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The David Sheff Solution
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As the author of Beautiful Boy and Clean: Overcoming Addiction and Ending America's Greatest Tragedy, David Sheff has confronted the difficult challenges presented by addiction on both a deeply personal and a societal level. Beautiful Boy is a moving, jarring account of Sheff’s battle to save his son, Nic, from crystal meth addiction while struggling to protect his family.
As an influential voice in the addiction and recovery arena, Sheff was noted in Time magazine's annual list of the world's 100 most influential people in 2009. Sheff stands as a symbol for the desperate struggles with the addiction of a loved one that plague families across the socioeconomic landscape. In Clean, Sheff applied his abilities as an investigative journalist to confront the problem of addiction in the United States as a whole— examining mistakes made and changes needed to improve treatment outcomes.
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It’s so important for those people to know that healing can happen because where there is love, there is always hope.
The Fix has covered Sheff in the past, but his voice grows ever more relevant.
At the Yale Department of Psychiatry Grand Rounds Lecture, you described how, “Our culture emphasizes self-determination and willpower… We want to be masters of our own destiny, but sometimes we aren’t.” Was this the hardest lesson that you had to learn in regards to your own personal experience with your son Nic’s addiction? Is that powerlessness over a child’s addiction the most difficult experience a parent goes through upon first encountering the disease on such an intimate level?
It is. It is impossible to overstate the impact of that revelation, a revelation that, by the way, doesn’t come like a lightning bolt from the sky. Rather, it comes over time and through pain. And it only comes with the slow process of education. When a child becomes addicted, there’s chaos and terror – the sleepless nights, the anguish, the not knowing, the middle-of-the-night phone calls to the police and to hospital emergency rooms, the middle-of-the-night phone calls from the police and hospital emergency rooms – and there is also horror on a whole other level.
That other horror was utter bafflement about this person who I knew, who I raised, who I knew to be a kind and loving person, and a moral person as well. How could they do what they were doing? I thought, how could Nic forsake his family – even his little brother and sister, whom I knew he adored? There was no sense to this. I thought, how could you do this to me? How could you do this to your family? How could you do this to yourself?
It often begins with this cycle of judgment. Once I went through some therapy, in combination with family sessions at rehab centers where Nic had been admitted, I heard for the first time about addiction being a disease. I resisted the idea at first. I didn’t’ think Nic was sick. Someone who has cancer is sick. I thought he was a selfish, narcissistic teenager in rehab because he wanted to get high and have a good time no matter the impact on the rest of us.
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What I came to understand was that addiction is a disease, that Nic was really, really, really ill with a mental illness. It was a revelation; it was no longer about judgment and blame and self-blame. It was about an illness. When someone we love is ill, we don’t judge them. We don’t blame them and insist on their contrition. We look at them with compassion and love and do everything we can to help them to get better.
Your son Nic is now in long-term recovery from crystal meth addiction and has written about his experiences as an addict in the book, Tweak. In addition, he just published his first novel, Schizo. It would appear that your family has survived the crisis that you wrote about in Beautiful Boy. Given the general societal view that the past is the past, why do you choose to continue to spend a majority of your time writing and lecturing about the disease of addiction?
Yes, we are one of the lucky families. I am just so lucky to have my son. But it shouldn’t be about luck. This is a disease, and we know that it is preventable and we know that it is treatable, and yet we are not preventing it and we are not treating it. When I finished Beautiful Boy and it was published, I had planned to go back to writing a business book that I had been working on before all of this happened. But I just couldn’t.
There were so many people who were not as lucky as we were and I met them and I talked to them and I heard what they had to tell me. They would send me private Twitter messages and Facebook messages and email me and send letters in the mail, and I learned about the ubiquity of the problem and the suffering. I mean, I knew about our hellish experience, but I didn’t know how many others were suffering. I found that I just couldn’t ignore it and go back to other work. I'd been dragged into this world of addiction and was compelled to try to understand everything I could about what addiction is, why it's so pervasive, why so many people are dying, and if and how we could help more people with this illness. I’ve spent these last years trying to answer those questions.
