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An Interview with Patricia Owen, Ph.D.

The following is the edited transcript of an interview by Bill Moyers with Patricia Owen, Ph.D., on addiction treatment.  Owen is the director of the Butler Center for Research and Education at the Hazelden Institute in Center City, Minnesota. Portions of this interview appear in the CLOSE TO HOME television series.

Moyers: What brought you to the addiction field?

Owen: I was doing my training in a psychiatric hospital. I saw many people struggling with alcoholism and addiction and I thought, "Well, I'd like to learn more about that in order to be a good psychologist." I planned to spend just a few months and learn a bit about addiction, and then I'd go off and start a private practice. But just three months’ experience made me realize that something was different here in addiction recovery. People actually changed, and that was news to me. I saw all sorts of psychiatric patients who were struggling with depression, with schizophrenia, with personality disorders, and their course of recovery was not as predictable as it can be with addiction. Now there's hope of change with those other disorders too, but what I was seeing 20 years ago in the field of addiction was that people could change and get completely well, unlike those with the other conditions. And that was fascinating to me.

Moyers:  What have you learned about how people change?

Owen: We're learning more and more each day, but there is still a great deal we don't know. Let's break it down step by step. First of all, we know that frequently, the process of change has started even before people get here -- because something had to have happened to make them decide they did want help.  Now, some people are just put in a car and driven up by their families, but that's really quite rare. For most people, there's at least some decision on their part: "OK, I'll at least go along with it." I often ask people, "What made you decide to address your alcohol or drug problem?" and I expected to hear stories of major tragedies, and sometimes that would be the case. I would hear about car accidents or spouses leaving -- that sort of thing. But astoundingly, to me at least, it frequently was the seemingly insignificant things which made people want to change. 

Moyers: Such as?

Owen: I remember talking to one person who described her moment of truth. She said, "I was walking out of a school building. I was a teacher, and my colleague asked what I was going to do that evening. I was really burned out and instead of saying, 'I'm going to go home, take my jacket off, put my feet up and have a beer,' I reversed it and said, 'I'm going to go home, have a beer, put my feet up, and take my jacket off.' It was a dumb joke but I could tell by the look in my fellow teacher's eye that he really didn't think it was funny. There was a moment where he had this look on his face that made me see myself in a new way, and all the way home I started to recognize that I've got a big problem." Now, in taking this person's history I had learned that there had been all sorts of stormy discussions with her family. She had experienced serious consequences on the job, and even had some run-ins with the law due to her drinking. I would have thought those things would have brought her to her senses, but it was this small incident that woke her up.

Moyers: Does change begin when someone starts to take responsibility?

Owen:  Well, I envision it is as a brick wall around the addict. Impassable -- this person cannot get through. But with every piece of information that you provide -- truthful, honest information about addiction -- you are creating a piece of a doorway. Those pieces get built, it is cumulative, and you never know what the last piece is going to be which completes the door and opens the way to recovery. That analogy is very useful for family members who are frustrated because they've tried telling the person about the dangers over and over and it seems like nothing is getting through. It is, but you don't know when it will be enough.

Moyers: But information helps?

Owen: Yes. When I talk to people, they're able to tell me in pretty specific detail about when they realized that they had a problem. They aren't deaf, they do hear when people point it out to them. But for some reason they're not able to act on it, and that's what we call denial. It's not lack of intelligence, it's not even lack of psychological insight, it's something that prevents a person from seeing what's really happening to them.

Moyers: And when they do see?

Owen: When people realize they have a problem, it's sometimes just a few weeks until they are on a course of recovery. You look at this person now in front of you, and you learn about what they were like a few months or years previous to that, and it is like a biography of two totally different people. The transformation is fascinating.

Moyers: I remember when I came here with someone who needed help, I saw people arrive who looked hollow and wasted. Almost as if they were casualties of a battle. There was a frightened look in their eyes, a sense of intimidation on their part. And just a few weeks later, I would really see a change. I didn't believe addicted people could change that quickly.

Owen: Yes. We did a study once where we asked people how they could tell when they were changing, and how they could tell that the patients around them were making changes. What we found is similar to what you're talking about. When we asked people about their own internal processes, one person said -- I love this phrase -- "I became more truthful in my heart." Another person said that she lost her shame -- up until that point she was filled with shame about being an addict, and she began to lose that. Another person talked about how he laughed to remember how he blamed everybody else for his problems, and then he began to realize, "It's not other people's problems. It's my problem. I need to learn how to deal with it." Now, when we asked them how they could tell other people were changing, they said things similar to what you said -- "I could see that they had a sparkle in their eye," or they could see that people were being more helpful. They had a lighter step. They walked taller. They laughed more. When people were observing change in somebody else, they picked up more on those external characteristics.

