When it comes to addiction treatment, many people believe you need to start a 12-step program and practice complete abstinence. The general belief is that these are the only treatment options and ways to judge success. If you have a relapse and start using again, you’ve failed and need to start over.

But is that true?

Join us as today’s guest, Dr. Michael Tkach, explains that there’s more to treating addiction than just the well-known abstinence-only approach. Listen as he discusses how important concepts like harm reduction, social support, and family and friends are to the recovery process.

Dr. Michael Tkach

Dr. Michael Tkach is the chief behavioral health officer for Affinity. He oversees the integration of mental health-informed practice and related research initiatives for select divisions of Affinity, as well as leads the Return-to-Work division where Affinity is an industry leader in providing enterprise-wide COVID-19 testing to employers, universities, and other business partners.

Tkach has 15+ years of mental health and addiction treatment experience and is a published researcher on addiction treatment, semiotics, mobile therapeutics, employee recruitment and retention, evidence-based practice, and trauma-informed care. He’s also a seasoned presenter to a variety of audiences on numerous clinical and research related topics. He has been the recipient of professional awards for his work including the Distinguished Alumni Award and a Clinical Innovation Award, and has appeared on radio and other media platforms for professional interviews on a variety of topics.

Gabe Howard

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

To learn more about Gabe, please visit his website, gabehoward.com.

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.

Gabe Howard: Welcome, everyone, I’m your host Gabe Howard, and I want to give a quick shout-out to our sponsor, Better Help. You can grab a week free just by visiting BetterHelp.com/PsychCentral. Calling into the show today we have Dr. Michael Tkach. Dr. Tkach is the Chief Behavioral Health Officer for Affinity and a published researcher on addiction treatment and a subject matter expert for the Wisconsin Governor’s Task Force on Opiate Abuse. Dr. Tkach, welcome to the show.

Michael Tkach, Psy.D., LP: Thank you, thank you very much for having me. Very happy to be here.

Gabe Howard: Addiction and addiction treatment is one of those things that does seem to be openly talked about. However, there’s a lot of misconceptions, misunderstandings and still debate on exactly what addiction is, what addiction treatment looks like. And typically, when people think of addiction treatment, the first thing that comes to mind is the 12 step model and abstinence only recovery. Is this still the best approach for the treatment of addiction?

Michael Tkach, Psy.D., LP: There’s a really interesting history that goes along with this, that contributes to how this works and why people immediately jump to the 12 steps. When we go back to when psychology was a budding field back in the late 1800’s, early 1900’s, there was kind of a loss of what to do with addiction. So a lot of treatments involved having people in their confined spaces, restrained areas and really just hoping that the addiction over time went away. And what ended up happening was there was a lot of community and faith based organizations that went ahead and tried to find other approaches to help address addiction within the community. And this is where 12 steps and a couple of other movements started coming out from. And then somewhere in the mid-1900’s, you see the introduction of the Minnesota model, which starts incorporating these 12-Step approaches into treatment. And what happens is you get this parallel track where you have medical and psychological treatments on one side and on another track, you’ve got the 12 steps abstinence only process that’s going. Now, 12-step abstinence only processes helped a lot of people, and now that they’re trying to look at how to combine those with actual medical science and psychology, you see that there’s some conflicting evidence there. There’s some conflicting approaches. So a lot of people have moved away from a very strict interpretation of the 12 steps and using that abstinence only approach. Part of it has really been because of the way that we start conceptualizing addiction and what’s actually going on with it.

Michael Tkach, Psy.D., LP: If you look at this from a treatment point of view and think of addiction as a disease or any other type of set of symptoms to address, you start looking at the idea of the actual expression of addiction as a symptom of other things that are going on either neurologically, biologically as a confluence of a lot of different stressors that are happening. The actual act of using is an expression of a symptom. And so this idea of doing abstinence only in a very strict interpretation of the 12 steps and saying, OK, if somebody goes back to using, we’ve got to start over or they’ll have to come out of the program doesn’t add up anymore, because now you’re saying, OK, if somebody has a symptom of what they’re being treated for, we look at that as a complete, utter failure. You wouldn’t approach that with diabetes. You wouldn’t approach that with heart disease. You wouldn’t approach that with anything else. Instead, you’d say, OK, we need to really just look at our treatment methodologies and say, Is it working? Is it expected that you would sometimes see symptoms flare up? And if so, then how do you manage that and what are the best approaches?