We are losing so many people. Because of prescription medication misuse alone, a person is dying every 19 minutes. Overall, addiction is now the number three killer in America. There is so much harm being done. Beyond the suffering of individuals and families and communities, the societal costs are staggering as well; the crime and the resulting prison costs, the emergency room and health-care costs, and the incredible loss of productivity. The damage is just staggering.
When I got sober, I tried to make an amends to my father, but he didn’t want to hear any of it. With a zero interest in 12-step talk, his only desire was to see me change and walk the proverbial walk of being a self-supporting, responsible adult. Has this been anything like your experience with your son? Do you believe in the idea of a “living amends” as discussed in both 12-step recovery programs and Al-Anon?
I do. And I hope your father has come around to seeing that as well. As I said, it changes everything. Once I came to understand that Nic was ill and what his behavior was about, my feelings of anger and resentment disappeared. Once I knew he wasn’t trying to hurt us, all I wanted was to see him get well. I wanted him to get sober and go into recovery. I wanted him to get better. It broke my heart that my son had this illness.
Once he was in recovery, two things happened that allowed us to repair the damage. Families break apart, people are broken as well, and the process of healing takes a long time, but it is possible. It happened for us because we were all devoted to it happening. Although we had been hurt, we were committed to going forward and repairing the damage. As much as this impacted my wife Karen and me, it was worse for Nic’s little brother and sister, Jasper and Daisy. They couldn’t understand and were traumatized, not only because of their worry about their big brother, but because their parents were immobilized.
Nic was really, really sensitive to the reality of the process of healing, especially for the little kids. After he had been sober for a while, Karen and I felt comfortable enough with the idea of having him come up and be in our home again. For a long time, we had been afraid and hadn’t allowed him back because of Daisy and Jasper. We were worried and didn’t want them to be traumatized again in case something went wrong as it had so many times in the past.
So finally there was a time when we did come around and invited Nic to come up from Los Angeles to San Francisco for the weekend. I was surprised when Nic said, “I want to wait, because I don’t want to spend time and open up to Daisy and Jasper only to disappoint them again. I want to be clean for longer before I see them.” To me, that was a critical moment in his recovery and for our family because he acknowledged what had happened and revealed an instinct to protect his little brother and sister and to go forward gently. He was cognizant of the fact that it does take a long time to heal and he was willing to put in the work to ensure that more damage would not be done.
Their relationship did heal and our relationship has healed, as well. We are closer than we have ever been. Nic is one of the most extraordinary people I know. The healing is the result of effort on everyone’s part in the family, but mostly Nic’s. He went forward gently and conscientiously.
As a quick note, my relationship with my father is better than it has ever been in my life. We are close friends and we talk every week. He and my mother are both incredibly supportive and loving. My fiancée and I are actually going to Park City, where they live, to spend the holidays with them and my sisters. And just like Nic, it is all due to the gift of my recovery and the work that I have done.
I’m so glad. I was going to ask you about that, but I am so happy to hear it. People in the throes of active addiction should know that they are loved. Their families may retreat, but it’s because they don’t understand. They’re confused and angry. But the love is there.
Our family is proof to people who feel that things can’t get better and the damage can’t be healed. I meet so many people in recovery who are completely alienated from their families and they believe that their relationships can never ever, ever, ever get better. I also meet families who claim to want nothing to do ever again with their addicted loved ones because there has been so much damage or they fear it will never happen because the person they love is too far gone.
It’s so important for those people to know that healing can happen because where there is love, there is always hope. It’s no surprise that it takes a long time for people to get well and repair the damage, because going through addiction is like being in a war. You emerge from it shell-shocked –there’s literally PTSD -- and there is a lot of hard work to be done in order to heal.
In a previous interview you said that going public and stepping beyond the 12-step confines of anonymity is important because such a step “helps people in recovery because it affirms their recovery.” The new advocacy movement as represented by Steps4Recovery and the Anonymous People documentary believes that going public needs to evolve into an active grass roots movement that helps raise awareness about the disease of addiction and the freedom offered by recovery.
Do you agree with them? If so, what steps do you think should be taken to enhance public awareness about recovery?