Moyers: When they come here, what do you do to help people change?

Owen: We like to think of it in terms of education, fellowship, and therapy. That's the essence of the Minnesota Model, which Hazelden pioneered. It's starts with a belief in abstinence and the use of the 12 Steps and other therapies to help maintain it. We teach people about their disease, and that may seem quite simple, but it's often new information for them. We teach in lectures, and that's a safe way for them to learn. They can walk into a lecture hall, for example, and say, "I'm not an addict," when they go in. But then they'll hear about the five characteristics of addiction, and they'll think to themselves, "Wow. This person doesn't know me, and yet I have those five things." We'll also give them many individual assignments, perhaps interviewing other people on the unit about their addiction and its characteristics.  If they just learn about addiction in general, quietly and subtly, they're learning something about themselves.

Now, that's important, but it's not enough.  There certainly is the medical side where we detox people and get them stabilized. Again, that needs to be done, but as we always tell people, there's so much more to recovery then just putting the cork in the bottle.  So we create an environment where they can feel safe with other people. The fellowship of being with other people who share a common problem probably is as important as anything in the recovery process. Addicts find out they're not alone. They're accepted for who they are -- they don't have to pretend any more. And, they don't have to use drugs or alcohol to be accepted. As I indicated, they'll find out things about other addicted people which they haven't dared to admit about themselves, and they'll say, "I have that symptom too and I see that other person admitting it and getting better, so maybe I can, too."

There's also therapy. Working with the staff psychologists, chemical dependency counselors, patients get individual assignments more specific to their own particular sets of problems.

Moyers: So much of what you do here is in group situations. Why is group so important?

Owen: Two primary reasons. One, they can learn so much about the disease and other people without having to go through every struggle by themselves. As one person said, "I am informed and enlightened every time I hear about somebody else's struggle." So think how rich that is if you have 10, 20 people in a group. Second, they have a chance to disclose things about themselves or to state intentions about themselves that perhaps before they've only mulled around in their head and kept secret. By getting that out in the open, you create a clearing for more change. You can learn what you have in common with others much more easily in a group than in individual therapy. It's easier to see the other patients as understanding your problems because they don't have the agenda that a therapist might.

Moyers: If you're talking to people like you who also are addicted, that removes the shame too.

Owen: It certainly does.

Moyers: Suddenly you're just not the only one with the badge on your chest that says "A" for addict . . .

Owen: In fact, sometimes people are surprised when they're new -- they'll walk by a group, and everybody is laughing uproariously. They'll wonder what's so funny and nine times out of ten the reason is that somebody has started off by saying, "I can't imagine anybody is going to understand this. I'm sure this has only happened to me," and they've told an anecdote about something which nearly everyone in the room has experienced.

Moyers: I was astonished at how ignorant I was of addiction when I first visited your family program. I was in my early 50s, and I thought I knew a lot about the world. Most addicts are in a similar situation, aren't they?

Owen: Oh, yes. They may not even fully know that they're addicted. They know their own experience certainly, but they don't know what pieces of that experience are direct symptoms of addiction. They may have thought, "Well, I just have trouble with alcohol, because I'm a shy person," and they may not realize that actually, they have trouble with alcohol because they are alcoholics. Their shyness might have to do with why they started or continued to drink, but it isn't the case that if you cured that shyness, they would be able to drink normally again. The alcoholism is why they are drinking now -- not their shyness or because their wives don't understand them or whatever they may blame it on. Their drinking is now a symptom of alcoholism, and that's often news to them.

Moyers: What do you think when you see these people the first time? How do they seem to you?

Owen: When I see people for the first time, typically I feel a combination of despair and hope. It's an odd mixture, because you don't know who is going to make it and who isn't. It's a huge limitation in our science and treatment.  When they get here, people are really at a crossroads. For many of them, you truly know that if they use again, they may die. That's not an exaggeration -- it's not a hysterical conclusion that we use to try to scare people with -- you just know that this may be the last chance for some people because they have had serious medical consequences. It's a frightening thing to see. On the other hand, it's very easy to pick up bits of resiliency, bits of potential that you just know will make it possible for this person to recover.

Moyers: How long before you see any change?

Owen: Sometimes you see it within a couple of days, but usually it isn't until perhaps two to three weeks that you really see some people beginning to turn the corner. With others, you only see small steps towards change, and you don't see them turn the corner. You realize that this is going to be a tough journey for them for quite some time.

Moyers: Are there milestones?

