Herbal_Medicines_for_the_Management_ofOpioid_AddictionSafe_and

Herbal Medicines for the Management of Opioid Addiction Safe and Effective Alternatives to Conventional Pharmacotherapy?

Jeanine Ward,1 Christopher Rosenbaum,1 Christina Hernon,1 Christopher R. McCurdy2 and Edward W. Boyer1

1 Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts

Medical School, Worcester, MA, USA

2 Department of Medicinal Chemistry, Laboratory for Applied Drug Design and Synthesis, School of

Pharmacy, University of Mississippi, University, MS, USA

Abstract Striking increases in the abuse of opioids have expanded the need for pharmacotherapeutic interventions. The obstacles that confront effective treatment of opioid addiction – shortage of treatment professionals, stigma associated with treatment and the ability to maintain abstinence – have led to increased interest in alternative treatment strategies among both treatment providers and patients alike. Herbal products for opioid addiction and withdrawal, such as kratom and specific Chinese herbal medications such as WeiniCom, can complement existing treatments. Unfortunately, herbal treatments, while offering some advantages over existing evidence-based pharmacotherapies, have poorly described pharmacokinetics, a lack of sup- portive data derived from well controlled clinical trials, and severe toxicity, the cause for which remains poorly defined. Herbal products, therefore, re- quire greater additional testing in rigorous clinical trials before they can ex- pect widespread acceptance in the management of opioid addiction.

1. Introduction

Striking increases in the abuse of opioids have been observed over the last decade in the US, Eastern Europe, China and the Middle East.[1-3]

As rates of abuse and addiction have grown, the need for pharmacotherapeutic interventions has increased as well. Unfortunately, obstacles such as shortages of treatment centres and ad- dictionologists inhibit the delivery of evidence- based pharmacotherapies such as methadone and coformulated buprenorphine/naloxone in many locations.[3,4] In addition, there are high rates of

relapse associated with conventional interven- tions for opioid addiction. Finally, the stigma of receiving daily opioid replacement therapy in pub- lic venues such as methadone clinics may prevent some from seeking treatment in the first place.

The limitations of currently available conven- tional pharmacotherapies for opioid addiction may compel some individuals to use therapies that are more easily obtainable, perceived as having longer-lasting effects, and/or greater social accept- ability. As a result, interest in alternative treat- ment strategies for opioid addiction has increased among both treatment providers and patients

alike.[5,6] Formulations of the more recognized alternative interventions, kratom and ibogaine, are derived from herbal material, but a number of Asian remedies used in the management of opioid abstinence syndromes incorporate animal and mineral materials as well. This review will de- scribe the pharmacology, toxicology and efficacy of herbal-based interventions, as well as assess potential risks to users. To identify the material synthesized in this review, we conducted initial searches of the English language literature using PubMed and Google Scholar databases. We did not restrict our search results by date. Results from these primary searches served as starting points for secondary searches related to specific topical matter for inclusion in the review. Although we relied upon peer-reviewed primary literature as sources for medical and scientific data, we cited anecdotal publications describing historical events related to clandestine treatments.

2. Kratom

Kratom (Mitragynia speciosa Korth) is a tree found in Southeast Asia that contains medici- nally relevant alkaloids known as mitragynines within its leaves.[7-9] The ability of the plant to produce these compounds is highly dependent on geography; plants growing in Southeast Asia elaborate mitragynines, but those grown elsewhere, even in tropical greenhouses, do not. Kratom leaves have traditionally been used as a substitute for opium or to treat withdrawal, as well as for their stimulant effects.[10] Moreover, Thai villagers use extracts of kratom leaves as a medicine to treat cough, diarrhoea and musculoskeletal pain.[8,10]

Ingestion by chewing, smoking, brewing into a tea, or swallowing a tarlike solid that has been extracted and reduced from the leaves are typical modes of administration.[7]

The predominant alkaloid isolated from kratom extracts is mitragynine; a minor component is 7-hydroxymitragynine, an oxidized congener.[8]

These compounds appear to be responsible for the analgesic effects of kratom through opioid receptor binding in vivo and in vitro.[11] Animal studies have demonstrated that the antinociceptive activity of mitragynine in the tail-pinch and hot-

plate tests is completed abolished by the pure opioid receptor antagonist naloxone.[12] Re- petitive administration of 7-hydroxymitragynine produces tachyphylaxis as well as cross-tolerance to morphine.[10] Furthermore, administration of naloxone to 7-hydroxymitragynine- and mor- phine-dependent rats produces abstinence symp- toms of comparable intensity.[13] Moreover, the chemical structure of the mitragynines also in- corporates the tryptamine nucleus, which may be responsible for the observed activity of the mol- ecules in the serotonin and adrenergic systems.[8]

The mitragynines, however, have a novel structural scaffold for opioid receptor affinity and activity.[8,14]

For example, both molecules contain the amino functionality and the phenolic moiety common to all opioid-based ligands.[8,15] Interestingly, based on the current understanding of the structure- activity relationships for the mitragynines, the phenolic methyl ether is more potent in analgesic paradigms.[11] This is in contrast to morphine where methylation of the phenol moieties (to produce codeine) reduces analgesic potency; for morphinan-based ligands, the phenolic hydro- gen provides critical interactivity with the opioid receptors.[16]

The pharmacokinetics of kratom in humans are poorly described; for example, the volume of distribution, half-life, protein binding, metabolism and elimination in humans are unknown. Clinical effects appear to be dose dependent.[7,17,18] In small amounts, manual labourers use kratom for its stimulant effects so that they may work in harsh conditions.[17,18] With larger doses, the euphoric effects of kratom are the basis for its use as a re- placement therapy for opium among addicts.[17,18]

Clinical effects of kratom mimic those of a m-opioid receptor agonist.[19] As early as 1897, kratom was recognized as an analgesic, antitussive, antidiarrhoeal and as a remedy for opium with- drawal. To date, however, no formal clinical trials have studied the efficacy and safety of kratom in the treatment of opioid addiction. Adverse effects from kratom are limited. Kratom use does not appear to be associated with the emesis that commonly accompanies opioid use. Interestingly, respiratory depression following kratom admin- istration has not been observed in either humans

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or in animal toxicity studies; even in rats that received high oral doses of mitragynine (up to 807mg/kg), respiratory depression did not occur.[20] Similarly, no evidence of respiratory depression was observed in mice at oral doses up to 920mg/kg of mitragynine.[20] In humans, generalized tonic- clonic seizure activity has been documented in at least two cases; neither individual had a history of seizure disorder nor was taking a pro-convulsant substance.[19,21] Chronic use of kratom has been associated with anorexia, weight loss, constipation and hyperpigmentation of the face.[9] An absti- nence syndrome similar to mild opioid withdrawal is characterized by rhinorrhoea, insomnia, lacri- mation, lethargy, myalgias, arthralgias and my- oclonus.[9] Although confined to anecdotal reports, a relatively mild rhinorrhoea has been the leading complaint of individuals suffering withdrawal fol- lowing rapid cessation of kratom use.[19]

Despite a paucity of pharmacokinetic, phar- macodynamic and toxicological data, kratom appears to enjoy widespread use among specific populations.[19,22] An ethnographic study has ex- amined website postings generated by individuals who self-treat chronic pain with opioid analgesics purchased from online pharmacies.[22] Striking increases in the number of posts generated by the study population that identified kratom as a highly effective method for treating opioid with- drawal and promoting abstinence from prescrip- tion opioid analgesics were seen over a 12-month study period.[22] In addition, case report-level data have reported the use by an individual of kratom as an effective replacement therapy for parenteral hydromorphone abuse.[19] Formal epidemiologi- cal data describing kratom use in the general population are lacking, but the number of web- sites that sell kratom – sometimes in kilogram quantities – suggests the popularity of the herbal product.[22]

While kratom may have medicinal uses, it also carries some abuse liability. Although unsched- uled in the US, kratom has been criminalized in a number of countries around the Pacific Rim, in- cluding Australia.[7] Compulsive use of kratom in a number of distinct populations, including injec- tion opioid abusers and individuals with chronic pain who self-prescribe opioid analgesics, is a well

described phenomenon.[19,22] Moreover, reports that students at some college campuses congregate to drink decoctions of kratom at ‘tea parties’, as well as the sale of kratom in bars, suggest its re- creational use may be growing.[23,24] For popu- lations who are too young to legally ingest ethanol, kratom may be a viable option to drinking in bars and may be a precursor to problematic opioid use.[23]

3. Ibogaine

Ibogaine is an indole alkaloid hallucinogen derived from the root bark of the African shrub Tabernanthe iboga.[25] Among indigenous peoples, ibogaine plays an integral role in ethnoreligious ceremonies where it induces hallucinations of protracted duration.[25] The hallucinogenic effect of ibogaine eventually led to recreational use, and in the early 1960s a young heroin addict experi- menting with ibogaine claimed that he felt no opioid craving after experiencing potent ibogaine- triggered hallucinations.[26] A group of self-treating heroin addicts reported the same outcome fol- lowing ibogaine use, leading to a small number of uncontrolled studies among opioid and cocaine abusers that have led some investigators to attri- bute substantial curative powers to ibogaine.[26]

Of even greater interest has been the proponents’ claim that ibogaine-mediated detoxification from opioids was associated with dramatically lower rates of relapse than conventional therapy.[26]

Unfortunately, the wealth of animal data direct- ed toward establishing the neurochemical basis of the putative anti-addiction effects of ibogaine has failed to overcome persistent concerns about the safety of the drug.[27,28] Consequently, outcomes from ibogaine-based treatment of opioid addic- tion are poorly defined because the drug has yet to be entered into rigorous clinical trials. At pre- sent, ibogaine carries a US Drug Enforcement Administration Schedule I classification and is deemed to have no clinical value.[28,29]

Comprehensive pharmacological data for oral administration of ibogaine are lacking. Ibogaine is a highly lipophilic molecule that is absorbed following oral, mucosal and intraperitoneal admin- istration. Ibogaine undergoes extensive first-pass

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metabolism.[25] Demethylation by cytochrome P450 (CYP)2D6 to noribogaine occurs in the gut and liver; after absorption from the gastro- intestinal tract, ibogaine distributes to tissues ac- cording to a two-compartment model. Ibogaine and noribogaine distribute to the spleen, liver, brain and lung; both drugs cross the blood-brain barrier and are secreted in bile.[30] Estimated a and b elimination half-lives of ibogaine are ap- proximately 7.3 minutes and 3.3 hours, respec- tively. Drug clearance rates are calculated at 5.6 L/hours.[31]

The exact neurochemical mechanisms under- lying the putative anti-addictive properties of ibogaine have not been elucidated but likely in- volve modulation of multiple neurotransmitter systems.[25] Ibogaine agonizes the m- and k-opioid receptors, although binding affinity is dependent on experimental technique; ibogaine also antag- onizes glutamate NMDA, as well as a3b4 nico- tinic, receptor sites.[32-39] This observation has led to the hypothesis that the anti-addictive effects of ibogaine may arise from complex intracellular signalling cascades that reset neuronal function and eliminate drug craving.[40,41] Unfortunately, this hypothesis awaits further investigation.

Although ibogaine has been used to treat the compulsive use of cocaine, methamphetamine, ethanol and other drugs, its greatest recogni- tion is for the management of opioid addiction. Only a handful of cases describing treatment outcomes, however, have been published despite nearly 50 years of experience using ibogaine for opioid abuse.[25] Moreover, the quality of the methodology described in these publications is frequently substandard, with the studies being poorly controlled, enrolling small numbers of participants and with often short durations of evaluation.[26,42-45] One publication described the treatment of 33 patients undergoing acute opioid withdrawal with nonstandardized ibogaine doses over a 31-year period; participants were followed for up to 72 hours after ibogaine treatment, a period so short that the major reported finding, absence of drug-seeking behaviour, is almost meaning- less.[43] Another study conducted by ‘a loosely-knit organization’ of an ‘Amsterdam squatter commu- nity’ described administration of nonstandardized

ibogaine doses to seven patients to treat opioid withdrawal symptoms.[42] Of these individuals, three used heroin during the 24-hour treatment period or immediately thereafter; 71% of partici- pants relapsed to opioid abuse within 3 weeks of treatment.[42] These results support the central finding of the study that ibogaine induces an in- terruption in heroin use, although the benefit of ibogaine is unclear if recipients relapse to heroin use during a treatment period of approximately 24 hours in length. In addition, an open-label study conducted at a private detoxification facil- ity in the Virgin Islands involved administration of fixed doses of ibogaine to 27 cocaine- and heroin-dependent individuals who were followed for up to 1 month.[45] Unfortunately, the total number of heroin-dependent patients, the time from last use of heroin and the number of partic- ipants completing treatment was not reported in this publication.[45] These shortcomings, coupled with the observation that expensive treatments often entice patients to distort the benefits of the intervention, raise questions about the extent to which any beneficial effect was realized.[46] No controlled trials using ibogaine have been pub- lished in the peer-reviewed literature.

Because ibogaine is most commonly adminis- tered in unconventional settings, formal data on the clinical and adverse effects of the drug are lacking.[47] Clinical findings associated with ibo- gaine ingestion include profound vomiting for many hours, sometimes longer than 1 day. The most prominent feature of ibogaine use, open- and closed-eye hallucinations, occurs at oral doses of greater than 200–300 mg.[42] Above this dosage range, ibogaine has been associated with hallucina- tions that may persist for up to 36–48 hours.[42,48,49]

Cerebellar dysfunction, including ataxia, tremor and nystagmus, is commonly observed and has an onset within 2–4 hours of drug administration. These signs may resolve within 12 hours of use.[49]

Individuals ingesting ibogaine have also reported muscle pain and soreness that persist beyond res- olution of the neuropsychiatric effects.[47]

The most feared complication of both ‘ther- apeutic’ and exploratory ibogaine use remains sudden death, most likely due to torsades de pointes arising from prolongation of the QT interval.

1002 Ward et al.

One patient who survived ventricular dysrhyth- mias following ibogaine administration had dra- matic prolongation of the QT interval to 616msec when corrected for heart rate.[50] Two features of this patient’s clinical course are notable. First, the QT interval was unresponsive to the standard intervention of rapid electrolyte correction.[50]

Second, the QT interval remained prolonged for a protracted period, normalizing during the second hospital day.[50] This derangement in cardiac rhythm may not be unique to this patient. At least 11 sudden deaths have been associated with ibo- gaine use, but in each case, the cause of death could not be determined despite autopsy.[50,51] Despite extensive investigations using animal models into the neurochemical properties of ibogaine, little effort has been directed toward understanding the basis of its cardiotoxicity.[52]

4. Chinese Herbal Remedies

Opioid abuse and addiction have been a pub- lic health hazard in China for much of the last 200 years.[3] Governmental policies enacted in the 1950s curtailed opioid abuse, but economic re- forms of the 1980s led to a widespread resurgence of heroin addiction.[3] To confront the growing problem of drug addiction, the Chinese government has initiated pharmacotherapy programmes based on Western addiction treatment protocols.[3] Un- fortunately, the predominant treatment for opioid addiction is short-term detoxification with metha- done or buprenorphine at compulsory reeducation- through-work centres.[3] These programmes have faced great difficulties. Treatment centres are un- derfunded, and because patients undergo forced detoxification, they have high rates of relapse and low rates of recovery.[3] Finally, many opioid ad- dicts live in rural areas, where the reach of treat- ment programmes is limited.[3]

Traditional Chinese medicines have therefore received considerable interest as potentially more acceptable and less costly alternatives to standard pharmacotherapy. The Chinese State Food and Drug Administration has approved at least ten herbal-based products for the treatment of opioid withdrawal, with several more in clinical trials.[3]

Although Asian herbal remedies are often mix-

tures of plant matter, animal material and, in some cases, minerals or even toxic metals, the use of specific components in these complex mixtures as treatment for opioid withdrawal is supported by preclinical and clinical data.[53,54]

Corydolis yanhusuo is a herbal analgesic with sedative, hypnotic and antihypertensive proper- ties.[55] The active component, the natural pro- duct levotetrahydropalmatine (l-THP), inhibits in a murine model the locomotor hyperactivity induced by oxycodone.[56] In addition, treatment with l-THP can attenuate morphine-induced with- drawal syndromes and conditioned place pref- erence in mice.[57] These promising preclinical findings have triggered clinical investigations of l-THP. In a randomized, double-blind, placebo- controlled clinical trial, l-THP was administered to 120 heroin addicts over a 4-week period.[58]

Although l-THP effectively reduced opioid crav- ing, withdrawal syndromes and relapse rates in heroin-dependent patients, several features of this trial deserve mention.[58] First, all study par- ticipants had completed a 7-day detoxification period before enrolment in the study; virtually none, therefore, were likely to have been in acute withdrawal.[58] Second, of the 59 participants ran- domized to the l-THP group, only 44 ‘survived’ 2 of the 4 weeks of treatment whereas 59 of 61 participants who received placebo completed 2 of 4 weeks of treatment.[58] Third, the authors never state the number of participants in either group who completed the 4-week treatment period.[58]

Less than half of the l-THP-treated individuals who remained in the study at 2 weeks remained abstinent at 3 months; any beneficial outcomes, therefore, could have been driven by increased motivation to overcome addiction in a subset of the treatment population as much as from the effect of l-THP.[58]

Ginseng is another botanical commonly used in Chinese traditional remedies.[53] Two major types of ginseng exist, Panax ginseng (Asian gin- seng) and Panax quinquefolium (American gin- seng). The main active natural products in Panax ginseng are called ginsenosides, of which more than 20 have been characterized.[59] Ginsenosides have putative effects on the CNS and cardiovascular system, and may alter metabolism and immune

Herbal Medicines for the Management of Opioid Addiction 1003

function.[60] Panax ginseng attenuates the phys- iological effects of drugs of abuse including morphine in pre-clinical studies.[61] A multicentre clinical trial found that Radix ginseng (the root of Panax ginseng) was safe and effective for the treat- ment of moderate-to-severe acute heroin with- drawal.[62] In this double-blind study, 212 heroin addicts were randomized to treatment with either the ginseng herbal mixture or to lofexidine over a 10-day period.[62] The investigators found that the herbal mixture was as effective as lofexidine at alleviating the symptoms of opioid withdrawal, with patients reporting only gradual improvement in symptomatology over the study period.[62]

Unfortunately, lofexadine is minimally effective at treating acute opioid withdrawal, and the study design did not incorporate a placebo arm.[62] It is therefore possible that what was observed in the patients was untreated opioid withdrawal, the natural history of which is improvement over time. Significant adverse effects included eleva- tions of liver transaminases, but because Chinese herbal mixtures are manufactured with little reg- ulatory oversight, the specific cause of hepatic injury cannot be ascribed.[62,63]

The active chemical in Panax quinquefolium, not found in Panax ginseng, is pseudoginsenoside- F11 (PF11), a saponin.[59] Panax quinquefolium, especially PF11, exerts distinct effects following morphine administration. PF11 attenuates mem- ory impairment in the Morris water maze test, analgesia measured by tail pinch, locomotor sen- sitization and, at higher doses, the expression of conditioned place preference.[64] Neurochemically, PF11 antagonizes opioid receptor signalling and decreases the concentrations of dopamine and its metabolites in the brain of test animals treated with morphine.[65,66] While these findings suggest that formulations containing PF11-elaborating herbal products can be applied to the management of opioid withdrawal, the clinical evidence support- ing their use is mixed. For example, WeiniCom is a herbal product mixture that contains Corydalis and Panax quinquefolium; some formulations that are sold online appear also to contain kra- tom (Mitragynia spp.).[67] A double-blind, clin- ical trial compared WeiniCom (also called Xian Xu Qudu Jiaonang) treatment with buprenor-

phine in 42 heroin addicts entering treatment.[68]

WeiniCom not only relieved opioid cravings more rapidly than buprenorphine, it also treated sub- jective measures of withdrawal symptoms such as abdominal pain, diarrhoea, rhinorrhoea, myalgias and piloerection.[68] Adverse effects from WeiniCom were not reported.[68] The beneficial effects from WeiniCom could have been due to kratom be- cause (i) kratom appears to treat opioid with- drawal; (ii) some WeiniCom formulations contain kratom; and (iii) the exact composition of Chinese herbal remedies is often poorly defined.

In addition, a randomized, double-blind, pla- cebo-controlled, multicentre study compared another Chinese herbal mixture called Tai-Kang- Ning with lofexidine in 64 heroin addicts.[69] Im- provement in symptomatology by treatment day 3 was achieved in both groups. Because patients were enrolled up to 36 hours after last heroin use, however, and the symptoms of untreated, acute heroin abstinence resolve in approximately 5 days, this Chinese herbal medication may have actually had little impact on withdrawal.

Although the side-effect profile of traditional Chinese remedies is often unreported, the low incidence of adverse effects compared with lo- fexidine suggests that they are safe to use.[62,69,70]

For example, a product known as FYP (Fu Yan Pellet) was tested against lofexidine in a random- ized, double-blind, placebo-controlled, multicen- tre trial in 225 heroin addicts.[70] In this study, treatment with either FYP or lofexidine decreased opioid withdrawal symptoms by day 3 of treat- ment.[70] The incidence of adverse effects from FYP (e.g. dry mouth) was comparable to that of lofexidine (e.g. dry mouth, transient hypotension and bradycardia). Notably, respiratory depres- sion from traditional remedies has not been re- ported in the peer-reviewed literature.

5. Heantos

Heantos, a complex mixture of materials cre- ated by a Vietnamese herbalist, is intended to treat opioid addiction.[71] Despite funding from the United Nations and other sources, this product has not yet been tested in formal clinical trials.[71]

Furthermore, unconfirmed reports of at least six

1004 Ward et al.

deaths associated with heantos therapy have led Vietnamese authorities to proscribe heantos ther- apy.[72,73] Some investigators suspect that the main component of heantos may be kratom.[72]

6. Conclusions

Clinicians hoping to incorporate herbal rem- edies into treatments for opioid withdrawal and addiction will be confronted by a striking lack of data from well constructed clinical trials in- vestigating the efficacy and effectiveness of these substances. Nonetheless, herbal treatments for problematic opioid use offer some advantages over existing pharmaceutical-based interventions. Some, such as kratom, are believed to have less respiratory depression and fewer lethal side effects than methadone therapy; others, such as traditional Chinese remedies, are less expensive and may be more culturally relevant than standard opioid re- placement protocols. To fully incorporate herbal interventions into existing treatment regimens, several lines of evidence should be developed.

First, the pharmacology, pharmacokinetics and toxicology of herbal materials in humans should be described in greater detail. For example, the pharmacological basis of kratom-associated seizure activity should be investigated, as well as the clinical features that place individuals at risk for this outcome. In addition, the impact of ibo- gaine administration on the QT interval and other cardiac effects should be investigated rather than discounted. Second, sufficient rigor should be incorporated into clinical research studies to allow meaningful assessments of outcome. For example, a study design that compares a remedy with an intervention does not allow clinicians to determine if that remedy is more effective than placebo. If a herbal substance has no benefit, then its use carries only risk; using proper study design would ensure that the potential for benefit can be incorporated into decisions related to medication selection. Third, clinicians should develop the social and cultural contexts in which herbal re- medies have utility. For example, methadone- based opioid detoxification in some cultures has been associated with high rates of relapse and treatment failure. Studies that examine the con-

texts in which culturally relevant interventions may be incorporated into evidence-based treat- ment regimens may improve outcomes. Ultimately, herbal therapies for opioid addiction and with- drawal can complement existing treatments, and future studies should explore the relationship between evidence-based pharmacotherapies and traditional remedies.

Acknowledgements

The authors declare no conflicts of interest. Dr Boyer is supported by NIH ARRA (Challenge) grant RC1-028428. No other sources of funding were used to prepare this review.

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Correspondence: Dr Jeanine Ward, Department of Emer- gency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA. E-mail: [email protected]

Herbal Medicines for the Management of Opioid Addiction 1007

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COLLABORATION: A METHODOLOGY FOR IMPLEMENTING A WHOLISTIC, CHRIST-CENTERED APPROACH TO STOP

THE REVOLVING DOOR OF DRUG ADDICTION

Rosunde Cummings Nichols, D.Min. B.A., Antioch University, 1980

M.Div., United Theological Seminary, 1994

Mentors Robert C. Linthicum, D.Min.

Paul Hertig, Ph.D.

A FINAL DOCUMENT SUBMITTED TO THE DOCTORAL STUDIES COMMITTEE

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF MINISTRY

UNITED THEOLOGICAL SEMINARY DAYTON, OHIO December, 2001

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P.O. Box 1346 Ann Arbor, Ml 48106-1346

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CONTENTS

ABSTRACT...................................................................................................................... v

ACKNOWLEDGEMENTS ............................................................................................. vi

DEDICATION ................................................................................................................. viii

LIST OF ABBREVIATIONS ........................................................................................ Lx

INTRODUCTION............................................................................................................. 1

Chapter

1. MINISTRY F O C U S ............................................................................................ 4

2. THE STATE OF THE ART IN THIS MINISTRY MODEL ......................... 22

3. THEORETICAL FOUNDATION .................................................................... 46

Biblical Focus

Theological Focus

Historical Focus

4. METHODOLOGY............................................................................................. 65

5. FIELD EXPERIENCE ...................................................................................... 70

6. REFLECTION. SUMM.ARY. AND CONCLUSION..................................... 82

Appendix

A. BAPCO SUBSTANCE ABUSE TREATMENT AND PREVENTION PROGRAM: STANDING IN THE G A P .............................. 90

B. BLUE BAY: PEACE THROUGH SOBRIETY .............................................. 95

C. COMMUNITY SUPPORT GROUP OF THE ATLANTA MASJID ........... 101

iii

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D. FREEDOM NOW! THE SUBSTANCE ABUSE MINISTRY OF BETHEL A.M.E. CH URCH..................................................................... 103

E. MULTI-LAYERED PROGRAM: ST. SABINA ROMAN CATHOLIC CH URCH............................................ 107

F. ONE CHURCH— ONE A D D ICT................................................................... 109

G. PARENT POWER: KEEPING OUR KIDS DRUG F R E E ........................... 113

H. STREET PSYCH: A CRIME AND SUBSTANCE ABUSE PREVENTION PROJECT FOR INNER-CITY MINORITY FAMILIES AND T E E N S ........................................................... 116

L SOUTHWEST COMMUNITY AT A G LA N CE........................................... 123

J. DATA COLLECTION..................................................................................... 136

K. WHOLISTIC SPIRITUALITY G R A P H ........................................................ 142

L. OPEN DOOR COLLABORATIVE STRUCTURE ...................................... 144

M. WEEKLY WORSHIP FORMAT .................................................................. 147

N. MINISTRY BOARD MEETING MINUTES ............................................... 150

O. CONTEXTUAL ASSOCIATES' MEETING ............................................... 152

P. .ADVERTISEMENTS ...................................................................................... 156

Q. WORSHIP ACTIVITY FO R M ....................................................................... 160

R. SPIRITUAL TWELVE S T E PS ....................................................................... 162

S. OPEN DOOR HIGHLIGHTS ......................................................................... 164

Glossary ......................................................................................................................... 174

BIBLIOGRAPHY ............................................................................................................ 176

I V

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ABSTRACT

COLLABORATION: A METHODOLOGY FOR IMPLEMENTING

A WHOLISTIC, CHRIST-CENTERED APPROACH TO STOP

THE REVOLVING DOOR OF DRUG ADDICTION

Rosunde Cummings Nichols

United Theological Seminary, 2001

Mentors

Dr. Robert Linthicum, D.Min. Dr. Paul Hertig, Ph.D.

The Open Door Collaborative Ministry in Dayton, Ohio, tested the effects o f a wholistic

Christ-centered treatment approach to recovery. This study o f pre- and post-residents in

treatment for substance abuse was evaluated through qualitative analysis. The results

show that participants and community residents alike were empowered and transformed

during the implementation o f the ministry model. The field study revealed that

spirituality is a significant factor in the recovery process toward healing and wholeness.

This model for people overcoming substance abuse is particularly adaptable for the

church in urban communities.

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ACKNOWLEDGEMENTS

I am thankful to God for God's faithfulness and sustaining strength when the enemies

o f my soul came to discourage me and the completion o f this project, and that the ever-

abiding Presence o f a Victorious Christ would come and empower me in this journey.

I extend my appreciation to The Open Door Collaborative Ministry Team for their

prayers and support, and the context associates for their commitment, leadership, and

faithfulness as co-designers and implementers o f the project: Gerald Davis. Carlene

Wilson. The Reverend John Allen. The Reverend Beverly Lee. The Reverend Mark

McGuire. Chaplain Danny Felix. Sherman Holmes. Shallon Coleman. The Reverend

Robert Beikman. and Dr. Shirley Johnson.

I share great respect and appreciation for my consultants who gave me their time,

wisdom, support, prayers, and expertise: Dr. Robert Walker. Dr. Mary Olson. Dr. Daryl

Ward. Dr. Faye Taylor, and Ms. Zell Skelton.

Credit goes to Jan Baxendale for her support during the past two years. I am deeply

grateful to a devoted friend. Jo Ann Gilmour. who assisted me with the laborious task of

typing and editing the final document.

Deep appreciation and gratitude to my loving husband. Johana. who supported me

with his patience, iove. encouragement, and understanding to complete this project.

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Special thanks to my daughter, Londe. and my grandchildren. Marcus and TiTi. for

their love and prayers.

Thanks and much gratitude to my peers and sista* friends who have enriched my life

with their encouragement, love, and support. Our time spent together laughing, praying,

crying, worshiping, and planning, is an experience I will always cherish.

I also praise God for dear friends who. in the most critical period o f my doctoral

journey, opened their hearts and homes to me: Dr. Jerrie B. and Charles McGill; Mrs.

Cecil Peters; Ms. Delores Smith; Elder Flonzie Brown Wright; Ms. Geneva Beard: and my

beloved Victory community.

Finally. I thank Dr. Robert Linthicum and Dr. Paul Hertig — mentors, spiritual guides,

and friends— who were the prime movers o f my work. Without them this project would

not have happened.

M l

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DEDICATION

I dedicate this project to the Glory o f God and for the up building o f God’s Kingdom

and shalorn among the poor and marginalized. This endeavor would not have been

possible without empowerment from the Holy Spirit along with the love, support, and

personal sacrifice o f my wonderful husband, Johana.

I also dedicate this project to my faithful friends, colleagues, and sisters in ministry:

The Rev. Dr. Mary Olson. The Rev. Dr. Faye Taylor, and The Rev. Dr. Lois Fortson. who

always encouraged me to walk in excellence and spiritually nurtured me in my times of

weakness.

Finally. i dedicate this project foremost to the memory o f the Lord's prophetic

women in my family, past and present, who have forged God’s paths o f justice before me.

empowering others through God's cali and anointing: My loving mother. Carrie Oletha

Long: Great-great-great Grandma Rose: The Rev. Carrie Harden-Harrison: The Rev.

Rosie Lee Long: The Rev. Lillie Mae Harrison: Ms. Londe Rene Givan: and Miss

Alexandra Nicole Givan.

To God be the glory for the things God has done!

viii

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ABBREVIATIONS

AA Alcohol Anonymous

A.M.E. African Methodist Episcopal Church

BAPCO Baptist Pastors Council o f Greater Detroit Area

NA Narcotics Anonymous

NIV Holy Bible, New International Version

NLT New Living Translation. The Life Recovery Bible

ODCM Open Door Collaborative Ministry

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INTRODUCTION

The biblical mandate, '“the Kingdom o f God,” is to confront and call dehumanizing

and destructive systems o f oppression to accountability by exercising God's jubilee

principles o f liberation and restoration—setting the captives free. Visual observations and

listening to the cries o f the people in our communities should be our motivating force to

unite with other concerned individuals who are committed to the prophetic call of

demonstrating and proclaiming Christ's liberating gospel.1 The phrase. "Kingdom o f

God.” has also been referred to as "Kindom o f God” by Dr. Carolyn Bohler. Emma

Sanborn Tousant Professor o f Pastoral Theology and Counseling at United Theological

Seminary in Dayton. Ohio. Dr. Bohler used the term in the context o f inclusivity and

equality as compared to the traditional hierarchal expression o f "Kingdom."

The Open Door Collaborative Ministry will prove to the reader that a Christ-

centered ministry model will indeed liberate, restore, and empower those drug addicts who

dare to stretch out into the "deep resources o f their being." This is accomplished through a

wholistic spirituality-based community outreach ministry. The wholistic methodology is

centered around the worship experience which includes: gospel musical praise, meditations

for living, testimonies, preaching, anointing with prayer, and fellowship gatherings after

worship.

: Robert Linthicum. D.Min.. Building a People o f Power. Video Series. Sessions 6-7. Crown Ministries International. Colorado Springs. 2000.

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Chapter Summaries

In Chapter One, the writer chronicles her spiritual journey, including her pastoral

call and her ministry o f empowering the poor with Victory' United Methodist Church in

Dayton, Ohio, and her work as founder and pastor o f the Open Door Collaborative

Ministry, a community-based ministry with recovering drug addicts. The area o f ministry

this model addresses is a faith-based community ministry's response to the endemic social

illness o f substance abuse in an urban community. Also included is a socio-economic

profile o f the City o f Dayton and the model context community o f Southwest Dayton.

In Chapter Two, there is a review o f various models which offer a definition of

wholistic Christ-centered ministry that is also applicable for healing and spiritual

transformation with individuals who are in recovery from substance abuse. This chapter

will also bring to bear themes from other authors relating to cause and effect o f social ills

that face this society.

Chapter Three contains the theoretical foundation for this project, the rationale and

justification for this work. The writer shows how' the methodology for the design and

implementation o f this model begins with the wholistic ministry response o f a radical Jesus

through salvation, healing, and deliverance o f the poor and marginalized from systemic

oppression. It also presents the theological, biblical, and historical focus for this model of

ministry.

Chapter Four includes the replicable model consisting o f an explanation o f the

empowerment worship components o f this wholistic collaborative recovery model for

substance abusers. There is also a discussion of meetings between the contextual

associates and the writer in preparation for implementation o f the model.

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In Chapter Five, the writer shares the results o f what occurred during the actual

implementation o f the model, the hypothesis tested in the study, and the instruments

utilized to measure the efficacy o f this model. The writer also summarizes the results o f

the self-administered group survey, pre- and post-assessment interview's, and collaborative

representative one-on-one interviews.

Reflections, a summary, and the conclusion appear in Chapter Six.

The Open Door family believes with the Apostle Paul that “The Lord will deliver

us from every evil work and will bring us safely to his heavenly kingdom" (1 Tim. 4:18.

Revised Standard Version).

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CHAPTER ONE

MINISTRY FOCUS

God is a God! God don 7 never change!

Like Jeremiah, this writer believes God calls God's prophetic men and women to

tear down, uproot, and rebuild. Like Jeremiah, she questions, "How' long before people

will listen to the voice o f a loving God o f justice, righteousness, and mercy?' Like

Jeremiah, her call is from the womb. Every step o f the way, her encounters with God are

true to the experiences o f her fore-parents' understanding o f the faithfulness o f God. and

their exemplary lives of living out the justice o f God with the marginalized.

God is a God! God don 7 never change! Gcd is a God a n ' He always will be God! The earth his footstool a n ' heaven his throne, The whole creation all His own. His love an" power will prevail. His promises will never fail. God is a God! God don 7 never change! God is a God a n ' He always will be God!'

The God-breathed theology written in the genre o f .African American spirituals

composed by her fore-parents have continued to bare witness to the biblical story lived out

in every age. These earthy poetic lyrics cut through the language o f the academy to the

praxis o f the justice o f God's continuing activity in all of creation. The biblical witness o f

the Word becoming flesh in community has always been fundamental to their existence

1 “Clod Is a God." Songs o f Zion (Nashville: Abingdon Press. 1981). 140.

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and survival. Society too often defines the worth o f humanity by race, class, or gender.

However, from infancy this writer was taught that Jesus demonstrated through his ministry

o f miracles and healing that all humanity is valued and defined by our divine inheritance o f

Imago Dei—created in the image o f God (Gen. 1:272). Jesus' ministry- in Galilee and

beyond is the prescribed model for "doing the Gospel” in the world, especially among the

least o f these, the marginalized in our urban and third world communities. Jesus' ministry

paradigm—Theo-Praxis— is action-based ministry that demonstrates and produces divine

hope in the hard, painful, difficult places where people live.

In July 1990, this writer was invited to become one o f two pastors in the first bi-

racial female clergy team in the Dayton North District in the West Ohio Conference o f The

United Methodist Church. The team pastors believed that the church o f Jesus Christ must

accept Christ's vision o f demonstrating a ministry o f equality with shared power and

authority. It was a blessing to serve Victory United Methodist Church for eight years as a

team pastor and three years as senior pastor.

The Victory Church congregation declared an intentional bold witness to become

transformed from an all-white homogeneous faith community to a faith community o f race

and class diversity. The transformation came not from the bishop or the district

superintendent, but in answer to Jesus" mandate that the kingdom o f God be one in Christ.

The team appointment offered the pastors an opportunity to put Jesus' ministry paradigm

o f race, class, and gender inclusiveness into praxis. The call to Victory- Church challenged

the pastors and congregation to confront the systems o f racism and classism found in the

: The New Internationa! Version o f The Holy Bible (NIV).

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church and in the community. Victory’s acceptance o f a highly visible black and white

female clergy team initially met with strong opposition from a racially tense,

predominantly Appalachian community. The pastors and congregation remained steadfast

in their mission to serve the poor and stand on the side o f God’s unconditional love, grace,

mercy, forgiveness, and justice for all people.

Within the Victory congregation, a mother who took the life o f her child found

forgiveness, redemption, and healing. Teenage girls, terrified of pregnancy, turned to

prayer and the church community for spiritual healing and hope. Displaced families,

hungry and without shelter, found newr beginnings in the community o f faith. Within the

Victory family, distressed single-parent mothers found support, encouragement, and

empowerment to rise above oppressive systemic conditions. Drug addicts driven by

hopelessness and unresolved rage resulting from ingesting crack-cocaine cried out in pain

and learned that traditional clinical approaches to rehabilitation alone will never cure or

lead to sustained recovery. This pastor has heard constant testimonials that only a God o f

redemption is pow erful enough to deliver one's soul from the demon o f crack and bring

healing to shattered lives and broken dreams.

It was out o f this ministry o f justice, pain and tragedy, successes and failures, along

with the foundational faith teachings from the writer's youth and the experiences o f her

spiritual journey, that she received the call to develop with the grassroots community a

wholistic ministry of recovery for persons challenged with the illness o f drug addiction.

This is the wrrci fh-ma (solid ground) that gave birth to the Open Door Collaborative

Ministry in the Southw est community o f Dayton. Ohio. It was also this same

uncompromising commitment to ministry with the poor and disenfranchised communities

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that called her from the organized structures and traditionalism o f The United Methodist

Church to a recovery ministry with the poor and those who are addicted to substance

abuse.

Her family heritage o f living out the justice o f God dates back to the time o f the

birth o f her Great-great-great-grandmother Rose. The rich royal blood o f her motherland,

Africa, and the Cherokee nation streamed through her veins. According to family history,

Grandma Rose was intelligent and breathtakingly beautiful. When the Massa o f the

Alabama plantation desired her for his house mistress, Grandma Rose vowed that death

was better than to lie with him. Her refusal to submit to his desire resulted in a severe

beating. Beaten, yes! Painful, yes! Flesh broken, yes! But she knew that faith in a God o f

justice and righteousness for the oppressed was more than sufficient for her protection.

That "On Time God" allowed His Spirit to touch the Massa's heart with compassion and

she lived on the plantation under his protection from abuse and harm until her death.

Grandma Rose lived out the justice o f God on the plantation, knowing that God is

stronger than any slave-master.

God is a God, God don't never change!

God is a God, A n ' He always will be God!

Little has been recorded about my great-great-grandmother other than what she

shared about Grandma Rose with Great-grandmother Carrie to encourage her. It was

imperative to plant in her daughter's heart the Joshua seed for understanding that God’s

justice is ever present. It was in the spirit o f Joshua that she encouraged her daughter to

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"Be strong and courageous; do not be afraid; do not be discouraged, for the Lord your

God will be with you wherever you go" (Josh. 1:9).

Grandma Carrie was the oldest o f seven children. Her mother met with an untimely

death, leaving thirteen-year-old Carrie with the responsibility for the care o f the younger

children. It was not long after her mother’s death that John L. Harrison came to town and

eyed this lovely young girl working in the fields while she cared for six siblings. He had

recently been discharged from the army and came to settle in the Auburn, Alabama,

community. Research into the military clothing he wore—as seen in a photo album—and

consultation with a local historian leads us to believe that Harrison served in the Spanish-

American War in the late 1800s and, as an African-American, probably served for financial

security. After courting Carrie for six months, they married. Harrison, now Grandpa John,

assumed the responsibility o f rearing his wife’s siblings, after which they began a family o f

their own.

Grandpa John had a look and the stature o f an elder statesman—a commanding

presence o f gentle authority. They were both committed Christians and their spiritual

journey eventually led them to accept the call to ordained ministry.

Grandma described Grandpa John as a man o f strong faith with a gentle spirit. She

often reminisced that he was a loving husband and a good provider. "Even during hard

times we were not worried.” she would say. "because he had confidence that the Lord, if

we were faithful, would somehow make a way.” And throughout their lives the Lord

proved faithful, sufficient, and true. Grandpa John was a loving husband and father who

pastored and preached the liberating Gospel o f Jesus for over forty years. They lived out

God's justice beyond the boundaries of segregation. Jim Crow laws, and lynchings.

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God is a God, God don 7 never change!

God is a God. An ’ He always will be God!

Grandpa John and Grandma Carrie gave birth to two sons and a daughter. Rosie

Lee was named after her Great-great grandma Rose. Rosie Lee would eventually answer

the call to be an instrument o f G od's living, just as her family before her. She completed

boarding school and graduated from the Tuskegee Normal School with a certificate in

teaching. Grandma Rosie taught basic academic skills and Bible to African American

children in a one-room schoolhouse. Her passion for justice led her on a mission to

eliminate the evil o f illiteracy among African American children in her county. Every

moming she would get into a small boat and row across the river to the schoolhouse. She

understood the danger involved in crossing the river, but she knew the Lord traveled with

her, and it was worth the risk in order to help children learn the skills that would provide a

brighter and more prosperous future for them. Many young lives were changed from

despair to hope, from disappointment to joy. from failure to success.

The author's grandfather. Mr. Richard Myles Long, was passing through town and

observed the well-dressed lady school teacher. Miss Rosie Lee. climbing out o f the boat

on her way from the schoolhouse. He introduced himself, and. as they say. the rest is

history. It was like the movies: the lovely local schoolmarm meets the dapper young man

traveling through town, and they soon had a beautiful wedding. From that holy union the

writer's mother. Carrie Oletha. was bom. Grandma Rosie, school teacher in a one-room

.Alabama schoolhouse. living out the justice o f God through educational empowerment.

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God is a God, G od don't never change!

God is a God, A n ’ He always will be God!

At the age o f seven, mama was stricken with scarlet fever and the physicians

informed her parents that she would not live to reach adulthood. But God's grace seems

to be most amazing in what humans find to be almost impossible.

The story is told that the Spirit o f the Lord risked Carrie Oletha and announced to

her that she would give bkth to a female child and that she should name the girl child

Rosunde. Her life, the story goes on, would be a sacrifice o f praise and a blessing to many

through the preached Word, her compassion, and her gift o f song. The mother repeated

the story over and over o f how the Lord named her child and called her forth into ministry

even before she was bom. Her parents told her they prayed, read, played classical music,

and sang to her during the nine months she was carried in her mother's womb. After her

birth, her parents, who were Ministers o f Music at McKinley Methodist Church in Dayton.

Ohio, continued to surround her with spirituals, music, and intellectual stimulation.

Although there were many blessings during her lifetime, the child also experienced

times o f pain and suffering. It u'as during the turbulent storms that she was strengthened

with the assurance that even before she existed. God knew her name and continues to hold

her as a loving parent. The act o f “naming'' in the African and Hebraic traditions is to call

forth into existence the virtues, character, and God's vision according to the spirit o f the

name. Biblical authorin' confirms the reality that words have power, and naming in ancient

communities was looked upon as a prophetic act that identified meaning, purpose, and

vocation for one's life.

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The blessed beginnings in Rosunde's life were rudely interrupted when, at the age

o f five, she would first realize Satan’s desire to designate her soul as a battleground for

testing the strength o f God's call upon her life. How does one explain to a young child

that the sexual assault upon her is a demonic attempt to abort God’s vision for her life?

How does one explain away the emotional trauma suffered by the child when her parents

divorced? She was fortunate to have family and extended-family support which sustained

and nurtured her through prayer and Christ-centered counseling as she moved through the

process of healing.

God is a God, God don 7 never change!

God is a God, A n ' He always will be God!

It was Great Grandma Carrie who helped shape Rosunde's initial understanding of

the importance o f developing an intimate loving relationship with Jesus as Savior, friend,

sustainer, comforter, deliverer, and waymaker. ‘*Mv All and All.” The child was held

spellbound by such Bible stories o f deliverance as Daniel in the Lion's Den. David and

Goliath. The Three Hebrew Boys in the Fiery Furnace, and Noah's Ark. In Great

Grandma Carrie's house was a picture o f a starving family with the mother offering her

flesh as food for her children. Tears came to the child's eyes every- time she looked at that

loving mother sacrificing her life to save her children. Although the child didn't understand

why that picture seemed to impact her spirit so strongly, now. following her family’s

teachings about Jesus, and experiencing a personal relationship with Christ, she knows

without question that it reminded her o f Christ's unconditional, sacrificial love for her—

giving up all so that she might have life. From her early childhood years she remembers

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hearing. "You can tell the kind o f tree it is by the fruit it bears.” She has grown to know

and experience the length, the depth, and the breadth o f that adage as she looks back on

all those saints whose wisdom recognized that she would eventually respond to God's call

to ordained ministry.

God is a God, God don't never change!

God is a God, A n ' He always will be God!

At the age o f six Rosunde and her brother accompanied their grandmothers to the

mission church in the Drexel community, a suburb of Dayton, Ohio, where they had been

blessed to plant this mission unit at the request o f their pastor, the Rev. Warren Hill. Their

grandmothers worked the community with the fervor and spirit o f nineteenth-century

revival preachers. This dynamic duo knocked on doors, prayed in homes, created a

community worship center, and preached revivals telling folks about God's amazing grace

and Christ's power to heal broken lives. Every week people from the community would

come to the one-room church building with the iron potbelly stove in the middle o f the

floor to celebrate the goodness o f the Lord. Those daughters of thunder belong to the

company o f faithful pioneering clergy women who refused to stay put in the pew where

some say they belonged. Instead, they said yes to the will o f the Lord to preach and live

God's vision o f justice for the poor and downtrodden. They believed, as this writer now

believes, that "In Christ there is no longer slave or free, there is no longer male or female:

but all o f us are one in Christ Jesus” (Gal. 3:28-29a).

Every rainbow has a beginning and an ending: every day has a sunrise and a sunset:

and every life is a grace-filled experience from birth to the transition to life eternal. This

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writer's childhood years presented her with the same challenges that other children face.

But her mama believed that an idle mind is the devil's workshop, so she tried to fill her

children's days with meaningful activities. One day she sent them to the comer drugstore

to purchase an item for her. After completing the purchase, the children playfully ran from

the store. A police car suddenly stopped beside them. The policeman ordered them to

spread eagle and place their hands on the car so that he could search them for stolen

goods. They were frightened and ashamed. They were angry! They questioned the

whereabouts o f God and how God could allow this humiliating incident to occur in the

lives o f innocent children. That was their first encounter with the demon o f systemic

racism, but a lifetime o f similar encounters would follow. From such encounters the writer

would growr to learn that she lives in a society' programmed to perpetuate and preserve the

principle o f white dominance.

God is a God. G od d o n '! never change!

God is a God. A n ' He always will he God!

On August 22. 1961. the Lord blessed Rosunde’s marriage with a beautiful baby

girl. She was named Londe. When her father and mother had been dating, they saw a

Greek mythology film and one o f the characters was a magnificent female queen whose

name was Londe. She had the spirit o f Queen Esther, the liberator, who saved her people

from being destroyed at the hands o f their enemies. Should the couple marry and give birth

to a baby girl, she would be called Londe—a name given in the spirit o f Queen Esther, the

liberator, living out acts o f justice in a racist society. The family legacy o f Great-great-

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great grandma Rose and the mantle o f meting out God's vision o f justice would be passed

from Mommy Rosunde to Baby Londe.

The question o f G od's whereabouts was once again raised on November 11. 1966.

Systemic racism upon African American males and their families contributed to

introducing violence into their home, which brought injury to her and destruction to their

marriage, as it foiled another black male. On that cold Veteran's Day Rosunde became a

victim o f family violence at the point o f a .38 caliber gunshot wound to her forehead. The

bullet left her paralyzed, her husband in jail, and a six-year-old daughter on tranquilizers

and in the care of her Great-grandma Rosie. Those early childhood faith beginnings

became the lifeline to help the mother scale the mountains ahead. She was in a ripe

position for the miracle o f G od's love to bring healing and hope to her life. But the greater

miracle was God's ability to use a bullet as the catalyst to bring forth a ministry o f

encouragement and preaching the Good News to others caught in the throws o f human

pain and despair.

It was not an easy climb up that mountain, but God's faithfulness was present all

along the journey. During her rehabilitation she experienced the inexhaustible power and

grace o f Jehovah Nissi—G od's banner o f love over her. God's call became ever clearer

and more focused as she came into healing and wholeness. Suffering and pain were

transformed into inexpressible joy as she said yes to her call to ordained ministry.

God is a God. God don't never change!

God is a God. A n ' He always will be God!

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When she felt the prompting o f the Holy Spirit to enroll in seminary, she was in the

process o f planning a national concert tour to promote a new album o f Gospel music. She

was unhappy about the Holy Spirit making a move on her to shut down her plans. But the

Lord was determined to be heard, and her spirit would know no peace until she ceased to

ignore the tugging at her heart. She felt that she was being coerced even as she decided to

ask United Theological Seminary for an appointment to discuss ministry opportunities.

She argued with the Lord: Hasn't it been said that this is a white racist institution, that

Jesus is not present? Lord, what could be learned from them that has not already been

learned from you? What about ministry already offered to people in prison and on the

street, with the developmentally disabled, and with struggling families, and at-risk-youth?

What can be learned at the seminary that a degree in social w'ork and behavioral

counseling can't handle?

Perhaps the Lord directs his children's steps for a blessing, even when they come

kicking and screaming. As soon as the author drove onto the seminary grounds, she felt

the presence o f God's spirit and peace. Without question, she was in the right place. And

because she was obedient, even reluctantly so. the Lord blessed her and opened doors that

would have been impossible for her to enter without being connected to United

Theological Seminar}-.

During the fourth year at the seminar}-, her thoughts began to turn to the joy of

remarriage. Her prayer was that God would send a husband to complement the ministry to

which she is called. One year later she met a handsome artist with gentle strength and a

smile that has the ability to warm your heart and light up your spirit. His name is Johana.

Eighteen months later she was blessed to receive her Master o f Divinity degree, travel to

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South Africa for the second time, and become Johana's bride. The Lord richly blessed

their ministry at Victory Church and in the Northridge community.

From a plantation in AJabama, where Grandma Rose said ‘‘N o" to the desires o f

the slave-master, to Dayton, Ohio, where a great-great-great-granddaughter continues the

struggle for justice for all o f God's children—how could it happen? It must have been as it

continues to be—God’s “Amazing Grace."

Amazing grace, how sweet the sound that saved and set me free! I once was lost but now I'm found. Was blind but now I see. Through many dangers toils and snares, I have already come; 'Twas grace, grace, grace that brought me safe this far.

And grace will lead me on. (John Newton)

As her grandparents and parents did before her, and with the help o f God. she is

going to run on, pray on, work on. and shout on as she continues to roll up her sleeves,

get her hands dim-, and live out the vision o f God’s justice.

Community Context

The questions that continue to challenge the church and community in relationship

to their response to the endemic social problem o f substance abuse are: Where do we

begin? .Are we capable o f developing a model o f ministry that will give birth to hope and

stability in the families o f our communities? What methodologies will produce long term

results to stop the revolving door syndrome o f drug addiction? It has been noted that the

degree o f drug abuse in the United States is higher than any industrial society/' This social

? Alcohol. Tobacco, and Other Drug Abuse: Challenges and Responses fo r Faith Leaders (Washington. D.C.: U.S. Department o f Health and Human Services. Substance Abuse and Mental Health Services Administration. 1995). 3.

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disease is so entrenched in the culture that our United States law enforcement and criminal

justice system are said to be overwhelmed by it.4 Educational campaigns fall short.

Endorsement by the United States Government to fund faith-based community initiatives

in an effort to reduce the effects o f illicit use and violence in the nation is an open

acknowledgement o f the inability o f secular structures to bring transformation and healing

to a morally sick nation. The Open Door Collaborative Ministry (ODCM) response to the

pandemic condition o f drug addiction in the Southwest community o f Dayton. Ohio (see

appendix I), was to develop a collaborative approach to recovery where the care and

treatment emerges from a core o f w holistic spirituality addressing the mental psycho

social. and physical dimensions of drug addiction. This non-tradhional recovery paradigm

is designed to promote healing and spiritual transformation in the lives o f persons addicted

to substance abuse.

The City of Dayton is known for being the home o f Wilbur and Orville Wright and

the birthplace o f aviation. it is also celebrated for its love o f the arts and another famous

Davtonian. Paul Laurence Dunbar, the first African American poet to be published

nationally and internationally. Dayton's heritage o f invention and innovation continues

today with aerospace research at Wright Patterson Air Force Base and research into

manufacturing products from advanced composite materials.'

And who can forget the Israeli-Palestinian Peace Talks— known as the Dayton

Accord— hosted by President Bill Clinton at Wight Patterson Air Force Base? The picture

J Ibid.

( 'i/i'l'ian Ikn'.'o*. Pte 2<> -<> lh:->n t ''Dayton Comprehensive Plan rDavton. OF L May 1999). 8-

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o f Dayton is impressive until we look at some disturbing statistics. The City o f Dayton has

the ninth highest child poverty rate.6 City o f Dayton residents are four times as likely to be

living in poverty as residents living in the rest o f Montgomery County. In Dayton. 25

percent o f the residents live in poverty compared to 6 percent in the rest o f the county. In

the nation, 18 percent o f children live in poverty, while 40 percent o f children live in

poverty in Dayton.7

Poverty, crime, and violence in economically poor neighborhoods are a part o f the

political economy o f low income communities because these factors reflect systemic

dimensions that are shaped by forces that lie beyond the control o f the community.8 The

politics o f economics are significant in contributing to the rise o f the social disorder in

urban communities. Often, much of the research in social analysis tends to continue the

use o f racist and culturally biased language which perpetuates the victimization o f the poor

and people o f color rather than address the oppressive systemic flaws of the political,

economic, religious, and educational systems.9

The average family income per capita in the Southwest Dayton community—the

location o f the Open Door Collaborative Ministry— is less than $11.000. which includes

supplemental income dollars. Over 70 percent o f the residents are single-parent families.

6 Montgomery County Department o f Community Human Services. Dayton, Ohio. Montgomery Coimty s Socio-Economic Profile (1996). 8.

' Ibid.

8 Robert C. Davis. Arthur J. Lurigio. and Dennis P. Rosenbaum, eds.. Drugs and the Community (Springfield. IL: Charles C. Thomas. 1993). 26.

* Ibid.. 27.

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and the average educational level is 11.5.10 This community is overrun with boarded-up

housing and buildings, heavy drug trafficking activity, fast food eateries, street

prostitution, and beer and wine drive-thrus. The community can be characterized as one

with a diverse population o f seniors, children and youth, long-term home owners,

transients, the homeless, as well as the presence of vital churches, some with many and

some with few members, community organizations, and factories.