I can trace almost every single part of the problem, all of the devastation, back to the fact that there has been this stigma around addiction. A part of the reason for the stigma is this overwhelming sense of shame. We had to hide our child’s addiction at first because of shame. But why do we have to hide? Why do we have to remain anonymous? Well, there must be something wrong--morally wrong; there must be something to hide. The anonymity factor has contributed to that perception enormously. The suffering is worse and the isolation is pervasive. The fact that we keep this disease hidden has resulted in a lack of investment in research about addiction and in attempts to make treatment more accessible to more people. The stigma that’s led to hiding has allowed the nation to ignore addiction and meanwhile it’s worsened and worsened.
At the same time, it’s too easy to say that all addicts should toss their anonymity aside. First of all, from a psychological and emotional perspective, some people just aren’t there yet. Second, there are practical reasons for some people to remain anonymous, because we don’t live in a culture where everybody accepts that addicts are ill, not morally bankrupt and weak-willed. People are still judged, and those people can lose their jobs and be isolated from their communities. People need more of an understanding of addiction as a disease that does not need to be hidden. Only when such an awareness becomes accepted will the stigma evaporate. One way for it to evaporate is for people to understand the ubiquity of the disease.
People need to feel safe to be honest about their addiction. But the more people choose to be open about their struggles, the more people will realize that this is not an isolated disease. It is not about bad people. It is not about the negative image of addicts we get in the movies, on television, in our popular culture. It’s about everyone.
There is no question that the landscape is changing dramatically, and that change is all for the good. What’s happening is amazing to behold and to experience. I have been at events around the country where conversations are taking place that have not been discussed openly before. And many hundreds, sometimes thousands of people attend these events. Although, most of the people who come have been directly affected by addiction and they come to be with people who understand - to be supported, informed, and to get help navigating through the hell they’re in - not all have been. Others come to learn how they can help tackle the problems associated with drug use and addiction in their communities.
Beyond these events, there have been Congressional hearings because of the pressure being exerted by groups around the country—groups of people who have declared, I will no longer be anonymous. I am addicted. My son is addicted. My daughter is. My husband or wife or partner or parent or whomever it is. The result is building of a united voice of people insisting on change. There are governors' task forces, the lobbying of politicians, the founding of education and prevention campaigns, and support for treatment In communities. As marches and fundraisers have shown, the more we talk about it, the more open we are about the disease, the more support there will be and the stigma will slowly lessen. It’s all going in a hopeful, positive direction, but we have a long, long way still to go.
You have spoken strongly against what you describe as the 12-step myth that an alcoholic or addict needs to hit ‘rock bottom’ before they will be ready to accept help. You have said, “Waiting for someone to hit bottom is like waiting for a diabetic to lose a leg before we treat it.” What do you think is the origin of the “rock bottom” myth and why do the 12-step programs so loyally defend it?
It was Tom McLellan, the former Deputy Drug Czar under President Obama, who originally made that diabetes comparison and it is exactly right. It just makes sense that when it comes to any illness, whether psychological or physical, we want to catch and treat it as soon as we can. The idea that we wait until someone hits bottom, until they’re so ill that their addiction is life threatening, causing extreme problems that often include ending up in prison or the emergency room, doesn’t make any sense. We ought to do our best to try to prevent that from happening. There is no reason to wait until someone hits bottom.
The reason the idea of hitting bottom became accepted as a requirement of treatment is that in the past, people who ended up in treatment had indeed hit bottom. Because we didn’t talk about addiction, because there was such a stigma, people kept it hidden for as long as they could. People didn’t go to a 12-step meeting or rehab until they no longer had a choice. They hit what they felt was rock bottom. If they didn’t stop using, they’d die.
As a result, it was assumed that hitting bottom was what it took to find recovery. You hear those stories over and over again about what brought someone into those rooms and ultimately saved their lives. It took hitting rock bottom for many people to find recovery. But I can't tell you how many times I heard from people who said, like a dad put it, "They kept telling me he had to hit bottom. Well, he's dead now. Did he finally hit bottom?" Waiting for a person to hit bottom is too dangerous. Plus, this is a progressive disease. The longer we take to intervene, the worse it gets, so the worse debilitation and the harder it is to treat.