Owen: Yes, there are. It's difficult to know exactly which milestone is going to come first, but here are some of the key things that you can see. First, you see that the person is beginning to take some responsibility for his recovery. They're not denying that they are addicts, and they're not blaming their addiction on somebody else. When they really do look you in the eye and say, "I need to know more about this," we can tell that something is starting to change because they are opening up. We see specific changes in their behavior. They start to develop a structure to their day and show in that way that they're accepting responsibility for themselves.

Moyers: What do you mean structure to the day?

Owen: Doing simple things like eating meals three times a day.

Moyers: Addicts don't do that when they're using?

Owen: Frequently their days and nights are totally turned around, and they eat or don't eat when they feel like it, so simple things like getting a daily structure, eating three meals a day, being on time for appointments, maybe even helping other people out -- these are concrete milestones. Also, asking, "What should I be working on today to be prepared for tomorrow?" rather than just waiting to be told what's coming up.  Those things indicate to us they are working on getting better.

Moyers: Because that's something an addict hasn't done before -- planning for the future?

Owen: Well, there are some paradoxes here, but it is safe to say that they aren't fully in the present. They are trying to escape it. They're thinking ahead to their next fix. Or they're getting themselves so tied up in knots about tomorrow that they're unable to live today without getting high. Conversely, they may be so preoccupied about the past, and resentments, and how they've ruined their lives that today is not bearable.

Moyers: You help them take it "One day at a time."

Owen: Exactly. The more we can help people focus on just the day they have in front of them, and not worrying about "I'm never going to be able to get high again ever ever!," the easier it is for them to resist the urges that they experience right now. Soon, they will be amazed that they're able to put a whole string of days together and say, "Wow, my life has changed."

Moyers: That's a milestone, taking care of today and preparing for tomorrow. What's another milestone?

Owen: Another milestone is hope. This is very important, because we will see people who listen and after a while they say, 'OK, I've learned about addiction and I understand I am an addict or an alcoholic, but there's no hope for me. I can't change. I've tried a hundred times before, and I'm the sort of person for whom nothing is going to make a difference.' That is one of the scariest situations, because if we don't help them develop some hope, they may return to a very severe drinking or drugging pattern.

Moyers: So what do you do for the hopeless person?

Owen: It varies. Sometimes we help them look back on their achievements and accomplishments -- and here we're not talking about awards and honors, not external achievements -- but at ways they have overcome difficulties in the past and maybe haven't given themselves credit for. Ways they have traveled through difficult times and come out on the other side. For example, even though they've been in the throes of addiction, maybe they have done the very best for their handicapped child. Maybe in spite of being addicted, they have truly been there for their elderly parents or in other ways have demonstrated that they can be responsible, and that they have made a difference in the lives of others.

Moyers: Do you usually find something in everyone's life you can point to as a sign of resiliency and responsibility?

Owen: Absolutely, yes. I believe it's there for everybody, and one of the main things we have to do is help them see that themselves. I think it's a human characteristic that sometimes we can't see ourselves very clearly, but we can see other people. That's again where the peers or other patients come in so importantly. Because if someone else like you can do it, why can't you?

Moyers: Now, we've been talking about changes in behavior. Do you also look for changes in personality?

Owen: Yes, and that's an astounding thing for me as a psychologist. We were taught that one of the definitions of personality is that it's something rather immutable. That it begins to form in childhood, and is pretty well formed by the time a person is in later adolescence or early adulthood. I didn't think that people would change their personalities in recovery, but when you think of it, by the time a person gets here we often don't know what their personality really is. The addiction has attacked them right at their core. So what you think you see in terms of characteristics may not actually be the person's true personality. You may see someone in front of you who looks very self-centered and is scornful of rules and authority. They may be very self-protective, very tough, and you may draw all sorts of conclusions. You may decide that this person has an antisocial personality, and you may or may not be right. You cannot know until time has gone by, because I've seen over and over again, people who appear to be one type of personality change entirely.

For example, I was talking to a truck driver once who was what you'd think of as a stereotypical truck driver. He had big tattoos on his arms, and he was a big guy, and he didn't really have more than monosyllabic answers for every question. I was reviewing psychological test results with him, and I was curious about one particular scale that indicated there was quite a bit of sensitivity within him. I sure wasn't seeing that in the man sitting across from me. He looked like the epitome of toughness. So I said, "Do you like poetry?" His eyes got big, and he answered, "I write songs." He described a few of them, and they were beautiful. It touched my heart. I asked, "Would you be willing to share that with some of the men out there?" And I was sure he would say, "No way," but we talked about it further, and after a while, he agreed to do it. Now we had a different view of him.

Moyers: And you knew that real change was coming across when he was willing to do that? Because normally he would never want to read his poetry to other guys, right?

Owen: Right.

Moyers: Someone I respect has called addiction an affliction of the heart. So opening your heart up, pouring your heart out would be a milestone?