Urban profiles such as the Southwest Dayton community continue to present

challenges to its residents because o f social disorder resulting from white and black middle

class flight from the city for reasons other than employment in high-salary blue collar and

white collar positions. The departure o f the financially successful and middle class leaves

the city void o f economic strength, isolated, disenfranchised, and lacking resources to

offset the collapse and moral decay o f cities which have become the breeding grounds for

the rise o f informal economic systems (drug economies).11 Employment among young

minority' adults declined from 78 percent in 1968 to 55 percent in 1980 to about 35

percent in 1988. Family structures w eakened. The proportion o f African American

children living in households headed by a single parent increased 30 percent from 1970 to

1988.

Two factors fundamentally changed the labor market for poor young men and

w omen in the urban cities since 1970: the placement of unskilled and semi-skilled blue

10 Statistics: Dayton Planning Board/Southwest Priority Data 1999.

1! Davis. Lurigio. and Rosenbaum. Drugs and Community. 42.

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collar jobs with “pink collar*'jobs that required higher education and skill levels, and the

growth o f the informal economy, especially the illicit economy around jobs.12

In 1992 an estimated 10 million Americans were heavy drinkers. Over 11 million

used illicit drugs, and 54 million smoked tobacco cigarettes.13 Both Presidents George

Bush and Bill Clinton in their State o f the Union addresses identified the faith communities

as the major missing ingredient in the approach to the country’s problems o f substance

abuse. Their plea is that "the church and religious leadership must become involved in

fighting illicit drug use in our communities."14 Underlying this recommendation is the

understanding that for six out o f ten Americans, religious faith is the most important

influence in their lives. For eight out o f ten Americans, religious beliefs provide both

comfort and support. The faith community—consisting o f over 200.000 congregations

with an estimated 150 million adherents15—is a powerful force and has the potential to

play an instrumental role in the reduction o f the national pandemic problem o f substance

abuse.

There are no easy answers. The God who never changes continually seeks us in

our brokenness and pain. Addiction happens. Homelessness happens. Domestic violence

happens. Incest happens. Racism is real and eleven o'clock on Sunday morning is still the

most segregated hour o f the week. There is no promise that persons will liv e happily ever

after. God does promise that “My grace is sufficient" (Mk 10:27). Daily the Spirit o f

12 Ibid.. 28.

' ’Alcohol. Tobacco, and Other Drag Abuse. I.

14 Ibid.

Ibid.

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Christ visits at the deepest point o f a person’s need and somehow transforms the moments

o f pain, indecision, and failure into pastures o f healing, deliverance, and wholeness.

Without God, there is no recovery, only disappointing substitutions and repeated

failure. Faith communities represent a largely untapped but potent resource in America

and for global efforts in reducing the human devastation and debilitating effects that

psychoactive substances have upon poverty-ridden communities.

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CHAPTER TWO

THE STATE OF THE ART IN THIS MINISTRY MODEL

Today, Christ is calling his church to reclaim and offer healing and restoration

ministries along with the proclamation o f the gospel social witnessing, and discipling.

The poor are said to be the rag. tag, and bobtail o f humanity (Origen. AD third century). But Jesus did not leave them that way. Out o f material that society would have thrown away as useless. God fashions people o f strength—giving them back their self- respect. enabling them to stand on their feet and look God right in the eye. They are cowed, cringing, broken. But the Son has set them free.1

God uses medicine, hospitals, and various treatment modalities to bring about

healing, but these resources alone are not sufficient to meet the complex socio

psycho logical and health care needs o f families who are challenged with the debilitating

effects o f drug addiction. Church and faith-based community ministries will not replace

medical science and the healing professions, but the present health care trend for treatment

suggests that more Christians and community residents will seek health professionals who

provide a wholistic (mind, spirit, body) approach to health carer

1 Robert C. Linihicum. Empowering the Poor (Monrovia. CA: MARCAVorld Vision Publishers. 1999). front matter. 4.

■ Richard Rapp. Director. Wright State University Department for Treatment and Research for Substance Abuse, at a meeting for selected clergy at Omega Baptist Church. Dayton. OH. February. 2000.

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At the present time no domestic issue captures the attention o f faith communities

quite like substance abuse. Unfortunately, the ability o f faith communities to direct change

is diminished when their expectations exceed their knowledge o f substance abuse

resources and effective treatment models. The writer next presents eight researched

models of ministry with a faith-based methodology for the treatment o f individuals

addicted to substance abuse. The writer analyzes and comments on the models, and then

compares them to the Open Door Collaborative Ministry model (ODCM) model.

A Survey o f Faith-based Recovery Models

The Baptist Pastors Council (BAPCO) o f the Greater Detroit area is the

educational and charitable arm o f the Council o f Baptist Ministers.3 BAPCO is comprised

o f nine ministers o f black churches that represent over 18.000 men and women. BAPCO

was organized in 1984 to address the growing problem o f substance abuse in the local

ecumenical community. Historically. Detroit area Baptist churches have been reluctant to

confront the issues o f chemical dependency, particularly among their own members. This

group of ministers decided to develop a systematic and organized plan to combat the

effects o f drug abuse.

BAPCO's primary goal is to promote social change by networking within the total

religious system. The recovery model provides out-patient treatment, a network of

Narcotic .Anonymous and .Alcohol .Anonymous programs and related support groups,

community outreach, and education'prevention activities.

' Alcohol, Fohacco. anti Other Drug Abuse. 47.

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To meet the divergent needs o f clients and their families, the service system also

includes Relapse Prevention Therapy, HIV/AIDS Education, Effective Parenting

Education, and the Summer Youth Project.

Analysis

• Its approach recognizes the redemptive spirit o f humanity and that everyone is capable o f being restored to health and wholeness through love and caring.

• Commitment without competence is incomplete.

• The human therapist is viewed as a vehicle through which God works God's curative miracles.

• Good stewardship depends on good organization and strong administration. High standards o f management are practiced in carrying out its mission.

Comments

BAPCO is designed to be a systems-driven model, rather than a vehicle o f

empowerment for drug-dependent persons. It is reflective o f the Matthew 25 model of

perpetuating dependency—always doing fo r the people, perpetuating a co-dependent

marginalized sub-culture, instead o f subscribing to the Matthew 28 model of

empowerment by the Holy Spirit and faith community that provides persons with skills

and tools to move from a state o f dependency to productivity and self-sufficiency (see

appendix A).

Comparison

The Open Door Collaborative Ministry (ODCM). unlike a top-heavy agency

approach to treatment, is a grassroots ministry o f empowerment which emerges from

Christ-centered spirituality with worship as the centering experience. Both Christian

leaders and substance abusers are empowered in the process o f healing. Cecil B. Williams.

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pastor o f Glide Memorial Church in San Francisco, proposes that no healing takes place in

the river o f recovery unless both the addict and the ministering person experience God's

transformative healing touch.4 ODCM staff members, two-thirds o f whom are ex-addicts

with at least three years o f experience with persons addicted to substance abuse, believe

that Christ-centered spirituality is the transformative agent that empowers individuals from

drug addiction to a life style free o f drugs.

The second model is a model o f self-empowerment. Blue Bay: Peace through

Sobriety is located on the Flathead Indian Reservation in Northwest Montana.5 The

community worked together to name the enemy, establish a purpose for their campaign,

and develop an action plan based on clearly articulated tribal principles. Blue Bay is a

Salish-Kootenai effort— a celebration o f tribal self-determination and dignity (see appendix

B).

The Blue Bay model has three goals: 1) To foster personal recover}' from

alcoholism for high-risk individuals; 2) To develop a system for helping tribal youngsters

consciously choose not to abuse alcohol and other substances: and 3) To intervene in the

generational/cultural cycle o f substance abuse.

Analysis

The success o f this .American Indian model o f self-determination is attributed to a

design built upon the values in their tribal heading strategies. Those strategies are:

• The solution must come from within the community, although others may assist. The people must be the subject o f their own healing process and must direct the process in the ways o f tribal customs.

1 Cecil B. Williams. .Vo Hiding Place (New York: Harper San Francisco. 1992). 59.

' Alcohol, Tobacco, and Other Drugs. 51.

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• The future is separately linked to the past. People must rediscover their lives while preserving traditions and culture. They must understand their history and unite and build a new future for the children built upon the foundation of their culture.

• There must be an ongoing process for educating leaders that begins with the cradle and continues to the passing on and the journey into the next world.

• Healing the individual must go hand in hand with healing the community.

Comments

During his ministry with drug addicts in the Tenderloin area o f San Francisco. fl

Cecil Williams discovered that self-determination is the inner source o f power, and that

empowerment over a life o f drug addiction begins with authenticity.6 The local architects

o f the Blue Bay Salish Kootenai recovery model realized that the acceptance o f any other

model or outside power for their community would lead only to ultimate powerlessness.

Former drug addicts credit the participation o f the total community in the healing process

that led to their transformation.

Comparison

Both models (Blue Bay and ODCM) develop from within the environment and

community they serve. Members o f the ODCM staff have adopted two traditional faith

principles that have been critical in the survival o f African .Americans from systemic

oppression: "Nothing is impossible with God i Mat:. 17:20)“ for "God is a rewarder o f

them who diligently seek God's help ( Heb. 11:6t.”

” Williams. \ o Hiding Place. 5V

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The third model focuses on the Nation o f Islam. The Community Support Group

o f Masjid is a Nation of Jsiam spiritually-focused group o f citizens who are concerned

with providing a wholistic treatment approach to recovery from substance abuse. They

provide education and give emotional and professional support to individuals and families

o f the Masjid and local community.7

The Atlanta Masjid Community Support Group emphasizes that individuals can

recover and will not be addicts, alcoholics, or diseased people for the rest o f their lives. To

accomplish this goal, the Nation o f Islam has developed an Eight-Step program (see

appendix C).

.Analysis

The Nation o f Islam community has been successfully addressing the problems o f

substance abuse, alcoholism, immorality, and other socially debilitating diseases o f the

heart and mind for more than twenty years. Many converts have utilized its recovery

principles to clean themselves o f addiction and have remained drug-free for years.

Comments

Among all o f the faith communities which address the endemic problem o f illicit

drug activitv in the nation's urban centers, the Nation o f Islam has dev eloped one o f the

most impressive tract records for remov ing drug dealers and drug economies from urban

communities. Their no-nonsense, face-to-face tactics with these systems have benefited

cities with large project housing communities. Other faith communities could learn from

.l . iilinl, Tobacco, and Other Drug T'se. 57.

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their knowledge o f recovery principles and emulate their commitment and strategic

boldness in confronting systemic evil in the city.

Comparison

Several Muslim brothers visited ODCM last year and chose to commit their life to

Jesus Christ. What they express as the difference between the Muslim faith and the

Christian faith recovery models is the hope that comes with a risen savior. The teachings

o f Jesus provide a model for humanity, offering guidelines for living that will help a person

remove feelings o f guilt, accept forgiveness, and build self-esteem—all critical on the

journey to complete recovery.

The fourth model was performed out o f an African American Methodist Episcopal

(A.M.E.) church in Maryland. Freedom Now is a substance abuse ministry o f Bethel

A.M.E. Church in Baltimore. Mary land.8 This model matches each participant with a lay

counselor, usually someone who has been healed from an addiction and understands what

the participant is experiencing. Lav counselors must have maintained a drug-free status for

one year, must have had a salvation experience, and must be involved in a power cell, such

as studying the Word o f God. They are given in-service training that includes spiritual

counseling and how to facilitate spiritual groups. Weekly group meetings and one-on-one

counseling sessions comprise the recovery program. Since addiction abuses the physical

body, proper diet is stressed. Freedom Now has developed a five-step spiritual nutrition

plan in conjunction with Dick Gregory's Correction Connection nutritional supplements.

' Alcohol. Tobacco, and Other Drug f.'se. 59.

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Their goal is to address all pans o f the drug abuser in need of healing: the spirit,

the soul, the body. The ministry serves individuals who are suffering from legal and illegal

addictions.

Analysis

The effectiv eness o f Freedom Now can be attributed to its disciple-making

approach. Ministers daily talk with individuals, in person or on the phone, teaching them

the Word o f God so that they in turn can reach out and disciple others. Freedom Now has

ministered to sev eral hundreds o f persons who have been set free from addiction and are

continuing in their spiritual walk (see appendix D). God lovingly creates for us a life o f

fullness and freedom, yet God reminds humanity o f their own limitations, powerlessness.

and need for redemption. Trials and tribulations come: nevertheless. God's grace is

sufficient and abundant for all.9

Comments

The Freedom Now model avails itself to recovering addicts through a placenta

relationship— spiritually feeding, teaching Scripture, and nurturing the drug addict until

they understand that God's grace is much more than a static possibility o f love. It is an

outpouring, a boundless burning offering of God's self to us. in us. and through us which

leads to deliverance from substance abuse.

‘ < ierald I’. May. M.D.. Addiction (New York: I larperSanFrancisco. 1991). 9 i .

Williams.. 48.

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Comparison

The theological position o f this writer and ODCM in their treatment o f the

chemically dependent is akin to G od's call to the Israelite nation in Deuteronomy 8:3-6 to

remember and obey the commandments o f the Lord. Although God does not lead people

into the lifestyle o f becoming addicted to substance abuse, often in the painful wilderness

experience o f addiction they come to understand the importance o f the redemptive

relationship with God.11 ODCM. unlike the Freedom Now model o f recovery, also

includes, along with Bible study and counseling, a weekly worship celebration, which is

the centering experience that provides the spiritual core which empowers the ODCM

wholistic system o f recovery.

The fifth model represents a study from the approach of Roman Catholicism. St.

Sabina Roman Catholic Parish multi-layered program believes that drug use is primarily a

spiritual problem with clear psycho-physiological ramifications. They knew there must first

and foremost be a spiritual underpinning to deal with the core issues which produce these

problems (see appendix E). The presence o f drug trafficking and violence severely

affecting both young and elderly residents prompted this Southside Chicago parish to

develop a multifaceted program that would begin to attack the plague o f drug activity.

The goal of St. Sabina is to address the problem o f drug abuse through education and

collaboration with agencies that can provide necessary services as needed.

‘ I.irj Rccnvcn liihle: .Wir Living Transition (Wheaton. If: Tyndalc House Publishers. 1998).

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Analysis

Information available does not speak to the model's level o f success or failure:

nonetheless, any positive community-organized action is a deterrent to social disorder in

that community.12

Comments

In Empowering the Poor, Robert Linthicum writes. "The assumption upon which a

community organizational effort is built is ‘United we stand, divided we fell."'13

Neighborhood churches like St. Sabina recognize the tremendous power generated by

people working collectively to deal with the forces that destroy a community and

consequently cause the residents to be powerless. Residents and agencies working

together become empowered to encounter, cope, and sometimes change urban structures

and systems.14

Comparison

ODCM operates upon the same principle as the St. Sabina Parish. In other words,

we also believe that a well organized community or collaborative effort is more effective

than individualism for addressing critical issues which affect the well being of its residents.

The sixth model looks at substance abuse nationwide. Public debate increases

about the role of churches in the nation's fight against substance abuse. Many churches

simply need direction on how to begin the process. The One Church—One Addict model

■ I>a\is. I.urigio. and Ritsenhaum. Drugs and Community. 101.

‘' l inthicum. Empowering the Poor. 31.

!J Ibid.. 31.

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provides churches with a plan that identifies an appropriate role for the church, as well as

a model for turning motivation into action.15

One Church— One Addict goals include 1) To increase the levels o f social and

moral integration and o f practical community-based support around the drug problem; 2)

To reduce the negative effects o f drug addiction; and 3) To increase the positive effects o f

drug prevention in the lives o f church members and in society.

Analysis

This program seeks to assist churches to actualize the love o f God in the world.

The program is a call for the church to show, in a practical way, its love for the addict and

its hate for the addiction (see appendix F).

Comments

With this model the hope is that churches will contribute to the reduction o f the

systemic effects and the devastating societal problems that contribute to and stem from

drug addiction. This model is a great place for churches to begin acquiring the body o f

knowledge and fundamental skills needed for ministry with substance abusers.

Unfortunately, the expectation o f the organized church often exceeds its knowledge o f

treatment modalities and resources for developing effective models for treatment and

prevention. Nevertheless, the education, practical training, and sensitivity for working with

the substance abuse population is av ailable and attainable.

'■ Alcohol. Tobacco, and Other Drug Abuse. 65.

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Comparison

The ODCM model is supportive o f any effort to reduce the cancerous effects o f

illegal drugs and their breeding grounds o f social disorder and disintegration o f values

within our communities. However, ODCM staff conclude from their experience that

pandemic social ills such as substance abuse and lethal drug systems will not be eliminated

through the traditional approaches o f most mainline churches. ‘"In order for shalom to

come to broken and wounded communities, the institutional church as it exists now must

die. so the Kingdom o f God can usher justice and wholeness into God’s city.*'16

The seventh model represents a study performed in a Jewish community. Parent

Power: Keeping Our Kids Free, was a model performed in a Jewish community. It was an

initiative o f the B’nai B’rith Community Volunteer Services in Washington, D.C. They

have declared war on the system o f illegal drugs which negatively impact the lives o f the

innocent who are victims o f drug-related crime (see appendix G). The focus is on parents

and the implementation o f preventiv e measures that will stop substance abuse among their

children. A “Parent Power Kit" was designed to enable parents to be actively involved

with their children in the fight against substance abuse.

Analysis

The program is an example o f a community of parents who are taking

responsibility and control for what impacts their children. This approach to prevention is

commendable, although it does not guarantee a lifetime free o f contact with illegal drugs.

16 Linthicum. Robert. D.Min. and Paul Hertig. Ph.D.. Peer Seminar VII. Signature Inn. Columbus. OIL May 3-4. 2001.

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Comments

Information about drugs and education about drug addiction are widely used as

methods o f prevention or deterrence. Concerned parents, reclaiming their role as

transmitters o f positive values in the battle against illegal drugs, is a worthy goal o f our

nation.

Comparison

'T rain up a child in the way he should go and when he is old he will not depart

from it” (Prov. 22:6), has been a lived reality' according to the testimonies o f many

worshipers at ODCM. Frequently those who are in recovery from substance abuse will

attribute their safety and protection from the insanity o f addiction to God's amazing grace

and the prayer covering o f saintly mothers.

The eighth and final model a study o f the inner-city minority family and teens,

provides important insight for black churches. Street Psych: A Crime and Substance

Abuse Prevention Project was designed by mid-west clinicians to train black pastors and

church leaders to effectively utilize cultural strengths found in our minority communities.

Pastors are taught enabling skills that will assist their parishioners to use faith systems and

imagery to promote and enhance their mental health and the mental health o f their families

(see appendix H).

Analysis

Traditional mental health and counseling centers do not provide the cultural, socio

economic. religious, and political understandings which contribute to the systemic

oppression that influences the behavior and lifestyle o f the poor and people o f color.

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There is a critical need for faith-based treatment facilities with professionals who can

identify- with and be sensitive to residents in poor and ethnic-specific communities.

Comments

When a therapist or pastor seeks to nurture wounded, hurting, dysfunctional

personalities to wholeness, many factors must be considered. Healing will not occur

without a resolve o f the root cause o f the pain. In an open society o f violence and social

dishevel there is a need for capable practitioners who are also spiritually equipped to be

wounded healers in a world o f brokenness.

Comparison

The success o f ODCM can be attributed to its leaders who are sensitive and

knowledgeable about the nature o f and treatment for people addicted to substance abuse.

Their ability to implement a spiritually-based wholistic methodology as an effective

treatment for substance abuse derives from the ministry team's personal journeys o f being

set free from drug addiction through a relationship with Christ.

While the models included in this chapter identify- many approaches to prevention

and treatment for substance abuse by faith-based community organizations, the list is not

exhaustive. The types of approaches are as numerous as the faith-based communities

attempting them.

The driving motivation to develop a ministry model for addressing the social illness

o f drug addiction flows from the writer's personal experiences. They are: 1) vocation as

ordained clergy: 2) licensed social worker and counselor: 3) brokenness resulting from an

abusive marriage: 4) recovery from a .38 caliber gunshot wound to the forehead: 5) pain

associated with rejection and failure: and 6) challenges o f being a single parent.

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The writer realized that it was not the clinical setting that brought her to a place o f

healing and wholeness. It was not the surgeon's scalpel that saved her life. It was not the

meetings or buildings. It was the Spirit o f the Lord that enabled her to gain worth, dignity,

and restoration in her life. It was mentors, faith persons, walking, crying, and journeying in

a special way that lifted the writer. It was this knowledge that allowed the birthing o f this

project.

Spirituality

Albert E. Day's prayer from his letters on the healing ministries captures the

spiritual tone o f community in the healing process embraced by the Open Door

Collaborative Ministry methodology.

Spirit o f the living God, whose presence we now seek and claim, we lift up to you

our questions and answers, our doubts and affirmations, our stories o f failures as well as successes.

As we covenant together, may we learn from one another, may we be totally receptive to your wisdom and insights, may we eventually emerge with a better understanding o f your gracious healing ministry.

And in this learning, growing process, grant each o f us wholeness in body. mind, spirit, and in our relationships.

In the name o f Jesus Christ, we pray. A m e n f

When faith communities are able to hear the soulful utterances o f substance

abusers or the oppressed, they will be able to bring healing and shalom to the city—freeing

1 Albert F.. Day. Letters on the Healing Ministry (Nashville: Disciplined Order o f Christ. 1990). 12. Reprinted by permission o f the Disciplined Order o f Christ, founded in 1945 by Albert Edward Day.

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both the oppressor and the oppressed. This is the mission goal o f ODCM. During ODCM

worship celebrations substance abusers testify that Christ-centered spirituality is essential

to their total recovery. ODCM leaders who have been completely delivered from

substance abuse make this same profession. Cecil Williams speaks o f crack addicts who

told him "they could not find in other twelve-step programs the vital component o f

spirituality. We heard their cries and longings for the Spirit o f God which had been pushed

way down with every substance and habit. Still they yearned to feel the Spirit—the

essence o f life.”18

James Wagner expresses this same philosophy o f spiritual health when he quotes

Paul Toumier. the Swiss physician: "Dealing with one’s relationship with God is first and

primary. A spiritual unrest underlies almost every chronic and acute illness."19 Clergy have

acknowledged the venomous effects o f drug abuse since 1961. "Teen Challenge, a drug-

free. religious, therapeutic community, has grown and expanded its operations to include

centers in the United States and abroad." This ministry has grown to international

proportions as the result o f spirituality being used as the core methodology o f healing

from which recovery springs.20

Much is written concerning the role o f spirituality as it relates to liberation and

recovery. The question is raised, however: Does the marriage o f spirituality and recovery

begin with life or does it begin with death? At ODCM the hurting people suffering with

Williams. Ad Hiding Place. 35.

lv James K. Wagner. An Adventure in Healing and Wholeness (Nashville: Upper Room Books. 1993). 42.

" Alcohol. Tobacco, and Other Drug Abuse. 33.

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enslavement to drugs enter the worship area adorned and bound in their grave clothes.

Before the evening has ended, the Spirit of God has touched their lives with a resurrection

experience. Some remove their grave clothes after singing the gospel songs o f praise.

Others remove their grave clothes after hearing the testimony o f how the Lord delivered a

brother or sister from a fiery furnace experience. Grave clothes are pulled off at the

hearing o f the Word o f God. Finally, as people come for anointing and praying, the grave

clothes are shed for the garment o f salvation and healing.

A spirit o f recovery begins at the tomb, but it doesn't end there. When the spirit moves in. lives move in. When the spirit lifts, the people are lifted. Any spirituality that isn't about how you live every day isn't about the Holy Spirit. The spirit is the power o f God that creates and liberates. When you are spiritual, you have the power to create and free yourself. The spirit brings you back to life in the here and now.21

Howard Thurman's understandings o f the inner Christ and spirituality exceeded

the limiting constraints o f traditional hermeneutical approaches to biblical interpretation in

relation to spirituality.22 Thurman believed "that the hermeneutical language o f the western

w orld was insufficient for the task at hand."~ His analysis o f spirituality involves the

bathos and pathos o f the human experience. The language expressed in the letter o f

Hebrews and in the African American spiritual, according to Thurman, is a hermeneutic

which transcends the cognitiv e constraints of tradition, reason, and the law. to a faith

21 Williams. Xo Hiding Place. 37.

~ Henry James Young, ed.. G od and Human Freedom: A Festschrift in Honor o f Howard Thurman (Richmond IN: Friends United Press. 1983). 75.

Ibid.. 75.

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living hermeneutic o f being in relationship with the inner Christ. This Christ has the power

to redeem, empower, and heal humanity from a lifestyle o f drug addiction.24

Empowerment

Preaching is a significant link to spirituality and empowerment components o f the

ODCM recovery model. The hermeneutic o f recover}' and prayer are the primary Divine

agents used to affect spiritual transformation and healing in the lives o f substance abusers.

Samuel DeWitt Proctor in Preaching About Crisis in the Community, focuses on the

essential link between the gospel message and the problems o f society. He illustrates how

this kind o f preaching “involves making sermons responsive to such problems as abuse,

decline in family life, homelessness, and lack o f educational opportunity-."25

Proctor's book has been instrumental in the development o f a hermeneutic of

recover}- for ODCM. The weekly worship celebrations consist o f music, liturgy, and

sermons with scriptural empowerment themes o f salvation, healing, and deliverance as the

means to recover} from substance abuse. ODCM recognizes the need for other services,

o f course, such as medical care, adequate housing, education and vocational training,

employment, personal and family counseling, to stabilize a person in recover}-.

Grassroots ministries with indigenous leadership from the community have had a

measure o f success. The inherent wisdom, experience, community and cultural expertise,

and contextual knowledge which they bring to a project are invaluable. In Street Corner

;a Ibid.. 76.

Samuel D. Proctor. Preaching About Crisis In the Community (Philadelphia: Westminster Press. 1988). 12-13.

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Theology. Carlyle Stewart presents the stories o f eight people who have developed their

own theologies from every day life on the streets o f Black America. The author’s personal

theological interpretation follows each story. Stewart writes, “The ultimate concern in this

book is for the spiritual vitality o f African American people. Street comer theology is thus

rooted in a culture o f hope and filled with the positive expectations o f the possibilities o f

God. Predicated on life in the streets or the church pew. the highways or byways o f Black

life in America, the quest is for human wholeness, personal and spiritual transformation.

and the establishment o f authentic personhood.”26 The stories and Stewart’s commentary

are insightful in the research o f human phenomenon and God's presence among the poor

and marginalized persons in urban communities.

Any ministry model which advocates a wholistic methodology for ministry must

have a genuine encounter with the radical Jesus whose mission is to empower the poor

and liberate the oppressed. In The Mind o f Jesus. William Barclay writes o f the revelatory

aspects o f the life, context, and ministry o f the Galilean Jesus. Barclay's response to Jesus'

opening manifesto in the sy n a g o g u e in Nazareth (Lk. 4:18. 19) is:

Therein, there is outlined a programme of the most practical help, and the determination to accept the task o f alleviating the sufferings and sorrows o f men. By that proclamation Jesus was committed to a life, not o f words, but o f actions. It is clear that He will go out on a campaign in which He will teach as much, and more, by His deeds as by His words.2'

This book radiates the author’s devotion to Christ, the historical Jesus, and breathes a

compassionate understanding o f the Christ who walked among and suffered for humanity.

JS Carlyle Fielding Stewart III. Street Comer Theology (Nashville: James C. Winston. 1996). 2.

■ William Barclay The \fin d o f Jesus (New York: Harper and Brothers. 1961), 66.

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The Prophetic Imagination provocatively describes prophetic imagination as a

force which brings religious traditions together with the contemporary realities o f the

society. Walter Brueggeraann conveys a clear understanding o f the dominant culture and

prophetic imagination potential to transform the present in powerful and unexpected ways

by combining the rich Old Testament heritage and the prophetic ministry o f Jesus, which

he describes as energy in the face o f crisis. Brueggemann further states that "the work o f

Jesus was not the dismantling, but the inauguration o f a new thing/’28

In City o f God— City o f Satan. Robert C. Linthicum powerfully communicates to

clergy-, laity, and community organizers a long-awaited biblical theology which addresses

contemporary societal issues through biblical imagery'. He clearly defines the mission of

the church and the systemic roadblocks o f oppression that prevent her from birthing God’s

shalom in urban centers.

The vocation to which the church is called is not to be the savior o f the city (only Christ is that) but to be the body which exposes the lies the systems tell to keep the city in bondage and to the advocate of the city given over to the kingdom o f god. To this the church witnesses in its prayer, its presence, its proclamation, and its practice, as it works for the empowerment o f the poor (the victims of principalities), the liberation o f the powerful (those seduced by the systems) and the reformulation o f the city into a Godly- community (the kingdom o f God).29

Linthicum's liberating message provides a biblical formula for setting the oppressor

and the oppressed free to become kingdom builders in the city. He helps leaders to

understand how to speak truth to pow er and to learn the benefits o f negotiating win-win

strategies.

■s Walter Brueggemann. The Prophetic Imagination (Minneapolis: Fortress Press. 1973). 97.

^ Robert C. Linthicum. City o f God-—City o f Satan (Grand Rapids. MI: Zondervan. 1991). 234.

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Restoration

After one is empowered by energy, the next level toward wholeness and healing is

the ministry o f restoration. Brueggemann extends an invitation to "the kingdom o f God on

earth" to develop an alternative consciousness for the purpose o f transforming systems o f

dominance. The City o f Dayton is fortunate to have the leadership o f Richard Rapp.

Wright State University Research Center Director, who launched an initiative with Dayton

clergy and Wright State for the purpose o f developing a new system o f services that will

expedite the process for treatment o f substance abuse clients and bring a greater sensitivity

to transitional and community aftercare. ODCM was invited to participate as a member o f

the team.

In No Hiding Place. Williams records the journey he took at Glide Memorial

Church to lead the way for community transformation in the morally toxic Tenderloin

Community o f San Francisco. He created a community which lives up to the words

"emblazoned on their wall: Justice. Dignity. Peace, and Self-Affirmation."30 The ODCM

model is a reflection o f some o f Williams' theology o f recovery and wholistic

methodology. The weekly chant. "It's recovery time" and the invitation to "wade in the

spiritual waters o f recovery” (salvation, prayer, healing) were adapted from his ministry.

In recent years, several African .American scholars have made significant

contributions to biblical hermeneutics for the purpose o f clarity and historical authenticity.

In Siony the Road We Trod. Cain Hope Felder credits African American religion for its

10 Williams. S o Hiding Place. 22.

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distinctive use o f the Bible in creating commentary, resisting oppression, and fomenting

social change.31

Samuel Proctor: My Moral Odyssey is more than the chronicle o f one man's

search for moral standards. It is a powerful call from its author, Samuel D. Proctor, for

developing a personal and community moral consciousness that is both Christian and

relevant in a society o f complex choices. The strength of Proctor's definition o f genuine

community tolls a bell for all humanity.

My moral understanding culminates with a commitment to a kind of community that builds on acknowledging one another's total personhood, looking upon persons as equal to ourselves and not as our pawns or instruments o f our designs. Each person is endowed with rights that are inherent and with worth that is conferred by God. our Creator. The immediate conditions o f their lives do not diminish their worth or render them any less significant as persons.32

A portrait o f Jesus, recorded in the synoptic gospels and in the Gospel o f John,

demonstrates Jesus' concern for healing the total person. The healing process for persons

addicted to substance abuse is filled with complexities, because the debilitating effects o f

drugs influence the spiritual, psychosocial, and physical condition of the human body.

Repeatedly the gospels illustrate Jesus' sovereign power to bring recovery and wholeness

to crippled humanity.

Many urban communities reflect innumerable crippling conditions that make it

impossible for some indi\iduals to go any further on their own in life. The Lord promises

to meet all persons in their time o f need when they genuinely seek God's help.

’’ Cain Hope Felder, ed.. Stony the Road We Trod (Minneapolis: Fortress Press. 1991).

Samuel D. Proctor. Samuel Proctor, \ f v Moral Oth'ssex■ (Valiev- Forge. PA: Judson Press. 1989). 149.

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ODCM goes to the pool and stands ready by the pooL in the presence o f God, to assist the

physically, mentally, and spiritually crippled to wade in the redemptive waters o f healing

and recovery.

The success o f the ODCM model is due in part to adoption o f a community ethic

o f inclusiveness which brings down walls o f divisiveness and exclusion, and fosters the

spirit o f restoration.

Conclusion

The writer concludes this chapter with theological voice on the power o f prayer in

the shadows of broken lives and shattered dreams. Prayer has been the writer’s bridge

over troubled waters, the peace in the midst o f life's storms. Prayer has been the wind and

strength beneath the writer’s faltering wings. Prayer has removed doubts and fears when it

would have been easier for her to give up. Prayer has illumined her path with hope in her

midnights o f distress. Prayer is the foundation that feeds this writer’s soul, energizing her

faith. Prayer holds the key to success o f the Open Door Collaborative Ministry as reflected

in the results of this model o f ministry.

One of this writer’s most powerful childhood memories is the call to her

grandmother's knee at the age o f five, when her grandmother asked for a show o f the

child's hands. Upon keen examination, her grandmother. The Rev. Rosie Lee Long,

embraced the child and spoke these prophetic words: "These are healing hands! The Lord

is going to anoint and bless you to bring healing into the lives o f many." Then

Grandmother Rosie instructed the child in prayer by the laying on o f hands, followed by

the ministry of prayer.

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That life-changing experience planted the seeds o f faith and the power o f prayer in

the writer's soul. In her adult years, that mustard seed faith took on deep roots when the

harsh rains o f adversity flooded the writer's life.

Prayer enabled this writer to continue even in the face o f grievous pain

encountered during the implementation o f this ministry model. This kind o f pain bears

witness to the authenticity o f prayer in the ODCM community, as well as one’s personal

life. The transference of faith principles for the empowerment o f others through the

instruction o f God's word and prayer is possible because o f the indwelling spirit o f

Christ’s dynamis power alive in a community whose goal rests upon the precepts o f God's

power to save. The ODCM model o f ministry has successfully demonstrated what has

been presented through the writer's study and comparison o f other community faith-based

models, a review of meaningful literature, and the productive completion o f this project.

The next chapter includes theoretical foundations for the ODCM model through

theological, biblical, and historical reflection.

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CHAPTER THREE

THEORETICAL FOUNDATION

We recognize that all are sinners in recovery through Christ; and yet, God has called us from various Christian traditions into a covenanting community so that we may participate in the ministry o f Jesus Christ with those in the use o f alcohol and other drugs.

We resolve to be faithful to the teachings o f Jesus Christ and walk in the freedom and responsibility to ourselves and to our neighbors.

We will commit ourselves to be informed fully about the spiritual, psychological, economic, social, and political dimensions o f this crisis.

We will work, wherever we are, for justice and against systemic acts o f violence, oppression, and dehumanization that affect children, youth, and adults.1

This covenant summarizes the biblical and theoretical foundations o f this Doctor o f

Ministry project. Within the meaning o f its words lies the process to Stop the Revolving

Door for people struggling with addiction and capability o f working for justice for the

sake o f themselves and others. This project was developed within the context o f the

Doctor o f Ministry Program focus: Community-Based Urban Ministry.

Today. Christ is calling the church to reclaim and offer healing ministries along

with preaching, teaching, social witness, and discipling. Throughout the ages God has

called the community o f faith to be God’s primary source o f healing. .And at Jesus’

inaugural sermon in Nazareth o f Galilee, he ushered in the perpetual mission o f the church

as a healing remedy for the suffering of the poor and oppressed.

1 Worship Bulletin Cover. Breaking the Chains o f Addiction (Nashville: Abingdon Press. 1992).

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Biblical Foundation

The factors which contribute to the crisis o f drug abuse are overwhelming,

complex, and too numerous to address in a single project. Faith-based communities have

been identified as being critical in the healing and recovery process for addicted persons.

The scriptural applications for the categories o f spirituality, empowerment, justice, and

healing were specifically chosen for how they might apply as a remedy to Stop the

revolving door o f drug addiction.

The Holy Bible is a book about recovery. It records how the world began and how God created it to be good. Then it tells us about the beginning o f sin—about the first time people decided to reject God’s plan. It spells out the fetal consequences that result from rejecting God's program. Nonetheless, the Bible doesn't leave us in despair. It reveals a plan for recovery and the source o f the power to accomplish it. It provides us with the only pathway to wholeness— God's program for reconciliation and healing.2

It is recorded in Lk. 4:18-19 that one day Jesus stood up in the synagogue to read

these words from the Scriptures:

The Spirit o f the Lord is upon me. because he has anointed me to preach the good news to the poor. He has sent me to proclaim freedom for prisoners, and recovery o f sight for the blind, to let the oppressed go free, to proclaim the year o f the Lord's favor.

The exegetical process in this pericope o f Scripture is used to illustrate the integration of

spirituality, empowerment, healing, and justice in Jesus' ministry with the disenfranchised

and oppressed. Luke begins by placing Jesus in the synagogue reading from the sacred

' The Lite Recovery Bible. S e w Living Translation, foreword.

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writings o f the prophet Isaiah. Jesus’ posture o f standing to read indicates a position of

religious authority in the Jewish communal worship tradition.

The good news— Jesus is God’s freedom song o f liberation for the poor,

oppressed, and suffering. "There is a balm in Gilead, to make the wounded whole. There is

a balm in Gilead, to heal the sin sick soul.”3 The Isaian passage read by Jesus in the

synagogue is a servant song, and "anointed me” means "'made me the Christ or Messiah.”

When understood literally, this passage says the Christ is God’s servant who will bring to

reality the longings and hope o f the poor, oppressed, and imprisoned: ushering in the

amnesty, the liberation, and the restoration o f the year o f Jubilee (freedom).4 The whole

meaning o f Jesus’ movement o f radical ministry' (salvation, healing, empowerment, and

justice) can be summarized in staggering simplicity.5 The blind receive their sight, lepers

are cleansed, and the deaf hear. The dead are raised up. The poor have good news

preached to them (Lk.7:22).

Jesus’ claim as the "anointed one” is a ministry o f liberation which encompasses

spiritual restoration, moral transformation, rescue from demonic oppression, and acts of

healing.6 This liberation passage o f redemption, healing, and justice for the oppressed as

read by Jesus (Lk. 4:18-19) provides a wholistic biblical foundation for the development

3 "Balm in Gilead." Songs o f Zion (Nashville: Abingdon Press. 1981). 123.

4 Interpretation Commentary. “Luke." 62.

’ Brueggemann. Prophetic Imagination. 100.

* The .Vfu Interpreter s Bible. "Luke." 108.

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o f a Spirituality o f Recovery7 which has the capacity to heal, set free, and transform

people and systems from the bondage o f addiction. Evil is not just personal but structural

and spiritual.8 Crack cocaine and other illegal drugs have led a whole generation o f the

poor and marginalized down the path to cultural and ethnic genocide. If we are to reverse

this demonic trend o f substance abuse, we must collaboratively seek solutions that are not

currently available in our communities.

The impact on families has been devastating in terms o f manpower due to death

and incarceration.9 Therefore any effective rehabilitation program for individuals and

families recovering from drug addiction must be grounded in biblical principles which

nurture the reclaiming o f their spiritual birthright (humanity) which is inherent in the

theological understanding o f Imago Dei. Those o f us who labor in love in the wastelands

o f addiction have counseled drug abusers, buried our brothers and sisters, and comforted

loved ones. Our commitment to serve is inspired by the prophetic vision o f a just, merciful,

and redeeming God where each life is infinitely precious and sacred. The Torah, the New

Testament, the Qur'an, the Sikh scripture, and the Guru Granth Sahib all bear witness that

each person has immeasurable value because life itself is a gift from the creator.10

Williams. S'o Hiding Place. 36.

* Walter Wink. The Powers Thar Be (New York: Doubleday. 1998). 31.

Clarence l.usane. Pipe Dream Blues: Racism & The War on Drugs (Boston: South End Press. 1990). 44.

10 Alcohol. Tobacco, and Other Drug Abuse. 1.

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Reclaiming our Humanity

Gen. 1:26 provides the scriptural support which authenticates the biblical record

that humanity is created in the image o f God—“Then God said let us make humanity in

our own image.” Before the process of recovery and healing can occur, one's spiritual

birthright must be reclaimed. The process for recovery is grounded in the need for divine

restoration to our original image o f God—Imago Dei. Humankind is G od's crowning

glory o f all creation: therefore all share a covenant-bond with their Creator who has

created them to be expressions o f God's living justice within community. Because o f the

sin and evil within personal, corporate, and systemic structures, humankind are always in

need o f Christ’s unmerited grace that forgives, pardons, redeems, and sustains

transforming humanity and systemic evil.

Jesus, the human face o f God. came to the city, the battleground between God and

Satan, to release people, systems, and the entire created order from the power o f sin.

death, and the law.11

Rom. 8:37-39 states that all believers regardless o f our weaknesses and life

struggles that “we are more than conquerors through him who loved us.” This text also

assures addicted persons that nothing can separate them from the love o f God regardless

o f past sins and failures if they commit their way to the Lord. It is vital for persons in

recovery who suffer from low self-esteem and enormous guilt to be confident o f God's

unfailing love and forgiveness. Chemical dependency counselors state that guilt and low

self-esteem and forgiving oneself for past mistakes are the greatest barriers in the recovery

: Linthicum. C ity o j God—City o f Satan . 234.

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process. Ex-substance abusers who are Christian state that a relationship with Christ, the

Holy Scriptures, and the support o f the faith community lights the path o f hope for

recovering substance abusers. The following biblical texts confirm through scripture the

position o f empowerment through Christ.

Therefore if anyone is in Christ, they are a new creation: the old has gone, the new has come. (2 Cor. 5:17)

It is for freedom that Christ has set us free. Stand firm then, and do not let yourselves be burdened again by a yoke o f bondage. (Gal. 5:1)

I have seen their ways but I will heal them: I will guide them and restore comfort to them. (Isa. 57:18)

The Apostle Paul shares with Christians and non-Christians alike a spiritual

prescription that is applicable for healing from psycho logical problems associated with

addicted lifestyles.

And so dear brothers and sisters. I plead with you to give your bodies to God. Let them be a living and holy sacrifice— the kind he will ac c e p t. When you think o f what he has done for you, is this too much to ask? Don't copy the behavior and customs o f this world, but let God transform you into a new person by changing the way you think. Then you will know what God wants you to do. and you will know how good and pleasing and perfect his will really is. (Rom. 12:1. 2 NLT)

Jesus traveled throughout Galilee teaching in the synagogues, preaching everywhere the Good News about the Kingdom, and he healed people who had every kind o f sickness and disease. (Matt. 4:23 NLT)

Jesus' ministry o f empow erment through acts o f restoration, healing, and justice brought a

new dimension to the meaning o f the Kindom o f God. For it is in community—God's holy

ground— in which salvation and recovery are actualized.

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Theological Foundation

We Wear the Mask We wear the mask that grins and lies, It hides our cheeks and shades our eyes. This debt we pay to human guile; With torn and bleeding hearts we smile. And mouth myriad subtleties.

Why should the world be otherwise. In counting all our tears and sighs? Nay, let them only see us, while We wear the mask.

We smiles, but, O great Christ, our cries To thee from tortured souls arise, Beneath our feet, and long the mile: But let the world dream otherwise. We wear the mask.12

The original intent o f Paul Laurence Dunbar in his soul-wrenching poem is not

about individuals who are challenged with drug addiction, but it speaks to the plight o f

African Americans who live daily in a schizophrenic social mind-set in order to cope with

the affects o f systemic evils, such as racism, classism. and social, political, and economic

exploitation in the land o f the free and home o f the brave. However, this poem does

address the lies, guilt, pain, and feelings of psycho logical and spiritual numbness—a reality

o f individuals caught in the stranglehold of drug addiction. The words of this poem

somew hat describe the condition o f individuals engaged in active addiction, but the words

don't speak to the cure. The cure is found in a redemptive theology which proclaims that

Jesus' healing power sustains today and tomorrow. "The Lord has to do it! If the Lord

• Paul Laurence Dunbar. "We Wear the Mask." in Breaking the Chains o f Cocaine by Oliver J. Johnson (Chicago: Images. 1992). 52.

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doesn't do it. it w on't be done" (spoken by a contextual associate who has been clean

since 1985).13

People who are the walking dead need to be resurrected, not bombarded with

religious dogma and pious cliches which tend to bury them further in the deep abyss of

guilt and pain. People in recovery need to hear the good news that Jesus Christ has the

power to set them free nowl "We are all addicts," declared The Reverend John Allen,

contextual associate, who has been clean since 1986.

We are all addicted to sin—it began with humanity's first thought o f disobedience to God. Biblical history also confirms that the Nation o f Israel was addicted to sin; they just couldn’t stay clean from the act o f sinning. Our bodies belong to God; they have been bought with a price and recovery from the addiction o f sin would be impossible without a redeeming Christ.14

This is the theological praxis that makes sense to our brothers and sisters in

addiction who are the victims o f shattered lives and broken dreams. The words o f God to

Isaiah, which were also shared in Jesus* inaugural sermon, are very explicit concerning the

ministry o f God's people to those who are suffering with addictive lifestyles. You are my

ministers; I am anointing you to go to my addicted ones and set them free—the

brokenhearted, the wounded, the blind, the captive, the imprisoned.

Carlyle Fielding Stewart has developed a "street theology”— an authentic

theological position for the use o f understanding how to do effective ministry with

individuals struggling with overcoming addiction. The beauty o f Stewart's book. Street

Theology, is that the theological genre is birthed from the experience o f street people's

1' Gerald Davis, interview by author. March 8. 2000.

14 The Rev. John Allen, interview by author. March 8. 2000.

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encounters with a God who is with them even in the hell holes o f society. The

marginalized communities identify western theology as being indifferent and oppressive to

the poor and disenfranchised. Stewart's in-depth insight is strategic in understanding the

context o f grassroots theology for developing a wholistic ministry with people in

substance abuse.

Stewart's definition o f street theology- is Affocentric-specific; yet, the definition

would appear to be applicable to the theological concerns o f marginalized populations

regardless o f cultural identity or gender.

Indigenous black theology is concerned with the eradication of those political material, social, personal, relational and spiritual impediments preventing the full realization o f human wholeness, the actualization o f personal empowerment, and the spiritual and relational transformation o f African American communities (the addicted) It is concerned with the identification, exploration, and development o f black spirituality and theology unique to indigenous African Americans. Its pragmatism lies in the capacity- to raise African Americans' consciousness o f their power and potential as persons o f infinite worth.15

The traditional white western theology o f Christendom does not identify with or

pro\ide a theological frame which legitimizes and affirms the personhood and experiences

o f the poor regardless o f ethnicity. Therefore, in order for the church and faith

communities to be effective in a technology-driven, morally depriv ed society, we must

proclaim and demonstrate a theological praxis o f redemptioniiberation theology.

" Stewart. Street Comer Theology. 9.

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Historical Foundation

The word o f God comes to us largely in the form o f God-encounters with people

in human history. God has entrusted the recording o f these events and their interpretation

to human beings who were part o f the historical process.16

The Spirit o f the Lord is upon me . . . to preach the good news to the poor. (Lk. 4: 18a) The religious, social, political, and economic climate in the present post-modern

society mirrors the corrupt systemic realities experienced by Jesus with the poor in the

territory o f Galilee. Some biblical scholars have stated that this Lukan passage signals

Jesus* appointment and empowerment as the Isaianic figure who heralds and brings

salvation, but the salvation he brings, represented by Jubilee imagery, does not call for an

implementation o f Jubilee legislation.17 However, my argument with this position is that

Jesus' statement at the closing o f his reading—“Today this scripture is fulfilled in your

hearing"— is a distinct acknowledgment ofG od?s in-breaking into human history

establishing through Jesus Christ a new social order established upon the justice and

righteousness o f God. It w as in Nazareth of Galilee— God's kairotic moment in the history

o f humanity that Jesus was chosen to announce his messiahship and coming forth in the

energizing which Brueggemann calls “leading to radical beginnings precisely when none

seem possible."18 It is also evident that Luke clearly uses this text to express Jesus*

16 Paul Hertig. “Matthew's Narrative L'se of Galilee and Missiological Journeys o f Jesus" in Meiien Biblical Series, vol. 46:10.

1 Century Commentary. “Luke." 202.

18 Brueggemann. Prophetic Imagination. 99.

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identity, to define his mission, and to acknowledge his authority over the Roman

domination system o f principalities, powers, and spiritual wickedness.

They struggled with the oppressive issues o f racism, classism. economic

exploitation and sexism.19 Therefore the time was ripe for a fresh in-breaking o f G od's

liberating action through Jesus Christ within human community. Today the church and

faith communities need to experience the fresh energetic winds o f the Holy Spirit so they

may be empowered to confront the demons which rob God’s human creation o f its

spirituality and humanity. Religious leaders have not been consistently committed to the

vision o f God’s liberating justice among the poor.20 Therefore the pathos o f God brought

forth Jesus the Christ as a remedy for sin and suffering, demonstrating the salvific

relationship between redemption, justice, physical mental and spiritual health. The

salvation that Jesus offered to humanity included, but went beyond, spiritual well being.

The Son o f Man loved and ministered to the whole person. The gospel accounts o f Jesus’

life and ministry repeatedly illustrate this truth.

The flaw o f post-modem westernized Christianity is that its focus has been too

individualized, instead o f addressing the total person.21 Latin American liberation theology

was among the initial offerings to reinterpret "principalities and powers." not only as

disembodied spirits inhabiting the air. but as institutions, structures, and systems. “For our

struggle is not against flesh and blood, but against the rulers, against authorities, against

the powers o f this dark world and against spiritual forces o f evil in the heavenly realms"

The A’trvi Interpreter 's Bible. 106.

Ibid.

Wagner. Achenture in Healing. 27.

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(Eph. 6:12). The vvholistic approach to salvation is the authentic ministry- paradigm Jesus

practiced to affect redemptive liberation with the marginalized.

In Matt. 9:1-8 there is recorded the story o f a man on a stretcher whose friends

brought him to see Jesus. Before Jesus healed the man physically, he dealt with the man's

spiritual condition. In Jn. 5:1-15 there is an account o f a man who had been paralyzed for

thirty-eight years. Before Jesus could heal him physically, he had to work with the man’s

negative attitude. He asked the man the question. “Do you want to be well?' This is the

question that must be answered by persons struggling with addiction. The road to healing

begins with G od's age old salvific principle o f repentance— accepting the responsibility

that we are sinners in need of salvation through Jesus Christ. The ministry o f healing

occupied an important pan in the theology- o f Jesus and in the experience o f the church

during her first three hundred years o f existence.22

In the fourth century there was a serious decline as the result of a shift in societal

anitudes. resulting in a waning passion for teaching the doctrine of healing in the church.

Human factors were interfering with their Christian commitment to include healing as a

significant component o f Jesus' teachings.- ’ In A.D. 313 Emperor Constantine's Edict o f

Milan gave official tolerance to Christianity and later became the official religion o f the

Roman Empire.24

Mark A. Pearson. Christian Healing (Grand Rapids: Chosen Books. 1994). 29.

:3 Ibid.

:4 Ibid.

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Beginning with the period from the crumbling o f the Roman Empire in the fifth

century through the dark ages, people were encouraged to expect their blessings from the

world to come. A spirit o f unwonhiness to seek God’s favor and blessings poisoned the

life o f the community to the extent that the ministry o f healing was lost to the western

church.25

One result o f the church abdicating its role as an agent o f God’s redemptive justice

and healing is an addicted society o f epidemic proportions. A recent report from the

Substance Abuse and Mental Health Services Administration revealed that an estimated 10

million Americans are hea\y drinkers. Over 11 million Americans use illicit drugs, and 54

million smoke tobacco cigarettes.26 For each individual harmfully involved with

psychoactive substances, at least one other person is negatively affected as a victim o f a

drunk or drugged driver; as the neglected child o f a crack-dependent mother; as the

bartered spouse o f an alcoholic husband; or the frantic parent o f an uncontrollable, drug-

affected adolescent. The list is endless and crosses all socioeconomic lines.2

The use o f alcohol, tobacco, and other drugs which alter thoughts, feelings, and

perceptions predates recorded history, although the absolute starting point of their use in

human society is unknown.:s Archaeological studies reveal that alcohol use dates back to

at least 3500 B.C. in ancient Egypt, and the Sumerians were using opium around 5000

Ibid.. 33.

Alcohol. Tobacco, ard Other Drag Abuse. I.

Ibid.

;s fbid.. 5.

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B.C. The Ebers Papyrus, which dates from the sixteenth century B.C.. describes more than

seven hundred herbal remedies that were known and used by the Egyptians. And 2.500

years ago in the Mediterranean Islands, leaves and flowers o f the marijuana plant were

often thrown on bonfires and the smoke inhaled.29

Americans have used all manner o f substances throughout the nation’s history. For

example, from the colonial period until the late 1800s the use and abuse o f alcohol was a

common occurrence. One o f the first exotic (non-indigenous) substances to become a part

o f the nineteenth century American culture was opium introduced to American culture by

immigrant Chinese laborers who were building the transcontinental railroad across the

United States.30 By 1832 the use o f morphine was being used by American

pharmaceutical companies as a replacement for opium in patent medicines. Physicians

believed the new opium derivative to be non-addicting and could cure opium addiction in

patients.'’1

Between 1890 and 1906 cocaine was a basic ingredient o f numerous ointments,

powders, lozenges, and wines. These products were advertised as cures for asthma, colds,

corns, eczema, neuralgia, opiate, alcohol addiction, and even venereal disease. Coca leaf

flavor was a key ingredient of Coca-Cola, which first appeared in 1885 and was marketed

as a ruling remedy/- Many indhiduals became addicted to Coca-Cola. The first federal

:v Ibid.

v' Ibid.. 6.

Ibid.

Ibid.. 7.

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legislation passed by the federal government in response to the growing concern for the

widespread misuse and abuse o f proprietary medicines was the Federal Pure Food and

Drug Act in 1906.33 After the Act was passed. Coca-Cola switched from using

unprocessed cola leaves to decocainized leaves. By 1930 the Internal Revenue Service

Narcotics Unit became an independent unit—The Federal Bureau of Narcotics.34

During the 1960s and 1970s illegal drugs escalated to an all time high. Heroin use

was at epidemic levels, marijuana use was on the rise with college students with a

downward spiral to high school and elementary grade students, and psychedelic drug use

was growing in popularity/5

Today there has been a re-emergence and comeback o f cocaine, marijuana, and

psychedelic drugs among middle class youth. Crack cocaine and its derivatives are

entrenched in our urban and suburban neighborhoods across the country, and inexpensive

smoked and snorted heroin is also once again increasingly popular.36

Walter Wink uses the term “System o f Domination"' to describe what the New

Testament writers have named principalities and powers. The destructive domination

system being addressed by the ODCM in this project model is the use o f spirituality as a

methodology to transform the deadly systemic effect o f illegal drugs and the drug industry

through a non-traditional clinical approach and a collaborative city-wide strategy. Wink

■5 Ibid.

M Ibid.. 8.

" Ibid.. 9.

’-6 Ibid.

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states that “These systems are an entire network o f powers which have become integrated

around idolatrous values. The characteristics o f a domination system are economic

exploitation, oppressive political structures, bias race relations, patriarchal gender

relations, and the use o f violence to maintain them all/’37

Robert Linthicum defines this complex social environment as “Systemic Evil"

which is driven by money, power, the economics o f privilege and exploitation, and he adds

to this list: individualism/8

The answer to these social ills will not be resolved solely with the aid o f legislative

input from politicians, or from the expertise o f social workers, community agencies,

treatment and counseling centers, or medical professionals. Communal and human

redemption is the work o f the church empowered by the Holy Spirit. When the Body of

Christ submit to God's will and fully trust God's spirit at work in and through them,

redemption happens, liberation happens, healing happens, justice happens, recovery

happens—empowering the total community becomes a reality.

