Promoting healthy lifestyles as a biopsychosocial approach to addictions counseling.

Dear Editor:

Despite progress in understanding the biochemistry of drug addiction and the effects of drugs on the body, most treatment programs lack a health education protocol. A review of the literature suggests that more attention needs to be directed to the physical aspects of recovery, including nutritional therapy, exercise regimes, and relaxation techniques as well as concrete social survival skills and employment skills. To achieve a holistic approach to addictions treatment, we may need to place less emphasis on mental health issues in favor of promoting the physical and social aspects of healthy living. The goal should be to assist the addict in achieving physical well-being, useful life skills, and concrete social supports.

Relapse prevention, self-help groups, and brief therapy are the trademark of addictions counseling today. Psychological triggers that bring about cravings are addressed in treatment, but little attention is placed on the long term physical effects of drugs on the body, and the physical and social crises that bombard the recovering addict daily. Helping the recovering addict successfully renegotiate the work world or recognize the importance of the evening meal as a social event in place of "happy hour" may be as important in avoiding relapse as identifying the triggers that instigate reuse. How many addiction programs have a nutritional therapy component or exercise regime as part of their protocol? Without these components, how can the addict be expected to resume healthy eating and other physical maintenance regimes that are essential to offset the physical damage done by the addiction?

Helping addicts alter their life style is recognized as part of counseling, but what are the components of a healthy life style? It is most certainly more then the absence of drugs. For many, daily crises have always been a part of their lives, especially if they grew up in dysfunctional families and never experienced a "normal" life where the daily routine of eating, sleeping, and recreating were taken for granted. The ordinary life may seem monotonous and boring to the recovering addict, requiring that the counselor help the addict understand the value and importance of normalcy and routine to restoring health and avoiding relapse.

The literature across the professions (social work, medicine, nursing) reflects a commitment to a "good health" approach to helping the addict in recovery. Recovering from addiction is a process that goes on long after the initial detoxification, and the medical community is recognizing the need for medical intervention beyond the few days now allowed for inpatient stays. Ruden (1997) points out that the most difficult part of handling withdrawal is not the initial physical problems (however painful they may be), but rather dealing with the more subtle longings that come later. These, he suggests, can only be remedied by a "biobalance approach" that restores the neurochemicals in the brain to normal levels. According to White (1998), alcoholism treatment facilities were prescribing special diets to help the alcoholic as early as 1840. In the 1930's, vitamin therapy was a routine accompaniment to alcohol detoxification. Later, the use of vitamin B-3 (niacin) was added to the treatment of alcoholics. Bill W., founder of AA, published three papers on the potential of vitamin B-3 and credited vitamin therapy with relieving long-standing emotional problems (White, 224). In his book, The Prevention of Alcoholism through Nutrition, Williams (1981) suggests that pantothenic acid and folic acid are essential to a healthy cellular environment and should be promoted as part of good health. Somer (1999) confirms in Food and Mood that a deficiency of pantothenic acid (readily available through sources such as oranges, broccoli, brown rice, and wheat germ) can result in depression, fatigue, irritability, and restlessness. A deficiency of folic acid (available through spinach, bananas, and avocados) can also result in depression, along with forgetfulness, insomnia, and dementia.

Mood may also be affected by external variables. Some employment, by its nature, creates a high-low cycle. The cycles associated with securing business contracts or winning bids are usually followed by celebratory events that often promote drinking and drugging. The process of securing an education, with the pressures associated with papers due and end-of-semester exams encourages relapse, especially when the response in the past has been to medicate, get high or drink, to cope with the stress, especially when there is considerable social pressure to reuse and abuse. Being aware of these triggers is not enough if there is no obvious clear alternative. Dealing with the social pressure associated with alcohol and drug abuse is not sufficiently addressed in most treatment programs. To identify a new social group and be accepted may work for the college student, but what about the Yuppie whose boss is the negative influence (namely, three martini-lunches)?

Avoiding mood swings, whether they are results of biochemical imbalances or environmental stressors, is an outcome of healthy eating and adoption of daily routines that mandate three meals, eight hours of sleep nightly, and an exercise regime. The link between mood monitoring and a healthy life style should begin with attention to nutrition. Is it unreasonable to expect treatment programs to have books of this nature on hand? Other "tools of recovery" that must be in place to assist the recovering addict, are resource manuals that detail available gyms and exercise clubs as well as alternative treatment resources for physical ailments (including acupuncture and chiropractic services).

To be avoided are substitute addictions, at least those that are antithetical to a healthy life style, including compulsive overeating, gambling, and excessive work. Many persons in recovery cannot cope with free time very well and may need considerable help learning not to overwork as well as to identify and enjoy healthy leisure activities.