We have to remember that for so many years, virtually the only treatment that was offered for addiction were the 12 steps. At that time, there was no model for somebody to get help in order to address an early stage of addiction, to deal with the beginnings of problematical use that could clearly lead to addiction or was a result of addiction. No one was going to go into one of these meetings and say that they were an addict or alcoholic if they weren’t convinced that they were. For many people, AA was a place of last resort.
The more the medical model takes over, the more we understand that we want to catch this disease at the earliest possible stage. If someone we love has cancer, we get them into treatment immediately before it progresses. Once the stigma is removed, the family and the community will help addicts get into treatment so they don’t hit bottom. Hopefully addicts themselves will have been educated so they understand the signs of addiction and will recognize that they need to seek help before the condition worsens.
After reading Tweak and We All Fall Down, Nic’s accounts of his addiction, it was such a piercing realization for me to understand the dire straits he was in and the extent of his pain. Upon that understanding, I saw how important it is to catch addiction as early as possible to prevent such suffering.
We have teachers, counselors, medical providers, who have little or no training in addictive disorders and in knowing how to recognize and catch the disease early. When I read a study that said only 6% of pediatricians are trained to the point where they are able to recognize that one of their patients have a drug or alcohol problem, I couldn’t believe it. We entrust pediatricians with our children’s health. What about our kids’ mental health? They must be trained to recognize the early signs of drug problems and addiction and to intervene using tools such as SBIRT (screening, brief intervention, and referral to treatment). Teachers and others on the front lines should be trained to recognize the signs of drug and alcohol abuse and to get kids help immediately.
In your Yale Department of Psychiatry Grand Rounds Lecture, you made two powerful statements that seem intimately related. The two statements are as follows: First, “People in pain are desperate for relief,” and, second, “Stress is related to addiction on the most primal level.” Given the overwhelming prevalence of stress and the pressures of a consumer society that manipulates people to consume beyond their needs, isn’t drug abuse a given? Is there any way to avoid addictive uprisings like the recent plague of prescription painkiller abuse in such a society?
What you just described explains the reason behind the prevalence of the disease in the United States. Twenty-three million people addicted is the official number they give, but the actual number could be much higher. Life is really, really hard, and the stresses are enormous. People are overwhelmed, and it starts at a very young age. Kids are overwhelmed so it makes sense that they go out and want to get high. If you get high, the stress evaporates, at least for a little while. Drugs can provide a temporary escape from depression and anxiety; they're a temporary solution to real problems for many people. But that solution ends up leading to greater stress and ultimately addiction. Stress and addiction are related on the most primal level.
The disease of addiction is hard enough to deal with for people who do have resources. There are good community programs in some places and there are 12 step groups everywhere, but the chances are very bleak for people without quality health care.
The reason that everyone isn’t addicted is because everyone’s different. Some people are more resilient and protected against addiction just like they are against other diseases. There’s no specific recipe that causes any one individual to become addicted. Some people can become addicted with only a single or even without an apparent risk factor. Others have multiple risk factors and never become addicted. But risk factors increase the likelihood that an individual will become addicted. Stress is just one. There is often a genetic component. Beyond that, people with mental illness or psychological or neurological disorders are at higher risk. Those with learning disabilities are subject to a heightened risk. Stress can come from something obvious, like physical or sexual abuse, or something subtler, like divorce and families where there’s constant discord. It’s no surprise that poverty is a risk factor.
The manner in which our neurological systems respond to chemicals explains why not everybody gets addicted. At the same time, addiction is not the only negative reaction to stress. There are people who don’t become addicted, but are suicidal. Twice as many people are killing themselves now than did only ten years ago. What’s that all about? The levels of binge-drinking and sexual assaults on college campuses have greatly increased. Is that related to the level of stress that is being generated by our present culture or are there other factors that we haven’t identified?
In a recent article for Time Magazine, "If You Want to See Inequality in the U.S. at Its Worst, Visit an Impound Lot," you wrote: “We must also acknowledge and condemn the daily injustices born of a system that slowly grinds down the people who can least afford it, and, in too many cases to count, leads to their early death.” How can the battle for addiction be won in a country where such inequality seems to be the name of the game?
First of all, it’s why the challenge is so formidable. There are so many people from a socioeconomic perspective that are so vulnerable. I got a glimpse of the impact of socioeconomics recently when my car was towed in San Francisco. I went to the impound lot and gave the clerk my credit card. I was charged an outrageous fee—about $475—and went on my way. But the office was filled with people without credit cards or the ability to get that much cash.
