Our Integrative Model
Our model is different from most. We treat people who are struggling with complex co-occurring eating disorders, substance use disorders, mood disorders and trauma and we do so using an integrative model. Many other programs treat a similar patient population using the same evidence-based modalities such as DBT, Expressive Therapy, Motivational Interviewing, MAT (Medication Assisted Treatment) and 12 step facilitation. However, they do so using a parallel model or a serial model. Our model treats the behaviors and underlying causes all at the same time, under one roof in an outpatient setting in our patient’s home communities. Does it work? Does it work as well, better or not as well as other programs who use the serial or parallel model, or even as compared to residential “fly away programs”? Are we seeing more success with some behaviors than others and if so, can we tell why? We want to know the answers to all of this. And we want current and prospective patients and their families to know.
OUR INTEGRATIVE MODEL
Historically, treatments for addictive disorders and eating disorders have overlooked the deep-rooted psychological effects of trauma. Adverse early-life experiences often lead people to “attach” to addictive substances or behaviors instead of other people, often perceived by survivors as untrustworthy. Yet traditional approaches have targeted symptoms while disregarding psychological, biological and spiritual underpinnings. The authors are applying an integrated approach using a coherent treatment model to treat patients with a spectrum of addictive disorders along with underlying trauma in a Chicago area-based outpatient treatment center. Building on decades-long focused study and clinical observations as well as insights and findings from the scientific realms of trauma, developmental psychopathology and neuroscience, the authors describe a state-of-the-art model they have implemented in two settings, in Chicago and in Northbrook, IL. The centers are drawing people from Chicago and suburbs as well as from other parts of the country and outside the U.S.
The philosophy of SunCloud Health Outpatient Treatment Center departs from traditional models of intervention in that trauma, associated mood disorders and addictive behaviors that people frequently rely on for self-regulation in the wake of trauma are addressed simultaneously in a primarily group-based treatment, with individual therapy and evidence-based medication management. Additionally, we conceptualize eating disorders as an addiction disorder involving food and eating/weight related behaviors. Further, we view addictive and eating disorders on a continuum, with degrees of severity. Also, there are differences in levels of tolerance both for pain caused by trauma and for suffering caused by the consequences of addiction.
People with addictions—involving alcohol, drugs, food, sex, love, internet, technology, work, money—transform by “attaching” to a culture of recovery. Many health care professionals, policy makers and lay people alike assume that addiction is about the substance compulsively consumed or the behavior compulsively performed. We believe that addiction is a brain disease, with symptoms that play out behaviorally. According to ASAM, the definition of addiction is, “A primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”
Common to all addictions is a compulsion to consume a substance or engage in a behavior; a preoccupation with using behavior and rituals; and a lifestyle marked by an inability to manage the behavior and its harmful consequences (Schwartz, Nickow, Arsenau & Gisslow, 2015).
The treatment approach at SunCloud represents a shift away from solely medical models to integrated models focusing on recovery from addictive disorders from biological, psychological, and importantly, spiritual perspectives. Aspects of the highly integrative model have been described by Dennis (2019); Schwartz et. Al (2015); and Korshak, Nickow, & Straus (2014). The model builds on attachment theory and family systems theory and integrates 12-step principles to help the afflicted develop and engage with recovery support networks. Treatment groups and ongoing, long-term psychotherapy aftercare groups with medication management may serve as “cultures of resilience” to help support and sustain life-long recovery (Nickow, 2006). We recommend and offer long-term group psychotherapy to encourage ongoing transformative processes leading to a better quality of life and increased resiliencies. A further benefit for ongoing care and chronic disease management, is that in recovery we become the preventative care agents for other areas of patient’s health care which could stand to interfere with recovery were an addiction specialist no longer involved in and coordinating care for the patient. For example, a patient in recovery from cocaine addiction seeing a family practitioner for complaints of binge eating disorder is quite likely to be prescribed Vyvance for her BED. An engaged and well-informed ongoing care team, psychiatrist or NP, can intervene on this well-meaning intervention that has risks from an addiction relapse perspective which likely outweigh any potential benefits.