Gabe Howard: A common phrase that I hear in addiction recovery is that relapse is part of recovery, which lends itself to your abstinence only is not necessarily the best method. We need to be mindful of it. So it seems like folks have left some space for it. The second follow up question that I have based on what you just said is where you said about the medication assisted. A lot of folks believe that if you’re on any sort of medication, you are not abstinent and therefore you’re not in recovery.

Michael Tkach, Psy.D., LP: I’m going to go ahead, and I’m going to address that second one first, because that’s a really pressing one. And when we start looking at this, a lot of this starts based off of what the foundation of the 12 steps came from, which is the big book. And within it, there is some notes about abstinence only, but there’s also some key phrases about how medication prescribed from the doctor should be OK. Well, when you start interpreting that, you can get people that interpret it different ways. And what you brought up right there, where some people are saying, if you’re on any type of medication, you’re not abstinent, is some people’s interpretation of that. I ran into this a lot working in the field where you would get either support groups in the community or different types of sober homes where people are trying to reestablish themselves away from their home environment, where they were being kicked out of or treated differently if they were on any type of medications.

Michael Tkach, Psy.D., LP: There was a strong bias in the community about that. And typically when we think of different types of medications, a lot of times we automatically jump to thinking about things like methadone or Suboxone or any of those types of medications. But we actually were seeing in the community was that it was also antidepressants and other things that would typically seem less controversial, were being treated by some people as being not sober and there had to be a lot of work done, and there still does have to be a lot of work done, to address that and to combat that because for some people, medications are an essential part of their treatment. There are multiple different paths to treatment. And so to have a mentality or have any type of approach out there that says you can’t take medications as prescribed, frankly can be kind of dangerous and may sometimes be against someone’s best interest in their recovery.

Gabe Howard: And then to address the relapse is part of recovery, because it does seem like they have some acknowledgment that abstinence isn’t, I don’t want to say not possible, but that phrase does exist for a reason and for a good reason, I think.

Michael Tkach, Psy.D., LP: Absolutely. Let’s look at it similar to other types of any type of disease or health situation that we’re trying to address, like if somebody has diabetes or somebody has a heart condition, they’re going to be times where people default to past behavior. Changing behaviors can be really difficult. I always say if change was easy, there wouldn’t be a profession of psychology. You wouldn’t need it. And so when you start thinking about addiction, you’re trying to change behaviors. And to set a expectation that somebody is not going to have any type of symptom expression during that treatment process is an unrealistic expectation to set. I don’t think it’s in the patient’s best interest to go ahead and approach it from a way that once those symptoms show up, that it’s indicative that there is some type of failure on their behalf of them engaging in treatment. Instead, you want to bring the person in and say, OK, if this happens, these are the steps you take to get back on track. When there is that mentality that I must not relapse, I can’t relapse, you know, if I go back to using all of these negative things will be associated with me, I’ll feel really bad and I’ll have quote-unquote failed my treatment. If that mentality is there, then it tends to create this atmosphere where people become embarrassed or ashamed and they want to hide those symptoms that otherwise could have been kind of the markers that let you know, Hey, we should do something here. And instead, what tends to happen is people hide that, but then they have a return to use episode. Then they’re addressing it after the fact. Rather than saying, OK, we could have maybe identified some things beforehand that could have helped prevent this.

Gabe Howard: I’m fairly certain that I know the answer to this question, but what are your thoughts on medication-assisted treatment?

Michael Tkach, Psy.D., LP: I think that when used effectively, it can be extremely beneficial for patients under the right circumstances and with the right type of support. Medication assisted treatment does not mean that the medication substitutes other types of treatment. It’s used as an adjunctive therapy to help support the other types of treatments that people are going through, rather than a replacement. That’s a key part. It’s not just we’re going to give these medications, and there you go. Good luck. There has to be that other type of programing around that or support around that to help ensure that’s a success. The other thing with medication assisted treatment is that it’s extremely effective when it’s used. Those medications save lives, and it can be an extremely important aspect of treatment when looking at addiction, especially when looking at something like opioid addiction, where the risk for death related to overdose or return to use can be so high.

Gabe Howard: From the outside, looking in, it always seems like these two approaches are mutually exclusive. That’s really the debate that I’m seeing. You are either using medication assisted treatment for addiction recovery or you’re using peer support therapy for addiction recovery. There doesn’t seem to be this concept that you can utilize both.

