Chapter 1—What is Chemical Dependency/Addiction?

The problems of chemical dependency that affect people when they use alcohol or drugs, and even after they have stopped using, include the following.

Malnutrition and metabolic dysfunction. The addict's ability to function normally is damaged by the effects of alcohol and/or drugs on the brain and body. Only after a period of proper diet and taking supplements can normal body chemistry be restored. This process affects the way the addict thinks, feels, and acts.

Liver disease and other medical complications. The addict's liver enzymes may be far above normal. This can cause poisonous effects within the body and may lead to infections and illnesses that need to be treated before normal functioning can resume.

Brain dysfunction. Alcohol and drugs damage brain cells, interrupt the production of certain brain chemicals called neurotransmitters, and alter the way the brain functions. Some of these changes may be permanent.

Addictive preoccupation. A chemically dependent person's thinking patterns are altered by chemical dependency as the disease progresses. These changes cause the person to have strong thoughts, desires, and physical cravings for alcohol or drugs. These processes also change the way the person sees the world. They lead the person to believe that using is better than not using, despite the bad things that result from using.

Social consequences. As the physical and psychological problems identified above get worse, the person's behavior becomes more antisocial and self-destructive. Frequent social consequences of addiction are job loss, money problems, car accidents, domestic violence, criminal behaviors, illness, and death.

Criminal behaviors. Chemical dependency can cause a person to commit crimes. People who are chemically dependent commit crimes related to their use of alcohol or drugs (drunk driving, public drunkenness, assault, etc.), the support of their addiction (selling drugs, committing crimes to get drugs or money for drugs, etc.), and secondary consequences of drug or alcohol use (not paying child support or court fines, failing to follow through with probation requirements, etc.). Some people do not commit crimes until they become chemically dependent. Others have personality problems that initiate their criminal behavior. Most of those who have personality problems either become chemically dependent on or abusive of alcohol and drugs. Any relapse into behavior that leads to criminal actions is likely to cause a relapse into the use of alcohol or drugs. Any relapse into chemical use is likely to cause a relapse into criminal behavior.

Because dependency on alcohol or other drugs creates problems in a person's physical, psychological, and social functioning, treatment must be designed to work in all three areas. The worse the damage in each area, the greater the chance of relapse and return to old behaviors (criminal actions and/or the use of alcohol or drugs). Total abstinence (not using any alcohol and drugs) plus personality and lifestyle changes are essential for full recovery.

• The type and intensity of treatment depend on the patient's:
• Current physical, psychological and social problems
• Stage and type of addiction(s)
• Stage of recovery
• Personality traits and social skills before the onset of addiction
• Other factors in life that cause stress.

Chemical dependency is a chronic condition that has a tendency toward relapse. Abstinence from alcohol and other mood-altering drugs is essential in the treatment of chemical dependency. It is also an important part of relapse prevention therapy. There is no convincing evidence that controlled drinking or drug use is a practical treatment goal for people who have been physically dependent on alcohol or drugs.

Many chemically dependent people who exhibit criminal behaviors were raised in families that did not provide proper support, guidance, and values. This caused them to develop self-defeating personality styles that interfere with their ability to recover. Personality is the habitual way of thinking, feeling, acting, and relating to others that develops in childhood and continues in adult life. Personality develops as a result of an interaction between genetically inherited traits and family environment.

Growing up in a dysfunctional family causes a person to have a distorted view of the world. He or she learns coping methods that may be unacceptable in society. In addition, the family may not have been able to provide guidance or foster the development of social and occupational skills that allow the person to fully participate in society. This lack of skills and distorted personality functioning may cause addictive behaviors to occur. These problems may also contribute to a more rapid progression of the addiction, make it difficult to recognize and seek treatment during the early stages of the addiction, and make it hard to benefit from treatment.

There are four goals in the primary treatment of dependency on alcohol and other drugs:

• Recognition that chemical dependency is a bio/psycho/social disease
• Recognition of the need for life-long abstinence from all mind-altering drugs
• Development and use of an ongoing recovery program to maintain abstinence
• Diagnosis and treatment of other problems or conditions that can interfere with recovery.

Traditional treatment has taken one of two general approaches:

The Medical Model.

This approach tries to help the patient meet the first three goals listed above.

The Social/Behavioral Model.

This approach focuses on the fourth goal listed above.

The DMR has been devised to help recovering people and treatment professionals identify appropriate recovery plans, set treatment goals, and measure progress. The DMR describes six stages or periods of recovery.

Transition Stage

The transition stage begins the first time a person experiences an alcohol or drug-related problem. As a person's addiction progresses, he or she tries a series of strategies designed to control use. This ends with recognition by the person that safe use of alcohol and/or drugs is no longer possible.

