelae, we believe that most patients with co-occurring ED and SUD are best managed in inpatient ED treatment facilities that offers detoxification services. At Remuda, we treat ED and SUD together in safe, intensive programs. Because of their interaction, the detoxification and ED issues need to be addressed simultaneously. Treatment teams at such facilities should include at minimum a psychiatrist, primary care provider, dietician, family therapist, 24-hour nursing, and a therapist skilled in cognitive-behavioral therapy (CBT).
Remuda’s post-discharge outcomes suggest that among patients we treat with co-occurring ED and SUD, 95% are in good ED recovery and 67% report complete abstinence from substance use at one-year post-discharge. This 95% ED recovery rate is substantially higher than the 50-75% one-year recovery expectation in the field (Richards et al., 2000). Likewise, the 67% substance use abstinence rate appears higher than the 25-50% one-year abstinence expectation for those who have completed a residential chemical dependency treatment program (Substance Abuse and Mental Health Services Administration, 2005).
Biological Considerations
Most people exposed to addictive drugs do not become addicted or dependent on them. Evidence suggests that the likelihood of addiction, especially to alcohol and nicotine, is strongly affected by heredity. Greater vulnerability to alcohol abuse, for example, has been identified on the A1 allele of the D2 dopamine receptor gene. An additional 20+ receptors are being studied to understand the genetics and possible treatment options for those with SUD. Clearly, the physiological effects of addictive drugs on the human body and brain are partially engineered by each person’s genetic code. How a person responds physically to a drug also involves setting, mood, previous use experiences, and social/peer influences. We discuss these factors later.
Most drugs of abuse release dopamine and other chemicals that produce pleasure. As tolerance builds, drug dependence is further reinforced, because more of the drug is needed to obtain the same effect. Neurons in the brain change—possibly permanently. Cocaine, nicotine, alcohol, amphetamine, and cannabis all release dopamine in the nucleus accumbens, a brain site producing neuronal reinforcing effects. After detoxification, addicts’ brains may be permanently altered, sensitizing them to relapse.
Our brains seek balance or homeostasis where we feel good. When our bodies need something to maintain homeostasis, we experience unpleasant feelings. Dopamine is a neurotransmitter associated with pleasure. Studies suggest that individuals with substance abuse problems have fewer dopamine sites and, thus, possibly need more dopamine. Many street drugs increase dopamine levels. It is believed that this abnormal need for dopamine makes individuals more prone to SUD. There is also some evidence that repeated drug use may decrease brain dopamine sites, exacerbating the need for dopamine.
Individuals with attention deficit/hyperactivity disorder (ADHD) are prone to SUD. Those with ADHD have brains that are congenitally under-stimulated. Thus, they seek stimulation to bring about balance. It is likely that individuals with ADHD self-medicate through SUD. Appropriately, medical treatment of ADHD involves stimulant medications. Individuals with anxiety disorders also have an elevated SUD risk. In this case, substances are used to reduce anxiety. Because substances can do this quickly with little effort, SUDs are readily reinforced.
The drugs we primarily see at Remuda include nicotine, alcohol, marijuana, cocaine, and amphetamines. Opiates, hallucinogens, solvents, and designer drugs like ecstasy are not common in our treatment setting and will not be discussed in this article, though many of the treatment principles are the same.
Whether legal or not, prescribed or not, all addictive substances must be carefully reviewed by a physician to obtain the information needed to treat the individual properly. At Remuda, a psychiatric provider includes lab results to determine whether to begin detoxification according to evidence-based protocols.
Nicotine
When offered a chance to quit smoking, most of our ED inpatients refuse because they believe they can only deal with one addiction at a time. In their perception, smoking helps with their anxiety. Many also fear weight gain following smoking cessation. There appears to be con-vincing evidence for the association between smoking cessation and weight gain, but the actual mechanisms are not well understood. We do know that weight gain is related to a decreased resting metabolic rate following nicotine cessation. Nicotine Replacement Therapy (NRT) appears to be effective in delaying post-cessation weight gain with nicotine gum being particularly effective. The post-cessation weight gain for women is generally 10 pounds in the first year, even if they do not eat more.