Michael Tkach, Psy.D., LP: Like with anything, you’ll get some people who are very passionate about their beliefs and the people that are very passionate about it tend to speak the loudest. And this is where you start getting some aspects of care that becomes politicized. There’s a similar debate that tends to between this idea of abstinence only and an approach called harm reduction and harm reduction came out of public health approaches, and it started as different ways to look at how do you reduce the most harmful behaviors in a community so that you get overall better public health? So this is where safe needle exchanges came in and other types of approaches. And within psychology, what happened is people said, OK, what can we do to help reduce the highest risk behaviors and help move towards better overall health? This is where you get people that approach addiction from the point of if somebody is using one substance that has a higher lethality and risk for death, but they’re also using another substance that might not be as dangerous. Do you focus on the higher lethality, the more risky one first and maybe address the other one later versus try to address everything all at once?

Michael Tkach, Psy.D., LP: Or if you get somebody that’s drinking a lot, can you get them to reduce the amount of alcohol that they’re consuming and start moving a little bit more towards moderation or towards a place where they’re not using in a way that is causing problems? There have been advocates on both sides that have been very vocal and that really present this either/or mentality. And as people were drawn towards the either/or. We love our dichotomies, we like to think of things as either right or wrong or, you know, if we’re on one side or the other of a topic. But when you actually think about treatment, you actually say, OK, as a clinician, as somebody working with patients, how do I deal with this individual patient? And often that answer is that it’s either a combination or somewhere in the middle in that gray area, which isn’t as easy to communicate, isn’t as easy to go ahead and have big debates about where you say, Yeah, we’re somewhere in the middle. Instead, you tend to get more attention drawn to people that are on the ends or the extremes with it. So I think there is room for a hybrid. There is room for kind of thinking about this as a spectrum and thinking about what’s appropriate for that patient rather than being so strictly on one camp or the other. I think we actually do a disservice to the treatment field when we try to force a dichotomy on this where people have to be either/or.

Gabe Howard: We’ll be back in a minute after a word from our sponsors.

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Gabe Howard: And we’re back discussing new thoughts on addiction recovery with Dr. Michael Tkach.When we think of all the discussions that are happening all around society and on the internet, they seem to be people living with addiction or their friends and family. What’s the medical perspective on this conversation? What would you as a doctor like to see the conversation be? What do you think that we are missing as a society to help people reach recovery better? Because more often than not, I know there’s a lot of emotion in these discussions, and emotions aren’t necessarily the best way to get to the right decisions.

Michael Tkach, Psy.D., LP: There’s a lot of passion with this, and part of it is fear. Part of it is anger. Part of it is just also the dominant culture tends to portray addiction in certain ways. There’s been movements to either vilify it or make it moral failings. With that comes a lot of emotion, a lot of feelings, a lot of shame, a lot of anger, a lot of blaming and whatnot. And that’s done a lot of damage towards thinking about how do we actually address addiction as it presents? And instead we start thinking about how to tailor towards those emotions and those strong opinions. And when we think about what is best for moving treatment forward, it is thinking about how do we go ahead and address this in a way that’s supported by research? How do we address addiction in a way that’s supported by looking at best practices and thinking about individualized care and making sure that we’re not being too reductionistic and too sweeping? Because that’s the other thing is that when people get very passionate about their approaches, it can come off sometimes that their approach is the approach for everybody rather than this approach was really impactful for me, and therefore I feel really strongly connected to it.

Michael Tkach, Psy.D., LP: It can sometimes move from that to this is the approach that I thought was best, and everybody should then feel the same way. That doesn’t help move science. Rather than saying, OK, I’m satisfied with this, let’s sit back and just enjoy it. You should always be looking for how do you continue to advance it? That requires being able to step away from the emotional investment in it, be critical of an approach and say these are the results we have so far, but how do we continue to move forward? With addiction, it can be one of those areas where people tend to have a stronger emotional connection to because a lot of times going through recovery or when people aren’t successful in going through recovery, those tend to elicit really strong emotional responses.

Gabe Howard: It’s an interesting quandary we have in addiction recovery because we need a sense of community and the easiest way to build that community is generally our friends and family. But in addiction, there’s a lot of people that get hurt around the person who has the addiction, and those are generally the friends and family. Do you think that sometimes it’s wise for the friends and family to step back and for the person with the addiction to get help from other people?

Michael Tkach, Psy.D., LP: The family themselves, if they’re going through a situation where somebody has addiction and are going through treatment more often than not, there tends to be strains in those relationships. We can look at it where if somebody is going through a situation where a family member has cancer or other types of chronic or terminal diseases, we can say, Oh, that makes sense that we’re going to say that family should seek support and have support. It’s not as common for people to make that connection when they start thinking about how do I look at a family that’s addressing symptoms of addiction? We really want to change that mentality. And there are things like Al-Anon and other types of programs out there, but also as a field, we’re just starting to think clinically from a point of view of how do you actually provide more strategic and structured care to those family members? And I think that’s essential because those people they can have a major influence on the recovery process of the individual who’s going through treatment themselves. We know just in general in mental health, social support is one of the key factors that actually helps determine outcomes for pretty much any symptom expression, any type of diagnosis. Their recovery is going to be predicated on what’s the quality of their social support? How much social support do they have and where are they getting it from? That doesn’t mean that if somebody doesn’t have good social support, they’re not going to get better. We just know that social support plays a key role and is a large influence on any type of recovery or treatment.

