In Defense of Anthony Weiner?

After recent revelations that former congressman and New York mayoral candidate Anthony Weiner continued sexting on social media sites after apologizing for his indiscretions, many have been quick to accuse him of being a consummate liar and a person of poor moral character who should be punished for his actions. Is it possible that Mr. Weiner is exhibiting the telltale signs of an addicted person needing treatment?

While there remains controversy as to whether sexual compulsivity is truly a disorder, his behavior clearly displays symptoms similar to a substance use disorder.


The most notable characteristic of any addiction is loss of control over the behavior in question. I have discussed this in detail in a previous blog, entitled What is Chemical Addiction? Few would argue that Mr. Weiner made a conscious choice to place his political life in jeopardy, as well as his marriage and overall reputation. Why would he continue such damaging behavior with evidence available in the public domain to prove his misconduct? We could cite many public figures, including sports celebrities and movie stars, who have placed their careers and exorbitant salaries in jeopardy by compulsive behaviors, most frequently involving compulsive substance use. The answer is loss of control over the behavior despite the evident negative consequences. A recent article in the Sunday edition of the New York Times dated July 28, 2013, asked why cigarette smokers continued to smoke despite knowing the serious risks to their health. The author, Eyal Ert, an expert in behavioral science, argued that smokers have a personality flaw involving poor self-control. Mr. Weiner seems to exhibit a similar lack of self-control over his behavior, suggesting the need for treatment.


Other characteristics of addiction (for which we lack information as it relates to Mr. Weiner) include preoccupation with the behavior and strong cravings for the behavior. It is my belief that Mr. Weiner would likely prove positive for these criteria as well, if he were to honestly confront this issue. Is it fair then to assume he lacks moral character, or should we consider that he is suffering from a debilitating disorder that needs to be addressed by trained professionals?

Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

Drug Addiction is a Chronic Condition Needing Chronic Treatment

In the recent publicity related to the death of yet another celebrity due to drug use, Glee star Cory Monteith, People Magazine wrote a piece suggesting that 30 days of inpatient treatment for substance use disorders may not be enough treatment, and recommended extended care for up to 90 days in sober living facilities.  While I believe this to be a step in the right direction, even 90 days is usually not enough treatment support to adequately curtail a disorder that is commonly believed to be an incurable and chronic condition.

Medical professionals would never suggest short-term treatment for other conditions considered incurable, such as diabetes and hypertension, but would insist that they be adequately contained with ongoing monitoring and medication,.  So why is the treatment of substance use disorders any different?

Sure, there are recovery support groups available in the community that provide adequate long-term support, such as Alcoholics Anonymous, SMART Recovery, and Women for Sobriety, but these self-help meetings are not for everyone who has suffered from substance-related disorders. Often, people need ongoing professional help and support through counseling, relapse prevention skills, and the provision of one of the growing number of addiction medicines used to help block the euphoric effects of drugs or reduce the cravings for these substances.

While I am not suggesting long-term inpatient treatment, I believe in long-term outpatient treatment to arrest these disorders.  Studies have shown that participation in even a once-weekly supportive intervention could significantly increase the prevention of relapse to substance use.  These supportive meetings can be group sessions or individual sessions.  These meetings can take place face to face, or even be held online in the form of videoconferenced sessions, chat discussions, email therapy, or phone sessions.

I personally lead weekly long-term group sessions for recovering addicts and alcoholics.  Some of the members have been attending for over 10 years.  Is it a coincidence that the 15+ individuals who have attended these sessions weekly for years have maintained consistent sobriety?  I think that ongoing support is essential for maintaining sobriety.  Why hasn’t the rest of our society caught on yet?  Thirty days at an inpatient facility may be the start of treatment, but it is certainly not THE treatment.  Let me know your thoughts on the subject.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.  He can be reached at

Chat2Recovery on The Fix!

Today, Chat2Recovery was featured on The Fix!

The Fix is the world’s leading website about addiction and recovery, featuring a daily mix of breaking news, exclusive interviews, investigative reports and essays on sober living.

View the article here and let us know what you think in the comments!

