Addiction is a symptom of an unhealthy social environment - SeekHealing
image by: Addicts Anonymous Forum
In 2015, Jennifer Nicolaisen was working in consulting and getting by some days on just two hours of sleep. She was a 27-year-old statistician in northern Virginia, basking in what she called “rising star energy”—the glow that came from approval from her boss, her clients, and her peers. It was a thrill, she says.
She was also downing Adderall and Vyvanse like candy, medications prescribed for her ADHD but also used to maintain a relentless pace of work and life.
Nicolaisen might have recognized some of the symptoms of her addiction—she had gone to rehab as a senior in high school for cocaine use, bouncing back with support from her family and going on to thrive at the University of North Carolina Chapel Hill. But unlike cocaine, Adderall and Vyvanse were legal. They were prescribed by a doctor. She was fine.
That is, until she wasn’t.
After her best friend from college nearly died from a heroin overdose, Nicolaisen had her own wake-up call. She recognized that she was addicted to pills, and her problem wasn’t only with the prescriptions. She was also isolated, in spite of being surrounded by people. “It was constant human interaction, but with every single one of those interactions feeling empty and transactional,” she says. Everything was driven by external validation, but there was no place, she said, to be real, or vulnerable, or anything other than what others wanted her to be.
“Even my romantic relationship was a façade,” she says. “It was what the world wanted to see.”
And so Nicolaisen moved to Asheville, North Carolina, to create what she hoped would be a new kind of rehab—not a place that tried to fix broken-down addicts, but a place, informed by neurological research, that emphasized the importance of human relationships. A place that would seek to connect lots of people, addicted and not, in substantive ways.
“The opposite of addiction is not sobriety,” she says. “The opposite of addiction is genuine, meaningful interactions and authentic connections and experiences with ourselves, each other, and the world around us.”
The tagline for SeekHealing, the nonprofit she launched in 2018, is “Rethink Rehab.” It is far more radical than a typical addiction-recovery program. Funded by state health organizations and private donations, it’s one of a growing number of initiatives around the world aimed at tackling loneliness, social isolation, and deep-rooted disconnection by helping people develop critical social skills and offering a safe place to practice them, as well as a menu of ways to meet connect, interact, build trust, and give back.
These initiatives are emerging in response to a real crisis. So-called “diseases of despair”—substance use disorders, suicides, and alcohol-related diseases—are increasingly pervasive. Every day in the US, more than 130 people die after overdosing on opioids. Levels of anxiety and depression are perceived to be rising in countries like the US and UK; meanwhile, opioid-related deaths surpassed automobile fatalities in the US as the leading cause of death in 2017.
There’s a growing realization that supply is only part of the problem. Widespread loneliness and despair—from losing jobs to automation and trade, to mental health problems and a dearth of adequate opportunities—drive people to seek the relief that opioids and heroin seem to offer. In a recent BBC poll of 55,000 people, 40% of adults between 16 and 24 reported feeling lonely often or very often. According to a Kaiser Family Foundation survey of rich countries in 2018, 9% of adults in Japan, 22% in America, and 23% in Britain always or often felt lonely, lacked companionship, or felt left out or isolated. Suicide rates in the US have increased 33% between 1999 and 2017, reaching the highest levels since World War II.
“We have this great untapped resource available to us in each other as a community to provide really supportive healing work,” says Nicolaisen. “It’s not the same as therapy, but it can be supportive in a way that’s as powerful, if not more so.”
The healing power of community
SeekHealing aims to take shame out of recovery with an approach that’s distinct from 12-step programs focused on achieving and maintaining sobriety.
All participants in the program are referred to as seekers. About one-third are still using drugs, have just stopped, or are ping-ponging between stopping and starting. One-third are in long-term recovery. And one-third have no substance abuse issues, but are seeking connection of some kind. Every activity is free to those in the community, which is currently limited to just Asheville.
Seekers set their own goals. They do not have to aim to be sober, only to improve their relationship with the substance which is causing them harm. The program refers to addiction as bonding, since we bond to substances or behaviors or when we can’t bond to one another. Relapse is “returning to patterns one is trying to avoid.”