Understanding what happens chemically with the use of drugs and alcohol has become part of most treatment programs on the assumption that an awareness of the self-destructive effects of drugs may prevent a relapse. The question for the addict is how to repair the damage that has already occurred. Avoiding additional drug use won't by itself relieve the physical discomfort and cravings. Understanding that our dopamine levels have been severely compromised as a consequence of cocaine abuse does nothing to restore these neurotransmitters, and it doesn't help to know that the reduced serotonin levels in the brain contribute to the inability to sleep. The neuronal system is affected by a variety of environmental stimuli and situations, and a withdrawal state can occur many years after the last dose (Stefanis & Hippius, 1995).

The relationship between neurotransmitter levels and mood is well established. When the crack addict is released from detoxification, the mood swings continue, as any addictions counselor can confirm. We know that high dopamine levels are associated with decreased appetite and that malnutrition has been recognized as a symptom of alcoholism; however, we do not have a quick and simple remedy for restoring nutritional balance or relieving the severe depression associated with dopamine deficiencies.

The inability to sleep is related to the effects of drugs on nor-epinephrine and serotonin levels, and severe sleep deprivation can be deadly. To suggest to someone who is having trouble sleeping that they go home and eat some carbohydrate-rich foods or drink warm milk may be unconventional, but it may also be a necessary part of tending to the biological aspects of recovery.

Restoring neurotransmitter levels to normal should be a part of the educational component of treatment. It may relieve some of the guilt and self-doubt that results in relapse when the client "fails" to exert enough willpower to overcome the cravings.

There needs to be a link between physical restoration, feelings, and social relationships in recovery. The "bio" cannot be separated from the psychosocial; they are inter-connected. The environmental condition of the workplace may, for example, decrease or increase the risk of relapse. Job reintegration is an important part of improving one's life style. For those who must return to the job that they held before recovery, it is unquestionably more difficult, causing stress and guilt that can trigger relapse. A counselor can assist in facing the readjustment in going back to work by incorporating discussion of this process in the therapeutic group meetings, and working with an EAP representative on the job site. Many jobs are by nature boring and may cause the recovering addict to miss the adventure and risk-taking that were a part of the pre-recovery days. Gardner (1999) suggests that those who score high on sensation-seeking or novelty-seeking scales are at higher risk of addiction and relapse. Their ability to forego the unconventional lifestyle and adjust to a crisis-free environment is inherently limited. The appropriate response, according to Waal and Morland (1999), is to help addicts learn to weigh the short-term against the long-term. That is, they must balance the intense desire for the short-term thrill with the interest of achieving the long-term goals arrived at in treatment. More attention may have to be devoted to setting future goals and monitoring more intensely their progress towards these goals. Instead of focusing on securing a job, any job, focus on finding employment that is stimulating and provides opportunities to experience success and provide stability and perhaps even a career path. It may also be helpful to identify more adventurous risk-taking recreational activities, so that leisure time is spent in a more exciting way. The rewards of a job well done, when reinforced by the counselor or colleagues, can help meet the need for excitement, and is consistent with the cognitive behavioral approach. Beware the new convert, however, who having found religion, gets "high on God" in lieu of drugs. This may be a short-term solution if the next time things don't go well they blame God. They need to look to their strengths to find ways of coping with challenges rather than relying totally on God or their higher power. An expression that may help put this into perspective is: "Do your best and pray that God will take care of the rest".

Prescription drugs are becoming more available to restore neural deficiencies and reduce physical cravings, but these drugs will not relieve the environmental pressures. Peer pressure and the need for social acceptance influence various age groups differently, requiting a differential approach, depending on the age of the client population. For example, much alcohol abuse among the elderly has its roots in the need for social relationships. Routine participation in "happy hour" may be a way to meet this need, but may also cause a relapse, even if the alcoholic has been in recovery for an extended period of time. Remediation requires alternative social activities to respond to the elder's social isolation.

The adolescents' drug cravings are often more intense physically because of the immaturity of the teenagers' metabolic system. The pressure from peers to use alcohol and/or drugs is very difficult to resist. A stable steady lifestyle is the antithesis of adolescence, making it even more difficult to help them move to a balanced diet and routine health regiment. Treatment must take these differences into account, perhaps by utilizing peer pressure positively through the group work process. Reifman et al. (2001) suggest that "health values" can buffer environmental risks for drinking behavior in adolescents. It may be time to recognize "health values" as important for addiction treatment as well as prevention.

Environmental circumstances, age and developmental status, genetic predisposition to risk-taking--any or all may contribute to the addict's inability to cope with addiction. None can be ignored if long-term sobriety is to be achieved.