DSM-5: New Criteria for Substance Use Disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is considered to be the ”bible” of classification and diagnostic criteria for mental disorders. After a wait of approximately 13 years since the revised Fourth Edition, the DSM-5 was released on May 18th. I will briefly detail some of the changes to the category of Substance Use Disorders.

In the previous edition, Substance Use Disorders (SUDs) were divided into two separate diagnostic entities: Substance Abuse and Substance Dependence. Substance Abuse was considered less severe than Substance Dependence. For a further explanation of these two diagnostic entities, please read my January 2013 blog, “What is a Substance Use Disorder?”  In the new edition of the DSM, these two diagnostic entities have been eliminated and replaced with the term Substance Use Disorders on a severity continuum with three levels: mild, moderate, and severe.

There are now 11 symptom criteria to assess for each individual presenting with the possibility of an SUD. In the new edition, a person needs at least two criteria for a SUD diagnosis. In the previous edition, a person needed only one symptom criterion to meet the diagnosis of Substance Abuse. These symptom criteria must be present within the past 12 months and lead to “clinically significant impairment or distress.” They are:

  1. ______ is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control _____ use.
  3. A great deal of time is spent in activities necessary to obtain ______, use _____, or recover from its effects.
  4. Craving, or a strong desire or urge to use ____.
  5. Recurrent _____ use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued _____ use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of _____.
  7. Important social, occupational, or recreational activities are given up or reduced because of _____use.
  8. Recurrent _____ use in situations in which it is physically hazardous.
  9. ____ use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by _____.
  10. Tolerance, as defined by either of the following:  
    1. A need for markedly increased amounts of _____ to achieve intoxication or desired effect.
    2. A markedly diminished effect with continued use of the same amount of ____.
    3. Withdrawal, as manifested by either of the following:
      1. The characteristic withdrawal syndrome for ____
      2. ____ is taken to relieve or avoid withdrawal symptoms.

Severity of an SUD is now determined by the number of symptom criteria present over the past 12 months. In order to have a diagnosis of a “Mild Substance Use Disorder,” the patient must have met the above criteria for 2 to 3 symptoms. For a diagnosis of “Moderate Substance Use Disorder,” the patient must meet 4 to 5 symptom criteria. For a diagnosis of “Severe Substance Use Disorder,” the patient must meet 6 or more symptom criteria.

While the newly merged diagnosis of Substance Use Disorder seems to be perceived as an improvement, primarily due to greater simplicity of diagnosing, I am not such a fan. As you may have read in my previous blog on “What is a Substance Use Disorder?” I see Substance Abuse and Substance Dependence as two distinct entities with clear differences. I have previously written that Substance Abuse is essentially a pattern of inconsistent loss of control over a substance or substances, whereas Substance Dependence exhibits a more consistent pattern of loss of control. I believe the difference goes beyond severity factors, toward a more distinct pattern of use. I have often found that individuals who have met the criteria for Substance Abuse have difficulty relating to the individual who is considered Substance Dependent. Time will tell whether this newly merged diagnostic entity improves our work or hinders it.

Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.  He can be reached at

Nick’s Picks: The Art of Happiness

Periodically, I will highlight the main points of books and articles that I have read and strongly endorse related to spirituality, self-growth, and recovery. The first of these is The Art of Happiness: A Handbook for Living, co-authored by His Holiness the Dalai Lama and Dr. Howard C. Cutler, a psychiatrist. This book, initially written in 1998, is now in its tenth anniversary printing and on many lists as one of the best books about spirituality ever written.

For those unfamiliar with the Dalai Lama, he was born Tenzin Gyotso in 1935, and is thought to be reincarnated from the 13th Dalai Lama.  He is considered the head of state and spiritual leader of Tibet.  In 1959, he was forced to escape Tibet by a brutal Chinese invasion, and has been in exile ever since, living in India.  In 1989, he was awarded the Nobel Peace Prize for his nonviolent struggle for the liberation of Tibet.  He has authored more than 72 books.