The struggle for control is a symptom of a fundamental conflict over personal identity. Alcoholics and drug addicts enter this phase of recovery believing they are normal drinkers and drug users capable of controlled use. As the progression of addiction causes more severe loss of control, they must face the fact that they are addictive users who are not capable of controlled use.

During the transition stage, chemically dependent people typically attempt to control their use or stop using. They are usually trying to prove to themselves and others that they can use safely. This never works for very long. Controlled use is especially tough for people who are participating in criminal behavior because the high level of alcohol and drug use among their peers makes their lifestyle and use seem normal.

The major cause of inability to abstain during the transition stage is the belief that there is a way to control use.

Stabilization Period

During the stabilization period, chemically dependent people experience physical withdrawal and other medical problems, learn how to break the psychological conditioning causing the urge to use, stabilize the crisis that motivated them to seek treatment, and learn to identify and manage symptoms of brain dysfunction. This prepares them for the long-term processes of rehabilitation.

Traditional treatment often underestimates the need for management of these issues, focusing instead on detoxification. Patients find themselves unable to cope with the stress and pressure of the symptoms of brain dysfunction and physical cravings that follow detoxification. Many have difficulty gaining much from treatment and feel they are incapable of recovery. The lack of a supportive environment for recovery that many criminal offenders experience adds stress and undermines their attempts to stabilize these symptoms. They often use alcohol and drugs to relieve such distress. It takes between 6 weeks and 6 months for a patient to learn to master these symptoms with the correct therapy.

The major cause of inability to abstain during the stabilization period is the lack of stabilization management skills.

Early Recovery Period

Early recovery is marked by the need to establish a chemical-free lifestyle. The recovering person must learn about the addiction and recovery process. He or she must separate from friends who use and build relationships that support long-term recovery. This may be a very difficult time for criminal justice patients who have never associated with people with sobriety-based lifestyles.

They also need to learn how to develop recovery-based values, thinking, feelings, and behaviors to replace the ones formed in addiction. The thoughts, feelings, and behaviors developed by people with criminal lifestyles complicate and hinder their involvement in appropriate support programs during this period. Major intervention to teach the patient these skills is necessary if he or she is to succeed. This period lasts about 1B2 years.

The primary cause of relapse during the early recovery period is the lack of effective social and recovery skills necessary to build a sobriety-based lifestyle.

Middle Recovery Period

Middle recovery is marked by the development of a balanced lifestyle. During this stage, recovering people learn to repair past damage done to their lives.

The recovery program is modified to allow time to reestablish relationships with family, set new vocational goals, and expand social outlets. The patient moves out of the protected environment of a recovery support group to assume a more mainstream and normal lifestyle. This is a time of stress as a person begins applying basic recovery skills to real-life problems.

The major cause of relapse during the middle recovery period is the stress of real-life problems.

Late recovery period

During late recovery, a person makes changes in ongoing personality issues that have continued to interfere with life satisfaction. In traditional psychotherapy, this is referred to as self-actualization. It is a process of examining the values and goals that one has adopted from family, peers, and culture. Conscious choices are then made about keeping these values or discarding them and forming new ones. In normal growth and development, this process occurs in a person's mid-twenties. Among people in recovery, it does not usually occur until 3B5 years into the recovery process, no matter when recovery begins.

For criminal offenders, this is the time when they learn to change self-defeating behaviors that may trigger a return to alcohol or drug use. These self-defeating behaviors often come from psychological issues starting in childhood, such as childhood physical or sexual abuse, abandonment, or cultural barriers to personal growth.

The major cause of relapse during the late recovery period is either the inability to cope with the stress of unresolved childhood issues or an evasion of the need to develop a functional personality style.

Maintenance Stage

The maintenance stage is the life-long process of continued growth and development, coping with adult life transitions, managing routine life problems, and guarding against relapse. The physiology of addiction lasts for the rest of a person's life. Any use of alcohol or drugs will reactivate physiological, psychological, and social progression of the disease.

Although some patients progress through the stages of recovery without complications, most chemically dependent people do not. They typically get stuck somewhere. A Astuck point" can occur during any period of recovery. Usually it is caused either by lack of skills or lack of confidence in one's ability to complete a recovery task. Other problems occur when the recovering person encounters a problem (physical, psychological, or social) that interferes with his or her ability to use recovery supports.