The identification of drug addiction and/or alcoholism as a disease has helped rid the abuser of some of the stigma formerly attached to the problem. The body's inability to metabolize alcohol and the neural damage resulting from drug abuse are part of the disease. The absence of necessary nutrients in the body compounds the problem. "I must continue to drink because I have inherited my alcoholism", suggests the self-fulfilling potential danger in adopting the disease approach. When the disease is inherited, or presumed to be inherited, one way of reversing the danger is to recognize and bring attention to the role of the family in recovery. Slaght (1994) confirmed the importance of family ties for the substance abuser in her study of ex-convicts. Whether or not the ex-convict found and/or retained a job, she found, was not directly related to his relapse; rather how his family handled his unemployment became the issue. Where family members were more patient, drug reuse was less likely to occur. The simple fact that the family was willing to take the convict back and provide food and shelter ungrudgingly was also critical to recovery. The family's belief that the addict can overcome the addiction becomes a crucial support.

According to Nixon (1996), stress and anxiety have a profound effect on the immune system, and thus on health. Interpersonal relations with family and peers are tremendous stress producers. Family and friends are important in making mealtime a social event. If it is an occasion for quizzing the addict about his daily activities, it will be stressful rather than pleasant. Cooking and eating should be pleasurable activities. Making cookies together or planning and carrying out a gourmet meal with a friend can be socially uplifting as well as psychological rewarding. In addition to dealing with the emotional aspects of these relationships, treatment programs should include a component that teaches stress management and relaxation techniques.

Likewise, exercise is more fun and more likely to occur when it is done with others. Aerobics and yoga are good examples; to attend regularly and participate actively depends on a certain amount of social pressure that contributes to a successful exercise program. The addict new in recovery may need help incorporating and maintaining these types of activities into his life style.

Where family is not involved, recovery will depend heavily on peers. Setting up coffee houses in the community is an example of a successful way in which one recovering addict found to meet his need for social support, while also providing a drug-free environment for others. NA and AA meetings were held at the coffee house as well. This approach created an environment where sober behavior was more socially rewarding than drinking or drug using behavior.

Dietary changes, three meals plus snacks, at least one hour of exercise per day, maintaining a balance between work and play, and plenty of rest are necessary for recovery, but they are only possible in the presence of a social support system. In the early stages when physical discomfort dominates, it may be necessary to monitor daily activities through a journal or other self-reporting system to let the counselor and the support group know whether a proper diet is being maintained and new social contacts are being attempted. Are counselors knowledgeable enough about nutrition to take on the task of educating addicts? Simply instructing the client to avoid highly refined processed products isn't enough. We may agree that it is important to restore potassium and amino acids that tend to be depleted with excessive drug use, but what then? How do we help the client progress to the point that monitoring is no longer necessary?

If an integrated multidisciplinary approach is to be incorporated into treatment, a different approach to counselor training that involves nursing, psychology, and social work may be needed. Now that licensing and certification is required in most states for addiction counselors, continuing education may provide an opportunity to help counselors expand their knowledge base.

Once it is agreed that a biopsychosocial approach is needed, the next issue is where to begin? Not only is it necessary to assess total health needs, but the order in which to begin to meet those needs must be considered. Is the depression, anxiety, irritability, and insomnia experienced by the recovery addict caused by vitamin deficiencies or are these psychosomatic symptoms that require psychotropic medication?

Those who promote the physical aspects of recovery are not concerned with an analysis of the history of the addiction that is often considered essential to developing an appropriate treatment plan. They contend that recovery cannot begin until the body begins to overcome the toxicity that is part and parcel of excessive drug use (Milam & Ketcham, 1981). That is, the client needs to feel better before any treatment will be effective. While an emphasis on physical health may be essential initially, the reality under the current managed care system is that few programs other than the short-term detoxification protocols, respond to the biological aspect. In order to meet the ongoing health needs of recovering addicts, it falls to the traditional psychosocial treatment programs to meet the need. Additionally, they must go beyond health education--in some cases, make medical interventions available, especially when it is clear that power and environmental changes alone will not suffice. Combining medication and therapy may be a viable approach.

Long-term recovery requires counseling for many months after detoxification, and perhaps the continuance of some drug therapies is needed in instances where drug abuse has been long-standing. One patient who took advantage of the new rapid detox process reported that the drugs he received "put me in the right direction", but gave credit primarily to his family and NA for his continued sobriety.

For former addicts, incorporation of a "healthy lifestyle" module into educational programs should contain discussion of employment, including how to get and keep a job. Vocational testing may be useful in helping the addict determine career aptitudes and interests thus increasing the probability of job satisfaction. Clients may need support in not settling for the first job they find, and may require assistance utilizing online resources as the primary source of job availability.