Psychological trauma is a key but often unrecognized element in the etiology and treatment of addictive and eating disorders. Instead, many clinicians diagnose borderline personality disorder and other personality disorders, sometimes with antipathy for the patients. Ironically, the patients’ interactional styles were often their best survival strategies–adaptive, self-protective responses to early life trauma and to subsequent traumatic reenactments (Dennis, 2019; Schwartz et. al, 2015).
A majority of patients with addiction meet at least partial DSM-5 criteria for Posttraumatic Stress Disorder (PTSD). Most present with “developmental trauma disorder” (van der Kolk, 2009). The term refers to exposure in childhood to physical, sexual, or emotional abuse; rageful behavior or other violence; family alcohol and drug abuse; neglect; and inadequate caregiving. In the Adverse Childhood Experiences (ACE) study by Kaiser Permanente and the Centers for Disease Control, traumatic childhood experiences were found to negatively impact adult health, increasing vulnerability to alcoholism, drug abuse, obesity, cigarette smoking, depression, suicide attempts, sexual promiscuity, and domestic violence (Felitti et al., 1998).
According to the National Center on Addiction and Substance Abuse (CASA) at Columbia University, up to 50% of individuals with eating disorders also abuse alcohol or illicit drugs, compared to 9% of the general population. Up to 35% of alcohol or illicit drug abusers have eating disorders, compared to 3% of the general population. The bidirectional relationship between depression and substance use disorder is clearly documented. The National Bureau of Economic Research reports that people who have been diagnosed with a mental illness at some point in life consume 69 percent of the nation’s alcohol and 84 percent of the nation’s cocaine
Our integrative approach is one of harm reduction (Dennis, 2019), or “progressive recovery” (Schwartz et. al.) With progressive recovery, addicted people are offered groups as cultures of resilience to begin to develop healthy, emotionally regulatory relationships with people in a professionally facilitated clinical setting. Gradually, the patients can rely less on substance or process addictions as authentic attachments develop with the help of therapeutic holding environments. The term, “process addictions,” refers to out-of-control behavioral processes such as gambling, sex addiction, relationship addiction, exercise addiction, technology addictions, and work/activity addiction. Eating disturbances can have components of both chemical and process addictions. Awareness of the interplay among eating disorders, addiction involving drugs/alcohol and process addictions is critical to successful treatment outcomes (Schwartz et al., 2015).
Patients who develop the disease of addiction involving one substance often develop addiction involving another substance and/or behavior. In part this is because the underlying brain reward circuitry has been already primed and altered as the disease of addiction developed. As patients progress in recovery from what most in our field would refer to as a “primary” addiction, addictions involving other behaviors or substances often magnify, emerge, or rise to the surface from a more concealed place. Across the lifespan, a person may engage in addiction involving multiple different behaviors or substances, with patterns often shifting with efforts to manage harmful consequences. A person may entirely give up one addiction, such as anorexia, only to subsequently engage in others, such as alcoholic drinking, compulsive spending, or sex addiction.
Most treatment providers, our DSM, public policy and lay people alike view addiction not as a primary illness commonly co-occurring with other illnesses like mood disorders, PTSD, rooted in underlying brain pathophysiology involving reward circuitry, front striatal circuits, limbic lobes and prefrontal cortex, but as a drug or behavior specific phenomenon. From this vantage point, focus is maintained on the substance (a symptom) rather than the disease (a brain disorder with spiritual, psychological, social and emotional ramifications). Public policy, prevention and treatment efforts remain focused on drug epidemics rather than addiction epidemics, addiction treatment and addiction prevention.
According to NAMI, Dual diagnosis (also referred to as co-occurring disorders) is a term for when someone experiences a mental illness and a substance use disorder simultaneously. This also applies to eating disorders. According to the 2006 National Survey of Drug Use and Health, 5.6 million people in the United States have co-occurring substance use and mental health disorders. According to a 2014 National Survey on Drug Use and Health, 7.9 million people in the U.S. experience both a mental disorder and substance use disorder simultaneously. The problem is growing, and these figures are likely significantly underestimated due to misdiagnosis.
