There are many different therapeutic approaches that science has shown to be effective in treating addiction. This is good news! But it’s also a bit misleading, particularly if you have been to treatment before and continue to struggle. The reason is that there is not one specific approach that can effectively address all that needs to happen to successfully overcome addiction. In my early days as a counselor I became extremely frustrated seeing clients who had successfully completed treatment return weeks or months later due to relapse. It got me very interested in why treatment often failed clients, and what we can do about it.
Over the years I realized that treatment had not really failed. I was doing good work, and so were my colleagues. Nor had clients failed either, they had worked very hard in treatment. What we had all missed, was that for most who struggle with addiction, treatment needs to be a long term venture, delivered over years, and often a lifetime. Just like other chronic medical conditions (asthma, diabetes, hypertension), when the treatment is removed, problems return. This led to the realization that if treatment for those who struggle was to be delivered over many years, then the interventions needed to adapt and change as the client’s life changed. This meant developing a framework where many different treatment approaches could be utilized at different stages and times in therapy. The approaches that work best in the first few months of treatment are different than what works best a few years later. Thus the 5 Actions framework was born!
The 5 Actions represent the bare-bones necessary components to successfully overcoming addiction. Within each action, there are numerous interventions that can contribute to good outcomes. While somewhat sequential, in truth the various actions get implemented more based on needs in the present moment. And there is no endpoint to any of them, because there is work to be on each over the lifespan. Here is a brief summary of the 5 Actions:
Action 1: Motivate
All behavior change (initial and sustained) requires motivation. It is the fuel for getting from A to B, and is at the center of a number of the most influential theories on addiction (e.g., Motivational Interviewing, PRIME). It is the first action because it is the fuel necessary for following-through with the other actions. Overcoming addiction is incredibly challenging, in part because motivation to do what is necessary is so dynamic and influenced by stress. Those who have been to multiple treatment programs and continue to relapse often lose hope that change is possible. Motivational fuel decreases with every treatment failure. Fortunately, the science of motivation has evolved considerably, and there are numerous interventions that when utilized appropriately with the other actions, can keep the motivational tank full enough to overcome addiction.
Action 2: Evaluate
One failure of our current addiction treatment system is the lack of a consistent use of a validated and reliable evaluation tool that both diagnoses addiction and co-occurring disorders. The most commonly used tool today, the Addiction Severity Index (ASI), assesses severity of substance abuse problems, but fails to assess behavioral addictions or diagnosis mental health disorders (although it does screen for them). This action takes a different approach, a systems approach to evaluation. It not only assesses all the most critical factors contributing to addiction, but it also motivates clients to identify and understand how the factors relate to each other. The primary reason is that it allows clients for the first time to identify powerful leverage points for intervention that most often are missed. In addition, it also provides evidence that not every factor needs to be treated. Why? Because all factors are connected. If you intervene on a factor that is a leverage point in the system, the other factors will change as well. In short, it is impossible to know how to best help someone who struggles without a comprehensive, accurate, systems evaluation.
Action 3: Resolve
Unlike chronic problems, there are a number of issues that should not be managed, but instead resolved, permanently (e.g., being homeless, suicidal, in the criminal justice system, or in physical pain). Perhaps one of the most important for those who struggle with addiction is receiving developmentally-based treatment to address the common gap between chronological and emotional developmental age. While many struggling addicts spend thousands on treatment, most leave programs no better off than when they arrived at knowing how to initiate, develop and maintain healthy intimate relationships. This is because most therapists do not know how to do developmentally-based interventions. And without the developmental capacities to succeed in human relationships (e.g., marriage, work, family), those who struggle with addiction will continue to struggle in life, most often relapsing and losing hope that change is possible. In sum, this action addresses issues that have well-established evidence-based solutions.
Action 4: Manage
Addiction, as well as many other issues in life, are chronic, meaning that acute interventions will most likely fail. Chronic problems require continuance of care over time, often for years or a lifetime. One outcome of completing the evaluation in Action 2 is an understanding of all disorders and life issues that are chronic and most likely will require intervention for years to come. Addiction fits this category, but so too do chronic medical conditions, chronic mental health issues, and many other life issues. The importance of grouping them by chronicity is that most evidence-based interventions can be deployed across the entire range of problems, not just addiction. While there are specific interventions for specific chronic problems, such as a medication to treat hypertension, the vast majority of interventions that help clients manage chronic problems are applicable across the spectrum of chronic problems. These interventions include: setting goals and tracking behavior, preparing for and managing relapses, exercising, eating healthy, getting proper sleep, mindfulness practices, and many other things.
Action 5: Create
Treatment fails clients because it most often neglects individual talents, strengths and virtues. Energy is expended on problem-solving interventions, when there is significant evidence that setting problems aside (yes, even addiction) and focusing on optimizing life experiences may be more productive. The essence of this action is that for addiction to cease being a powerful force in a client’s life, something more powerful must take its place. The force behind this action is creativity. The term is used to capture the spirit of what makes life worth living. Each person who struggles with addiction inadvertently develops the optimum relapse prevention program when they discover what makes their heart sing, what they are meant to do with their life. The field of positive psychology now provides a broad and evidence-based toolbox of interventions for helping clients create the life they were meant to live.