Overcoming mental health problems is more than possible

Addicts and others with mental health issues continuously feel as if they need to hide their problems as well as hide from them. But an ongoing west-coast (U.C.L.A. and U.S.C.) study with a group of mental health patients suggests that hiding may be the wrong approach.

The participants in the study, all successful individuals with ongoing mental health problems who seem to be stable and productive are being examined for the specific factors that make them defy the stigma so closely linked with mental health problems. Doctors, lawyers, and CEOs are all part of the group and have all figured out ways to work with their mental health issues and succeed in life.

Mental Health Problems, Addiction, and Stigma

We’ve written before about the dilemma of mental health disclosure and I’ve talked over and over about the notion that stigma is one of the major obstacles to addiction treatment and recovery. This study’s preliminary results suggest that indeed, taking ownership of one’s problems and figuring out how to best function with the characteristics each of the holds has allowed these individuals to succeed where most psychiatrists and psychologists would have expected them  to fail – in high-pressure, high-stakes, positions of power.

The relevant metaphor I share often, especially to those who attend our A3 Academy sessions is this:

Imagine that two people you know drive two very different cars. One owns a Toyota Prius, one of the most efficient cars on the market with lots of storage and convenience. The other drives a Lamborghini Gallardo, one of the world’s fastest cars with an engine that makes your whole body shake and a body that reminds everyone of speed and sex. If tasked with giving the two a little guidance on taking the drive between Los Angeles and San Fransisco you would probably give the two very different suggestions…

To your Prius owner-friend you would tell that they should feel free to bring a suitcase and that the entire trip will likely require less than a full tank of gas, making the trip very cheap and economical. However, it’s likely going to take him 7 to 8 hours each way so he should leave early to not waste the day on the road. At least he won’t have to stop for gas. But the Lamborghini driver has a very different trip ahead of him, one that likely includes 2-3 stops for gas but, assuming no speed-traps or traffic, he can still probably make it to San Fran in 4 hours flat. He’s also not likely to be able to bring anything along except for an overnight bag and even that is only true if he’s not bringing anyone on the trip with him.

Unless one comes to the table with judgements about fast versus slow, or gas-efficient versus gas-guzzling, driving I think that few would suggest that I am somehow stigmatizing the cars or their owners in this story. Instead, I am offering a pretty objective description of their most likely and appropriate functioning. But when talking about people, feelings and stereotypes often get in the way.

Overcoming Mental Health Problems

This study from UCLA and USC in collaboration with The Veteran’s Administration shows us that in reality it is likely that, even for those with mental health problems, the real key is to figure out what the requirements of the “machine” you’re driving are and then plan your life accordingly. For Ms. Myrick, one of the participants in the study, that meant a high powered detail oriented job rather than a hiding spot on her favorite couch at home. Still, the researchers have identified a set of common characteristics they’ve written about. Many of the study’s participants do the following:

  1. Adhere to a medication regimen
  2. Often check their thoughts and perceptions with those around them
  3. Actively control their environment, sometimes with the help of a therapist.
  4. Some avoid travel, or crowded, noisy places while others prefer not to be alone.
  5. Stay away from illicit drugs and alcohol.

Knowing where you're going and believing you can get there is key when struggling with mental health and addiction issues.Overall, it’s obvious that their mental health diagnoses have made them very aware, and thoughtful, about daily activities that most people disregard. Still, with a specific regimen and some help, they’ve all managed to succeed.That regimen might include medication to control attention problems, delusions, or depression; it seems to certainly include some outside perspective when it comes to big decisions; it may also include some regular exercises (physical and mental) to control anxiety and other related emotional responses.

I believe that identifying your own recipe for success is key to success, that believing in your ability to succeed is necessary, and that plotting the course between here and the future is helpful if you’re trying not to get lost. That’s not stigma, it’s practicality.

Loss, but not absence, of control – How choice and addiction are related

In a recent post the notion that “loss of control” is an addiction myth was raised by our contributing author, Christopher Russell, a thoughtful graduate student studying substance abuse in the U.K. Though I obviously personally believe in control- and choice-relevant neurological mechanisms playing a part in addiction, this conversation is a common one both within and outside of the drug abuse field. Therefore, I welcome the discussion onto our pages. I’d like to start out by reviewing some of the more abstract differences between my view and the one expressed by Christopher and follow those with some evidence to support my view and refute the evidence brought forth by him.

