#9 The RSAT Program

I moved to Roseburg OR. in 2002 to become the lead counselor for a program funded by the Federal Gov't called RSAT (Residential Substance Abuse Treatment). It was conducted in the Douglas County Jail and those referred were facing prison terms for drug related crimes. It was a co-ed program with the clients living in dormitories. These were was connected to a classroom where we conducted the program keeping the number of clients to 15. If the clients completed the program, and committed no further crimes or major probation violations after treatment, they could avoid a prison term. Duration of treatment varied from a 6 month minimum to 9 month maximum depending on our evaluation of their progress. Intensive aftercare for at least a year followed treatment. The program was based on the data that with long term treatment there is no difference in the rates of recovery between those who volunteer or are forced by the courts.

In our best year, 61% of those completing inpatient treatment were still clean and sober after a year. One client was arrested for a DUI right after release from jail and was sent to prison but this was the only criminal violation that year. The Federal Supervisors did not trust our figures, as that rate is unheard of. Any program that has 20% - 30% of clients still clean and sober after a year is considered successful, and the criminal recidivism that low was also unheard of. They sent a small team to investigate for a week, sitting in our process, and ended up taking our treatment model back to Washington DC as a model for future grantees. 

The program was solid, using a model of individual therapy in group dealing with developmental trauma, a strong emphasis on the 12 steps of A.A., accountability personally and to the group, an educational emphasis with treatment plans on addiction, and a strong emphasis on family involvement. Some new clients chose going to prison and rolled themselves out of the program as it was not a softer, easier way. But, that wasn't what made the program so successful. 

In retrospect, the success was because of a "perfect storm" of cultural / social support discussed previously in my posts on "Proximity" (#5 and #6). Roseburg is a small town with about 21,000 which meant there was little funding competition for social services that unfortunately often occurs in larger cities.  My female co-therapist and I had an incredible professional relationship balancing each other's strengths. The Lieutenant of the Jail was pro-treatment and he appointed a deputy as a liaison between the other deputies, the clients and our staff which smoothed the issues with many deputies who didn't understand treatment and felt we were giving privileges to criminals. She also directly dealt with our clients breaking rules. In extreme cases she put them in isolation which was dead time towards graduation. The  liaison deputy arranged for the local community college to grant 9 hours college credit for the morning addiction education. Also graduates were offered a free semester upon graduation from the program. GED was already offered in the jail and many were able to complete this while in treatment.

There was one probation officer for the whole program and he had a background in counseling and would sit in group from time to time. The Mental Health associate who came in once a week was an old friend I had known twenty years before in Dallas TX. Medical was totally cooperative with occasionally needed psychotropics as we began to notice a high correlation between ADD-ADHD and meth addiction as well as health concerns. The Oxford House movement expanded to Roseburg which provided safe and sober living. A local civic group built 8 apartments for men and a house for 5 women for safe living. A former colleague was there during the daytime providing supervision. A local restaurant was willing to provide employment, and the graduates working there were highly thought of. Other local businesses followed suit and employment became possible for graduates.

Roseburg has strong recovery self help groups, and so graduates were able to find strong sponsorship and had many options for the regular attendance required. Two after care groups were led by my therapy colleague and myself for a minimum of six months, and then once a week minimum for the second six months. An outpatient family group was also available once a week to help the recovery for families damaged by addiction. 

One interesting aspect of the program was that on Friday afternoons I would hold a session where clients could ask questions about the Bible. It was a voluntary process to respect their civil rights, but all members of the groups chose to attend. In one graduating class we had four clients, two men and two women, return to the churches of their childhood and be baptized signifying their re-commitment. 

Tragically, for circumstances beyond our control, the "perfect storm" of cultural / social / support was not to last. Initially, because of competition for funds with economic cutbacks, we lost the cooperation of Mental Health. Then the leadership of the jail changed and the new lieutenant did not have the openness and cooperation we had enjoyed.  Medical no longer cooperated as it was now run by a individual contractor seeking to cut expenses. The liaison deputy facing relocation to save funds, resigned and went into social work at the local hospital. My personality was too confrontive of the changes, and I was removed from the program to work back in outpatient corrections. 

Sadly, the program regressed back to the recovery rates expected from such a program and then funding ran out shortly after. When I do workshops with churches, I use this as an example of how a church could provide a refuge of recovery for addiction. I attempt to organize committees to assist pastors in coordinating the necessary ingredients for a cultural / social/ spiritual involvement by the church. 