Michael Tkach, Psy.D., LP: Second, when we start looking at the communities, and this is something that I’ve written about before and published on before is that one of the things that happens is that people start looking at self-identity. It can be extremely helpful for somebody to either step outside their normal support group, step outside their family and get support from a 12 step group or any other type of community support. That can be extremely helpful. What can sometimes become problematic is when it starts creating these in-group out-group associations. If you’re in recovery, if you’re in sobriety, if you’re in my community group, I can associate with you. If you’re not, I can’t. So saying I identify with these other individuals and they’re my people and they’re my support can be extremely supportive at first. It can also create later difficulties and saying, OK, how do I go ahead and expand my support? And one of the things that I always recommend is that we look at how do we not narrow somebody’s sources of support? Instead, how do we expand them? So if we suddenly say only people in recovery can be support, now we’ve gone ahead and eliminated a vast majority of people that are most likely in that individual’s life that could potentially be very great support from being even considered or looked at.

Michael Tkach, Psy.D., LP: We also don’t want people to say, Well, I’ve got support here, I’ve got support there, so I don’t need the actual other types of treatment. When you look at it, when we’re trying to help somebody address something like addiction, the more support you have and the more different resources, including if you’re thinking about medication or you’re thinking about therapy or thinking about community groups or you’re thinking about a supportive family, the more of those things that you can put together as appropriate, the better chances somebody will have for success with whatever they’re looking for with their treatment goals. What you hit upon was really key there, Gabe, is that it’s how do you bring all of this together rather than trying to get to an either/or or one or the other type situation.

Gabe Howard: It’s difficult to find that middle road on addiction.

Michael Tkach, Psy.D., LP: Mm-hmm.

Gabe Howard: You would get a lot of people that want to talk about sort of the extremes, which sort of provided the basis for a couple of my questions. We get a lot of pitches about how medication is not addiction recovery and how we need to stop. And we get a lot of pitches for addiction isn’t a mental illness. But it’s not like this nuanced debate of where it fits. It’s you’re either an addict or you’re mentally ill. And that’s so frustrating because it’s like saying you either have cancer or diabetes. No, comorbidity exists, and to pretend that it doesn’t does a disservice to people who are suffering. So we can’t have them on the show.

Michael Tkach, Psy.D., LP: [Laughter] I think that’s one of the things that you run into is that once people start thinking about it that way, there tends to be this chicken or the egg approach like, well, they’re just using substances because they’ve got mental health or because they’ve got depression. And if that goes away, then that solves everything. And the way that we’re moving as a field, and the way that you really have to think about it, is that any type of diagnosis or whatever is just a collection of symptoms that tend to statistically more often than not appear together. Our concept of any type of diagnosis is just we’ve gone ahead and drew arbitrary lines around these symptoms, especially mental health and whatnot, saying these went together more often than not. When we see them, we’ll call them depression. We’ll call them anxiety. It’s the reason the DSM gets re-done all the time is because it’s not a sound construct the same way that we could say this bacteria or this virus is present, so therefore it’s COVID or anything like that. It’s not as straightforward as that. You’re not doing a blood trial and saying, Oh, this virus is present, and therefore it’s depression. Instead, we’re working with these abstract concepts of when we have constellations of symptoms called syndromes, and we’re labeling those as diagnoses and then using those arbitrary collections to then guide treatment. It’s fascinating, but it’s a process of statistics, and we do a disservice when we start saying you can have one or not the other, because really we’re saying you can have this symptom, but you can’t have that symptom. Biologically and psychologically, it doesn’t work that way. We don’t get to dictate which symptoms people experience.

Gabe Howard: And I can only imagine how infuriating or frustrating or sad it would be for the person who is experiencing both of those symptoms to be told, no, no, no, this one’s important and we’re not even going to acknowledge that this one exists. It’s this self-imposed barrier or a societal imposed barrier or a culturally imposed barrier to getting care. And again, that’s got to hit like a ton of bricks. We care that you’re suffering in this area, but we don’t care that you’re suffering over here. And in the meantime, it’s the same person.