Traditional models of treatment are based on the idea that once a person is detoxified, he or she can fully participate in the treatment process. Although this is true for many patients in the early stages of addiction who have had functional lives before their addiction progressed, it is not true for most of the criminal justice population. In addition, most traditional programs have a program format that is applied to all people regardless of their education, personality, or social skills. Patients whose needs fit within the program usually do well. But those whose needs do not fit, such as criminal justice patients, generally do not do well.

The DMR recognizes that there are abstinence-based symptoms of addiction that persist well into the recovery process. These symptoms are physical and psychological effects of the disease of chemical dependency. In the DMR, these symptoms must be stabilized and the patient must be taught how to manage them before general rehabilitation can take place. This model identifies the specific symptoms that a patient needs to overcome.

This model also contains methods and techniques that recognize the learning needs, psychological problems, and social skills of the patient.

Post Acute Withdrawal

Some of the symptoms of withdrawal from alcohol or drugs are the result of the toxic effects of these chemicals on the brain. These symptoms are called Post Acute Withdrawal (PAW). PAW is more severe for some patients than it is for others. Other factors cause stress that aggravates PAW. Below is a list of conditions affecting the criminal justice population that tend to worsen the damage and aggravate PAW.

Physical conditions that worsen PAW through increased brain damage or disrupted brain function:

• Combined use of alcohol and drugs or different types of drugs
• Regular use of alcohol or drugs before age 15 or abusive use for a period of more than 15 years
• History of head trauma (from car accidents, fights, falling, etc.)
• Parental use of alcohol or drugs during pregnancy
• Personal or family history of metabolic disease such as diabetes or hypoglycemia
• Personal history of malnutrition, usually due to chemical dependence
• Physical illness or chronic pain.

Psychological and social conditions that worsen PAW:

• Childhood or adult history of psychological trauma (participant in or victim of sexual or physical violence)
• Mental illness or severe personality disorder
• High stress lifestyle or personality
• High stress social environment.

Addictive Preoccupation

The other major area of abstinence-based symptoms is addictive preoccupation. This consists of the obsessive thought patterns, compulsive behaviors, and physical cravings caused or aggravated by the addiction. These behaviors become programmed into the patient's psychological processes by the addiction. They are automatic and can cause the recovering patient to return to use unless he or she has specific training to identify and interrupt them.

Addictive preoccupations are activated by high-risk situations and stress. Because of the environment surrounding most criminal justice patients, they often experience high-risk situations and stress. These situations and stresses can include

• Exposure to alcohol or drugs or associated paraphernalia
• Exposure to places where alcohol or drugs are used
• Exposure to people with whom the patient has used in the past or people the patient knows who are actively using
• Lack of a stable home environment
• Lack of a stable social environment
• Lack of stable employment.

Traditional treatment focuses on either detoxification alone or detoxification with movement into a rehabilitation program aimed at changing the patient's lifestyle. Programs are similar for all patients. Many programs omit teaching the specific stabilization skills that are necessary before lifestyle rehabilitation can take place.

For the purpose of relapse prevention therapy, chemically dependent people can be categorized according to their recovery/relapse history. These categories are as follows:

• Recovery-Prone
• Briefly Relapse-Prone
• Chronically Relapse-Prone.

These categories correspond with the outcome categories of continuous abstinence, brief relapse, and chronic relapse described above. Relapse-prone individuals can be further divided into three distinct subgroups.

Transition patients fail to recognize or accept that they are suffering from chemical addiction in spite of problems from their use. This failure is usually due to the chemical disruption of the patient's ability to accurately perceive reality, or to mistaken beliefs.

Unstabilized relapse-prone patients have not been taught to identify the abstinence-based symptoms of PAW and addictive preoccupation. Treatment fails to provide these patients with the skills necessary to interrupt their disease progression and stop using alcohol and drugs. As a result, they are unable to adhere to a recovery program requiring abstinence, treatment, and lifestyle change.

Stabilized relapse-prone patients recognize that they are chemically dependent, need to maintain abstinence to recover, and need to maintain an ongoing recovery program to stay abstinent. They usually attend Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or another 12-step program in addition to receiving ongoing professional treatment. They also make protracted efforts at psychological and physical rehabilitation and recommended lifestyle changes during abstinence. However, despite their efforts, these people develop symptoms of dysfunction that eventually lead them back to alcohol or drug use.

Many counselors mistakenly believe that most relapse-prone patients are not motivated to recover. Clinical experience has not supported this belief. More than 80 percent of relapse-prone patients admitted to the relapse prevention program at Father Martin's Ashley in Havre de Grace, Maryland, had a history of both recognition of their chemical addiction and motivation to follow aftercare recommendations at time of discharge. In spite of this, they were unable to maintain abstinence and sought treatment in a specialized relapse prevention program. he or she became aware of during this exercise.