Jesus' mandate for every age is now is the acceptable time for the faith community

to develop strategies of redemption, healing, and justice as a positive response to the

issues related to substance abuse treatment and intervention ministries. This is the process

for moving addicted persons from victim to victory.

Wink. Powers That Be. 31.

'* I .inthicum. City o f Gcx/ Ciry o f Satan.

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The Gaps

"The poor are said to be the rag, tag. and bobtail o f humanity. But Jesus does not

leave them that way. Out o f material you would have thrown away as useless, he fashions

people o f strength—giving them back their self-respect, enabling them to stand on their

feet and look God in the eye. They were cowed, cringing, broken things. But the Son has

set them free” (Origen. A.D. third century).39

In conclusion, there are service gaps for addicted persons that need to be

identified. Biblically, faith communities can quote the Scriptures and pray with the

suffering from a distance. Historically, they can document the devastating effects o f drugs

and their destruction in human lives and in the community. Theologically, they are still

grappling with constructing suitable praxis for addressing the complex issues o f addiction.

Nevertheless, within the last decade many faith communities have begun to develop

community-based treatment and intervention ministries which are making a difference.40

There are support groups, centers, and residential treatment facilities whose

treatment models are based on the 12-Step Program for people in recovery. There are

crisis intervention services available for individuals who are in life-threatening situations.

There are local and private hospitals that will provide detox and counseling services for a

limited period o f time. However, there are very few centers where a wholistic spirituality

is the core from which all care emerges. Likewise, because spirituality has not been the

Linthicum. "Empowering the Poor.” back cover.

u Alcohol. Tobacco, and Other Drag Abuse. 33.

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core, there is no peace for the addicted to be seen as justice-bearers in the community.41

The primary service gap for people in recovery from addiction is a continuum o f

care and support network after they are released from residential treatment. Addicted

persons can get assistance for short periods o f time, but they need long-term

assistance— spiritually, emotionally, and physically—to regain their sense o f humanity and

economic stability.

Walter Brueggemann treats this topic with the following analysis: "The task of

prophetic ministry is to nurture, nourish, and evoke a consciousness and perception

alternativ e to the consciousness and perception o f the dominant culture around us."42

Literature is almost non-existent relative to vvholistic treatment models with

spirituality as the foundation for treatment o f recovering addicts.

There is need for centralized resource pools of appropriate services so that the

weight of frustration and discouragement for people in recovery does not lead them back

to the path o f the revolving door (relapse). Most o f all. the critical role o f trained, caring

pastors, professionals, and lay persons as a vital network o f support for hath the addicted

persons in the recovery process and their families must not be ov erlooked.

The gift o f developing a community-based ministry which addresses the pervasive

epidemic o f drug addiction is that it provides an opportunitv tor participating in

collaboration with others to build G od's vision of justice in the city for the purpose of

/c l! bkeron. [ xecutive Director o f Project Cure. Treatment and Residential Center for Drug Rehabilitation. I>jv:>n. ( )hi> >. interview bv author. November. 1999.

*" Brueggemann. Prophet:.- Inuginatiim. 46.

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redemption among community residents who desire to be resurrected from the death grip

o f drug addiction.

Summary

This document was written with the cooperation o f the context associates who

were involved in the process o f historical research, group exegetical discussions relative to

Is. 61:1 -5. Lk. 4:18-19. and identify ing additional Scriptures that were helpful in the

development o f this ministry model. The sharing o f their personal journeys has been

helpful in understanding the psychology o f addiction and how they moved from victim to

victory. They were affirming, excited, and committed to the project. This writer believes

that a sound theoretical foundation is critical for developing and sustaining any ministry

with community.

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CHAPTER FOUR

METHODOLOGY

The context for this ministry model was the Open Door Collaborative Ministry in

Dayton. Ohio, a ministry with pre- and post-treatment residents of Project Cure. Inc.. who

are addicted to substance abuse. Wesley Community Center, a collaborative partner,

provided a weekly meeting room for implementation o f the ministry. The center is located

in a Southwest Dayton neighborhood where the average family yearly income per

household is less than SI 1.000. The community is overrun with the socio-economic

problems o f drug addiction, drug trafficking, prostitution, unemployment, lack of adequate

health care, poor housing, and homelessness1 (see appendix I). These unhealthy, socio

economic realities breed a climate of apathy, moral corruption, and hopelessness— a

climate that is sustained by economic systems o f exploitation. Walter Wink refers to this

social dilemma as "being stripped o f life's spiritual depths by a shallow materialistic

culture resulting from an oppressi\e System of Domination.”' Wink's description o f the

Domination principle is "when an entire network o f powers become integrated around

idolatrous vaiues.'" The characteristics of the community surrounding Wesley Center are

NatisticM Dayton Planning Hoard South w ot Priority Data. Dayton. ( )f L 1990. I7.

Walter Wink. V i c P o w e r s i h . n He ( N e w York: IXuihleday. 1998). 31.

I b i d .

6 5

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synonymous with the effects o f what transpires when a community is "being stripped o f

life’s spiritual depths." Southwest Dayton mirrors Wink's description o f his System o f

Domination in addition to the realization that violence is the underlying mechanism which

maintains them all (see appendix I).4

Out o f this environment came the birthing o f the Open Door Collaborative

Ministry (ODCM). Ministry leaders looked face-on at the numerous socio-economic

problems in the community and decided to address the problem o f alcoholism and

substance abuse. They asked the question: What element appears to be missing in the local

treatment modalities and recovery process to better help the substance abuser to break the

destructive cycle o f addiction?

Based on all seventeen participants* personal experience with addiction to

substance abuse, the collaborative identified Christ-centered spirituality as the key

element.

Eight men and nine women from the Open Door Collaborative Ministry were

selected to participate in evaluating this Doctor o f Ministry project: 1) to test the validity

o f the Open Door Collaborative Ministry as a process through which who list ic ministry

emerges: 2) to test the validity o f the w holistic ministry o f the ODCM as a means o f

sustaining recovery.

A targeted sampling plan was emploved b> identifying and recruiting participants

selected from among the ODCM leadership, agency representatives, volunteers, and

" [hie.

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residents from the Project Cure Treatment Facility who were in attendance at ODCM

celebrations.

The context associates assisted this wTiter in designing questions to use as the

survey instrument (see appendix J). At an informal gathering o f the ODCM. this writer

distributed questionnaires among the pre- and post-treatment residents o f Project Cure in

order to measure their spiritual awareness at the beginning o f the study. At the end o f five

months o f attendance at ODCM. the questions were repeated in order to measure the

residents' growth in spiritual awareness.

Data was collected by this writer through one-on-one interviews with collaborative

administrators. Open Door leaders. Project Cure residents, and volunteers (see appendix

K). Questions w ere asked to ascertain the effectiveness or ineffectiveness of the

collaborative aspect o f the model o f ministry (see appendix J). Other data included

minutes o f the meetings o f context associates and the ministry' board: journal notes on

sermons and the use o f liturgy: w orshipers' responses to invitations to discipleship and

pra>er: and the personal journal o f this writer.

Design Approach

The selected research design was the qualitati\e approach. This design is defined

as "an inquiry process o f understanding a social or human problem based on building a

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complex, wholistic picture, formed with words, reporting views o f informants and

conducted in a natural setting"5

Barbara W. Cheshire also refers to this process o f investigation as

■•phenomenological” which is a qualitative method o f inquiry- focusing on how people

experience the world. She further states that *the important reality is what people imagine

it to be. not on empirical evidence.”6 Phenomenology belongs to a view o f research which

"holds that human beings can be understood in a way that other objects o f study cannot:

humans have purpose and emotions. They make plans, construct cultures, and hold certain

values, and their behavior is influenced by such values, plans, and purpose.”7

Based on Creswell and Cheshire, the collaborative believed their assumptions

could be validated. If the substance abusers know their divine destiny and purpose in God.

they can realize that they have tiie strength to turn their lives around.

The purpoce o f this study was 1»to design a replicable model for recovery from

substance abuse which emerges from a wholistic spirituality (addressing spirit, mind, and

body ), and 2 } to test the effectiveness o f the collaborative aporoach as a viable model in

the treatment process for substance abuse (see appendix K and appendix L). The research

was conducted from January 25. 2001 through June 28. 2001 at Wesley Center in

Southwest Dayton. Ohio, with participants in the ODCM (including residents o f Project

Cure Treatment Facility. Inc.).

' John Creswell. Research ami Design: Qualitative ami Quantitative Approaches (Thousand 1 >ak.N. CA: Sage Publications. 1 W ). 2.

6 Barbara Cheshire. The Best Dissertation is a Finished Dissertation (Portland. OR: National Rock Companv. 1993). 7.

' Ibid. 24-25.

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The Model

The collaborative leadership realized that no one system or institution alone can

fully address the complex needs o f persons in recovery from substance abuse. Therefore,

she utilized staff and volunteers from their individual disciplines or organizations to form a

wholistic approach to recovery. The volunteer staff and collaborative network included

clergy, administrators, substance abuse counselors, educational instructors, job-readiness

and re-entry employment skills trainers, wrap-around service providers, individual and

family support counselors, and medical support treatment facilitators.

The Open Door weekly ministry components are fused into a wholistic

empowerment celebration with worship as the centering experience (see appendix M).

Worship components are musical praise, meditations for living from a devotional written

for recovering substance abusers, testimony time, offering, sermon, ministry of prayer, and

the afterglow fellowship with refreshments. Additional links to the collaborative ministry,

which continued the empowerment instruction for recovery and healing from a biblical

perspective, included three community Bible study groups and a five-day spirituality group

held at the Project Cure Treatment Facility. The primary leadership in this model was

comprised o f this writer. Christian ex-substance abusers, professionals specializing in the

field o f substance abuse, and volunteers from the greater Dayton community.

The collaborative organized a ministry board whose function, along with Rev.

Nichols, pastor/director, w as to keep the ministry accountable to the vision and mission o f

The Open Door Collaborative Ministry (see appendix N).

The results o f tools utilized during the length o f this study will be reflected in the

following chapter.

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CHAPTER FIVE

HELD EXPERIENCE

Persons who are addicted to substance abuse are in need o f ministries that will

empower and enable them in the process o f recover,’. Narcotics Anonymous and

Alcoholic Anonymous Twelve-Step programs are helpful, but often the addicted will stop

actively using drugs but their lifestyle has not changed. This condition is known on the

streets as a "dry drunk." These individuals need more than a program to transform their

behavior to wholeness. The ODCM successfully tested their hypothesis that spirituality is

the transformative agent which allows sustained recovery and wholistic healing to occur in

the lives o f substance abusers.

Research for the model began with the writer initiating a planning meeting with the

project team o f context associates on October 10.2000. Ideas w ere shared for the

development o f a recovery model which emerges from a core o f Christ-centered

spirituality. The context associates served with the writer as co-designers and co

mplementers o f the Open Door Collaborative Ministry model (see appendix L). The

context associates are Christians with a past history o f substance abuse (drug addicts) who

feel called and committed to the ministry o f empowering others to sobriety through a

Christ-Centered methodology . The project team discussed biblical liberation themes and

how Scripture serv es as a guide for the theological development o f a wholistic recovery'

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model. The discussion led to the development of a Christ-centered model that addresses

the complex recovery needs o f drug addicts. The biblical text chosen to support the

liberation theology theme for the research project was taken from Jesus' manifesto

recorded in the fourth chapter o f The Gospel o f Luke.

In November 2000, the writer and the project team met to develop a pre- and

post-test survey tool for the purpose o f gathering data to measure the difference between

Project Cure residents' spiritual awareness at their first worship celebration compared to

their spiritual awareness five months later at the conclusion o f the research. A sub

committee was appointed by the writer for the task of developing the survey instruments

for approval and adoption by the project team. Nine context associates attended the first

meeting: the team later narrowed to seven working context associates in addition to four

professional associates. The context associates met monthly following implementation o f

The Open Door Collaborative Ministry (see appendix O).

Implementation o f the research design began on January 25. 2001. Context

associates approved the design for the worship format and flyer. Advertisements were

placed in the local newspaper and in community newsletters to inform the community

about the availability o f this ministry for residents (see appendix P).

Components o f The Open Door Collaborative Ministry included:

• a weekly informal worship celebration which began in January with an average

attendance o f twenty worshippers and grew to an average attendance o f fifty-five

during the five-month period:

• a volunteer ministry staff (worship leader, musician, and meditation-for-living lay

minister);

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• special music from the recovery community:

• preachers representing the diverse (race, class, gender) population drawn to the Open

Door Collaborative Ministry';

• special prayer concerns were led by the writer following the sermon. The ministers

assisted her in praving individually with worshippers, and a closing benediction circle

for corporate prayer and a blessing that sends the worshippers forth into the world

empowered by Christ to live a victorious life over addiction and other challenges they

may confront throughout the week day;

• a time for fellowship (with refreshments prepared by volunteers), informal

conversation, counseling, and individual prayer:

• The pastor/director coordinated all aspects o f the evening, recruited the leadership,

and served as a gate-keeper, along with the ministry board, for monitoring the

preaching o f appropriate doctrine, keeping the worship and leadership accountable to

the mission o f the collaborative ministry, and maintaining a balance o f the Open Door

Collaborative Ministry policy among staff and volunteers.

Twenty-three worship sessions and fellowship gatherings with a focus on recovery

from substance abuse were completed (see appendix Q). The recovery themes for all

sermons and meditations w ere designed to bring a theological focus o f salvation, healing,

and deliverance (see appendix R).

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Sampling o f Sermons and Theological Focus

February 1. 2001 Sermon title: Hold On— Help Is On the Way. Text: Joshua 10:1-11; Proverbs 24:9 Focus: God's Spirit can save and deliver us from the bondage o f addiction. Preacher: The Rev. John Allen (clean from addiction since 1985). St. Paul Baptist Church Ministry o f Prayer (7).

February 8. 2001 Sermon title: God Is Determined to Work on You— Without Hope. Men Are Dangerous Text: Philippians 2:13 Focus: Restoration and healing. Preacher: The Rev. Danny FelLx. Omega Church Ministry o f Prayer (5): received Christ as their Savior (3).

February 15. 2001 Sermon title: No Strings Attached Text: Luke 7:36-50 Focus: Our capacity to love is based on our capacity to live Preacher: The Rev. Robert Biekman. Residence Park United Methodist Church Ministry o f Prayer (11).

March 3. 2001 Sermon title: When the Lord Touches You. Good Things Happen Text: Daniel 8:15-18 Focus: Emotional and physical healing— Daniel had an encounter with God and acknowledged the power o f God. Preacher: The Rev. John Allen. St. Paul Baptist Church .Altar response (8). Received Christ as their Savior (2).

March 22. 2001 Sermon title: Do You Have the Hook Up? Text: Ezekiel 37:1-11. Focus: Can these bones live? God has the power to take that which is dead and bring it back to life. Preacher: The Rev. Beverly Lee Ministry o f prayer (8). Received Christ as their Savior (4). For healing from addiction (2).

April 26. 2001 Sermon title: Where Are You Standing? Text: Daniel 3:8-25 Focus: If you don't stand on God's side, you will fall for anything. Lay preacher: Beverly Daniels. Ministry o f prayer (6 prayers for strength to stand in the face o f temptation).

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Other Components o f the Worship Celebration

Special music was provided at each worship celebration by residents o f Project

Cure, the MonDay Treatment Facility Choir, and community residents who are in

recovery. The opening songs o f praise created an atmosphere o f freedom with spiritual

integrity. All worship celebrations began with prayer and the leading o f musical praise by

this writer. The musician, a student at Wright State University, is a recovering drug addict.

The worship team incorporated a segment called Meditations for Living. A woman

with nine years clean from addiction and newly certified to be a substance abuse counselor

was responsible for this ministry.

The ministry o f testimonies proved to be one o f the high points o f the Open Door

celebration. During this time the Open Door family shared their joys and how the Lord is

blessing and at work in their lives. There would be shouting and clapping and responses o f

"Thank you. Jesus" and "Praise the Lord" as brothers and sisters rejoiced with one

another.

Participation in the ministry o f fellowship grew in numbers and in community

support. Each week during a time o f fellowship, refreshments were prepared and served

by volunteers from the families o f persons in recov ery , or from other supporters of the

Open Door ministry.

The number o f opportunities for w eekly Bible study grew from one to four. The

groups were led by pastors and laity who are pan of the doctoral project.

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Organizational Structure

The Ministry Board began its work on March 8. 2001. Members o f the board

include a substance abuse counselor with an active caseload and a family support

counselor from Wesley Center. A local Christian attorney volunteered to assist the board

with filing for non-profit incorporation.

Comparative Evaluation

The pre-suppositions o f the survey instrument designed by the writer and the

context associates were found to be invalid for the intended purpose. However, the

instrument yielded valuable insight for the project. Results o f the Initial Survey of

Substance Abusers:

Believe God is important in the recovery' process (96%; 1 descent).

Believe that a relationship with Christ is necessary for recovery' (88%; 3 descents).

Believe that Open Door worship celebrations are helpful to their recovery (80%; 7 descents).

A significant number feel that the sermons provide them with the spiritual strength and courage to stop using drugs.

Feel that the ministry o f prayer is a source o f healing for mind. body, and soul (96%: 1 descent).

Feel that praise songs are a ministry o f healing and a source o f strength in their spiritual walk to recovery (96%; 1 descent).

Believe that Christ-centered spirituality is helpful in the healing and reconciliation of broken family relationships (88%; 3 descents).

The project team planned to repeat the survey at the end o f the project in order to

measure the comparative changes in the Open Door participants" spiritual growth.

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However, this tool was deemed invalid (see Data Analysis section). The substance abuse

counselor and the family support coordinator submitted information concerning the

relapse rate during the implementation o f this project. Due to the time constraints o f the

project, it was not possible to follow the process o f Project Cure residents* relapse rate

over an extended period to the completion o f this treatment process, although two persons

who returned for treatment have been identified.

Observation

Although indi\iduals may come from the same drug culture, class, age ethnicity,

education, religious exposure, and gender are factors in a person’s approach to recover}-.

Data Analysis

The initial survey questionnaire administered to twenty worshipers from Project

Cure Treatment Facility proved to be an invalid instrument for measuring pre- and post

spiritual awareness for the following reasons: 1) The assumption that Project Cure's

residents have limited spiritual awareness was proven not true. Almost all residents (96

percent) were highly aware o f the potential role of spirituality as a means to a moral life

and the foundation of a legitimate value-based system. 2) The other residents (4 percent)

only varied by 1 to 4 points below the 96 percent.

Based on the data, the writer concludes that societal assumptions that substance

abuse is caused by a lack o f spiritual knowledge are not valid. Follow-up discussions with

the same group o f respondents revealed that oppressive systemic issues, e.g.. poverty,

economic exploitation, family \iolence. miseducation. lack o f gainful employment

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opportunities, were the dominant contributing factors to coping with reality by the use o f

or sale o f illegal drugs.

The following responses are a summary of the seventeen pre- and post-assessment

interviews with Open Door Collaborative Ministry informants. Informants included clergy,

administrators, leader/participants. Project Cure residents, and volunteers.

Each interview lasted for approximately thirty-five minutes (see appendix J).

Strengths o f the Open Door Collaborative Ministry

• All agreed that a collaborative ministry provides a greater reach o f services and a

"wrap-around" support network for persons and families affected by the social disease

o f substance abuse.

• All agreed that it is better to work together, rather than separately, to address

substance abuse in the community. A collective effort enables planning, acting, and

negotiating from a position o f strength.

• Worship and preaching leaders said they have experienced and witnessed the result o f

God's divine touch o f healing and a deepening spirituality at work in worshiper's lives.

One leader stated that he "had become transformed by not taking people’s addictions

for granted . . . I have grown to understand that drug addiction is a sickness, but I

know we can be made whole through Jesus Christ because the Lord changed my life."

His church. Saint Paul Missionary Baptist, a former dying urban church in a

deteriorating neighborhood, has come alive. Many Saint Paul members are from

Project Cure, former addicts, and participants in Open Door Ministry.

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• Informants from Project Cure conclude that ODCM remained true to its mission o f

empowering people in their recovery from substance abuse by introducing people to

Christ (spirituality). One person said, “I know that Jesus was the only power that

could rescue me from the street life o f Gieking (the street chase for crack),

prostitution, and death. I've lost a lot o f my friends to the street. I know somebody's

been praying for me. My children were not enough, my mother was not enough, my

husband was not enough to stop the insanity and revolving cycle o f relapse, but when I

found Jesus, old things passed away and I became a new creature. The Lord restored

my family, opened up doors for gainful employment, and provided us with a home.

What I love about Open Door is everybody accepts you right where you are and you

feel affirmed and loved by the leaders and people."

• Project Cure residents agreed with leaders and volunteers that much of the success o f

ODCM can be attributed to it being a grassroots ministry initiative led by grassroots

leaders who are former addicts working with other committed Christians in substance

abuse ministry. The worshipers' personal testimonies o f healing and overcoming life's

crises, and the ministry of music, prayer, and preaching received unanimous

affirmation by the informants for being the components which seemed to energize,

encourage, and sustain them the most.

• In one clergy interview, the informant shared the following message which is a good

summation o f this research model. “Open Door has proven to be a sanitarium (a safe

place where people get well) and a sanctuary (a safe haven for everybody and

anybody ). "We started with a small group and have grown to a weekly ministry when

often there is standing room only." w as the comment o f a volunteer informant.

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Summary o f Interview Data o f Collaborative Administrators

• Project Cure staff have observed that clients' behavior is calm and non-combative

when they attend the Open Door worship services.

• The collaborative provides a link in a support system which is critical for people in

recovery.

• Overall I feel that spirituality enhances the growth o f our clients and enables them to

make better choices in life.

• ODCM is a critical ministry for any community where it allows its disconsolate to find

a place o f welcome and reconnection with family and friends in the faith tradition.

• The most strategic piece is that the leadership and ministry board stay committed to

personal and professional growth, retain diversity among staff, and to be steadfast in

the ministry o f redemption, reconciliation, and affirmation.

• Become more intentional in the process o f inclusion with family members as a

significant part o f the wholistic approach in the recovery process for the recovering

addicts and their families.

Summary o f Data Expressing Limitations in this Ministry Model

• Attendance would probably increase with a reliable system o f transportation, w hich

includes a reliable driver with a phone.

• Funding is needed for operational needs.

• A city-wide publicity campaign.

• Additional time to further test this model.

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Summary o f Data Expressing Recommendations for this Model o f Ministry

• Dayton could benefit from city expansion o f the ODCM.

• Seek support from additional churches and treatment facilities in the community who

lack appropriate resources for a recovery ministry'. There is no need to “reinvent the

wheel” when ODCM is already providing the service.

• Enlist the aid o f a grant-writer.

• Complete process for non-profit incorporation status.

Other Results Yielded During Model Project

• Three additional Bible study links led by ODCM staff were begun in community

churches and Wesley Community Center for people in recovery' from substance abuse

(Twelve Steps to Victory/St. Paul Church: People Taking Charge/Women's Group:

New Life Community Church).

• One spirituality group. Monday through Friday, conducted by ODCM staff member at

Project Cure was started (Project Will).

• Overall attendance at worship and study groups increased by almost 50 percent.

• Increase in number of volunteers who prepare and serv e refreshments during the

fellowship time following worship each week.

• Established business checking account.

• Ministry board was organized for the purpose o f keeping leadership responsible and

accountable to the vision and ministry o f ODCM.

• Forty recovering addicts made a commitment to Christ.

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• Recovering addicts shared testimonies during worship concerning how the Lord is

blessing in their lives.

• Families began to join in worship with the family member who is a resident o f a

treatment center.

• ODCM is providing a training ground for clergy and laity who are called to substance

abuse ministry.

• When worship services were first organized, special guests were recruited for the

ministry of music. During the study, gifted vocalists and musicians for worship were

discovered within the community o f recovering addicts.

• The study concluded on June 28. 2001. with a major anniversary celebration o f the

Open Door Collaborative Ministry (see appendix S).

Conclusion

Based upon field experience, research data, and the efforts o f the participants, this

model has exceeded the expectations o f the writer. The data suggests that this ministry

model can be expanded upon and contextualized for use in urban communities. The writer,

as a result of experiencing this model o f ministry, has become spiritually strengthened,

empowered, and transformed by observing and participating in a ministry where lives have

been touched and made whole through the liberating gospel of the radical Jesus from

Galilee.

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CHAPTER SIX

REFLECTION, SUMMARY, AND CONCLUSION

Reflection

God o f fire and freedom, deliver me from my bondage to what can be counted and go with me into a new exodus towards what counts. but can only be measured in bread shared and swords become plowshares: in bodies healed and minds liberated: in songs sung and justice done: in laughter in the night and jo y in the morning: in love through all seasons and great gladness o f heart: in all people coming together and a kingdom coming in glory: in your name being praised and my becoming an alleluia. through Jesus the Christ. 1

Ted Loder's powerful poem. Go With Me In a A’eu- Exodus. mirrors the heartfelt

cries, pain, restoration, and celebration experienced by the participants in the Open Door

Collaborative Ministry during the implementation o f this model. The goal o f the ODCM

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healing for residents in treatment for substance abuse. In preparation for the development

o f this ministry, the writer solicited the input o f Christian ex-drug addicts to serve as

context associates. As a result o f their personal journeys, they brought strong leadership,

valuable insight, life experience, and the transmission o f their deep faith commitment and

values to the development and implementation process. The writer, as she reflected upon

the Lord's faithfulness, was persuaded that the omnipotent God o f history still tabernacles

among humanity, continuing the redemption story. Surely this same God, working through

the faith community, could transform the lives o f substance abusers to become

ambassadors o f Christ. The writer's grandmother, the Rev. Rosie Lee Long, would have

added, "Ain't that just like the Lord!"

The writer's observations at Victory United Methodist Church as pastor for eleven

years and as a professional social worker and counselor for twenty years has brought

experience, spirit, and authenticity- to this project. Victory church hosted four AA groups

and one NA group, thus affording the writer an opportunity to personally interact and

develop meaningful relationships with members o f the recovery community. A level o f

trust was built as the writer showed genuine concern for their well being as persons o f

worth. The writer readily discerned how one addiction can be replaced by another which is

known in the Dayton recovery community as a "dry drunk." The after-meeting fundraisers

and recreational actirities often became opportunities for members to gather at the

recovery clubs or in homes. While they celebrated without "drinking" or "using." there

still was an exhibition of all the other behaviors associated with active addiction:

suggestive sexual dancing, cussing, thirteen steppers, gambling. hea\y smoking,

adulterous relationships, and violence, were exhibited. The social gatherings did not

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require a change in lifestyle beyond stopping the use o f alcohol or illegal drugs. The

ODCM staff recognized the critical need for spiritual transformation in the recovery-

process for drug addicts. The goal o f complete sobriety requires an intentional change in a

person's lifestyle that is reflected in their morals and values; this seems to be especially

critical in a society where pleasure and thrill-seeking are encouraged. The Victory church

and the ODCM leaders who adhere to the goal o f "complete sobriety” state that this can

only be accomplished by surrendering our life to God through a relationship with Jesus

Christ. They are committed to reaching out and inviting others to wade in the "redemptive

waters o f recovery" through an intentional and genuine relationship with the savior and

divine elder brother. Jesus. The writer recognizes that other faith organizations have

effective recovery programs for the addicted person: nonetheless. ODCM advocates a

Christ-centered, holistic approach to recovery- from drug addiction.

Following the implementation o f the project, the writer continued as pastor of the

Open Door community. When the writer's husband accepted a job in another state, there

was little time to prepare the ODCM staff for her impending move. The staff were pleased

with the results o f the model o f ministry: an increase in attendance at weekly worship

meetings: dynamic preaching: personal accounts of conversion: the emergence o f new

leaders: four active Bible study groups: uplifting music and fellowship: enthusiastic

testimonies o f faith: and soul-stirring praise reports o f healing. Yet. the staff expressed

concern as to how the absence o f the pastor would affect the ministry. The writer has

always known that effective administrators empower others to do the work o f ministry, so

that unexpected changes in leadership do not negatively impact the ministry. A meeting o f

the executive members o f the ministry board was called for the purpose o f developing a

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strategy to maintain the stability o f the ODCM. It was evident by the cooperative nature

o f all fifteen members in attendance that God was part o f the plan. They said they felt

confident that whatever happened, the Lord would empower them to weather the storm.

Unfortunately, shortly after the writer moved away from Dayton, one o f the

founding leaders and a context associate on the ODCM team. Gerald Davis, died

suddenly. Known affectionately as “The Bishop,’” Gerald had coordinated weekly ministry

responsibilities and had scheduled preaching dates for rotating clergy. The writer returned

to Dayton for a brief visit and was graced with the privilege to be the guest teacher for the

Bible study class that Gerald had taught at Project Cure (a collaborative partner in the

ODCM model). The determined spirit o f the class to overcome their addictions and

become disciples o f Christ is a monument to Gerald’s personal witness, passion, and

extraordinary gift for teaching drug addicts in treatment about Christ’s power to deliver

them from the demonic grasp o f addiction. Ain 7 that ju st like the Lord! The writer also

had the honor o f an invitation to preach to old and new friends at an Open Door worship

celebration.

When Gerald died, the ODCM staff and the participants in the Open Door ministry

felt somewhat abandoned with what they perceived as the weight o f another loss of

leadership. However, they discovered once again that the Lord will always raise up

committed people to bloom in places that some hav e identified as the wastelands of

humanity. The writer gives God praise and honor for energizing the ODCM staff with

Christ's resurrection power becoming the wind beneath their wings. The ODCM

leadership and volunteers continue to thrive with the same fiery Holy Spirit-filled passion

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for people who are lost in a sea o f drug addiction. And the people just keep coming to

wade in the redemptive waters o f recovery.

After being exposed to precious souls— men, women, and youth—dying on the

streets o f Dayton, Ohio, as a result o f drug overdose, as well as homicides, random

shootings, toxic illnesses, and other drug-related conditions, the writer sought Divine

counsel and guidance to develop a ministry o f recovery for substance abuse. Her level o f

compassion and commitment was severely tested when she encountered religious biases

and systemic opposition to ”those people.” The writer's faith and trust in God were

summoned to a place o f steadfastness and total reliance upon God's provision to manifest

God's wisdom and plan for the birthing o f a nontraditional wholistic recovery ministry in

Dayton. Ohio.

Summary-

One o f the ODCM community executive directors. Ms. Zell Skelton o f Project

Cure. Inc.. made some affirming and insightful professional comments and observations

providing authenticity to the need for ministry models such as the ODCM in our national

and international communities. The writer has intentionally included international

communities as the result o f personal conversations with clergy, community leadership,

and residents in travels to Haiti, the Caribbean. Russia. Korea. Brazil. Zimbabwe, and

South Africa. Ms. Skelton's comments resonate with the spirit o f universal truth to the

power o f God to deliv er, heal, and sustain drug addicts in other countries. She continues.

"We have the capability to provide all the professional counseling and the most advanced

treatment available for chemically dependent clients and residents: however, two vital

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realities must exist in the hearts o f people with substance abuse problems. They are: a

genuine will and desire to stop ‘using.* and a sincere relationship with Christ. Then,

transformation from ‘addict* to being ‘set free* from addiction can become real! That is

w hy we are thankful for our community partnership with ODCM and the Bible study

classes at Project Cure. At Project Cure, the staff and I have observed a change in clients

who include this life changing dimension in their lives. It makes the job easier for us and it

benefits the clients and residents.** The writer's personal convictions and the comments o f

staff have given encouragement and affirmation to the credibility and need for ministries

such as ODCM to empower recovering addicts to become ambassadors o f healing and

justice-bearers in ministry with Christ.

The writer, as a result o f national and international travel, has identified

institutional religion's refusal to acknowledge and address systemic evil as being at the

root o f social disorder, disintegration o f morals, and injustice. In the United States o f

.America and abroad, the endemic problem o f drug cultures can be traced to racism,

human exploitation, and the politics o f economics.' In spite o f this painful reality, the

writer agrees with Brueggemann that "hope can be affected by the reclamation o f the

prophetic tradition o f evoking, informing, and reforming an alternative consciousness

which is built upon the teachings o f a redeeming Christ. * This tradition is not reductionism

of divine call and responsibilitv. but rather a remembrance o f a faith tradition that is rooted

in the energizing hope o f a radical Jesus.

' [ a>anc. f ’.r-: I ire am Bine-*. 5.

H rucggcrr.^r.n. Prtjpiicric Im agination. 99.

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Conclusions

The seemingly unorthodox journey o f the writer during this model o f ministry

surely required her to see others with "Jesus lens.” drawing upon the wisdom o f the late

Dr. Samuel DeWitt Proctor, a mentor and friend. As the writer prayerfully engaged the

process o f seeking divine assistance, the plan began to unfold as a beautiful tapestry with

the assistance o f a faithful and dedicated Doctor o f Ministry core group o f three persons.

The control and structured part o f the writer's personality was challenged and humbled

during this experience. There was personal pain and frustration, but also the comfort o f

growing to be more aware that the Holy Spirit's work in community involves submission

to others' needs. It was this learning experience o f loving submission unto Christ that

enabled the redemptive, beloved community o f the ODCM to emerge. Even the birth

pangs felt by the writer were tempered with satisfaction as the ODCM model took on a

life o f its own at the Wesley Community Center in the southwest Dayton community..

Recommendations for replication o f this ministry model in other cities:

h It is beneficial to have the use o f a van and the services of a reliable driver in

order to offer transportation to participants.

2) D e\elop funding from such sources as grants, fundraisers, and donations. All

financial endeavors are for the operational needs and for ministrv expansion.

5) Host ministrv is most effectiv e in a communitv center setting.

4 ) Appoint a publicity c o m m itte e to m arket the m inistry in the immediate

com m unity and bevond.

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5) Incorporate into the ministry by-laws a process for keeping ministry accountable

to its mission and for recruitment and replacement o f strategic leadership and

ministry board members.

And from the voice o f the writer's ancestral spirituality

is heard once again an affirming

A in 7 that ju s t like the Lord!

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APPENDIX A

BAPCO SUBSTANCE ABUSE TREATMENT AND PREVENTION PROGRAM STANDING IN THE GAP

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S U B S T A N C E A B U S E M I N I S T R I E S I N A C T I O N : i n t e r v e n t i o n / t r e a t m e n t m o d e l s

BAPCO SUBSTANCE ABUSE TREATMENT AND PREVENTION PROCRAM:

STANDINC IN TH E CAP

O v e r v ie w T he BAPCO Pastors Council of the Greater D etroit A rea is th e educational and charitable a rm o f the C ouncil o f Baptist M inisters. BAPCO is com prised o f n ine p a sto rs b o m some of Detroit's m ost p ro m i n e n t black churches. T hrough their congregations, these p a sto rs represent over 1S.OOO black m en a n d w o m e n ; th ro u g h th e services th ey pro v id e, th e ir reach is e v e n greater.

5 A P C O w a s o rg a n iz e d in 1964 to a d d r e s s th e g ro w in g su b s ta n c e a b u se n e ed s o f its local e c u m enical com m unity. Historically, the D etroit Area B aptist C h u rc h es h a v e b een reluctant to con fro n t th e issue of chemical dependency, particularly th at of its o w n members. This position is not u n iq u e to the Baptist Church. Few organized church g ro u p s h a v e h e e d u p to th is problem w ith a system atic a n d o rg a n iz ed approach.

B A P C O e s ta b l is h e d in 19SS a c o m p r e h e n s iv e S u b s ta n c e A b u s e T r e a tm e n t a n d P r e v e n tio n P r o g r a m t h a t is d e s ig n e d to m eet the n e e d s c : a d u lts . y o u th , and fam ilies w ithin the local faith c o m m u n ity , as w e ll as in th e b r o a d e r D e tr o it c o m m u n ity . BAPCO s subsmr.ee abuse p ro g ra m p ro v id e s o u tp a tie n t trea tm e n t a n d counseling, a n e tw o rk o f church-based N arccncs A n o n y m o u s i N'.A) a n d Alcoholics A nonym ous (AA) p ro g ram s a n d related support groups, comm unity outreach, a n d e d u ca tio n /p rev e n tio n activities.

F unded b y the District Health Departm ent th ro u sh the Office o f Substance Abuse Services, the goals or the p ro g ra m are as follows

S u p p o rt religious and persona! growth bv d e v elo p in g those attitudes and skids n e ed ed to su p p o rt the pu rsu it c f a productive lifestyle free from the effects cf aiconol and o th er chemicals, and

- P rom ote sc c a i change ar.d acrtcr. by n e t w o r k i n g w ith in th e to ta l r e lig io u s com m unity

P r o g r a m A p p r o a c h a n d M e t h o d o l o g y

B A P C O recognizes th a t tre a tm e n t fo r alcohoiistr. a n d o t h e r d r u g d e p e n d e n c ie s v a r ie s w ith each in d iv id u a l a n d family. A ssessm ent o f ciier.t needs is c o n d u c te d b y professional sta ff to determ ine if re sid e n tia l inpatient trea tm e n t is req u ired .

T h e fo llo w in g o u tp a tie n t tre a tm e n t services are o ffere d b y the BAPCO p rogram ;

• A sse ssm e n t and referral.

• S e lf-help g ro u p in v o lv em en t (N'A. AA).

• In d iv id u a l counseling,

• F a m ily counseling, • G r o u p therapy.

• S p iritu a l counseling.

• V ocational readiness referrals, a n d

• D id a c tic lectures.

In d iv id u a l, group, and fam ily th e ra p y are the pr.- m a ry m o d alities used in the d ie m 's treatm ent regi m en. In d iv id u a l sessions a re sch ed u led according to th e c lie n t's need, w ith a minimum, o f one visit pe r m o n th . G roup th era p y m eetings a re scheduled tw ice p e r m o n th ar.d fam ily th era p y as indicated O th e r th e ra p e u tic m odalities u se d to m eet dien: n e e d s in c lu d e m arital counseling, conjoint therapy, v o c a t i o n a l c o u n se lin g . le is u re c o u n s e lin g , and b e h a v io ra l therapy

An in itia l treatm ent plan, consisting of a minimum c f c r.e g o a l a n d the objectives to tnitiaie prelimi- n a ry tre a tm e n t, is de v elo p ed a t intake A master tre a tm e n t plan is developed for each ciier.t as socr as p o s s ib le a fter the b io p sy c h o so c ia i assessment h a s b e e n com pleted, b u t no late r than one mor.tr a.-ter a c c e p ta n c e into th e program . Through, the t r e a t m e n t p la n n in g p ro c e s s , w h ic h in clu d es a c o m p r e h e n s iv e a sse ss m e n t of th e c lie n t's needs ■ b i o p s y c h o s o c i a i a s s e s s m e n t , m e n t a l health a s s e s s m e n t, a n d vocational n e e d s assessm.er.r;. a c o m p le te conceptualization of the client's problems a n d r e e d s is d eveloped A m e a tm e n regim.e.t a

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then d e v elo p ed to m ee t th o se n e ed s a n d e n h an ce th e client's re c o v e ry effort.

T n e project o p e ra te s a 24-h o u r-a-d ay con ta ct s y s tem to m o n ito r a n y crisis th a t its d ie n ts m ig h t h a v e o u ts id e o f n o r m a l b u s in e s s h o u r s , a s w e ll a s to re sp o n d to a n y referrals received d u rin g th a t time.

Each p a rtic ip a tin g c h u rc h h a s a p p o in te d a t le a st tw o liaisons w h o a re tr a in e d to se rv e a s th e first p o in t of c o n ta ct w ith in th e ir re sp ec tiv e c h u rch e s. T he telephone n u m b e rs o f these p e o p le a re p o ste d in th eir re sp ec tiv e ch u rch es, a n d a re p laced o n file w ith the project d ire c to r a n d staff. A n y incom ing calls after w o rk in g h o u rs a re screened a n d assessed by die liaisons, t h e n p a sse d o n to th e full-tim e staff, if necessary.

I n t a k e a n d A d m i s s i o n P r o c e d u r e s

A ny ap p lican t re q u e stin g ad m issio n w h o m anifests a chem ical d e p e n d e n c y p ro b le m a n d w h o . a fte r b e in g a s s e s s e d b y a p r o f e s s i o n a l t h e r a p is t , is deem ed su itab le fo r tre a tm e n t is a d m itte d into th e p r o g r a m . T h is a s s e s s m e n t is m a d e d u r i n g a c o m p re h e n s iv e c lin ic a l in ta k e c o m p le te d b y th e therapist w ith in tw o visits.

B efore o r u p o n a d m i s s io n in to th e p r o g r a m , a v ariety of d i e m in fo rm a tio n is collected, including:

• Data on b a c k g ro u n d a n d h istory including mrarmaooci or. family, education, occupation, a n d iegai a n d co u rt-re la ted considerations.

• T h e n a m e o f th e r e f e r r i n g a g e n c y , if ap p ro p riate

• i n f o r m a t i o n or. t h e c l i e n t 's p r e s e n t su b stan ce a b u s e pro b lem , a n d o n h is /h e r h i s t o r y o f s u b s t a n c e a b u s e , i n c l u d i n g in fo rm a tio n a b o u t p re s c rib e d d r u g s a n d a lc o h o l, s u b s t a n c e s u s e d in t h e p a s t , in c lu d in g p r e s c r i b e d d r u g s ; s u b s ta n c e s u s e s re ce n tly , especially those w ith in the last 4-5 h o u r s ; su b sta n c efs) of p re fe re n ce , freq u e n c y w i t h w fucr. e a c h s u b s ta n c e is u se d , p r e v io u s o c c u rre n c e s of o v e rd o se , w ith d ra w a l, o r a d v e rs e d r u g o r alc o h o l re a c tio n ; h i s t o r y o f p r e v io u s s u b s ta n c e abuse tre a tm e n t received, a n d y e ar of firs: use of each su b s a r.e e .

• Info rm atio n on o th e r counseling se rv ice s re c e iv e d , in c lu d in g th e a g e n c y , t y p e o f service, a n d date service w as received.

D urir.g the in ta k e process, every' effort is m a d e t o e n su re th a t e ac h client a n d h i s / h e r fa m ily m e m bers h a v e a c le a r un d e rstan d in g o f th e t r e a t m e n t p ro g ram . P ro g ram goals, rules, a n d r e g u la ti o n s , th e h o u r s d u r i n g w h ic h s e rv ic e s a r e a v a i l a b l e , tre a tm e n t c o sts a n d p a y m e n t a rra n g e m e n ts , d i s charge p rocedures, and a n y family p a rtic ip a tio n i n the treatm ent process are explained.

M o n i t o r i n g o f T r e a t m e n t P rocess

Initial tre a tm e n t services are b a se d o n th e a s s e s s m ent inform ation gathered a t th e tim e o f in ta k e , i n accordance w ith the initial treatm ent p lan o u t li n e d in the p ro g re ss notes com pleted a t intake. W h ile the client m ay b e involved in a variety o f tr e a tm e n t s e rv ic e s d u r i n g the f irs t 30 d a y s , t h e p r i m a r y em phasis is o n completing th e psychosocial a s s e s s m e n t

A w n tte n treatm ent record is m ain tain ed fo r e a c h client in treatm ent. This record;

• P rovides accurate d o c u m e n tatio n o f each client's sta tu s a t die tim e of adm ission;

• Serves as a basts for tre a tm e n t p la n n in g , coordination, and im plem entation;

• P r o v id e s a m e a n s o f c o m m u n i c a ti o n a m o n g s t a f f i n v o lv e d i n t h e c l i e n t 's treatm ent.

• Facilitates continuity o f treatm en t a n d th e d e te rm in a tio n , at a n y fu tu re d a te , of th e c lie n t's c o n d itio n a n d t r e a tm e n t a t a n y specified time;

• D o c u m e n ts o b s e rv a tio n s o f th e c lie n t's be h av io r, o rd e re d a n d s u p e rv is e d tr e a t m ent. and response to treatm ent.

• P rovides d a ta for use in training, e v a lu a tion. and quality assurance m easures.

• D ocum ents protection of the rights of th e clie n t, p a r e n s , siblings, o r o th e r fa m ily m e m b e r s in t h e c l i e n t ’s t r e a t m e n t p ro g ra m

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- S U B S T A N C E a b u s e M I N I S T R I E S I N A C T I O N : i n t e r v e n t i o n / t r e a t m e n t m o d e l s

P r o c r a m M o n i t o r i n g T o be tte r e n su re th a t i s p rogram is p e rfo rm in g in a m a n n e r c o n s is te n t w ith o r i g in a l e x p e c ta tio n s . BA PCO crea te d a Q u a lity A ssu ra n c e C o m m itte e (Q A Q . QAC is com posed o f th e pro g ram d irector, p ro g ra m therapist, a n d a representative o f a n e v al u a tiv e consultant firm.

Q A C 's function is to design a n d im p lem en t a q u a l ity a s s u r a n c e p r o g r a m of B A P C O 's S u b s ta n c e A b u se T reatm ent a n d Prevention Program . In p e r fo rm in g this function. QA C h a s th e a u th o r it y to id e n tif y a re a s o f c o n c e rn w it h in th e p r o g r a m 's a d m in is tr a tiv e a n d c linical c o m p o n e n ts a n d to d e v e lo p p rio ritie s o f in v estig a tio n b a se d on th e p o ss ib le im p a c t o f th e area o f co n ce rn o n c lie n t care. QA C d ev elo p s corrective actions for id e n ti fied problem s.

Q A C m eets a t lea st m o n th ly to re v ie w p ro g ra m a c tiv itie s a n d m ake recom m endations fo r id e n ti fie d a re a s o f co n cern , and re v ie w s a n d m o n ito rs pro g ress m ade. Q A C generates a n an n u al p ro g re ss r e p o r t w h ic h c o n ta i n s a n e v a l u a t i o n o f th e p r o g r a m 's p e r f o r m a n c e in m e e tin g its g o a ls a n d o b j e c t iv e s , a n d h o w B A P C O i n t e n d s to im p r o v e th e q u a l i t y o f c a r e a n d o t h e r a r e a s n e e d in g im provem ent.

O t h e r S u p p o r t iv e S e r v ic e s T o m eet the d iv erg e n t needs o f its clients a n d their fa m ilie s a n d e n s u re th e success o f its tr e a tm e n t e ffo rts . BAPCO o p e ra te s a w id e v a rie ty o f p r o g ra m s Several o f these are highlighted b e lc w -

R e l a p s e P r e v e n t i o n T h e r a p y . . .

A p p ro x im ately half c f the ad d ic ts w ho get so b e r re m a in that way. Of the rem aining half, m a n y sta y so b e r for a while, then relapse one or m ore tim es be fo re they accept t h e " new lifestyle Tne re st go t h r o u g h a "re v o lv in g d o o r." g e ttin g so b e r a n c then relapsing u n d i they die

B A P C O h a s d e v e l o p e d a p r o g r a m to r r o v . d e Relapse Prevention T herapy (R£-PRH) to its events, as w ell as to o th er people referred to it by p a rtn e r agencies and organioaoans Tne goals o f Rc-PRH a re to give chem ically d e p en d e n t people w no do n o t re sp o n d to trad itio n a l trea tm e n t m e th o d s an un d e rstan d in g c f the relapse process, a kr.cw ledge c f th e :- ow n relapse patterns, and knew .e d g e ct how :o j . cid relapse

H I V / A I D S E d u c a t i o n . . . N ationw ide satisfies indicate th e frig h te n in g expo nential rise o f the incidence o f AIDS a n d H IV infec tion. The A in can A m erican c o m m u n ity h a s been disproportionately affected.

R esponding to the c o m m u n ity 's g re at n e e d fo r safe sex e d u ca tio n . BAPCO h a s in c o rp o ra te d factu al, n o n ju d g m e n ta l AIDS tra in in g in to a ll p r o g r a m m in g . T h ro u g h a p ro jec t f u n d e d b y th e D e tro it H e a lth D e p a rtm e n t, tw o h ig h - r is k p o p u l a t i o n s h a v e b e e n ta rg e te d — A frica n A m e ric a n w o m e n a n d fellowships of N'A and AA.

W o m e n a re reached in n a tu r a l g a th e r in g places s u c h a s b e a u ty sa lo n s , c h u r c h e s , s c h o o ls , a n d p a re n tin g groups. M em bers o f N A a n d A A and their families are offered inform ation o n re d u cin g h ig h -risk behaviors o f in tra v e n o u s d r u g u s e and unprotected sexual activity. T he p rim a ry g o a l is a m o te inform ed public.

C h e m i c a l D e p e n d e n c e E d u c a t i o n . . .

Presentations are m ad e to c o m m u n ity a n d churcn re sid e n ts, including y o u th in D e tro it p u b lic and C atholic m id d le schools a n d to B A P C O 's e d u c a tio n a l o utreach p ro g ram s. D e sig n e d to c r e a te a g re a te r aw areness of the d r u g p ro b le m afflictin g society, the workshops enhance in d iv id u a ls ' ability to cope w ith or help others experiencing a n y cvpe of d ru g problem.

E f f e c t i v e P a r e n t i n c P r o c r a m . . .

U sin g th e c u ltu ra l s tre n g th s a n d h is to r y o f the black fam ily, a 12-week p a r e n tin g p r o g r a m has b e e r d e v elo p ed to im p ro v e p a r e n n n g s k ills ar.d com m unicanor. w ithin the iam ily T n e program , p a rtic u la rly targ e ts fam ilies o f p e rs o n s in tr e a t ment. Tne comprehensive training includes stages of child developm ent, c o m m u n ic a tio n /lis te n in g , behavioral m anagem ent techniques, p ro b le m soi-- - m g self- esteem, black history, a n d role m o d elin g

S u m m e r Y o u t h P r o j e c t . . .

in conjunction with the D etroit C ath o lic P astoral AlLanct. BAPCO conducts an 5-w eek s u m m e r pre- gram. d e s ig n e d for 40 h ig h -ris k y o u th , a g e s II through 13 Through a com bination of 12 w o r k shops and 10 field trips, the pro g ram is d e sig n e d to im p a rt spirituality and de v elo p social c o n s c io u s ness. cultural enrichment, a r c d r u g a b u se a w a re ness W orkshop topics in clu d e s u b s ta n c e a b u se info rm atio n te n s io n m aking. ne alth e d u c a tio n

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stre ss m anagem ent, dra m a a n d m o d e m d a n c e , a tti tu d e s . self-actual iza non. a n d black histo ry . H e ld trip s are m ade to Greenfield Village, the M u s e u m o f A fric a n A m e ric a n H is to r y , th e D e t r o it Z o o . C e d a r Point. C ran b ro o k Science Institute. D e tro it Science Center, M otow n M useum , a n d C h a n n e l 50 TV station.

T n e S u m m er Y outh Project c om bines fu n w ith a h istorical, cultural, and business aw are n e ss p re v i o u s ly u n k n o w n to p a rtic ip a n ts . Even fo r y o u th w ith b e h a v io ra l d iffic u ltie s , th e S u m m e r Y o u th P roject has p ro v e n successful. P a rtic ip a n ts h a v e a c c e p te d r e s p o n s ib ility f o r t h e ir b e h a v i o r a n d s h o w e d e x cep tio n al social g ro w th a n d d e v e lo p m e n t. M any o f the y outh se rv ed b y the p ro je c t are th e c hildren of people in treatm ent.

L a y m e n 's R i t e s o f P a s s a g e

B o y s ’ G r o u p . . .

S o n s o f s in g le p a r e n t s w h o r e s i d e i n F ir s t C o m m u n ity Baptist C h u rc h 's n e ig h b o rh o o d m eet w e e k l y w ith la y m e n f r o m th e c h u r c h . T h e s e c h u r c h m em b e rs act as ro le m o d e ls to th e boys. T h e y p re sen t a sp irit o f tea m w o rk , enfo rc e d isc i p lin e . teach decision-m aking a n d v a lu e s c la rific a tio n skills, and identify th e c o p in g skills th a t have e n a b le d them to survive a n d excel; they s h a re these characteristics a n d strategies w ith the p a rticipants.

F re q u e n tly a difficult p o p u la tio n , th ese 4- to 14- v e a r-o ld boys h a v e sh o w n im p ro v e m e n t in th eir a c a d e m i c p e rfo rm a n c e a n d s c h o o l c i t i z e n s h i p m ark s, as well as a noted lack o f in v o lv e m en t with th e crim inal justice system. A large n u m b e r o f the b o y s have parents who are tr. tr e a m e r .t

2 n d C h a n c e M e n t o r s h i p P r o j e c t . . .

BAPCO works collaboraavely w ith 2nd C h a n ce , a m e n t o r s h i p p r o g r a m d e v e l o p e d fo r h i g h - r is k y o u th from a foster care b a c k g ro u n d B A P C O s ro le is to provide interactive w orkshops d e sig n e d to p re v en t self-desm icrve be h av io r and c o n trib u te to p o s itiv e lifesty le g r o w th . W o rk s h o p to p ic s in clu d e increasing self-esteem, values c ian ficaao r. conflict resolution. and substance abuse e d u ca tio n

C o n c l u s i o n T h e BA PCO S u b s ta n c e A b u s e T r e a tm e n t a n d Prevention Program is successful for several reasons:

• Its a p p ro a c h re co g n ize s th e r e d e m p tiv e sp irit of m ankind a n d realizes th at e v e ry one is capable o f b e in g re sto red to h e a lth a n d wholeness through tru e love a n d c a r ing. It therefore does n o t o p e rate w ith in a service system, but rather w ith in a fam ily c oncept b a se d u p o n love, caring, m u tu a l respect, and tr u s t

• BAPCO recognizes th at com m itm ent w ith o u t com petence is incom plete. It therefore ensures th at all people w orking w ithin the program —w hether professionals o r v o lu n teers—are well trained

• BAPCO v iew s the h u m a n th e ra p is t a s a v e h ic le th r o u g h w h ic h G o d w o rk s H is curative miracles. Therefore, in its th e ra p e u tic practice. BAPCO is m in d fu l o f th e tru e so u rc e o f the h e a lin g p o w e r t h a t it a tte m p ts to harness o n b e h a lf o f th o se it serves

• BAPCO is a w a re th a t g o o d s te w a rd s h ip d e p en d s on good organization a n d stro n g a d m in s manor. It therefore pracaces h ig h standards of m anagem ent in c arrying o u t its mission.

C h u rc h es w ishing to take on the re sp o n sib ility o f r e c a p tu rin g th e sou! lo st to th e a b u s e o f ille g a l a n d / o r legal drugs, alcohol, a n d o th er su b s ta n c e s m u st understand that they are engaging in b u sin e ss r h a t m u s t be ta k e n s e r i o u s l y if s u c c e s s i s to acrieved. The effort recvures a m aior com m itm ent of tim e and other resources, including hum an resources.

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APPENDIX B

BLUE BAY: PEACE THROUGH SOBRIETY

9 5

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• S U K T A . N C t A S U S E M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E A T M E N T M O D E L S -

BLUE BAY: PEACE T H R O U G H SOBRIETY

B lue B a y : A T r i b a l A p p r o a c h

At Blue Bay. th e C onfederated Salish a n d K ootenai Tribes o f th e F lathead Indian ."••e rv a tio n in n a rth - w e sK B don- '??. h i v e taken c ontrol o f th e ir b attle a g a in s t a lc o h o l a b u s e . T h ey h a v e e m p o w e r e d th e m se lv e s to u tilize th e ir re so u rce s a n d c all th e shots. T h e y h a v e w o rk e d to g e th e r to d e fin e th e e n em y , e s ta b lis h th e p u rp o se o f th e ir c a m p a ig n , a r.d d e v e l o p a n a c tio n p la n t h a t is b a s e d u p o n d e a rly a rtic u la te d tribal p rin d p le s.

