If you have not seen the television show, Life on Mars, in which a police officer is transported back 33 years from 2006 to 1973, you should. It does a credible job of comparing that distant past world to the near-present. For example, DNA testing, penetration of the blue wall, acknowledgement of “compassion fatigue” for first-line responders, workplace intervention for substance use, methods of interrogating people of interest, have all changed significantly over the years.
Addiction Therapy Then and Now
But the “present” in Life on Mars is 15-years old now. Watching this show again caused me to reflect on my entry into the addiction recovery field 30+ years ago. And the fact that even since 2006, a profound number of changes have occurred in the substance use disorder (SUD) treatment field. As I enter a new phase of life, my retirement, I am reminded that time allows for knowledge and growth. And looking back on my career as a clinical therapist, I would also assert that the quality of care continues to increase into the 2000s and beyond.
The Start of My Career 1970s
I spent the first six months of my career in prevention at Alcohol Outpatient Services (AOS) in Grand Rapids, Michigan. After all, I thought I knew something about street drugs and the nomenclature of the times. While in high school, I attended a convocation where two graduates from NYC’s Phoenix House arrived in miniskirts. They gave a “drugalogue” regarding their use and entry into treatment. They even used the F-word in front of the principal and teachers! None of the students in my small-town Indiana school could even remotely relate to their experiences. Later, I read about Synanon, Odyssey House, and other early efforts at rehabilitation, and became intrigued.
So, if I were hip enough to read High Times, I could relate to young people, right? What else did I need to know? Six months after I started, the AOS prevention department disbanded. This was because we couldn’t “prove” what we had prevented. I was absorbed into the counseling center. I overheard one support staff member telling another about a colleague who made that same transition. She said, “It changes all of them.”
And it certainly did change me and my world view. I still wince when I think about my early clinical work with extremely ill clientele. I felt so inadequate I wanted to hang Dante’s quote “abandon hope all ye who enter here” over my door. However, I was astute enough to understand that by doing so, there would be no return customers.
What we did not have…
But in my defense, when I started out (think Donna Summer, the Iran hostage crisis, and Three Mile Island), we couldn’t research material on the internet or attend webinars. And there was little emphasis on continuing education to keep our therapy license. We did not have instant drug testing or movies and television shows about recovery. Sports figures, celebrities, religious leaders and politicians did not admit their drug use. And there was precious little public perception regarding the seriousness of addiction and the journey of recovery.
Given the nature of therapeutic communities and the reliance on peer-led treatment, early strategies in the SUD field relied primarily on the use of confrontation. The rationale concerned breaking through the denial and defense mechanisms of the afflicted individual. In my initial outpatient organization in Grand Rapids, Michigan, administration endorsed a variety of therapeutic approaches, necessitating a staff with different training history and backgrounds.
One such staff member was trained in Primal Scream Therapy via Janov and Cassriel. This involved taking people into a specialized room with cushions layering the floor and a curtain surrounding the room in an attempt to muffle noise. The management was well-intentioned, but communication was poor. As a result, clinical staff knew of this approach, but support staff lacked notification. When clerical staff heard individuals shouting, “HELP ME,” “I HURT,” and other piteous cries, they immediately called the police, who barged their way into the room, disrupting the session.
Often people talk about the “good old days” of addiction treatment. I’ve heard the 60s and 70s referred to as “the golden age.” But was it really golden? What can be agreed upon, is that it was a time of frozen government funding and a paucity of treatment providers. A time when the field was impacted by managed care, becoming tenuously dependent on the criminal justice system for referrals.
Cha-Cha-Cha Changes 1980s
In my local municipality, Grand Rapids, Michigan, the changes were tremendous. A merger occurred between the substance abuse coordinating agency and the local mental health authority. Many predicted disasters and an erosion in community addiction services. But what resulted instead, was incredible innovation.
Reflecting back to the early 1980s, most treatment consisted of inpatient care initiated within hospital-based programs. Conversely, outpatient care was considered “aftercare.” Of course, this spawned readmissions into rigid and predictable programming. For example, repeated viewings of lectures and the films patients had memorized.
AOS was unique in Grand Rapids and Michigan. It was staffed by primarily, masters-prepared (non-recovering) staff. We were young, idealistic 60s style counselors. And as one trainer noted, “We were from as far back into the system as we could come.” We had an executive director who encouraged the clinical staff to provide services based on complimentary, but divergent philosophies from a strict 12-step approach. This was because clients could obtain self-help for “a dollar a meeting”. And payment for service meant (in his mind) professionally rendered services.
Many old timers will remember the schism that existed in those days. With most counselors being graduates of therapeutic communities, or having come into the field as a result of their personal recovery. (They were quite suspicious and distrusting of those with professional training.) I remember colleagues in other counseling practices asking, “Why, with an advanced professional degree, would you work in the recovery field?”