Addiction conceptualization – Philosophical and logical differences and misinterpretations

One of the first issues I take with the argument against control as a major factor in drug addiction is the interpretation of the phrase “loss of control” as meaning absence, rather than a reduction, in control over addiction and addictive behavior. Clearly though, one of the definitions of loss is a “decrease in amount, magnitude, or degree” (from Merriam-Webster.com) and not the destruction of something. Science is an exercise in probabilities so when scientists say “loss”, they mean a decrease and not a complete absence in the same way that findings showing that smoking cigarettes causes cancer do not mean that if an individual smokes cigarettes they will inevitably develop cancerous tumors. Similarly, the word “can’t” colloquially means having a low probability of success and not the complete inability to succeed. Intervention that improve the probability of quitting smoking (like bupropion or quitlines for smoking) success are therefore said to cause improvements in the capacity for quitting.

Next, Christopher wants scientists to identify the source of “will” in the brain but I suggest that “will” itself is simply a term he has given a behavioral outcome – the ability to make a choice that falls in line with expectations. In actuality, “will” is more commonly used as a reference to motivation, which while measurable, isn’t really the aspect of addiction involved in cognitive control. Instead, what we’re talking about is “capacity” to make a choice. The issue is a significant, not semantic one, since the argument most neuroscientists make about drug abuse is that addicts suffer a reduced capacity to make appropriate behavioral choices, especially as they pertain to engaging in the addictive behavior of interest. If someone is attempting to get into a car but repeatedly fails, we say they can’t get in the car (capacity), not that they don’t want to (will). Saying that they simply “don’t” get in the car doesn’t get at either capacity or will but instead is simply descriptive. I don’t believe that science is, or should be, merely descriptive but instead that it allows us to form conclusions based on available information.

That there is a segment of individuals who develop compulsive behavioral patterns tied to alcohol and drug use and who attempt to stop but fail is, to my mind, evidence that those individuals have a difficulty (capacity) in stopping their drug use. Their motivation (will) to quit is an aspect that has been shown to be associated with their probability of success but the two are by no means synonymous. It is important to note, and understand, that the attribution for the performance should not fall squarely on the shoulders of the individuals. We humans are so prone to making that mistake that it has a name, “The fundamental attribution error,” and indeed, individuals who show compulsive, addictive, behavior do so because of neuropharmacological, environmental, and social reasons in addition to the complex interactions between them all. But no one is disputing that and in fact, the article used by Christopher to point out the notion of a “tipping point” in addiction directly points out that fact in the next paragraph (Page 4), which he chose not to reference or acknowledge.

“Of course, addiction is not that simple. Addiction is not just a brain disease. It is a brain disease for which the social contexts in which it has both developed and is expressed are critically important… The implications are obvious. If we understand addiction as a prototypical psychobiological illness, with critical biological, behavioral, and social-context components, our treatment strategies must include biological, behavioral, and social-context elements.” (Lashner, 1997)

Lastly, Christopher’s philosophical musings are interesting, but they seem to stray away from trying to find an explanation for behavior and instead simply deconstruct evidence. In a personal communication I explained that while most addiction researchers understand that addiction, like most other mental health disorders is composed of a continuum of control ranging from absolute control over behavior to no control whatsoever (with most people fitting somewhere in the middle and few if any at the extreme ends), categorization is a necessary evil of clinical treatment. The same is true for every quantitative measure from height (Dwarfism is sometimes defined as adults who are shorter than 4’10”) to weight (BMI greater than 30 kg/m²). I think it’s equally as tough to argue that someone with a BMI of 29.5 is distinctly different from an individual with a BMI of 30 as it is to argue that there is no utility in the classification. Well, the same applies for drug addiction, although some people categorically object to classification and believe it has no utility or justification.

Now for the evidence – “Choice” and “control” are not the same as “will”

Some people quit, even without help – Christopher and a number of the people he cites in support (Peele, Alexander), suggest that because some people do stop using that it can’t be said that there is a problem with any individuals’ capacity to stop. The problem with that argument is that it supposes that everyone is the same, a fact that is simply false. As an example I would like to suggest that we compare cognitive control with physical control and use Huntington’s Disease (HD or Huntington’s Chorea) as an example.

HD patients suffer mental dementia but the physical symptoms of the disease, an inability to control their physical movement resulting in flailing limbs often referred to as the Huntington Dance, are almost always the first noticeable symptoms. Nevertheless, HD sufferers experience a number of debilitating symptoms that originate in brain dysfunction (specifically destruction of striatum neurons, the substantia nigra, and hippocampus) and that alter their ability (capacity) to control their movements and affect their memory and executive function leading to problems in planning and higher order thought processes. So, while it is true that most people can control their arm movements, here is an example of individuals who progressively become worse and worse at doing so due to a neurophramacological disorder. There is currently no cure for HD but some medications that help treat it no doubt restore some of the capacity of these patients to control their movements. If a cure is found it would be difficult to say, as Christopher suggests of addiction, that the cure does not affect the capacity of HD patients to control what they once could not. I chose HD for its physiological set of symptoms but a similar example could easily be constructed for schizophrenia and a number of other mental health disorders (including ADHD and drug addiction). Importantly, cognitive control is a function of brain activity, activity that can become compromised as the set of experiment I will discuss next show.