Blue B ay is a Salish-Kootenai e f fo r t it is a celebra tion o f trib a l self-determ ination a n d d ig n ity .

This [n a rra tiv e ] looks at the process b y w h ic h Blue Bay w as d e sig n e d a n d operates.

It explores how the Salish and Kootenai Tribes see the problem o f alcohol abuse o n their reservation, and it describes th e v alue a n d p rincples o n w h ic h th e bribes operate th e ir prevention and treatm ent cam paign.

Tne [n a rra tiv e ] a ls o looks a t th e re s o u r c e s u p o n which th e Salish-Kootenai have called a n d review s the acoon p lan a n d strategy which a re n o w Blue Bay.

Finally, a step-by-step outline s u m m a ry o f th e Blue cay a p p ro a c h is presented.

H o w It H a p p e n e d : T h e P r o c ess

I t d e s ig n in g a n d o p e ratin g Blue B ay. th e S alish- Kootenai pe o p le used a sim ple process. " W e used sue basic s te p s." sa y s Anna W hitm g-Sorrel. D irector s i the T rib a l A lcohol Program w h ic h a d m in iste rs the Blue B a y H ealing Center

'F ir s t, w e lo o k e d a t th e p ro b le m fa c e - o n W e asked w h o is being h u rt and n o w ’

"Ther. w e assessed o u r tribal v alues, a sk in g w h a t is im p o rta n t to us a n d h o w the p ro b le m th re a te n s those v a lu e s.

"We id e n tifie d fo u r healing p rin c ip le s th a t c o u ld r.tip u s a d d r e s s o u r p ro b lem in a w a y w h ic h sup p o rted o u r rr.ba! values

"N ext w e looked at o u r resources a n d d e te rm in e d w h a t w e h a v e w ithin u s a n d o u r system th a t c an help u s g a in control o v e r d ie problem .

"We t h « outlined an action p lan a n d im plem ented it.

" F in a lly , w e e v a lu a te d a n d s t a r t e d th e w h o l e process o v e r again."

W h a t W e D is c o v e r e d : T he P r o b l e m

The Salish-Kootenai p e o p le d e te rm in e d th a t th eir trib a l c o m m u n itie s h a d w h a t th e y c o n s id e re d a serious problem w ith alcohol abuse.

"F rom o u r tribal statistics." A n n a W hiting-S orrel says, "w e sa w that alcohol and d r u g d e p e n d e n c y is the leading cause o f d e a th a m o n g In d ia n p e o p le . W e learned that such d e p e n d e n c y is a A'i » k > a n d is FATAL if n o t se a te d . We learned th a t alcohol a n d d ru g abuse affect n o t only the abuser, b u t each family m em ber, the com m unity, a n d the tribes.

"From recent research, w e saw th a t c h ild ren raised in hom es w here alcohol a n d d ru g s are a b u se d are a : high risk to abuse them selves. W e realized o u r young p e o p le today a re forced to m ake decisions a bout th eir ow n use a t a yo u n g er age th a n before. Also, there a re m any m o re substances th e y c an use to ’get hig h .'

"W e also saw shat our y o u n g ste rs w ere m a k in g the im portant decision w h e th er to use o r abuse alcohol a n d o th e r substances w it h o u t g o o d in fo rm a tio n a nd skills. We saw th at they often choose alcohol a nd d ru g s because th a t's the decision th eir friends and family m em bers h a v e m ade."

In a d d itio n , the C o n fe d e ra te d S a lis h -K o o te n a i Tribal C ouncil d e te rm in e d th a t the tribal alcohol program , as it was o p e ra tin g in the e a rly 19S0's. w a s n o t w o r k in g T h e p r o g r a m , w h i c h h a d focused o n detoxification w as— the council felt— n o : p r o v id in g the n e c e s s a ry ra n g e o f s e r v ic e s . Prever.aon and aftercare were n o t being a d eq u a te ly addressed.

"Tne c etox services h a d become a revolving d o o r." says a Biue Bay staff m em ber. "5pm d r . T hree

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then d e v elo p ed to m eet those n e ed s a n d e n h a n c e th e client's re co v e ry e ffo rt

T h e project o p e ra te s a 24-hour-a-day c o n ta ct s y s tem to m o n ito r a n y crisis th at its d ie n ts m ig h t h a v e o u ts id e o f n o r m a l b u s in e s s h o u rs , as w e ll a s to re sp o n d to a n y referrals received d u rin g th a t tim e.

E ach p a r tic ip a tin g c h u rc h has a p p o in te d a t le a s t tw o liaisons w h o a re train ed to se rv e a s the E rs t p o in t of c o n ta ct w ith in th e ir respective c h u rc h e s. T he telep h o n e n u m b e rs o f these people a r e p o ste d in their respective churches, and a re placed o n file w ith th e project direc to r a n d staff. A ny in co m in g calls a fter w o rk in g hours a re screened a n d a sse ssed b y die liaisons, t h e n passed o r to the full-tim e staff, if necessary

I n t a k e a n d A d m i s s i o n P r o c e d u r e s

A n y a p p lic a n t re q u estin g adm ission w ho m an ifests a c h em ica l d e p e n d e n c y p ro b le m a n d w h o , a f te r b e in g a s s e s s e d b y a p r o f e s s io n a l t h e r a p i s t , is d e em ed su itab le fo r treatm ent is a d m itte d in to th e p r o g r a m . T h is a s s e s s m e n t is m a d e d u r i n g a c o m p re h e n s iv e c lin ica l in ta k e c o m p le te d b y th e th erap ist w ith in tw o visits.

B efore o r u p o n a d m is s io n in to th e p r o g r a m , a v ariety of client in fo rm a tio n is collected, including:

• Data on b a c k g ro u n d a n d h istory i n d u d m g m iorm aaon o n family, education, occupation, and legal a n d c o u n -re late d considerations.

• T h e n a m e o f t h e r e f e r r i n g a g e n c y , if a p p ro p n a te . I n f o r m a t i o n o n t h e c l i e n t 's p r e s e n t su b sta n c e a b u se problem , and o n h i s / h e r h i s t o r y o f s u b s ta n c e a b u s e , i n c l u d i n g in fo rm a tio n a b o u t p re sc rib e d d ru g s a n d a lc o h o l , s u b s t a n c e s u s e d m th e p a s t , i n c lu d in g p r e s c r ib e d d r u g ; s u b s ta n c e s u sed recently, especially those w ithin the U s: 4 : h o u rs , su b stan cets) of p re fe re n ce , fre q u e n c y w ith w h ic h each s u b s ta n c e is u se d , p r e v io u s o c c u rre n c e s of o v e rd o se , w ith d r a w a l, c r a d v e rs e d r u g o r a lc o h o l re a c tio n , h i s t o r y of p re v io u s s u b s ta n c e abuse tre a tm e n t received, and v ra r ot firs: use o : each s u b s a n c e

• In fo rm atio n on o th e r counseling services re c e iv e d , in c lu d in g th e a g e n c y , ty p e o f service, a n d d a te service w as received.

D u rin g th e intake process, every effort is m a d e t o e n s u re th a t each client a n d h i s / h e r fam ily m e m b e rs h a v e a clear u n d e rsta n d in g o f th e t r e a tm e n t p ro g ra m . P rogram goals, rules, a n d re g u la tio n s , th e h o u r s d u r in g w h ic h se rv ic e s a re a v a i l a b l e , tre a tm e n t co sts a n d p a y m e n t a rra n g e m e n ts, d i s ch arg e p ro ced u res, and a n y family pa rticip a tio n i n th e e e a tm e n t process a re explained.

M o n i t o r i n g o f T r e a t m e n t P rocess

Initial tre a tm e n t services a re based on the a s s e s s m e n t info rm atio n g athered a : th e tim e o f in ta k e , i n accordance w ith the initial treatm ent p lan o u t lin e d in the p ro g re s s notes co m p leted a t intake. W h ile th e client m ay b e involved in a variety o f tr e a tm e n t s e r v ic e s d u r i n g th e f ir s t 30 d a y s , th e p r i m a r y e m p h a sis is on com pleting the psychosocial a s s e s s m ent.

A w ritte n treatm ent record is m aintained fo r e a c h client in treatm ent. This record:

* P ro v id e s accurate d o c u m e n ta tio n of each client's sta tu s a t the tim e o f a d m iss io n

* S erves a s a basis for tre a tm e n t p lan n in g , coordination, and im p ie m e n atio n :

* P r o v i d e s a m e a n s o f c o m m u n i c a ti o n a m o n g s t a f f i n v o l v e d in th e c l i e n t 's trea tm e n t.

* r a d i i a t e s continuity o f treacner.r and the d e te rm in a tio n , at a n y fu tu re dare, of th e c li e n t's c o n d itio n a n d tr e a tm e n t a t a n v specified Qme;

* D o c u m e n ts o b s e rv a tio n s of th e c lie n t's b e h a v io r, o rd e re d a n d s u p e rv is e d tr e a t m ent. a n d response to treatm ent.

P rovides d a ta for use in tra in m s. e v a lu a tion. a n d quality assurance m easures.

* D ocum ents protecnor. of the rights of the c lie n t, p a re n ts , sib lin g s, o r o th e r fam ily m e m b e r s in t n e c l i e n t ' s t r e a t m e n t program .

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- s u b s t a n c e a b u s e m i n i s t r i e s i n a c t i o n : i n t e r v e n t i o n / t r e a t m e n t m o d e l s -

W ith th e ir o w n p e o p le a n d traditions, th e Salish- K ootenai re aliz e d th a t they could accom plish the th ir d h e a l in g p r i n c i p l e . W here p o s s ib le , th e y w o u ld re su rre c t th e o ld tribal learning processes. W here n o t possible, they would create n e w ones.

The v e ry act o f w o rk in g together, in the tribal tra dition. w o u ld b e th e resource that w o u ld a ssu re the fo u rth p rin c ip le , th e hand-in-hand h e a lin g o f the individual a n d th e community.

The trib e s' re so u rce s a re inte rd ep e n d e n t The peo ple. th e v a lu e s, t h e traditions, th e n e tw o rk in g all flow one in to th e o ther. Recognition o f this provid e d th e c o re o f w h a t w a s needed to fig h t alcohol, abuse o n the reservation.

W h a t W e C r e a t e d : O u r A c t io n P l a n

W ith a r e c o g n i ti o n o f th eir v a lu e s a n d th e ir re so u rc e s , t h e t r i b e s p re p a re d a n a c tio n p la n fo r fighting alcohol a n d d ru g abuse.

T hree g o als w ere established:

1. T o f o s t e r p e r s o n a l re c o v e ry fro m a lc o ho lism fo r h ig h -risk individuals;

Z To d e v e l o p a s y s te m fo r h e lp in g trib a l y o u n g s t e r s c o n sc io u sly c h o o se M O T to ab u se a lc o h o l a n d other substances; a n d

3 To in te r v e n e in th e g e n era tio n a l/c u ltu ral cycle o f su b s ta n c e abuse.

Tne co n ce p t o f a healing center, to act as a focus for fire trib e s e ffo rts , w as explored. S uch a healing center w o u ld p ro v id e a core, a visible place o u t of w hich to o p e ra te .

Tne id ea o f th e healing center w as fo u n d to have m erit. It w o u l d be com m unity-based. It w ould accom m odate individuals, families, a n d com m unity g ro u p s I t c o u l d be d esig n ed to o p e r a te using trad itio n a l Salish-K ootenai system s. It c o u lc p u t th e S a l i s h - K o o t e n a i h e a lin g p r i n c i p l e s i n to operation. It w o u ld be a visible expression of tribal unity a n d p rid e

Ir. 19S7. a f t e r t h e p lan n in g y e a rs, th e Biue Bay Healing C e n te r becam e a reality. Ten acres o f land cn th e n o r t h s h o r e o f F lathead L ake w ere e a r m ark e d f o r u s e in heaim g trib a l m e m b e rs w ho were stru g g lin g w ith alcohol a n d substance abuse. Tne la n d in c l u d e d a nu m b er of o ld lo d g e s and cer-.p.s t h a t h a d c r e io u s ly b e e n p a r t o f a

com m ercial re so rt a n d econom ic enterprise.

U sing fu n d s from a v a r ie ty of sources, in c lu d in g lim ited fu n d s from th e In d ia n H ealth S ervice a n d funds from th e F ederal Office for S ubstance A b u se Prevention. Blue Bay p ro v id e s a n e w co m p o n e n t in the c o n tin u u m o f s e rv ic e s offered by th e S a lish - Kootenai to fight alcohol a n d substance a b u se .

T he Blue Bay c o m p o n e n t m erges p re v e n tio n a n d aftercare in a m a n n e r t h a t is based o n c o m m u n ity a n d family p a rticipation. I t is intended to su p p le m en t th e trib es' t re a a n e n t program s. It is b a se d o n a c o n ce p t th a t p re v e n tio n and aftercare flo w o n e into die o th e r in a c irc u la r continuum w h ic h h a s n o beginning o r end.

H o w W e O p e r a t e : O u r S t r a t e g y

Blue Bay op e rates o n th e fo u r Salish-Kootenai heal ing principles:

1. It is co m m u n ity designed.

Z It is a p a r t o f th e Salish-K ootenai c u ltu re a n d tra d itio n , e v o lv in g to m ee t t o d a y 's needs.

3. I t o ffe rs a l e a r n i n g p ro c e s s to e d u c a t e Salish-Kootenai fam ilies in the v a lu e s a n d practices o f th e ir tradition.

4. Ir focuses o n th e in d iv id u a l as a p a rt o f foe tribal co m m u n ity a n d the tribe as a p a r t o f the ihdividuzL '

T w elve w o rk e rs s ta ff B lu e Bay. T h e s e w o r k e r s a r e — s o to s p e a k —o n . d u t y 24 h o u r s a d a y . 'W o rk in g a : Blue B a y ," o n e staff m e m b e r jo k es, 're a lly w recks th e ba sk e tb a ll season for m e. I fin d I a m o n call e v e n d u r in g interm ission. W h e n y o u w ork a t Blue Bay. y o u a r e always id en tifie d w ith the program a n d its p u rp o se . You h a v e [to] m o d el g ood behavior. You h a v e to be willing to e x am in e v our o w n life a n d face y o u r own issues. A n d y o u have to be available to ta lk and listen. Y o u 'v e g o t to show that recovery is possible, that y o u feel it is of p ru n e .-' im p o rta n ce , a n d that you a r e th e re to h e lp .'

Blue Bay H ealing C e n te r is unusual in its a p p ro ac h . T n e S a lis h - K o o te n a i v a l u e fa m ily . W h e n a n in d iv id u a l r e tu r n s to th e reserv atio n fro m s u b stance a b u se tr e a tm e n t, h e /s h e w a n ts t o b e w ith fam ily m em b e rs. B ut th e individual n e e d s so m e tra n s itio n a r.d a d j u s t m e n t time. If t h a t is n o t

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)

p r o v i d e d , t h e s u b s t a n c e a b u s e r r e t u r n s to h i s / h e r o ld e n v ir o n m e n t a n d ab u siv e p a tte rn s resum e.

W hy n o t utilize th e fam ily a s a resource? W hy n o t b ring the fam ily in to the transition a n d adjustm ent process? W hy n o t in c lu d e th e m in the recovery learning process? Focus on th e individual as p a rt of the family. A t Blue Bay. the Salish/K ootenai d o just t h a t

W h e n a n i n d i v i d u a l r e t u r n s fro m r e s id e n ti a l treaan en t. h e o r s h e is joined b y fam ily members a t the Blue Bay H e a lin g Center. T ogether the fam ily heals. They s p e n d a p e rio d o f tim e in an environ m e n t s u p p o r t e d b y c e n te r s t a f f a n d re co v e rin g tribal m em bers. T o g e th e r th e y lea rn about a lc o h o lis m : th a t tt is a disease, h o w it a ffe c ts th e a lc o h o lic h o w it a ffects o th e r fam ily members, the role a n d games e a c h p e rso n plays.

A : Blue Bay. fa m ilie s a ls o le a rn h o w to have fu n together. They liv e in a n e n v iro n m e n t that proudly practices Indian trad itio n . Role m odels are provid e d . P a re n tin g a n d in tr a - f a m ily c o m m u n ic a tio n techniques are e x p lo re d . R esources are identified a n c each family m e m b e r is sh o w n w here to g o for help w hen it is n e e d e d .

Space, meals, a n d a pre d ic ta b le ro u tin e are p rovid e d . Y oungsters a r e g iv e n re sp o n sib ilitie s. Each family m em ber p itc h e s in to h e lp . Trained stair are available for c o u n se lin g a n d teaching.

Biue Bay Healing C e n te r also functions as a team ing cen ter for specific g ro u p s w ith in th e com m unity. Special sho rt-term live-in p ro g ra m s are pro v id ed for young ch ild ren w hose [m o th e r a n d /o r father], for example, a b u se alcohoL

These youngsters a r e b ro u g h t to g e th e r in various age groups as in d iv id u a ls w h o s h a re the b o n d s of th e Salish-Kootenai heritage. T ogether, they learn from tribal m e m b e rs w ho u n d e r s ta n d the y o u n g ste rs' environm ents. T he c h ild ren a re taught ab o u t alcoholism. T hey le a m w h a t it is a n d w hat it does T h e y learr. t h a t t h e y are n o t re s p o n s ib le f o r a p a re n t s drinJting p ro b lem . T h e y learr. that they h a v e a choice a b o u t w h e t h e r t h e y th e m s e lv e s drm x. They learr. how- to recognize th e posioves ir. their families. A n d th e y le a m w h e re they can get help They learr. th e y are n o t a lo n e . Tnev lea m they are a part o f a cu ltu re a n d heritage of w hich they can be p ro u d .

o .-e Bay is a place o f su p p o rt. It hosts a num ber of su p p o rt groups w h e re tribal m e m b e rs can ge: ir

to u c h a n d e x p r e s s t h e i r f e e lin g s . A lcoholics A n o n y m o u s a n d C h i l d r e n o f Alcoholics meetings a n d w -orfcshops t o d i s c u s s g r ie f a n d suicide are held a t th e c e n te r.

B lu e B ay H e a l i n g C e n t e r is a c e le b ra tio n . Its a tm o s p h e re is p o s it iv e . I t cham pions activities— d a n ce s, h ik in g , s w im m i n g , c a m p in g and rafting. O ne m o n th ly c o m m u n ity - w id e sober recreational e v en t is h e ld a t B lu e B ay. A ll com m unity members a re e n c o u ra g e d to u s e th e facilities. It is an upiifang a n d e x d ti n g p la c e t o b e . B iue Bay demonstrates that p e o p le w h o a r e n o t d r in k in g can be m ore than just sober. T h e y c a n b e h a p p y a n d have fun.

Blue Bay [is] a n I n d i a n p r o g r a m [that] unites the p a s t, th e p r e s e n t , a n d t h e f u tu r e . The resident m an a g er a n d c a r e ta k e r a t B lue Bay is a man o f dig nity w ith I n d i a n b r a i d s a n d sto ries of tim es p a st H e is q u ie t, s t e a d y , a n d k in d . C hildren love him. H e sp e a k s o f t r a d itio n .

The c o u n s e lin g a n d c u lt u r a l sta ff are younger. All In d ian , th e y h a v e d i f f e r e n t d e g re e s of association w ith tra d itio n . M o s t a r e c o lle g e educated. Most have lived a w a y c o m th e reservation for long periods o f tim e. A f e w h a v e b e e n o n vision quests. Some p articipate i n s w e a ts .

But th e p o i n t is . a s d i f f e r e n t a s each is from the o t h e r , a ll B lu e B a y s t a f f a r e a p a r t o f a vital, ev o lv in g trib a l e x p e rie n c e .

As the v isito r e n te r s B iu e B ay. h e [or she] enters the Salish-K ootenai trib a l c o m m u n i tv.

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100

• S U B S T A N C E A B U S E M I N I S T R I E S I N A C T I O N : I N T E R VE N T I O N / T R E A T M E N T M O £> E I S -

T h e S i x - S t e p P r o c ess ! We looked face-on a t the p roblem of alco

hol a n d substance a b u se in o u r com m uni ties. asking w h o is betr.g h u r t by w h a t a n d how.

1 We assessed o u r e ib a ! values, askm g w hat is im p o rta n t to u s a n d h o w is th at being d a m a g e d by a lc o h o l/s u b sta n c e abuse

3 We a d o p te d fo u r healing principles w hich h o n o r o u r values a n d h e ip u s attack alco hol ''substance abuse.

i W'e looked a t o u r resources, a sk in g w h a t d o w e h a'.e w id e r, o u r tribes a n d c om m u n itie s th at w ill h e lp u s g a m c o n tro l o v e r alcohol and substances

f We outlined o u r acnor. plan.

: As w e im plem ent o u r sc a te g ie s. w e e v alu a te a n d a d ju s t, s t a r ti n g th e cycie a g a in w ith step i

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APPENDIX C

COMMUNITY SUPPORT GROUP OF THE ATLANTA MASJID

101

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- S U * S T A N C E A l U S E M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E A T M E N T M O D E L S

C O M M U N ITY SU PPO RT CROUP OF T H E ATLANTA MASJID

O v e r v i e w : A p p r o a c h o f t h e N a t i o n o f I s l a m t o

A d d i c t i o n T r e a t m e n t A p p a re n tly one o f th e m o s t successful g ro u p s in d e a lin g w i t h th e t r e a tm e n t of a d d ic tio n s ts th e N ation o f Islam. T h is h a s been tru e for a n u m b e r o f years, a n d c o n tinues to b e so.

Tne N a tio n o f Islam 's a p p ro ac h to treatm ent d o e s n o : c o n s id e r a tr e a tm e n t m e th o d to be s e p a ra te f r o m lif e a s a w h o l e . I n s t e a d , th e N a t i o n 's a p p r o a c h is to i n c o r p o r a te th e p e rs o n in to t h e (drug-free) w a y o f life.

Initially. sh o u ld th e p e rso n e n te rin g recovery n e e d to "get o v e r the h u m p " o f w ith d ra w a l that p e rs o n m ig h t b e p u t in to s e c lu s io n w ith o n e o r s e v e ra l brothers in atte n d an c e. T his seclusion m iehr las: a s long as th re e days, o r u n til d ie person has " sw e ated it c u t " A t th is p o i n t the "n e w p erso n " would ta k e h is o r h e r p la c e in th e g r o u p , k n o w in g t h a t to rem ove o n e ’s self fro m the g ro u p w ould be risk in g failure in o n e ’s recovery.

Trus idea o f resoctalira n o n m eans th at the recover ing addict is p ut in to a family. Tne family a n d i s w ay of life becom e th e o n g oing m aintenance g ro u p

Focus: T h e A t l a n t a M a s j i d C o m m u n i t y

S u p p o r t C r o u p It. a a nte c f stress, trau m a, disease, and econom ic chaos, the c o m m u n ity n eeds a spiritually focused g ro u p c : c o n c e r n e d c itiz e n s T h e C o m m u n ity ou oport C ro u p of th e A tlanta Slasiic serves as th e agency tc e ducate, as well as establish em o tio n al ar.d professional s u p p o r t to. individuals c r tam.iiies or the Masj'.c and local comm unity

irt su p p o rtin g the n e e d for recovery. the S u p p o rt C ro u p of professionals acknow ledges that m divtd- u z j can change for the b e tte r w ith proper u n d e r s ta n d in g V.e s u p p o r t th e 1 2 -ste p A lc o h o itc s A nonym ous pro g ram a n d nave prov ided our o w n e :g r:-s te p pro g ram . O u r program , s focus is c r stressing tc i r.c r.ic u a is that the;, ca" re c r-e - a n d

w ill n o t be addicts, alcoholics, o r d ise ased p eople fo r th e rest of th eir lives.

[In o u r program ], the subcommittees o f the Support G r o u p re p re se n t ar. identified n eed a n d are s u p p o r t e d by an ele m en t leader a n d associate. T n e a r e a s c o lle ctiv e ly a d d re sse d in clu d e fam ilv life, p a r e n t education, m arital and couples counseling, consultation a n d education, codependency recovery. a d u l t c h ild r e n o f d y sfu n c tio n a l fa m ilie s , c ris is in tervention, divorce m ediation, adolescent su p p o rt g r o u p , a n d c h e m ic a l d e p e n d e n c y re c o v e ry , to n a m e a few.

H ist o r y T h e M u slim c o m m u n ity in A tlan ta . G eorgia, h a s b e e n a d d r e s s i n g th e ills o f s u b s ta n c e a b u s e , a lc o h o lis m , im m orality, and other d iseases of the h e a rt a n d m in d for m ore than 20 years. M any of th e c o n v e rts to A l-lslam have u se d the recoverv p r o g r a m to c le an them selves of th e a d d ic tio n to a lc o h o l a nd substance abuse a nd have been able to re m a in " d e a n " for years.

T h e E ig h t ^ P o i n t R e c o v e r y P r o c r a m

STEP 1. Recognition and Repenran

STEP 2. Attachment

STEP 3. Therapy and Support

STEP 4 D eprogram m ing

ST E PS. Fundam entals

STEP 6. Repair

STEP 7. Re-Entry

S T E P S . Building and Fropagar.cn

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APPENDIX D

FREEDOM NOW! THE SUBSTANCE ABUSE MINISTRY OF BETHEL A.M.E. CHURCH

103

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- S U B S T A N C E A B U S E M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E A T M E N T M O D E L S

FREEDOM NOW!: THE SUBSTANCE ABUSE MINISTRY OF

BETHEL A.M.E. CHURCH

T he F re e d o m N o w M in is try is a s p ir itu a l d r u g r e h a b i li ta t io n p r o g r a m t h a t re a lly w o rk s . T h e secret or F reedom N o w is th a t it a d d resses all three p a r ts o f t h e d r u g - a h n s e r— th e s p i r it, s o u l, a n d body:—w isic h x e c u iie h e a lin g The m in istry serves those w h o a re su ffe rin g legal o r illegal addictions.

F reedom N o w m atc h es each p articipant w ith a lay co u n selo r, u su a lly so m e o n e w ho h a s been healed fro m a n a d d i c t i o n a n d u n d e r s t a n d s w h a t t h e p a r d d p a n t is g o in g th ro u g h . T hese leaders h a v e m a in ta in e d a d ru g - f r e e sta tu s for o n e year, h a v e been sa v e d , a n d a r e in v o lv e d in a p o w e r cell su c h as s tu d y in g the W o rd o f G o d T hey are p ro v id e d w ith ir.-service tr a in in g a n d d e v elo p m en t o p p o r tu n ities o n h o w to facilitate sp iritu a l g ro u p s a n d sp iritu al c o u n se lin g

T nere a re g ro u p m e e tin g s once a w eek as well as one-o n -o r.e c o u n s e lin g sessions. A lth o u g h so m e m ay re ce iv e d e liv e ra n c e a n d he alin g rig h t a w ay , they a re still p u t o n the five-step spiritu a l n u tritio n plan to b u ild th e ir b o d ies back up.

Freedom N ow re ce n tly sta rte d a n AIDS p ro g ram , w h ic h is a im e d a t e d u c a t i n g a d d ic t s a n d th e c o m m u n i t y in h e l p i n g p r e v e n t A ID S f r o m s p re a d in g In M a rch 19SS. Freedom Now- held its first conference o n AIDS a n d c m g s It received a m ayoral citation a s th e firs: biark c hurch to have such a conference

N u t r i t i o n a l P l a n The F reedom N o w M m is s y o re ra tes by a five-steo soinruu. n u trra o n a l plan:

To be c o n v erted a n d see me need to be free from su b sta n c e abuse

I To p u rg e the b o d y periodical:;, w-.m. juices a n c distilled w a ter.

a To e at a n u tritio u s d i e t

4 Tc use me C o rre ctio n C c m e c r.b r Flan c : v :ta rn .- su p p le m e n ts

: Tc snub. Cc-c s W ord t r mob r. b e - e . i c : a r c c-c.-. s o :n n a il;.

T h ese five steps m inister to spirit, body, and so u l. In ste p I. participants are enjoined to accept Je su s C h rist as their sa v io r a n d to give u p th eir healing to Hirm w ith this action, they a re a ssu re d that m o st o f th e ir troubles a re over.

Steps 2 .3 . and 4 m ay b e die m ost un u su a l c om po n e n t o f the program . Freedom N ow recognizes d ie physical dam age long-term addiction can d o to th e b o d y , a n d o f f e r s a p r o g r a m o f c le a n s in g a n d re p la c e m e n t o f lo s t n u tr ie n ts : th is c a n h a v e a rem ark ab le effect. This detoxification p ro g ra m is s u p p l e m e n t e d b y D ic k G r e g o r y 's C o r r e c t i o n C o n n e c tio n , a n u tritio n a l s u p p le m e n t th a t p u t s back the vitam ins a n d m inerals th at h ave been lo st o r replaced because of abuse.

" S t e p 5 d e a ls w ith a b u s e rs ' a d ju s tm e n t to a n e w d r u g - f r e e l i f e s t y l e . S e v e r a l F r e e d o m N o w p r o g r a m s s u p p o r t th is a d ju s tm e n t, n o ta b lv t h e H o u s in g P ro g ra m , w h ic h p ro v id e s h o u sin g f o r su b stan ce abusers a n d is p a n of a su p p o rt svstem in w h ic h die W ord will be all-pervasive. Tne g o a l of th e Housing P rogram is to teach, love, and g u id e th o se w h o are a d d ic te d b u t believe th at Jesus c a n h e a l. A n o th e r s u p p o r t e le m e n t is a c o m p le te e d u c a tio n a l p ro g ra m , w h ic h in c lu d e s a lite ra c y tuto ria l program , a GED program , a n d a n associate d e g r e e p ro g ra m , a ll o ffe re d in sid e th e c h u rc h . Plans are also u n d e r w»y to have a program w ith in the house at which people can leam how to w o rk w ith computers.

G r o u p S e ssio n s In a d d ib o n to the spiritual nutritional p la r. e th e r se rv ice s offered a re four g roup sessions held o n T h u rsd a y evenings Each evening begins w t ~ a o n e -h o u r prayer session after w hich the p a rtir:- par.ts break out into four groups, described below

O R IE N T A T IO N A N D ED U CA TIO N (RELAPSE C R O U P ). In this group, first-cine p a n a p a r r s a re e d u c a te d over th e c o u rse o f fo u r w e e k ; a b o u t relapse Tne teachmg comes from a social lea m in e m ode! developed by John Johnson, a professor a”: the ’••.'ashm.gtor Area Cc-inci! o r A iro h : .: a r.d

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105

D r a g Abuse A dm inistration. T he p u r p o s e o f the g r o u p is to e d u c a t e s u b s ta n c e a b u s e r s a b o u t re la p se sy m p to m s, to teach them a b o u t d iffe re n t i n t e r n a l a n d e x te r n a l th in g s t h a t c a n t r i g g e r relapse, and to help them cope w ith th e n i g g ers in th e ir environm ent. T he teaching also re m o v e s any m is c o n c e p tio n s a b o u t re la p se th a t a b u s e r s m a y h a v e heard o n th e stre e t. G ro u p m e m b e r s also s tu d y the U -s te p deliverance p lan (see b e lo w ).

• S P IR IT U A L STEP C R O U P ( S U P P O R T CR O U P FO R RECOVERINC A D D IC T S ). A t this g ro u p session, in d iv id u a ls s u p p o r t one another in recovery T hey b e g in e ac h session w ith a sharing nine, d u r in g w h ic h they discuss th eir problem s a n d e x p erien c e c a th a r s is ( a n " e m p ty in g o u t* o f t h e m selves). T h ey becom e a family, s u p p o r tin g o n e another. T hey share p h o n e n u m b e r s to serve a s p ra y e r partners to o n e a n o th e r. R e co v e rin g a d d ic ts be co m e s p o n s o r s to these group m em bers.

Next, they join th e Relapse G ro u p fo r a 15- m inute teaching o n the 12-step d e liv e ra n c e plan. The 12 Steps to Freedom a r e sim ila r to those u s e d by Alcoholics A n o n y m o u s , b u t the difference is that the F reedom N o w ste p s recognize G o d as the h ig h e r p o w e r b e y o n d t h e i n d i v i d u a l w i t h o u t w h o s e help no m eaningful change can cake p la c e T his teaching is sp iritu al th erap y : p a r tic i pants do n o t receive m uch m o re c h u rc h o r Bible s tu d y th a n this, since m a n y o f th e p a rtiz p a n ts are n o t ready for c h u rch , a r.c w ould re tu rn to th e streets if they w e re tc recer- e toe m u ch 5ibie teachm g In ste ad , th e group becom es their church u n til the-, a re ready. T he recovering a d d ic t le a d e rs n u r tu r e a n d s u p p o r t th ese p e o p le u n t il th e y b e co m e s p ir itu a l e n o u g h tc b e or. th eir own.

A t tre end o f the teaching, there is a n in v i tation tc C h n s c a n d isz p le sh ip S u b sta n c e abusers a re invited to accept Jesus as th e ir savior. W hen they accept Jesus, th e y m o v e to the f.rst s p m r u a l step of th e F re e d o m N ow plan. A fter they internalize thus, they m ove tc th e second step

• FAMILY S U P P O R T C R O U P. H ere, the family is e d u c a te d abcut substance a b u se - r e la ie c p r o b l e m s . T h e fa m ily a l s o is ta u z r : row to m inister :c m e a d d ic t m the h e m e The g r o u p ertiea-. ors : r s u p o o r t

fa m ily m e m b e rs w i t h i n te n s i v e p r a y e r , " e m p ty in g o u t" sessions, a n d b y actin g as a n e x te n d e d fa m ily w h e n n e e d e d . T he g ro u p is in te n d e d f o r p e o p le w-ho a r e in r e la tio n s h ip s w ith o n e o r m o r e p e rs o n s w ho a re substance a b u s e rs o r h a v e addicted p e rs o n a litie s . Tne g r o u p s h a r e s e x p e ri ences. gives praise r e p o rts , a n d continues to seek G o d 's g u id an ce fo r th e ir o w n lives a n d the lives o f those th e y c a re for.

M ost F a m ily S u p p o rt G r o u p p a rtic ip a n ts d i s c o v e r t h a t th e y h a v e v e r y lo w se lf- e steem . M any have e x p e rie n c e d h u rts in th eir y o u th in d y sfu n c n o n a ! fam ily situ a tions. T hey try to c o v e r a n d conceal their h u r ts in c o n ju n c tio n w i t h t h e w a y th e y deal w ith th eir a d d ic te d lo v e d ones. Tne g r o u p u s e s a w o rk b o o k t h a t d e a ls w ith o n e -w ay relationships. T h e in fo rm a tio n in t h is w o r k b o o k h e l p s t h e f a m i l y to b e h ealed o f the c o d ep e n d en c y p ro b le m s that relate to substance a b u se . T h e y lea m that c o d e p e n d e n c y is t h e p r o b l e m in a ll o f them th a t m akes th e m lo v e. c are , o r give for th e w ro n g reasons. F a m ily m em b e rs becom e e n a b l e s to th e ir lo v e d ones. The F a m ily S u p p o r t G r o u p p a r ti c ip a n ts u se the re la tio n sh ip a sse ss m e n t m o d e l to d is c o v e r t h e i r o w n r e la ti o n s h ip d y n a m ic s. T h ey l e a r r h ow n o t to b e e n a b le r s . a n d le a m to recogroze th e c e s tr u c a v e n e s s of cod ep e n d en c y

• B O R N T O BE FREE. T h is n e w e s t session is a c h ild re n 's group, m w h ic h ch ild ren are n u rtu re d in a sp m ru a l d irec tio n . M ost of the p a rticip a n ts are c h ild re n b o m affected b y d r u g s o r b o rn i n t o a d r u g - r e l a t e d e n v iro n m en t. Tne c h ild re n a r e m inistered to w h e n e v e r n e ce ssa ry . T h e p u rp o s e of the g ro u p is to n u r tu r e th e c h ild re n in a s p i r i t u a l l y new d i r e c t i o n t h r o u g h the teaching o f prayer. Bible s tu d y , self-esteem buiidm g, d ru g p re -.e n z o r. a.-.z the love of God

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• S U B S T A N C E A B U S E M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E A T M E N T m o d e l s

S u m m a r y F r e e d o m N’o w is a d is c ip l e - m a k in g m i n i s t r y . M inisters talk w ith individuals daily, calling th em a n d teaching them the W o rd so th at th e y w ill in tu rn be a ble to disciple others. To d a te . F re e d o m N o w has m inistered to o v e r 1.000 persons. M a n y have b een set free from a d d ic a o n a nd a re w o rk in g tow ard spiritual growth.

W ord o f th e w o rk o f Freedom N o w h a s re a c h e d th e com m unity. Several p e ople have been re fe rre d from the courts w ho h a v e long h isto rie s o f d r u g a b u se a n d involvem ent w ith o th er p ro g ra m s th a t h a d n o t w o rk e d for them ; these p e o p le a re n o w g row ing spiritually in Freedom N ow .

Freedom N o w has become a m o d e l O ther c hurches have called on Freedom N o w to help th em s t a r t a d ru g or AIDS program in their parishes. A t lea st s ix d r u g p r o g r a m s h a v e b e e n f o u n d e d in Baltim ore, and one in Pennsylvania, b ased o n the Freedom N o w program . T he m in istry is k n o w n i n t e r n a t i o n a l l y , a n d w a s i e a t u r e d o n t h e M a c N e i i /L e h r e r N e w s H o u r . T h e m in is try - w o rk e d c lo s e ly w ith th e C o n g re ss o f N a t i o n a l Black C hurches in a recent conference d e s ig n e d to h e lp consolidate church efforts a g ainst T h e N e w Slaverv"— com m um tv croolem s such a s d r u s s a n d A ID S '

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APPENDIX E

MULTI-LAYERED PROGRAM: ST. SABINA ROMAN CATHOLIC CHURCH

107

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• S U B S T A N C E A B U S E M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E A T M E N T M O D E L S

MULTILAYERED PROGRAM: ST. SABINA

R O M A N CATHOLIC CHURCH

K ey M o t iv a t i n g I n s i g h t W h a t m o v e d th e p a s to r a n d p a r is h io n e r s o r S t. S a b in a 's R o m a n C a th o lic C h u r c h [in S o u th s id e C hicago 1 to b e g in their m ultifaceted p ro g ra m w a s the re alisatio n th a t d ra g s w e re to u c h in g the lives of all th e p a r is h io n e r s in w a y s b o th a c tiv e a n d i p a ssiv e . T h e re w a s a n a g g re s s iv e n e s s fro m th e I street. Y oung p e o p le w-ere v isu a lly a s s a u lte d b y ! th e p re s e n c e o f d ru g traffick in g o n th e ir stre ets. O ld e r p e o p le w e r e fe a rfu l o f th e v io le n c e t h a t a c c o m p a n ie s s u c h tra ffic a n d h o w t h a t w-ould affect b o th th e m a n d their families.

K e y S p ir it u a l I n s i g h t ii D ru g s c o m e fro m s p iritu a l b a n k r u p tc y . If o n e know s h i s / h e r d iv in e c e s z n y a n d p u rp o s e in G o d . j one then realizes th at h e /s h e has th e stre n g th a n d d i v i n e p u r p o s e to t u r n h i s / h e r l i f e a r o u n d ; In s ig h t - > s tr e n g t h - * p u r p o s i v e liv in g - * p e r s o n a l I a n d c o m m u n ity fu lfillm e n t. S in c e d r u g u se is p n m arily a sp iritu a l problem w ith d e a r psy ch o lo g ical a n d p sy ch o p h y sio io g ic a l ram ifica tio n s, th e re ! m u st first a n d forem ost be a sp iritu a l u n d e rp in n in g ■ to th e w a v s w ith w hich these p ro b lem s a re dealt. j

St. S abina ' 5 d o e s n o : offer residential treatm ent. 1: does, how ever, w ork cioseiy w ith a gencies th a t c an • p r o v id e r e s i d e n t i a l s e r v ic e s w h e n a b s o l u t e l y necessary. T here is an u n d e rstan d in g b etw een th e j parish a n d these a g e n c e s th at coo p era tio n betw een 1 them re q u ire s th a t there be a quick re sp o n se to a • request for h elp J

The c o m m u n ity or 5: Sar-uta has co m m itted is e if to a g g ressiv ely a tta c k :-.; tne p la g u e of d ru g s bv me followmg-

1 T re re is a com.pter.ensive d ru g e d u c a c o r. i p ro g ra m in Sc S a c ira school tor g ra d e s K j th ro u g h S T h is p ro g ra m w o u ld ir .d u d e rvamun.g a n d re c o g rc z n g d ru g s C h ild re n re ce iv e a b u n d a n t bad in fo rm a tio n from the stre e t This is a -.<■ av of giving specific a n : u s e fu l in fo — .an.cn a n d a t th e sam e

time recognizing that these y o u n g people are raised aro u n d d ru g s a n d d ru g dealers i-e..—users.

Z There a re Narcotics A nonym ous (XrA) and Alcoholics A nonym ous (AA) m eetings and classes o n T u esd ay . W ed n e sd a y . Friday, and Saturday. There a re Big Brother and Big Sister su p p o rt program s. M aintaining t h e i r a n o n y m i t y , s o m e N A a n d AA m em b e rs ta lk to th e e le m e n ta ry sc h o o l c h ild re n a : in te rv a ls d u r i n g th e sc h o o l year.

3. There a re tw o y o u th facilities Tne M artin L u th e r K in g C e n t e r is c o m m i t t e d to d isc u ssio n , tu to rin g , c o m p u te r le a rn in g , and d rop-in services. T ne ARK offers both e d u c a t i o n a l p r o g r a m s s u c h a s C E D preparation, physical a n d spiritual fitness p ro g ra m s , se lf-d e fe n se , a n d b a sk e tb a ll. Both o f th e s e p r o g r a m s o ffe r p o s it iv e a l t e r n a t iv e s t h r o u g h o u t th e w e e k for youth involvem ent.

4 There are both counseling and referrals far treatm en t f a r u se rs th ro u g h 'R e a c h O ut a n d T o u c h ." a c o m m u n i ty t r e a t m e n t refe rra l o rg a n iz a tio n th a t began o u t of the c hurch in re sp o n se ta the ract th a t if a w o u l d - b e c li e n t h a s n o m o n e y o r insurance, there is no place for h i m / h e r to gc

5 GED classes a n d job referrals are o tte re d ta re co v e rin g a d d ic ts tc er.abie th e m to re-enter society

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APPENDIX F

ONE CHURCH— ONE ADDICT

1 0 9

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110

• t U I I T A N C E A B U S E M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E A T M E N T M O P E L S -

ONE CHURCH—ONE ADDICT

C h u r c h e s a n d t h e P r o b l e m o f D r u c

A d d i c t i o n The N a tio n ’s d ru g p ro b le m h a s m an y sid e s to i t M any institutions— the m edical a n d m ental health system, th e crim inal justice system , the educational system —a re involved in a d d re ss in g the p roblem of d ru g s. E ach o f th e s e in s titu tio n s a d d r e s s e s th e problem o f drugs from its o w n perspective.

From a c hurch p ersp ectiv e the question arises, do th e c h u r c h e s , th e r e li g i o u s i n s t it u t io n s ir. o u r society', h a v e an y th in g u n iq u e to contribute to the N ation's ffr’T T r- -T*d-~T *** * p - n H r n s associated 4>ith d ru g s? H o w d o th e religious in stitu tio n s of o u r s o c i e t y r e la t e to t h e h e a l t h , j u s t ic e , a r.d e d u c a tio n a l in stitu tio n s a s th e y g ra p p le w ith the problem s related to d r u g abuse?

C h u r c h e s p r o v id e m e a n i n g ir. th e liv e s o f th e m a io riry o f A m e r ic a n s , f o r c h u r c h e s a r e s till p rim ary places o f c o m m u n ity in o u r society. W hat th e c h u r c h e s c a n u n i q u e l y c o n t r i b u t e to th e Nation's smuggle to re d u c e the p roblem s associated w ith d r u g a d d itio n is th e r e f o r e a so c ia lly a n d m o r a lly i n t e g r a t e d c o m m u n i t y w h i c h h a s a p o sitiv e effect on m e n ta l h e a lth a n d crim e, ar.d w hich is a pow erful so u rc e of p ublic e d u c a c o r.

F:ve very practical p o in ts a b o u t churches speak to the p o te n tia lly pow-err'ul c o n tr ib u tio n th e y car. make in b a ttin g the d r u g problem ;

1 C H U R C H E S H A V E M A T E R I A L R E S O U R C E S — h a l l s , m e e t in g r o o m s , auditorium s, finances, classrooms that can be u s e d as p a r t o f th e i r c o n tr ib u t io n to combating the d ru g problem .

2 C H U R C H E S H A V E H U M A N RESOURCES— d o c to rs n u rse s, teachers, c o u n se lo rs, la w y e rs, fam ilies, v o lu n te e rs w ho w a n t to m ake a difterer.ee m the lives of individuals and in sc o e ty a n d w ho can be m obilized to a d d re ss tne p ro b lem o f crim e

3 CHU RCHES H A V E A V A ST REACH— every town, village, n eighborhood, a n d an. m the United S a te s has churches— that car. be used to reach the v a st n u m b ers of re c o le w ho have problems with, d ru g addiction

d CHU RCHES H A V E NEEDS— » ; . e er.

c hurch has m e m b e rs w-ho a re reco v erin g addicts w ho need social s u p p o r t to p re v e n t their relapse, a n d e v e ry c h u rc h has a d u lts w ith ch ild ren w h o n e e d h e lp to p r e v e n t the in v o lv e m e n t o f t h e i r c h ild re n w i th d ru g s— which, if a d d r e s s e d b y c h u rch e s, w ould reduce th e e ffe c ts o f d ru g -re la te d problems

5 . C H U R C H E S H A V E LEA D E R S—a n e t w ork of earn e d m in is te rs , priests, rabbis, d e rg v . y o u th m in is te r s — w h o are key to enlisting and m o b ilizin g th e churches in a national program to re d u c e d ru g addiction.

Because churches a re c o n n e c te d to th e e v e ry d a y lives of th eir m em bers, th e y c a n be said to b e m th e fro n tlin e o f social p ro b le m s . Thus, se rv ice s provided by the c hurch a re s a id to be "com m unity- based.'

T ne social tnscrucons o f th e h e a lth care system , the crim inal justice system , a n d th e education system , how ever, tend to p ro v id e m o re specialized services th a n those p rovided b y t h e c h u rc h . T hese m ore specialized services te n d to b e p ro v id e d in situ a tio n s so m e w h a t s e p a ra te d fro m the " fro n tlin e s ” (e .g .. in h o sp ita ls, p r i s o n s , sc h o o ls ). T h e O n e C hurch— One Addict p ro g ra m , how ever, can t » i . b rid g e t o jo ir . the m o r e s p e c ia liz e d s e rv ic e s of health care. c n m naT justice. a n d education w ith the m ore generalized, c o m m u n ity -b a se d s e rv ic e d i the churches.

O n e C h u r c h — O n e A d d ic t P r o c r a m G o a l s

Tne program hypothesis b e h in d the One C hurch— O ne A ddict m ovem ent is:

• if the churches a re m o b ilize d through th eir leaders, and

• it the resources of th e c h u rc h e s are used in an orgarzzed fashion so th a t each church addresses or.e p ro b le m o f d r u g addiction a n d one problem o f d r u g prevention, then

• p e o p le w ho are a f f e c te d o r th re a te n e d by th e p roblem o f d r u g a d d ic tio n w-lii experience increased lev e ls of social a r.d n o ra ! integration a n d of practical support.

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I l l

• th e O n e C h u rc h —O n e A d d ict m o v e m e n t w iU re d u c e th e n e g a tiv e effects o f d r u g a d d ic tio n a n d increase the positive effects o f d r u g p re v e n tio n in the lives o f c h u r c h m e m b e rs a n d in sooety.

T h u s, d ie g o a ls o f th e O ne C hurch—O n e A d d ic t m o v e m e n t a re to:

1. I n c r e a s e th e le v e ls o f so c ia l a n d m o r a l i n te g r a tio n a n d o f p ractical c o m m u n ity - b a s e d support aro u n d the d ru g problem .

2. R educe the negative effects of d rug addiction.

3 I n c r e a s e th e p o s i t i v e e f fe c ts o f d r u g p re v e n tio n in the lives of church m e m b e rs a n d in society.

P r o c r a m D esig n T he b a s ic idea fo r th e Or.e C hurch—O n e A d d ic t p ro g ra m is th a t each c hurch congregation th a t p a r tic ip ates in th e p ro g ra m agrees to em b ra ce w h o le h e a r t e d l y a t le a s t o n e r e c o v e r in g a d d i c t a n d a c c o m p a n y th a t a d d ic t in the recovery p ro c e s s for a p e r i o d o f o n e y e a r . E ac h c o n g r e g a tio n a ls o a g re e s to u n d e rta k e a t least o n e d ru g p re v e n tio n a ctiv ity in its co m m u n ity

T he c o n g re g a tio n receives tra in in g fro m th e O ne C h u r c h — O n e A d d ic t p ro g ra m ir. p r o v id in g the fo llow ing services.

• I d e n tify in g p e o p le m th e c o m m u n ity in n e e d o f c o m m u n ity - b a s e d h e lp i n t h e process of th e r recover.' r o tr. drag addiction.

• M a k in g re fe rra ls to co m m u n ity a g e n c ie s th a t offer ap p ro p riate professional se rv ice s fo r re covering d ru g addicts.

• C a r i n g a p p r o p r i a t e l y fo r a r e c o v e r in g a d d ic t—p ro v id in g friendship, job referrals, w a rm th . b e lo n g in g role m odels, a n d a n a u r a o f resp ectab i.ity for the re c o v e rin g a d d ic t.

• D o in g reiapse prever.ocr..

• S u p p o r tin g a r.d te a rh m g fam ilies ir. th e c o n g re g a tio n to taka c o n stru ctiv e a c tio n a b o u t d r u g a b u s e or. th e p a r: of f a m ily m em b e rs, and

• Im p le m e n tin g d r u g p re v en tio n a c riv tr.e s !e.g . training teenagers tr. h o w to re p o rt to a n a u th o r ity th a t p e o p le thev k n o w a re u s in g c r dealing d ru c s school.

P r o c r a m E l e m e n t s T hese a r e th e key o rg an isatio n al elem ents o f O n e C h u rc h — O n e A ddict:

• A n a tio n a l office.

• A b r o a d b ase o f support w ithin the national re lig io u s leadership.

• A b ro a d base o f su p p o rt w ithin the national a r .h d r u g leadership a n d research c o m m u nity.

• S tate b o a rd s o f key religious leaders w irhin each State.

• T h e s u p p o r t o f the S ta te G o v e rn o r a r.d " d r u g czars."

• P o lic ie s a n d p r o c e d u r e s for e a c h S ta te b o a rd .

• P r o t o c o l f o r c la s s if y in g p o te n t ia l p a r t i c i p a n t s .

• A u n i f o r m tra in in g p ro g ra m for c h u r c h c o m m itte es.

• A n a t i o n a l n e w s l e tt e r f o r o n g o in g e d u c a t i o n .

• A m a n a g e m e n t in fo rm a tio n s y s te m fo r p r o g r a m m an ag em en t a n d evaluation.

• A re se a rc h d e sig n for p ro g ram evaluation.

• C h u r c h , c o m m itte e s in e a c h m e m b e r c h u rc h .

T hese a re t h e key o p e n z o n a l elements.

A g re e d -u p o n eligibility criteria (classinca- t o r in stru m e n t) for participants.

• P ro c e d u re s for church c o m m ittees to u se m a s s e s s m e n t a n d re fe r r a l o f p o te n tia l p a rtic ip a n ts .

• S t a n d a r d s a n d p ro c e d u re s for m in im u m le-. el o f o n g o in g support activities betw een tn e c h u r c h c o m m ittees a n d p a r o n o a n t s . a n d

• S t a n d a r d s a r.d p ro c e d u r e s for p e r io d ic r e p o r t s b y c h u r c h c o m m i tt e e s to t h e n a o o n a l office.

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- S U t S T A N C E A S U S E M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E A T M E N T M O D E L S

C o n c l u s i o n T here is g ro w in g public d e b ate a n d c o n versation a b o u t in c r e a s in g the ro le or a ll c h u rc h e s in th e N a t i o n 's f ig h t a g a in s t s u b s ta n c e a b u se . M a n y c h u rc h e s s im p ly need d irec tio n in ho w to p lay a p a rt in th is struggle.

O n e C h u rc h O ne—A d d ic t lays o u t a su s ta in a b le a n d n a tional p lan that (1) identifies a n a p p ro p ria te role fo r the churches a n d (2) provides a m odel for tu rn in g th e m o av a co r. of the churches into action.

O n e C h u r c h - O n e A d d ic t will m obilize c hurches to p r o v i d e r e c o v e n n g a d d ic t s w ith th e c ru c ia l social s u p p o r t necessary to su s ta in them in th eir r e c o v e ry p ro c e ss . T re a tm e n t p ro g ra m s c a n n o t p r o v i d e t h is lev e l of social s u p p o r t. T h e v ita ! s u p p o rt p ro v id e d by O n e C h u rc h —O n e A d d ic t to re c o v e n n g a d d ic ts will increase d ie effectiveness o f d r u g tre a tm e n t program s a nd h elp ensure th a t the h u g e in v estm e n t of the N a tio n 's financial resources in d ru g tre a s n e n r and p re v en tio n pays div id e n d s.

T h e O ne— C h u rc h O ne A d d ic t p ro g ram se e k s to a ssist c h u rch e s to actualize the love of C od in o u r w o rld . T h e p ro g ra m is a c all fo r th e c h u r c h to show-, in a practical way. i s love for the a d d ic t a n d i s h ate fo r th e addiction- Ir. th is way. it is h o p e d t h a t th e c h u r c h e s w-:Il m a k e th e i r c o n tr ib u tio n to th e r e d u c t i o n o f t h e d e v a s t a t i n g s o c i e t a l p r o b le m s t h a t ste m fro m d r u g a d d ic tio n ir. o u r p r e s e n t d a y so ciety

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APPENDIX G

PARENT POWER: KEEPING OUR KIDS DRUG FREE

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• S U B S T A N C E A B U S E M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E a T m E N T M O D E L S

PARENT POWER: KEEPING O U R KIDS DRUG FREE

O v e r v ie w M o st A m ericans c onsider d ru g a n d alcohol a b u s e to b e the n u m b e r o n e problem in o u r s o d e tv to d a y . S ubstance abuse ruins lives It ru in s the liv e s o f th e a b u se r a n d o f the family. I: is a key factor in o u r h i g h c rim e ra te . It im p a c ts o n th e liv e s o f t h e in n o cen t w h o are victims o f drug-related c rim e . It is r a m p a n t a n d w i d e s p r e a d — p e r v a d i n g e v e r y segm enr o f o u r so c e ty and every area of o u r c o u n try .

B n a i B 'n th 's C om m unity V olunteer Services (CVS) C o m m is s io n is jo in in g t h e w a r on d r u g s . O u r f o c u s is o n p a t e n t s a n d h o w w e c a n p r e v e n t su b s ta n c e a b u se ir. o u r children.

To th is e n d . CVS h a s d e v elo p ed a kit for p a r e n ts T he kit. " P a re n t P o w e r K eeping O u r K ids D r u g F r e e ." a n d a v i d e o c a s s e tte . " A G ift f o r L if e " ( p r o d u c e d by th e A m e ric a n C o u n c il f o r D r u g E d u c a tio n ), are m a d e po ssib le ir. p a rt t h r o u g h a special g ra n t from the P lough Foundation. T h e l e t is d e s ig n e d to be u se d a t h o m e b y p a re n ts w it h th e ir ch ild ren so a s to get p a ren ts involved in th e fight a g a in st substance abuse.