And my joking response was, “Who would not want to get paid to talk about sex, drugs, and rock and roll all day?” The truth was, that the majority of innovation in counseling or social work was occurring in the recovery field. This was thanks to the giants, Wegscheider-Cruse, Black, Whitfield, Subby, Fathers Martin and Booth, Bradshaw, Kellogg, Gorski, and others.
After founding an Intensive Outpatient Program in 1985, our program was accused by other treatment facilities of “setting clients up to fail.” Because (according to the “treatment authorities”) effective treatment could only consist of a 28-day inpatient program. At the same time, we were rebuffed by insurance companies. It seems they could not conceptualize organizing outpatient in such a concentrated way, thus refusing to reimburse for services.
Wrong turns, losses, and gains
There were some wrong turns and losses. We experienced termination of unlimited insurance benefits, several local treatment facilities meeting their demise. We also experienced the exiting of non-degreed staff, and the “Just Say No” campaign. And we experienced those who acquired HIV through unsafe sex or sharing needles. But there were also gains: ASAM criteria, stage specific treatment, motivational interviewing, peer support, drug courts, state programs for health-care professionals needing services, and more recently, recovery-oriented systems of care (ROSC), principles of evidence-based practice, and trauma-informed services.
Addiction Therapy 1990s
Still to come was acceptance of different paths to recovery. With books like Kasl’s Many Roads, One Journey, and more recently the White Bison movement, acknowledging dual addiction. Similarly, the terms “chemical dependency” and “substance abuse” were eventually re-labeled poly-drug patterns and substance use disorders (SUD).
Younger people with drug histories began to gain acceptance in Alcoholics Anonymous (AA). And they established nonsmoking 12-step meetings, and acknowledged diversity in the recovery populations, such as LGBT, women’s groups, and different ethnic backgrounds. Other items not yet on the clinical horizon were the advent of dual diagnosis (co-occurring disorders), codependency, the role of family in treatment, Adult Children of Alcoholics (ACA), harm reduction, cognitive behavioral therapy, medication-assisted treatment, tethers, and ankle detection monitors.
Early Psycho-Educational Efforts
I remember sitting in group rooms with large pillows and beanbag chairs, encouraging clients to discharge feelings. We sometimes used tennis rackets and what I have learned to call “projectile vomiting of emotions.” Early psycho-educational efforts (predating SAMHSA, illness management and recovery, or psycho-education models) involved an eight-week workshop for third offense DUI arrests.
This workshop was designed for individuals who were too “resistant” to enter other groups or individual therapy. Other programs held marathon encounter sessions, giving haircuts, and breaking down egos and defenses. I met one client (from another facility) who was forced to wear a toilet seat around his neck for a week.
Innovation was hard fought. We told clients, “Insanity is doing the same things over and over and expecting different results.” And “If you keep doing what you have always done, you will keep getting what you always got.” Yet, as service delivery professionals, we repeated strategies and techniques that benefited few. Similarly, we labeled those who relapsed as “not ready to change.”
I’ve heard counselors say to clients in precontemplation/contemplation stages of change, “Don’t let the door hit you in the ass on the way out.” At another residential program they said, “There are twenty other potential admits for this bed, so hit the road and come back when you are ready.” Not exactly what we would consider welcoming or stage-specific interventions today.
Back to the future – The 21st Century
Catching Up from 2006
Around 2006, the term and perspective of Evidence-Based Practice became a primary theme in the field. This involved co-occurring disorders (COD), which were originally labeled “dual disorders”. Ken Minkoff and Chris Cline challenged the field to examine COD with their CCISC model. This included looking for the following:
- barriers to treatment access
- how systems and organizations excluded individuals with either side of the COD presentation (mental health organizations not wanting to treat those with substance use disorders or SUD treatment not wanting to address mental health conditions)
- and how systems involve silos to follow funding streams, not to address the needs of the client.
While addressing trauma was initially perceived as a means to avoid dealing with one’s illness, and avoiding engaging in recovery, the ACE study taught practitioners how trauma predisposes the brain to addiction. Thus, the need for trauma-informed care became apparent. So too, the Seeking Safety model emerged as a treatment for those experiencing childhood neglect and abuse who had acquired a SUD. Practitioners established a variety of protocols for medication-assisted treatment (MAT). They initially started with methadone, however MAT expanded to suboxone, buprenorphine, and naltrexone. Even implants assisted those with both opioid disorders and alcohol use disorders.
SMART, SOS, Wellbriety and Mindfulness
During the initial decade of the 21st century, 12-Step approaches like AA and NA were supplemented with SMART recovery and SOS (both Save Our Selves and Secular Organization for Sobriety), for those who needed a humanistic, secular recovery approach. Alternative spiritual paradigms emerged including: White Bison movement (or Wellbriety); Refuge Recovery, emphasizing Buddhist principles; and Father Thomas Keating’s Centering Prayer approach. Refuge Recovery paralleled the advent of mindfulness approaches into recovery, first starting with Jon Kabat-Zinn and Alan Marlett, who pioneered urge surfing. Eric Garland furthered mindfulness approaches in the past few years with his Mindfulness-Oriented Recovery Enhancement (MORE) model.