The pilot program was launched in March 2018. As of 2019, on a budget of $65,000, the group has 200 seekers in the database; over half have been “paired,” meaning they get together two to three times a month to talk and build a mutual relationship (different from therapy, or codependence, which can happen in recovery). At least one person in every pair has to participate in listening training, which Nicolaisen calls “yoga for conversation.” It’s a way to practice something that is critical to human interaction but which causes many people anxiety.
That listening training, a core educational component of the program, aims to undo the transactional way many people converse—with an intent to fix, solve, be clever, or respond quickly. Instead, the goal is to actually listen without judgement. This creates the conditions which allow the types of interactions that flood the brain with natural opioids and make us feel good. Everyone needs this training, Nicolaisen explains, because it is not the way people in society today relate to one another.
“There’s no outcomes we are going for,” she says. “We are just being with each other.”
Aside from listening training, the calendar is packed with ways of building connection muscles, meeting people, doing things, and learning. There are Sunday meet-ups in West Asheville and connection practice meetings in which facilitators encourage vulnerability and substantive conversation. There are pick-up basketball games, Reiki workshops, art therapy, and Friday night emotional socials (“no substances; no small talk”).
“The whole project is a playground of different ways to help people feel connected in this intentional, non-transactional way,” says Nicolaisen.
Being a statistician, she is keeping close track of the program’s impact based on participants’ self-reported outcomes. Seekers report feeling significantly less depressed, and their sense of connection increased by 38%. Among 28 emergency care seekers—those who are at a high risk of overdosing—21 actively engaged with the program (these people were newly detoxed); and 18 of them have been successful in meeting their intentions to avoid using substances. Thirteen have sustained their recovery for more than six, and in some cases nine, months. For context, with heroin, relapse rates are 59% in the first week and 80% in the first month.
The goal is not just to help individuals heal, but also communities. In the US, which celebrates individual achievement above everything, more people see loneliness as an individual problem than their counterparts in the UK or Japan, according to a Kaiser Family Foundation survey. When asked whether government should have a role in trying to address loneliness and social isolation, 60% of respondents in the UK and Japan said yes; in the US, that figure was 27%.
The neuroscience of addiction and recovery
Rachel Wurzman, SeekHealing’s director of science, is a neuroscientist who studies brain plasticity—how brains wire and rewire—specifically around compulsive and addictive behaviors. Her interest in brain systems is personal: at age seven, she was diagnosed with Tourette syndrome. She was interested in what her brain could control and what it couldn’t. What was the difference between a compulsive activity and an addictive one? What was “normal” and what was “sick”?
Her work took her deep into the striatum, a part of the brain implicated in involuntary movements and compulsive behaviors, but which is also central to the effects of addiction and social disconnection. The human brain uses naturally occurring —“endogenous”—opioids to maintain a balance among important brain circuits that shape social thinking and behavior, making certain experiences, like deep social connection, feel good. These compounds, the most commonly known of which are endorphins, have a similar chemical structure to morphine, heroin, or oxycodone. But they are produced in the brain rather than the lab.
A lack of strong social connection disrupts the balance among the brain circuits that use these feel-good chemicals produced by close relationships. When we are really hungry, Wurzman says, we will eat anything. “Similarly, loneliness creates a hunger in the brain which neurochemically hyper-sensitizes our reward system,” she says.
“Loneliness creates a hunger in the brain.” Responding to the pain of loneliness, which is rampant in society, our brains prompt us to seek rewards anywhere we can find it. “If we don’t have the ability to connect socially, we seek relief anywhere,” she says. And if we seek it with heroin or opioid painkillers, “it will be a heat-seeking missile for our social reward system.” That’s in part because the striatum, which is also our autopilot system, sets the drug as the default state that keeps pain at bay and relief close, overriding the system that would otherwise prompt us to seek human connections.