P a r e n t P o w e r S u b s ta n c e a b u se e x p e rts a g r e e t h a t c a r i n g a n d inform ed p a ren ts are the b e st defense against d r u g ab u se by kids. A nd they a d c a w o rd of ad v ic e — p a r e n ts sh o u ld b e g in rrr.'y ta g e t th eir m e s s a g e across.

H ow does a parent d o this’ Most parents w a n t rc p ro tec t a n d n u rtu re their children. But ir. th e face c f th e d ru g problem., m any feel heipless T hey fee! they lac k th e p r o p e r o p p o r tu n it y and th e r i g h t ■'Oris Som e ieei th a t they them selves are p c o r iy --fo rm e d a o o u t the effects c f c ra g s. Others s im p ly d o r r b e iie v e m at d ru g s w ill find their w a y in to their n e ighborhoods a n d hom es

But r c p a re n t car. e rrors to ig rc re the threat c n t g s p re se n t Clear'.;, ed u catio n c fp a re r.e s is the firs: step re w a rd h a ir ie r vourtg p e cp ie stay drug free

K i t C o n t e n t s a n d U se T he m a n u a l a n d o ther materials ir. th e B 'nai B 'rith k it helps pro v id e parents w ith the facts a n d skills they n e ed to h eip o u r young p e o p le c o m b a t d ru g s. T ne kit in clu d e s a videotape. "A G ift for Life." The acc o m p a n y in g m anual in d u d es a su m m a ry o f the v id e o ta p e 's guiding principles in the fa rm o f a 12- s te p p ro g ra m . It contains im p o rta n t " P o in ts for P a re n ts " [re p rin te d below]. T he se c tio n e n title d "Beating P e e r Pressure" provides v alu ab le d p s on h e lp in g k id s d evelop the d ru g re fu sal sk ills th e y neerf "W h a t to Do When You S uspect S u b s ta n c e A b u s e " h e lp s d e te rm in e w h e n i n t e r v e n t i o n is n e ce ssa ry , a n d how to proceed. Ir. a d d itio n , the m a n u a l c o n t a i n s th e r.a m e s . a d d r e s s e s , a n d t e le p h o n e n u m b e rs o f sta te a n d r a t i o n a l d r u g re so u rc e c e n te rs.

T h e k it a ls o c o n ta in s s e v e ra l p a m p h l e t s t h a t describe th e properties and effects o f se m e w id e ly u s e d d r u g s . A p am p h let. "T a lk in g to C h i ld r e n A b o u t D r u g A b u s e ." h e lp s s e t t h e s t a g e f o r c o m m u n ica tio n . All of these sh o u ld c e r e a d a n d discussed a t hom e

Artec using the kit. parents should sp re ad th e w o rd to o th er parents. They should organize a n e tw o rk o f inform ed parents dedicated to w orking to g e th e r 'to set safe g uidelines for their children P a re n ts a re u rg e d to rem em b er the w ards a t the con clu sio n o f th e video 'P a r e n t p o w e r is s tro n g e r th a n p e e r p r e s s u re !'

P o i n t s f o r P a r e n t s 1 S u p p ly in g k id s w ith in fo rm a tio n is n o t

enough. They re e d :u—r? Parer. 3 are the b e s t a n d m o s t n a tu re : t r a n s m i t t e r s o f values

2 Ka-.e rules of b enavicr curfew s ffter.ds. p ro p e r dress, p a n e s C cnsnuallv reinforce th e clear m essage that d ru g s a n d alcohol are not p e rm isrh ie Be sure k-ds knew the c o r s e c u e n c e s fo r b r e a k i n g th e r u i e s

3 Lister, to. dor. t mst hear w he- y c u - chil dren and their m ends are .say me

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115

4. Be w illin g to d is c u s s a n y th in g w ith y o u r c h ild ren . But rem em ber, d isc u ssio n does n ot m ea n debate.

5. C h e c k th e v a lu e s a n d life s ty le s o f y o u r c h ild re n 's caretakers: d a y c a re p ro v id e rs , c a m p c o u n s e l o r s , f r i e n d s , p a r e n t s o : friends.

o Set u p a p a re n t p e er group to s u p p o r t the ru les a n d values y o u have set. You'll find th a t th e y 're pro b a b ly m uch lik e y o u r ow n.

M ost o f all. be p re p a re d to c o n fro n t a child if be h av io r seem s suspicious o r if y o u find e v id e n c e o f s u b s ta n c e abuse. D o n 't ju st t h r e a te n — be r e a d y to c a r r y o u t c o n s e qu e n ce s for u nacceptable beha vior.

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APPENDIX H

STREET PSYCH: A CRIME AND SUBSTANCE ABUSE PREVENTION PROJECT FOR INNER-CITY MINORITY FAMILIES AND TEENS

116

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- S U I S T A N C E A I U J ! M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E A T M E N T M O D E L S •

STREET PSYCH: A CRIME A N D SUBSTANCE ABUSE

PREVENTION PROJECT FOR INNER-CITY M IN O R ITY FAMILIES A N D TEEN S

St r e e t P s y c h : H is t o r y a n d C o n c e p t

O v e r th e p a st five y e ars, th e M id w e st C h ris tia n C o u n s e l i n g C e n t e r (M ID W E S T ) h a s b e e n a p p ro a c h e d by black m inisters requesting counsel in g a s s i s t a n c e w ith the m o u n tin g p r o b le m s o f s t r e e t c rim e , v io le n c e, a n d d r u g a b u s e i n th e ir n e ig h b o rh o o d s. A s these pastors have sh a red th eir c h a lle n g e s and n e e d s w ith MIDWEST sta ff, th e y h a v e s p o k e n of th e follow ing p ro b lem s re g a rd in g p s y c h o l o g i c a l c a r e f o r t h e i r p e o p l e . W h il e d e s tr u c tiv e behaviors a b o u n d , b lack p e rso n s h a v e i n a d e q u a te financial resources a n d p o o r in su ra n ce c o v e ra g e to pay for the h ig h cost o f m ental health r e s o u r c e s a n d t r e a t m e n t c e n t e r s . A f r i c a n A m e r ic a n s e x p ress a ttitu d e s o f im p a tie n c e w ith tra d itio n a l therapy seen as un p ro d u c tiv e activity o r "(ust talk in g ." T reatm ent is perceived a s d e m e an ing. th rea te n in g , a n d a v io la to r, o f confidentiality r e g a r d in g one's struggles. M ental h e alth c are is for " c ra z y p e o p ie " w ho have falien from grace because o f a n e ro sio n of faith in their religious system .

F u rth e rm o re , p a st ex p erien ces w ith m o st service p r o v i d e r s c o n f ir m e d p a r i s h i o n e r b e lie fs th a t th e ra p is ts are unfam iliar w ith econom ic h a rd sh io . in s e n s itiv e to racial a n d cultu ral issues, a n d a n ta s - orusric to sp ir.n ial values. Little u n d e rsta n d m g of i m p o r t a n t e x te n d e d fa m ily a n d c h u r c h farm!-.- n e tw o r k s w a s c o n v ey e d d u n n g th e th e ra p e u tic p ro c e s s C o u n se lo rs a p p e a re d to be y o u n g a n d p ro fessio n ally too 'inexperienced w ith the realities or itfe d e a th , and fortune w hich face m em bers c- the n i n c r t t y comm unity on a caiiv b a ss.

R e c o g n i z i n g th e p a u c i t y o f m e n t a l h e a lt h re so u rc e s, the shortage of r-am ed m in o rity c o u n selors th e centrality of c hurch and pastor, a n d the i n h e r e n t s t r e n g t h s a n d r e s o u r c e s w i t h in th e A fric a n A m e n c a r c o m m u n ity . S tre e t Psych w as re ce n t.y fram ed i r resp o n se to re p ea te d requests mom b u c k pastors for M ID’.VEST assistance This p ro ec- w ill in tro d u ce in n o v ativ e te c h n iq u e s for - r e - e n t i r e a r c r e s o lv in g " s tr e e t" p r o b le m s —

p a rtic u la rly th o se o f crim e, v io le n c e , d r u g a n d a lc o h o l a b u s e — u s i n g a n u n o r t h o d o x d e liv e rs - system.

P astors o f b lac k c h u rc h e s, c o n s id e r e d b y m a n y p anshioners to be p a r t of their e x te n d e d families, have am ple family access, m eaningful influence, a n d e ss e n tia l c re d ib ility w ith in th e ir c o m m u n i ti e s . These m inisters o ffer vast re serv o irs o f u n ta p p e d p o w e r to m a k e p e r m a n e n t b e h a v i o r a l c h a n g e s w ithin their constituencies. {In the w o r d s c f S ishop Fioyd P erry, a le a d e r in the p re d o m in a n tly black Pentecostal g ro u p . C h u rc h of G od in G i r i s t . w hich c airn s 3 m illion V S . m em bers, " th e C h u r c h is the a nsw er in th e battle a g ain st d ru g s a n d c rim e . . . Treatment is the band-aid. it only patches th e p ro o ie n . but the churches m u s t d o the healing. W e h a v e to reach o u t to o u r youth, to help change m e n 's lives."

Elark pastors and c h u rch leaders w ill b e train ed by MIDWEST clinical sta ff to effectively u tiliz e c u ltu r al s tre n g th s fo u n d in th e m in o rity c o m m u n ity , such a s su rv iv a l sk ills , stro n g e x te n d e d k in s h ip netw orks, family relationships, and p o w e rfu l sp iri tuality a n d retigious orientation, to p r e v e n t a n d resolve d y sfu n c tio n a l behaviors. P a s t o r s w ill be enabled to help parishioners use faith s y s te m s a n d im a g e ry to p ro m o te a n d e n h a n c e t h e i r m e n ta l health a n d that of th eir families

R isk Fa c t o r s The S treet Psych p ro tec t will a d d re s s s ig n ific a n t tiiv .-actors at tnree levels: C om m unity. P e rs o n a !' Famuiy. a n d Ir.d iv td u al/P e e:

C o m m u n i t y R is k Fa c t o r . . . 1 E C O N O M IC A N D SOCIAL D E P R IV A

T IO N . Tr.e p opulation o: c o ngregationa! membe.-s p a m rip a ttn g in the S treet Psych project will include the frilowm.g-

i C h ild re n and th e tr tam.ilies w h o iive in d e te r io r a t in g and r t im .e - r id d e .-

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n e ig h b o rh o o d s w h o a r e a t r i s k f o r engaging in d elin q u en t b e h a v io r;

b. C h ild r e n w h o h a v e b e h a v i o r a n d adjustm ent problem s e a rly i n life, w h o are a t greater risk fo r s u b s ta n c e a b u s e and related crime:

c. Children and families w h o c o m e fro m economically d e p riv e d a r e a s w h o a re therefore a : greater risk f o r b e c o m in g involved w ith drugs.

2. LOW N E I G H B O R H O O D A T T A C H M E N T A N D C O M M U N I T Y D I S O R G A N IZ A T IO N . M e m b e rs o f c h u r c h e s p a m c ip a m g in Street P sy ch m a y e x p e ri ence d ru g problems b ecause t h e y r e s id e in neighborhoods w here p e o p le m a y h a v e lit tle attachm ent to com m unity.

3. T R A N S I T I O N S A N D M O B I L I T Y . Children of families in e a c h p a r tic ip a tin g parish are at risk for d r u g u s e a n d o th e r behavior problem s because o f h i g h lev e ls of school transitions cau sed b y t h e m a g n e t school b u sin g p ro g ra m , h o u s i n g o r r e n t problems, and other m obility factocs. It is known th at comm unities c h a ra c te riz e d by- high rates of m obility a re a t a n in c re a s e d risk for d ru g abuse and re la te d c rim e .

A. C O M M U N IT Y N O R M S F A V O R A B L E T O D RU C A BU SE. F a m ilie s a n d th e ir children w ho are m em bers o f S tr e e t Psych participating congregations m a y b e c h a ra c terized as follows:

a. C o m m u n ity a t t i t u d e s f a v o r a b l e to d r u g use w h ic h p u t f a m i l i e s a ; increased risk for a b u s e a n d r e la te d problems.

b Community sta n d ard s th a t a r e u n d e a r to * a rd d ru g and a lc o h o l u s e w h ic h put young peooie a t a h ig h e r risk for drug abuse

P e r s o n a i / F a m i i .y . . . The Street rsyctt p r c e c t a d d re s s e s th e fo llow ing farrui;. -focusec personal risk factors

1 FAMILY HISTORY OF A L C O H O L I S M T nose c o n g re g a tio n m e m b e r s o f S tr e e t Psych p a rsc tp a n n g ch u rch e s w h o s e chul- dren are com or raised in fa m ilie s w ith a hatory or alcor.ciism are a t g r e a te r risk of c e -.e ic rm g a iro h c a r c o t h e r s u b s ta n c e ao use rror'.em s

2 . FA M ILY M A N A G E M E N T PR O B L E M S . It is expected th a t S treet P sych c o n g re g a n ts m a y b e experiencing th e follow ing!

a. F a m ily m a n a g e m e n t a n d p a r e n t i n g p ro b le m s w h ic h in c re a s e th e r is k o f d r u g a b u s e w i t h i n a f a m i l y u n i t including failure o f p a re n ts to m o n ito r th e ir c h ild ren , a n d e x ce ssiv e ly se v e re o r inconsistent p u n s h m e n r.

b. F a m ily -re la te d fa c to rs t h a t p u t c h il d r e n a n d th e ir p a r e n t s a t i n c r e a s e d r i s k fo r s u b s ta n c e a b u s e p r o b l e m s su c h a s m a rita l con flict a n d d iv o rc e , d e a th a n d grief, se x u a l a n d p h y s ic a l abuse, etc.

I n d i v i d u a l / P eer R i s k Fa c t o r s . . . T h e S tre e t P sych p ro je c t w ill a d d r e s s in d iv id u a l a n d p e e r risk fa cto rs th a t c h a lle n g e in d iv id u a ls . p a rticu la rly y o u th w ho experience th e follow ing:

1. -R L Y A N T I S O C I A L B E H A V I O R . c h i l d r e n in e a r ly sc h o o l y e a rs , o f S tre e t P sy c h fam ilies, m a y d e m o n s tra te a g g re s s iv e b e h a v io r w h ic h p u ts th e m a t h ig h e r n s k fo r d ru g abuse.

2. A L I E N A T I O N A N D R E B E L L IO U S NESS. G iiid re r. a n d adolescents o f Smeet Psych families m ay also exhibit th e follow in g charactehstms:

a. F e e lin g s e p a r a t e fro m m a i n s t r e a m s o c ie ty w h ic h m a y p ro m o te g r e a t e r n s k far d r u s abuse.

b. F a ilu re ir. try in g to be s u c c e s s f u l o r responsible w hich car. p ro m o te g re ater risk far d ru g abuse.

c Antisocial b ehavior such as m is b e h a v ing m school, sk ip p in g school, a n d g e t tin g in to fig h ts which, p u t s t h e m a t g r e a te r risk for b e c o m in g in v o lv e d with, c ru g s or alcohol

3 FRIEN D S W H O USE DRUGS. C h ild re n o f families p a —ctpatm.g m the S tre e t Psych, p ro g ra m s are more likely to asso ciate w ith p e e rs w ho a re u sin g d ru g s , a f a c to r th a t m a k e s th e m m u c h m o r e lik e l y t o u s e d r u g s them selves

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100

St r e e t P sy c h P r o j e c t E v a l u a t i o n

P rogress or the p ro je c t w ill b e m o n ito re d b y the P ro je c t A d v is o r y C o u n c il w h i c h w i l l s e e k to m e a s u re p ro je c t s u c c e s s b a s e d u p o n r e v ie w o f com pleted project objectives. Beyond this, how ever, e v a lu a tio n o f p ro je c t r e s u l ts w-ill b e m e a s u r e d u p o n conclusion o f p ro je c t y e a r t w o b y a re v ie w o f th e fo llow ing p ro je c t o u tc o m e s a n tic ip a te d to result from project activities. A M IDW EST project e v a l u a t o r t r a i n e d i n s t a t i s t i c a l m e t h o d s a n d co m p u te r use in p sychological re se a rc h w ill c o n d u c t t h e e v a l u a t i o n . P r o j e c t e v a l u a t i o n w ill a tt e m p t to q u a n tify p r o je c t o u t c o m e s b y u s in g a v a i l a b l e p r e - a n d p o s t - p s y c h o l o g i c a l t e s t in s tru m e n ts a n d b y d e v e lo p in g n e w te s t m easures a s n e e d e d . R e v ie w a n d i d e n t i f i c a t i o n o f te s t in s tr u m e n ts a n d th e d e v e l o p m e n t o f n e w te s t m easures to be u se d w ill take p la c e d u r in g the first y e ar of the p ro jec t

• Reduced crim inal a n d vio le n t b e h a v io r in parishioner families

• Prolonged re d u c tio n in d r u g a n d alcohol use by parishioners, especially teens-

• R e d u c e d s e x u a l a c t i n g o u t a n d te e n pregnancy in the parish.

• Im proved a n d re n ew e d in te re s t in b a r r i n g and self-im provem ent b y p a rish io n e rs.

Im p ro v e d s e lf-e s te e m a n d e s t im a te s of self-worth by p arish io n ers

• Im proved relationships w ith a n d b e tw ee n panshioners

• im p ro v e d q u a lity o : i n te r a c tio n w ith in fa m ily s y s te m s a n d i m p r o v e d f a m ily a n d e x te n d e d f a m ily r e l a t i o n s h i p s fo r parishioners

M o re e f fe c tiv e u t i i i r a t i o n o f p e r s o n a l s t r e n g th s , p o w e r , a n d r e s o u r c e s f o r parishioners

More effective u ttiica co r. o f faith sy s te m s ro nea.’ personal d ysfuncsotval behav tors.

• R e d u c e d n e g a t i v e s v m p r o m s . a c t i n g o u t ben.aviors a n d c o p in g m e c h a n is m s among teens

im prov ed p a sto ra l c a r e a n d c o u n s e .m g skiLir ror castors

• Greater pastor sensitivity a n d a w a re n e s s of the m en ta l h e a lth n e e d s o f p a r is h io n e r s and their extended families.

• Reduced parishioner th rea t a n d stig m a of utilizing m ental health resources.

• Increased referrals to c o m m u n ity m e n ta l health resources such as S w o p e P a rk w a y Health Center. Samuel Rodgers C o m m u n ity Health Center, MIDWEST, etc.

• Im proved psychological re so u rc e accessi b ility a n d r e le v a n c e f o r t h e A f r i c a n American comm unity.

• New lay persons identified a n d tra in e d to assist pastors m their pastoral a n d m e n s ! health care roles

• Good mental health m odels p r o m o te d by pastors and b y leaders w ith in th e p a ris h that continue a fte r form a! c o m p le tio n o f me project

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This a s se ss m e n t w ill h e lp to e n s u re th a t th e pas* tor's role a n d p o sitio n o f lea d ersh ip in h i s / h e r con g r e g a tio n is m a i n t a i n e d a n d r e s p e c te d d u r in g h is /h e r p a rtic ip a tio n in th e p ro je c t

O ne-hour a sse ssm e n t in te rv iew s w ill tak e place a : project o n s e t a n d a t 3- a n d 5 -m onth intervals after initial p a r ti d p a d o n in th e p ro je c t

R e s i d e n t T h e r a p i s t s — The se rv ic e s o f a n o n -s ite in te rv e n tio n sp e c ia list within e a c h p a rd d p a d n g c hurch w ill su p p o rt pastor intervention a n d p e e r g ro u p activities, a n d through such s u p p o r t p ro m o te p o s itiv e fam ily a n d social relationships. T h e availability o f a trusted, skilled in te rv e n tio n s p e d a li s t w ill p ro v id e c o n g re g a n ts w ith a n o u t le t to d is c u s s p e rso n a l problem s, and thus w ill e n h a n c e th e ir feelings o f w ell-being, self- esteem . a n d c o n tro l o v e r th e ir lives. S u c h well being lea d s to g re ater self-confidence and a feeling of investm ent in the fu tu re. In a d d itio n , intervention specialists w ill reinforce n e g a tiv e attitu d e s tow ards drugs a n d p ro m o te ethical b e h a v io r a n d m orality.

In terv e n tio n sp ecialists w ill h e lp m itigate against m any risk factors faced b y y o u th b y offering tim ely family in te rv e n tio n s th a t p ro m o te positive relation sh ip s b e f o re p r o b le m s a r e f u r t h e r e x a c e rb a te d ; cause gre ater h a rm to youth; o r place them a t greater risk fa r su b s ta n c e ab u se , violence, a n d crime.

Four h o u rs o f th era p ist tim e p e r w eek will be allo cated to e a c h o f th e 10 p a r ti d p a t in g c h u rc h e s ir. this project, fo llow ing th e ini dal needs assessm ent interview w ith e a c h p a sto r. T h e Project D irector will a s s ig n th e M ID W E ST th e r a p is t w hose skills best m atch n e e d s o f each congregation. This thera pist will w o r k for a n d w ith the p a s to r a n d w ill in effect b e c o m e th e c h u rc h 's r e s id e n t psychologist. The th e r a p is t w ill b e a v ailab le d u r in g th ese four weekly h o u r s to p ro v id e se rv ice s deem ed b v the pastor a n d Project D irector to be th o se m ost a ppro priate to th e n e e d s o f each congregation.

Services o ffe re d b y re sid en t therapists m ay include group th e r a p y m ee tin g s fo r co n g reg a n ts a n d the training o f lay g ro u p leaders isee below). In addi- aon. in d iv id u a l a n d fam ily th e ra p y m ay be offered by each r e s id e n t therapist.

R esident th e r a p is t s w ill a ls o p r o v id e e x te n siv e pastor training. R esident th e ra p ist pastor consulta tion will in c lu d e assistance w ith p a s to r counseling methods, a d v ic e o n th e u s e c : fa ith im agery and cultural p r i d e to p ro m o te m e n ta l health, a sse ss m e n t of con g reg an ts, su p e rs iston of pastoral care

a n d co u n se lin g , a n d re fe rra ls for congregants w ho re q u ire m o r e in te n siv e m e n ta l healthcare.

T o p ro v id e c o n tin u ity f o r p a sto rs and congregants, a n d to e n s u r e c o n t i n u i n g su c c e ss for th e c o n s t i tu e n t s o f e a c h p a s t o r , th e s e activities w ill be o n g o in g fo r a tw o -y e a r te rm , o r for an additional y e a r fo llo w in g th e f irs t y e a r o f th e project.

La v C h u r c h L e a d e r C r o u p s . . . E a c h p a s t o r m a y w i s h to id e n tify se v e ra l lay c h u rch m e m b e rs to b e co m e leaders of parishioner s u p p o rt g r o u p s o rg a n iz e d a ro u n d topics of parent in g a n d s i n g l e p a r e n t i n g , fa m ily re la tio n sh ip s, su b s ta n c e a b u s e , tee n issu e s, cultural strengths a n d id e n tity , s t r e e t v io le n c e , ra p e a n d sexual ab u se , m ale role m o d e lin g , e tc . C ro u p s also may include re g u la r A lcoholics A n o n y m o u s. Ala teen. Narcotics A n o n y m o u s m e e tin g s , a n d specialized teen p e e r s u p p o rt g ro u p s . In th a t th ese groups will include o u trea ch to a d o le sc e n ts, g r o u p leaders also m ay be selected f ro m the teen p o p u la tio n .

C r o u p l e a d e r s w ill b e tr a in e d b y the p a sto r a n d r e s i d e n t t h e r a p i s t t o o r g a n i z e g ro u p s a n d to p ro v id e e ffe c tiv e g r o u p leadership. For example, p o te n tia l g r o u p le a d e rs w ill b e giver, group process skills, le a r n in g d ie fo rm a tio n a n d s a g e s of groups, g u id e lin e s t o r th e c o n d u c t o f groups, expectations fo r g r o u p a c h ie v e m e n t, g u id a n c e for interaction b e tw e e n fa m ily sy s te m s a n d g ro u p therapy o f peer s u p p o rt g r o u p s , etc. C r o u p leader training will be d e s i g n e d t o e n a b l e r e s i d e n t g r o u p le a d e r s to o p e r a te in d e p e n d e n t l y a t th e e n d o i a tw o-year p a rtic ip a tio n p e rio d in th is project.

Aii g ro u p s w ill m ee t o n -site a t p a m a p a c n g church lo c a tio n s a n d w ill b e l e d b y g ro u p le a d e rs in conjunction w ith the p a s to r a n d / o r resident therapist. G ro u p s w ill m e e t re g u la rly o n a weekly, biweekly, o r m o n th ly b asis, b a se d u p o n the discretion o f con g re g a n t p a rtic ip a n ts , t h e g ro u p leader, pastor, and re sid en t th e ra p is t. C r o u p leaders win refer p e ts o rs r e q u i r i n g p e r s o n a l i z e d a tt e n ti o n to the p a s to r a n d / o r r e s i d e n t t h e r a p i s t a sso c iated w ith each c o n g r e g a t i o n , w h o m a y r e f e r p a ris h io n e rs to o u t s i d e c o m m u n i ty m e n t a l h e a lth re so u rce s if a p p ro p ria te .

A p r o g r a m b r o c h u re d e s c rib in g the street Psych protect, c o n c e p ts , a n d a c d v itie s w ill be prepared for d istrib u tio n to p a n s h io n e rs a t each church location T h is b r o c h u r e w ill p r e s e n t in fo rm a tio n m lay t e r m i n o lo g y t h a t c o n v e y s a n u n d e rsta n d in g of A frican A m e ric an c u ltu ra l identity and trn .g re g ir:

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121

- S U B S T A N C E A B U S E M I N I S T R I E S I N A C T I O N : I N T E R V E N T I O N / T R E A T M E N T M O D E L S •

n e e d s . T h e b ro c h u re w ill a ssist g ro u p le a d e rs to r e c r u i t c o n g r e g a n ts fo r p a r tic i p a ti o n i n g r o u p m ee tin g s.

P e e r s u p p o r t g ro u p s b a se d w ith in c o n g re g a tio n s w ill p la v an im p o rta n t rote in b o n d in g co n g reg an ts to e a c h o th er and th eir families. Peer g r o u p s will g iv e c ongregants a n o p p o rtu n ity to be a c tiv e con tr ib u t o r s a n d m e m b e rs o f g ro u p s — a sig n ific a n t p ro te c tiv e factor, p a rticu la rly for youth.

Y o u th s u p p o r t g r o u p s w ill p ro m o te t h e a tta c h m e n t s o f a d o le s c e n ts w ith n o n - d r u g u s e r s a n d fo s te r a n t i d ru g n o rm s , th u s p r o m o tin g p o sitiv e m o ra l b e lie fs a n d c o u n te rin g th e n o rm s o f d ru g a c c e p t a n c e a n d u s e in th e w i d e r c o m m u n ity . Y o u th s u p p o r t g ro u p s w ill p ro v id e a sp e c ific sys t e m o f r e w a r d s a n d r e c o g n i ti o n s . T h e y w ill e s t a b l i s h a f r a m e w o r k f o r a c c e p t a b l e a n d u n a c c e p ta b le b e h a v io r, a n d th ro u g h r u le se ttin g e s t a b l i s h c o n s e q u e n c e s fo r v io la tin g p o lic ie s , in c lu d in g those p ro h ib itin g su b sta n c e u se . A ciear system o f rew ards a n d recognition o f be h av io r is an im p o rta n t b on d in g factor for youth.

In a d d itio n , y o u th s u p p o r t g r o u p s w ill p ro v id e m e m b e r s w ith o n g o in g o p p o r t u n it i e s to le a rn a b o u t a n d create p ositive relationships w ith others, will o ffe r them a se n se o f in v estm en t in th e future, a n d e n c o u r a g e s t r o n g b e lie fs a b o u t r i g h t a n d wrong.

C l i n i c a l T r a i n i n g f o r P a s t o r ? . . . Inasm uch as most p a sto rs have n o t received prior tr a i n i n g in p s y c h o lo g ic a l a n d fa m ily s y s te m s theory, th is series o r nine sem inars of th re e hours each w ill c o n stitu te the fo u n d a tio n a n d fram e of reference for all e n su in g p astoral counseLr.g activi ties. S e m in a rs will take piace at MID'•VEST offices o v e r a 2 0-w eek p e rio d , follow ing in itia l p a s t o r / congregation assessments.

The clinical r a in in g c om ponent of tne 5 creel Psych project w ill greatly enhance positive relationships with o th e rs and wili reinforce pastor reach-ngs and b e lie fs a b o u t w h a t is r t g h t a r.d v. r o n j Intervention tratnm g will give m inisters a stronger role ir. te a c h in g y o u th a n d th e ir fa m ilie s m o ral solutions to tneir problem s. Problem id er.tih caao n and a s s e s s m e n t te c h n iq u e s tra in in g w i ll enable pastors to prom ote ar.d enforce p o s tu r e relation sh ip s w i t h i r c o n g r e c a r .t farr.iiies. a r .d a m e n ; n e ig h b o r; a r c peers

O n c e m i n i s t e r s h a v e m a s t e r e d t h e s k i l l s o f id e n tif y in g r is k fa c to rs a n d a sse ssin g fa m ily a n d in d iv id u a l p ro b le m s, th ey w ill b e able to intervene c o m p e te n tly , a n d th ro u g h s u c h intervention, relate re lig io u s m o r a ls a n d th o se o f their c h u rc h to th e n e g a t i v e v a lu e o f d r u g u s e in th eir c o n g r e g a n t c o m m u n i ti e s . T h e p a s t o r s w ill h a v e a g r e a t e r o p p o r t u n i t y to i n s till e th ic a l b e h a v io r, p o s itiv e social b o n d in g , a n d a r.tid ru g attitudes.

C o n s u l t a t i o n S e m i n a r s . . . T n is s e c o n d se rie s o f se m in a rs w ili take place u p o n c o m p le tio n o f th e clin ica l se m in a rs n o ted above. T h is s e r ie s w ill c o n s is t o f 15 th re e -h o u r se ss io n s o v e r a 3 0-w eek p e rio d a t MIDWE5T offices d u rin g th e f ir s t y e a r o f th e pro jec t. T hese se ssio n s w ill g iv e p a s to r s th e o p p o r tu n ity to present actu al r a w a n d s i t u a t i o n s w i t h w h ic h t h e y a re w o r k i n g , tr a n s f o r m i n g t h e th e o re tic a l c oncepts le a rn e d in c lin ic a l s e m in a r s in to p ra c tic a l application. T w o M ID W E ST sta ff p sy c h o lo g ists w ill supervise, teach, facilitate, a n d o ffe r clinical leadership d u rin g these

[ s e s s io n s . P a s to rs w ill b e e n c o u ra g e d to in te rac t. | o ffe rin g p ro b le m -so lv in g tec h n iq u e; and solutions I to the c a s e s p re se n te d .

O n - < I a l l T e l e p h o n e C o n s u l t a t i o n . . . P ro fe ss io n a l h o tlin e crisis in terv en tio n ba ck u p for

I m in is te rs w ill e n h a n c e the ab ility of such m inisters i to d if f u s e a n d re s o lv e crisis situations. P eaceful | re s o lu tio n o f c ris e s a m o n g th e co n g reg an t p o p u - I l a t i c n w i l l h e lp c o n g r e g a n t s feel s a fe r in th e ir I c o m m u n ity . T e le p h o n e crisis intervention services j w ill h e ip p a s to r s to p ro m o te a m o n g c o n g reg a n ts ] th e p ro te c tiv e fa c to r o f in v e stm e n t in the future.

j O n-call t e le p h o n e c o n su lta tio n w ill be available to J e a c h p a s to r a n d la y c h u rch le a d e r participating in | th e p r o je c t T nis re so u rce m ay be used for suicidal | a n d o r h e r c ris is m a tte r s , re fe rra l in q u irie s, c a s e j m a n a g e m e n t , a n d ir. o t h e r w a v s d e e m e d j a p p r o p r ia te a n d im p o rta n t b y tne pam npar.cs

j W hile fo rm a l c o n su lta tio n se m in a rs above will be ! lim ite c to th e first y e a r of the project, on-call tele- ! p h o n e c o n s u l t a t i o n w ill b e o ff e r e d to p a s t o r

p a r ti c ip a n ts fo r a 3 -y e a r p e rio d , o r 2 years beyond th e first y e a r o f th e proiec*. A ll Scree: Psych MID-

l W E S T c i m i c a l s t a f f w ill s h a r e the t e l e p h o n e ‘ c o n s u lta tio n re sp onsibility

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APPENDIX I

SOUTHWEST COMMUNITY AT A GLANCE

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PRIORITY BOARDS

NOKTICA5T ..NOKTHWEST

•SOUTHEAST

SOUTHWEST

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T otal

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128

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Open Door Collaborative Ministry

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Musical Praise

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131

Testimonies

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132

Ministry O f Prayer

T A

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Ministry Of Prayer

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134

Open Door Collaborative Ministry

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Fellowship Gathering

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APPENDIX J

DATA COLLECTION

1 3 6

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Open D oor M inistry Survey Form

Always Sometimes Usually Seldom Nevei

Questions 1. I believe God is important in the recovery process?

□ □ □ □ □ 2. I believe recovery is possible without a relationship with God? □ □ □ □ □ 3. I believe a relationship with Jesus Christ is necessary for Recovery?

□ □ □ □ □ 4. I feel that the worship service at at Open Door Chapel is helpful in my recovery process?

□ □ □ □ □ 5. The sermons preached at the Open Door worship provide me with the spiritual strength and courage to stop using?

□ □ □ □ □ 6. The sermons and meditations Help me to understand that I am Powerless without God?

□ □ □ □ □ 7. The prayer service at Open Door is important in my recovery Process0

□ □ □ □ □ 8. The prayer service at Open Door is a source of healing to my mind, sonl, and body during the recovery process'^

□ □ □ □ □ 9. The praise songs speak about healing in my recovery process? □ □ □ □ □ 10. Christ centered spirituality is necessary for healing of my family in the recovery process. □ □ □ □ □

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Model Project Pre-Assessment

Stop the Revolving Door o f Drug Addiction

Participant Leader_________________________________ Date

The purpose o f this pre-assessment tool is to ascertain information from participant leaders concerning their clarity o f the model goals and objectives o f Open Door Community Ministry’s Wholistic, Christ-Centered Approach to Recovery from substance abuse (mind, soul, body).

1. What do you understand the mission o f the Open Door Ministry to be in the greater West Dayton community?

What are the components o f the Open Door Ministry which are unique from other 12-step programs in the community?

3. What do you perceive your role to be as a leader with the Open Door Ministry?

4. What qualifications and experiences do you feel are critical for leadership in the Open Door Ministry?

5. Why do you believe a Christ-Centered theology is important in the recovery process from substance abuse?

6. How do you perceive the role o f the pastor/director and the ministry board’s function in the over-all program o f Open Door Ministry?

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139

Model Project Post-Assessment

Collaboration: A Methodology for Implementing a Wholistic, Christ-Centered Approach to Recovery from Substance Abuse

Follow-up questions for data analysis for determining the effectiveness o f the test model.

Participant Leader_________________________________ .Date_____________

1. Do you feel that the Open Door Collaborative Ministry model, “Stop the Revolving Door o f Drug Addiction,” has remained true to its mission and theology o f recovery for persons challenged with substance abuse?

2a. Has the experience o f the worship celebration components at Open Door Ministry (songs o f praise, testimonies, Scripture, preaching, ministry o f prayer, fellowship) been effective in creating an environment conducive for healing?

2b. What kind o f spiritual dynamics have you observed and experienced as a leader in the lives o f the individuals who attend Open Door worship?

3. What are the benefits o f having a collaborative recovery ministry model in the community?

4. What are the limitations o f this recovery ministry model?

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5. Do you feel that this collaborative ministry model (Open Door) can be replicable and effective in other urban communities?

6. What has been your empowerment experience as a leader with the Open Door Collaborative Ministry?

7. What have you observed as a leader that indicates our worship format (a theology o f recovery) assists in the process o f empowering people in recovery from substance abuse?

8. Comments or recommendations.

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QUESTIONNAIRE

Collaboration: A Methodology for Implementing a Wholistic, Christ-Centered Approach to Recovery from Substance Abuse

Agency:_____________________________ Title:___________________________

Date:

1. Why is the existence o f a ministry collaborative such as Open Door important for the greater Dayton community?

How do you perceive your agency/organization role as a partner in the Open Door Collaborative Ministry?

3. How do you as an administrator o f a participating collaborative facilitate your role with staff in support o f the ministry collaborative?

4. What do you perceive to be the strengths o f working with a collaborative to address the social disease o f substance abuse?

5. What have you experienced or observed to be the needed areas o f growth for the ministry model?

6. Comments or recommendations:

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APPENDIX K

WHOLISTIC SPIRITUALITY GRAPH

142

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A C h r is t C e n t e r e d W h o listic A p p r o a c h T o R e c o v e r y O p e n D o o r C o lla b o ra tiv e M in istry

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APPENDIX L

OPEN DOOR COLLABORATIVE STRUCTURE

144

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145

C ollaborative Partnership Structure

C o m m u n i t y P artn ers M im strv B o a rd

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C o l l a b o r a t i v e P a r t n e r s h i p S t r u c t u r e

Partners. Wesley

Project Curs Area Clergy Community Churches

Ministry Board

Rep. From Dayton

C o m m u n e

Executive Director Spiritual Coordinator

Substance Abuse Counselor

W orship Leadership Team

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APPENDIX M

WEEKLY WORSHIP FORMAT

147

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OPEN DOOR (O /A A W K fT Y (HAPEL, iN C (An Open Door Collaborative Ministry with Wesley Center, Project Cure, and community churches) A Wholistic Spiritual Approach to Recovery

I KNOW ALL THINGS YOU DO, AND I HAVE OPENED A DOOR FOR YOU THAT NO ONE CAN SHUT. (The Revelation o f Jesus Christ 3:8a)

Opening Praise Worship Praise Songs Opening Prayer

Scripture or Meditation for Living

Ministry o f Song

Announcements

Testimonies

Offering

Ministry o f Song

The Word (sermon)

Ministry o f Prayer for Salvation, Healing, and Deliverance

Benediction Circle o f Peace Get Ready, Get Ready, Get Ready

Get Free and Stay Free with God’s Help!

rrs RECOVERY TIME!!!

Volunteer Ministry Staff Volunteer Preaching Staff Gerald Davis Carlene Wilson Worth Sherman Holmes Iola Hays, treasurer Beverly Stewart, attorney Dorothy Thomas Winnifred Frazier Keely Watkins

Rev. Shirley Johnson Rev. Mark McGuire Rev. Danny Felix Rev. Shane Floyd Rev. Beverly Daniels Elder Flonzie Wright

Rev. John Allen Rev. Robert Biekman Rev. Beverly Lee Rev. John Mays Dr. Shirley Johnson Nurturing o f Eagles Group

Executive Director. Rev. Rosunde Cummings Nichols

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' r m victim to m m • its p c c o v « n i/w c

COVENANT

For O urselves V/e recognize mar w e ail are s.rr.e-% m recovery mrougn Cnnst; arte

y e - Goc has c a t e * us - cm v a - a u s Chnsban traciScns into a covenanting ca m —unity s o that * e may p a n c p a t e in me ministry of Jesus Gnrs: witn m osa .vrto suTer from tne u s e of alcohol and otrter drugs.

V/e resolve to c e faithful to tne teachings of J e s u s Cnnst and to walk m freedom and responsibility to o u rse lv es and to our neigneors.

V/e will exam ine our ow n lifestyles and modify our behavior a s it contnbutes to tne en sis c a u s e d by the a b u se of alcortoJ and other drugs.

V/e commit ourselves to b e informed fully about tne spmtual. psychological, econom ic, social, a n d political dimensions of Dus en sis

V/e will work, w.nereve* w e are. for |u sa ce and against system ic acts of violence, oppress-on. and cenumartization mat affect children, youtn. ano adults.

For Our Congregations v /e will foster worshiping co n g reg a o o n s w here the practice of

hospitality tnrougn tne lo v e of C m s t ensu res mat those in n eed will expenenee w elcom e

V/e wli call u ccn all fa.tnful C n n ss a n s to lift up in tne<r devobonaf life this crisis. and wherever possible, to pray for particular persons in need.

For Our Church We *HI present me c r s is a s a top prcnty o f our churenes' ag en d a s,

ano we will hold cur lead ers accountable for keeping it mere. We wll designate a person of our churches resources tc m is task.

For Our Giccal Commurity v /e recognize mat m e crisis is g icca l and m at no na:on is exem pt

from God's salt for iu scc e and me'dy w e «-ii ce Cilige-it m reminding our pciiccal leaders mat to n eg lect me

ensis pieces our nation under me judgm ent of GcC

in H j—c-e Sennce w e c c .- n it o u - s e 'i e s to m e p re v e n c c n c i m e furmer sp re a d of me

a c c s e ;f alconoi a n c o m e r c ru g s a t eve*/ level cf life

V ll - E F E 3 V M i < = 7-11S C O V E N A N T . ANO V/E WILL HOLD O U R S E L V E S A C C 0 U N T A 3 L E F O P i t s F U L F IL L M E N T v/E R E C O G N IZ E ~ - A 7 s o C O i n G M U C H W IL L E E REQUIRED 0 = u S E L * v / E a .= e - E D 5 V G C C TO a c d E F T t h i s C O V E N A N T

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APPENDIX N

MINISTRY BOARD MEETING MINUTES

150

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151

Open Door Board Minutes W esley C o m m u n ity C e n te r

D elp h o s A v e n u e Dayton O h io 4 5 4 1 7

July 27. 2001

C Opening Prayer by Pastor Rosunde’ Cummings Nichols £- Minutes read by secretary Carlene Wilson from previous meeting on Tuesday March 13.

2001. Minutes approved by consensus of Open Door Ministry Board. Z Treasurer Report by Winifred Frazier in the absence of Treasurer lola Hayes: £ Beginning balance: S 334.28

* Anniversary expenses: Building facility ( Hoover Party House) donated by Mr. & Mrs. Greg Harris.

£ Plaque for honoree Gerald Davis S25.00 Z Food donated by staff and Collaborative Partners Z Paper Goods and eating utinsils donated by volunteer staff. Z Cake donated by volunteer staff member. Z Decorations S 100.00 ( 21table coverings and balloons. Z Total after expenses: S 209. 28 Z Total monies received from Offering from Anniversary Celebration: S 198.00. Z Ending balance: S 334.23 Treasurer’s report approved by consensus of M. Board.

Z Update by Pastor Nichols in reference to Doctoral process. Z The following officers were elected 2 Scheduling of Preachers and Guest speakers Rev. Beverly Lee. Chair. Rev. Mark GMC

Guar. Shannon Coleman. 2 Ministry Of Hospitality: Mrs. Winifred Frazier. Chair, lola Hayes . and Dorothy Thomas, 2 Ministry Of Greeters: Agnes 2 Mentors for Eagles Ministry: ( Lav ministers and new candidates of ministry) Lee,.Beikman,

Me Guire

It was approved by consensus o ‘ r e Ministry Board to convene every fifth Tnursday o f the calendar year

Closing praye* Rev Robe-t Ee-k~="

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APPENDIX O

CONTEXTUAL ASSOCIATES’ MEETING

152

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Contextual Associates Focus Session I Victory United Methodist Church

March 9, 2000

Attendees: Pastor Rosunde’ Cummings Nichols, Chair Rev. John Allen Gerald Davis Carlene Wilson- Worth

A genda

Prayer: Pastor Rosunde’

Purpose of Session:

Topic o f Discussion”

1) Isaiah 61:1-2, and Luke 4: 18-19, and their scriptural relationship to the recovery process.

□□ Why is it relevant? DO How is it relevant ? DO What is God saying to the church concerning our responsibility

Closing Prayer: Rev. John Allen

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C o n t e x t a s s o c i a t e s m i n i s t r y T e a m M i n u t e s 2 0 0 1 J a n u a r y 9 ,

ATTE.VDA.VCE

OPENING DEVOTION

INTRODUCTIONS

DISCUSSION

J o h n C . a l l e n , R o b e r t B i e k m a n , S h a l l o n C o l e m a n . G e r a l d D a v i s , D a n i e l F e l l x , R o g e r G o d s e y - B e l l P a s t o r S h i r l e y - J o h n s o n . P a s t o r B e v e r l y L e e . P a s t o r R o s u n d e * c . N i c h o l s a n d M a r y S k e l t o n , e x c u s e d a b s e n c e : C a r l e n e W o r t h .

D e v o t i o n b y R e v e r e n d R o b e r t B i e k m a n , P a s t o r f o r W e s l e y C e n t e r a n d UAL P a s t o r a t R e s i d e n c e P a r k U.M.C.

P a s t o r R o s u n d e * C. N i c h o l s w e l c o m e d e v e r y o n e a n d EXPRESSED GREAT CRATITUDE AND APPRECIATION OF THOSE PRESENT FOR THEIR COMMITMENT TO PARTICIPATE AS CONTEXT ASSOCLATES LN THE DEVELOPMENT OF A REPLICABLE MODEL OF MINISTRY FOR RECOVERING SUBSTANCE ABUSERS. P a STOR N i c h o l s s h a r e d t h e m i s s i o n .a n d b i r t h o f o p e n d o o r m i n i s t r y , r e f e r r i n g t h e m a l s o t o t h e m i s s i o n s t a t e m e n t a t t h e b e g i n n i n g o f t h e p a g e .

D u r i n g t h e d i s c u s s io n o f p r o j e c t d e s i c n , t h e c o n t e x t a s s o c l a t e s o f f e r e d t h e f o l l o w INC s u g g e s t i o n s , r e s u l t i n g FROM G R O U P DISCUSSION:

( 1) S u g g e s t i o n s t o b e i n c l u d e d in t o p i c . C h a n c e f r o m s p i r i t ■-UALiTY . t o C h r i s t c e n t e r e d s p i r i t u a l i t y , c l a r i f y i n g t h e n a t u r e o f t h e r a p u d i c m i n i s t r y f o c u s .

( 2 ) T o INCLUDE CHURCH NAMES OF CONTEXT ASSOCIATES AS p a r t n e r s in p r o j e c t d e s i c n : F a i t h M i s s i o n C o m m u n i t y C h u r c h , N e w L i f e C o m m u n i t y O p e n B i b l e C h u r c h , O m e g a C h u r c h . R e s i d e n c e P a r k U.M.C. C h u r c h . S t . P a u l B a p t i s t C h u r c h . T a b e r n a c l e , a n d V i c t o r y U.M.C.

(3 ) T O INCLUDE IN THE Q l ALIFICaT IO nS FOR LEADERSHIP THAT ALL L e a d e r s h i p f u n c t i o n s w i l l b e p e r f o r m e d by C h r i s t l a n s W HOSE LIVES HAVE BEEN TRANSFORM ED, HEALED. AND d e l i v e r e d f r o m t h e l if e o f s u b s t a n c e a b u s e a n d C h r i s t i a n s W HO HAVE EXPERIENCED WORKING W ITH RECOVER* AND PREVENTION. A L L INDIVIDUALS MUST HAVE AT LEAST FIVE YEARS OF SOBRIETY OR FIVE YEARS O F PROFESSIONAL EXPERIENCE W O RK IN G W ITH THE S I BSTANCE ABU SE POPU La T IO V

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155

( 4 ) G r o u p d i s c u s s i o n i d e n t i f i e d : - S e v e r a l o n g o i n g s p i r i t u a l i t y g r o u p s a r e p r e s e n t l y b e i n g l e d b y c o n t e x t a s s o c i a t e s . C o n t e x t a s s o c l a t e s d e c i d e d i n o r d e r t o e f f e c t i v e l y , m o n i t o r t h e CONTROLLED GROUP. WHICH IS THE O P E N DOOR MINISTRIES, THEY WOULD RECRUIT MEMBERS OFTHEIR CHURCH BASED SPIRITUALITY GROUP WHO ARE IN RECOVERY TO PARTICIPATE IN THE PROJECT IN ORDER TO TEST THE HYPOSTASIS OF THE PROJECT DESICN.

( 5 ) V o l u n t e e r s f o r f a m i l y s u p p o r t c o u n s e l i n g a r e :

( 1 ) D r . S h i r l e y J o h n s o n , l i c e n s e d s u b s t a n c e a b u s e a n d a i d s c o u n s e l o r . ( 2 ) S h a l l o n C o l e n l a n , P r o g r a m c o o r d i n a t o r o f p e o p l e t a k i n g c h a r g e . W e s l e i C o m m u n i t y C e n t e r . ( 3 ) C a r l i n e W o r t h , t o f u n c t i o n a s c h r i s t l a n s u b s t a n c e a b u s e c o u n s e l o r , a n d c o o r d i n a t o r OF SUPPORT SERVICES, A N D D IR E C T O R OF RECOVERY MINISTRY A T VICTORY C h u r c h .

(6 ) R e s e a r c h St r a t e g i e s :

V o l u n t e e r s t o d e v e l o p p r e a n d p o s t e v a l u a t i v e t o t o o l f o r m i n i s t r y : R e v . B e v e r l y L e e , D r S i u r l e y J o h n s o n , P a s t o r R o s u n d e ’C N i c h o l s . T h e t o o l i s u s e d TO DETERMINE THE GROWTH OF THEIR SPIRITUALITY OVER A THREE TO SIX MONTH PERIOD . EACH PARTICIPANT WILL nsnLALLY b e ASKED TO COMPLETE A SURVEY FORM FOLLOW ED BY A POST TEST.

( 7 ) C o n t e x t a s s o c l a t e s s u g g e s t e d t h a t w e e l i m i n a t e t h e i n t r o d u c t o r y s e n t e n c e . W HICH CREATES NECATIVE TENSION B E T W E E N T H E PU R PO SE PHILOSOPHY AND THEOLOGY OF EX IST IN G 12 STEP PROGRAMS AND O U R P R O JE C T DESIGN SPIRITUALITY TREA TM EN T MODEL. ALSO REVERSINC THE ORD ER O F THE L A S T SE N TE N CE TO INTRODUCE RESEARCH OBJECTIVES SECTION.

M e e t i n c w a s a d j o u r n e d w i t h a c l o s i n g p r a y e r b y R e v . B e v e r l y L e e .

S u b m i t t e d b y :

M a r y S k e l t o n P r o j e c t R e c o r d e r

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APPENDIX P

ADVERTISEMENTS

156

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O P E N DOOR

Moving From V IC T IM to V IC T O R Y A Wholistic Christ-Centered Approach to Recovery

Every Thursday a t 7:30 P.M.

G r e a t M u sic and Fellowship T estim on ies D y n a m ic Speakers Refreshm ents

O th e r Services :

S p iritu a l Nurturing Inform ation , Education, Prevention T ra n sitio n a l Counseling C o m m u n ity AfterCare

D irector : Pastor Rosunde C um m ings Nichols

For Information c a l l : 2 7 5 -7 9 9 3 or 2 6 2 - 3 5 2 0

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158

J >

W esley/St Andrew FeIlowship...Focusing on the CriminalJustice System P a ir D a v is a n d R obert E . Biekman - VietUjf St. A ndrrsr FtUmcship

I V ^»'c4eyl V Anbcw Fdjcs-Slup V.3 S Ssxmcxi ci KHC in the vska uf ihc Rake? Hn» trot v trfc t Iwtfijaaivvts ic rixsuA-itialvjuc Ob: brutes Ihc p a Ociwaa (he Acian Amman and Eso-Anwion ocmiariees.

3a t h e last issue of t h e A d v o c a to r a n a r tid c identifying h o w t h e Am erican crim inal |iistic e sy ste m im - . pingi'S un lairh u p o n m inorities, th e p o o r a n d African Americans in particular w a s w ritte n . M u c h o f th e

m aterial from th at a r ti d c is excerpted from a r e p o rt titled, "What Every A m erican Should K tia v .About the* C nm m al Justice System" p u b lish ed by th e N a tio n a l C e n te r on Institutions and A lternatives (visit th eir w e b s ite at w w w .gixsgle.com l. This a rticle is a c o n tin u a tio n o f th a t Holiday Edition article a n d focuses on w h a t p r e

ve n tiv e measures can b e u kc n to improve th e criminal justice system in America. T he crim inal justice system in A m erica is larger than any o th e r in tn e w orld b e c a u s e i: p u n ish e s le sso r

offenses m o re frequently a n d se v e re ly M in o r offenses such as DU'l. trespassing, disorderly c o n d u c t, a n d p o s session o f small amounts of illegal s u b s ta n c e s for personal use are treated in other in d u strialized nations as srxnal a n d m edical issues ra th e r th a n legal issu e s. N o t only are th e re m o re p e o p le in US p riso n s but p riso n p o p u la tio n s d o n o t reflect p o p u la tio n statistics.

T here a rc se v e n tim es a s many minorities in prisons as whites. These ra o a l d isparities a re explainer! by d isp a ra te law e n fo rc e m e n t p ra c tic e s (e.g. racial profiling. Airican Americans make up 12% or trie I S papulation, 13% o f the drug using population, bu t an amacing 74% o f the people sent to prison As m in o ritie s m ove through the system, they encounter harsher treatment at every ste p . Marginal disp a rities at arrest are c o m b in e d with m arginal disp a rities a t t h e bail, charging and sentencing riecisrors.

Knsv can communities becom e involved in reforming curcnrr.ina! justice s\stem ? T h e c o m m o n e le m en ts th a t underlie successful reform initiatives, particularly Ihnse organized a: tn e grass rants level a re ; a fte r- srhixil recreatio n al program s w h e r e c h ild re n re c e iv e m entoring, social support, a r d discipline. ed.n.at io n a! innovations th at m otivate c h ild 'e n to sta v in sc h o o l, job training linked to ]nu cTeation. c n m m u ritv b a s e d p o licing th e ra p e u tic interv en tio n s d e s i g r c d for p e o p le w ith m ir ta l health riif im lti- s a n d d 'u g addictions, p a rental in v n h e 'n e n r. F rn n an e c o n o m ic p e rsp e c tiv e , m ost community initiatives a re less th a r re v . p risons. T he

g re jtes: obstacles to im p le m e n tin g t h e s e p ro g ram s a re political will a n d revising m m i'-c o n tro l budget.- to fu n i s less nr .’aw enfo rc e m e n t apparatus icorrection and fcews more nr cnerjll public safety ■ :> r 'ie r u n r '.

Exam alcs of proven p ro v i'n lin r p ro g ra m s m ilu d e H ead Stan*. C hildren born m [.ir,.-;-. w h o a l t e r d H ead S t a r nave Hal’ as man-, crim in al arrests, a s th o se w ho do not a tte n d . A r.x h er is " d u g ;r •aim-nt*. A |

stud', o f drug treatment ir California revealed thar th e level of comma! act v i i v In program pan. ;i:>anN d e - | < re a re d tv. ht>% following tre a tm e n t. F-nally, recreation* is sil-ri a - an c»ffc~ t ve n-e.iris to r-d .i. r g i n n e . J >oun§ p e o p le ergac-ed m healthy activities. a r e li-si M-elv to he involved in gang or illegal a -Ii. t F u tu re is- I sues writ : V l - cn a idit/.m al p r v e r t v e measures to reform t> - tnmmal ju r n e S'.stem. ■

The O p e n D o o r C h a p e / i n v i t e s You t o F e l l o w s h i p j H e c o v e r y . 1 Ica lim }. 1 )e \: v e.'ctn cc ' !