With nicotine withdrawal, initial symptoms include anxiety, increased appetite, nicotine cravings, irritability, frustration, anger, decreased heart rate, restlessness, and concentration difficulties. These symptoms begin within 4-24 hours. When patients choose to stop smoking, an individualized program may include NRT, such as nicotine patches and gum, plus cognitive-behavioral therapy and clinical support. With ED patients, it is important to directly address weight gain fears as part of smoking cessation interventions.
Alcohol
Alcohol is generally avoided by those with restricting anorexia because it contains calories. However, in individuals with anorexia nervosa, binge-eating/purging type, and in those with bulimia, alcohol is frequently used and then purged.
Alcohol is a sedative. Many ED patients start using alcohol to self-medicate anxiety. In low amounts, alcohol calms the nerves and creates disinhibition. Over time, it takes more alcohol to potentiate the anxiolytic effect, such that self- medication can become alcohol dependence.
All patients admitted to Remuda with alcohol dependence and some with alcohol abuse are placed on an evidence-based detoxification protocol. Detoxification is not a substitute for treatment, but is one component of a comprehensive treatment strategy. The long term consequences of alcohol abuse/dependence may not be known for months. Mild mental confusion, common in the first weeks of detoxification, may be prolonged in severely malnourished ED patients.
Cannabis
Cannabis, commonly known as marijuana or pot, is the most commonly used illegal drug in the United States. It is likewise the most commonly used illegal drug among Remuda’s ED patients. Nevertheless, cannabis is seldom used by our patients with anorexia because of its known appetite-stimulating properties.
Cannabis can cause undesirable side effects, increasing with high doses. Side effects may include dry mouth, red eyes, increased appetite, impaired perception and motor skills, decreased short-term memory, paranoia, mood swings, and hallucinations. The degree of and reaction to these side effects varies across individuals.
Fortunately, medical detoxification is not needed for cannabis cessation. Supportive interventions for headache, malaise, and sleep disturbance are indicated. If cannabis users also smoke cigarettes, cannabis relapse rates are higher. Therefore, such patients should be strongly urged to give up all smoking or they are apt to impair their recovery from cannabis abuse.
Stimulants
Stimulants are often used by ED patients for weight control. Stimulants described here include illegal amphetamines such as methamphetamine (“crystal meth”) and prescriptive amphetamines such as Dexedrine®, Adderall®, and Phentermine (the phen in fen-phen). Cocaine and crack cocaine also fall into this general class. Nicotine and caffeine both have stimulant properties, but not to the same extent.
Amphetamines and cocaine are appetite-suppressing drugs. Although those with restricting anorexia generally do not use them because they are able to manage their appetite without drugs, these substances of abuse/dependence are used frequently by patients with bulimia. A patient with bulimia will often use them following a several day binge, to curb appetite and to resume restrictive ED behaviors.
Stimulant withdrawal signs and symptoms include aches, pains, anergia, increased appetite, drug craving, anhedonia, depression, chills, tremors, and hypersomnolence. No medications have demonstrated efficacy for detoxification from stimulants, but fortunately there are rarely life threatening symptoms. Medications that have been used to treat symptoms of stimulant withdrawal include tricyclic anti-depressants and short-acting benzodiazepines such as lorazepam.
When someone uses stimulants, massive amounts of dopamine are released. Stimulants are very addicting, because dopamine creates pleasure. The consequence of chronic stimulant use is decreased dopamine activity. Ultimately, it may take months for recovering stimulant addicts to achieve stable dopamine levels so they are able to feel normal without using drugs.
A significant challenge exists for psychiatric providers treating patients with severe attention deficit/hyper-activity disorder (ADHD) and co-occurring anorexia. Medications for ADHD include stimulants such as Adderall® or Concerta®. These medications decrease appetite, further promoting weight loss and intensifying anorexic symptoms. Individuals with anorexia who need stimulants for ADHD should thus be treated in an inpatient setting or intensive lower level to monitor their ability to focus, concentrate, and gain weight.
Psychosocial Considerations
A carefully designed study found that non drug-using individuals with lower dopaminergic activity experienced an injection of a stimulant as pleasant; non drug-using individuals with normal or high levels of dopaminergic activity found the stimulant to be unpleasant. This suggests that fewer dopamine receptors may be a cause of stimulant abuse, whereas normal or high levels of dopamine receptors may reduce the likelihood of stimulant abuse.