An experiment conducted at UCLA (1) has shown that cocaine administrations reduced animals’ ability to change their behavior when environmental conditions called for it. Even more meaningful was the finding that once animals are exposed to daily doses of drugs, the way their learning systems function is altered even when the drugs themselves are no longer on board and even when the learning has nothing to do with drugs per se.

In the experiment, conducted by Dr. David Jentsch and colleagues, monkeys were given either a single dose (less than the equivalent of a tenth of a gram for a 150lb human) or repeated doses (1/8 to 1/4 of a gram equivalent once daily for 14 days) of cocaine. The task involved learning an initial association between the location of food in one of three boxes and then learning that the location of the food has changed. We call this task reversal learning since animals have to unlearn an established relationship to learn a new one.

Obviously, the animals want the food, and so the appropriate response once the location is changed is to stop picking the old location and move on to the new one that now holds the coveted food. This sort of thing happens all the time in life and indeed, during addiction it seems that people have trouble adjusting their behavior when taking drugs is no longer rewarding and is, in fact, even troublesome (as in leading to jail, family breakups, etc.).

In the experiment, animals exposed to cocaine had trouble (when compared to control animals that got an injection of saline water) learning to reverse their selection when tested 20 minutes after getting the drug, which is not surprising but still an example of how drug administration can causally affect an individual’s ability to make appropriate choices. As pointed above, the most interesting finding had to do with the animals that got a dose of cocaine every day for 14 days. Even after a full week of being off the drug, these animals showed an interesting effect that persisted for a month – while their ability to learn that initial food-box association, they had significant trouble changing their selection once the conditions changed. Remember, this effect was present with no cocaine in their system and with learning conditions that had nothing whatsoever to do with cocaine.

If that’s not direct evidence that having drugs in your system can alter the way your brain makes choices, I don’t know what is.

Another study conducted by Calu and colleagues with rats found similar (or even more pronounced) reversal learning problems after training the animals to take cocaine for themselves, clarifying that it is the taking of cocaine and not the method that causes the impairments.

Another entire set of studies has shown that stimuli (also known as cues or triggers) that have become associated with drugs can bring back long-forgotten drug-seeking behavior once they are reintroduced. This was shown in that Calu paper I mentioned above and in so many other articles that it would be wasteful to go through all the evidence here. Importantly, this evidence shows that drug associated cues direct behavior towards drug seeking in a way that biases behavior regardless of any underlying will. My own research has shown that animals who respond greatly to drugs (nicotine in our case) likely learn to integrate more of these triggers than animals who show a reduced response, indicating once again that these animals bias  their behavioral selection towards drug-seeking more than usual. While we have more studies to conduct, we believe that genetic differences relevant to dopamine and possibly other neurotransmitters important for learning (like Glutamate) are responsible for this effect.

While we can’t do these kinds of experiments with people (research approval committee’s just won’t let you give drugs to people who haven’t used them before), there is quite a bit of evidence showing an association between trouble in reversal learning and chronic drug use in humans (see citation 3 for example) as well as research showing very different brain activity among addicted individuals to drug-associated versus non-drug cues (like seeing a crack pipe versus a building). All this evidence suggests that drug users are different in the way they learn generally, and more specifically about drugs, than individuals not addicted to drugs. When it comes to genetics, we know quite a bit about the  association between substance abuse and specific genes, especially when it comes to dopamine function. As expected, genetic variation in dopamine receptor subtypes important in learning about rewards (D4 and D2) has been revealed to exist between addicts and non addicts. Without getting into the techniques and analysis methods involved in these genetic studies, their sheer number and the relationship between substance abuse and other impulse disorders points to a direct relationship between drug use disorders (and possibly other addictive disorders) and a reduced capacity to exert behavioral control. Less capacity for control is what researchers have found sets addict apart from non-addicts.

Summary, conclusions, and final thoughts

The toyota Prius is slow but efficientIn closing, there are undoubtedly imperfections about the ways we diagnose addiction (drug addiction and others). It would probably be nice if we could figure out a way to incorporate what we know about the continuous nature of the disorder with the need for clinical delineation of who requires addiction treatment and who doesn’t. Addiction researchers are far from the only ones who wonder about this question though (the same issues are relevant for schizophrenia, depression, and nearly every mental health disorder) and I am certain that better and better solutions will emerge.