A fundamental shift involved transitioning from pathology-based, treatment specific approaches, to a recovery perspective, such as building recovery capital. Services became more community based, peer-based models emerged involving individuals with lived experience being welcomed back into the field, ironic in that these individuals represented the bedrock of treatment in the 1970s, however exited the field due to insurance requirements in the 1990s. In some ways, the field came full circle through Recovery Coaches and Peer-Based Recovery Specialists.
And along the way there were trends in substance use itself. There were T’s and blues (Talwin and Pyribenzamine), first powder and then crack/rock cocaine, designer drugs including Ecstasy, Oxycontin and Vicodin, the opioid epidemic, and the resultant methamphetamine epidemic. Demographics of the recovery population have also changed. They are less Caucasian, less male, less heterosexual, and more diverse in drug of choice (other than alcohol).
Therapy Then and Now – Trends
Some powerful therapeutic approaches also emerged, with Eye Movement Desensitization and Recovery (EMDR), being adapted from trauma to substance use disorders, primarily in addressing urges, cue, triggers, and cravings. Models include: DETUR, CraveEX, Resource State Development, and Feeling State Protocol. Aspects of this approach more recently have emerged in Brainspotting, such as the Crocodile Set-Up. In addition, the field of Neuro-Linguistic Programming offered a variety of options, including the Brooklyn Project, Core Transformation, and Coming to Wholeness.
Although the preceding descriptors describe various therapeutic approaches offered or integrated into SUD treatment, in terms of change and innovation the field as a whole parallels most individuals, society, and health-care. My mentor, Virginia Satir remarked, “Given the opportunity to change, we tend to choose the familiar over the healthy.” A pioneer in the Grand Rapids Behavioral Health community stated, “Changing a culture is like turning an iceberg.” W. H. Auden elegantly mentioned, “We would rather be ruined than changed. We would rather die in our dread than climb the cross of the moment and let our illusions die.”
How interesting that for decades, clients have been met with the statements: “If you keep doing what you have always done, you will keep getting what you always got.” And “Insanity is doing the same thing repeatedly and expecting different results.” That said, perhaps we can acknowledge the COVID pandemic forced adoption of long-needed service delivery innovation, through use of tele-medicine, and an emphasis on virtual mutual self-aid meeting.
Would I want to go back to 1979 and re-live those Life on Mars years? About as much as I would like to re-experience mullets, parachute pants, disco, reruns of Three’s Company, the Commodore 64, news reports about the Falklands War, Bartles and James commercials, the American 1980 summer Olympics boycott, or exclusionary recovery paths.
Challenges still exist in the addiction treatment field. There is certainly a need to further individualized care, integrate technology at both the documentation and service delivery level, and recruit younger people as professionals in the field. We also need to enhance the competency level of serving clients with complex needs. And we must gain community acceptance for medication-assisted treatment, and the establishment of Recovery Oriented Systems of Care.
The last question becomes, “What’s next?” What is the next major innovation? Genetic testing to determine those at highest risk? Vaccines or immunotherapies for a number of substances including cocaine? The use of avatars and virtual reality to teach drug refusal skills and better prepare for craving and urges?
Whatever alleviates unnecessary suffering, brings comfort to afflicted individuals and their family members, and promotes a healthy and productive lifestyle, count me in. I call that remission.
Our field knows more than ever about welcoming those who need us. We are working with stages of change, engaging family systems, and integrating care with physical medicine. In looking forward to those future accomplishments, I relish the already attained improvements in care, marvel at increased community understanding of recovery, and hope some of those with whom I crossed paths benefited.
Personal changes have occurred over the years too. This includes crossing the line with my own substance use and celebrating 25 years of recovery last Christmas Day. I ended a marriage and was estranged from my children. I entered into a 12-step program, increased humility and sensitivity, and on the best days, found serenity. And I gained the knowledge and opportunity to carry the message and share experience, strength, and hope.
Thomas L. Moore, LMSW, LLP, CAADC, MAC, CCS
A note from Sanford Founder, Rae Green
Those who find success and passion in their careers have likely found a mentor along the way. Tom Moore is one of those people for me. In fact, he has had a transformational influence on my personal and professional life. As my professor in graduate school, he inspired academic curiosity. As an advisor, consultant, and therapist for Sanford clients, he recognized intrinsic value in every single person. I am certain I am not alone, and that many readers are grateful to Tom for his influence, competencies, talents, humor and skills. His long and dedicated career exceeded common standards and motivated colleagues and clients alike toward self-improvement. Tom, thank you for being a role model and encouraging me to pursue my goals and dreams. Thank you for the honor of letting Sanford publish your history.