The integrative model at SCH is designed specifically for this patient population. In 2018 nearly 90% of our patient population had at least two or more diagnoses. Our model treats the whole person as a person, not as a single diagnosis, or 2 or 3 diagnoses in 2 or 3 different treatment “tracks”. Human beings don’t show up at our door in tracks. Those same human beings don’t get out of bed and face the world each day in recovery from track A, B, or C disorder. They have to find a way to sustain and grow in recovery as a whole human. And so, we treat all at the same time, under one roof. Our groups are combined, drawing on the similarities and connections between the various diseases, and supports connection in the recovery milieu based on humanness and spirituality rather than specific disease states as such. Addictions (behavioral and substance) as well as co-occurring disorders share common risk factors, similar etiologies, similar behavioral characteristics, similar courses of illness, and similar reward circuitry dysfunction in the brain. Much of the field today treats these diseases in a parallel or serial treatment model treating one behavior at a time or multiple behaviors at a time but with a different treatment team using different modalities. Unlike the integrative model, these models treat the behaviors in isolation from the underlying trauma and depressive disorder. Our model goes a step beyond integrated in that we use a unified treatment model to treat all 3, 4 or 5 DSM-5 diagnoses the patient has.
A key goal of treatment in the initial stages is to support patients in moving toward abstinence from mood-altering substances and behaviors (including behaviors like restricting food intake, dieting, purging, etc). Patients are encouraged to develop a strong recovery support networks, focus on emotional healing, and adhere to boundaries likely to create healthy balance. The primary task of recovery is to “surrender” to an agreed-on abstinence plan “one day at a time,” leading to improved physical and psychological health, spiritual progress, and more gratifying relationships, work experiences, and recreation. (The terms, “surrender,” and “one day at a time” are 12-step concepts.) Abstinence and recovery need to be defined in the context of the individual who is afflicted. For the person with an eating disorder, defining exactly what the problematic behaviors and/or food substances are for the individual is a complex clinical task. The end goal of abstaining from eating disorder behaviors and cognitions is moving toward health (actual health not orthorexia health), flexibility and balance. This becomes exponentially more complicated than defining sobriety as abstaining from using illicit drugs and alcohol (which in and of itself is an incomplete and naive understanding of sobriety).
Supporting recovery efforts in both addition and mental health arenas requires arming patients with emotional literacy, interpersonal skills that either were never learned or have been weakened by disease states involving high amounts of isolation, mindfulness skills to combat the flight/numbing response common to PTSD and addiction, and distress tolerance skills to be able to make it through emotional pain, weathering the storm without resorting to old patterns that may work in the moment to relieve pain but eventually reset the cycle of self-destruction. Dialectical behavioral therapy captures all of these domains. Originally created to treat borderline personality disorder, it has been shown in randomized trials to be effective in the treatment of depression, eating disorders and substance use disorders as well.
Historically, trauma focused therapies have been reserved for patients who have arbitrary amounts of time in recovery from addiction or eating disorders. Treating both from the start of treatment has been shown to yield best long-term outcomes for the MISA population, in which it has been most studied. For this reason, we begin to treat trauma with resource building, mindfulness, yoga, EMDR and psychoeducation on day 1 of treatment.
Although pharmacologic interventions have a limited role in the treatment of many psychiatric illnesses, when done with a deep understanding of what addiction is and in the context of treating underlying brain pathophysiology, it can have a profound positive effect on treatment. When co-occurring disorders are correctly diagnosed and treated with intelligent and evidence-based agents, patients are not only better equipped to manage the work of recovery but also better manage their health care as a whole (for example, engaging in preventative care, following dietary and exercise regimen to manage type 2 diabetes, etc). Conversely, when medication management is done solely with a focus on a co-occurring anxiety disorder or ADHD, without an understanding of what addiction is in the brain, psychopharmacologic interventions can have a profoundly negative, sometimes lethal impact on treatment. ‘
The goal with this form of treatment is not to answer the question of, “Why the (self-destructive) behavior?”, but rather, “Why the pain?” If we can get to the source of the pain, we have the best possible chance of helping our patients achieve a lifetime of long-term physical, emotional and spiritual recovery.
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