Those who abuse cocaine and those with obsessive compulsive disorder both have less dopaminergic activity in areas of the frontal lobe. Nora Volkow, Director of the National Institute on Drug Abuse, believes that this abnormal dopaminergic frontal lobe activity is “…likely involved in the obsessiveness of drug addiction….” (Macmillan, 2003). Here we have a biological condi-tion—lower dopaminergic activity—apparently intensify-ing a psychological experience—obsessionality. Not surprisingly, those with SUD often have intrusive and obsessional drug-related thoughts resisting their control.
Just when we think it is safe to make a direct connection between biology and substance abuse, further research complicates the issue. In one study, primates were divided into two groups. One group was isolated by being housed individually; the other group was housed socially. Across the group of primates housed individually, no differences occurred in the numbers of dopamine receptors. However, in the socially housed primates, the dominant members of the social group had higher numbers of dopamine receptors than non-dominant members. The dominant primates with greater numbers of dopamine receptors were less likely to self-administer cocaine than the members of the social group with ¬fewer dopamine receptors. This research suggests that interpersonal and social factors may influence brain structure, particularly the numbers of dopamine receptors.
These several studies combined demonstrate the complex and synergistic interactions between genetics/biology, environment, and behavior in the development of substance abuse. The biological clearly interfaces with the psychosocial. We cannot neatly compartmentalize the biological and psychosocial dimensions in terms of their impact on substance abuse, because our biology/brain influences our behavior and our behavior influences our biology/brain. In short, it is true that biologically some people are more prone to abusing substances. At the same time, individuals are not simply helpless victims of their genes who have no choice or responsibility, nor do they exist in a vacuum apart from the influence of other people. As such, authorities recognize that psychosocial factors, such as peers and individual choice, play a role in the development of substance abuse and must be addressed in SUD treatment.
Psychological Dimension: A Functional Perspective
All human behaviors, including SUDs, have a purpose or function. The function of most behaviors is to reduce physical and/or emotional pain or obtain physical and/or emotional pleasure. It is critical to understand SUD’s function(s) for each individual to help the person recover.
Behaviors are motivated by each person’s perception of needs. We may or may not be able to accurately verbalize a specific need, but at some point we become aware of it because it creates an unpleasant feeling for us—uneasiness, discomfort, or pain. At some point, for ex-ample, we become aware of thirst and are motivated to drink. Our thirst isn't the actual need; fluid intake for bodily function is the true need. Thirst represents our awareness or perception of the body’s need.
Needs can be subtle and hard to pinpoint or they can be intense and specific. As a need grows, the unpleasant sensation usually increases. Two or more needs can occur simultaneously and may compete for attention. There are many types of human needs, including physiological, emotional, security, relational, and spiritual needs. One of the developmental challenges all individuals face is learning behavioral strategies to meet their needs and gain control over when, how, and where to fulfill them.
Based on experiences, our brains learn which methods do and do not meet our needs. Behaviors that remove the aversive feelings of unmet needs are reinforced—more likely to be repeated in the future when we experience symptoms of the same need again. Behaviors that result in a sense pleasure are also reinforced—more likely to be repeated in the future. Some behaviors both remove aversive feelings and add pleasure; e.g., narcotics relieve pain and add a sense of euphoria. Most substances of abuse are of this type—they provide pleasure and also relieve aversive states.
As with any behavior, substance use will be more intensely reinforced when there is a short time interval between use of the substance and pain reduction or pleasure onset; i.e., when there is instant gratification. Most substances of abuse offer instant gratification, whereas many alternative ways of gaining pleasure or reducing aversive states take longer.
Punishment is the opposite of reinforcement: it suppresses behaviors, making them less likely to be repeated. Substance abuse almost always results in aversive consequences—punishment. However, the punishing con-sequences are often delayed by hours, days, months, or years—e.g., hangover the next day, liver disease years down the line. As such, the immediate gratification of substance abuse often outweighs the delayed punishment.
In short, substance use is reinforced because it takes away aversive and/or adds desirable experiences, usually does so quickly and without immediate punishing consequences. Substances therefore appear to meet our needs. As such, SUD assessment is not limited to diagnosis, but involves attempts to understand the function of the substance use in the individual’s internal and external world, i.e., what needs does the substance meet. The reasons are seldom limited to a few needs, though some needs may predominate.