Michael Tkach, Psy.D., LP: Absolutely. There’s this diagnostic overshadowing that tends to happen with people, with clinicians. It’s the same thing we’ve talked about. We like our patterns, we like our different ways that we engage and we approach things. If a clinician is used to treating a certain type of diagnosis, they’re more likely to see that diagnosis in other individuals that they’re treating and sometimes will be biased and start ignoring other types of symptoms to make it fit that mold. And you have to really hedge against that as a clinician to stay effective. You don’t want that diagnostic overshadowing to happen where it starts guiding what you’re seeing because that exact experience happens. You have somebody present, and they’re saying, I’m having this symptom, I’m having this symptom, I’m having this symptom. If you have a clinician that’s approaching it and saying, Well, I’m going to acknowledge these, but you know, either that’s not my area of expertise or I don’t believe in that or this conflicts with something with my, you know, the way that I conceptualize stuff, if they’re throwing that data out, if they turn those symptoms out, you’re dismissing a part of that individual and you’re saying, I accept you as a patient, but only this part of you. And that’s so invalidating as a patient, that creates so many barriers to care. I don’t know that as a patient, I, or many people, would want to engage in treatment when they’re being told that I’ll treat part of you. But the rest of it, I’m going to say it’s either a lost cause or I don’t acknowledge it, or it’s not important. It’s not the way that we create treatment alignment. It’s not the way that we create engagement. It’s not the way that we create effective outcomes.

Gabe Howard: I could not agree with any of that more. If we’re not treating the whole person, we’re leaving part of that person behind, a part of their experience. Over here, your doctor says, I don’t believe that this one is true, but I promise I’m doing my best to treat this one. You have a real reason to believe, huh? They’re not taking this one seriously. Why should I believe you that you’re taking the next one seriously? And roll that down into their families and to their support groups into so many other things. I don’t want to lay the burden at this just at the medical field. It’s everything. You don’t feel as a patient, as a person who is suffering from addiction, that you are being taken seriously. So even though they might be treating one symptom very aggressively or very seriously, you have a very, very strong suspicion of that. And, as you said, very large barrier to care. And of course, it creates this sense of hopelessness or misunderstanding.

Michael Tkach, Psy.D., LP: And the other factor that I think goes into this is that as a patient, patients tend to want to make their clinicians feel like they’re being engaged, that they’re being quote/unquote good patients. And so there can be this tendency to either then start saying OK, if they don’t acknowledge those symptoms or they don’t want to hear about it, I’ll either pretend they don’t exist, I’ll pretend they’re better or I’ll just kind of ignore sharing them because I’ve been told those aren’t important. Some people will challenge me when I start talking about this and they say, Well, do people really do that? And one of the things that I throw out there is just think of when people go into the dentist. Let’s move it out of mental health for a moment, let’s talk about the dentist. And when people are sat down in that chair and they’re asked, How’s flossing going? Now, for some people, it’s they started flossing a couple of days ago or a week before their appointment so that they can say, Oh, it’s going great or whatnot. There’s a tendency for people to want to say what they think their clinicians want them to hear, and that’s in any field, in any setting.

Michael Tkach, Psy.D., LP: So when clinicians start using their platform as a provider to say these are the things I acknowledge and these are the things that I don’t, what they’re doing is they’re saying, here are the implicit and explicit rules about what I expect and what are important to treatment and what aren’t. It starts narrowing it down to say, OK, if you’re going to work with me, here are my expectations of you, and this is what you need to do. It changes the dynamic from being Let’s focus on the patient’s needs to I’m telling you as a clinician, these are what my needs are, and this is what I expect of you.

Gabe Howard: Dr. Tkach, thank you so much. Where can folks find more information on the web?

Michael Tkach, Psy.D., LP: You can find more information about what we’re doing at Affinity at www.AffinityEmpowering.com, as well as we have LinkedIn and Twitter accounts out there where there’s a lot of information about the stuff that I’m doing in the field, as well as what we’re doing as a whole with Affinity.

Gabe Howard: Dr. Tkach, thank you so very much, I really, really appreciate that. A big thanks to our listeners. Please follow or subscribe to the show wherever you downloaded this podcast, it’s absolutely free. Also, take a moment to review the show. Let other people know why they should be listening. My name is Gabe Howard and I am the author of “Mental Illness Is an Asshole,” as well as a nationally recognized public speaker who is available to speak at your next event. You can grab a signed copy of my book or learn more about me just by heading over to gabehoward.com. I will see everybody next Thursday on Inside Mental Health.

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