The Greenhouse Effect – The Future of Behavioral Health

For a long time, our nation’s behavioral health care systems have been focused on treating people after they become unwell.  It has sort of been like waiting for the leaves to begin falling off of a plant before rushing in to provide any nourishment or care.  This approach has been problematic in many ways, most notably because there has far too often been an extraordinary amount of unnecessary suffering experienced at the individual, family and community levels when a person is not treated until acutely unwell.  We know that the longer an illness progresses, the more difficult it is to treat and the more severe the adverse impact on an individual’s life becomes.  A close second in terms of this approach being problematic is the financial cost – the United States spends more money on healthcare than any other country in the world yet ranks the lowest in terms of positive health outcomes in many categories.  It is clear that the current way of doing behavioral healthcare in our country is not working – so what do we do about it?

If we continue to use the analogy of a sick plant, our current paradigm is situated perfectly to wait for a plant to become unwell, remove that plant from its soil and then place it into an expensive incubating environment for treatment.  Unfortunately, this incubating environment is not designed to treat all of the different kinds of plants that exist in the world and additionally, many plants are unable to gain access to these incubating environments.  For the plants that are privileged enough to gain access to and receive individually relevant treatment in an incubating environment, sometimes there is growth and signs of getting better.  The plants become a little healthier and then are removed from the incubating environment to be placed right back into the soil from which they came.  Also unfortunately however, the very soil from which the plant initially came was never treated – it is still the same soil which failed to nourish and sustain the plant to begin with.  As a result, even those plants that gained access to and experienced improved health from treatment received while incubated will often go on to become unwell again a short time after being placed back into the same untreated soil.  Our current paradigm treats the plant, not the soil.  We must shift to begin to treat the soil at the same time as the unwell plant.

Treating the soil to sustain returning plants that have become unwell is not enough though.  We need to go a step further.  We need to nourish the soil and pump it full of the nutrients needed to prevent plants from becoming unwell to begin with.  In this regard, our current behavioral health systems need to shift to serve as greenhouses of sorts.  With the knowledge that lifestyle and environmental factors are responsible for 70% of good health outcomes, there is no reason why behavioral health systems should not move toward fostering improved access to these positive social determinants of health.   Additionally, with the knowledge that many behavioral health challenges have known risk factors and early warning signs which make prevention and early intervention a very real possibility, there is no reason why behavioral health systems cannot move toward fostering environments equipped to respond early.  If we are truly to see any significant changes in positive behavioral health, our systems need to serve as greenhouses in which good health is promoted and sustained, early warning signs of becoming unwell are detected and addressed, and the environment is made rich with the nutrients of resources and supports needed for all inhabitants to maintain good behavioral health overall.

Marijuana Legalization – It’s Time For The Field To Think More Broadly

I am a huge fan of the Office of National Drug Control Policy’s (ONDCP) Director Michael Botticelli and hold both him and the transforming ONDCP agency he leads in the highest regard.  I could write endlessly on what an amazing recovery advocate and ally we have found in Director Botticelli and the ONDCP’s recovery-oriented approach to addressing the nation’s substance misuse challenges.  To that end, what follows is in no way an attack on Director Botticelli and the ONDCP but more so a challenge to the substance use disorder prevention, treatment and recovery field – this is directed at the practitioners, advocates, individuals and family members in recovery, researchers and educators who all share the common goal of making prevention, early intervention and recovery from a substance use disorder more accessible and available to all.

Currently we see a debate raging on regarding the legalization of marijuana.  This debate has been supercharged in recent weeks by Director Botticelli’s reiteration of the federal government’s stance on opposing the legalization of marijuana as some states have moved toward legalization.  Director Botticelli cited the ideas of marijuana as a “gateway drug”, young people having a low perception of risk regarding the use of marijuana and research that supports the dangers of marijuana use on the developing brain as some of the core reasons for opposing legalization.  Many experts and advocates are in agreement and see the legalization of marijuana as potentially increasing use among youth.  Many other experts and advocates disagree and see this as a step backwards in what has been forward momentum around decriminalizing substance use and substance use disorders.