In my next blog we will begin to explore neuroscience and how drugs affect the brain. 

#8 Rat Park

The traditional and long standing theory of addiction maintains that most people who use drugs beyond a certain amount become addicted (alcohol is a drug).  No matter what proportion of drug users become addicted, this is caused by exposure to the drug. The solution then is to eliminate drugs, but the War on Drugs has been shown to escalate the illegal drug industry as the rates of addiction continue to rise. Has nothing has been learned from the Prohibition Era (1920-1933)?

Data supporting this prevalent theory of addiction came from numerous laboratory trials with rats and monkeys and observing how frequently caged animals would push levers to obtain drugs. Predictably, the caged animals would avoid normal eating and drinking leading to death without intervention. 

Dr. Bruce Alexander, author of The Globalization of Addiction: A Study in Poverty of the Spirit challenged this belief in the late 70's with his experiments known as Rat Park.  He professed that the laboratory rats kept in cramped metal cages were distressed (dislocated) and like distressed people would relieve their distress pharmacologically. 

To test his hypothesis, he designed an alternative laboratory environment based on the needs of the rats rather than the researchers. Rat Park was 95 sq ft or 200 times larger than a standard laboratory cage. There were 20 rats of both sexes, an abundance of food, wheels for play, aromatic cedar shavings, woodland vistas painted on surrounding walls and enough space to socialize as well as for mating and raising litters. Given a choice of plain water or water laced with morphine they chose the plain water. Then rats that had been forced to consume morphine for 57 straight days were introduced to the colony and chose the tap water and went through withdrawal. This validated his theory that addiction is not directly caused by access to drugs but is a symptom of dislocation. (refer to blog post #7)

Major science journals at the time rejected his paper mainly because it challenged the current theories. Dr Alexander feels we over-individualize addiction, rather than look at the cultural / social / spiritual roots of his theory of dislocation. Although these experiments have been replicated they still have not influenced the mainstream of addiction theory. Rat Park measured not the addictiveness of opiates, but the cruelty of the stresses inflicted on rats in solitary confinement and dislocation from their natural environment. 

It is estimated that at least 80% of those incarcerated in North America are there for a drug related crime and very few jails and prisons offer treatment. It seems there is money to build prisons which have become a major industry often run by contractors.  I believe those who manufacture or sell drugs should be incarcerated, but we need to re-evaluate the process of incarcerating users of drugs when no other crime was committed. The answer is not legalizing drugs but discussing decriminalizing the possession of small amounts and providing treatment. Sadly, with budget cuts the former availability of treatment even 5 years ago is not available in the USA.

My next post will discuss the success of a long term treatment program in the Douglas County Jail in Roseburg OR. that integrated the theories of Proxemics and Dislocation.

#7 Theory of Dislocation

Dislocation is a term developed by Dr. Bruce Alexander in the single, most important book I know on addiction, The Globalization of Addiction: A Study in Poverty of the Spirit.  He has become a personal friend and colleague and this post will rely heavily on his written work, workshop, and our conversations. His theory of dislocation gives me a way to include and integrate all the other things I believe about addiction including the spiritual issues.

My last two posts introducing the theory of Proxemics developed the spaces where “Psychosocial Integration” develops. It is a profound inter-dependence between an individual and society that normally grows and develops throughout each person’s lifespan.  Psychosocial integration reconciles people’s need for social belonging with their equally vital needs for individual autonomy and achievement.  Psychosocial integration is as much an inward experience of identity and meaning as a set of outward social relationships.  Establishing the delicate interpenetration of person and society enables each person to satisfy simultaneously both individualistic needs and needs for community -- to be free and still belong.  An enduring lack of psychosocial integration, which is called "Dislocation” is both individually painful and socially destructive.

It denotes psychological and social separation from one’s society which can befall people who never leave home, as well as those who have been geographically displaced.  People can endure dislocation for a time. However severe, prolonged dislocation eventually leads to unbearable despair, shame, emotional anguish, boredom, and bewilderment.

Psychosocial integration is experienced as a sense of identity, because stable social relationships provide people with a set of duties and privileges that define who they are in their own minds. Psychosocial integration makes human life bearable and even joyful at its peaks.

