New Approach in Substance Abuse Treatment: The Self-Medication Model
There are many theories for addiction, and almost all of them involve “craving”. Much of the substance abuse treatment is based on trying to diminish or eliminate that craving. I think this approach takes us in the wrong direction in understanding substance abuse, and it leads to therapies that are less effective than they could be. My experience over the last seven years while treating clients in recovery with Direct Neurofeedback is that substance abuse has very little to do with craving. Rather, substance abuse is a form of self-medication, whose primary aim is to ameliorate the symptoms of underlying anxiety and depression (and to a much lesser extent, the symptoms of shame, guilt, boredom, ADD, the discomfort of withdrawal and other causes of acute and chronic distress).
In fact, because the concept of craving is off the mark, the term “addiction” is somewhat misleading. I think the “self-medication” model may be more accurate and consequently more helpful in guiding therapy.
When taking the history of a new client, I have found the single most revealing question to ask is, “At the time your are taking the substance in question, are you experiencing acute anxiety or depression?” In other words, is substance abuse a result of “craving” the “high” or avoiding the anxiety and depression? And the answer I get is almost invariably the latter. Clients are not abusing drugs for the high. Rather, they are self medicating to cope with anxiety and depression. While this might seem to be a common sense observation, the implications for treatment are important.
In the “self-medication” model, if the underlying anxiety and depression aren’t adequately treated, abstinence will remain very difficult. And to a great degree I think this is why abstinence rates are typically so abysmally low–the underlying basis for self- medication is still present regardless of how much emotional support and therapy one undergoes. Without effectively dealing with underlying anxiety or depression, the client in recovery is often “white knuckling” it, trying to cope on his own. In the spirit of not being dependent on any substance and trying to avoid abuse of prescribed medicines, clients often get the message to take as little medication as they can tolerate. In other words, they are told to stay away from medication unless he or she absolutely needs it. This may in fact be counterproductive at times making coping with anxiety and depression all the more difficult and leading to more self-medication. Counseling and therapy are important modalities for providing insight and understanding of patterns and relationships. They are an important part of the rehabilitation process, but they are less effective at reducing anxiety and depression than many people assume.
The self-medication model also suggests taking a second look at another conceptual mainstay of rehabilitation–“dual diagnosis”. The idea is that some people with addiction problems also have, at the same time, other serious disorders such as bipolar disease or significant depression. If these additional (“dual”) disorders are not addressed then recovery will be even more difficult. Viewing this from the self-medication model, “dual diagnosis” is a less useful concept.
If the majority of clients with substance abuse are self-medicating for anxiety and/or depression, then the term “dual diagnosis” is somewhat redundant. If most substance abuse is self-medication for anxiety and depression, then virtually every addiction, with some exceptions, is dual-diagnosis. Using the self-medication model, we assumed that every client has some combination of anxiety and depression until proven otherwise.
Even the concept of “addiction” is worth taking a second look at. I think the terms “substance abuse” or even better, “self medication” would be more useful. We associate “craving” with “addiction”, which supports the rationale for existing treatments. However, in the “self-medication” model, the emphasis is more on modulating the nervous system so self-medication is less necessary. Anxiety is an over-aroused nervous system. The “flight or fight” (sympathetic) part of the peripheral nervous system is over stimulated and experiences “threat”, which provokes anxiety. Even when the threat is no longer there, the brain has “forgotten” how to ratchet down and relax into “rest and digest” mode (homeostasis). This over arousal becomes chronic, easily flaring up to acute anxiety.
Depression is less well understood than anxiety and fear. One way to see depression is as an “under-arousal” of the nervous system. When significant, it leads to severe dysphoria. When someone has a low tolerance for the dysphoria or uncomfortableness of anxiety or depression, then prescribed medication and self-medication come in. Focusing more on the “self medication” model stresses the critical importance of effectively addressing the underlying anxiety or depression and keeping that emphasis front and center.
Depression can be so dysphoric and debilitating for family and work life, that self-medication is common. Antidepressants are only modestly more effective than placebo and are limited by side effects. Drugs for anxiety (anxiolytics) are more effective. But with the benzodiazepines (Xanax, Ativan, Valium, etc.), there is a risk of addiction and often problems from withdrawal when trying to stop taking the medications. The SSRIs, the most common antidepressants, are also used for anxiety. They are generally more benign in terms of withdrawal but aren’t always effective and have their own set of side effects.
Another benefit of maintaining a focus effectively on treating anxiety and depression is that progress is seen in therapy. Therapists from recovery centers are very happy to refer their clients to us. With a marked reduction in anxiety and depression, clients are more capable of insight and more open to new ways of looking at things. Growth occurs quickly, which is extremely helpful if there is a limited stay at a residential center.
The reason I emphasize the underlying anxiety and depression is that we are now able to treat them more effectively than in the past and without the use of medication. The first new tool in our clinical arsenal was traditional neurofeedback. In traditional neurofeedback, electrical information from the brain is picked up from sensors on a client’s scalp. That data is transmitted to a computer and monitor, which a client interacts with. A client is “rewarded” by results on the screen to increase or decrease certain brainwave patterns, and a type of brain training is taking place. This can be very helpful in decreasing anxiety and a lessening of depression.
A big step forward from traditional neurofeedback is Direct Neurofeedback, which is what we offer at The Dubin Clinic. The client experiences almost immediate initial results (usually in the first session). There are fewer and shorter sessions; there is better compliance (less dropout) and the ease and simplicity of treatment all distinguish Direct Neurofeedback® from traditional neurofeedback.
Sensors measure electrical activity of the brain, which goes to the Direct Neurofeedback system. Then a very weak, imperceptible signal is sent back to the brain. This signal causes a tiny fluctuation in brainwave patterns and allows the brain to get out of frozen, stuck patterns. It’s like rebooting a frozen computer. Direct Neurofeedback® “dis-entrains” the brain from unhealthy stuck pathways. Clients don’t do anything other than sit still for a few moments. That brief, tiny signal to the brain does all the work. Direct Neurofeedback® is a positive feedback loop. The electrical activity from the brain determines what signal goes back to the brain. This signal causes a change in the brainwaves. This change in brainwaves then causes a change in the signal going back to the brain.
At the Dubin Clinic we use Direct Neurofeedback, a very effective treatment for a range of disorders including traumatic brain injury (TBI), ADD/HD, PTSD and, in particular, anxiety and depression. Direct Neurofeedback is effective with anxiety 90% of the time and depression 80% of the time. Those who undergo Direct Neurofeedback in collaboration with other routinely used modalities have much lower rates of recidivism than those who just take the traditional approach.