This book is structured as a comparison of the Dalai Lama’s Buddhist understanding of mental health issues and human well-being with our current scientific understanding of the same issues in Western culture.  What struck me was how deeply the Dalai Lama focuses on training our minds to find happiness and how closely associated that view is with cognitive therapy as we presently understand it.

The Dalai Lama believes that we can train ourselves to be happy, much as we can train for any other skills.  He believes that “the purpose of our existence is to seek happiness.”  He also believes that, with inner discipline, even profoundly unhappy people can undergo a transformation of attitude, outlook on life, and approach to life. He writes that happiness is determined more by one’s state of mind than by external events.

The factors involved in this transformation of attitude begin with education.  We must learn how negative emotions and behaviors are harmful to us, and how positive emotions are helpful to achieving happiness.  “If you seek happiness, you should seek the causes that give rise to it, and if you don’t desire suffering, then ensure that the causes and conditions that give rise to it no longer arise.”  After learning about positive and negative emotional states, our next task is to clearly identify different mental states and make a distinction, classifying them according to whether they lead to happiness or not.  For example, hatred, jealousy, and anger are harmful.  Kindness and compassion are definitely very positive. A genuine inner transformation occurs by systematically training our minds to deliberately select and focus on positive mental states and challenge negative ones.  Developing self-discipline within one’s mind is the essence of the Buddha’s teaching.  This same training occurs in cognitive therapy, in which we challenge the negative thoughts that lead to negative emotional states and develop skills to transform our thinking from negative thoughts to positive ones.

“When our life becomes too complicated and we feel overwhelmed, it’s often useful just to stand back and remind ourselves of our overall purpose, our overall goal.  When faced with a feeling of stagnation and confusion, it may be helpful to take an hour, an afternoon, or even several days to simply reflect on what it is that will truly bring us happiness, and then reset our priorities on the basis of that.  This can put our life back in proper context, allow fresh perspective, and enable us to see which direction to take.”

The Dalai Lama spends a considerable amount of time discussing the strong association between happiness and the practice of compassion. Dr. Cutler goes on to report that researchers on human happiness identify compassionate service to others as one of the key characteristics shared by many of the world’s happiest people.  “When we help others, the focus of our minds assumes a broader horizon within which we are able to see our own petty problems in a more realistic proportion.  What previously appeared to be daunting and unbearable, which is what often makes our problems so overwhelming, tends to lose its intensity.”  He goes on to claim that love, affection, closeness, and compassion bring happiness.

This is a book that I strongly recommend for those who suffer with unhappiness, depression, and anxiety. However, reading is only a first step towards transforming one’s life.  One must ask oneself the following questions:  How important is it for me to change?  Am I ready to commit to a new way of thinking and behaving?  Am I ready to take the actions necessary for change to occur?  If you can answer these questions fully in the affirmative, you are clearly on the way to transforming your life and achieving happiness.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.  He can be reached at

Substance Abuse Treatment – What Really Works? (Part Two)

In the previous blog, I spoke about the importance of a thorough assessment to individualize a person’s treatment, the inclusion of group, individual, and family services, the use of education about the recovery process, and the utilization on an outpatient basis of consistent urine toxicology and breathalyzer screening.  In today’s blog, I will focus on the importance of medical care, psychiatric services, addiction medications, and community recovery support.

Many abusers of substances come to treatment with an array of medical issues, including malnutrition, infections, sexually transmitted disease, HIV, hypertension, or poor hygiene.  Many have not been seen by a medical professional in years.  It is a sign of good care that any patient entering substance abuse treatment be seen early in the process by a medical care professional.  This screening should determine what medical issues need to be addressed immediately and what issues need to be monitored throughout the treatment process.

Good treatment should also include a thorough screening of mental health concerns.  This may begin with completion of standardized screening tools used to pinpoint areas of concern around suicidal or homicidal thoughts, mood disorders, anxiety disorders, psychotic disorders, trauma, or personality disorders.  Any concerns identified would lead to a more specific exploration with a psychiatrist or other trained mental health professional.  This may lead further to a recommendation of medication to alleviate some of the symptoms of mental health disorders.