A behavior that is meeting needs cannot simply be terminated. It must be replaced by another behavior capable of meeting the same needs, or the needs will remain unmet and unpleasant feelings will mount. The individual must also believe that alternative behaviors can meet their needs, or they will be unwilling to try replacement behaviors.
Needs can be biological, psychological, social, and/or spiritual. Our biological needs are obvious—food, air, water, sleep, and so on. We all experience psychosocial needs, but they are not as easy to describe. Though not an exhaustive list, the following includes some of the most important psychosocial needs: the need to love, be loved, belong to a group, be autonomous, be creative, be secure, be special, contribute, and feel good about who we are. Psychosocial needs can be expressed in positive terms, such as the need for love, or in the negative terms, such as the need to avoid rejection. Negative needs are often more powerful. For example, the need to avoid rejection may overpower the need to belong, resulting in avoidance of others. Psychosocial needs are often more powerful than biological needs. Drug use for social acceptance may thus be a more powerful reinforcer than drug use to increase dopaminergic activity in the brain.
Need states change over time. We have all felt extreme thirst, but once we drink water, the need dissipates, losing its power to control our behavior. The need states underlying SUDs also come and go. When a need typically met by substance abuse goes away for awhile, those with SUD may truly believe, “I will never drink again,” because they are unaware that the need driving their SUD may reappear later.
When a need is temporarily satisfied, other needs become more salient and powerful in influencing behavior. A woman who drinks to cover the pain of romantic rejection may cut back on alcohol when she meets a new boyfriend. However, if he breaks up with her, the drinking will likely increase again. Our sense of reality and predictions about our behavior, e.g., “I will never drink again”, typically reflect whatever need(s) are strongest at any given time.
Social/Cultural Factors
A range of social and cultural factors are also associated with SUD, including poverty, access to drugs, perception that drug use is a low risk activity, perceived parental apathy, parental substance abuse, and perceived peer approval for drug use. There are also social and cultural factors that protect against SUD, including religious faith, goals that would be impeded by substance abuse such as academic or athletic success, perception of strong parental reaction against drugs, strong parent-child bonds, clear limits set by parents, consistent discipline, and perceived peer rejection of drug abuse. Among these social and cultural factors, the two primary groups of influence are family and peers. We explore these below.
People associate with groups by which they are accepted and receive affirmation. Peer groups have been referred to by several names, including social reference groups and social comparison groups. We have a sense of belonging and security in these groups and take from them our cues about how we should behave, what we should believe, how we should dress, and so on.
Developmentally, our first social comparison group is our family of origin. The family reinforces how we behave and what we value. Reaching school age usually means that exposure to groups outside the family increases significantly. The need for social acceptance by peers increases as children age. This need can have a dominant influence on the choice to use substances.
Young adolescents sometimes try to maintain inclusion in the family and peer group by living double lives, with one set of behaviors and values at home and another at school. This double life can include the use of substances. If parents do not have strong standards against substance use, the peer group often wins out.
Adolescents with extreme needs for social approval and popularity, and/or with tenuous social relations, are more vulnerable to peer influences. For these adolescents, peer acceptance may overpower needs for family acceptance, athletic and academic success, health, and spiritual values. Although needs may shift over time, by then, persons may have become psychologically and/or physically addicted to a substance such that, even when the need for social acceptance wanes, substance use continues.
As such, when patients have an ED with a co-occurring SUD, dealing with the issue of return to a substance-using peer group becomes imperative in treatment, family sessions, and aftercare planning. The chances of recovery from either the SUD or ED decrease if patients maintain a substance-using social reference group. Although the group may tolerate patients who don’t use substances, it is often nearly impossible for patients to refrain at parties and gatherings where alcohol/drugs are used.
Psychosocial Assessment and Treatment
Twelve Step programs have been instrumental in leading millions with substance use problems into a lifetime of recovery. In this section, however, we will not discuss the 12 Steps, because a large body of literature already exists dealing with the 12 Steps from both secular and Christian standpoints. Instead, we discuss assessment and treatment issues that must be addressed in the complex, dynamically interacting, co-occurring world of ED and SUD, where research indicates that 12 Steps alone would be insufficient for recovery (Yager et al., 2006).
In treating SUD, it is important to assess whether the substance use is ego-syntonic or dystonic. Ego-syntonic refers to behaviors consistent with individuals’ self-perception and values. Ego-dystonic refers to behaviors incongruent with individuals’ self-perception and values. This assessment guides treatment. The table outlines a SUD assessment strategy used at Remuda.