Conventional wisdom is that drug and alcohol abuse are the prototypical addictions. The historical perspective views addiction as a societal problem. It is seen as a symptom of dislocation. This is the breakdown of the cultural integrity of every segment of its population and the lack of a rebuilding of a new replacement culture.

Material poverty frequently accompanies dislocation, but they are definitely not the same thing. Although material poverty can crush the spirit of isolated individuals and families, it can be borne with dignity by people who face it together as an integrated society.  On the other hand, people who have lost their psychosocial integration are demoralized and degraded even if they are not materially poor. They have lost their sense of dignity and experience toxic shame about who they are and where they belong.  Neither food, nor shelter, nor the attainment of wealth can restore them to well-being.  In contrast to material poverty, Dr. Alexander calls dislocation “poverty of the spirit”.

1.    “The first principle of the dislocation theory of addiction is that psychosocial integration is an essential part of human well-being,  and that dislocation – the sustained  absence of psychosocial integration – is excruciatingly painful.”

2.     “The second principle of the dislocation theory of addiction is that the globalization of free-market society produces a general breakdown of psycho-social integration, spreading dislocation everywhere. “

3.     “The third principle of the dislocation theory of addiction is that addiction is a  way of adapting to sustained dislocation “   

Bruce maintains we have over individualized addiction and ignored the social / cultural dislocation issues that are creating it. For example the country with the highest rate of addiction today is China. With the mass dislocation from primarily an agricultural system to the mass manufacturing in large and congested cities, addiction is epidemic. It is interesting to note that China has capital punishment for selling or manufacturing drugs but this has not had any major impact on addiction nor the War on Drugs here in North America.

Dr. Alexander documents culture after culture that had few problems with addiction until they went through dislocation. For example the Native American (First Nations in Canada) problems with alcohol and drugs are well known and documented.  The fur traders brought rum with them to try and influence the natives, but it had no impact. It was not until the natives lost their land, language, culture and traditions that it became the problem it is today. 

In the DTES where I serve, if a native there is over 40 they generally were a product of the residential school system that took children from their homes to assimilate them. They were punished for even speaking their native languages among other numerous abuses of their culture. 

Dr. Alexander's book is researched thoroughly and is a must read for students of addiction. In my next post we will explore his research and findings from his experiment known as “Rat Park.”

#6 Proxemics and Identity (part 2)

In my last post I introduced you to the theory of proxemics (identity being formed from having a sense of belonging and knowing “Who Am I.” in four different spaces.)  Disruption in the development of the psychosocial / spiritual roots of belonging are a main source of dislocation which I will be discussing in future blogs.  All who have experienced dislocation do not become addicts, but all addicts have been dislocated. My use of addiction includes alcohol and other drugs as well as gambling, eating disorders, pornography, shopping etc. We will see the commonality of all addictions in future blogs. But I am getting ahead of myself. 

If you refer to the diagram from my last blog, you will notice there are a series of numbers at the bottom of each space. That is, under Public Space the number is 8, Cultural / Social 4, Personal Friends 2, and Intimate 1. Their purpose is to provide a comparison of the impact of each space on the overall development of identity. Note they add up to 15.

 Identity must be reinforced through life or can be lost. For example consider someone in full blown addiction.  In the Public Space, let’s imagine that their interest, involvement, and conformity in this area is halved giving it a factor of 4. In the Cultural / Social space, the only culture the addict really belongs to is the drug culture and we will give it a 2. Personal Friends are few, and not authentic as it is hard to trust anyone active in the drug culture, so we give it a 1. Our total is now 7. 

Subtracting 7 from 15, leaves 8. The quandary is now where will the addict look to for the other 8 factors of identity?  Most often this is sought through the Intimate Space, and now we can begin to understand co-dependency.  Addict relationships are always toxic as one can never achieve a sense of identity primarily from another person. 

Co-dependency (addiction to another person) is a lack of identity being formed in the spaces other than the Intimate Space. The solution as adults comes from more involvement in the Cultural / Social Space which also enhances identity in the Public Space and Personal Space. Being part of a recovery oriented Cultural /Social Culture may encourage growth in the Public Space like further education, job training, getting over-due medical checkups, paying more attention to nutrition and healthy living habits, or starting to travel to explore other places geographically and culturally.