Owen: Oh yes. It was a milestone for him. The willingness to be vulnerable -- to show that to other people. That's a huge milestone. It's critical, and as professionals looking on we can only see glimmers of it. We can't see it definitely happening until the person is doing the behavior. Now, this is where it can be tricky, because some people who have been through the treatment process many times will try to fake it. They'll say, "OK. I know what they're looking for. I'll disclose something about myself," but you can tell whether or not a person is truly taking risks opening up.  That's what the fourth and fifth step of AA is all about.

 Moyers: And those steps say?

Owen: To do a searching and fearless moral inventory of yourself and share it with another person. The point is not to beat yourself up for all the bad things you've done -- it's not about that at all.  It's really to take time for self-examination, and then to start revealing it to other people. To let go of the barriers. To let go of the shame, and claim yourself as a person and be rid of that terrible fear that if people really knew you, they would never love you.

Moyers: What's the core of the 12 steps? What do the 12 steps really add up to?

Owen: To me, the most important part of the 12 steps is that they help a person understand they are part of something larger. That's how they can be transformed. The steps in a very simple way help a person onto that path of transformation. They give a sense of meaning, a sense of purpose, a sense of belonging to a loving community -- often for the first time in their lives.

Moyers: Would you describe them as a blueprint for change?

Owen: Yes. In fact, one of the chapters of the Big Book, as it's fondly called by members (it's actually titled ALCOHOLICS ANONYMOUS), is "How it Works." It's laid out very clearly, and it's not a prescription of: you must do this, and you must do that -- rather, it's a description of the collective experience of a group of people and how it worked for them.

Moyers: You're not only after changes in behavior and changes in personality. You're seeking changes in feelings and perceptions about yourself and the world?

Owen: That's right, and what happens over time truly is a total transformation. What's paradoxical about this is that the person is oftentimes transformed into the person they were meant to be.

Moyers: Explain that.

Owen: We find people who are able to reclaim who they were before the addiction began and that's often new to them and new to everybody around them. But everyone can see that it's right. The new personality seems to fit much better, to be more natural for them.

Moyers: That's interesting, because the recovering person I know best -- when he was using, he was selfish and possessive and secretive and conspiratorial and deceptive, but this person naturally is open, sharing, gregarious, trusting, giving . . .

Owen: Exactly, that's a wonderful example. For some people, it's been so long since they've been that person that they were intended to be, or perhaps they were only that person as a child -- often people themselves have forgotten who they were. Frequently, addiction is a long, long journey away from yourself, so recovery is a journey back to yourself.

Moyers: The substances bring about powerful changes in a human being.

Owen: Here's how it was explained to me once, and it's an image that I love. Imagine a circle, and that's you. In that circle, imagine all sorts of small circles, and those are your interests and your attributes. They might be family, friends, spirituality, health, career, hobbies, etc. Now, imagine one small dot on that map is alcohol or other drugs. Perhaps you only use occasionally. For the person who has an addiction, that small dot becomes huge. It becomes a circle within that circle and crowds everything else out. There's no room for family, friends, health, hobbies, spirituality. Somehow addiction does that. It takes over a person's life -- it becomes the overarching, only important thing. It becomes a person's best friend, and sometimes only friend. At least, that's how addicts and alcoholics perceive it.

Moyers: So what is transformed? Is it a person's beliefs about himself or herself? Is it the person's attitude towards the drug itself that changes in the process?

Owen: For a person who's truly in recovery, it's a total transformation. That may sound glib, but it isn't just transformation in terms of their relationships, or transformation in terms of not using the chemical, or how they feel about themselves -- it's a new way of being in the world.

Moyers: Is anyone ever really cured?

Owen: We say no. It gets down to semantics. We do know that people can get into lifelong recovery, but for a person who is in recovery, an important part of the change process is maintaining that recovery, doing things intentionally to maintain the recovery, which you wouldn't do if you thought you were cured.

Moyers: What do they need to do?

Owen: Well, things like periodically taking a personal inventory of themselves -- continually monitoring how they are doing in the world, whether or not they're being honest, whether or not they're being responsible, whether or not they're apologizing when they've made a mistake. That's something that they can do to maintain their recovery. Another thing is to help other people. Doing service for other addicts helps them remember what it was like, and also continues to enlarge them as human beings. They may meditate or pray. Staying in connection with that power greater than themselves however they might choose to conceptualize it, that can help.

Moyers: So where does abstinence come in?