Addiction is a disorder that has biological origins, including alleles that may make it hard to experience the subjective feeling of being connected. It also shaped by psychological factors, cognitive patterns, and distortions that make depression and anxiety worse, and by the relationships we have in social environments.
Recovery requires treatment across all three categories. The first two are pretty well-covered: There is medical detox and rehab, and counseling and therapy are thriving. But the social aspects have been relatively ignored. Wurzman says the medical community sees disease as being located in an individual. She sees the symptoms in individuals, but the disease is also between individuals, in the way we relate to each other and the kind of communities we live in. The striatum, she argues, is a source of hope here. It can be rewired by reprogramming it with the deep social connections it longed for in the first place.
“We need to practice social connective behaviors instead of compulsive behaviors,” she says. It is not enough to just teach healthier responses to cues from the social reward system. We have to rebuild the social reward system with reciprocal relationships to replace the drugs which relieve the craving.
“Our culture and communities either create environments that are either full of things that cause addictions to thrive, or full of things that cause relationships to thrive,” Wurzman says.
Rob, 39, is a butcher who grew up in northern Virginia in a home soaked in anger and addiction, from alcohol to needles. He started using drugs when he was 12 or 13. He has used heroin, meth, and coke; overdosed four times; and been to jail once. He moved to South Carolina four years ago to be near his father and ended up on life support. When a friend in rehab recommended SeekHealing, Rob was deeply skeptical. “I didn’t trust anyone,” he says. But he had a conversation with Nicolaisen, who is profoundly warm and radiates a contagious vulnerability, and decided he would give it a shot.
“When I came in, I had a lot of shame and guilt for being in active addiction for so long,” he says. “I didn’t know who I was.”
He confronted his deep-rooted social anxiety by practicing conversations in safe spaces with people he said genuinely did not seem to be judging him. This opened a new world of people and activities that were off limits before due to his paralyzing social anxiety and shame.
“When it goes unchecked, it gets disabling,” he says of social anxiety. “It causes you not to do things that cause you joy.”
Now Rob goes to the Sunday meet-ups and volunteers as much as he can to help others. SeekHealing is only part of his recovery. He has been in and out of Narcotics Anonymous for years, and speaks with his sponsor every day, noting, “I need to be held accountable”. He also lives in Oxford House, a democratically run sober home.
But SeekHealing offered something those programs couldn’t: access to a world that is not defined by addiction, but connection to others. “I am interested in things I never thought I would be interested in— growing plants, art, poetry,” he says. “Not the violent things I grew up with. I am always looking for new ways to grow.” He has been sober for one year, and says he now gives way more than he takes—something he notes is remarkable for an addict, who has spent most of his life taking.
Paul, another participant at SeekHealing, has a long history of addictive patterns and behavioral health challenges, from kleptomania to substance abuse. When the 33-year-old was released from prison last year, he was desperate to avoid the things that caused himself harm. He found the inclusivity and sense of safety at SeekHealing a welcome change from his previous experiences.
“My experience is that I got punished for things that were out of control for me,” he says. “I’d be treated like a bad person, as if the punishment would heal me. It didn’t.”
He completed the listening training and now is a trained “space owl.” (Owls are the group’s mascot.) That means he attends weekly group conversations with an eye toward assisting anyone who might need extra support, or space from the group, for example, reliving some kind of trauma.
“Every time I go to an event, it’s a chance to connect and feel a sense of warmth from the environment and the people,” he says, noting that was very different to his typical experience of recovery in medical venues with strict guidelines and ample judgement.
Addicts do not talk about being “cured”; rather, they’re in recovery. Rob says he’s better today than yesterday, a different person today than he was six months ago, and that’s his recovery. But in one regard, he is willing to talk about a cure. “The epidemic is not to drugs—the epidemic is the loneliness and the pain and the feeling that you can’t belong anywhere,” he says. “They offer the cure for that.”
The question of abstinence
Jesse Smathers is the community relations regional director of Vaya Health, a public managed care organization that uses Medicaid, federal, state and local funding, and contracts with 1,000 different organizations to support people with mental health issues, substance use problems, and intellectual and developmental disabilities. Vaya provided the largest grant to support SeekHealing’s first year; the rest came from private donors. Smathers, who endorsed the funding, says the reason was clear: “People who move into recovery from substance abuse have often burned all their bridges. This helps them build new ones.”