It is my premise that the church should be the ideal setting for recovery. Couples may attend worship services together, and then participate in individual bible study or other interest groups in the community.  Alanon and Co-dependants Anonymous meetings usually held in church buildings address these issues directly, as do Alcoholics Anonymous, Narcotics Anonymous, Gamblers Anonymous, Overeaters Anonymous and Sex Addicts Anonymous address other addictions. Celebrate Recovery, a Christ Centered group has a nice balance.
They have a brief worship service and then break into smaller groups for specific addictions.

One of my greatest disappointments over 31 years of experience working as an addictions counselor is the few relationships (often including children) that stay together in recovery. If both partners are addicted they rarely get clean and sober at the same time and grow apart. When one continues to use, the temptation is to get drawn back into the addict culture through contact with them.  When only one of a couple has been addicted and the other doesn’t seek help for their co-dependency they often grow apart. Addiction affects the whole family. Children exposed to the ravages of addiction may be overtly abused and are generally neglected. Children also start taking on family roles abdicated by the parents in their preoccupation either with addiction or their partner’s addiction.

My next post will begin to explore the topic of Dislocation as we continue to consider why 1 of 8 people becomes addicted to alcohol and other drugs.

#5 Belonging, Identity and Theory of Proxemics (part 1)

In my last post we started exploring identity and its relationship to addiction. We saw identity is directly related to the psycho-social-spiritual development of a sense of belonging. Now we will begin to explore the theory of proxemics and a study of the "spaces" where belonging and identity develop. Identity must be reinforced through life or can be lost. Not only addiction, but illness, death, trauma or any other life crisis challenge where one feels like they belong. We lose sense of who we are and become dislocated.

   
         PUBLIC SPACE:

How one’s family responds to the issues listed shapes how a child feels like they belong. This development gets its roots primarily in the first eight years of life and generally is also an adaption to social conformity. The factors are inter-dimensional, for example gender and race are seen differently in different geographical areas of the USA and the world in general. People in the northern states read more than those in Florida and California where you can play tennis and golf in the winter.  I am using Religion in the global sense as Muslim, Hindu, Christian etc.  Identification with Sports Teams is seen in the wearing of their team jerseys.

Ethnicity and language have impact particularly if children are raised bilingual and the child forms multicultural identity. Economics and the consequential standard of living can influence the formation of identity. The more affluent feel more privileged as more opportunities present themselves. Poverty on the other hand often limits opportunity. This can carry over to opportunities for education, medical care, hobbies, and even the style of clothing worn as children.   Economics can determine the quality of the community in which one lives including  the possibility of vacation, leisure, and hobbies.      

   SOCIAL - CULTURAL SPACE:

Your definitions of who you are helps you and the other persons in this space to connect, thus nurturing an experience of belonging for all of you. Cultural and social groups have great impact and become a fulcrum to expand and enrich the other spaces shown in the figure above.  By providing contrast they often have the power and influence to alter core values or re-think under-standings formed in the public spaces of childhood. They also provide the contacts where the personal space is developed.

This is an active space where we participate in sports teams rather than watch Team sports. We attend a specific church or church group rather than just identify broadly with a national religion. Neighborhoods used to be cultural / social contacts, and specific neighborhoods would have a distinct identity.  In larger and older cities, there are still “Italian, Jewish, Chinese neighborhoods.” As today's society has less interest in community and service groups, more people are participating in  Starbucks, Facebook, and computer dating.

For adults struggling with identity and belonging issues, cultural and social groups have great impact and are a fulcrum for the other spaces. For example when people become very involved groups like Alcoholics Anonymous, they begin to review incomplete issues from Public Space like going back for more education or skills training. They may get some counseling or begin reflection about life shaping incidents in their formative years. As a fulcrum this space also lends itself to more vital and functional friendships in the personal space.

It is my belief that the church should be the ideal "Social - Cultural - Spiritual Space" for recovery from addiction and other mental maladies. Only 12% of pastors, priests, or rabbis report any formal education on addiction.  It is in this space that I offer my workshops on addictions to local churches and civic organizations.  Recovery requires involved and healthy belonging in this space to overcome the pull of the alcohol and drug abuse culture. The impact of small groups is part of the solution. The ministry of Jesus was primarily to the marginalized of society, and we must guard from becoming exclusively churches for the churched.  

     PERSONAL SPACE:

It is important it is to have authentic friendships in the formation and maintenance of identity.  The dynamics of Personal Space are birthed naturally out of Cultural / Social space. When we have shared ourselves and our story, listened to others, and feel like we belong, personal relationships will develop with individuals wanting to spend more time together.   Relating to each other’s story, the individuals begin to take risks with self disclosure. Gradually finding that they are not being judged or criticized, promotes more self disclosure always contingent on a compatible level of comfort and emotional safety. Some relationships reach a certain level, and do not precede towards sharing our most private experiences, feelings and thoughts.