Owen: We work on the basis that total abstinence is the best state for someone who has an addiction. We know that not everybody is going to be able to maintain total abstinence all the time. It's the nature of the disease that there will be relapses. However, we do expect that a person will get the education and experience to know, first of all, how to anticipate a relapse, and to do what they need to do in order to prevent that relapse, but if that doesn't work and they've experienced a slip, we want them to be able to get back on track relatively quickly. Using doesn't have to spiral into total despair and chaos again. We do know, though, that once a person is in recovery and chooses to use or drink again -- and this is one of the mysteries of the disease -- that person will tend to pick up where he left off.

Moyers: I'm not sure what you mean.

Owen: A person may say, "OK, I have not used for five years, and I am in a very stable relationship right now. I really know who I am. I don't think I'm going to have any problems with alcohol like I used to." Let's say that when they had stopped drinking, they were totally out of control and had severe medical consequences from their drinking. When they start to drink again, they aren't able to just have a few drinks.

Moyers: They don't go back to kindergarten?

Owen: No, they start wherever they left off, in an advanced phase of their disease. And so the consequences of their disease will probably accrue rather quickly and severely. Say it took them ten years to develop the disease. If they have a relapse, it won't take them ten years to get them back to where they left off.

Moyers: How do you look at a relapse? As a crisis? As a setback, as a defeat?

Owen: In the most broad-minded way, we look at it as a learning experience. Sometimes we even say to the person sitting in front of us, "Maybe you need more education, maybe you need more experience." We don't say this in a blaming way, but if they truly believe that alcohol and other drugs are not a problem for them, they may not be able to recover until they are convinced that they're wrong. So maybe they need to try it again to prove to themselves that they can't handle it. We don't recommend this, because we cannot tell what will happen in that relapse. They could get better and learn from it. But they also could get hurt or killed.

Moyers: But you do consider relapse as an expected, normal act at some point in recovery.

Owen: I hesitate to say that because I don't want to create a self-fulfilling prophecy for anyone, but the truth of the matter is that, as with other diseases like cancer, recurrence is common. What we do hope is that the person is in a safe environment if it happens, and can get back on track pretty quickly. Ideally, they're able to avoid it all together.

Moyers: How do you explain the widespread perception that treatment doesn't work?

Owen: It's a phenomenon that's been frustrating to me, because we have studies which have been done for years and years and years showing, depending on the study, that between at least 30-60% of people are able to get into recovery after any given treatment. Maybe more, maybe less, but we know that a sizable proportion of people are able to get into recovery. We can show those studies to people over and over again, but I think it's more of an emotional thing. We all have had experience with somebody who's using and has not gotten into recovery, so if I'm trying to convince you that treatment works, and I bring ten of the best most recent studies that have been done by objective, excellent researchers, and say, "Bill look at this one, look at that one," but if your brother-in-law got drunk yet again the day before, and beat up your sister and crashed the car, and everybody has talked to this person about the importance of recovery and he hasn't gotten it, what are you going to be convinced by more? My numbers or the experience the night before? I think, unfortunately, we see the people who don't make it. Recovering people are invisible, because they're functioning so well in society -- we don't know that they ever had a problem unless they tell us. But active addicts and alcoholics are quite visible.

Moyers: And what about those people who can't get treatment? We have no way of knowing what happens to them, do we?

Owen: No. Some studies show that they have an earlier death. There's no doubt about that, and we do know that they often end up estranged from family and friends, unable to earn a living, or even if they can function in a superficial way in society, they've lost themselves in the process.

Moyers: I saw one study which suggested that perhaps 20% of people in recovery never went to treatment. No AA, no support, they have just done it with their own resources. Is that plausible to you?

Owen: Yes, absolutely. Sometimes it's called spontaneous remission, and we know that happens in other diseases too. It's a mystery, but I don't think it's entirely a mystery. What happens in treatment is that we try to create an environment where change can happen -- through fellowship, education and therapy. But some of those things can occur on a natural basis in a person's life. So it's entirely possible that a person could experience a natural situation which similarly creates a place for transformation.

Moyers: If 50% of the people you've seen in treatment were abstinent a year later, would you consider that a good result?

Owen: Yes, I would because I would know that, well, abstinence is a bell weather, it's a surrogate measure that gives us a sense of quality of life, which usually improves during abstinence. I would also know from the research that the 50% who are not abstinent may have just used once or twice and have now decided to get back on track, or are continuing to struggle towards recovery. That in itself can improve things in the family or at work, even though they haven't been able to get totally on board. But even if you say only 50% got better and the rest didn't improve at all, with other diseases, if half of the people are doing quite well a year later that's awfully good.

Moyers: Do you think it's important to think of addiction as a disease?

Owen: Yes, I do. When I first came into this field and heard people refer to it as a disease, I thought, "Well that's kind of a cute euphemism. Maybe that's just Minnesota nice or something, makes people feel better about having been so irresponsible and unable to get their lives together, so let's help them feel better by lifting that moral tone." I was tolerant of the notion, but it didn't sit right with me. As time has gone by, however, I've become fully convinced that it truly is a disease, and here's why.