While I do not pretend to know the best direction to go in, I do believe there are some aspects of this debate that are important for all of us to consider.  As a person in long-term recovery from a substance use disorder who has utilized an abstinence-based pathway to recovery for close to 11 years, I recognize that for me personally, using marijuana – whether it is illegal or legal – is not something that is in the best interest of my recovery and therefore not something I can engage in.  Just like the act of indulging in the currently legal substances of alcohol, tobacco and McDonalds cheeseburgers is not in alignment with the practices I need to maintain my health and wellness, marijuana is in the same boat.  Moreover, I can recognize that my abstinence from alcohol, tobacco and McDonalds cheeseburgers is what remains the best practice for me personally while not imposing my personal needs and choices on other people.  Millions of individuals can use these substances and eat a cheeseburger afterwards without it moving into problem use or a substance use disorder.  I just happen to not be one of them.  I do not need to oppose other people’s use of these substances just because it would not be a good idea for me and many of my friends.  I recognize that many of my friends and I, despite sometimes living in still siloed recovery systems that do not allow for us to see it, are actually in the minority when it comes to this need for abstinence only.

In addition to the idea that abstinence from marijuana is not the goal of nor necessary for more individuals than not, another point to consider is the following.  Alcohol, a legal drug and the most deadly, has seen a steady decline among youth and was actually used less than marijuana among 8th graders in 2014 according to the National Institute on Drug Abuse.  The use of tobacco, another legal and the second most deadly drug, has also steadily declined among young people. The idea that legalization increases use falls flat when we look at steady decreases in the use of these two substances.  Perhaps we ought to explore more how education and prevention efforts may have aided in this decline and how these efforts can be enhanced and more effective when substances are in fact legal.  At the very least, the data shows that marijuana use among youth is already happening at a rate higher than that of legal substances, so keeping marijuana illegal doesn’t seem to be working out too well for our nation’s young people.

To reiterate, I do not pretend to know the answer as to whether the legalization of marijuana would increase or decrease use among youth.  I believe more unbiased research is needed and there is much to consider.  What I do know however is that we have a lot of evidence showing continued decreased use among youth when it comes to legal substance use with increases in illegal substance use.  I also know that we have a lot of old thinking still pervading how we approach this issue and that some of us who subscribe to and apply the abstinence-based pathway in our own lives have difficulty seeing other possibilities outside of only abstinence. Ultimately, for those of us who practice, advocate, educate, shape policy around and aim for change in the area of substance misuse, I only propose that we step back for a moment and think more openly, critically and broadly about the idea of legalizing marijuana use.  We owe it to our young people to be doing just that.

Inspiration, Humanity and Humility In Recovery

The act of openly sharing one’s recovery status with the world around them allows for some of the most extraordinary of things. When those of us in recovery talk or write about our journey through and past the difficulties associated with mental health and substance use challenges, we are then able to serve as beacons of hope and visible guideposts for others who seek to do the same. It is most certainly one of the highest acts of selfless service; to be willing to disclose that we have experienced illnesses and challenges that are still so highly stigmatized and discriminated against takes courage, guts and a willingness to be vulnerable. In sharing ourselves so candidly, we help to shatter stigma, strip away shame and stomp on the sordid idea that recovery is not possible.