People were weeping and pleading and were completely distraught because they couldn’t get their cars. These people needed their cars to get to work or to pick up their kids from childcare or daycare. Many of them would never be able to get their cars. The frustration people feel. The constant wearing down by an injustice of the system toward the people who can least afford it. Sometimes, I’m amazed that there isn’t more addiction and other results of stress.
The question is how do we help people who are vulnerable? Yes, we want them to have access to schools and doctors who can detect problems early and intervene, but that’s not enough. We have to help kids and help families, and that involves a whole array of social services that either do not exist now or are hanging on by a thread and are threatened because of budget cuts. All of the organizations that potentially could help these people are being forced to operate on shoestrings. It’s a great challenge. It’s part of what underlies addiction and other specific disease.
People are desperate to get treatment for their own addiction or a child’s addiction. They constantly contact me, but they don’t have money or decent insurance or any insurance at all. The disease of addiction is hard enough to deal with for people who do have resources. There are good community programs in some places and there are 12 step groups everywhere, but the chances are very bleak for people without quality health care. As a culture, it’s unconscionable that we let so many people fall off the grid and enter into a spiral that makes everything worse in their lives. The suffering is incalculable.
With the Affordable Care Act now in place and in full swing, do you think it is hurting or helping addiction treatment options? It appears that many of the insurance offerings under the Affordable Care Act are trying to opt out of extensive addiction treatment coverage. You recently said, “The Affordable Care Act should help on the treatment end, but people have to hold the government accountable for making sure the law does what it's supposed to do.”
What is the Affordable Care Act supposed to do in terms of treatment options for addicts and alcoholics? Given your past hope that the ACA might change the landscape of addiction treatment in the United States, what’s your present perspective and what do you believe should come next?
I think the Affordable Care Act is a profound, almost miraculous step forward. Suddenly insurance plans have to cover addiction treatment and other mental illness treatment at the same rates--in parity-- as treatment for any other disease. In theory, it’s great, and we have never had that before. If addiction was covered at all, it was always covered inadequately. Always.
Now, insurance companies are supposed to pay for comprehensive addiction care, but I have heard two different things about what is happening. First, in some places, I’ve heard that the Affordable Care Act has actually hurt programs, because plans are paying at lower rates than they’ve paid for in the past. We have to hold our legislators’ feet to the fire and have them fix the law where there are problems and enforce regulations. On the other hand, I’ve visited community-based treatment centers that provide a vast array of services that have told me that they now get a much larger reimbursement than ever before; much higher rates per person per day that they are actively treating for addiction. It’s a huge step forward because that means they’ll be able to offer better services to more patients with a better-trained staff.
As importantly, with more people covered, more people will have access to treatment for themselves and for their loved ones. At the same time, insurance companies will demand that programs provide evidence-based treatment, not a haphazard collection of treatments that have little or no efficacy. Programs will adapt and provide evidence-based care or they’ll go out of business.
I recently interviewed some of the top addiction researchers in the country: Professors Richard Rawson, M. Douglas Anglin and Michael Prendergast of the UCLA Drug Abuse Research Center. In talking to them and learning about their findings, it baffled me how their cutting edge work on addiction treatment and ways to improve recovery outcomes is largely ignored by the treatment industry.
Why are the majority of providers in the addiction treatment industry so resistant to the expertise of these top researchers? If you were given the power to change the addiction treatment industry, what would you do beyond licensing and basic regulation? What other improvements need to be made?
The resistance is there because people are threatened and people are uneducated. Traditional programs are almost all based on the 12 steps. The people running those programs are often devoted to helping others, but only know a single treatment paradigm -- often the one that helped them, which is most often the 12 steps. They don’t want to change because they simply do not accept that there are other options beyond the 12 steps. They mistakenly believe that other treatments threaten the 12 steps, whereas they can co-exist. If they offer behavioral treatments and psychopharmacology when it’s appropriate, particularly when it comes to opiate addiction, they are going to realize that they’ll be able to save more lives.