Ideally, balance is having at least three to five authentic relationships. People with quality sobriety count on these relationships as critical in their lives and many express having many more than suggested. These relationships need to be of the same sex.  Identity as a man is gained through his relationship with men, not through the projections of women and conversely women bonding with other women.  The openness required in this space complicates the relationships between sexes and too easily spill over to the next level reserved for wives or prospective wives. Men learn how to treat women from other men and women learn about relating to men from other women. Inter-gender relationships are important, just not at the level of intimacy of these authentic  friendships. 

   INTIMATE SPACE:

This space is reserved for the exclusive and most intimate relationships that are also sexual. This process of this mystical spiritual / sexual union is described biblically as “two becoming one.” There is a shared identity ("the one") that is unique among all other relationships.  And yet paradoxically, this union cannot happen unless each of the couple is secure in their own separate identity ("the “two”), formed in the previous spaces just commented upon.

Husbands and wives belong to each other in four spaces even though marriage will not meet all the individual spatial belongings necessary for identity. Marriage announcements are usually public in newspapers and social media.. Often couples wear wedding rings which proclaim their joint identity   Socially / culturally /spiritually couples regularly redefine themselves beginning from “boy friend—girl friend” progressing to “engaged“ to "newlyweds and husband—wife” to “parents and mother—father.” We admire couples who identify each other as “my best friend.” The disruption of relationships disrupts the couples other spatial identity reinforcement as well.

Paradoxically, the best solution for struggling relationships is more involvement in the Cultural – Social space where “Public Identity” (the first space) can be salvaged or maintained. The more secure “I am” the more available I can be to who “you are.”

Lack of a secure identity is one of the many factors in understanding the complexity of addiction.   My next post will deal with addiction and the theory of proxemics more specifically.

#4 Identity and Belonging

Life has some big questions.  What is the meaning of life and is there a purpose?  Why am I here?  Is there a God and is He involved? These are just a few.  I think the big questions in life can be answered by knowing our identity.  All of the big questions become Who am I?  The answers to this question are a key to our identity.  The best way I can illustrate this is to encourage you to take a notepad, write at the top I am... and start itemizing your responses.  Then expand this by itemizing I am a person who...

Identity is shaped by our developmental sense of belonging and where we experience recognition and acceptance.  We initially gain this from birth in our families.  After their basic survival and instinctive needs are met, children move to the all important emotional development of being loved and belonging. Then we look for belonging in public places like school and activities, and then with our involvement in social or cultural groups where we experiment with where we feel like we fit. If this development of identity is arrested, flawed, dysfunctional, or traumatic, then issues of identity are to be expected. It becomes a sense of being dislocated (or lost). We don’t have a secure sense of belonging, the most critical issue of emotional development and a link to understanding addiction.

In summary, this developmental process begins as an infant, is shaped initially through parenting, expands into the local community and ultimately expands to be influenced by the world and universe.

But even if we grow up with the healthiest development and sense of psychosocial identity, there is still a larger issue of spiritual identity. Sadly this is one that is often ignored. If this is not resolved then one will form attachments to individuals and groups that are poor imitations. What is my identity in terms of the universe? It is a primary perception. One of my favorite passages in the Old Testament is when God told Moses to lead the Israelites out of Egypt, Moses asked who he should tell the people has sent him?  God answered "I AM WHO I AM" (Exodus 3:14).  Another is found in the New Testament  where it states I am a "new creation" in Christ (2 Corinthians 5:17). 

On your I Am list you might modify the title to I am a person who believes... and list your faith beliefs, your value system. Then on your list modify the next title to I am a person who desires to...  to itemize where you feel your identity is leading to in the future.

“Each of us needs to belong, not just to one person, but to a family, friends, a group and a culture. It is only through belonging that we can break out of the shell of individualism and self-centeredness that both protects and isolates us."                            Jean Vanier: Becoming Human.   
                   
The next post will explore the formation of identity in more detail and its relationship to addiction. Thanks so much for those who have been writing in response to this recent series of posts on addiction. I have enjoyed the interaction with questions and comments, allowing me to be in touch more personally.

Ross