Another area of good practice is the inclusion of addiction medicine in the overall treatment plan.  Today, we are fortunate to have a variety of medications that can aid in reducing urges and craving for particular substances or to act as a better substitute for physical addiction to particular drugs.  For example, naltrexone seems to benefit many individuals dependent on opioids and/or alcohol.   Oral naltrexone acts as an opioid blocker in the brain, blocking the euphoric effects of opioids, and also seems to decrease the urges and cravings for alcohol.  For those who may not be compliant with taking the medication daily, there is now a monthly injectable version of naltrexone with the product name of Vivitrol.  Acamprosate, with the product name Campral, has also shown benefit in decreasing the urges and craving for alcohol in many users.  There are also medications to replace opioid dependence, such as methadone and the newer medication buprenorphine.  For nicotine dependence, there are now nicotine replacement aids, such as patches, gums, and even an electronic cigarette.  There is also an effective medication, Chantix, which appears to help decrease the cravings for nicotine.

Lastly, good treatment involves educating clients about the usefulness of participating in community recovery support services during and after leaving the treatment program.  Since substance use disorders are no longer considered to be an acute care disorder, but rather a chronic care condition needing a lifetime of monitoring, ongoing support is vital to arresting the disorder from reoccurring. This community recovery support may include participation in such programs as Alcoholics Anonymous and Narcotics Anonymous, or newer groups including SMART Recovery, Women for Sobriety, and Secular Organization for Sobriety (SOS).  There are now online support groups with chat rooms and videoconferenced services, such as Chat2Recovery.  Community recovery support can also include working with a particular professional specializing in helping people maintain a lifestyle free from substance use.  There are now even groups such as Moderation Management that support those who wish to attempt controlled use of substances.

High-quality substance abuse treatment can be very effective when it consists of the ingredients mentioned in the last two blogs.  Before entering any treatment program, ask specifically about the services offered and make certain that the program that you are considering includes many if not all of the services mentioned.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.  He can be reached at

Substance Abuse Treatment – What Really Works?

When I began working in the substance abuse treatment field over 30 years ago, the general philosophy seemed to be that the individual fit into the program model rather than the other way around.  There was little individualized care being offered.  While there are still treatment programs following this model of “one size fits all,” quality treatment programs today follow the philosophy of providing individualized care for each person based upon his or her particular needs or problems.  In order to provide effectively for this individualized care, programs today must have access to an array of treatment services to meet the particular needs of their patients, whether within the program itself or through links to specialized services outside of the program.

Since my expertise is in outpatient treatment settings, I will focus on effective services provided on an outpatient basis.  The array of services that should be offered on an outpatient basis includes, at a minimum, the following: a comprehensive assessment; individual, group, and family counseling; recovery education; toxicology and breathalyzer screening; psychiatric monitoring; medical care; addiction medicine; and access to community recovery support.

Effective treatment of substance use disorders begins with a thorough assessment of a person’s history.  The assessment should include a review of the individual’s substance use and treatment history, including use of objective screening tools to confidently ascertain that there is a diagnosable Substance Use Disorder (SUD).  The substance use history should attempt to understand whether the factors leading to an SUD are associated with physiological, psychological, social, environmental, or spiritual factors.  The assessment should include a review of mental health factors, including objective screening tools for signs of mood disorders, anxiety disorders, psychotic disorders, trauma, brain injury, and other compulsive behaviors (e.g., gambling, sex, eating).  A comprehensive assessment looks at the person’s physical health, and refers the individual for a physical examination as indicated.  A review of the individual’s family and social history is needed to understand the significance of relationships present and past, as well as the individual’s interpersonal functioning.  A review of education and employment history is important, including educational or vocational deficits.  Understanding a person’s living environment and leisure activities is very important.  It is also useful to be aware of any legal issues that may be impacting an individual’s life.  It is this comprehensive assessment that should be the basis of someone’s individualized treatment program.  I would recommend finding an alternative treatment program if this kind of assessment does not occur soon after enrolling in a program, or if the program offered to you appears to have no association to the problem areas identified in the assessment.