I think of a disease as having three characteristics. First, it has a rather predictable course, and we certainly know that's true for alcoholism and addiction. Number two, knowing the disease has a name informs you about what to do about it, how to treat it, and we certainly know that with addiction. We have very good ideas about how to help a person. Number three, with a disease there is either a biological cause or a biological involvement, and certainly we know with addiction that for many people there's a genetic component, and certainly there are medical or physical consequences. Now, the word disease is just a word or a concept, and it's imperfectly applied even to more medical disorders, such as hypertension or diabetes, but in fact, addiction resembles those diseases in very parallel ways. We know that some people develop those disorders because there was a very strong genetic propensity. They didn't have a chance -- they were just born to have heart problems or to be diabetic, unfortunately. For other people, there's a much greater environmental component to it. With hypertension or with heart problems, people can have risk factors that have nothing to do with the body they were born with.

Moyers: The job they do, or the stressful environment can affect it.

Owen: Yes, or you could eat all the wrong foods, fail to exercise, etc. And yet those people incur the same symptoms as somebody who had the genetic loading for becoming hypertensive or developing heart disease. Now, whether or not a person's heart disease is caused by genes or whether it's due to their lifestyle -- most likely it's a combination -- but either way, it's still called heart disease and we don't blame a person for it even if it was caused entirely by bad choices. I think we should see addiction the same way. I think that the reason that some people object to the idea of applying the concept of disease to addiction is that they think that it excuses the person, that the person will say, "Well, I have a disease, what do you expect?" In fact the opposite is true -- you have a disease, therefore you have a responsibility to learn everything you can about it and to take care of yourself in a way that maintains you in recovery for as long as you can.

And as with those other conditions, that the process is lifelong. You can't just take care of yourself for a few years, and say, "OK, now I can eat greasy hamburgers and French fries and work 20 hours a day and not exercise." Or, "OK, now I can use again and it will be no problem." Hopefully, one of the things treatment does for addicts is to ruin the experience of using for them in the sense that if they do relapse, once they are aware that they have the disease, it will no longer seem like harmless fun any more, and they won't really enjoy it. They know where they will wind up if they don't stop.

Moyers: Have you found that there are certain types of people who become addicted?

Owen: There has been research on that, but there is no one personality type shared by all addicts. Basically, there are some sub-groups of people who are more prone than others, but no one is immune. Some people, for example, won't develop dependency on alcohol, but they'll experience a back injury and develop an addiction to pain medications. That will totally take them by surprise, because they didn't see themselves as the addict type.

Moyers: Do you understand why some people think of it as a moral failing?

Owen: I think so. By the time a person has become an addict, many times he's become so irresponsible or deceitful that it is hard to see his behavior any other way. But that behavior might just be a symptom of the disease. We see people here who are addicts or alcoholics and they often have the most dreadful moral view of the disease. They come into to treatment saying, "I am a terrible, horrible person. I have defied God and everybody around me by becoming an addict. I don't even deserve to live." We say, "Wait a minute, let us teach you a little bit about what this disease is." Nobody I've ever met has intentionally become an alcoholic or addict, or has even wanted to become an alcoholic or addict.

Moyers: So if an addict can see it as a disease rather than as a failure of character or will, he can stop beating himself up for it and move into recovery?

Owen: Yes. Once a person understands that it is a disease, that takes away a lot of the shame.  Would you be ashamed of having heart disease or cancer? Chances are you wouldn't be, you'd recognize that it could happen to anyone. And you would see that you have a responsibility to take steps to take care of yourself and treat it, rather than sitting around blaming yourself for having gotten it.

Moyers: What have we learned about treating addiction from people who've stopped smoking?

Owen: One thing that we know about smoking is that one of the strongest predictors of who will succeed at quitting is a high number of attempts to stop.

Moyers: The fact that I keep trying augurs well?

Owen: Yes, absolutely. The more times you try the more likely it is that you are going to succeed. And the same is true with other addictions.

Moyers: So if the person I love has relapsed twice, that's a hopeful sign in one in one respect?

Owen: In some ways it is. It sounds paradoxical, but here's why. You take two people -- one person who has never tried to quit, and another who has tried two or three times. The one with the best chance is the person who has tried two or three times. He's further along in the learning process -- he knows more about what works and what doesn't for him, and isn't as likely to make those same mistakes again. And this is very important to tell people who are struggling, because they may think, "I've tried again and again and this means I can't do it." When in fact, the opposite is true.

Moyers: Have you learned anything else from smoking cessation that's helpful in treating other addictions?