That didn’t make supporting SeekHealing an easy decision. He worried about what other service providers would think, especially those focused on abstinence. But the reception has been uniformly positive, he says. “A lot of people come in [to other rehab services] and the groups have no way to connect with them.” The service providers often do not have a clear way to help people who are still using, so “they are quick to refer them to the program when people aren’t ready to give up the substance.”
Does this attitude toward abstinence risk enabling the users? Smathers says no. “Even people who are still using, once they start making connections, the chance of them staying alive, and not OD-ing, and moving into greater levels of service, to maybe using medicine-assisted treatment, and becoming productive members of society increases.” Rather than limit recovery to those who are ready for abstinence, the theory goes, try giving help to those who aren’t ready yet, but may become so. This falls under the approach known as harm reduction, defined by the National Harm Reduction Coalition as “a set of practical strategies and ideas aimed at reducing negative consequences associated with risk-taking.”
Traditional 12-step programs like Alcoholics Anonymous or Narcotics Anonymous help a lot of people. But they do not work for many others, not least because of the rigidity of their abstinence requirements. Some people trying to give up heroin will rely on alcohol; others might turn to food. Someone addicted to painkillers might turn to fewer pills at a lower strength. In SeekHealing, “people are free to set their own intentions for what their recovery needs to involve when it comes to abstinence,” Wurzman says. She is clear that they are not encouraging people to use substances or practices that aren’t healthy; just that the program doesn’t judge participants for doing so.
Lance Dodes, a retired professor of psychiatry at Harvard Medical School and author of The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, says that peer-reviewed studies peg the success rate of AA somewhere between 5%-10%. “About one of every 15 people who enter these programs is able to become and stay sober.” Many people arrive at 12-step programs when they hit rock bottom. But plenty of people need help before that.
What’s needed is to be “integrated back in to the world, and not in the basement of a church.” According to Jake Flanagin, writing in the Atlantic, AA’s internal, self-reported figures are better. “A 2007 internal survey found that 33% of members said they had been sober for more than a decade. Twelve percent claimed sobriety for five to 10 years, 24% were sober for one to five years, and 31% were sober for under a year.” He notes, importantly, that those figures don’t take into account the large number of alcoholics who never make it through their first year of meetings, thus never completing the 12 steps which AA requires for “success.”
Amanda Carey works at the Justice Resource Center in Buncombe County, helping people leaving prison find the support they need when they get out of jail. A 12-step program “helps to form connections for people going through the same thing,” she says, but “it doesn’t get you into the community.” What’s needed is to be “integrated back in to the world, and not in the basement of a church,” she says. (She also describes herself as in long-term recovery, noting that the 12 steps never worked for her.)
She has referred everyone she works with from the prison system to SeekHealing, about 95% of whom struggle with substance abuse, she says. One, a young man in his 30s who has had substance abuse issues his whole life, tried it out. He’s now getting acupuncture and playing basketball every Friday night.
One of his triggers for using was getting paid. So the group got together that day to make a meal. “Connecting was a healthy way for him to get through that trigger,” she said.
SeekHealing has its own ways of informing the broader community about substance abuse as well. The group runs an Opioid 101 course that teaches people how to administer Narcan, or Naloxone, to stop the effects of an overdose. There’s funding for emergency care, which gives anyone at risk of overdosing, whether because they are recently out of detox or because they have had a major negative life event, free access to counseling, acupuncture, work with a program manager, body work, and Lyft rides to the center. No drug tests are required.
Jennifer’s journey When Nicolaisen talks about how SeekHealing came to be, she exudes vulnerability. Her best friend from college was an adventurer, a bit of a rebel, charismatic and quirky. After she overdosed and Narcan saved her life, her friend was furious. “Heroin was worse than death,” Nicolaisen says, choking up thinking about it. She felt certain that if she didn’t help, her friend would die.