The Oper.Tteor Chapetis o. eoBchoroCon. between. Utydey Community Goiter, Thojet Ctm, onL Comrarity Cbtrsres. Open-Tbor mirustty meets eocfuTtmrsdty eserirq at 7 3 0 pm. at Uiexfeq

Community Cents. CoS. 2S3-3SS6 lor irfsnrtfkio.

T h e A d v o c a t o r - S p r i n g 2 0 0 1

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Public service Announcement

“'CPCls/ 0002" Community Chapel extends an invitation to our brothers and sisters in the Recovery Community to come and ‘‘celebrate life.”as we walk together from "Victim to Victory.”

Every- Thursday evening at 7:15 p.m

Wesley community Center, 3730 Delphos Ave. at Oakridge.

Worship Menu:

Great Music, Dynamic Speakers, Victory Testimonies, Prayer Time,

Warm Fellowship & Refreshments

For transportation call: 2~5-7993.

Contact person: Gerald Davis (937)262-3520 Open Door Ministries

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APPENDIX Q

WORSHIP ACTIVITY FORM

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Open Door Worship Activity Form

Date_____________________

Opening Prayer

Praise Hymns 1.

3.______

Meditation for Living Title___

Scripture

Focus__

Sermon Title_____________________

Preacher

Sermon Focus_______________

Altar Response No.___________

Prayer Request Needs 1 2 . 3." 4." 5.] 6 . " 7." 8 . " 9." 1° ~

No. in Attendance

Submitted by_____________________________ . context associate

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APPENDIX R

SPIRITUAL TWELVE STEPS

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THE TWELVE STEPS AND RELATED SCRIPTURE

STEP ONE: We admitted we were powerless over alcohol and that our lives were unmanageable. “I know nothing good lives in me, that is, in my sinful nature. For I have the desire to do what is good, but I cannot carry it out." (Romans 7:18) STEP TWO: Came to believe that a power greater than ourselves could restore us to sanity. “For it is God who works in you to will and to act according to his good purpose." (Philippians 2:13) STEP THREE: Made a decision to turn our will and our lives over to the care o f God as we understood him. “Therefore, I urge you, brothers, in view o f God’s mercy, to offer your bodies as living sacrifices, holy and pleasing to God— which is your spiritual worship." (Romans 12:1) STEP FOUR: Made a searching and fearless moral inventory o f ourselves. “Let us examine our ways and test them, and let us return to the Lord.” (Lamentations 3:40) STEP FIVE: Admitted to God, to ourselves, and to another human being the exact nature o f our wrongs. “Therefore confess your sins to each other and pray for each other so that you may be healed." (James 5:16a) STEP SIX: Were entirely ready to have God remove all these defects o f character. “Humble yourself before the Lord, and he will lift you up ” (James 4:10) STEP SEVEN: Humbly asked him to remove our shortcomings. “If we confess our sins, he is faithful and just and will forgive us our sins and purify us from all unrighteousness." (1 John 1:9) STEP EIGHT: Made a list o f all persons we had harmed and became willing to make amends to them all. “Do to others as you would have them do to you.” (Luke 6:31) STEP NINE: Made direct amends to such people wherever possible, except when to do so would injure them or others. “Therefore, if you are offering your gift at the altar and there remember that your brother has something against you, leave your gift there in front o f the altar. First go and be reconciled to your brother, then come and offer your gift." (Matthew 5:23-24) STEP TEN: Continued to take personal inventory and, when we were wrong, promptly admitted it. “So, if you think you are standing firm, be careful that you don’t fall.” (1 Corinthians 10:12) STEP ELEVEN: Sought through prayer and meditation to improve our conscious contact with God as we understood him, praying only for knowledge o f his will for us and the power to carry that out. “Let the word o f Christ dwell in you richly." (Colossians 3:16a) STEP TWELVE: Having had a spiritual awakening as a result o f these steps, we tried to carry this message to others, and to practice these principles in all our affairs. “Brothers, if someone is caught in a sin, you who are spiritual should restore him gently. But watch yourself, or you also may be tempted.” (Galatians 6:1)

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APPENDIX S

OPEN DOOR HIGHLIGHTS

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Open Door Ministry Annual Anniversary Celebration

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GLOSSARY

Bathos. Depth, a. the depth o f a stratum and b. depth as a dimension. Also used figuratively for greatness or inscrutability in relation to God o r the world.1

Dry drunk. A person who is not drinking, but has not made any changes in lifestyle. This word is included in a glossary o f terms developed by Sinclair Community College for use in a substance abuse counseling curriculum. In some areas o f the United States the term is used to define siblings o f chemically dependent parents who are not using, but their lifestyle exhibits the same addicted behaviors.

Dynamis. [ability, possibility, power] physical or intellectual or spiritual.2 «

Empirical. Relying on experience or observation alone without regard for consideration o f systems, science, or theory.

Kindom. Contemporary term used by some feminist theologians and scholars to replace the traditional, gender-biased, hierarchal term, kingdom. Kindom is used to emphasize inclusivity, equality, and community.

Pathos. Emotion, passion, suffering or death.3

Phenomenology. The view o f research that holds that human beings can be understood in a way that other objects o f study cannot.

Sobriety. The condition o f a person who is not drinking or using illegal substances and has chosen to make positive changes in their lifestyle

Terra Firma. Solid ground.4

1 Geoffrey W. Bromiley. ed.. The Theological Dictionary o f The New Testament (Grand Rapids: William B. Eerdmans. 1990). 89.

2 Ibid.. 186.

3 Ibid.. 789.

4 The Merriam-Webster D ictionary (Springfield. MA: Mcm'am-Webster, 1995), 532.

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Thirteen-Stepper. An addict who frequents Alcoholic Anonymous or Narcotics Anonymous for the purpose o f developing relationships for sexual exploitation, rather than for the therapeutic benefits o f the organization.

Wholistic. The treatment o f nurturing substance abusers back to health and sobriety through an interdisciplinary team treatment approach, utilizing a combination o f Christ-centered spirituality and clinical and medical expertise. This term is used commonly by professionals where there is a need for an interdisciplinary approach for the treatment o f clients or patients in a counseling, educational, or medical setting. Often in clergy or alternative medicine circles, when there is a strong emphasis on spirituality or healing, the spelling o f this term is “holistic.”

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BIBLIOGRAPHY

“Balm in Gilead.’’ Songs o f Zion. Nashville: Abingdon Press, 1981.

Barclay, William. The M ind o f Jesus. New York: Harper and Brothers, 1961.

Breaking the Chains o f Addiction. Worship Bulletin Cover. Nashville: Abingdon Press, 1992.

Brueggemann. Walter. The Prophetic Imagination. Minneapolis: Fortress Press, 1978.

Building a People o f Power. Video Series. Sessions 6-7. Colorado Springs: Crown Ministries International. 2000.

Century Commentary. “Luke.’’

Cheshire, Barbara. The Best Dissertation is A Finished Dissertation. Portland, OR: National Book Co.. 1993.

CitiPlan Dayton: The 20/20 Vision o f Dayton Comprehensive Plan. May 1999.

Creswell, John. Research and Design: Qualitative and Quantitative Approaches. Thousand Oaks, CA: Sage Productions, 1994.

Davis, Robert C., Arthur J. Lurigio. and Dennis P. Rosenbaum, eds. Drugs and the Community. Springfield, IL: Charles C. Thomas, 1993.

Day, Albert E. Letters on the Healing Ministry. Nashville: Disciplined Order o f Christ, 1990.

Dunbar. Paul Laurence. “We Wear the Mask.’’ In Breaking the Chains o f Cocaine. Oliver J. Johnson. Chicago: Images, 1992.

Felder, Cain Hope, ed. Stony the Road. Minneapolis: Fortress Press, 1991.

“God Is a God.” Songs o f Zion. Nashville: Abingdon Press, 1981.

Hertig, Paul. M atthew’s Narrative Use o f Galilee and Missiological Journeys o f Jesus. Mellen Biblical Series, vol. 46:10.

176

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Interpretation Commentary. “L uke."

Linthicum. Robert C. City o f God—City o f Satan. Grand Rapids: Zondervan, 1991.

___________ . Empowering the Poor. Monrovia. CA: MARC/World Vision Publishers. 1999.

Montgomery County Dept, o f Community Human Services. Montgomery County’s Socio- Economic Profile, 1996.

Loder, Ted. Guerrillas o f Grace. San Diego: LuraMedia, 1984.

Lusane, Charles. Pipe Dream Blues: Racism & The War on Drugs. Boston: South End Press, 1990.

Pearson, Mark A. Christian Healing. Grand Rapids: Chosen Books. 1994.

Proctor. Samuel D. Preaching About Crisis in the Community. Philadelphia: Westminster Press. 1988.

____________ . Samuel Proctor, My Moral Odyssey. Valley Forge, PA: Judson Press. 1989.

Statistics. Dayton Planning Board/Southwest Priority Data, 1990.

Stewart III, Carlyle Fielding. Street Corner Theology. Nashville: Winston. 1996.

The Life Recovery Bible: New Living Translation. Wheaton, IL: Tyndale House Publisher. 1998.

The New International Version o f The Holy Bible.

The New Interpreter s Bible. "Luke.''

U.S. Department o f Health and Human Services. Substance Abuse and Mental Health Services Administration. Alcohol, Tobacco, and Other Drug Abuse: Challenges and Responses fo r Faith Leaders. Washington, D.C., 1995.

Wagner, James K. An Adventure in Healing and Wholeness. Nashville: Upper Room Books. 1993.

Williams. Cecil. No Hiding Place, New York: Harper Collins, 1992.

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Wink, Waiter. The Powers That Be. New York: Doubleday, 1998.

Young, Henry James, ed. God and Human Freedom: A Festschrift in Honor o f Howard Thurman. Richmond, IN: Friends United Press, 1983.

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_______________________________________________________________ Report Information from ProQuest June 19 2016 18:25 _______________________________________________________________

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Table of contents

1. Targeting Opioid-Induced Hyperalgesia in Clinical Treatment: Neurobiological Considerations................. 1

19 June 2016 ii ProQuest

Document 1 of 1 Targeting Opioid-Induced Hyperalgesia in Clinical Treatment: Neurobiological Considerations Author: Arout, Caroline A; Edens, Ellen; Petrakis, Ismene L; Sofuoglu, Mehmet ProQuest document link Abstract: Clinical use of opioids is further complicated by an increasingly deleterious profile of side effects beyond addiction, including tolerance and opioid-induced hyperalgesia (OIH), where OIH is defined as an increased sensitivity to already painful stimuli. This paradoxical state of increased nociception results from acute and long-term exposure to opioids, and appears to develop in a substantial subset of patients using opioids. Recently, there has been considerable interest in developing an efficacious treatment regimen for acute and chronic pain. However, there are currently no well-established treatments for OIH. Several substrates have emerged as potential modulators of OIH, including the N-methyl-D-aspartate and c-aminobutyric acid receptors, and most notably, the innate neuroimmune system. This review summarizes the neurobiology of OIH in the context of clinical treatment; specifically, the authors review evidence for several pathways that show promise for the treatment of pain going forward, as prospective adjuvants to opioid analgesics. Overall, they suggest that this paradoxical state be considered an additional target of clinical treatment for chronic pain. Links: Linking Service Full text: Headnote Published online: 4 July 2015 ©Springer International Publishing Switzerland 2015 Abstract Opioid analgesics have become a cornerstone in the treatment of moderate to severe pain, resulting in a steady rise of opioid prescriptions. Subsequently, there has been a striking increase in the number of opioid- dependent individuals, opioid-related overdoses, and fatalities. Clinical use of opioids is further complicated by an increasingly deleterious profile of side effects beyond addiction, including tolerance and opioid-induced hyperalgesia (OIH), where OIH is defined as an increased sensitivity to already painful stimuli. This paradoxical state of increased nociception results from acute and long-term exposure to opioids, and appears to develop in a substantial subset of patients using opioids. Recently, there has been considerable interest in developing an efficacious treatment regimen for acute and chronic pain. However, there are currently no well-established treatments for OIH. Several substrates have emerged as potential modulators of OIH, including the N-methyl-D- aspartate and γ-aminobutyric acid receptors, and most notably, the innate neuroimmune system. This review summarizes the neurobiology of OIH in the context of clinical treatment; specifically, we review evidence for several pathways that show promise for the treatment of pain going forward, as prospective adjuvants to opioid analgesics. Overall, we suggest that this paradoxical state be considered an additional target of clinical treatment for chronic pain. 1 Introduction In 1870, English physician T. Clifford Albutt chronicled the first documented observation of increased pain sensitivity, or hyperalgesia, resulting from opioid exposure. He stated ''At such time, I have certainly felt it a great responsibility to say that pain, which I know is an evil, is less injurious than morphia, which may be an evil. I have much reason to suspect that a reliance upon hypodermic morphia only ended in a curious state of perpetuated pain''. In his discourse, he questioned whether morphine ''tends to encourage the very pain it pretends to relieve'' [1]. Over 140 years later, we are only beginning to unravel the enigmatic mechanisms underlying this paradoxical phenomenon and are ultimately coming to the realization that Albutt's observations were likely accurate. Predicated from a sample of non-institutionalized adults in the US, an estimated 100 million people suffer from

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some form of chronic pain [2], with an approximate 25 million experiencing moderate to severe, debilitating pain [3]. Encompassing a range of chronic pain states, estimates of cost range from US$560 to US$635 billion each year [2]. It is notable that the estimated 33 % prevalence rate for chronic pain in the US appears to be higher when compared with other countries; for instance, sample estimates for India were approximately 13 % [4], while another study reported chronic pain in 22 % of women versus 17 % of men in a Danish sample [5]. Further, an Australian study reported chronic pain in 19 % of their primary care sample [6], while a Canadian study reported similar estimates in 2011 [7]. The assertion by the US Joint Commission on Accreditation of Health Care Organizations that pain be considered ''the fifth vital sign'' has resulted in an increased focus on providing treatment for chronic non-cancer pain. This assertion has been criticized by some, as pain is more accurately perceived as a subjective, multidimensional symptom rather than an objective sign [8]. Nonetheless, limited availability of alternative therapies often leaves opioid pharmacotherapy as the only viable option, the result of which has been a dramatic increase in prescription of high-dose opioids for chronic pain. Opioids have become the most frequently prescribed drug class, surpassing 259 million prescriptions in 2012 in the US [9]; this increase in number of prescriptions has given rise to a drastic increase in the rate of opioid addiction, along with a striking increase in the number of deaths due to prescription opioids. Of particular concern is that the majority of fatal opioid overdoses (50-80 %) have occurred in patients with a history of chronic pain [10]on prescribed opioid regimens [11]. Particularly disconcerting is that opioid prescription is at its highest in spite of reports questioning the efficacy of long-term opioids for chronic pain, and supporting a dose- dependent risk in misuse, addiction, overdose, and death [3, 12]. In fact, one observational study reported that 90 % of patients presenting to a pain management center were already on an opioid regimen [13], suggestive of either inadequate pain relief, addiction, or both. A solid estimate of patients presenting with chronic pain and a comorbid opioid use disorder (OUD) is not available, is likely dependent on duration and dose of opioid prescription [14], and reportedly ranges between 3-40 % [15]. Furthermore, OUD has an estimated economic cost of US$72.5 billion in healthcare services in the US [16], and those who abuse this drug class generate an average annual healthcare cost that is 8.7 times higher than non-abusers [17]. Opioids are associated with multiple adverse effects that include respiratory depression, constipation, cardiovascular issues such as hypotension and bradycardia, and a high abuse liability [18]. Furthermore, opioids elicit a paradoxical state of increased pain sensitivity, known as opioidinduced hyperalgesia (OIH). OIH manifests as an increased pain sensitivity that leads to higher opioid consumption, and in turn putatively diminishes overall pain relief [19, 20]. Further, OIH may interfere with the patient's overall chronic pain treatment outcome and has the potential to propagate addiction. Thus, it has been suggested that OIH be considered a treatment target in addition to analgesia to ultimately improve management of patients treated with opioids [21- 23]. The purpose of this review is to evaluate what is currently known about the neurobiological substrates of OIH, to encapsulate the human studies on pharmacological treatments for OIH, and to recommend future considerations for addressing OIH in clinical settings. To provide background for our review, we first provide definitions for OIH and similar phenomena such as tolerance and sensitization. We then summarize the recent advances on the neurobiological mechanisms of OIH, and address issues related to assessment of OIH in preclinical and clinical studies. Several relevant systematic reviews of OIH have been published recently [20-22, 24-26]; our review extends the previous work by providing an updated evaluation of the field with a focus on viable clinical treatment targets. 2 Methods Between August 2014 and April 2015, a search of PubMed, EMBASE, and Google Scholar was conducted to retrieve articles related to OIH. Specifically, both original reports and past review articles pertaining to OIH's definition, prevalence, measurement, relationship to other opioid-induced phenomena, underlying neurological

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substrates, and treatment paradigms were sought. Search terms included the following: opioid-induced hyperalgesia, pain, opioid use disorder, NMDA receptor, GABA receptor, glia, gabapentinoids, neurosteroids, and cannabinoids. All terms were filtered by either animal or human studies when relevant. 3 Definition and Theories of Opioid-Induced Hyperalgesia (OIH) Following opioid exposure, OIH contrasts analgesia (relief from pain) and antinociception (decreased pain sensitivity), and manifests as subjectively perceived increased pain sensitivity to an already painful stimulus. OIH frequently includes allodynia, which is pain evoked by a stimulus that is not under normal circumstances considered painful [22, 27]. Perhaps most notable is that this increased pain sensitivity is diffuse and often manifests beyond the area of original pain, is independent of the condition that the opioids were initially prescribed for, and persists or even worsens after dose escalation of opioids [28-30]. There are several prominent theories underlying OIH. Perhaps the most intensely debated theory, though recently largely unsupported, is that OIH is a causative factor in analgesic tolerance (see Sect. 3.2). Specifically, the increased pain sensitivity that one experiences after opioid treatment causes the need for increasing doses of opioids, thus reflective of tolerance [31-33]. A second theory has postulated a role for pronociceptive opioid metabolites, specifically resulting from morphine biotransformation. However, recent studies have suggested otherwise (see Sect. 4.4). A third prevalent theory is that OIH is an adaptive response that serves as a systems- level opponent process in response to opioid analgesia after prolonged opioid treatment. That is, as the body works to retain homeostasis, one's adaptive response to exogenously elicited analgesia is to create an opposing state of hyperalgesia in an effort to regain physiological equilibrium [19, 34-36]. Finally, a fourth theory that is gaining popularity, and is related to the aforementioned opponent process, is that OIH is the result of a glial-regulated immune response (see Sect. 4.2)[37, 38]. 3.1 Prevalence of OIH in Humans OIH is observed in patients who utilize opioids with both acute and chronic administration, though its overall prevalence remains indeterminate. The closest estimates indicate that a disconcerting proportion of patients present with what may be OIH; for instance, Mercadante et al. [39] reported nearly 14 % of 81 patients with cancer experienced diffuse pain not otherwise explained by patient history or disease progression, which was unresponsive to morphine titration and alleviated only by rotation to methadone. Ackerman [40] described a similar outcome in 28 % of a sample of 197 patients with chronic pain receiving opioids. While some studies suggest that OIH develops after chronic opioid use [41-43], both rodent [44, 45] and human studies [46-49] have documented OIH within hours of acute opioid administration. Studies using shorter-acting opioids such as remifentanil, sufentanil, fentanyl, and morphine provide the most suspicion of OIH [49-56]; however, there is documentation of this phenomenon in patients receiving long-acting opioids (e.g., methadone or buprenorphine) as well [23, 43, 57-60]. Though ample preclinical studies spanning over three decades provide evidence for OIH, clinical studies have several notable limitations which challenge accurate assessment and thus prevalence estimates of OIH. Of primary concern is the fact that studies investigating OIH often utilize different measures of pain (e.g., thermal or cold stimulation) that may not be related to clinical pain, so interpretation and comparison between studies becomes difficult. These limitations led some authors to question the validity of OIH in humans [20, 25, 61]. Secondly, the numerous populations under study likely influence the evaluation of OIH. Specifically, a majority of existing clinical studies of OIH focus on several cohorts: healthy volunteers receiving acute opioids while undergoing human experimental pain testing [62-65], those with acute pain following various surgical procedures [51-53, 66, 67], patients suffering from chronic pain [41, 68-70] or chronic illnesses such as cancer [50, 71-74], and populations of individuals with OUD [23, 43, 57-60]. Third, OIH does not manifest in all patients receiving opioids; individual differences, including psychological factors, likely play a role in whether one develops OIH following opioid exposure, though research on this topic is needed. Finally, distinguishing OIH from tolerance and opioid withdrawal remains a challenge in clinical settings, as these phenomena share similar

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features, but are indeed distinct (Sects. 3.2, 3.3; Table 1). For instance, many studies assessing OIH, particularly under surgical contexts, are often criticized for not accurately measuring OIH but rather opioid tolerance and/or withdrawal. Specifically, a hallmark outcome of these studies is an increase in postoperative opioid consumption following abrupt termination of an acute, fastacting opioid, indicative of tolerance and/or withdrawal rather than OIH [20, 25]. As outlined in Tables 1 and 2, OIH, opioid tolerance, opioid withdrawal, and OUD have distinct clinical features and thus can be separated. 3.2 OIH versus Tolerance OIH is often associated with development of analgesic tolerance, defined as decreased analgesic potency following prolonged opioid administration [18, 75]. While it has been commonly believed that analgesic tolerance and OIH are synonymous, both preclinical and clinical studies have indicated that OIH is unrelated to prior opioid analgesia or tolerance [42, 68, 76-78]. In an attempt to elucidate the clinical ambiguity between tolerance and OIH, Chen et al. [30] distributed a survey to 1408 US practitioners consisting of targeted questions that assessed their clinical experiences with opioid treatment. The results identified a significant knowledge gap in the differentiation of tolerance versus OIH; the distinguishing factor was the finding that increasing opioid dose overcomes tolerance, but leaves OIH unresolved [30]. Most striking is the finding that a hyperalgesic patient subject to upward dose titration experiences a significant worsening of diffuse hyperalgesic symptoms as the opioid dose increases [18]. As such, effectively treating chronic pain while adjusting for tolerance and attempting to define and avoid hyperalgesia becomes a difficult clinical problem (see Table 2 for suggested criteria for diagnosing OIH). 3.3 OIH's Relationship to Addiction An additional complexity is OIH's unexplored relationship with OUD. In the Diagnostic and Statistical Manual of Mental Disorders 4 (DSM-IV) [79], opioid use was diagnosed as either abuse or dependence, with the former being a less severe or early phase manifestation of the latter. However, the DSM-5 has combined abuse and dependence into a single diagnosis of OUD, measured on a continuum ranging from mild to severe. According to the DSM-5, OUD is defined as a pervasive pattern of opioid use despite significant consequences [80]. OUD includes criteria clusters for impaired control over drug use, social impairment, risky use, and pharmacological criteria that includes tolerance and withdrawal (Table 1)[80-82]. It is important to note that for individuals who are taking opioids under proper medical supervision, tolerance and withdrawal are expected and thus should be weighted appropriately when considering a diagnosis of OUD. It is possible that OIH may increase the likelihood of developing OUD. Specifically, OIH manifests as increased pain sensitivity, which could lead a patient to believe that they must consume more opioid than truly required to treat the original underlying pain condition. Furthermore, it is not clear if the hyperalgesia seen during opioid withdrawal is synonymous with OIH seen during continuous use, as preclinical studies have demonstrated a mechanistic difference [78, 83-86]. In the case of opioid withdrawal syndrome, hyperalgesia appears after abrupt termination of opioid use. For instance, in preclinical paradigms using discontinuous morphine delivery (i.e., multiple injections), hyperalgesia may be intensified by 'mini-withdrawal' episodes when compared with chronic administration paradigms [35, 87-89]. However, in the case of OIH, increased nociception persists or even worsens following continuous treatment with any one opioid [29, 42]. Further, case reports suggest that OIH typically dissipates after opioid cessation [50, 90]; however, only a handful of studies have investigated this directly, the results of which suggest that more than 1 month of abstinence is necessary for pain responses of former opioid users to approach that of healthy control participants. Specifically, Compton [91] reported the resolution of OIH in former opioid users abstinent for an average of 1 year, although Pud et al. [60] reported no change in reduced cold pressor pain tolerance after 1 month of opioid cessation in a similar population. Opioid overuse pain syndrome (OOPS) has recently been proposed by Mehendale et al. [8] to classify a subset of opioid users with chronic non-cancer pain who do not adequately respond to high doses of opioids, show signs of inappropriate use/OUD, have decreasing function despite opioid use, favor pharmacological

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treatments, and demonstrate OIH. Of particular importance, OOPS takes into consideration the biopsychosocial aspects of pain, noting that opioids also alleviate depression and anxiety related to pain catastrophizing, while also propagating euphoria. As such, the authors postulate that opioids may actually be treating the psychological response to pain more so than the physical pain itself. Such a diagnosis may be warranted in patients with chronic non-cancer pain who demonstrate the need for multidimensional treatment beyond the sole use of opioids, the latter of which should only be managed by a highly trained pain management physician as a last resort. In fact, it is recommended here that patients are tapered off opioids completely, and referred to other pharmacological and psychological interventions [8]. One should also note the distinction between OIH and pseudoaddiction, the latter representing scenarios in which a patient presents with drug-seeking behaviors/reports of increased pain as a result of insufficient treatment. In such a case, these behaviors cease once an effective pain management regimen is established [92]. 4 The Neurobiology of OIH Potential mechanisms underlying OIH have emerged from the escalating amount of attention this phenomenon has received over the past several decades. Perhaps most intriguing is the finding that OIH occurs independently of opioid receptors [42, 77, 93-96], and is not a consequence of either prior or concurrent opioid receptor activity [42]. As such, research spanning nearly two decades has focused on understanding how OIH manifests without direct involvement of the opioid receptor system, the main findings of which are summarized in the following sections. 4.1 Central Sensitization in OIH Prolonged opioid exposure leads to positive system adaptation, or central sensitization, that includes allodynia, hyperalgesia, and an expansion of the receptive field, which results in secondary hyperalgesia. In nociceptive pathways, sensitization specifically references increased synaptic transmission/efficacy in somatosensory neurons of the spinal dorsal horn, and thus pain hypersensitivity, following peripheral noxious as well as innocuous stimuli [97, 98]. Importantly, as central sensitization results in reduced nociceptive thresholds and the consequential phenotypic expression of pain, it is likely an important mechanism for the development of OIH [98, 99]. Specifically, OIH may result from sensitization of primary afferent neurons as well as microglia [98], resulting in neuroplastic changes of receptor systems in the peripheral and central nervous system that lead to enhanced production, release, and spread of excitatory neurotransmission. This, in turn, results in the suppressed reuptake or increased release of neurotransmitters such as glutamate and substance P, subsequent sensitization of pain pathways, and ultimately manifests as amplified subjective nociceptive responses [32, 33, 89, 97, 100]. For instance, cells in the dorsal horn that express G-protein coupled neurokinin-1 receptors (NK-1) have been shown to project to supraspinal areas that facilitate pain processing, and an upregulation of this receptor has been implicated in OIH [101]. The endogenous ligand for NK-1, substance P is an excitatory neurotransmitter synthesized by primary afferent nociceptors [102], and is released in the dorsal horn after noxious stimulation [103]. Importantly, substance P has a documented role in central sensitization-induced hyperalgesia accompanying inflammatory pain [100]. For instance, in pathological pain states, there is increased substance P release in primary afferents following noxious stimulation, resulting in the internalization of NK-1 receptors in both superficial regions and deep layers of the dorsal horn. Although this is the theorized neuronal substrate of inflammatory pain, this mechanism has been hypothesized to play a role in the neuronal plasticity associated with OIH [104]. For example, preclinical studies have shown that substance P administration evokes chemical, thermal, and mechanical hyperalgesia following either intermittent or chronic exposure to morphine. Further, OIH evoked by both systemic and intrathecal morphine elicits substance P activity and increases spinal NK-1 receptor expression, suggesting a strong role for central sensitization in this paradoxical pain state [33, 89, 100].

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In addition to the sensitization of afferent pathways, descending facilitation of nociception from the rostroventral medulla (RVM) has also been implicated in OIH. Specifically, this descending feedback has been found to increase spinal levels of the endogenous opioid peptide dynorphin [105-107]. Though originally proposed to be antinociceptive, dynorphin has more recently been found to be a paradoxically pronociceptive kappa-opioid receptor agonist, modulating synaptic transmission via non-opioid receptor mechanisms [107]. That is, dynorphin potentiates pronociception that is naloxone-insensitive by increasing neuronal receptive field size and sensitizing N-methyl-D-aspartate (NMDA) receptors, resulting in the increased release and subsequent binding of excitatory neurotransmitters (i.e., glutamate) as well as cytokines [108], and consequent release of intracellular calcium [107, 109]. For instance, preclinical studies indicate that intrathecal administration of dynorphin produces mechanical, tactile, and cold allodynia, and mechanical hyperalgesia that is blocked by NMDA receptor antagonism (MK-801 or LY235959), but is unresponsive to opioid receptor blockade. Additionally, dynorphin antiserum obfuscates morphine-induced hyperalgesia [107, 110, 111]. The results of these studies suggest a role for central sensitization involving endogenous opioids in the descending, facilitative control of OIH. 4.2 Neuroimmune Mechanisms Microglia are activated in response to drugs of abuse, including opioids, through activation of the toll-like receptor 4 (TLR4). As suggested by multiple studies, microglial activation results in reduction of the analgesic efficacy of opioids by development of tolerance and hyperalgesia. Specifically, microglia activation results in the release of pro-inflammatory cytokines [tumor necrosis factor (TNF)-a, interleukin (IL)-1b, and IL-6 and others], chemokines, lipid mediators of inflammation, matrix metalloproteases, excitatory amino acids, and nitric oxide [36, 38, 112-118], all of which enhance neuronal activation. The release of pro-inflammatory cytokines results in increased number and conductance of alpha-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate (AMPA) and NMDA receptors, and down-regulation of gammaaminobutyric acid (GABA) receptors [36, 38]. Thus, the consequence is neuronal hyperexcitability and pain enhancement [36, 116, 117, 119, 120]. This pronociceptive microglial activity suggests that OIH may be a neuroinflammatory response initiated in opposition to analgesia, resulting from prolonged exposure to exogenous opioids [34, 38, 117, 118]. Thus, it is plausible that these proinflammatory mediators (cytokines and chemokines) may be clinically assessed as a biomarker of microglial activation and thus potentially OIH [37, 112, 115, 121] (Fig. 1). Opioids have been shown to have direct actions on brain and spinal microglia [38, 115, 117, 119, 122-125]. Specifically, microglia express opioid receptors, though the behavioral significance of this remains unclear [113]. Of particular interest to microglia's role in neuroexcitatory opioid effects is TLR4, where morphine, buprenorphine, oxycodone, meperidine, methadone, fentanyl, and remifentanil are thought to exert significant agonist activity [36, 38, 114-116, 119, 120, 122, 126]. TLRs are innate immune pattern recognition receptors found primarily on microglia, and following inflammation, this receptor's activity is increased throughout the CNS. TLR4 stimulation is fundamental in the downstream activation of inflammatory transcription factors and release of proinflammatory factors [36, 117, 118, 127, 128] (Fig. 1). TLR4 agonists reportedly enhance pain, whereas antagonizing TLR4 activity by blockade of either TLR4 or downstream signaling, or the use of TLR4 knockout mice, show potentiated morphine analgesia and attenuated morphine tolerance [117]. Furthermore, TLR4 binds (-)- and opioid receptor-inactive (?)- ligands nonstereoselectively; thus, studies have found that (?)- and (-)- naloxone and (?)naltrexone stereoisomers block TLR4 signaling to suppress glial activation and neuropathic pain [36, 38, 116, 119, 120, 122, 129, 130]. While these studies indicate a potential role for TLR4 activation in OIH, other studies report conflicting evidence. For instance, a mouse model of OIH employed by the Kest lab utilizes concomitantly administered naltrexone in both acute and chronic models of OIH induced by either morphine [42] or fentanyl [44]. That is, while morphine analgesia is prevented in this paradigm, OIH persists in the presence of NTX, conceivably narrowing the possibility of morphine working directly via TLR4 to mediate hyperalgesia. However, further research is needed

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to determine the precise role, if any, that TLR4 has in OIH. 4.3 Neurotransmitter Mechanisms Both the glutamate and GABA neurotransmitter systems have been implicated in the development and maintenance of OIH. Their proposed role in modulating opioid effects is summarized in the following sections. 4.3.1 Glutamate The majority of research regarding the systems modulating OIH implicates a role for the NMDA receptor, for which glutamate is the endogenous ligand. The NMDA receptor system has a well-documented role in neural and behavioral plasticity, long-term potentiation, learning, and memory. In 1991, Trujillo and Akil [131] indicated a likely role for the NMDA receptor in the development of opioid tolerance and dependence, resulting from neural adaptations after repeated morphine exposure. As such, it is an excellent candidate receptor system for the study of the mechanism underlying opioid-induced effects, including OIH [131, 132]. NMDA receptors play a primary role in central sensitization and consequent inflammatory pain, although a knowledge base for the role it plays in peripheral sensitization and OIH is not comprehensively established [46, 133-135]. As opioids do not have any binding affinity for NMDA receptors and NMDA receptor antagonists do not negatively affect acute opioid analgesia, it is implausible that opioids directly interact with this receptor system [31]. However, NMDA receptors are present in particularly dense concentrations in areas of the CNS that modulate pain signaling such as dorsal root ganglia, superficial layers of the dorsal horn laminae, the thalamus, and the hippocampus [93]. NMDA receptors in the spinal dorsal horn [31, 136, 137] and RVM [32, 33] appear to be particularly associated with OIH. Thus, several NMDA receptor antagonist compounds have been found to reduce OIH in both animal and human research, further illustrating a substantial role for this system in the modulation and potential treatment of this nociceptive state [39, 42, 46, 64, 88, 93, 138, 139]. 4.3.2 GABA The GABA receptor system and the opioid receptor system are closely intertwined, both neuroanatomically and functionally. For instance, GABA neurons express opioid receptors, particularly l-opioid receptors, in multiple regions of the central nervous system critical to nociception [140, 141]. It has been suggested that chronic opioid administration leads to a downregulation of GABA receptors, resulting in decreased inhibition of pain signaling [36, 142]. Opioids exert their analgesic effects by inhibition of GABAergic neurons in the periaqueductal gray (PAG), a region critical to pain processing. Furthermore, opioid inhibition of GABA indirectly results in increased excitatory activity, and likely contributes excitatory opioid effects, including OIH [140, 143, 144]. For instance, a recent preclinical study demonstrated that morphine induces hyperalgesia by downregulating the K?/Cl- co- transporter KCC2, resulting in altered Cl- homeostasis in the dorsal horn. The authors suggest the clinical application to be the restoration of GABAA inhibition to restore Clhomeostasis in the dorsal horn, as this was effective in preventing OIH induced by morphine [78]. Another promising avenue of research is revealed in neurosteroids acting via the GABA receptor system. Neurosteroids bind to GABAA receptors to modulate a number of therapeutic effects (reviewed in Sect. 6.3.), including neuropathic pain [145-147]. As such, the GABA receptor system serves as a promising target of treatment in patients with OIH and warrants further investigation. 4.4 Opioid Metabolites Subsequent to the finding that morphine metabolites possessed pronociceptive properties, it was initially thought that opioid metabolites mediate OIH. However, more recent preclinical studies have suggested otherwise. For instance, mice possess a variant UDP-glucuronosyltransferase (UGT) isoform involved in glucuronidation, which allows only for the formation of M3G and no M6G following morphine administration [148]. Thus, M6G is likely uninvolved in OIH, as mice do not produce this metabolite but nonetheless exhibit hyperalgesia [149]. Further, Swartjes et al. [93] demonstrated an indirect relationship between OIH and blood plasma concentrations of M3G in mice. Specifically, the group found that trough plasma levels of M3G

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corresponded to peak levels of morphine, at which point hyperalgesia worsened. This finding was detrimental in that it suggests morphine itself as the mediator of OIH; however, human studies have reported conflicting results regarding subjective pain relief and the ratio of morphine to its metabolites [150-152]. Swartjes et al. [93] also reported that mice lacking the ability to export M3G from the liver into systemic circulation (MRP3-/- mice) also develop OIH after an acute morphine administration. Further, Arout et al. [45] reported that while morphine in combination with the opioid receptor antagonist naltrexone resulted in significantly less activation in the PAG during a hyperalgesic state, naltrexone combined with M3G resulted in no such reduction of activity. Finally, other opioids shown to produce hyperalgesia, such as fentanyl, do not yield any known pronociceptive metabolites [44, 153]. As such, a rationale for opioid metabolites in the modulation of hyperalgesia induced by administration of the parent opioid is implausible. 5 Prospective Treatments for OIH It is possible that OIH manifests as an adverse reaction to one particular opioid in an individual; as such, clinical findings indicate that opioid rotation [154] is sometimes sufficient to eliminate hyperalgesia and allodynia [39, 50, 71, 155]. Other studies suggest that downward dose titration [156-159] or complete discontinuation following detoxification [72, 91] is the most efficacious way to relieve this opioid-induced increased pain sensitivity. However, opioid discontinuation is not always a viable option; therefore, a solution that attenuates OIH such that the patient may continue benefitting from chronic opioids is needed. If a way to treat OIH can be elucidated, this will allow clinicians to continue prescribing opioids without concern over paradoxically increasing the very symptom they set out to treat: pain. Thus, adding adjuvant medications to opioids that target the receptor systems thought to underlie their hyperalgesic effects appears most promising (Table 3). As reviewed above, there are a multitude of receptor pathways implicated in the modulation of OIH. Thus far, a host of animal studies have found that OIH is reversible by the NMDA receptor antagonists MK-801 [31, 42, 160- 165], ketamine, or traxoprodil [93]. Human studies have found similar results by adding adjuvant ketamine [46, 54, 88, 166], as well as gabapentinoids such as pregabalin [49, 55] or gabapentin [23], or the cyclooxygenase-2 inhibitor parecoxib [48, 167], as reviewed in the subsequent sections. However, more recent research has shown that manipulating these substrates does not unequivocally resolve OIH. As such, other more recent studies have begun targeting other receptor systems in attempt to attenuate OIH in clinical treatment. 5.1 NMDA Receptor Antagonists 5.1.1 Ketamine Ketamine is a potent noncompetitive NMDA receptor antagonist, first used for surgical anesthesia, and later found to produce analgesia through a possible opioid receptor-mediated mechanism [134, 168, 169]. There is an abundance of preclinical and clinical literature describing the ability of ketamine to reverse various pain states, ranging from chronic neuropathic pain contexts to OIH [170-172]. A wealth of literature details ketamine's use as an adjuvant to several opioids in a perioperative context; for example, it has been found to significantly reduce the amount of postoperative opioid consumption, attenuate incisional hyperalgesia (Table 3), and in some cases enhance analgesia in both animal and clinical investigations [66, 134, 138, 173-180]. How precisely ketamine induces analgesia is somewhat nebulous; it demonstrates activity at several different receptor systems in addition to the NMDA and opioid receptor systems, and affects multiple neurotransmitter pathways including both the cholinergic and monoamine systems. Additionally, it is not entirely clear if the pain relieving properties are due to analgesia, or antihyperalgesia [134, 169]. Further, it has been suggested that ketamine's analgesic properties may be partially mediated by its active metabolite, norketamine. Norketamine has a longer half-life than ketamine itself, is yielded in higher concentrations than ketamine following biotransformation, and is proposed to significantly contribute to ketamine's analgesic effects [181-183]. Nonetheless, ketamine's use in clinical practice for pain is limited, despite promise in studies of chronic pain [184], as well as clinically applied and experimental pain models of OIH (Table 3), in part due to its

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cardiovascular and psychotropic side effects [172, 185]. Further, ketamine is administered intravenously in clinical practice, as oral formulations are not commercially available; thus, use of this drug for chronic pain management is currently challenging and warrants further research. 5.1.2 Dextromethorphan An antitussive drug, dextromethorphan is typically used as an over-the-counter cough suppressant, but has shown promise in pain suppression. Dextromethorphan antagonizes the spinal NMDA receptor system, and may manipulate opioid effects via this mechanism [186, 187]. Several studies have shown mixed results with dextromethorphan as an adjuvant medication in treating opioid tolerance [188-191] and withdrawal symptoms [192-197]. Numerous studies have cited dextromethorphan's ability to reduce intra- and post-operative morphine consumption [198- 200], while others have not replicated these findings [201, 202]. Accordingly, Compton et al. [203] sought to determine if dextromethorphan would alleviate OIH in methadone maintenance patients. Following a 5-week trial, this group found no effect of dextromethorphan on OIH, as assessed by the cold pressor test and electrical stimulation pain measures [203] (Table 3). To date, no other clinical trials have investigated dextromethorphan in the context of OIH during concurrent opioid use. 5.1.3 Other NMDA Receptor Antagonists While Swartjes and colleagues [93] attenuated hyperalgesia in rodents by administration of ketamine, they found additional evidence for the novel NR2B selective NMDA receptor antagonist traxoprodil in reversing hyperalgesia. Others have illustrated analgesic actions of this compound in rodents [204]. Such findings suggest a promising role for the NR2B subunit in particular in the development of OIH; this subunit densely populates both spinal and supraspinal sites such as the dorsal root ganglia, superficial layers of the dorsal horn laminae, the thalamus, hippocampus, and cortex [93]. Perhaps most appealing is that, in comparison with ketamine and other potent NMDA receptor antagonists, due to its selectivity for the NR2B subunit, traxoprodil appears to have limited psychotropic side effects. Thus, traxoprodil may be a plausible option for preventing or alleviating OIH. However, it is unexplored in this context, as only four animal studies [172, 204-206] have examined its potential use for the treatment of acute and chronic hyperalgesic states. The results of these studies suggest that although less potent when compared with ketamine, traxoprodil may be clinically efficacious for pain relief; further, it possesses few or no side effects when administered at analgesic doses. Several studies have demonstrated OIH in patients enrolled in methadone maintenance treatment [23, 43, 57- 60]. However, other studies have documented a reduction in OIH after patients were rotated onto methadone treatment. For instance, Axelrod and Reville [71] reported the success of methadone in reducing OIH in the case of a young girl suffering from cancer pain, who had previously been treated unsuccessfully with a multitude of other opioids. Additionally, Mercadante and colleagues [39] reported an individual case in which adjuvant methadone effectively reduced fentanyl-induced hyperalgesia. More recently, Mercadante et al. [39] reported the successful rotation of 12 patients to methadone, whose pain was originally unaffected by morphine. Methadone exhibits weak NMDA receptor-antagonistic properties; as such, it is plausible that a subset of patients that develop OIH resulting from other opioids may benefit from rotation to methadone. However, methadone's potential efficacy for OIH remains to be tested in randomized, controlled studies. 5.2 Gabapentinoids There are two gabapentinoids that are used clinically: pregabalin and gabapentin. Pregabalin was designed as an antiepileptic drug and manipulates a multitude of neurotransmitters including glutamate, norepinephrine, and substance P [207]. A host of clinical research has elucidated a role for pregabalin in alleviating both postoperative pain and neuropathic pain, and in 2004, pregabalin was approved by the FDA for the treatment of the latter [208]. Subsequently, one study has directly investigated the potential effect of pregabalin in patients receiving opioids. Specifically, Lee et al. [55] reported the attenuation of putative OIH in patients receiving intraoperative high-dose remifentanil by a single preoperative dose of pregabalin. A second study by Martinez et al. [49] combined pregabalin with ketamine, and reported that while patients who received only ketamine or

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pregabalin both demonstrated a significant decrease in postoperative morphine requirement, the combination of the two resulted in a significantly larger decrease in postoperative morphine. Thus, the combination of ketamine and pregabalin putatively offers a larger clinical benefit than the two in isolation (Table 3). As the impact of pregabalin on OIH is unclear, future studies should further investigate any potential benefit. The anticonvulsant drug gabapentin was originally designed as an analog of GABA for the treatment of spasticity. Since, it has shown promise in chronic pain states, although its mechanism for this indication is not clear. It appears as though gabapentin may inhibit NMDA receptors, calcium channels, and peripheral nerves through GABA-mediated pathways. While a host of literature exists describing the ability of gabapentin to effectively treat neuropathic pain, clinical pharmacological studies regarding its impact on OIH are nearly nonexistent [209]. In fact, there is only one direct investigation of gabapentin this context. Specifically, Compton et al. [23] found that gabapentin effectively reduced OIH over the course of 1 week, as measured by cold pressor test latencies, in former opioid addicts currently maintained on methadone replacement (Table 3). These promising findings need to be replicated in different clinical samples that display OIH. 5.3 Propranolol A b -adrenergic antagonist, propranolol was first administered to treat hypertension, and later found to attenuate anxiety. Following the results of a genetic study linking the b-adrenergic receptor to OIH [210], speculation arose regarding the clinical therapeutic effect of propranolol in treating OIH. Accordingly, Chu et al. [47] conducted a clinical trial in which propranolol effectively eliminated secondary hyperalgesia in healthy volunteers receiving remifentanil infusion and undergoing experimental pain testing (Table 3). As such, propranolol may prove useful in precluding OIH; however, further studies are needed. 5.4 Cyclooxygenase Inhibitors Cyclooxygenase (COX) is an enzyme that is important for the formation of prostaglandins, which are hormones with a large role in sustaining homeostasis and mediating physiological effects in the body [211]. One proposed function of prostaglandins is to regulate inflammation; accordingly, several studies have sought to investigate whether inhibition of this system would affect OIH by utilizing NSAIDs that directly target COX. Specifically, two experimental pain investigations in healthy volunteers found that administration of one such drug, parecoxib, differentially affected experimentally induced OIH following remifentanil infusion [48, 167] (Table 3). Further, Tröster et al. [167] reported that parecoxib augmented remifentanil-induced analgesia. Thus, COX inhibitors such as parecoxib may have therapeutic potential in alleviating OIH. 6 Future Considerations in OIH 6.1 Glial Targets To date, all approved medications for pain work by manipulating neuronal activity; however, more recent preclinical studies have suggested that other mechanisms be considered. Specifically, Hathway et al. [212] demonstrated hyperalgesia resulting from microglial central sensitization following brief, low-frequency stimulation of C-fibers in the dorsal horn, preventable by minocycline pretreatment. Importantly, these findings may have important implications for OIH; that pathological as well as physiological stimuli, the latter of which does not result in tissue damage, can lead to a microglial-regulated central sensitization state that is akin to that postulated in aberrant chronic pain [98, 212]. Further, co-administration of glial inhibitors has been found to potentiate opioid analgesia [117, 213, 214]; while their effects on OIH in clinical populations remain to be extensively studied, opioid administration does result in increased proinflammatory cytokine release and subsequent analgesic opposition [115]. Thus, it is feasible that glial inhibitors may attenuate OIH. In light of the growing recognition that microglia play an important role in the development of nociception, this system may serve as a novel treatment target for OIH. Accordingly, numerous groups are studying the potential of inhibiting the glial system to enhance treatment of pain. For instance, the glial inhibitor ibudilast (MN166) has shown promise in the treatment of allodynia in neuropathic pain in an animal model [215, 216]. Considering that neuropathic pain and OIH share similar neurobiology, it is quite possible that targeting this system in treatment

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would reduce OIH and, in turn, increase the efficacy of opioid treatment. Further, another study reported an ability of this drug to induce a [3-fold increase in morphine analgesic potency [214]. Though the majority of research on ibudilast is in the preclinical stage, it has completed safety testing in humans [217, 218] and is thus of interest for the treatment of OIH. A host of other glial-modifying agents have undergone animal testing in models of pain, the results of which are reviewed in Hameed et al. [127]. Minocycline has also shown promise in studies of pain, particularly in an animal model of morphine effects. Though minocycline has nonselective actions at both neuronal and glial cell types within the nervous system [219], its anti-inflammatory actions are theorized to be a result of its inhibitory influence on the latter [220, 221]. Studies have shown this tetracycline antibiotic microglial inhibitor to reduce negative aspects of morphine treatment (respiratory depression, tolerance, and reward) while augmenting analgesia [213, 222]. This is of particular interest for treatment of OIH in populations with opioid addiction; it is possible the minocycline could alleviate OIH while also potentially dampening the risk of addiction resulting from long-term opioid treatment. Appropriately, there is currently one ongoing clinical trial investigating the effects of this drug on OIH in opioid-maintained patients (NCT02359006; ClinicalTrials.gov). Interestingly, minocycline is also reported to have neuroprotective effects [219, 222, 223]. Studies should be undertaken to examine the role of these drugs in alleviating OIH, as a host of literature highlights a potential role of glia in both pain and opioid- induced effects [38, 113, 115, 117, 212]. 6.2 Cannabinoid Targets Since the successful cloning of the cannabinoid receptors in the early 1990s [224, 225], many studies have examined the therapeutic potential of the cannabinoids in the treatment of chronic pain. Several studies have found no pain relieving benefits of delta-9-tetrahydrocannabinol (THC). For instance, Attal et al. [226] reported negative findings of oral THC in patients with chronic neuropathic pain. Interestingly, Wallace et al. [227] reported a dose-dependent analgesic effect of inhaled cannabis on experimental capsaicin-induced pain in a study of healthy volunteers. Specifically, they found no effect with a low dose, and analgesia resulting from a medium dose. Other studies have found negative results in postoperative acute pain patients, where oral or smoked cannabis yielded no benefit and in some cases enhanced pain [227-230]. Redmond et al. [231] also reported no effect of nabilone in healthy volunteers undergoing experimental pain testing. These sporadic negative findings are perhaps due to differences in formulation, administration, and potentially a lack of effectiveness for said acute pain conditions. Overall, it seems that studies of cannabis under acute pain paradigms and in healthy volunteers do not yield reliable results [227-231]. In the context of chronic pain, preliminary results indicate that agonists of this receptor system effectively reduce pain resulting from various conditions such as cancer, neuropathic pain, rheumatoid arthritis, multiple sclerosis, fibromyalgia, and HIV, putatively via anti-inflammatory properties [232-242]. For example, Eisenberg et al. [243] reported successful use of inhaled cannabis for the treatment of chronic neuropathic pain; a single dose was found to reduce pain by 45 % within 20 min, lasting for approximately 90 min with minimal adverse reactions. Unfortunately, generalizability of such findings is complicated by variations in cannabis products employed, ranging from crude herbal cannabis to several pharmaceutically developed products (described in [244]). Additionally, there are a limited number of large-scale randomized clinical trials examining efficacy and determining risk- benefit [244]. With that said, a function for cannabinoids in pain is mechanistically logical, as this receptor system densely populates regions intricately involved in pain processing such as the PAG, RVM, the dorsal spinal cord, and microglia [244, 245]. As such, the cannabinoid system may yield interesting results when combined with opioid therapy to reduce pain sensitivity, thus potentially eliminating OIH. In fact, Narang et al. [233] found that the combination of dronabinol and opioids resulted in increased pain relief when compared with participants utilizing only opioids; this synergy between THC and opioids has been supported by some investigations [246], but not others [247]. However, no studies have evaluated the effect of cannabis on OIH. Future studies should investigate a potential relationship between opioids, the cannabinoid system, and OIH,

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such that cannabinoids may be used as adjuvants to long-term opioid treatment to attenuate OIH. 6.3 Neurosteroids Neurosteroids are steroidal hormones that are synthesized in the brain, and exert inhibitory effects mainly via GABAA receptors, glycine, and L- and T-type calcium channels [145-147, 248-251]. Among the most common neurosteroids are progesterone, pregnanolone, and allopregnanolone. Studies have revealed neurosteroids to have a therapeutic role in a number of conditions such as epilepsy, drug withdrawal-induced seizures, anxiety, premenstrual syndrome, stress, depression, and alcohol withdrawal. Furthermore, it is possible that some neurosteroids are produced in the nervous system in response to injury, exerting anti-inflammatory effects at the site of insult [145, 251]. Of particular relevance to pain and opioid research is neurosteroids' role in modulating neuronal plasticity and related activities of the nervous system, as well as their role in the sexual dimorphism of pain processing [145]. Subsequent to the finding that neurosteroids produce anesthesia in rat models and thus suppress pain sensation [252-254], neurosteroids have been found to promote analgesia [251, 255], and have documented efficacy in the treatment of neuropathic pain [145]. Whereas lower levels of testosterone or progesterone have been associated with low nociceptive thresholds, injecting these steroidal hormones has been found to elicit analgesia [251, 256-260]. Several studies have also found that higher levels of progesterone decrease anesthetic [261] and postoperative analgesic requirements [262]. For instance, Lee et al. [262] found that parturient women with higher than average serum progesterone levels required less anesthesia and postoperative analgesic during cesarean delivery. Due to their neuroprotective and antinociceptive effects [146], neurosteroids are a possible treatment target for alleviating OIH. Allopregnanolone in particular has shown promise in treating neuropathic pain (reviewed in [145]), and thus may be a potential candidate to attenuate OIH. While clinical use of neurosteroids is complicated by low bioavailability following rapid inactivation during metabolism, they have a favorable adverse effect profile and are markedly safer than currently available analgesics [145]. An interesting speculation lies in the potential connection between the aforementioned putatively dysregulated Clhomeostasis in OIH [78] and the use of neurosteroids to treat OIH; while the authors suggested the use of benzodiazepines to restore the GABA inhibition induced by opioids [78], this combination is hazardous in clinical practice and is increasingly advised against [263]. Thus, neurosteroids could potentially achieve the same restoration of GABA inhibition while minimizing hazardous contraindications. 7 Concluding Remarks This review highlights the importance of OIH in hindering the analgesic effects of opioids, especially with long- term opioid use. Additionally valuable would be considering OIH, in addition to analgesia, as a treatment target in the drug development process. Presently, clinical studies of OIH focus primarily on identifying this phenomenon in opioid-receiving populations, and determining its clinical relevance in regard to tolerance. To a lesser extent, there are studies investigating prevalence and methods to treat it; however, several methodological issues are present. Of primary concern is that while numerous investigations study OIH, it is not unequivocally recognized by clinicians due to a lack of a valid assessment tool to reliably separate OIH from tolerance or withdrawal, and aid in their diagnosis of suspected OIH. As a result, there are only a few studies examining the prevalence of OIH in clinical samples. Similarly, there is no consensus among researchers or practitioners as to the most appropriate method to detect OIH, as studies comparing the sensitivity and specificity of paradigms for detecting OIH are nearly nonexistent [264]. Furthermore, it has been reported that manipulations producing profound OIH on one pain assay may show no hyperalgesic liabilities on other assays, suggesting that OIH is both drug and modality specific. Animal studies also suggest that it is influenced by varying genetic backgrounds [265-268] and epigenetic factors [269], which needs to be further investigated in future human studies [270]. Secondly, most reports on successful treatment of OIH are case studies; there are few controlled experiments,