However, the discussion of stigma in this context needs to allow us to discuss the reality of addiction without having to resort to blaming and counter-blaming. If I describe the Toyota Prius as being slow but incredibly efficient I am no more stigmatizing than if I describe a Ferrari as being incredibly fact but wasteful in terms of fuel. The same applies, or should apply, to health and mental health diagnoses – Just because an individual is less able to exert cognitive control over impulses should not by definition call into question their standing as a human being. We are complex machines and by improving our understanding of the nuts and bolts that make us function we can only, in my opinion, improve our ability to make the best use of our capabilities while understanding our relative strengths and weaknesses. Any other way of looking at it seems to me to be either wishful (I can do anything if I want it badly enough) or defeatist (I will never be anything because I’m not good at X) and neither seem like good options to me.

Citations:

1) Jentsch, Olausson, De La Garza, and Tylor (2002): Impairments of Reversal Learning and Response Perseveration after Repeated, Intermittent Cocaine Administrations to Monkeys. Neuropsychopharmacology, Volume 26, Issue 2, Pages 183-190

2) Calu et al (2007) Withdrawal from cocaine self-administration produces long-lasting deficits in orbitofrontal-dependent reversal learning in rats. Learning & Memory, 14, 325-328.

3) Some evidence in humans from Trevor Robbins’ group: Reversal deficits in current chronic cocaine users.

Creating a better system of addiction treatment: Matching rehabs to patients

I can’t hide it any longer, I just have to confess: I hate the way addiction treatment is managed nowadays. With over 25 million people meeting criteria for addictions in the U.S., only 10% are seeking treatment on a yearly basis. Sure, part of the problem is that others just don’t want it, at least yet, but there’s something else going on and it’s terrible.

The horrible pain of finding addiction treatment

If you, or someone you know, needs help for an addiction, your options aren’t just limited, they’re hard to find and are simply too stressful to deal with. Where do you even start? Most people wouldn’t dare go to their neighbors or family members with something like “Bobby is really struggling with his cocaine problem, do you have an idea of what we should do?” Instead, everyone is left fending for themselves, scared of going to doctors for fear of later insurance trouble, ashamed to admit their difficulties for fear of being stigmatized, and inundated with conflicting information about their chances for recovery if they do seek help.

So people go online, they seek out information, and they call provider after provider, often getting only partial semi-truths. At the end, most are left confused and the rest simply check in to the first place that will take them given their financial reality. Could you imagine if the same were true when someone broke their leg?

But isn’t addiction treatment really useless?

No, it’s not. Treatment works. It’s just that most people don’t get the treatment they need and end up paying the price (literally and figuratively). Well guess what, help is possible, it’s available, and it shouldn’t be this damn hard to find!

I think it’s about time we create a system that makes it easy for those suffering from addiction to find the right treatment for them. Not everyone needs treatment that costs $50,000 a month, and to be perfectly honest, that treatment is rarely better than much cheaper options. Still, no one would know that given bogus advertisements by rich addiction-industry-players that promise cures and fixes. The truth is that recovery is a difficult road and that different individuals may need different treatment.

Still, we know things that work: CBT works, motivational interviewing works, social-support, contingency-management, exercise, meditation, and specific medications work! So why is it that the addiction treatment industry still looks like something put together by a couple of addicts who suffer from too much self-focus and not enough organizational-capacity? Well, probably because that’s exactly our reality at the moment.

How can we make things better? Matching rehabs to patients

I say it’s time for a new age, especially given the passage of mental-health and addiction parity laws and the slow, but eventual inclusion of our most vulnerable citizens in the American health care system. As addiction-treatment becomes (finally) incorporated with medical care, the increased resources are going to mean an increased need for some standardization. It’s time for us to put people in treatment that works, that everyone can afford, and that is easy to find.

We’re currently testing a system that will use some basic, and some a bit more advanced, criteria to help direct addicts towards the right provider for them. Don’t have much money and working full-time? Then residential treatment should probably not be your first choice? Medicated for schizophrenia? You better stay away from providers that don’t offer serious mental health services (though they’ll sure take you if you walk through their doors)

We’re still figuring out the kinks, trying to improve the system even further than its current state, which I think is nothing short of magical. Eventually, I hope that it will be available for everyone, giving people real, reliable, objective access to addiction-treatment providers that do good work across the united States. It’s that easy to find a condo to buy, why shouldn’t it be that easy to find help?

Yes, I have almost 10 years of research experience into what works, but in truth, most of the issues here probably don’t require that at all. What’s needed is a little big-picture thinking and a little less fine-tooth combing. Hospitals can triage people based on a pretty quick, efficient, assessment. We can too.