There are many times that I’ve been called an inspiration as a result of my own candor regarding my recovery journey. For me, this is the most humbling of adjectives and one that I have always felt privileged to show up as in the world for others. The idea that some of the most painful experiences of my life are now used to serve as a light for the world is one that brings personal fulfillment and a deep level of gratitude. I am tremendously appreciative of the opportunity to serve as an inspiration, however I also recognize that there are certain responsibilities that come with carrying that adjective. One of the responsibilities, for instance, is to always remember for myself and to inform others of the reality that my recovery is largely as a result of many factors for which I cannot take credit. Some of these factors include access to resources and supports that I had while so many others are literally dying to have. Another responsibility when being called an inspiration is to share the whole story – not just the neatly packaged pretty parts but the entire barrel of all that comes with it. If I tell you that you can accomplish something because I have, but do not tell you all of the obstacles and barriers I have experienced while attempting to accomplish it, am I really doing you a fair service in the end? It is therefore important to authentically share the challenges along with the successes if we truly wish to serve as guideposts for others seeking to do the same.

To that end, it is important to share that recovery is messy, just like being human is messy. With nearly 11 years in sustained recovery, I can tell you that for me, there are still some days when the idea of continuing on in life can be overwhelming and scary. There are still many instances in which I struggle with depression, insecurities, feelings of unworthiness, bad decision making, fear, loneliness and a multitude of other challenges. There have been many times when not using alcohol or other drugs has been replaced by an astoundingly creative wide variety of other self-destructive things. There have been many occasions when a Taco Bell drive-thru served as the cop-man or self-pity surfaced regarding all of the things in this world that I cannot indulge in. For every monumental milestone, awesome achievement and inspirational impression, there are equal amounts of hard work, mistakes, struggle, falling down and getting back up, lessons learned and opportunities for improvement.

The beautiful thing is, recovery still happens. In all of our humanity and with all of our imperfections and flaws, when we share our recovery journeys honestly, openly and transparently with the world around us, we truly do serve as inspirations. Not as pie-in-the-sky, unachievable, perfectly packaged inspirations but as very human, very real examples of recovery being possible from mental health and substance use challenges, and really, for humanity as a whole. At the end of the day, perhaps the greatest act of service when it comes to being an inspiration is in sharing this: I am human, I am flawed and I still recover…so can you.

Beyond Treatment: Let’s Not Forget About The Soil

We know that any gains made in treatment often plummet and fall apart when communities aren’t equipped with the nutrients of resources necessary to serve as fertile soil for continued recovery.

Whenever a public health crisis cascades upon us, it is natural that we grasp at the quick fixes and shiny objects that capture our attention. As history has shown us however, these sort of responses rarely yield long-term success and can instead result in a slew of unanticipated consequences that further compound the concern. With increased attention and a much welcomed sense of urgency emerging when it comes to addressing substance use challenges in this country, it is important that we continue to think globally on the issue and not settle for narrow and insufficient resolutions.

One area in which we can direct our focus is in the public perception that treatment is the be-all and end-all solution to addressing substance use challenges. While access to evidence-based, clinically sound, culturally appropriate and readily available mental health and substance use treatment is of extraordinary importance, access to initiating and sustaining recovery is something that extends far beyond merely access to treatment. We must take care to remember, as well as to educate others, that increasing access to treatment in and of itself is far from a comprehensive response to facing addiction and facilitating recovery.

Treatment is but one pane on the larger recovery umbrella that encompasses all of the resources and supports an individual and their family may need to initiate and sustain recovery.

Although it is true that for many folks, having immediate access to quality treatment is an instrumental ingredient in their wellness and recovery journeys, we must not forget that long-term community-based recovery support services are just as influential and necessary when it comes to sufficiently addressing substance use challenges in this country. As a matter of fact, long-term community-based recovery support services that offer peer support in the areas of employment, education, housing, life skills and more are a vital and critical resource if we are ever to see true, lasting opportunities for individual, family and community recovery.

As we continue to advocate for a large-scale response to our country’s large-scale substance misuse and associated costs problem, it is imperative that we do not settle for anything less than what is truly necessary for individual, family and community recovery. While we certainly ought to continue assertively advocating for much needed improved access to quality treatment, we must also speak just as loudly to the need for increased and improved community-based recovery support services.  We must not settle for narrow and insufficient resolutions.  We must not forget about the soil.