Assessment Area Sample Content of Assessment
Need Acceptance, belonging, respect, autonomy, etc.
Symptom Loneliness, insecure feelings, anxiety
Target “I’m not attractive.” “I need peer ap-proval, guys paying attention to me!”
Behavioral Strategy Lose weight, get toned. Do whatever it takes to fit in, including substance use.
Outcome: Did it work? Reinforcement: Decreased anxiety, increased security, increased pleasure.
The treatment team pays particular attention to understanding patients’ needs. Psychological needs are “felt” in the form of symptoms, such as sadness, anger, loneliness, and shame. Individuals attribute their symptoms to particular causes. For example, a patient may believe that she feels lonely because she is fat. These attributed causes are known as the target(s). The target then leads to a behavioral strategy. For example, if an ED patient believes she is lonely because she is fat, she may use ED behaviors to fix the targeted cause of her loneliness—weight. However, because the attributed target differs from the true need, the behavioral strategy will not meet the need and the negative feelings associated with the need will remain.
In the case of EDs, the true need is normally psychosocial or spiritual, and rarely physical. Therefore, even if the ED behaviors are reinforced, the unpleasant symptoms of the need soon return. For instance, if a patient loses weight and received attention from guys, this attention will reinforce her ED behaviors. However, her true need was not attention from guys based on her appearance, but acceptance as a person. Hence, lonely feelings will return. ED patients erroneously conclude they must still be too fat and thus intensify their ED behaviors. This vicious cycle is hard to break unless the true need is identified.
The same logic applies to substance abuse. Fundamentally, almost all behaviors are motivated by needs. Hence, substance use is a behavioral strategy designed to meet needs by changing the felt or experienced symptoms of these needs.
Treatment, at least in part, involves helping patients to see the connection between the underlying need(s) and their SUD/ED behaviors. Then, treatment offers alternative ways for patients to meet their needs to prevent ED and SUD relapse. Often, SUD and ED are used by patients to meet the same underlying needs and must thus be treated simultaneously. If not, patients will lean more on the one when the other is removed. For more details on alternative methods that patients may use to meet their needs, see Eberly, Wall, & Cabrera, 2003 or Linehan, 1993.
Clearly, part of treatment is untangling the legitimate need from the behavioral strategy. We may say, "You need to stop drinking", but patients may hear, "you have to go back to extreme social anxiety and not have friends." It is easy for people to confuse a need with the method they have used to meet that need. For instance, people spend their whole lives pursuing money—and in so doing, sacrificing time with family and friends, recreation, and spiritual development—when the underlying need may be self-esteem or respect. The selected method or behavioral strategy for fulfilling the need can quickly become someone’s focal point, such that people lose sight of the true underlying need. We see this often with ED patients, where thinness becomes the only obsession; whatever need they had hoped to achieve by being thin blurs and is lost in the past. The Bible eloquently describes this situation: "Why spend money on what is not bread, and your labor on what does not satisfy? Listen, listen to me, and eat what is good and your soul will delight in the richest of fare" (Isaiah 55:2).
As with any therapy, a critical component is the establishment of rapport. Most of us feel good when we talk with someone who listens and demonstrates that he or she truly understands our feelings. Helping professionals need to be able to see the world through their patients’ eyes, to the point that they can understand the patients’ logic, even when that logic is faulty and causing severe problems. Understanding and validation must precede confrontation. Confrontation without validation will simply be perceived as an attack. We earn the right to confront patients by careful listening, understanding their wounds, and demonstrating our understanding, combined with concern and empathy.
Of further use in treating patients with co-occurring SUD and ED is a stages of change model developed by Prochaska et al. (1995). The stages are not linear, progressive steps, but involve movement backward and forward. Remuda has adapted this approach in our assessments and interventions.
In Remuda’s adaptation, there are four stages: Pre-Contemplation, Contemplation, Preparation/Action, and Maintenance. In Pre-Contemplation, patients are not even thinking about recovery. In Contemplation, patients have some ambivalence about their SUD and/or ED and are considering recovery. Preparation includes the decision that change is needed, which typically leads to Action—taking behavioral steps to achieve the change. Finally, maintenance involves relapse prevention.