Owen: Oh, yes. One is the importance of behavioral cues. All addicts need to learn to avoid people, places and things that may trigger use. With cigarettes we know one of the reasons they are so addictive is that reinforcement typically occurs strongly at least 20 times a day. If a person is smoking a pack a day, that person needs to learn how to respond to those behavioral cues without using. The same thing is absolutely true with other drugs.

Moyers: So you try to teach them alternatives to lighting up that cigarette or injecting heroin?

Owen: Yes. It's not easy for some people, but they need to learn right away to try to avoid those people, places, and things where they will have that urge, because they're not yet far enough along in recovery to be able to resist it. If you live with a drug dealer, for example, you need to think about living elsewhere.

We try to help people identify their own behavioral cues. The situations where they typically use, the people, places, and things -- we help them avoid those if possible. But in cases where it can't be avoided, we teach them refusal skills or other techniques to manage the situation. Let's say that a salesman needs to attend a company party. He may feel that if he's not standing there with a drink in his hand and or has to explain to everybody, "Well, I can't drink because I'm a recovering alcoholic," this is not going to go over too well. We'll teach him to drink sparkling water or soda -- and to bring it with him if he thinks it won't be available. We show our patients how to answer questions in a simple way if there are questions about what they're drinking and why. We really take them through those scenarios, so that they can start to unlearn their old behavior.

And these behavioral cues come in two main forms. One is all the daily things which confront us. If a person always comes home, goes in the refrigerator and gets out a beer, that's a daily cue that she's going to have to learn to undo. But addicts and alcoholics also have to learn how to undo the big connections. How do they experience intense grief without having a drug? How do they experience the death of a loved one without softening their feelings with alcohol? How do they learn to celebrate a huge success without alcohol or drugs? Those are huge stimuli for using that a person must learn to handle, and, in my estimation, even the best purely behavioral program in the world cannot prepare the person for every situation. So, we believe they need something more -- to learn something about themselves and the world, so that they can be more centered and handle those situations in a way which has meaning and allows some relief for them without using drugs.

Moyers: Why is it important to include the family in treatment?

Owen: Most importantly, for the family themselves. When families come here for the family program, they often assume that what they're going to learn is how to get their loved ones to stop drinking or using. They're somewhat shocked to find out that isn't really on the agenda. What's happened in the course of the addiction frequently is that the family has gotten so off track that all of them need to learn to do things differently.

Moyers: Because they've been responding to this powerful change in this other person, and their whole world becomes centered on that person's sickness?

Owen: Yes. I'll give you an example. Somebody in my family was struggling with alcoholism and I spent a weekend getting them into the hospital. It was quite a time, as you can imagine, but I came back to my house, and I opened the door, and I just had to crack up laughing at myself, because I looked around at disarray -- I hadn't washed any dishes, I hadn't put away things. I thought, "It looks like I've been on a binge," and that was a clue to me. It reminded me how powerfully the family is affected by somebody else's disease. So what we teach the families is how to keep their own lives on course. That's important for two reasons; number one, for their own sakes if nothing else. Even if, tragically, the addicted family member continues to use and can't get into recovery, at least they've saved themselves. But also, and somewhat paradoxically, the less they try to change that other person the more likely it is that they will influence them. By not preventing the addict from experiencing the consequences of his addiction, by not being hysterical about use or nagging about it, and just by being a good, solid family, they will make it more obvious to him who the person with the real problem is.

Moyers: When I came here to attend your family program, I wanted you to give me a prescription to fix my family member's addiction, and you didn't do it.

Owen: No. For one thing, there is no recipe -- if there was one we'd be the first to share it. But second, time and time again we've come to understand that you can't change somebody else.

Moyers: Yeah, that was the hardest thing to learn -- that I myself could not change this person.

Owen: That's right, no matter how well intentioned you are. No matter how intelligent, how informed a person is, no matter what, you cannot change somebody else. And that's hard to accept.

Moyers: Residential treatment has become so costly that many insurers refuse to pay for it. How does a facility like Hazelden justify its existence in these days of HMOs, managed care, and cost cutting?

Owen: Well, we know it works. We see miracle after miracle. It's something we believe in so much that we will do whatever we can to continue to make it possible. Because so many recovering people donate money back to help other people who are still struggling, we are fortunate and that helps us continue our efforts.  Many people who come into treatment are able to pay for it themselves, but there are tens of thousands of people out there who do not have the financial means to be in a good recovery program.

Moyers: And what do they do?

Owen: Some may get some short-term treatment that will help at least periodically, and maybe out of that they're able to patch something together. They may find their way into AA or other support groups, and if they do, there's good possibility of recovery as well. But managed care has really eroded access to treatment, and I'm afraid that that may harm people who really need more help.