Effective treatment programs must include an array of individual, group, and family counseling services.  The counseling services offered should be associated with the assessment issues identified. If a patient is identified as ambivalent about complete abstinence from substance use, this factor should help determine the proper placement in particular groups or individual counseling that can address this ambivalence.  If the patient is found to have significant co-occurring mental disorders, this should also be taken into account in the placement of counseling services.  The frequency of group and individual sessions should be individualized to the particular issues of the patient.  Furthermore, family treatment and couple counseling should be provided either on-site or as a referral to outside resources when indicated.

Some degree of recovery education is expected in an effective treatment program.  This education should include: developing new coping skills to deal with urges and cravings; dealing with drug refusal skills; understanding the process of recovery; and understanding addictive disorders from biological, psychological, social, and spiritual perspectives.  This education should be provided by a qualified professional who is comfortable with the material covered and can answer questions effectively.

Effective outpatient programs should include toxicology screening and breathalyzer screenings as needed and on a random basis.  Many participants in outpatient programs report that the screenings were a helpful deterrent to continued substance use.  When they felt a strong urge to use a substance, believing that a toxicology screening or breathalyzer might be awaiting them at the treatment center helped them choose not to use the substance.  Also, fear and shame lead participants to hide or minimize substance use.  Regular toxicology and breathalyzer screenings allow the treatment team to monitor progress and dangerous relapse patterns. 

In Part Two of this blog, we will focus on the remaining services recommended as part of an effective treatment program.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What are the Options for Substance Abuse Treatment? (Part Two)

In Part One of this blog, I discussed the more intensive levels of care, namely inpatient detoxification services and residential treatment services.  In Part Two, I will review outpatient levels of care. Moving from the most intensive to least intensive, the first outpatient level of care (LOC) to consider is ambulatory detoxification services.  This LOC is considered for the person who is using a substance or substances daily and is physically addicted.  Physical addiction was explained in Part One as having developed tolerance for a substance and experiencing withdrawal symptoms when discontinuing that substance. Ambulatory detoxification typically involves going to a treatment center daily for a number of days to obtain medication, monitor vital signs, and assess the person’s comfort level during the detoxification process.  A professional addictions specialist would determine whether a person appears to be a good candidate for ambulatory detoxification or would need monitoring in an inpatient detoxification.

Intensive outpatient (IOP) involves non-residential services that typically meet a minimum of 3 hours per day and typically 9 to 12 hours per week.  The services often consist of daily educationally focused workshops, group counseling, individual counseling, and urine drug screens.  This level of care usually lasts about 4 to 8 weeks, with the average being about 6 weeks.  It is similar in its treatment approach to a 28-day inpatient treatment model, but the participant does not have to live away from home or even take a leave from his or her job.

The person who would benefit from IOP services is the individual who is using substances quite regularly, although is not physically addicted, and cannot seem to abstain from his or her substance use for any extended period of time.  This LOC is also suggested for the individual who lacks education about substance use disorders and the recovery process.

Outpatient treatment is the next less intensive LOC to consider.  Outpatient treatment includes any non-residential treatment services involving less than 9 hours per week or less than 3 hours in any day.  It includes structured outpatient programs or treatment in the office of a private practitioner.  An example of a structured outpatient program may include two 90-minute group sessions weekly, combined with a weekly individual counseling session.  The treatment can last for weeks or months, depending on the provider’s treatment philosophy.  The types of groups offered at this LOC also depend on the provider’s treatment philosophy, and can be oriented to a more traditional 12-step disease-model approach or geared toward more of a harm-reduction approach.  You should ask about a provider’s orientation towards treatment prior to enrolling.  In New York State, all licensed treatment programs are now rated by the Office of Alcoholism and Substance Abuse Services (OASAS) on a star system for their quality of treatment.  This system in New York is known as Scorecards and can be accessed at

The newest developing LOC for treatment of substance use disorders is online addiction treatment, such as the Inter-Care program, Chat2Recovery.  For those individuals who are either reluctant to enter face-to-face treatment (for whatever reason), cannot commit to being at a specific location on a set schedule due to work or travel commitments, or cannot find accessible quality outpatient services, this may be an alternative for treatment.  Chat2Recovery (C2R) has a 6-week program consisting of twice-weekly videoconferenced groups and bi-weekly videoconferenced individual sessions with a licensed clinician.  The program is geared toward providing support and education about the recovery process.  You can access it at

If the level of care that you enter is not working for you, you can always go to a higher or lower level.  If you are using your health insurance benefits to pay for treatment, your insurance provider will clearly have a say in which level of care you choose. 