Individualized interventions are based upon patients’ stage of change. It would not make any sense to help a person who is not even contemplating recovery to develop a plan to avoid relapse. Without understanding stages of change, the timing and efficacy of even good interventions is compromised.
Interventions for Pre-Contemplation can involve increas-ing patients’ awareness of the negative consequences of SUD and ED, creating cognitive dissonance. At this stage, power-struggles between provider and patient may occur. Motivational interviewing is a therapeutic technique that helps patients to navigate the Pre-Contemplation stage. “Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence… Motivation to change is elicited from the client, and not imposed from without” (Rollnick & Miller, 1995).
"Without a vision people perish" (Proverbs 29:18). Using this principle, one question I ask substance abusing pati-ents in Pre-Contemplation is, “What is your vision for your life? What do you want?” This is important because it establishes that we are talking about the patients’ goals and objectives, not the therapists’, parents’, or partners’ goals. Once this is established, patients’ substance use can be viewed in the context of their personal goals, which decreases time-consuming power struggles.
At Remuda, younger patients often state that they want to have good career, to be married, and to have children. Having elicited their vision, we simply ask questions such as: “You said that you want to get married and have children. Do you want your husband to go out drinking on the weekends after you have children?” Almost always they reply, “No.” “If you keep dating guys who get drunk with you, who love to party and get drunk with their buddies or use drugs, what makes you think they will stop when you get married or have children?” If nothing else, this creates an internal conflict between patients’ drinking behavior and their own goals, as opposed to externally imposed value judgments. The ultimate question becomes, “Is your current substance use behavior moving you towards your goals or away from them?” The intention is to get them to contemplate change because change will help them achieve their own goals.
Patients in Pre-Contemplation and Contemplation can be derailed by words like “addict” or “alcoholic.” Reviewing patients’ behaviors with them and then discussing DSM-IV criteria for substance abuse or dependence is a more productive approach. With this approach, we have had many patients who do not yet see themselves as “addicts” or “alcoholics” say, "yeah, I do that stuff."
Other interventions are designed according to the remaining stages of change. The goal in the Contemplation stage is to have patients make a decision for recovery. The goal of Preparation and Action is for patients to take steps needed to move into recovery, such as pulling away from peers who abuse substances or have eating disorders, joining a 12 Step group, and so on. More detail about using stages of change with patients who have both ED and SUD can be found in Eberly, Cabrera, Wall, and Wolfe (2004).
Regardless of interventions used, a key challenge to recovery is that SUD and to some extent ED offer instant gratification, whereas healthier alternatives take longer, require more effort, and may not be as powerful. Here, support groups are vital, especially while new skills are being developed to meet underlying needs. In addition, finding ways to decrease stress, and learning to identify and avoid triggers, are critical. The Maintenance stage deals with these issues of relapse prevention. Identification of high risk situations and development of specific plans to deal with these to avoid substance use and ED behaviors are foundational. A range of relapse prevention resources exist for those with SUD and ED.
In sum, behaviors become addictive when: 1) they fill a need; 2) they lead to desired outcomes quickly; 3) negative consequences are delayed; 4) they work consistently; 5) alternatives for meeting the need are unknown or not believed in; and 6) the behavior does not violate one's values and/or can be rationalized. Comprehensive treatment deals with each of these variables. The true need is understood and validated, and the long-term consequences are made more salient. Viable alternatives are developed and values examined. Ongoing support guides patients through the early days of skill acquisition so they are less likely to return to the instant gratification of their disordered ED and SUD behaviors.
Spiritual Considerations
Because most Christians affirm the doctrine of free-will, we believe there is a critical role in human life for individual choice. Free-will moves us beyond deterministic influences of our biology and the stimulus-response environment in which we live. Individual choice creates another dimension that must be considered when contemplating the assessment and treatment of SUD.
Free-will is an aspect of the human spirit. The spiritual component does not make us impervious to the extremely powerful forces of biology and environment, but it enables us to make choices that are not completely controlled by them.
