Different kinds of therapy – group or individual – are appropriate at different times for different people. Yet controversy continues over which is “best.” Celebrity Rehab with Dr Drew may be a reality TV show, but it is highlighting some of the questions, and perhaps bringing therapy out of the shadows, into the mainstream, living room. Perhaps it signals a change in the stigma that has been attached to addiction, and treatment. Dr Inaba comments.
Transcript (edited):
HOWARD: Hi and welcome to the CNS Addiction Podcast. I am Howard LaMere here with Dr. Darryl Inaba and we are commenting on a variety of topics in the news this week – stories about addiction therapy. There was one story about Dr. Drew and his popular reality TV show, Celebrity Addiction Treatment, that article talked about the difference between group and individual therapy. And, Darryl, I wanted to chat about that a little bit. The article said that individual therapy is more effective, but in most drug counseling, chemical dependency counseling, its group that we hear most about. Can you help us understand that?
DARRYL: Well, its not that one or the other is effective for everybody, but when you step back and look at the research, the strong body of evidence shows that from research-based evidence empirical studies, actually group therapy ends up with a better long-term outcome and provides a better ability for people to remain abstinent. A group breaks the isolation, exposes people to others having the same problem. They get interventions or suggestions that have worked for other people and it really has been shown to be more effective. But at the same time you need individual therapy in certain circumstances. If the addiction, and it often is, related to some deep set trauma some form of abuse that occurred early in childhood, sometimes getting to that first works better if you feel safe with a single person. So, its not one or the other – but research is showing group therapy to be more effective. But I kind of see a dark side to that because that research is coming from a lot of policy makers and a lot of funders from the national government research base and state research base and resulted in many states like California saying were not going to pay for individual therapy in drug abuse treatment anymore, which I think is a total tragedy, because you need both to be effective. But legislators said well if group therapy is much more effective than individual, were not going to pay for individual So, I couldnt help but wonder is this sort of a government plot to say, you know we cant afford the expensive individual therapies and the costs of individual therapy if every client got individual therapy. Whereas with group therapy, you sit down with 20 or 30 people or at least 12 people in a group for the hour and youve got 12 times the bang for the buck. So maybe it was the economy of it all.
HOWARD: Cost efficient.
DARRYL: Having done both, I think there are many, many helpful ways that group is effective in reaching the real gist of what addiction is and helping people to recover, but I do know that working with the same client in individual sessions, things that they couldnt openly share with a group, are able to come so people can get more comfortable with them before they share those things in a group. So I still think both are very necessary and Im not sure about the celebrity thing, because not only are they showing or doing most of the work in groups, but theyre doing it in front of a whole national audience! And its open – one of the cornerstones of the treatment AA is based on is confidentiality, anonymity that the group is a fellowship or community of people working with each other who share the same problems, to help each other and not something that was supposed to be blared out in public – especially to a public who put a stigma and have so much bias about addiction. Its been on, I think 4 years now or something like that .and its strange even my daughters watch, call me up and say, did you see that, did you see that. I say, No, I dont watch that show. But its so popular that maybe the stigma about addiction is starting to wane and people are accepting it as a real, real issue and a real medical problem that people can get treatment for and do better on. I just cant see, you know, bearing all of your pain and suffering in front of a national audience. And I dont even know how they get permission to do so. I imagine some people want to air it out or maybe they pay these people even the celebrities.
HOWARD: Oh, Im sure they are paid.
DARRYL: They get paid to do it?
HOWARD: Hey, its show biz folks!
DARRYL: We were asked recently at our addiction recovery center to participate in one of these intervention shows and then provide the treatment and the producers were going to follow up, but as I expected to happen, when they did the intervention, the person said, Im not going to go there. Maybe that prevented that person from coming into treatment because of the notoriety – I hope the show offered the person treatment we would certainly have provided it at no cost even if they decided not to be in the program.
HOWARD: Well it is beneficial if this kind of thing reduces the stigma. There was another story about state budgets across the country are for the most part in dire straits as a result several years of recession and now many states are looking at severe budget cuts. Here is a story out of Texas about the reduction in treatment of chemical dependency as it relates in particular to the prison system. The somewhat astounding statistic that as they release people early from prison, like 70% of the 70,000 people recently released are chemically dependent and are likely to go back to their criminal ways to underwrite their habit. I think we have clearly shown the efficacy of treatment those costs are comparable to the cost of incarcerating people. So, what can the public do to make it known that this is penny wise and pound foolish to cut this?
DARRYL: Well, thats exactly it, Howard. Its a short-term gain or savings on a budget that will put states and the federal government back into a much deeper hole in the future. I dont think there are any studies that shows that treatment in prison was ineffective, even when it is cut short to let people out early. Actually the best results and the best outcomes for long-term sobriety from drug addiction and alcoholism has been when the criminal justice system, like prisons and drug courts and probations, team up with community based programs and provide a concerted effort. Because a big reason for recidivism of prisoners is that theyre given treatment while they are in prison and then theyre let loose or theyre just cut off and they go no place. Theyre not even sent to 12-step programs.