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What are the Options for Substance Abuse Treatment? (Part One)

Someone seeking treatment for a Substance Use Disorder for the first time can be confused about how to proceed. There are many options. If you ask for advice from someone who got help for themselves, they will often recommend what worked for them. That doesn’t necessarily mean that same treatment will be best for you. If you go to a treatment provider that only provides one option for treatment, guess what will likely be recommended for you. It’s important to be educated about making an informed choice that is best for you and will likely be effective. Let’s begin by discussing some of the more common treatment options or what we call levels of care. The options for treatment that I will be discussing include: medical detoxification, residential services, outpatient services, online treatment, addiction medicines, and self-help.

Let’s start with the most intensive and costly treatment options and progress to the least restrictive options. The most intensive option, or level of care, is known as medical detoxification or detox. This treatment is generally recommended for individuals who are heavy users or daily users of substances leading to physical addiction. A physical addiction is characterized by withdrawal symptoms (e.g., shakes, sweats, changes in blood pressure, fever) when discontinuing the substance and, when actively using the substance, high levels of tolerance (i.e., needing greater amounts of the substance to get to a state of intoxication). The setting for this treatment is typically a medical facility (e.g., hospital, private medical office) where your treatment is managed and monitored by medical staff, including doctors and nurses. Patients typically remain in this level of care for a few days (i.e., 2 to 5 days) depending on the severity of the medical condition. In our current health care model, insurance companies are often selective as to which substances are considered eligible for medical detox. Typically, the substances considered to lead to physical addiction with potentially harmful withdrawal symptoms include alcohol and sedatives from the benzodiazepine family (e.g., Valium, Xanax, Klonopin, Ativan). Opioids, which are pain killers, are also considered to lead to physical addiction. Opioids include heroin, codeine, morphine, methadone, oxycodone, hydrocodone, fentanyl, and buprenorphine, to name a few. However, because withdrawal from these substances, while unpleasant, is not considered life-threatening, many managed care companies will not authorize an inpatient medical detoxification for opioids, preferring treatment in what is known as an ambulatory or outpatient detoxification. Ambulatory detox involves going to a clinic each day for medication and monitoring of withdrawal symptoms for several days to a few weeks. Other substances, such as cocaine, methamphetamine, marijuana and hallucinogenic drugs, are not thought to lead to potentially harmful or life- threatening situations during withdrawal from heavy and chronic use patterns. Consequently, these substances are not usually authorized by managed care companies for inpatient medical detoxification.

Residential treatment services are the next option for care. Residential treatment involves entering a controlled environment where you will live for a specific duration of time, typically from 2 weeks to several months. There are a variety of residential treatment options. The most popular is the 28-day rehabilitation program, which has gotten a lot of publicity due to the number of celebrities who have participated in this form of treatment. The inpatient rehab model typically involves a daily, structured schedule of treatment activities, including specialized groups (e.g., cognitive-behavioral, trauma, relaxation, etc.), individual counseling, educational workshops on recovery-related issues, and reading and writing assignments. The quality of these programs, and the cost, varies greatly, and you will need to do a thorough review before choosing one. Your review should include what will and will not be covered by your health insurance plan, and you should obtain a copy of a typical schedule of activities, the current demographics of the population, the program’s treatment philosophy, and its reputation among former patients and addiction professionals. Usually, residential treatment is recommended for individuals who are unable to refrain from substance use for any extended period of time. If you are unable to abstain from a problem substance for at least three consecutive days, and are not exhibiting a physical addiction to alcohol, sedatives, or opioids, this level of care may be an option for you. Some residential programs combine medical detoxification services with the less intensive residential treatment services. Other residential services include an extended-care model, in which participants live in a sober environment for several months, and sober houses that do not provide treatment, but only provide a sober and supportive living environment. In Part Two of this blog, I will explore other, less intensive treatment options.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City. He has been in the field of substance abuse treatment for over 30 years. He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.