Moyers: Is there solid research to validate that treatment like this helps people change more effectively then those who do not go to treatment?

Owen: Research is difficult, because we can only measure the outward signs of change. We can measure whether or not a person is abstinent. We can measure reduced costs due to their use in terms of legal problems, medical problems, or employment problems. We can measure whether or not their behavior has changed. But it's much harder to measure the transformation we've talked about. We certainly ask questions about quality of life. We ask questions about whether your relationship with your wife or husband has improved. How about your relationship with your children, your performance on the job? What we find is that even if a person is continuing to use, we may get abstinence rates, say, between 40-50%, but 70-80% of people will say that their quality of life has improved. So we have all sorts of indicators that, yes, this form of treatment does do more than just help a person get to abstinence.

Moyers: There have been many studies by other researchers about how people change. Are you revising anything you do here in response to that research?

Owen: We certainly are. For one thing, from the behavioral scientists, we've certainly learned a lot about relapse prevention. We used to be afraid to talk about relapse, because it might give people ideas, but now we do talk about relapse and what to do about it. That has greatly enhanced the treatment process. We've also made other improvements along the way.

Moyers: What do you hope science may yet tell us about addiction?

Owen: I think the new medication research does have some promise. Right now we're skeptical, because we know that there's so much more than just getting a person to abstinence, but maybe it can help. Beyond that, what I hope is that one day we will truly understand how people change, and how to best encourage that process. We aren't yet able to predict exactly which ingredients of treatment work best for which people. I think that's a critical thing. Science has done a good job with detox and with the initial stages of recovery. That is now not a difficult thing, but what about after those first six weeks, when the honeymoon is over? That goes beyond medication. I think it requires change not just in the individual, but in society.

Moyers: How so?

Owen: As a society we have pretty confused ideas about the role of alcohol and other drugs. What is appropriate use, what is inappropriate. How we feel about addicts and alcoholics, how we treat them in our day-to-day life. If we got clear about the role of alcohol and drugs, it would make it easier for recovering people to get down to the process of recovery.

Moyers: How do we as a society see the addict?

Owen: As someone who's brought it all on themselves, and who deserves what he gets, unfortunately.

Moyers: Would that change if scientists developed a pill which could cure addiction?

Owen: We've thought about that a lot, especially because of naltrexone and other medications that they're developing. We have many fanciful, imaginative, wonderful conversations about the possibility. On the one hand, I think, "Would this mean that one pill could solve all of an alcoholic or addict's problems?" We really believe that could never be the case, because addicts' lives have been so damaged by their disease that even if a pill is able to completely eliminate craving, they still will need to learn to fill up the space which the drug once occupied and will still need to restructure their relationships. So we know that a pill cannot take the place entirely of treatment, but now could we prevent alcoholism or addiction, perhaps with a vaccination of some sort?  I don't have the answer to that. It's an intriguing idea, and I know people are working on it.

I don't know if you could immunize against all intoxicating experiences. We might be able to create a vaccination for cocaine, but what about hallucinogens? What about inhalants?  Would the liquor industry stand for an anti-alcohol immunization? And if you immunized against opiates, how would you treat pain? There seems to be something within us as humans which makes us want to seek intoxication. I'm not sure that we'll ever be able to come up with a chemical method of preventing or curing every chemical experience that human beings can dream up.

Moyers: What does the fact that people switch drugs mean for you practically? You treat someone for a cocaine addiction, and he gets over that, but now he's hooked on alcohol.

Owen: First, at Hazelden, we teach them to avoid all mind, and mood, altering drugs for just that reason -- if you have a problem with one thing, you are likely not to be able to use other drugs safely. It also means that we need to continue to learn how to help people. It may be human nature, and we may not be able change entirely, but what are we doing as a society so that we make it so attractive and so desirable for people to try chemical experiences, and to take that path? We all want excitement. We all want our lives to change. We all want transcendental experiences. But what is it about our world that makes it so difficult to create communities where people can achieve such experiences without drugs? Why do we need to seek chemicals? That is a far greater question than those of us in the field can address.

Moyers: Isn't your goal to help them through treatment to find a deeper sense of joy and pleasure and reward than drugs can offer?

Owen: Absolutely. That is the core of the 12-step philosophies and the Minnesota model. We as humans can have transcendent, spiritual experience without drugs, and can go through our pain without escaping into chemical bliss. We can teach that one person at a time in treatment, but ideally I'd like to see us get to a point where we don't need to do that alone. So we don't have to stand at the bottom of the cliff, and try to save people as they're falling. Instead, we can get to the place where society as a whole helps people be content within themselves so they avoid the cliff of addiction in the first place.
 

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A. Thomas McLellan | Patricia Owen | Paul Earley

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