HOWARD: Right, they dont go back to treatment.
DARRYL: Yes, and theyve got to realize that this is chronic persistent disorder. You dont get cured… you continue to treat it throughout and if people realize that and get people connected and do more case management to get people in continued treatment after, Im sure it would be much more effective. But even the things theyre doing now have created cost savings in terms of the addicts who participated have less recidivism, have lower criminal justice costs and all. I think it is not too wise to cut drug abuse treatment. Maybe they should cut something else in prison, but of course, what can you do? You cant cut guards because prison is about protecting the public. Its not anything about rehabilitating the person whos in prison. You know, prisons are there to keep these people away from harming the public. You cant cut food. I remember one of the big riots at Alcatraz was because I think they served spaghetti 3 times a week and the prisoners just had had it. They said, youre not serving us spaghetti a third time and the next thing we knew, we had the siege of Alcatraz so I dont think you can cut the food without, you know, prisoners taking things into their own hands. You cant cut the administration or the paper or any other costs, the munitions and all that, so I think the first thing they look at is well, well just get rid of any treatment or rehabilitation and leave it up to the individual prisoner themselves to work their issues out so that they dont come back. But what weve seen in the past and well see it again is thats not going to happen. If you dont provide any kind of therapy especially for drug abuse and most of our prisoners now are in prison with some sort of drug abuse problem – whether its a primary problem or a secondary problem to some other felony they committed, drug abuse is so prominent and if you dont deal with that, I dont think youre ever going to get any prisoner out of the criminal justice system.
HOWARD: There are some stories about cocaine. I noted President Obama is going to sign legislation equalizing the penalties for powder cocaine versus crack cocaine and thats been a long time coming. But there was a story about Lady Gaga, I think, and asking Can you be an occasional cocaine user? And I thought that was an interesting question and the article also highlighted the dangers of cocaine, especially to the cardiovascular system and the fact that its possible for young, healthy people to have a deadly heart attack after using just one time .
DARRYL: Well, actually drugs, alcohol included, maybe not so much heroin and nicotine, but cocaine, methamphetamine .at any given time just taking all the users at a single moment – youre going to see most of the people using the drug within a 30 day period . Theyre going to be casual users. Theyre going to be social, recreational users. They might even be habitual users or theyre going to be experimenters, but only a small portion of the people who try it or who have used it within a 30 day period are going to be addicted. I think for cocaine, we were last looking at an estimate of around 30% of all the people who use cocaine in a 30-day period, actually meet criteria for full scale addiction or dependence to cocaine. So that seems to imply that yes, you can be a casual user. But the problem is, it may not stay that way. You may move yourself into that 30% who are currently addicted while those people who are currently addicted are moving themselves into recovery or non-use or have moved themselves back into some sort of casual use situation if they werent fully addicted. So, theres that issue as well. When we look at addiction it is in terms of how powerful a substance is and it is measured a whole bunch of different ways. You can measure it by the severity of withdrawal symptoms. You can measure it by how quickly somebody goes from casual use to addiction, but if you measure it on its ability to cause somebody to use the drug again, cocaine is probably number 1. It is the most compulsive or reinforcing drug that there is.
HOWARD: Just because of the way it acts on the brain.
DARRYL: Yes and part of it is that huge dopamine release that hits the reward/reinforcement center of the brain, makes people want to use. But the other part of it is that its such a quick acting drug and it has such a powerful effect on unbalancing the dopamine in the brain .also glutamate glutamine, so that you get this powerful reinforcement or powerful do this again, very quickly within 40 minutes, then the brain turns off and it turns off at a much lower activity than where you started. So theres that sort of attraction too. That need to get back to that feeling that you had just 15 minutes ago or 20 minutes ago and now you feel worse than before you tried cocaine, so you want to take some more to get back to that feeling that youre missing. And the more you use, the lower you feel the worse you feel when it wears away in 15 minutes, so you get trapped into this, what we call chasing the green men or always trying to get back to that feeling. So cocaine very quickly becomes one of the more addictive drugs out there. Im so glad theyve changed the penalties and President Obama and Congress finally accepted that there was sort of a discrimination going on – a discrimination that has been called a racist discrimination as far back as the 1980s when smokeable cocaine or crack cocaine was associated with the African American population many people felt that African Americans abused crack, while Anglos and other people used powdered cocaine and snorted in. And there were laws making possession of just one piece of crack rock a ticket to jail – whereas if you had an 8 ball, 3.5 grams of pot or cocaine or anything less than an ounce, like 20 grams of cocaine, that was still breaking the law, but you didnt have to do jail time for that. So theyve equalized the law, that deals with this discrepancy and that disparity and it is not a racist law.
HOWARD: These are all good topics and things we will return to. The treatment matter especially, I think we need to talk about repeatedly. As ever, those of you with comments/questions, wed love to hear them. Drop us a note and well respond or comment as we can.