What Causes Substance Use Disorders? A Look at Spiritual Factors

What Causes Substance Use Disorders? 

A Look at Spiritual Factors

In previous blogs I have explored the physiological, psychological, social, and environmental factors contributing to substance use disorders.  Today, I will be writing about spiritual factors.  It’s not a coincidence that I write this blog just after returning from a vacation to my favorite place for reconnecting spiritually—a tiny island in the West Indies called Anguilla, a place of such natural beauty and loving people that it’s hard for me not to feel connected to something much larger.  On these trips, I also read spiritually based books that enhance my appreciation of being there or, more accurately, being here.

 It’s important that we feel a sense of purpose or meaning in our lives.  Without that, we feel a sense of emptiness—what is often termed a “hole in the soul.” In order to fill this hole, we often seek behavioral distractions, such as substance use, sex, work, food, or gambling, to fill this void. These behaviors, however, seem to help only temporarily at best.  We still feel empty, despite these distractions. I describe this state as having a spiritual deficit—the inability to feel purpose, meaning, or connection to something larger than ourselves.  This spiritual deficit is characterized by feeling alone, appearing depressed or apathetic, being involved in a variety of compulsive behaviors, having difficulty connecting to others, and suffering a variety of physical ailments.

Eckhart Tolle, in his classic book The Power of Now, succinctly depicts what it’s like to feel disconnected.  He writes, “The inability to feel this connectedness gives rise to the illusion of separation, from yourself and from the world around you. You then perceive yourself, consciously or unconsciously, as an isolated fragment.  Fear arises and conflict within and without becomes the norm.”  According to Tolle, feeling disconnected leads to a general sense of fear or dread.  It’s not surprising, then, that individuals with this spiritual deficit turn to drugs and alcohol to medicate the fear. 

How do we find purpose or meaning in our lives?  The simple answer is by finding passion for something.  This may include finding passion in our jobs, or through our roles, such as being a good parent.  However, many of us have not been able to find passion for anything.

One of the books that I took with me on vacation was The Art of Happiness.  A classic, it integrates our understanding of happiness from the perspective of the Dalai Lama’s Buddhism and that of Western science.  The Dalai Lama believes that our ultimate purpose in life is to simply find happiness.  He believes that the ways many of us seek happiness are often misguided.  He believes that the key to finding happiness and avoiding suffering is our state of mind.  He writes, “The greater the level of calmness of our mind, the greater our peace of mind, the greater our ability to enjoy a happy and joyful life.”  The way we develop this peace of mind is based upon the way we interpret the events in our life.  Cognitive therapy is a Western form of psychotherapy that challenges our irrational beliefs and helps us form new ways of thinking about situations in our lives.  The Dalai Lama believes that a systematic retraining of the mind by deliberately selecting and focusing on positive mental states (e.g., compassion, kindness) and challenging negative mental states (e.g., hatred, anger, greed, jealousy) can lead to happiness and the avoidance of suffering.

In my lecture with patients entitled “Spirituality: The Neglected Dimension,” I review common character weaknesses that foster unhappiness, including self-centeredness, irresponsibility, hatred, and resentment, and suggest ways to replace those responses with ones that lead to happiness and fulfillment.  For example, compassion can replace self-centeredness, discipline can replace irresponsibility, and compassion can replace hatred and resentment.

I truly believe that many individuals seeking treatment for substance use disorders are suffering from spiritual deficits and seeking something to replace their sense of isolation and lack of purpose.  It is our responsibility as practitioners to guide individuals toward greater fulfillment in their lives.


Nicholas Lessa is the Clinical Director of Chat2Recovery, an online substance abuse treatment program, and Inter-Care, a leading substance abuse treatment program in New York City.  He has been in the field of substance abuse treatment for over 30 years.  He is the lead author of two books, Wiley’s Concise Guide to Mental Health: Substance Use Disorders and Living with Alcoholism and Drug Addiction.