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and the few that exist are performed mostly in populations undergoing surgical procedures and subsequent short-term opioid treatment. In these scenarios, most patients are anesthetized with the short-acting opioid remifentanil, and subsequently given morphine in response to what is occasionally identified as remifentanil- induced hyperalgesia. While acute treatment of surgical pain is the scenario in which opioids were intended for, it is no longer the primary use, is not the sole context contributing to the rise in addiction, and thus does not accurately represent the modern day opioid-using population. Further, it is controversial as to whether these scenarios truly represent OIH, or are a manifestation of hyperalgesia resulting from opioid withdrawal. Future research should assess clinical manifestations of OIH in patients maintained on long-acting opioids for chronic pain conditions. Comprehensive analyses evaluating OIH in the entirety of opioid-consuming populations, using validated measures of pain with clinical relevance, are desperately needed, such that pain medicine can be fully informed with regard to this paradoxical, complicated state. OIH, in addition to analgesia, must be considered an aspect of chronic pain treatment, such that the efficacy of opioid therapy is increased by reducing the incidence of OIH in clinical practice. As highlighted by this review, there are several avenues of research that may prove fruitful in treating OIH via adjuvant pharmacotherapies. Perhaps the most promising route concerns glial mechanisms of inflammatory pain. As this area of study continues to bustle with new findings in the relationship between opioids and glia, we in the scientific community must address potential microglial inhibitors that may serve as effective adjuvants to opioids. Secondly, as the medical use of cannabinoids expands, we will likely see an increase in the number of patients reporting cannabis use for pain relief. As such, research is needed to assess the efficacy of cannabinoids in reducing OIH. Finally, OIH has been shown to manifest differently in females as compared with males, yet preclinical and clinical studies including both sexes are strikingly limited. Most studies utilize only males to eliminate hormonal influences, a variable that is proving to be of increasing importance in the effective treatment of chronic pain. The sexual dimorphism of OIH and pain in general is a fundamental characteristic that must not be ignored; future studies must be diligent in including both male and female participants, such that we may obtain the most accurate understanding of this paradoxical state of nociception. Author contributions C.A. Arout, E. Edens, I. Petrakis, and M. Sofuoglu have each significantly contributed to the concept, formulation, writing, and revision of this manuscript. Compliance with Ethical Standards Conflict of interest I. L. Petrakis reports a conflict of interest due to her role as a consultant for Alkermes. C. A. Arout, E. Edens, and M. Sofuoglu declare no conflicts of interest. Funding This manuscript was prepared for publication during C. A. Arout's postdoctoral fellowship (Grant # NIDA T32 DA007238; Principal Investigator: I. L. Petrakis), and is supported by Mental Illness Research, Education and Clinical Centers (MIRECC). Sidebar Key Points Opioid analgesic medications induce a paradoxical state of increased pain sensitivity, known as opioidinduced hyperalgesia, which likely interferes with patients' overall treatment outcomes. A unanimous method of diagnosing and treating opioid-induced hyperalgesia in clinical practice remains indeterminate. There are several promising avenues of research that may lead to an effective pharmacological treatment paradigm for opioid-induced hyperalgesia. References References 1. Albutt C. On the abuse of hypodermic injections of morphia. Practitioner. 1870;3:327-30. 2. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):715-24. 3. Reuben DB, Alvanzo AAH, Ashikaga T, Bogat GA, Callahan CM, Ruffing V, et al. National Institutes of Health

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250. Mitchell EA, Gentet LJ, Dempster J, Belelli D. GABAA and glycine receptor-mediated transmission in rat lamina II neurones: relevance to the analgesic actions of neuroactive steroids. J Physiol. 2007;583(3):1021-40. 251. Poisbeau P, Keller AF, Aouad M, Kamoun N, Groyer G, Schumacher M. Analgesic strategies aimed at stimulating the endogenous production of allopregnanolone. Front Cell Neurosci. 2014;8:174. 252. Cashin MF, Moravek V. The physiological action of cholesterol. Am J Physiol Leg Content. 1927;82(2):294-8. 253. Selye H. Anesthetic effect of steroid hormones. Exp Biol Med. 1941;46(1):116-21. 254. Selye H, Masson G. Additional steroids with luteoid activity. Science. 1942;358(96):2494. 255. Pathirathna S, Brimelow BC, Jagodic MM, Krishnan K, Jiang X, Zorumski CF, et al. New evidence that both T-type calcium channels and GABAA channels are responsible for the potent peripheral analgesic effects of 5alpha-reduced neuroactive steroids. Pain. 2005;114(3):429-43. 256. Kavaliers M, Wiebe JP. Analgesic effects of the progesterone metabolite, 3a-hydroxy-5a-pregnan-20-one, and possible modes of action in mice. Brain Res. 1987;415(2):393-8. 257. Frye CA, Duncan JE. Progesterone metabolites, effective at the GABAA receptor complex, attenuate pain sensitivity in rats. Brain Res. 1994;643(1):194-203. 258. Frye CA, Rhodes ME, Walf A, Harney JP. Testosterone enhances aggression of wild-type mice but not those deficient in type I 5a-reductase. Brain Res. 2002;948(1):165-70. 259. Frye CA, Walf AA, Rhodes ME, Harney JP. Progesterone enhances motor, anxiolytic, analgesic, and antidepressive behavior of wild-type mice, but not those deficient in type 1 5areductase. Brain Res. 2004;1004(1):116-24. 260. Pednekar JR, Mulgaonker VK. Role of testosterone on pain threshold in rats. Indian J Physiol Pharmacol. 1995;39(4):423-4. 261. Erden V, Yangn Z, Erkalp K, Delatioglu H, Bahçeci F, Seyhan A. Increased progesterone production during the luteal phase of menstruation may decrease anesthetic requirement. Anesth Analg. 2005;101(4):1007-11. 262. Lee J, Lee J, Ko S. The relationship between serum progesterone concentration and anesthetic and analgesic requirements: a prospective observational study of parturients undergoing cesarean delivery. Anesth Analg. 2014;119(4):901-5. 263. Gudin JA, Mogali S, Jones JD, Comer SD. Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med. 2013;125(4):115-30. 264. Krishnan S, Salter A, Sullivan T, Gentgall M, White J, Rolan P. Comparison of pain models to detect opioid-induced hyperalgesia. J Pain Res. 2012;5:99. 265. Mogil JS, Wilson SG, Bon K, Eun Lee S, Chung K, Raber P, et al. Heritability of nociception I: responses of 11 inbred mouse strains on 12 measures of nociception. Pain. 1999;80(1):67-82. 266. Mogil JS, Wilson SG, Bon K, Eun Lee S, Chung K, Raber P, et al. Heritability of nociception II.Types' of nociception revealed by genetic correlation analysis. Pain. 1999;80(1):83-93. 267. Liang DY, Liao G, Lighthall GK, Peltz G, Clark DJ. Genetic variants of the P-glycoprotein gene Abcb1b modulate opioidinduced hyperalgesia, tolerance and dependence. Pharmacogenet Genomics. 2006;16(11):825-35. 268. Liang DY, Liao G, Wang J, Usuka J, Guo Y, Peltz G, et al. A genetic analysis of opioid-induced hyperalgesia in mice. Anesthesiology. 2006;104(5):1054-62. 269. Liang DY, Li X, Clark JD. Epigenetic regulation of opioidinduced hyperalgesia, dependence, and tolerance in mice. J Pain. 2013;14(1):36-47. 270. Doehring A, Oertel BG, Sittl R, Lötsch J. Chronic opioid use is associated with increased DNA methylation correlating with increased clinical pain. PAIN^. 2013;154(1):15-23. AuthorAffiliation Caroline A. Arout 1* Ellen Edens1 * Ismene L. Petrakis1 * Mehmet Sofuoglu1

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&Caroline A. Arout [email protected] 1 Department of Psychiatry, Yale University School of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA Subject: Narcotics; Pain management; Drug therapy; Addictions; Studies; Drug dosages; Estimates; Drug overdose; Neurobiology; Location: United States--US Publication title: CNS Drugs Volume: 29 Issue: 6 Pages: 465-486 Number of pages: 22 Publication year: 2015 Publication date: Jun 2015 Year: 2015 Section: REVIEW ARTICLE Publisher: Springer Science & Business Media, Wolters Kluwer Health Adis International Place of publication: Auckland Country of publication: Netherlands Publication subject: Pharmacy And Pharmacology, Medical Sciences--Psychiatry And Neurology ISSN: 11727047 Source type: Scholarly Journals Language of publication: English Document type: Feature Document feature: Tables References ProQuest document ID: 1737513748 Document URL: http://ezp.waldenulibrary.org/login?url=http://search.proquest.com/docview/1737513748?accountid=14872 Copyright: Copyright Springer Science & Business Media Jun 2015 Last updated: 2015-11-30 Database: ProQuest Central

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1. Part 1 -- Nonconventional and Integrative Treatments of Alcohol and Substance Abuse............................ 1

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Document 1 of 1 Part 1 -- Nonconventional and Integrative Treatments of Alcohol and Substance Abuse Author: Lake, James, MD ProQuest document link Abstract (Abstract): Several herbs are used in traditional Chinese medicine to diminish alcohol craving, lessen alcohol absorption through the gut, or reduce symptoms of withdrawal.29 Kudzu (Radix puerariae) has been used as a treatment for alcohol abuse and dependence in Chinese medicine for almost 2000 years. Links: Linking Service Full text: The high cost to society of alcohol and drug abuse reflects a crisis of epidemic proportions that has not been adequately addressed by conventional treatment approaches, including mainstream pharmacologic treatments, psychotherapy, and social programs. The annual costs associated with alcohol and drug abuse in the United States were estimated to be $246 billion in 1992, the most recent year for which data are available.1 Results of controlled trials and patient surveys confirm that many of the conventional pharmacologic and psychosocial treatments for alcohol and drug abuse or dependence are only moderately effective in terms of discontinuation rates and long-term abstinence.2-4 In this context, it is important for psychiatrists and other mental health professionals to learn about promising nonconventional and integrative treatment strategies. In this 2-part column, I will concisely review the evidence for nonconventional and integrative treatments for symptoms related to alcohol and drug abuse, dependence, and withdrawal. Part 1 covers nonconventional and integrative treatments, the beneficial effects of which are achieved through a discrete biologic or pharmacologic mechanism of action. These modalities include dietary modifications; supplementation with specific vitamins, minerals, and amino acids; and use of medicinal herbs from disparate world systems of medicine. Part 2 will review the evidence for nonconventional and integrative treatments that are known to be beneficial but for which there is no evidence of direct biologic or pharmacologic effects. Modalities that will be reviewed in Part 2 include exercise, mindfulness training, cranial electrotherapy stimulation, virtual reality graded exposure therapy, light exposure therapy, acupuncture, and qigong. Nutrition and supplements Persons who chronically abuse alcohol are frequently malnourished because of malabsorption of essential nutrients through the mucosa of the stomach and small intestines, which results in reduced serum levels of thiamine, folate, and vitamin B6.5 Malnutrition contributes significantly to both the medical and the psychiatric consequences of chronic alcohol abuse. Hypoglycemia results from the toxic effects of alcohol on the liver and can manifest as confusion, anxiety, and impaired cognitive function. Rational approaches to the problems noted above include avoidance of refined carbohydrates and increased consumption of complex carbohydrates and quality food sources of protein. Persons with an alcohol use disorder who improve their general nutrition probably have a better chance of maintaining sobriety than those who do not.6,7 Findings from animal studies suggest that low serum thiamine levels may be related to increased alcohol craving.8 Niacin taken in the form of nicotinamide (1.25 g) with a meal before drinking may protect the liver against the acute toxic effects of alcohol in persons who are unable to abstain.9 When a patient is unable to stop drinking, taking antioxidant vitamins close to the time of alcohol consumption may reduce or prevent hangover symptoms by neutralizing the metabolites of alcohol that cause oxidative damage to the brain.10,11 Taking vitamin C (2 g) 1 hour before alcohol consumption increases the rate at which alcohol is cleared from the blood, possibly reducing acute toxic effects on the liver.12 Deficiencies in zinc, copper, manganese, and iron are common in persons who abuse alcohol and worsen with continued heavy drinking. Magnesium supplementation at 500 to 1500 mg/d may improve the

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neuropsychological deficits associated with chronic alcohol abuse by improving cerebral blood flow, which is often diminished in these patients.13 There are no contraindications to dietary modifications or supplementation with the vitamins and minerals discussed here when taking conventional drug therapies for relapse prevention or the management of craving or withdrawal. All persons who struggle with alcohol abuse, or who are in recovery following chronic abuse, should be strongly encouraged to optimize their nutritional status by changing their eating habits and taking the appropriate supplements to compensate for a probable alcohol-related malabsorption syndrome, to mitigate the toxic effects of alcohol abuse on the body and brain, and to reduce craving and the severity of withdrawal. Amino acid deficiency Malnutrition and malabsorption in persons who chronically abuse alcohol often lead to deficiencies in important amino acids including taurine, S-adenosylmethionine (SAMe), tyrosine, l-tryptophan, and acetyl-l-carnitine. Supplementation with amino acids helps lessen the severity of withdrawal symptoms, protect the liver, and restore normal brain function in patients with chronic alcoholism. Taurine supplementation may lower the serum level of acetaldehyde, a toxic metabolite of alcohol that can interfere with normal mental function.14 In an early controlled trial, 60 patients hospitalized for acute alcohol withdrawal were randomly assigned to supplementation with taurine, 1 g 3 times daily, versus placebo. Significantly fewer severe withdrawal symptoms, including delirium and hallucinations, were observed in the taurine-treated group.15 SAMe that is normally present in the liver is depleted by chronic alcohol abuse. Persons who abuse alcohol but who take SAMe at dosages of 400 to 800 mg/d may have less severe liver damage.16-18 Because of its established antidepressant effects, SAMe is a logical choice when treating patients with depression who abuse alcohol.19 Preliminary findings suggest that SAMe supplementation may also reduce alcohol intake.20 Patients with alcohol use disorders who were abstaining were treated with acetyl-l-carnitine at dosages of 2 g/d for 3 months. These patients performed better on tests of memory, reasoning, and language compared with a matched control group.21 Preliminary findings suggest that tyrosine may be a useful adjunctive therapy in treatment of cocaine abuse.22 Low serum levels of l-tryptophan were correlated with low serotonin levels in a subset of persons with alcohol use disorders who were at increased risk for early-onset alcoholism associated with antisocial behavior. This suggests that long-term supplementation with l-tryptophan (or 5- hydroxytryptophan [5-HTP], the immediate precursor to serotonin) may be a useful preventive intervention in this high-risk population.23 Taking l-tryptophan before drinking may reduce the severity of the cognitive impairment associated with alcohol use.24 Available evidence suggests that safety problems are seldom reported when typically used therapeutic doses of quality-brand amino acid supplements are combined with conventional psychiatric medications.25,26 However, rare cases of serotonin syndrome have been reported when l-tryptophan, 5-HTP, or SAMe were used concurrently with serotonergic drugs. Therefore, patients using this integrative strategy should be closely monitored for emerging adverse effects.27,28 Safety concerns have not been reported when combining taurine or acetyl-l-carnitine with conventional psychiatric medications. Herbal treatments Several herbs are used in traditional Chinese medicine to diminish alcohol craving, lessen alcohol absorption through the gut, or reduce symptoms of withdrawal.29 Kudzu (Radix puerariae) has been used as a treatment for alcohol abuse and dependence in Chinese medicine for almost 2000 years. Kudzu extract significantly reduces alcohol craving in dependent animals.30 The reduced alcohol craving is probably related to the high plant concentrations of daidzein and daidzin-2 biologically active molecules categorized as isoflavones.31 In a weeklong placebo-controlled study, 14 heavy drinkers were pretreated with 1000 mg tid of kudzu versus placebo. Participants were given the opportunity to drink beer during the study. Persons who were pretreated with kudzu consumed significantly fewer beers; however, they did not report diminished alcohol craving. More

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studies are needed to confirm the effects of kudzu on reducing alcohol consumption in at-risk populations. Findings from a small open trial suggest that Mentat, a proprietary Ayurvedic compound herbal formula, may reduce the risk of relapse in abstinent alcoholics.32 Using Chinese medicinal herbs and conventional Western drugs concurrently poses complex issues, and few studies have been performed in this area.33 Until research findings suggest that specific combinations of Chinese herbs and conventional drugs have positive synergistic effects, it is prudent to advise patients to use only conventional Western medications or a specific Chinese herbal formula under appropriate medical supervision. Ashwagandha (Withania somnifera) is another important herb in traditional Ayurvedic medicine. Animal studies and case reports in humans suggest that ashwagandha lessens the severity of withdrawal symptoms from morphine.34,35 Because of its sedating properties, caution should be exercised when ashwagandha is used in combination with benzodiazepines or other conventional sedative-hypnotics. Preliminary findings suggest that ginseng (Panax ginseng) may reduce the tolerance and dependence associated with the long-term use of cocaine, methamphetamine, or morphine.36-38 The mechanism of action that is responsible for reduced tolerance observed with ginseng may involve inhibition of narcotic-induced depletion of dopamine in the brain.39 Early findings suggest that glycosides derived from Aristeguietia discolor, a plant used in traditional Peruvian medicine, reduce withdrawal symptoms in morphine-dependent persons.40 Dr Lake is in private practice in Monterey, Calif, and is on clinical faculty in the department of psychiatry and behavioral sciences at Stanford University Hospital. He co-chairs the American Psychiatric Association Caucus on Complementary, Alternative, and Integrative Care (www.APACAM.org) and is author of the Textbook of Integrative Mental Health Care (Thieme). References 1. Swan N. Drug abuse cost to society set at $97.7 billion, continuing steady increase since 1975. National Institute on Drug Abuse Web site. NIDA Notes. Available at: http://www.drugabuse.gov/ NIDA_Notes/NNVol13N4/ Abusecosts.html. Accessed November 27, 2006. 2. Carroll KM. Relapse prevention as a psychosocial treatment: a review of controlled clinical trials. Exp Clin Psychopharmacol. 1996;4:46-54. 3. McLellan AT, O'Brien CP, Metzger D, et al. How effective is substance abuse treatment-compared to what? In: O'Brien CP, Jaffee J, eds. Advances in Understanding the Addictive States. New York: Raven Press; 1992:231-252. 4. Emrick CD. Alcoholics Anonymous: affiliation processes and effectiveness as treatment. Alcohol Clin Exp Res. 1987;11:416-423. 5. Gloria L, Cravo M, Camilo ME, et al. Nutritional deficiencies in chronic alcoholics: relation to dietary intake and alcohol consumption. Am J Gastroenterol. 1997;92: 485-489. 6. Guenther R. The role of nutritional therapy in alcoholism treatment. Int J Biosocial Res. 1983;4:5-18. 7. Lieber CS. Alcohol, liver, and nutrition. J Am Coll Nutr. 1991;10:602-632. 8. Zimatkin SM, Zimatkina TI. Thiamine deficiency as predisposition to, and consequence of, increased alcohol consumption. Alcohol Alcohol. 1996;31:421-427. 9. Volpi E, Lucidi P, Cruciani G, et al. Nicotinamide counteracts alcohol-induced impairment of hepatic protein metabolism in humans. J Nutr. 1997;127:2199-2204. 10. Altura BM, Altura BT. Association of alcohol in brain injury, headaches, and stroke with brain-tissue and serum levels of ionized magnesium: a review of recent findings and mechanisms of action. Alcohol. 1999;19:119-130. 11. Marotta F, Safran P, Tajiri H, et al. Improvement of hemorheological abnormalities in alcoholics by an oral antioxidant. Hepatogastroenterology. 2001;48:511-517. 12. Chen MF, Boyce HW Jr, Hsu JM. Effect of ascorbic acid on plasma alcohol clearance. J Am Coll Nutr. 1990;

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9:185-189. 13. Thomson AD, Pratt OE, Jeyasingham M, Shaw GK. Alcohol and brain damage. Hum Toxicol. 1988;7:455- 463. 14. Watanabe A, Hobara N, Nagashima H. Lowering of liver acetaldehyde but not ethanol concentrations by pretreatment with taurine in ethanol-loaded rats. Experientia. 1985;41:1421-1422. 15. Ikeda H. Effects of taurine on alcohol withdrawal. Lancet. 1977;2:509. 16. Lieber CS. Role of oxidative stress and antioxidant therapy in alcoholic and nonalcoholic liver diseases. Adv Pharmacol. 1997;38:601-628. 17. Lieber CS. ALCOHOL: its metabolism and interaction with nutrients. Annu Rev Nutr. 2000;20:395-430. 18. Lieber CS. Alcoholic liver disease: new insights in pathogenesis lead to new treatments. J Hepatol. 2000;32 (suppl 1):S113-S128. 19. Agricola R, Dalla Verde G, Urani R, et al. S-adenosyl-l-methionine in the treatment of major depression complicating chronic alcoholism. Curr Ther Res. 1994;55:83-92. 20. Cibin M, Gentile N, Ferri M, et al. S-adenosyl-methionine (SAMe) is effective in reducing ethanol abuse in an outpatient program for alcoholics. In: Kuriyama K, Takada A, Ishii H, eds. Biomedical and Social Aspects of Alcohol and Alcoholism. Amsterdam: Elsevier; 1988:357-360. 21. Tempesta E, Troncon R, Janiri L, et al. Role of acetyl-l-carnitine in the treatment of cognitive deficit in chronic alcoholism. Int J Clin Pharmacol Res. 1990;10:101-107. 22. Tutton CS, Crayton JW. Current pharmacotherapies for cocaine abuse: a review. J Addict Dis. 1993;12:109- 127. 23. Virkkunen M, Linnoila M. Brain serotonin, type II alcoholism and impulsive violence. J Stud Alcohol Suppl. 1993;11:163-169. 24. Westrick ER, Shapiro AP, Nathan PE, Brick J. Dietary tryptophan reverses alcohol-induced impairment of facial recognition but not verbal recall. Alcohol Clin Exp Res. 1988;12:531-533. 25. Berlanga C, Ortega-Soto HA, Ontiveros M, Senties H. Efficacy of S-adenosyl-l-methionine in speeding the onset of action of imipramine. Psychiatry Res. 1992;44: 257-262. 26. Levitan RD, Shen JH, Jindal R, et al. Preliminary randomized double-blind placebo-controlled trial of tryptophan combined with fluoxetine to treat major depressive disorder: antidepressant and hypnotic effects. J Psychiatry Neurosci. 2000;25:337-346. 27. Turner EH, Loftis JM, Blackwell AD. Serotonin a la carte: supplementation with the serotonin precursor 5- hydroxytryptophan. Pharmacol Ther. 2006;109:325-338. 28. Pancheri P, Scapicchio P, Chiaie RD. A double-blind, randomized parallel-group, efficacy and safety study of intramuscular S-adenosyl-l-methionine 1,4-butanedisulphonate (SAMe) versus imipramine in patients with major depressive disorder. Int J Neuropsychopharmacol. 2002;5:287-294. 29. Colombo G, Agabio R, Lobina C, et al. From medicinal plants promising treatments for alcoholism. Fitoterapia. 1998;69(suppl 5):20. 30. Keung WM, Vallee BL. Daidzin and daidzein suppress free-choice ethanol intake by Syrian golden hamsters. Proc Natl Acad Sci U S A. 1993;90:10008-10012. 31. Lukas SE, Penetar D, Berko J, et al. An extract of the Chinese herbal root kudzu reduces alcohol drinking by heavy drinkers in a naturalistic setting. Alcohol Clin Exp Res. 2005;29:756-762. 32. Trivedi BT. A clinical trial on mentat. Probe. 1999; 38:226. 33. Lake J. The integration of traditional Chinese medicine (TCM) and Western medicine: focus on mental illness. Integrative Medicine: Integrating Conventional and Alternative Medicine. 2004;3:20-28. 34. Ramarao P, Rao KT, Srivastava RS, Ghosal S. Effects of glycowithanolides from Withania somnifera on morphine-induced inhibition of intestinal motility and tolerance to analgesia in mice. Phytother Res. 1995;9:66- 68.

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35. Kulkarni SK, Ninan I. Inhibition of morphine tolerance and dependence by Withania somnifera in mice. J Ethnopharmacol. 1997;57:213-217. 36. Kim HS, Jang CG, Lee MK. Antinarcotic effects of the standardized ginseng extract G115 on morphine. Planta Med. 1990;56:158-163. 37. Kim HS, Kang JG, Seong YH, et al. Blockade by ginseng total saponin of the development of cocaine induced reverse tolerance and dopamine receptor supersensitivity in mice. Pharmacol Biochem Behav. 1995; 50:23-27. 38. Huong NT, Matsumoto K, Yamasaki K, et al. Majonoside-R2, a major constituent of Vietnamese ginseng, attenuates opioid-induced antinociception. Pharmacol Biochem Behav. 1997;57:285-291. 39. Oh KW, Kim HS, Wagner GC. Ginseng total saponin inhibits the dopaminergic depletions induced by methamphetamine. Planta Med. 1997;63:80-81. 40. Capasso A, Saturnino P, Simone FD, Aquino R. Flavonol glycosides from Aristeguietia discolor reduce morphine withdrawal in vitro. Phytother Res. 2000;14: 538-540. http://www.psychiatrictimes.com/ Copyright 2007 CMP Media LLC. All rights reserved. Subject: Herbal medicine; Chinese medicine; Alcoholism; Drug abuse; Medical treatment; Substance abuse treatment; Publication title: Psychiatric Times Volume: 24 Issue: 2 Pages: 10 Number of pages: 0 Publication year: 2007 Publication date: Feb 2007 Year: 2007 Section: Integrative Medicine Publisher: UBM LLC Place of publication: Manhasset Country of publication: United States Publication subject: Medical Sciences--Psychiatry And Neurology ISSN: 08932905 Source type: Trade Journals Language of publication: English Document type: Feature Document feature: References ProQuest document ID: 204567348 Document URL: http://ezp.waldenulibrary.org/login?url=http://search.proquest.com/docview/204567348?accountid=14872

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1. TOWARD AN INTEGRAL MODEL OF ADDICTION: By Means of Integral Methodological Pluralism as a Metatheoretical and Integrative Conceptual Framework................................................................................. 1

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Document 1 of 1 TOWARD AN INTEGRAL MODEL OF ADDICTION: By Means of Integral Methodological Pluralism as a Metatheoretical and Integrative Conceptual Framework Author: du Plessis, Guy Pierre ProQuest document link Abstract: This article introduces and briefly outlines some orienting generalizations of an integrally informed model of addiction. I argue that by applying integral Theory as a metatheoretical and transdisciplinary framework, we may be able to arrive at a comprehensive integrative model of addiction that honors all the existing single-factor etiopathogenic models as well as the integrative and dynamic models. In order to examine any part of reality, one must employ a particular methodology. Integral Methodological Pluralism (IMP) acknowledges that there are at least eight methodological families we can use to study any phenomenon. In this article, I use IMP to sketch the outline of a comprehensive and integrative model of addiction. I will explore some of the most dominant explanatory models and theories of addiction derived from the sociopsychological and biomedical sciences, and point out how each model's theory is enacted by a particular methodology as represented by one or more of the eight zones of IMP. Finally, I propose that an Integral Model of Addiction has the potential to integrate all existing evidence-based explanatory models of addiction into a truly integrative, coherent, and comprehensive conceptual framework and metatheory of addiction. [PUBLICATION ABSTRACT] Links: Linking Service Full text: Headnote ABSTRACT This article introduces and briefly outlines some orienting generalizations of an integrally informed model of addiction. I argue that by applying integral Theory as a metatheoretical and transdisciplinary framework, we may be able to arrive at a comprehensive integrative model of addiction that honors all the existing single-factor etiopathogenic models as well as the integrative and dynamic models. In order to examine any part of reality, one must employ a particular methodology. Integral Methodological Pluralism (IMP) acknowledges that there are at least eight methodological families we can use to study any phenomenon. In this article, I use IMP to sketch the outline of a comprehensive and integrative model of addiction. I will explore some of the most dominant explanatory models and theories of addiction derived from the sociopsychological and biomedical sciences, and point out how each model's theory is enacted by a particular methodology as represented by one or more of the eight zones of IMP. Finally, I propose that an Integral Model of Addiction has the potential to integrate all existing evidence-based explanatory models of addiction into a truly integrative, coherent, and comprehensive conceptual framework and metatheory of addiction. KEY WORDS addiction; Integral Methodological Pluralism; Integral model; metatheory In the last resort a civilization depends on its general ideas; it is nothing but a spiritual structure of the dominant ideas expressing themselves in institutions and the subtle atmosphere of culture. If the soul of our civilization is to be saved we shall have to find new and fuller expression for the great saving unities - the unity of reality in all its range, the unity of life in all its forms, the unity of ideas throughout human civilization, and the unity of man's spirit with the mystery of the Cosmos in religious faith and aspiration. -Jan Smuts (1927, pp. v-vi)1 Addictions have beleaguered society since human beings first discovered they could alter their consciousness by ingesting certain substances.2 How a society views and understands addiction has great significance for addicted individuals seeking treatment. In premodern times addiction was often understood as possession by demons and a moral aberration, and its consequent treatment was similarly archaic. It is only in the last 100 years that scientific theories and explanations for addiction have come into existence, and as a result, treatment

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has become more effective (DiClemente, 2003). Some scholars suggest that substance abuse is currently the most significant health problem in the United States (Bevins &Bardo, 2004). Today, many theories and models of addiction exist. Some of the most prominent explanatory models include the social/environment models, genetic/physiological models, personality/intrapsychic models, coping/social learning models, conditioning/reinforcing models, and integrative models like the biopsychosocial model. Although our explanation of addiction has become more sophisticated, there are still serious shortcomings in our understanding of it (Sremac, 2010). Furthermore, there is such a cornucopia of theories and models of addiction that for treatment providers and policymakers, who see a direct link between etiology and treatment protocol, it has become exceedingly difficult to integrate this vast field of knowledge into effective treatment and prevention protocols. Robert West (2005) believes that another problem faced in addictionology is that each of the many existing theories of addiction seem to stem from an innovative idea that accounts for selected aspects of the problem, but which does not account for other features that existing theories already cater for adequately. Highlighting some of the reductionist problems faced in addiction science, West (2005) further states that: Unfortunately, the prevailing approach in the field of addiction, like behavioural and social science generally, has been to develop theories with a less than complete analysis of what is already in the literature. In practice, theories of addiction have typically been developed because a researcher has, very understandably, wished to emphasise a particular approach to understanding a set of phenomena, or out of a set of specific observations from which the researcher has wished to generalize, (p. 17) Below, I argue that by applying Integral Theory as a metatheoretical and transdisciplinary framework, we may be able to arrive at a comprehensive integrative model of addiction which honors all the existing single-factor models as well as the integrative and dynamic models. Integral Theory has been applied in the context of integrally informed approaches to addiction treatment protocol design and therapy (Du Plessis, 2010, 2012; Dupuy &Gorman, 2010; Dupuy &Morelli, 2007; Ingersoll &Rak, 2005; Shealy, 2009), but not yet in striving toward a comprehensive etiopathogenic understanding and model of addiction that embraces all the contemporary evidence-based explanatory theories and methodological approaches into an explanatory meta- model of addiction. In this article I provide the cursory outline of an Integral Model of Addiction (IMA) that could provide a conceptual framework within which the genuine insights provided by the existing theories and models can be placed. It would be a synthetic theory, in the sense that it would attempt to pull together the accumulated wisdom, and provide a conceptual system in which the existing theories could be located. It would be as coherent as possible: the ideas would relate naturally to each other and not simply form a list of unconnected assertions. This article represents the first humble and cursory attempt towards an integrative and comprehensive integrally informed model of addiction. Integral Methodological Pluralism The five elements of the AQAL model (all-quadrants, all-levels, all-lines, all-states, and all-types) represent some of the most basic repeating patterns of reality (Wilber, 2000). Therefore, including all of these elements increases one's capacity to ensure that no major part of any solution is left out or neglected (Esbjörn-Hargens, 2009). Integral Theory is both complexifying, in the sense that it includes and integrates more of reality, and simplifying, "in that it brings order to the cacophony of disparate dimensions of humans with great parsimony" (Marquis, 2009, p. 38). The element of Integral Theory that is the most relevant in our attempt to create a truly comprehensive model of addiction is the eight zone extensions of the original AQAL model (Wilber, 2002a, 2002b, 2006). These eight primordial perspectives (8PP) are derived from an inside (i.e., a first-person perspective) and outside view (i.e., a third-person perspective) of the quadrants. Integral Theory states that reality has at least four interrelated and irreducible perspectives - the subjective, signified by the Upper-Left (UL) quadrant; the intersubjective, signified by the Lower-Left (LL) quadrant; the objective, signified by the Upper- Right (UR) quadrant; and the interobjective, signified by the Lower-Right (LR) quadrant - which should be

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consulted when attempting to fully understand any aspect of it (Esbjörn-Hargens, 2009). These four universal perspectives are known as the quadrants (Wilber, 1995, 2000, 2006). It is beyond the scope of this article to discuss the other elements of Integral Theory (levels, lines, states, and types), and its relevance for an integral understanding of addiction, although levels and states are briefly discussed. For a comprehensive understanding all of these elements needs to be incorporated. See Du Plessis (2010, 2011), Dupuy and Gorman (2010), and Dupuy and Morelli (2007) for in-depth discussion of levels lines, states, and types in the context of addiction treatment and recovery. Each of these 8PP is only accessible through a particular method of inquiry or methodological family, and represents at least eight of the most important methods for accessing reproducible knowledge (EsbjörnHargens, 2006, 2010). Furthermore, each of these methodologies discloses an aspect of reality unique to its particular injunctions that other methods cannot. For a truly integral understanding of any phenomenon, in our case addiction, one needs to include as many of these perspectives and methods of inquiry as possible. These 8PP are included in Integral Theory's own multi-method approach to valid knowledge, referred to as Integral Methodological Pluralism (IMP) (Wilber, 2002a, 2002b, 2006; Esbjörn-Hargens, 2006, 2010). As such, IMP represents one of the most pragmatic and all-encompassing theoretical formulations of any integral or metatheoretical approach to accessing reproducible knowledge (Esbjörn-Hargens, 2006). Wilber (2002b) states that "any sort of Integral Methodological Pluralism allows the creation of a multi-purpose toolkit for approaching today's complex problems - individually, socially, and globally - with more comprehensive solutions that have a chance of actually making a difference" (p. 14). IMP has two essential features: paradigmatic and meta-paradigmatic. The paradigmatic aspect refers to the recognition, compilation and implementation of all the existing methodologies in a comprehensive and inclusive manner.3 The meta-paradigmatic aspect refers to its capacity to weave together and relate paradigms to each other from a meta-perspective (Wilber, 2002b, 2006). Wilber (2002b) describes the meta-paradigmatic aspect of IMP as: ...a practice that can enact, bring forth, and illuminate the integral interrelationships between various holons originally thought discreet or nonexistent. In other words, this practice on a set of practices (or this meta- paradigm on the individual paradigms) brings forth and illumines the mutual interactions between actual occasions, and it does so only from a space that theory would later be called a second-tier probability wave, (p. 13) IMP can therefore be understood as the 8PP and its correlated methodologies with a meta-framework which provides meta-linking between these disparate perspectives and paradigms (Martin, 2008). The eight methodological families identified by Wilber (2002a, 2002b, 2006) are depicted in Figure 1. Wilber (2002a) uses each of the names of these methodological families as an umbrella term which includes many divergent and commonly used methodologies. Three Blind Men and an Elephant An Indian myth tells the story of three blind men each holding onto a different part of an elephant, as each was asked to explain what object it was they were holding.4 Each explained the object in a completely dissimilar way. Although they were all correct in their description of the specific parts of the elephant, nevertheless they were all wrong in giving an accurate description of an elephant as a whole. This story is a useful metaphor for how different etiological models attempt to explain addiction, by highlighting their respective usefulness as well as inadequacies. By applying IMP to explanatory addiction models, I will show that each of the singlefactor models understands addiction from a specific zone(s), because it applies a specific methodological approach, whereas the more integrative models view addiction across several of these zones. In striving for a comprehensive and integrative integrally informed model of addiction, we honor all the existing theories of addiction, with their respective methodologies, by acknowledging that they all have something valuable to offer through enacting certain aspects of the complex and dynamic process of addiction, and at the same time

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highlighting their respective inadequacies. By using IMP, one "generates a meta-practice of honoring, including, and integrating the fundamental paradigms and methodologies of the major forms of human inquiry (traditional, modern, and postmodern)" (Wilber, 2002b, p. 16). Applying IMP in the context of addiction models can lay the ground work for meta-paradigmatic mixed-methods research in addictionology. An integrally informed model of addiction will demonstrate that addiction can have its etiology in one or more of these zones, but will eventually enact across all eight zones (and influences levels, lines, states, and types). Therefore, treatment should include practices that address addiction across these eight zones or perspectives as they co-arise in levels, lines, states, and types. Previous articles on integrally informed approaches to recovery have addressed this issue (Du Plessis, 2010, 2011; Dupuy &Gorman, 2010; Dupuy &Morelli; 2007; Shealy, 2009).5 In the next section of this article I will explore some of the most dominant explanatory models and theories of addiction derived principally from the sociopsychological and biomedical sciences, and point out how each model's theory is enacted by a particular methodology as represented by one or more of the eight zones of IMP. Finally, I will show how an IMA could encapsulate and honor all the existing models, without reducing one perspective to another, into an integrative and comprehensive metatheory of addiction. Etiological Models of Addiction Developing accurate theories, models, and definitions of addiction is problematic in many ways. One reason is that addiction is an abstract concept. It has no simple location or boundaries, for example, as a chair does. Furthermore, it is socially defined, and therefore opinions can legitimately differ about the most suitable definition - it cannot be said that one definition is unequivocally correct and another incorrect, only that one is more useful or is mostly agreed upon by "experts" (West, 2005). Theories, models, and definitions of addiction in authoritative texts on the subject have changed over the years. At one time, addiction was defined as a state of physiological adaptation to the presence of a drug in the body so that absence of the drug leads to physiological dysfunction (DiClemente, 2003). West (2005) states that: "Nowadays the term 'addiction' is applied to a syndrome at the centre of which is impaired control over a behaviour, and this loss of control is leading to significant harm" (p. 10). What makes a good theory of addiction? West (2005) writes: Theories are central to science, but they form only a part of it. They are discrete, coherent accounts of a process that are arrived at by a process of inference, provide an explanation for observed phenomena and generate predictions. Much of science does not fall into this category because it consists of disparate observations or is descriptive rather than explanatory. The same is true for the field of addiction, (p. 16) The problem is that theories in the field of addiction are rarely tested adequately in real-world settings, because the dominant research methodology does not allow it. However, a good theory of addiction should explain a related set of observations, generate predictions that can be tested, be parsimonious, comprehensible, coherent, internally consistent, and not contradicted by any observations (West, 2005). I will now explore some of these models and theories of addiction and see if they can be classified as good theories or models. When using what Wilber (2002a, 2002b) refers to as an "integral calculus of indigenous perspectives," which is the sum total of all the various perspectives of "being- in- the-world," we can see what aspects a model honors and what it leaves out. It must be noted that it is beyond the scope of this article to provide an exhaustive discussion of models of addiction, and the discussion that follows only briefly outlines some of the most prominent explanatory models, grouped under broad headings for the sake of simplicity. Genetic/Physiological Models The most substantial evidence concerning the role of genetics in addiction is derived from studies of alcohol dependence (Shuckit, 1980; Shuckit et al., 1972). Theorists have suggested that addiction runs in families and can be transmitted across generations. Twin studies suggest that a genetic transmission of alcoholism and chemical dependence is possible, and seem to support the importance of genetics as a contributing factor

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(Hesselbrock et al., 1 999). What is now becoming evident is that the solution will be polygenetic and complex, and will not lie in finding a single gene that can explain addiction (Begleiter &Porjesz, 1999; Blume, 2004; Gordis, 2000). Historically, addiction and physical dependence were seen as synonymous. Addiction was traditionally characterized by increasing tolerance and onset of physical withdrawal symptoms. Theorists of the genetic/ physiological model of addiction argue that the physiological aspects of tolerance and withdrawal are indicators that addictions are biological entities and medical problems. However, not all drugs and addictions produce withdrawal symptoms or create physiological dependence. Yet the physiological component of addictions remains an important one, and there have been major advances in our understanding of the neurobiology of addiction (Roberts &Koob, 1997). Advanced neurobio logical insight into addiction as having a physiological component and not constituting morally reprehensible behavior has led to it being understood within a medical model as a disease. West (2005) states that "[t]he Disease Model of addiction seeks to explain the development of addiction and individual differences in susceptibility to and recovery from it. It proposes that addiction fits the definition of a medical disorder. It involves an abnormality of structure or function in the CNS [central nervous system] that results in impairment" (p. 76). The disease model has played a significant role in shifting society's view of addiction from one of moral deviance to one that promotes treatment and understanding. Most neuroscientists studying addiction view it as a brain disease (Volkow et al., 2002). Addiction affects, amongst others, the mesolimbic system of the brain, the area where our instinctual drives and our ability to experience pleasure resides. This area contains the medial forebrain bundle, prevalently known as the pleasure pathway (Brick &Ericson, 1999). In addicts, the pleasure pathway of the brain is "hijacked" by the chronic use of drugs or compulsive addictive behavior. Due to the consequent neurochemical dysfunction, addicts perceive the drug as a life-supporting necessity, much like breathing and nourishment (Brick &Ericson, 1999). It seems clear, based on our understanding of the neurobiology of addiction, that physiological mechanisms and genetic factors potentially play a role in addiction; however, there are many concerns about assigning sole causality to genetic/physiological factors (Gupman &Pickens, 2000). Although the genetic/ physiological models are some of the most widely accepted models of addiction, it has attracted a number of critiques (Blomqvist &Cameron, 2002; Moos, 2003). DiClemente (2003) states that "so many different individuals can become addicted to so many different types of substances or behaviors, biological or genetic differences do not explain all the cultural, situational, and intrapersonal differences among addicted individuals and addictive behaviors" (p. 11). From an IMP point of view, it is evident that the genetic/physiological theories understand and apply empirical observation methodologies from a zone-6 perspective (by viewing and studying the exterior of individuals from the outside). These models do not incorporate psychological, social, and cultural perspectives. Social/Environment Models Many models of substance abuse have been criticized for not sufficiently emphasizing the role of social and contextual factors (Coppelo &Orford, 2002). In addition, many research studies have shown that some of the greatest risks of becoming addicted are related to the social factors a person is exposed to (Srmac, 2010). The social/environment perspective highlights the role of societal influences, social policies, availability, peer pressure, and family systems on the development and maintenance of addiction (DiClemente, 2003; Johnson, 1980). Furthermore, influencing etiological factors of addiction is the prevailing degree of attitudinal tolerance toward the practice in the individual's cultural, ethnic, and social class milieu. Research has pointed out that macro-environmental influences also play a significant role in the initiation of addiction (Connors &Tarbox, 1995). For instance, since the breakdown of the apartheid system in early 1990s and the concomitant relaxation of border management, South Africa has been targeted as a conduit country for transportation of drugs as well as a lucrative new market for the sale of drugs (Myers &Parry, 2003). Poor law enforcement, combined with the availability of sophisticated infrastructure and telecommunications systems, have further compounded South Africa's vulnerability as a lucrative drug-trafficking destination, resulting in the increased use of heroin, cocaine,

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and methamphetamine in the country (Parry et al., 2005). Some supporters of the social/environment models focus on the more intimate environment of family influences as a central etiological factor of addiction (Merikangas et al., 1992, Sher, 1993). They suggest that the onset of addiction is influenced by certain variables that emerge from dysfunctional family environments (Coleman, 1980; Kandel &Davies, 1992; Stanton, 1980). These theorists emphasize that problematic family situations, such as conflicted and broken marriages, difficulties with relationships, and the use of alcohol and other drugs on the part of the parents, are important influences on the child's decision to experiment with drugs or continuing addictive behavior (Chassin et al., 1996; Jessor &Jessor, 1977). Research has identified familial dynamics such as lack of parental support and ineffective parental control practices as high-risk factors for adolescent substance abuse (Hawkins et al., 1994). It is clear that social/environment models have relevance in our understanding of addictive behavior at the population level, but they often fail to explain individual initiation or cessation in any comprehensive manner (DiClemente, 2003). The social/environment models attempt to understand and study addiction from a cultural anthropological perspective (zone 4) by taking an outside view of collective interiors; a social autopoiesis theory perspective (zone 7) by taking an inside view of collective exteriors; and from a systems theory perspective (zone 8) by studying the outside of collective exteriors. These models are valuable from LL and LR quadrant perspectives, but fail to incorporate an etiological understanding from the UL and UR quadrants in a meaningful way. Personality/Intrapsychic Models Proponents of the personality/intrapsychic perspective link personality/intrapsychic dysfunction and inadequate psychological development to a predisposition toward addiction (Flores, 1997; Khantzian, 1994; Kohut, 1977; Levin, 1995; Ulman &Paul, 2006). For example, pre-existing antisocial disorders, depression, low self-esteem, narcissistic disorders, hyperactivism, high novelty seeking, and emotionality have been acknowledged as possible precursors or predictors of later addiction (Jessor &Jessor, 1980; Kohut, 1977). This led theorists to seek a pre-addiction psychological profile for people who have become addicted. However, a single addictive personality type has not been established, in spite of the commonly held belief that there is such a thing as an "addictive personality." Arthur Blume (2004) affirms this by saying that "there are certain psychological disorders with specific clusters of symptoms that have a high co-occurrence with substance abuse and dependence . . . but there is no single personality type for people with addictive behaviors" (p. 73). A common explanation, from a psychoanalytic perspective, is to view the etiological and pathogenic origins of addiction as a narcissistic disturbance of self-experience (Khantzian, 1999; Meissner, 1980; Ulman &Paul, 2006; Wurmser, 1995).6 Kohut (1971, 1977) implies that there is an inverse relationship between an individual's early experiences of positive self-object responsiveness and their tendency to turn to addictive behavior as replacements for damaging relationships. Scholars who support the "self-medication hypothesis" believe that addicts often suffer from defects in their psychic structure due to poor relationships early in life (Flores, 1997; Khantzian et al., 1990; Levin, 1995). This leaves them prone to seeking external sources of gratification (e.g., drugs, sex, food, work in later life, etc.) (Kohut, 1977). Khantzian (1995) asserts that, Substance abusers are predisposed to become dependent on drugs because they suffer with psychiatric disturbances and painful effect states. Their distress and suffering is the consequence of defects in ego and self capacities which leave such people ill-equipped to regulate and modulate feelings, self-esteem, relationships and behavior, (p. 1) The self-medication model of addictive disorders points out that individuals are predisposed to addiction if they suffer from unpleasant affective states and psychiatric disorders, and that an addict's drug of choice is not decided randomly but chosen for its particular effect because it helps with the specific problem(s) that the person is struggling with. Therefore, initiation of drug use and the choice of drug are based on the particular psychoactive effect sought by the individual (Khantzian 1995; West, 2005). Richard Ulman and Harry Paul

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(2006), in their fantasy-based self-psychological model of addiction, believe that addiction is better conceptualized as a kind of self-hypnosis than a type of "self-medication." They state that an archaic form of narcissism, namely megalomania, is at the unconscious etiology of addiction. Like other forms of archaic narcissism, it could become developmentally arrested in the setting of a self-object milieu which lacks empathy. In certain cases, such a developmental arrest may lead to addiction in later life. When using addicts enter into a hypnoid or dissociated state involving an archaic fantasy of being a self as a megalomaniacal being endowed with a form of magical control over psychoactive agents (things and activities), these addicts imagine that through possession of these agents they will usher a metamorphosis or transmogrification into a radically new state of being (Ulman &Paul, 2006). Personality/intrapsychic approach obviously makes a valuable contribution toward a better understanding of addiction, and personality as well as intrapsychic factors appear to contribute to the development of addiction. However, as DiClemente (2003) points out, personality factors or deep-seated intrapersonal conflicts account for a possibly important but relatively small part of a comprehensive explanation needed for addiction. Personality/intrapsychic models attempt to understand addiction from a phenomenological mode of inquiry (zone 1) by studying the inside view of the individual interior; as well as by applying structuralassessment techniques (zone 2) (recognizing object relation structures from early development) by studying the outside of the individual interior. These models do a great job from an UL-quadrant perspective, but do not account for UR, LL, and LR quadrant factors. Coping/Social Learning Models Some theorists indicate that addiction is often related to a person's ability to cope with stressful situations. They believe that, as a result of poor or inadequate coping mechanisms, addicts turn to their addictions as an alternative coping mechanism for temporary relief and comfort. An individual's inadequate ability to cope with stress and negative emotions has been identified as an etiological factor in many theories of addiction. Therefore, the coping/social learning models relate addiction to inadequate coping skills, which result from certain personality deficits in the individual (Wills &Shiftman, 1985). According to DiClemente (2003), emotion- focused coping has been identified as a particularly important dimension from a coping model perspective. Some believe alcohol is addictive because of its capacity for tension reduction (Cappell &Greeley, 1987) and its stress response damping effect (Pandina et al., 1992). Researchers have shown that increased drinking after rehabilitation treatment is associated with both skills deficit and the failure to use alternative coping responses (Marlatt &Gordon, 1985). The social learning perspective emphasizes more than just deficits in coping skills; it emphasizes social cognition. Bandura 's social cognitive theory focuses more on cognitive expectancies, self-regulation, and vicarious learning as explanatory mechanisms for addiction (Bandura, 1977, 1986). Also, this perspective highlights the role of peers and significant others as models. When advertisers use prominent public figures to promote a product, they are applying social influence principles. Although coping and social learning perspectives have become popular in addictionology, generalized poor coping skills cannot be the only causal link to addiction. However, even if coping deficit does not sufficiently provide an etiological explanation, it certainly highlights an important consequence of addiction, namely the narrowing of the addict's coping repertoire (Shiftman &Wills, 1985). The coping/social learning models attempt to understand addiction from a phenomenological mode of inquiry (zone 1) by studying the inside view of an individual's interior; from a hermeneutical-interpretive perspective (zone 3) by studying the inside of collective interiors; from a cultural anthropological perspective (zone 4) by exploring the outside of collective interiors; and finally from an autopoiesis theory perspective (as do many of the cognitive sciences) (zone 5) by studying the inside of individual exteriors. Although the coping/social learning models do incorporate a multi-perspectival understanding of addiction, they still chiefly focus on the UL quadrant processes in understanding addiction. Conditioning/Reinforcement Behavioral Models

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The compulsive use of addictive substances and process addictions are governed by reinforcement principles. Addictive substances and behaviors deleteriously affect the pleasure centers of the brain (Blume, 2004). The stimulation of the pleasure center produces a euphoric experience that tends to positively reinforce addictive behavior. Reinforcement can be positive or negative. Reinforcement models focus on the direct effects of addictive behavior, such as tolerance, withdrawal, other physiological responses/rewards, as well as more indirect effects described in opponent process theory (Barette, 1985, Soloman &Corbit, 1974). Positive reinforcement involves pleasurable consequences related to addictive behavior. Negative reinforcement, as described by opponent process theory, occurs when a person is rewarded through the substance reducing withdrawal or psychiatric symptoms. Both positive and negative reinforcement play a part in development and maintenance of the addictive process (Blume, 2004). Some theorists have also used Pavlovian conditioning to understand the addiction process. These individuals state that anticipatory drug-related behaviors can be linked to cues associated with the act of using the drug. Therefore, situational cues can elicit initial drug reactions and consequently lead to the resumption of the addictive behavior (Hinson, 1985). More contemporary classical conditioning approaches include cognition and physiological mechanisms in their repertoire of cues and responses (Adesso, 1985; Brown, 1993). This has led to an integration of conditioning and social learning perspectives (DiClemente, 1993). Today there is significant evidence for the role of conditioning and reinforcement effects in the addictive process, and as with all of the previously mentioned models it offers insight into the nature of addiction. However, the conditioning/reinforcement behavioral models do not explain all initiation or successful cessation of addiction (Marlatt &Gordon, 1985). They predominantly attempt to understand addiction from a phenomenological mode of inquiry (zone 1) by studying the inside view of an individual's interior; by applying empirical observation methodologies (zone 6) via studying the exterior of individuals from the outside; and by means of an autopoiesis theory perspective (zone 5) by studying the inside of individual exteriors. These models tend to overemphasize a deterministic and behaviorist approach to addiction with disregard for many psychological factors (UL), as well as providing inadequate explanation from LL and LR quadrant perspectives. Compulsive/Excessive Behavior Models Some physiognomies of addiction, like the inability to successfully stop the behavior, as well as its repetitive nature, has led some theorists to link addiction with ritualistic compulsive behaviors. Theorists who link addiction to compulsive behaviors either come from an analytic or a biologically oriented view. The analytic perspective views the compulsive component of addiction as reflecting deep-seated psychological conflict, whereas the biologically oriented view understands the compulsive behavior as a result of biochemical imbalances reflected in irregular neurotransmitter levels in the brain. Adherents of the first view would see treatment in terms of analysis, whereas adherents of the latter would explore psychoactive pharmacological treatments to bring the compulsive addictive behavior under control (DiClemente, 2003). Some theorists view addiction as excessive appetite (Orford, 1985). Increasing appetite leads to excess and the developmental process of increasing attachment, which is similar to elements of the social learning model. Potentially addictive substances share not only the potential for excess but also a similar process of leading to access. Both the compulsive and excessive behavior models share the notion that an addicted individual's behavior is out of control and that the addict is attempting to satisfy a psychological conflict or need (DiClemente, 2003). Both the compulsive and excessive behavior models add some explanatory potential to some of the existing models. However, they do not highlight all the variables needed in order to adequately explain the etiology or why individuals continue addictive behavior. The compulsive and excessive behavior models attempt to understand addiction from a phenomenological mode of inquiry (zone 1) by studying the inside view of an individual's interior; and by applying empirical observation methodologies from a zone-6 perspective when understanding compulsive addictive behaviors from a biologically oriented view, by studying the exterior of

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individuals from the outside. These models do explain addiction from limited UL and UR quadrant perspectives, but do not account for social and cultural factors (LL and LR quadrants). Spiritual/Altered States of Consciousness Models Lesser-known models view the pathogenic and etiological roots of addiction from a spiritual, existential, and altered state of consciousness (ASC) perspective. Empirical research has shown that an inverse relationship exists between spirituality and drug addiction, suggesting that spiritual involvement may act as a protective mechanism against developing an addiction, and that a lack thereof can contribute toward developing an addiction (Laudet et al., 2006; Miller, 1997). Some theorists have suggested that addiction is a spiritual illness, a disorder resulting from a spiritual void in one's life or from a misguided search for connectedness (Miller, 1998). For addicts, drugs become their counterfeit god. Therefore, addicts may be unconsciously pursuing the satisfaction of their spiritual needs through drugs or addictive behavior. In a letter to Bill Wilson, co-founder of Alcoholics Anonymous, Jung (as cited in Kurtz &Ketcham, 2002) pointed out that he believed "alcohol was the equivalent, on a low level, of the spiritual thirst of our being for wholeness, expressed in medieval language: the union with God" (p. 113). In a sense, addicts and alcoholics, as Jung believed, are misguided mystics. Many addicts state that they turned to drugs initially due to an existential void in their lives. Drugs instantly provided a new and often spectacular sense of meaning for them in an otherwise barren existence. Luigi Zoja (2000) states that: The archetypal need to transcend one's present state at any cost, even when it entails the use of physically harmful substances, is especially strong in those who find themselves in a state of meaninglessness, lacking both a sense of identity and a precise societal role. In this sense it seems right to see the behavior of a drug addict who announces "I use drugs!" not only as an escape to some other world, but also as a naive and unconscious attempt at assuming an identity and role negatively defined by the current values of society, (p. 15) I believe viewing the etiological roots from an existential perspective is an important inclusion for a comprehensive understanding of addiction (Boss, 1983). A sense of meaning and purpose is closely related to hope. Empirical findings show that recovering addicts who have hope are better able to cope with life's crises (Sremac, 2010). Furthermore (and closely related to existential etiological perspectives), I believe that in some instances the etiological roots of certain individuals' addiction may be a dysfunctional attempt, borrowing terms from Robert Assagiloi (1975), at "self-realization," and the consequent flawed channeling of "superconscious spiritual energies" (i.e., energies to which these type of individuals are often sensitive to, but have not found suitable ways to actualize). This type of transpersonal etiology (an existential quest for postconventional meaning) should not be confused with a pre-personal etiology (narcissistic disturbance of self), which will result in a type of pre/trans fallacy (Wilber, 1995, 2000, 2006).7 Although I must add that I have observed that many addicts who could be classified as having a transpersonal etiological root for their addiction will also often have co-occurring pre-personal (archaic) narcissistic developmental failure. Some theorists believe that humans have an innate drive to seek ASCs, because they encompass systemic natural neurophysio logical processes involved with psychological integration of holotropic responses and reflect biologically based structures of consciousness for producing holistic growth and integrative consciousness (Grof, 1980, 1992; Siegal, 1984; Weil, 1972). Winkelman (2001) believes that addicts engage in a normal human motive to achieve ASCs, but in a self-destructive way because they are not provided the opportunity to learn "constructive alternative methods for experiencing non-ordinary consciousness" (p. 340). From this viewpoint, drug use and addiction are not understood as an intrinsic anomaly, but rather as a misguided yearning for the satisfaction of an inherent human need. In considering possible etiological roots for our society's immense addiction problem through an ASC perspective, Winkelman (2001) states: Since contemporary Indo-European societies lack legitimate institutionalized procedures for accessing ASCs, they tend to be sought and utilized in deleterious and selfdestructive patterns - alcoholism, tobacco abuse and