A positive example of change can be seen at Hazelden under the direction of Dr. Marvin Seppala, its chief medical officer. Hazelden is ground zero for the 12 step treatment approach, and the Minnesota Model, which is based on 12 steps, is the most prevalent treatment model around the country. I have a lot of personal experience with their approach. Nic was in 2 Hazelden programs.
As Hazelden's medical director, Dr. Seppala was frustrated that people would do well in treatment, but relapse soon after they were discharged. Many of those with opiate addiction would leave, relapse, and in too many cases, die. Acknowledging that they were losing too many people, Dr. Seppala investigated other options. Hazelden, like many similar programs around the country, had rejected the use of medications, like Suboxone. But the research showed that the medication was extremely effective. Since Hazelden is a major influence in the addiction-treatment field, Dr. Seppala’s decision has far-reaching implications. Other programs will follow suit. As a result, lives will be saved.
From a traditional 12 step perspective, you don’t treat drug problems with drugs. But in some cases, you do.
You recently did a podcast interview with Dr. Drew Pinsky where you discussed your latest work. Despite his powerful presence in the popular culture, Pinsky is a divisive figure in the addiction field because of his popularization of the treatment industry through the reality series Celebrity Rehab with Dr. Drew, Sex Rehab with Dr. Drew, and Sober Living with Dr. Drew. How do you find a balance between interacting with this popular culture side of the treatment industry and your criticism of the treatment model for addiction in the United States?
Anything that exploits addiction - makes it funny and fun and light-hearted – is beyond counter-productive. It’s dangerous. Sensationalizing a disease is harmful. On the other hand, portraying addicts for what they are, people with a serious illness—mostly, people—is useful. When--whether on television or interviews or elsewhere--people come out and speak about their recovery in public, it’s truly helpful. People know they aren’t alone. They know they can get help. They may seek treatment. For instance, Mackenzie Phillips works with the Pasadena Recovery Center, and she’s been a powerful advocate because she’s very open about her own recovery. I’ve heard from people in recovery who were inspired to go into treatment after hearing her speak.
My only criticism of Dr. Drew himself is specific. His thinking on this may have changed, but I’ve heard him tell people that they shouldn’t take drugs, like Suboxone. He’s a firm believer in the 12 steps, but suggests that addiction medications are anathema to being sober and staying sober, but they aren’t. Thank God for the 12 steps -- they have saved countless lives, but they are no longer the only treatment method. Everyone is different.
The problem is that whenever anyone, including myself, is given a public platform, desperate people tend to believe. We should all be called to task if we espouse treatments that aren’t effective, discount ones that are, or suggest that there’s only one way to treat a given person.
When you wrote “Game Over: How Nintendo Conquered The World,” you described how the Japanese company came to earn more money than the big three computer giants or all Hollywood movie studios combined at the time. Given that more American children recognize Super Mario than Mickey Mouse in addition to the rise of the new consoles like PlayStation and Xbox 360, do you think video game addiction is a serious problem that needs to be addressed? Does it place young people at significant risk and can it be compared to drug addiction?
There’s no doubt that video game addiction is real. The rush of dopamine that goes along with the kind of neurological stimulation produced by video games can become addictive to some people. There is a compulsion to use despite dire consequences to a person’s life. People who get into that destructive spiral need help, and there are programs that address video game addiction and other forms of addiction as well.
Still, there is a big difference between behavioral addictions and drug addiction. Drugs are toxic chemicals that change the way the brain functions. As opposed to the external stimulation of video games, drugs directly alter neurological function. That damage can’t be underestimated. I don’t want to minimize video-game addiction--the pain experienced by a person – but there isn’t the physical withdrawal and detoxification required in regards to drug addiction. It also takes a long time to recover from some drug addictions because the damage is severe. A doctor explained to me that it can take up to two years of continuous sobriety for the brain of a methamphetamine addict to return to so-called normal.
The good news is the brain almost always will repair itself - it’s incredible how resilient the human brain is. Too many people are being lost to this disease, and too many lives are in jeopardy because they’re unable to access the help they need. It’s changing, but way too slowly. At least after decades of ignoring addiction, the country is waking up to a disease that’s crippling us. It’s a time when addicts and their families have a reason to be hopeful.