It is helpful to know that the Apostle Paul completely identified with those who are caught in the mire of addictions, destructive compulsive behaviors, and obsessive thoughts. Paul, like all human beings, struggled with his human nature. He poignantly wrote: “No matter which way I turn I cannot make myself do right. I want to, but I can’t. When I want to do good, I don’t, and when I try not to do wrong, I do it anyway” (Romans 7:18-19, New Living Translation, NLT). Paul described these behaviors as “foolishness” because they result in painful exploitation of self and others. In stern words, he wrote: “At one time we too were foolish, disobedient, deceived and enslaved by all kinds of passions and pleasures. We lived in malice and envy, being hated and hating one another” (Titus 3:3-4). Elsewhere, the Bible reminds us of humanity’s fallen nature and its potential to nearly trounce free-will: “For a man is slave to whatever has mastered him…” (2 Peter 2:19). Biblically, then, we hear about enslavement, a logical sequence of events where addictive behaviors run amok and lead to an out of control life. The 12-Step model echoes this perspective in Step 1: “We admitted we were power-less over our addiction, that our lives had become unmanageable.”
In light of this strong Biblical language, it is essential to recognize that the Apostle Paul also preached the amazing news that “there is no condemnation…” for these behaviors (Romans 8:1). He was not interested in placing blame on those who are struggling, but in compassionately reaching out to them and introducing them to healing through Jesus Christ. We are not only flesh and bone. We have a spirit within us that responds to the encouragement and direction of the Scriptures and the still small voice of God speaking within us. We are loved by a God who offers us redemption. With these sources of strength, we can choose freedom. The 12-step model echoes this perspective, particularly in Steps 2 and 3: “We came to believe that a power greater than ourselves could restore us to sanity,” and “We made a decision to turn our will and our lives over to the care of God…” In these steps, a decision is made—an act of free will, assisted by a “power greater than ourselves…”
Yes, addictions are potent. Picture this. A man is walking in the woods and steps in a trap, getting caught up in it, snared to the point of frustration and confusion. While he is struggling to get out, the trap seems to grip tighter and tighter until he is desperate. There seems to be no relief, no release, and no escape from the situation. So the man sits down, exhausted, stops fighting, gives in, and stops trying. So many find themselves here at this hopeless place, where the addiction—a snare that has exhausted their efforts of escape—is now all they know.
God offers a special promise for those in this place of hardship and suffering, who have come to believe there is no escape. “But remember that the temptations that come into your life are no different from what others experience. And God is faithful. He will keep the temptation from becoming so strong that you can’t stand up against it. When you are tempted, he will show you a way out, so that you will not give in to it” (1 Corinthians 10:13). Sometimes the “way out” is admitting that the problem has overwhelmed us and deciding to get help from a professional. Often the “way out’ arrives when another human being comes alongside and becomes the hands and feet of Jesus for the one who is suffering. In order to escape the gravitational pull of both biology and environment, those who abuse substances typically need help from others—loved ones, professionals, support groups, and the church community. “A way out” or a “way of escape” often refers to a narrow mountain pass through which a trapped army can escape from an enemy seeking their destruction. One must decide to take the escape. The Bible assures us that it will be provided.
In the Hebrew Scriptures, there is the story of Benaiah (2 Samuel 23:20-21). Today we would call him, “Benny”. Benny took on a battle with an armed and very strong man in a pit, “plucked the spear out of his hand and slew him with his own spear”. Apart from the violent nature of this act, the premise here is that Benny faced his enemy squarely and fearlessly. This is the choice that one must make in recovery, to drive it out with deliberation fueled by a life or death, it’s you or me, mentality. For Benny, there was a victory in the pit. Finding oneself doing battle with the lion-like men of Moab in the bottom of a pit is not unlike facing another drug deal, another gambling opportunity, or another night at the bar. In these battles, God is faithful to offer us strength.
The hopefulness we suggest may not come to the hurting easily. Emotions can be so numbed by drug use and a history of pain that hopelessness and despair seem to be the addict’s closest friends. Christian health professionals have the opportunity to remind those with SUD of the hope of the resurrection and God’s promises of deliverance. Life arises from the ashes.
At Remuda, we seek to provide exceptional clinical treatment combined with hope that life can and will be different without addictions and ED. It is not hard to be convincing, since thousands of patients have come through our doors and found peace, sometimes for the first time in their lives.
The Book of Isaiah beautifully discusses community support and God’s direct assistance in overcoming addictive and compulsive behaviors: “…strengthen those who have tired hands, and encourage those who have weak knees, say to those who are afraid, ‘be strong and do not fear, for your God is coming to destroy your enemies. He is coming to save you’” (Isaiah 35:3, NLT).
References
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