But helping was hard. Her friend was alone. She had been to rehab six or seven times and her parents were spent, emotionally and financially. Nicolaisen took her to Mexico for ibogaine therapy (a naturally occurring psychoactive substance that is illegal in the US).
Like all good millennials, she documented the trip on social media with four hashtags: #rejectfear, #invitecuriosity, #seekhealing, and #wakeup. After three days in treatment, her friend seemed transformed. There was color in her cheeks and she asked Nicolaisen how she was doing, something that had not happened in ages.
When the program ended three weeks layer, her friend was in a better place. But she still had no place to live, no job, and no way to rebuild a life. “It’s like, now you are clean—get a job and get it together—be ‘normal,’ without creating a new narrative for what life looks like,” Nicolaisen says. The journey was a rough one. While the friend is still sober—she now eschews sugar and is vegan, too—Nicolaisen says what she saw was how much harder it was then it needed to be.
The experience also caused Nicolaisen to confront her own addiction.
“It was a powerful mirror for me,” she says. “I wasn’t shooting drugs, but I was doing incredibly addictive things.” Nicolaisen also did ibogaine therapy and then went off the grid, spending two months offline in Colorado. She had been thinking about how to help people heal through real connection and communication—not just because there was such a dearth of services for care after rehab, but also because a lack of social connection affects everyone, and drives people to whatever substance they can find to sate the hunger they feel: Screens, social media, porn, shopping, alcohol, Adderall, heroin.
She quit her job, started officiating weddings to make money, and moved to Asheville to build SeekHealing. She hasn’t taken a salary in over a year, and it is unclear whether the organization could exist without her, raising important questions about how sustainable it can be as a model. In finance, this is called “key-man risk.” Since everyone involved with SeekHealing mentions Jennifer, it seems she is the key woman.
Rediscovering our humanity
If the program seems unique, the underlying philosophy is not. Vivek Murthy, the former US surgeon general who declared loneliness an “epidemic,” said in a recent interview, “we will not solve the addiction problem in America if we don’t address social connection.”
There are plenty of challenges. It’s possible that SeekHealing has been successful in part because of its small size and intimate feel: can it get bigger and still maintain the same intensely personal environment? The group also needs more funding, and some are wary to support a program that does not require abstinence.
Nicolaisen’s dream is to build a residential community, and to have enough funding to make the program accessible to everyone who needs it. (There are already 200-300 people waiting to be connected.) An app is in the works to act as a matching engine for seekers. The group adds programs every week.
If you want to build human connection, you need to start with humans. It’s a work in progress, with plenty of mistakes along the way: Its first iteration was an app, which Nicolaisen realized made no sense. If you want to build human connection, she says wryly, you need to start with humans.
She’s getting to know everyone in Asheville, speaking recently to the Jail Diversion Leadership Council, social workers, social justice councils, harm reduction task forces, mental health advocates, and youth summits. To support herself she still officiates weddings and offers couples counseling. She’s a big believer in the importance of rituals and the need to find non-religious ways for those who are not religious to have them. Rituals, she says, are a fundamental human thing, bringing people together. “I am a nerd for creating new rituals, for how can we throw out the things that trigger us or make us feel weird and find ones that help us feel good,” she says.
Opposition to the work has been minimal. That may be because SeekHealing is still so small, or because it’s filling a need everyone sees. “We are quick to treat physical pain, but we are encouraged to repress emotional pain,” says Vaya’s Smathers. “The substances relieve the pressure that’s attached to that repression.”
The group will need to post bigger numbers to prove to the world that it is model that can be replicated. But of course, that’s not really the goal. The goal is to be with each other and to heal, from whatever it is one needs to heal from—substance, trauma, loss, loneliness, isolation.
“When people are disconnected from other people, they are disconnected from their own humanity and their own experience of being a human being,” says Wurzman. “Having a humanizing experience can make people remember and want a life worth living.”
Source: Jenny Anderson, A radical approach to confronting addiction puts human connection first, Quartz, September 19, 2019.