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illicit substance dependence. Since ASC reflect underlying psychobiological structures and innate needs, when societies fail to provide legitimate procedures for accessing these conditions, they are sought through other means. Incorporation of practices to induce ASC through non-drug means could be useful as both a prophylactic against drug abuse, as well as a potential treatment for addiction, (p. 240) For a comprehensive understanding of addiction, the inclusion of spiritual and ASC perspectives is essential, although addiction is too complex for its pathogenic origins to be reduced to these elements alone. Furthermore, in some instances one could run the risk of a type of a pre/trans fallacy by confusing developmentally arrested narcissistic needs and behavior with postconventional spiritual yearning, which is actually a fairly common phenomenon in certain drug subcultures (Almaas, 1996).8 The spiritual/altered state of consciousness models attempt to understand addiction from a phenomeno logical mode of inquiry (zone 1) perspective by studying the inside view of an individual's interior; and a cultural anthropological perspective (zone 4) by exploring the outside of collective interiors. The Biopsychosocial Model A dissatisfaction with the fractional explanations proposed by the previously described single-factor models have prompted some theorists to propose an integration of these explanations (Donovan &Marlatt, 1988; Glantz &Pickens, 1992). By calling their model the biopsychosocial model, they indicate the integration of biological, psychological, and sociological explanations that are crucial in understanding addiction. This model endeavors to unify contending addiction theories into an integrated conceptual framework. According to this model, addictive behavior is best understood as a complex disorder determined through the interaction of biological, cognitive, psychological, and sociocultural processes. Dennis Donovan, a proponent of the biopsychosocial model, states that "addiction appears to be an interactive product of social learning in a situation involving physiological events as they are interpreted, labeled, and given meaning by the individual" (Donovan &Marlatt, 2005, p. 7). The biopsychosocial model argues for multiple causality in the accusation, maintenance, and termination of addictive behaviors.9 Yet there are some academics who feel the biopsychosocial model is also inadequate in explaining addiction, and that further integrative elements are needed to make this model's tripartite collection of factors functional. DiClemente (2003) states that "without a pathway that can lead to real integration, the biopsychosocial model represents only a semantic linking of terms or at best a partial integration" (p. 18). DiClemente adds: [T]he biopsychosocial model clearly supports the complexity of and interactive nature of the process of addiction and recovery. However, additional integrating elements are needed in order to make this tripartite collection of factors truly functional for explaining how individuals become addicted and how the process of recovery from addiction occurs. (2003, p. 18) Without an orienting framework that can explain how these various areas co-enact and interlink, the biopsychosocial approach indeed often represents merely a semantic linking of terms. Although the biopsychosocial model has not provided the field of addictionology with a truly comprehensive and integrative model, it is one of the first models to recognize the importance of treating the whole person, not merely the addiction. This has contributed greatly to the application of more holistic treatment protocols (Sremac, 2010). The biopsychosocial model attempts to understand addiction from a multitude of perspectives, which include a phenomenological mode of inquiry (zone 1) by studying the inside view of an individual's interior; a hermeneutical-interpretive perspective (zone 3) by studying the inside of collective interiors; a cultural anthropological perspective (zone 4) by exploring the outside of collective interiors; an autopoiesis theory perspective (zone 5) by studying the inside of individual exteriors; empirical observation methodologies (zone 6) by viewing and studying the exterior of individuals from the outside; and finally a systems theory perspective (zone 8) by studying the outside of collective exteriors. The Transtheoretical Model In an attempt to find commonality among the diverse models of addiction, DiClemente and Prochaska (1998)

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proposed their Transtheoretical Model (TTM) of intentional behavior change. The TTM "attempts to bring together these divergent perspectives by focusing on how individuals change behavior and by identifying key change dimensions involved in this process" (DiClemente, 2003, p. 19). The primary developer of TTM, Carlo DiClemente (2003), argues for this model by stating that "[i]t is the personal pathway, and not simply the type of person or environment, that appears to be the best way to integrate and understand the multiple influences involved in the acquisitions and cessation of addictions" (p. 19). The TTM proposes that the process of recovery from an addictive behavior involves transition through phases described as precontemplation, contemplation, preparation, action, and maintenance. Different processes are involved in the transition between these different phases, and individuals can move forward and backward through these phases of change (West, 2005). Proponents of this model believe a person's choices influence and are influenced by both personality and social forces, and that there is an interaction between the individual and risk and protective factors that influence the pathogenic origin or cessation of addiction. This process requires a personal journey through an intentional change process that is influenced at various points by a host of factors, as identified in the previously discussed explanatory models. "The stages of change, process of change, context of change, and markers of change identified in the TTM offer a way to integrate these diverse perspectives without losing the valid insights gained from each perspective" (DiClemente, 2003, p. 20). Although this model demonstrates an integrative principle that is common to all the previous models, and although it highlights the dynamic and developmental aspects of addiction, I do not believe it provides a metatheoretical framework that truly accommodates all the previous perspectives into an integrative framework. The TTM predominantly focuses on one integrating principle (i.e., change) found in all the prominent addiction models, but does not provide the meta-paradigmatic framework needed for a metatheory of addiction. Furthermore, the model has attracted a number of critiques, and West (2005) states that "reservations have emerged about the model, many of which have been well articulated (Etter &Perneger, 1999; Bunton et al., 2000; Whitelaw et al., 2000; Sutton, 2001; Etter &Sutton, 2002; Littell &Girvin, 2002)" (p. 68). Yet the TTM has contributed greatly to our understanding of addiction and recovery as a dynamic process, by explaining it through a developmental-contextual framework. Furthermore, it has provided clinicians with a dynamic developmental framework to understand treatment resistance and ambivalence as well as to identify certain developmental markers indicative of positive change in recovery (Miller, 2006; Miller &Rollnick, 2002; Miller &Carroll, 2006). The TTM attempts to understand addiction primarily from a zone-2 perspective, applying structural-assessment techniques, by studying the outside of individual interiors. An Integral Model of Addiction In contemporary addictionology studies there is an ongoing debate concerning the nature of addiction, and there is no agreement on a single etiopathogenic model - a fact that clearly reflects the complexity of this phenomenon (DiClemente 2003; Sremac, 2010; West, 2005). As I have shown in this article, there are multiple etiological perspectives of addiction: biological, sociocultural, psychological, and spiritual/ASC theories are all important in understanding it. Srdjan Sremac (2010) states that "one of the difficulties for a comprehensive theory of addiction is the increasing 'medicalitazation' of the notion of disease" (p. 268). As Morgan (1999) points out, the search for biological and genetic explanations for addictive behavior has obscured the more holistic and interdisciplinary perspectives. Furthermore, most of the above-mentioned models apply the natural sciences paradigm that underlies modern medicine, which Medard Boss (1983) points out has its limitations in explaining the whole human realm, as it originated from and is only sovereign in the nonhuman realm. Our brief review of the most prevalent explanatory models of addiction highlights several important issues. First, addiction appears to involve multiple determinants, each representing very different domains of human functioning, ranging from individual factors like self-esteem and physiology to societal influences. Second, we can conclude that there is no single explanatory construct at a single point in the life of an individual that can adequately explain addiction. Finally, because of the inadequacy of the single-factor models to account for the

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complexity of addiction, integrative perspectives like the biopsychosocial model and TTM are beginning to dominate the field of addictionology (DiClemente, 2003). Legitimation Crisis in Addictionology Although there has been a move toward more comprehensive models in the field of addictionology, current holistic models have not yet achieved the goal of providing a truly all-inclusive and integrative framework to account for addiction. Carlo DiClemente (2003) states, pointing out the limitations of one of the most popular contemporary holistic models, "Although the proposal of an integrative model represents an important advance over more specific, single-factor models, proponents of the biopsychosocial approach have not explained how the integration of biological, psychological, sociological and behavioral components occur" (p. 18). What is missing in these integrative models is a metatheory that adequately explains the co-arising, multi-causality, and integration of the many factors. Unlike the biopsychosocial model and the TTM, a truly comprehensive and integrative framework would provide the scaffolding to bring together the various research-supported explanatory models, and orchestrate the integration of multiple determinants as well as the dynamic nature of addiction. The diverse etiological models discussed thus far mostly offer partial, often one-dimensional views. Moreover, the proposed integrative models, like the biopsychosocial model and the TTM, do not provide a comprehensive meta-framework to integrate these diverse explanatory perspectives and explain multiple "co- arising" determinants. What is currently happening in the field of addictionology is what Wilber (2002a) refers to as a "legitimation crisis" - a breakdown in the adequacy of a particular mode of translating and making sense of the world. The partial existing explanatory addiction models (LL quadrant) cannot keep up with and successfully account for all the results the various research paradigms (LR quadrant) are enacting. Consequently, the current move in addictionology is toward more integrative models of addiction that can account for the mounting data in addiction studies, data which highlight its multidimensional, dynamic, and complex nature. Toward an Integrative Conceptual Etiological Meta-framework By proposing an Integral Model of Addiction (IMA) through the application of the AQAL model, and elements of IMP in particular, we can move toward an integrative framework that could provide adequate scaffolding for all the current evidence-based etiological approaches. Because the IMA is based on IMP, it seeks to honor all the important methodologies used in addictionology. Each of the aforementioned models brings valuable insight from a specific paradigmatic point of view, and enacts certain features of addiction by virtue of applying a particular methodologies. By applying Integral Theory in the context of addiction models, it can provide us with a "meta-theoretical framework that simultaneously honors the important contributions of a broad spectrum of epistemological outlooks while also acknowledging the parochial limitations and misconceptions of these perspectives" (Marquis, 2008, p. 24). From an IMP perspective, none of these models or perspectives have epistemological priority because they co-arise and "tetra-mesh" simultaneously, although in some contexts a priority can be established and justified. Khantzian (1987) states that each of these explanatory models has "an advantage in describing certain features and etiological determinants of substance dependence. Each also has its limitation" (p. 534). Therefore, these models are all valid from the perspectives they use to understand and study addiction, but also always partial in their approach to the whole. This implies that a model is not correct or incorrect but rather that it is more suited to explaining addiction from a certain perspective, and more limiting from other perspectives. For instance, the genetic/physiological models are better at explaining the biological determinants and function of addiction than the personality/intrapsychic models, whereas the personality/intrapsychic models are better at explaining the phenomenological determinants and experience of addicted individuals than the genetic/physiological models. Yet both illuminate important and interlinked aspects of the same phenomenon. This highlights the phenomenon of addiction as a multiple and dynamic object arising as a continuum of ontological complexity (Esbjörn-Hargens, 2010). By viewing addiction through the quadrants and its 8PP, we can see that all these perspectives with their

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respective methodological families need to be acknowledged, and as many should be included as possible in order to gain a truly comprehensive view. This avoids what Wilber (2006) calls "quadrant absolutism," where all realities of a phenomenon are reduced to the perspective of one quadrant (e.g., reducing the multiple determinants of addictive behavior to merely impaired neurophysiology). An IMA, through the application of Integral Theory, acknowledges all these perspectives and their respective methodologies, and also provides a meta-paradigmatic integrative framework highlighting how these perspectives co-arise and interlink without having to reduce one perspective to another. Obviously, individuals can become addicted due to a host of different reasons, as articulated by the many explanatory models, and from an etiological point of view all these models may not be relevant in explaining the pathogenic origins of a particular individual's addiction. But what is clear is that once an individual becomes addicted, virtually all areas are affected and need to be included in a comprehensive understanding of the maintenance of addiction, as well as its treatment and the individual's recovery (Du Plessis, 2010, 2012; Dupuy &Gorman, 2010; Dupuy &Morelli, 2007). Integral Taxonomy of Etiological Models of Addiction An IMA highlights the need for a dynamic integrative understanding that includes paradigmatic as well as meta- paradigmatic orientations. Only by using a meta-paradigmatic practice can we create a metatheory that encapsulates, relates, and integrates the existing theories into a comprehensive conceptual framework of addiction. Moreover, a meta-model of addiction could help point the field of addictionology toward underexplored areas for etiological understanding of addiction (i.e., vertical developmental levels of zone 2; systemic aspects as represented by zone 7). Through the application of IMP, an IMA includes all the evidence-based models and explains which aspect of addiction they enact, and provides meta-paradigmatic integration of these diverse perspectives and their paradigmatic injunctions. In Figure 2, 1 provide a taxonomy of etiological models of addiction, using the eight zones and methodological families of IMP, into which each of the etiological models thus far discussed can be grouped. It must be noted that this classification highlights the predominant areas that each explanatory model explores, as it is often difficult to draw distinct boundaries. Consequently, this configuration opens itself up to certain methodological classification errors, and only serves the purpose of an exploratory overview of such a possible classification. Figure 2 illustrates how an IMA could integrate all the existing models into an integrative and comprehensive metatheory of addiction, without reducing one model to another. It provides a meta- developmental-contextual framework to view addiction from a multi-perspectival position from any of its possible developmental stages of self, culture, and nature. The Developmental Dynamics of Addiction Assimilating the TTM of intentional behavior change, as well as the "stages of development" element of Integral Theory, alongside addiction/recovery developmental models into an IMA highlights the dynamic and developmental nature of addiction as well as the recovery process (Du Plessis, 2010, 2012). Furthermore, each of these eight zones of IMP will enact differently at different phases of addiction and recovery as well as the different stages of psychological development of addicts. For a comprehensive IMA, we need to be able to adequately accommodate and explicate the dynamic and developmental nature of addiction, and at least provide some orienting generalizations. Furthermore, a stage perspective of addiction and recovery has significant implications for therapy. (See Du Plessis, 2010, 2012 for a discussion of the therapeutic application of stages with addicted populations.) In Figure 3, 1 indicate various developmental models often used in Integral Theory and developmental psychology (Wilber, 2006), some well-known developmental models of addiction and recovery (Whitfield, 1991; Bowden &Gravtiz, 1998; Nakken, 1998), as well as my own composite developmental model relating to addiction and recovery (Du Plessis, 201 1). The aim of this figure is to visually illustrate the developmental nature of addiction/recovery. The figure is a simplified example of the different developmental stages that an addict's center of addiction or recovery gravity can possibly rest at." Although the stages of addiction and

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recovery is better understood as chronological stages or phases, I do believe there is a correlation between the various stage models as articulated in Integral Theory and the various stages (or phases) of recovery models. Simply put, earlier stages of recovery may correlate with early developmental stages, and higher altitude stages of recovery may correlate with more complex developmental stages. Conclusion This article provides a preliminary sketch of what an integrally informed model of addiction could resemble. I argued that by applying Integral Theory as a metatheoretical and transdisciplinary framework, we may arrive at a comprehensive model of addiction that honors all the existing single-factor models as well as the integrative and dynamic models. IMP was used to propose the broad outlines of an integrative model of addiction. I explored the most dominant explanatory models and theories of addiction derived from the sociopsychological and biomedical sciences, and pointed out how each model's theory is enacted by a particular methodology as represented by one or more of the eight zones of IMP. Finally, I pointed out how an IMA could integrate all the existing models into an integrative and comprehensive metatheory of addiction, without reducing one model to another. Therefore, an IMA essentially comprises an integrative orientation that can include all the existing evidence-based etiopathogenic models and their respective methodologies, and a meta-paradigmatic conceptual framework that relates the various paradigmatic strands to each other in a dynamic manner. It thereby provides a meta-developmental-contextual framework to view addiction from a multi-perspectival position from any of its possible developmental stages in self, culture, and nature. Arriving at an adequate understanding of addiction has more than just epistemological and scientific value - it also signifies great benefit in the real world, for the way we understand addiction influences the way we treat it. Therefore, the more comprehensive our understanding, the more effective and sustainable treatment becomes. The main premise of this article is that the application of Integral Theory in the context of etiological models could provide a more advanced integrative conceptual framework than any existing metatheory of addiction. As Wilber (2002b) eloquently states, echoing the premise of this article: The more one actually practices an integral meta-paradigm ... the more Eros is set rumbling in through the system, agitating and pulling toward a second-tier transformation that explodes the legitimacy crisis inherent in all first-tier waves and throws them open to an enrichment beyond their first-tier imprisonment, an enrichment that is their own inherent potential and divine birthright set free in the deeper and wider spaces enacted by integral practices, (p. 44) This article is not the final word on integrally informed models of addiction. It is merely a cursory attempt to show what possibilities exist when applying Integral Theory in the study of the etiological and pathogenic origins of addiction, and it hopes to stimulate interest in other academics, clinicians, and researches with a view to the eventual development of a well-researched, integrally informed meta-model of addiction. Addiction is one of the greatest societal problems facing the world today, and I believe only a truly integral approach can adequately address this massive, mind-boggling, and heartbreaking problem. As Smuts said in 1927, presaging the Integral age: "If the soul of our civilization is to be saved we shall have to find new and fuller expression for the great saving unities..." (p. vi). Footnote NOTES 1 In my opinion, General Jan Smuts, South African statesman, philosopher, and author of Holism and Evolution (1927), was one of the first truly modern integral thinkers. Smuts, who coined the term "holism" and who was the first to promote a holistic epistemology, is mostly forgotten by contemporary academia. It is well known that Fritz Perls, co-founder of Gestalt Therapy, was greatly influenced by Smuts' holistic theory while living in South Africa after fleeing Nazi Germany, as was Alfred Adler. Adler used Holism and Evolution for his classes in Vienna (and had it translated into German) and describes Holism Theory, in a letter to Smuts, as "supplying the scientific and philosophical basis for the great advance in psychology which had been made in recent years"

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(Blackenberg, 1951, p. 81). Furthermore, in his book Psychosynthesis (1975) Roberto Assagioli acknowledges Smuts as the originator of the holistic approach as well as of the Psychology of Personality, subsequently influencing thinkers like Maslow and Allport. Assagioli (1975) describes Smuts' holistic approach as one of the most "significant and valuable contributions to the knowledge of human nature and its betterment" (p. 14). Unfortunately, the majority of modern holistic thinkers seldom acknowledge his pioneering work. However, Ken Wilber holds Smuts' work in high regard, and was influenced by him in the early stages of his career (personal communication, May 26, 2008). 2 The DSM-IV-TR does not use the term "addiction," but rather "substance abuse disorders," since the World Health Organization concluded in 1964 that addiction is no longer a scientific term. However, the soon-to-be- published DSMV will use the term "addictive disorders" instead of "substance dependence." For the purposes of this article, the term addiction refers to substance use disorders and process addictions such as sex addiction and pathological gambling. 3 1 use the term paradigm to mean a set of social practices or behavioral injunctions, as was originally intended by Thomas Kuhn (1970). 4 See Esbjörn-Hargens (2010) for a critique of this oft-cited parable. 5 See my previous articles in the Journal of Integral Theory and Practice (Du Plessis, 2010, 2012) for discussion of an integrally informed model for inpatient addiction treatment. The 2012 article proposes and outlines an integrally informed psychotherapy, known as Integrated Recovery Therapy (IRT), that is adapted for treating addicted populations. IRT as a therapeutic orientation is an Integral Methodological Pluralism to therapy for treating addiction. Its two main features are paradigmatic and meta-paradigmatic. The paradigmatic aspect refers to the recognition, compilation and implementation of various methodologies in a comprehensive and inclusive manner. The meta-paradigmatic aspect refers to IRT's capacity to weave together, relate, and integrate the various paradigmatic practices. IRT is a meta-therapy derived from the Integrated Recovery Model (Du Plessis, 2010), which is a comprehensive, balanced, multi-phased, and multi-disciplinary clinical model designed for inpatient addiction treatment. As with the Integrated Recovery Model, IRT's philosophy is derived from an integration of 12-step, abstinence-based philosophy, mindfulness, positive psychology, and Integral Theory. 6 For a comprehensive and very impressive discussion of addiction as a narcissistic disturbance from a self- psychology perspective, see Ulman &Paul's (2006) The Self Psychology of Addiction and its Treatment: Narcissus in Wonderland. 7 1 intend to write an article exploring the etiological roots of addiction from a transpersonal perceptive through the application of an integral view of Assagioli's psychosynthesis approach as a conceptual framework. This is not an etiological explanation that attempts to be applicable for all addiction individuals, but rather for isolated cases. 8 In certain subcultures, drug use is often glorified for its mystical and transcendent properties, and the individuals in these subcultures often justify their frequent use of drugs through spiritual values. The problem is not that the ingestion of psychoactive substances cannot produce authentic mystical experiences, or that some of these individuals are not authentically driven to find spiritual enlightenment through the use of psychoactive substances, but rather that the prevalent drug use in these cultures is often driven simply by a need "to get high," and not a spiritual motivation. Consequently, most individuals are there to get high, not to become enlightened, but use these lofty ideals as rationalizations for more primitive impulses. 9 For an integral critique of the biopsychosocial model, see Baron Short's (2006) article in the Journal of Integral Theory and Practice. 10 This article's primary focus is on the application of IMP, without adequately expounding the ontological pluralism of addiction as a multiple object enacted by various methodologies. I believe what is further needed in an attempt at a truly comprehensive integral metatheory of addiction is to incorporate Esbjöra-Hargens' (2010)

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Wilber, K. (2006). Integral spirituality: A startling new role for religion in the modern and postmodern world. Boston, MA: Integral Books. Wills, TA., &Shiffman, S. (1985) Coping and substance use: A conceptual framework. Coping and Substance Abuse. Orlando, FL: Academic Press. Winkelman, M. (2001). Alternative and traditional medicine approaches for substance abuse programs: a shamanic perspective. International Journal of Drug Policy, 72,337-351. Whitfield, C.L. (1991). Co-dependence, healing the human condition. Deerfield Beach, FL: Health Communications, Inc. Wurmser, L. (1995). Compulsiveness and conflict: The distinction between description and explanation in the treatment of addictive behavior. In S. Dowling (Ed.), The psychology and treatment of addictive behavior (pp. 43-64). Madison, CT: International Universities Press. Zoja, L. (1989). Drugs, addiction and initiation: The modern search for ritual. Boston, MA: Sigo. AuthorAffiliation Correspondence: Guy Pierre du Plessis, 35 Duiker Gate, Capricorn Beach, Muizenberg, Cape Town, South Africa, 7945. E-mail: [email protected]. AuthorAffiliation GUY PIERRE DU PLESSIS, B.A. Hons., is Clinical Director of Drakenstein Addiction Recovery Center. He holds a B.A. Honors degree from the University of South Africa in psychology, with specialization in psychological counseling. He is the developer of the Integrated Recovery Model, Integral Model of Addiction and Integrated Recovery Therapy, and also the first to pioneer and implement an integrally informed clinical model within an inpatient addiction treatment clinic. His work on the Integrated Recovery Model has been published in the Journal of Integral Theory and Practice. He is the author of a book about the Integrated Recovery approach, which is currently in development with SUNY Press. His main academic interests are developing well-researched, evidence-based theory and practice in the field of Integral Addiction Treatment. He is a Zen student under Sensei Mugaku Zimmerman (White Plum lineage), a musician/producer specializing in integrally informed avant-garde music, and his favorite activity and spiritual practice is spending time with his beloved daughter Coco. Subject: Studies; Addictions; Substance abuse treatment; Publication title: Journal of Integral Theory and Practice Volume: 7 Issue: 3 Pages: 1-24 Number of pages: 24 Publication year: 2012 Publication date: Sep 2012 Year: 2012 Publisher: Integral Institute Place of publication: Albany Country of publication: United States Publication subject: Philosophy, Psychology

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ISSN: 19445083 Source type: Scholarly Journals Language of publication: English Document type: Feature Document feature: Illustrations Tables References ProQuest document ID: 1271585003 Document URL: http://ezp.waldenulibrary.org/login?url=http://search.proquest.com/docview/1271585003?accountid=14872 Copyright: Copyright Integral Institute Sep 2012 Last updated: 2013-04-17 Database: ProQuest Central

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Table of contents

1. An Integral Approach to Substance Abuse[dagger]..................................................................................... 1

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Document 1 of 1 An Integral Approach to Substance Abuse[dagger] Author: Amodia, Diana S; Cano, Carol; Eliason, Michele J ProQuest document link Abstract: There is a pressing need in the substance abuse field for more comprehensive models of etiology and treatment that address the complex issues of addiction, including the biological, social, cultural, spiritual and developmental needs of individuals and groups. This article presents a theoretical framework for an integral approach to substance abuse that expands on the existing biopsychosocial model. One contribution of the model is an integrated approach to spirituality from a cross-cultural perspective. This integral approach examines substance abuse etiology and treatment from a four-quadrant perspective adapted from the work of Ken Wilber, and incorporates concepts from integrative medicine and transpersonal psychology/psychiatry. Implications of the model are explored. Links: Linking Service Full text: Headnote Abstract-There is a pressing need in the substance abuse field for more comprehensive models of etiology and treatment that address the complex issues of addiction, including the biological, social, cultural, spiritual and developmental needs of individuals and groups. This article presents a theoretical framework for an integral approach to substance abuse that expands on the existing biopsychosocial model. One contribution of the model is an integrated approach to spirituality from a cross-cultural perspective. This integral approach examines substance abuse etiology and treatment from a four-quadrant perspective adapted from the work of Ken Wilber, and incorporates concepts from integrative medicine and transpersonal psychology/psychiatry. Implications of the model are explored. Keywords-cross-cultural, spirituality, treatment philosophy Substance abuse has enormous costs to the nation, estimated at $143 billion dollars in 1998 (ONDCP 2001), and incalculable costs to the individual, family, and community. To adequately address this complex chronic relapsing disorder, an integrated system of treatment is desperately needed. Current systems of addiction treatment are limited and fragmented, focusing primarily on narrow behavioral treatments while at the same time the clients are increasingly presenting with co-occurring mental, emotional, spiritual, physical and transmissible diseases, and are culturally diverse. The typical client may go to different agencies for primary health care, HIV care, social service needs, and psychiatric medications, as well as a substance abuse treatment agency for social/behavioral treatments. Staff in these agencies often have very little, if any, training in addiction, cultural competency, or the holistic nature of addiction etiology or treatments. Clients with this degree of impairment have considerable difficulty negotiating these diverse agencies and systems that often give them mixed messages, culturally insensitive messages, fragmented care, or treatments that interfere with their addiction treatment. There is a critical need for integrated care of the whole client. The terms "integral," "holistic," "integrative, " and "mind-body" have been applied in the field of medicine (e.g. Gilbert 2003; Astin &Astin 2002) because "such care seeks to create health by engaging old and new approaches to health for the individual, system, community, and environment" (Sandman et al. 2002: 1). Within the field of mental health, this broadening of perspective and blending of new science and old wisdom traditions has occurred within transpersonal psychology and psychiatry, also called the human potential movement (Scotton 1996). These broader approaches recognize the essential role of attitudes, values, and spirit in health and illness. An integral approach to substance abuse treatment would include specific addiction treatment, mental health

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care and medical/physical care, as well as address issues related to legal problems, housing, employment, education, and relationships, deal with clients within their familial, cultural, and broader societal contexts, and address spiritual needs. This model requires multidisciplinary team coordination, including at minimum specialists in addiction medicine, addiction psychiatry, psychology, substance abuse counseling, and case management. All of the team members need to be trained to address the whole person, including the cultural and spiritual components of care. The scientific literature on addiction treatment acknowledges this multidisciplinary nature of addiction by labeling it a biopsychosocial disorder; however, even this definition is limiting, as it neglects the cultural, spiritual, and societal influences. In addition, very few existing treatment agencies actually deliver their services in a biopsychosocial manner. Even the more comprehensive treatment systems often lack true coordination among the different aspects of care. Many lack the spiritual and cultural components of treatment and give only lip service to the transformational change needed for long-term recovery. Transformational change is often linked to spiritual practice or "quantum change" (Miller &C' de Baca 2001 ). Altering lifestyle behaviors of any type is difficult, whether it involves reducing or abstaining from cocaine use, quitting smoking, exercising daily, or changing dietary patterns. Only treatments that recognize the multifactorial nature of human behavior and provide skills or practices that enhance change are likely to be successful. Motivation for change has multiple components within the individual, agency, culture, and society, all of which must be considered in a comprehensive treatment approach. When culture is considered in treatment, it is often highly specific to generalities of one culture, denying the multicultural nature of society and the enormous variation within any given culture. What is needed is a cross- cultural approach that addresses the commonalities across culture, in much the same way that Huston Smith (1976) has identified the commonalities across all the great world religions, and Angeles Arrien (1993) has identified commonalities in human interactions and communication. There is strength in difference when common bonds can be identified-diversity can be honored even while searching for common ground. Angeles Arrien (2001: 1-2) noted: Diversity is known by many different names-pluralism, unity, harmony, tolerance, inclusion, conflict mediation, facilitation, equity, intercultural understanding, anti-bias, multi-cultural education, equal employment opportunities, affirmative action, cultural competence, global competitiveness, social justice, racial understanding, and being politically correct. This quote suggests how much confusion there is surrounding the meaning of the term "diversity." No wonder staff in substance abuse treatment agencies do not always know how to address cultural differences in their programs when there is no consensus about the meaning of diversity. Currently, programs often offer a spiritual component to treatment, particularly if they use a 12-Step approach to treatment or recommend 12-Step self-help groups to their clients. However, the spirituality of Alcoholics/Narcotics Anonymous stems from a narrow Christian religious focus and is not relevant or useful to all clients, who vary widely in their religious and spiritual backgrounds and worldviews. An integral approach to substance abuse would offer a broader view of spirituality that could bridge cultural and religious boundaries. THEORETICAL FRAMEWORK The integral approach to substance abuse was informed by the work of several theorists, but most notably Ken Wilber's Integral Model. Wilber (2000) outlined a four quadrant theory of human consciousness development that is the most comprehensive model available today, integrating the work of western and eastern philosophy and developmental psychology. Figure 1 illustrates the four quadrants in two dimensional form, but in reality the quadrants are multidimensional and the levels of development are nested holarchies (hierarchical and nonhierarchical forms of development where higher levels transcend and include the lower levels) which are spiral rather than linear. The upper left and right quadrants represent individual development and the lower left and right quadrants represent the collective. Within the upper left quadrant (the I) are contained the many lines

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of human development such as cognitive, affective, and moral, which are relatively independent of each other. Therefore, development can be uneven. Recognition that the level of development is important in how substance abuse is perceived, experienced, and expressed in the individual is an important component of a truly integral model of treatment. Every human behavior has correlates in all four quadrants, and change in one quadrant precipitates change in the other three in a dynamic interaction. For example, a change in brain chemistry may result in a feeling or emotional pattern that we call "depression" experienced by the individual as sadness and hopelessness, defined by the sociocultural context as a mental illness, and eligible for medications or psychotherapy by the economic health care systems of our nation. Another major contribution of Wilber's work is the attention paid to spiritual development. Wilber (2000) reviewed many different perspectives on spirituality and identified five common definitions of spirituality:

* Spirituality involves the highest levels of any of the developmental lines (e.g., the highest level of cognitive or moral development, for example). * Spirituality is the sum total of the highest levels of the developmental lines. * Spirituality is itself a separate developmental line with a sequential stage-like unfolding. * Spirituality is an attitude (such as openness or love) that one can have at any stage (this is perhaps the most common definition of spirituality). * Spirituality involves peak experiences that can occur at any level of development. The first two definitions imply that psychological development must be complete or far advanced in certain lines of development before spirituality can emerge. On the other hand, one can demonstrate spirituality in the expression of unconditional love or acceptance in a nonhierarchical fashion. All of the definitions appear to have some validity. Spirituality in the context of addiction treatment will be discussed in a later section. Another important theoretical contribution to the integral approach to substance abuse comes from the work of cultural anthropologist Angeles Arrien (1993) who proposed a number of concepts and tools aimed at bridging cultural differences. This work suggests that the multiple, fragmented, culturally specific practices currently in existence can be unified via a cross-cultural approach to individual growth. That is, instead of having separate treatment programs for every diverse population, there are universal bridging concepts that both honor diversity and teach common principles of human conduct and communication. These bridging concepts are drawn from centuries of writing in indigenous wisdom traditions. After 25 years of hands-on experience with indigenous cultures around the world, Arrien found that 80% of them shared common values of communication (Arrien 2005; see also the work of Joseph Campbell 1973 and Huston Smith 1976). Learning these cross-cultural bridging techniques better prepares clients for dealing with the stresses of a diverse society. The integral approach suggests a fresh way of looking at the etiology and treatment of substance abuse, one that honors and expands on the biopsychosocial model. Figure 2 highlights the etiologic factors in each quadrant, as well as the treatment components that are suggested by each quadrant. Ideally, treatment involves actions taken in all four quadrants; change in one quadrant causes change in the other three. For example, a

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change in welfare regulations in the mid 1990s (lower right quadrant: LR) led to increased poverty (LL), particularly among women and children, which lead to a greater likelihood of drug-dealing for survival (LL) and drug use to self-medicate negative consequences of poverty (UL and UR). This led to a greater number of children in the foster care system (LL), changes in brain functioning (UR), greater cognitive impairments (UR), increases in symptoms of depression, anxiety, shame, and guilt (UL), increased stigmatization of drug-addicted women (LL), and stricter policies which increased the incarceration rate of drug-addicted women (LR). Figure 2 is not comprehensive, but offers some examples of etiologic and treatment variables that could be considered in designing integral programs. Inner Substance(TM) is a specific treatment approach that integrates the four quadrants and offers a way of bridging the left hand quadrants while addressing spirituality from a crosscultural perspective (for further information see Amodia &Cano 2002).

APPLICATION OF THE FOUR QUADRANT THEORY TO ADDICTION TREATMENT This section reviews in more detail the components of each quadrant, and their contribution to a more holistic or integral substance abuse treatment model. Although each quadrant is presented separately, it is important to keep in mind that the integral approach serves to integrate all four quadrants to promote transformational (positive, life-affirming) change via the process of providing access to spirit using cross-cultural bridging concepts. The Upper Left Quadrant (I) The upper realms of the integral approach to substance abuse (the individual level) have been studied the most extensively, and therapies dealing with cognitive, affective, and social development have been designed. However, three areas of individual development suggested by the integral approach have been somewhat neglected in the research on substance abuse etiology and treatment: the dynamic and uneven nature of human development (that is, the role of developmental stage or level), spirituality, and crosscultural issues. Lip service is given to individualizing treatment to meet the developmental level of the client, but because of lack of

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staff training, funding priorities, and other issues, most often all clients are subjected to the same generic treatment. This issue of lifespan development is too complex to explore here, but requires much more study. The determination of level of development is complicated by effects of drugs on many developmental functions such as attention, memory, higher cognitive functions, and moral decision making. Whereas the most widely used form of treatment, the 12-Step approach, is a spirituality based model (derived from a particular Christian religious perspective), many scientists have rejected the concept of spirituality as an unmeasurable, idiosyncratic factor (Miller 1998). Why has spirituality been such a central feature of actual treatment, but so rarely addressed in the research literature? As Wilber noted, there are many quite different definitions of spirituality, and many people have difficulty separating spirituality from religion (Working Group 1999; Miller 1998). Because the form of spirituality proposed by the 12-Step philosophy is so closely tied to a Protestant religious worldview, the entire concept of spirituality within the addiction treatment field has been linked to religion in the minds of many clinicians, clients, and scientists. Focusing on spirituality from only one religious perspective is as limiting as focusing on treatment from only one cultural perspective. Clients in substance abuse treatment often express an interest in obtaining spiritually based treatments and/or report that their recovery involved spiritual transformational change (Arnold et al. 2002; Miller 1999; Green, Fullilove &Fullilove 1998), yet many so-called evidence-based treatmerits focus on single lines of development (cognitive, behavioral, social) and ignore the spiritual aspects. There is a great need for treatment models that help clients access spirituality from a cross-cultural perspective, honoring the diversity in the specific paths or tools used to achieve transformational change. Whether spirituality is viewed as a separate line of development, dependent on other lines of development, or as a unique behavior, attitude or experience, thousands of years of wisdom traditions have identified methods of accessing spirit, ranging from prayer to meditation to ancestor rituals to acupuncture to nature experiences (Murphy 1992). Western science is just recently recognizing the health benefits of these indigenous traditions (e.g., Gilbert 2003; Robinson, Matthews, &Witek-Janusek 2003; Astin 1998, 1997; Kabat-Zinn et al. 1992). There is growing attention in the substance abuse treatment literature to the development of self and identities, particularly those social identities related to race, ethnicity, nationality, religion, sex/gender, sexual identity, and class. These social identities bridge the quadrants. One cannot identify with a gender, racial/ethnic, sexual, or religious identity in isolation of a social, cultural, or broader societal context. Some identities are based on the recognition of societal oppression (LR), whereas others are based on shared interests or beliefs (LL). To deal with these identities only on the individual level is limiting. The way that these identities should be addressed in treatment is not clear. How does an agency deal with the various identities of clients? What happens when one individual has multiple identities, such as a 65-year-old African-American Jewish woman? Clearly there is a need for a cross-cultural paradigm that honors cultural and subcultural differences but allows for identification of universal themes. Social identities are experienced by the individual (UL), but are rooted in the sociocultural (LL) and broader dominant ideologies (LR), thus cross-cultural bridging concepts are needed to expose these connections. In conclusion, most substance abuse treatment focuses on the upper left quadrant functions, but only pays attention to a fraction of the developmental lines, such as the cognitive and/or behavioral lines. There is a need for a more comprehensive view of the developmental and integral nature of addiction, particularly approaches that include spiritual development and cultural identities. Lower Left Quadrant (We) The substance abuse treatment literature points out the role of the social and cultural environment, recognizing the power of these social entities in relapse risks. For example, AA/NA slogans about the need for "new playmates, new playgrounds" recognize the power of family and peers. In addition, there are growing numbers of culturally-specific treatment programs, tailored for people based on their social identities (by race, sex/gender, age, sexual identity, or religion, for example). These programs, while offering a safe haven and

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cultural specificity, may not prepare the client to return to a culturally diverse world. In addition, they may make assumptions about the homogeneity of a particular cultural group that has little basis in reality. For example, a program based on traditional Chinese values may not be beneficial to all Asians, or even all Chinese individuals. Programs that have a mixture of clients have struggled with ways to make their staff and programs culturally specific or culturally sensitive. There has been little clarity in the field about how to do this, or how to assess whether an individual or a program has achieved cultural competency. Individuals must unlearn prejudice and stereotypes, recognize common cultural differences, eventually learn to honor or value diversity, and offer safe and inclusive services to all clients. However, the typical cook-book approach to diversity education has always been problematic. Making blanket statements about the characteristics of any socially- constructed group sets one up for stereotypical thinking (which led to prejudice in the first place). Merely replacing negative stereotypes with positive stereotypes has been more harmful than useful. Instead, a cross- cultural bridging paradigm that is able to deal with universal themes across cultures could be potentially revolutionary. For example, diversity textbooks often state "Hispanics value family." While true (stereotypes are almost always based in some level of truth), there is no cultural group on earth that does not value family. The differences lie in how family is defined, what cultural myths or archetypes about family have been passed down generationally, and what social roles an individual is expected to play in their family. The need for family is a universal cross- cultural bridging concept, whereas the specific behaviors related to one's family may be culturally specific. When diversity textbooks make statements about the characteristics of some group of people, they are broad generalizations based on the "typical" members of the group and ignore the wide diversity in the individual, such as degree of assimilation into the dominant culture, age, immigration status, language and religion, and many other differences. To group all people of one racial group or even one ethnic group together and ignore the intragroup variations has been referred to as "ethnic gloss" (Trimble 1995), and is an important limitation of culturally-specific treatment interventions. Diversity education has been ineffective, largely because it has been based on the assumption that lack of attention to culture is due to lack of knowledge. Therefore, diversity education programs focused on the cognitive aspects of human development and stereotypical characteristics of large groups of people, and ignored the fact that cultural differences are rooted in sociocultural assumptions and stereotypes (LL) and dominant ideologies (LR) that have cognitive, affective, moral, religious, and spiritual ramifications for the individual. Education alone is rarely effective in changing individual attitudes or cultural ideologies. Rather than continue to educate based on differences, the integral approach begins with cross-cultural bridging concepts, or similarities. Once interpersonal relationships are built across cultures, different perspectives and practices can be shared and a sense of community can emerge. Upper Right Quadrant Hundreds of studies have examined the biological correlates of addiction, including genetic transmission, neurochemical systems, metabolism of substances, and physical effects of substances on organ systems and bodily structures and functions (such as studies of intoxication, withdrawal, and their short and long-term effects on the physical body). Western science has effected a drastic separation from philosophy and religion (Austin 1998; Kabat-Zinn et al. 1992), that values empirical (observable) science over all else. Many authors have called for contemporary science to broaden its focus and begin to integrate wisdom traditions with the best of new science. In particular, many authors have called for the incorporation of spiritual care back into health care (Miller &Thoresen 1999). Biological researchers often work in isolation of those providing direct services, making policies, or dealing with the ravages of substance abuse in local communities. Biological findings take years to be translated into treatment approaches. An integral approach to addiction treatment would encourage biological researchers to translate their findings so that they are more quickly applied in the field, and clinicians would help researchers

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identify and prioritize research agendas that would provide a greater good to the field. An integral approach would also broaden the perspective of biological treatments to include concepts of fitness, nutrition, and biological effects of alternative and complementary treatments such as meditation and acupuncture. Until recently, biological studies have tended to treat human bodies as though they were all alike, thus the same medication or medical treatment was considered to be appropriate for all patients/clients. However, there is growing recognition that bodies do differ in terms of metabolism of drugs and responses to treatment, leading to subspecialities in sex/gender differences and ethnopsychopharmacology. For example, women have lower blood volumes, higher body fat, greater bioavailability and slower drug clearance than men (Robinson 2002; Kandall 1998), and African Americans, Asians, Caucasians, and Mexican Americans have genetic differences in enzymes involved in drug metabolism (Ruiz 2000). Some cultural differences appear to have underlying biological underpinnings whereas others are related to sociocultural differences. As one example of a cultural difference, in some groups, physicians are viewed as the ultimate authority and patients will follow instructions to the letter whereas in other groups, western physicians are viewed with distrust. Treatment philosophies are another example of subcultural differences. In spite of major changes in the past few years, some health care providers who recovered from their own substance abuse using 12-Step programs still believe that clients must be completely free of any mood-altering substance, and discourage clients from getting medications. This cultural attitude, or ideology, affects the treatment of clients with co-occurring mental illnesses. The integral approach recognizes the impact of all four quadrants and advocates for simultaneous (integrated) treatment. Drug effects on the physical body (UR) can create or mimic reactions in the Upper Left quadrant that we experience (UL) and interpret (LL) as love, mania, paranoia, or some other emotion. Practitioners who are not trained in an integral approach to addiction may misdiagnose the stimulant abuser as schizophrenic or in the manic phase of bipolar disorder, or misdiagnose the alcoholic as depressed. Of course, these mental disorders or symptoms often do coexist with substance abuse, but misdiagnosis can lead to ineffective and costly treatment. In the past hundred years, medicine has focused on curing illness. This emphasis stemmed from the mind-body separation and development of medical technologies that fostered rapid advancement of science, but the focus on physical health in isolation has been limiting. There is growing recognition of the interdependence of physical health with emotions, attitudes, values, and cultural belief systems. In addition, many physical health problems, including addictions, are chronic illnesses that cannot be cured. An integral approach emphasizes healing rather than curing, using techniques drawn from all four quadrants in a holistic fashion. Studies have shown that over 80% of cancer patients use complementary and alternative medicines (Montbriand 1993), many of which are drawn from old wisdom traditions, including yoga, meditation, acupuncture, herbal treatments, and so on. Many of these have been incorporated into addiction treatments, although there has been very little study of their effectiveness as of yet. Lower Right Quadrant The treatment field often comments on the politics of substance abuse treatment, but this information is rarely incorporated into the actual treatment models used in practice. For example, incarceration of substance abusers is related to contradictory societal myths-health care discourse labels substance abuse as a chronic illness whereas the legal/regulatory discourses label it criminal activity. Dominant religious discourses have varied responses to addiction, from labeling it as sin or lack of moral fortitude or as curable by religious conversion, to developing compassionate programs that support people suffering from addictions. The ever-changing political climate means that funding for substance abuse treatment waxes and wanes, depending on whether major policy makers are more responsive to supply or demand rhetoric, whether the nation is waging a war on drugs or a war on drug users, and whether the prevailing view is to scapegoat substance abusers for societal ills, or to promote compassionate care. The differences in political messages about drugs given by previous first ladies

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Betty Ford and Nancy Reagan illustrate these political vagaries. The message that substance abuse is a treatable disease (Ford) versus the "just say no" campaign (Reagan) influenced millions of citizen's attitudes about substance abuse. Political policy has always been more closely tied to dominant ideologies and philosophies of those in power than it has to science or empirical research. For example, in spite of evidence that treatment reduces crime and other costs to society much more effectively than incarceration, the 2002 federal drug budget allocated $2.304 billion to SAMHSA (about 20% of the total budget), part of which funds treatment, whereas 53% of the budget went to law enforcement efforts (ONDCP 2003). An integral approach to substance abuse would need to address the political climate in treatment. For example, social justice approaches to treatment put individual problems into their political context (for example, the feminist philosophy that the personal is political), helping clients to recognize the social, economic, and political circumstances that contribute to substance abuse, such as poverty, child abuse, and the proliferation of liquor stores in minority neighborhoods.. The recognition of racism, classism, sexism, heterosexism, and other forms of oppression can be empowering. This is not to take a victim stance, but to adopt a social justice orientation that equips clients with knowledge and skills to understand the political climate as it impacts their individual lives. In addition, physicians and other professionals need to take advocacy roles for the disempowered patient populations with which they work. CONCLUSIONS The integral approach to substance abuse presented in this article expands on the biopsychosocial model and proposes integrating knowledge from western, eastern, and indigenous wisdom traditions. The need for bridging paradigms has been widely acknowledged in many fields in recent years, from theories in science such as chaos and systems theories that recognize the interdependence of all life, re-affirming wisdom traditions from around the world, to the integration of medicine using combinations of new science and ancient practices for healing. The integral approach to substance abuse addresses the major gaps in current substance abuse treatment, as summarized by the six overlapping points below: 1. The need for multidisciplinary teams. An integral approach requires true collaboration among practitioners of different disciplines, as well as alliances with researchers and policy makers to be truly effective. No one isolated discipline is sufficient to address a complex, multifaceted problem like addiction. 2. The need for multimodal therapies. Cross-cultural techniques, combining the knowledge of modern science with thousands of years of indigenous wisdom, particularly in methods to access spirit, are likely to produce the conditions needed for transformative and long-lasting change. 3. The need for cross-cultural bridging paradigms. There is a need for highly specific treatment programs which target particular communities, and some communities with large numbers of such clients can sustain separate programs. However, many treatment programs must serve a diverse community and cannot afford to specialize. These generic programs need cross-cultural approaches that are based on common ground rather than difference. Even the culturally specific treatment programs could benefit from incorporating a cross-cultural perspective, as most clients will live and work in diverse communities when they finish treatment. 4. The need to consider individual development. Identifying the individual's developmental stages or levels, and recognizing the multiple lines of development is a first step to truly individualizing treatment and identifying the tools that are best suited for growth at that stage (Wilber 2001). 5. The need to address spirituality from a cross-cultural perspective, separate from any specific religious worldview. Spirituality is a key component to physical and mental health and appears to be necessary for the transformative change required for recovery from substance abuse. Providing tools for accessing spirituality that are inclusive of all cultures and religions will reach more clients than current approaches. 6. Those involved with substance abuse treatment needs to concentrate more attention to the lower right quadrant and work toward policy change and social justice. It is necessary to create a means through which clinicians can learn to be more effective policy advocates for the clients with which they work.

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In conclusion, substance abuse treatment, like other specialized forms of health care, could benefit from an integral approach that takes into account all etiologic factors, and blends the treatment approach with the best of contemporary science and the wisdom of centuries of indigenous traditions. This framework for an integral approach to substance abuse serves as a guide for developing these holistic services. Footnote [dagger] The authors wish to thank Angeles Arrien for her inspiration and guidance in applying cross-cultural techniques to the treatment of addiction and mental illness. References REFERENCES Amodia, D.S. &Cano, C. 2002. Inner Substance(TM). San Francisco, CA: Inner Substance, LLC. Arnold, R.M.; Avants, S.K.; Margolin, A. &Marcotte, D. 2002. Patients' attitudes concerning the inclusion of spirituality into addiction treatment Journal of Substance Abuse Treatment 23: 319-26. Arrien, A. 2005. Personal communication. Arrien, A. 2001. Introduction to "Working Together." In: A. Arrien (Ed.) Working Together: Diversity as Opportunity. San Francisco: Berrett-Koehler Pub. Inc. Arrien, A. 1993. The Four-Fold Way: Walking the Paths of the Warrior, Teacher, Healer, and Visionary. San Francisco, California: HarperSanFrancisco. Astin, J.A. 1997. Stress reduction through mindfulness meditation. Psychotherapy and Psychosomatics 66: 97- 106. Astin, J.A. &Astin, W.W. 2002. An integral approach to medicine. Alternative Therapies 8 (2): 70-75. Austin, J. 1998. Zen and the Brain. Cambridge, Massachusetts: MIT Press. Campbell, J. 1973. The Hero with a Thousand Faces. Princeton, NJ: Princeton University Press. Gilbert, M.D. 2003. Weaving medicine back together: Mind-body medicine in the twenty-first century. Journal of Alternative and Complementary Medicine 9 (4): 563-70. Green, L.L.; Fullilove, M.T. &Fullilove, R.E. 1998. Stories of spiritual awakening: The nature of spirituality in recovery. Journal of Substance Abuse Treatment 15: 325-31. Kabat-Zinn, J.; Massion, A.O.; Kristeller, J.; Peterson, L.G.; Fletcher, K.E.; Pbert, L.; Lenderking, W.R. &Santorelli, S.F. 1992. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry 149: 936-43. Kandall, S.R. 1998. Drug Addiction Research in the Health of Women. Rockville, Maryland: NIDA. Miller, W.R. 1999. Integrating Spirituality into Treatment. Washington, D.C.: American Psychological Association Press. Miller, W.R. 1998. Researching the spiritual dimensions of alcohol and other drugs. Addiction 93 (7): 979-90. Miller, W.R. &C' de Baca, J. 2001. Quantum Changes: When Epiphanies and Sudden Insights Transform Ordinary Lives. New York: Guilford. Miller, WR. &Thoresen, C. 1999. Spirituality and health. In: W.R. Miller (Ed.) Integrating Spirituality into Treatment. Washington, D.C.: American Psychological Association Press. Montbriand, M.J. 1993. Freedom of choice: An issue concerning alternative therapies chosen by patients with cancer. Oncology Nursing Forum 20 (8): 1195-1201. Murphy, M. 1992. The Future of the Brain: Explorations into the Further Evolution of Human Nature. Los Angeles, CA: Tarcher, Inc. Office of National Drug Control Policy (ONDCP). 2003. National Drug Control Strategy. Washington, D.C.: Office of the White House. Office of National Drug Control Policy (ONDCP). 2001. The Economic Costs of Drug Abuse in the United States, 1992-1998. Washington, D. C: Office of the White House. Robinson, P.P.; Mathews, H. &Witek-Janusek, L. 2003. Psychoendocrine-immune response to mindfulness-

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based stress reduction in individuals with HIV: A quasi-experimental study. Journal of Alternative and Complementary Medicine 9 (5): 683-94. Robinson, G.E. 2002. Women and psychopharmacology. Medscape Women's Health eJournal 7(1). Available at www.medscape.com/ viewarticle/423938 Ruiz, P. 2000. Ethnicity and psychopharmacology. In: J. Oldham &M. Riba (Eds.) Review of Psychiatry, Volume 19. Washington, D.C.: APA Press. Sandman, G.; Bezold, C.; Jahnke, R.; Wisneski, L.; Snider, P.; Dumoff, A.; Weeks, J.; Schmidt, T.; Whitworth, G.C. &clay, E. 2002. Design principles for healthcare renewal: Draft. Special Supplement to Alternative Therapies 8 (2): 1. Scotton, B. 1996. Introduction and definition of transpersonal psychiatry. In: B. Scotton; A. Chinen &J. Battista (Eds.) Textbook of Transpersonal Psychiatry and Psychology. New York: Basic Books. Smith, H. 1976. The Forgotten Truth: The Common Vision of the World's Religions. San Francisco, California: HarperSanFrancisco. Trimble, J. 1995. Toward an understanding of ethnicity and ethnic identity, and their relationship to drug use research. In: G. Botvin; S. Schinke &M. Orlandi (Eds.) Drug Abuse Prevention with Multiethnic Youth. Thousand Oaks, California: Sage. Wilber, K. 2001. JVo Boundary: Eastern and Western Approaches to Personal Growth. Boston: Shambala Press. Wilber, K. 2000. Integral Psychology: Consciousness, Spirit, Psychology, Therapy. Boston, Massachusetts: Shambala Publications. Working Group of NIA/Fetzer Institute 1999. Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research. Available at: www.fetzer.org. AuthorAffiliation Diana S. Amodia, M.D.*; Carol Cano, B.A.** &Michele J. Eliason, Ph.D.*** AuthorAffiliation * Co-Medical Director, State of California Office of Alcohol and Drug Programs; Visiting Researcher, UCSF Institute for Health and Aging, San Francisco, CA. ** Substance Abuse Counselor and Certified Eastern Practitioner, California Pacific Medical Center, Institute of Health and Healing, San Francisco, CA. *** Associate Professor, University of Iowa, Iowa City, Iowa, and UCSF Institute for Health and Aging, San Francisco, CA. Please address correspondence and reprint requests to Dr. Diana S. Amodia, UCSF Institute for Health and Aging, 3333California Street, Suite 340, San Francisco, CA 94118. MeSH: Humans, Models, Theoretical (major), Substance-Related Disorders (major), Substance-Related Disorders (major) -- etiology, Substance-Related Disorders (major) -- psychology, Substance-Related Disorders (major) -- therapy Publication title: Journal of Psychoactive Drugs Volume: 37 Issue: 4 Pages: 363-71 Number of pages: 9 Publication year: 2005

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Publication date: Dec 2005 Year: 2005 Publisher: Haight Ashbury Publications Place of publication: Oxford Country of publication: United States Publication subject: Drug Abuse And Alcoholism, Medical Sciences--Psychiatry And Neurology, Pharmacy And Pharmacology ISSN: 02791072 CODEN: JPDRD3 Source type: Scholarly Journals Language of publication: English Document type: Journal Article Accession number: 16480163 ProQuest document ID: 207972353 Document URL: http://ezp.waldenulibrary.org/login?url=http://search.proquest.com/docview/207972353?accountid=14872 Copyright: Copyright Haight Ashbury Publications Dec 2005 Last updated: 2012-11-14 Database: ProQuest Central,Nursing & Allied Health Database

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