Are you prepared to teach your clients how to have fun and to rediscover their sense of humor? Can you help your client see the irony and the humor in some of the behavior associated with drug use? Denial is a very serious business, but some of the behavior associated with denial is, indeed, humorous. The cartoon with a man buried in beer cans stating, "What do you mean you think I have a drinking problem?" comes to mind.

Discipline is facilitated by following a daily routine which can include an occasional diversion by reading a good mystery novel, seeing a movie, or visiting the amusement park, perhaps with children or grandchildren. Children give us permission to play and revisit our own childhood, perhaps this time in a more fulfilling way.

One thing that is very apparent to those in the addictions field is that the best-intentioned addict can relapse. The physical cravings become overwhelming; the emotional trauma that generated the need to escape returns, or the need for excitement and adventure can no longer be ignored. Treatment isn't working in these cases, prompting a need to reassess the approach. Are we providing sufficient rewards as a part of the behavioral approach or are we placing the emphasis on punishing those who fail?

It may not be possible to separate and analyze the effectiveness of each component of a drug treatment program. If we aren't sure what is working, then we may need to offer more rather than less, with the hope that some combination of the components, whether it be the biological, social and psychological, will be effective. Monitoring all three of these components will serve both as a tool to assess and reassess progress and as a research guide. The addict in recovery is the best source of information as to the effectiveness of a treatment or combination of treatments. Journaling by the person in recovery is one technique that can serve as a self-monitoring system and as a source of qualitative data on program effectiveness.

Until research clarifies what methods are most effective in preventing relapse, a comprehensive approach seems logical, avoiding the temptation to adopt the latest or the most comfortable method in treating drug addiction. History suggests that nutrition and diet cannot and should not be overlooked, and including health information in both treatment and professional training can facilitate that healthy recovery. Knowledge of brain chemistry is helpful in understanding the physical devastation of drug abuse as well as the pain and discomfort associated with withdrawal and cravings, but must be linked to remediation methodologies.

Assisting the person in recovery to restore a healthy lifestyle that includes attention to eating, sleeping, exercise, recreation, work, and family is a critical part of the treatment process. An advantage to modern society is the development of new medications and nutrient supplements. Medical discoveries that mediate physical cravings can be helpful, but should not be viewed as a panacea. Relapse rates remain unacceptably high in many treatment programs, suggesting that new or revised strategies are needed. Perhaps it is time to revisit the physical and social as well as the psychological aspects of recovery, and their place in a comprehensive flexible treatment effort that takes into account the multiplicity of needs of the recovery addict.

References

Gardner, E.L. (1999). The neurobiology and genetics of addiction: Implications of the reward deficiency syndrome for therapeutic strategies in chemical dependency. In J. Elster, ed. Addiction: Entries and Exits. New York: Russell Sage, 57-91.

Milam, J.R. & Ketcham, K. (1981). Under the Influence: A Guide to the Myths and Realties of Alcoholism. New York: Bantam Books.

Nixon, D.W. (1996). The Cancer Recovery Eating Plan. New York: Random House.

Reifman, A., Barnes, G., Dintcheff B., Uhteg, L., & Farrell, M. (2001). Health Values Buffer Social-Environmental Risks for Adolescents' Alcohol Misuse. Psychology of Addictive Behaviors. 15, 249-251.

Ruden, R.A. (1997). The Craving Brain: The Biobalance Approach to Controlling Addiction. New York: Harper Collins Publishers.

Somer, E. (1999). Food & Mood: The Complete Guide to Eating Well and Feeling Your Best, 2nd ed. New York: Henry Holt and Co.

Stefanis, C. & Hippius, H. (1995). Research in Addiction: An Update. Seattle: Hogrefe & Huber Publishers.

Slaght, E.F. (1994). Focusing on the family in the treatment of substance abusing criminals. Journal of Drug Education, 29 (1), 53-62.

Waal, H. & Morland, J. (1999). "Addiction as impeded rationality", In J. Elster, Addition: Entries and Exits. NY: Russell Sage Foundation.

White, W.L. (1998). Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, Il: Chestnut Health Systems.

Williams, R.J. (1981). The Prevention of Alcoholism through Nutrition. New York Bantam Books.

Evelyn Slaght, MSW, Ph.D., Associate Professor,

School of Social Work, Illinois State University 

Sue Lyman, MSW, Ph.D., Associate Professor,

Department of Social Work, Winthrop University

Scott Lyman, MSW, MPH, Ph.D., Assistant Professor,

Health Service Management, Winthrop University