Psychologist Michael Tkach, former director of recovery management for the Hazelden Betty Ford Foundation, joins host William C. Moyers to discuss the latest research and science on what it takes to stay sober. Three factors seem to make the biggest difference in building lasting recovery from addiction: meaningful engagement with a supportive community, healthy new routines and structure, and enough self-compassion to overcome negative emotions and thought patterns that can lead to a setback. Read the podcast transcript below, listen and subscribe on iTunes, Google Play or watch on YouTube. 0:00:15 William Moyers Hello and welcome to Let's Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on the issues related to addiction, treatment and recovery. I'm your host, William Moyers, I'm the vice president of public affairs and community relations for the organization. I joined Hazelden in 1996 but my personal experience actually goes back almost 30 years when I was a patient. Thank you for joining us today and welcome to our guest, Dr. Michael Tkach, former director of recovery management for the Hazelden Betty Ford Foundation. 0:00:50 Michael Tkach Thank you very much for having me. Very excited to be here today. 0:00:52 William Moyers Tell us what is recovery management? 0:00:55 Michael Tkach Great question. So recovery management is this idea where we're shifting from looking at people going into treatment and having their residential treatment situation and then discharging back into their daily lives without that extra support. We're saying that doesn't work. We need to make sure that people are engaged, that they have these systems built for them that will give them support in their day-to-day lives which is where people wanna also be able to bring their recovery too. So recovery management really sets it up to say what are those types of services, those types of things that we can do to build engagement so that people have those supports in their day-to-day lives. Which is ultimately what people wanna do once they go through recovery. It's integrate back into their daily lives. 0:01:36 William Moyers In fact, I've always said it's easy to stop using. I stopped a thousand times. It's hard to stay stopped. And when I went to treatment at Hazelden in '89, the organization was very good at getting people like me to stop using, but we hadn't really recognized yet that the recovery journey—well actually the organization has a role in the recovery journey. So what are some of the things that, in your role, you helped to teach the patients as it relates to managing after treatment? 0:02:03 Michael Tkach So, with that, when somebody comes in and I—I've had this experience when I'm working with families and what not. Often the family will say okay they've gone through treatment, they've done their 28 days, they're done! [both laugh] It's cured! It's gone! And, that expectation sets up a lot of kind of stigma around it. I—I remember when working with individuals that they'd come up and they'd say okay I'm having cravings. And they'd be really ashamed and embarrassed about it. And they'd try to hide it. And that doesn't do anybody any good. Because if you're trying to hide that, that contributes to then it coming up and catching somebody off-guard. And instead we looked at how do we change the way that people have support? And so, we looked at things like coaching. We looked at things like how do we keep people engaged in the alumni services? How do we build community? And more of a sense of being social around it so that they have those supports. So that it continues beyond being in residential treatment. I think traditionally we've looked at it as a field as residential is the end-all, be-all. But ultimately, we wanna change it because people get sober for life. They don't get to engage in life and be a part of life. They don't get sober, to again, like you've mentioned, just go to treatment and then that's it. 0:03:18 William Moyers We also saw that often times when people would—would come to treatment at Hazelden in the old days and I can—it's hard to believe that I can talk about the old days now from my own personal experience. But, that the end-all be-all after that would be to go to a Twelve Step recovery meeting. Now certainly you're not saying that people shouldn't do that, but there's more to it than that. 0:03:39 Michael Tkach Exactly. And I think one of the things that's really powerful and what we've learned from the Twelve Steps was that that sense of community that it gives somebody helps provide individuals with the support. A lot of times by the time somebody goes to treatment, they've had a lot of their personal relationships have been kinda strained. And so when we look at what are factors that help succeed, help someone in succeed, we're looking at that social support as a—as a major factor. And so, if we have somebody that goes through treatment and leaves and doesn't have that support there, then their chances of success aren't as great. And if we just say okay go back your family and friends, they'll be okay now that you went through treatment, we're not recognizing the reality of it. A lot of times you have to rebuild that trust, you have to rebuild those relationships. And even with these Twelve Step groups when people are going, that's one source of support. But, it's kinda like the metaphor if you have a—if you're trying to build a table, if you have multiple legs on the table it's gonna be a lot more stable. If you have just a single leg, it's gonna fall over. And so, in addition to these Twelve Step groups, we wanna expand the different resources that we have available for somebody. We also look at it from an insurance point of view. And when people are looking at what are the different levels of engagement that they can be involved in, ultimately we know that the longer that somebody's engaged in treatment, the better their outcomes are. Because it's that touchtone that reminder that's saying this is important and this needs to be front and center in your life. And that's just how addiction works. If we don't keep that focus on it, we shift. And so by providing these other services like coaches or visits to the renewal center or other things that we have available, it's different ways to keep it on the radar. Now some of these are covered by insurance and some of ‘em aren't. And there's actually a good reason for that. Because insurance as much as it can be a gateway towards treatment, at other times with various levels of care, there's not a lot out there that's being supported currently for when somebody is not at that acute level. It's almost a wait and see attitude. So we want a range of different options that are available for somebody. So that they don't have to wait for relapse in order to re-engage. And so with recovery management we're really looking at how do we cover that full spectrum so that we're not waiting for somebody to get to a point where okay it's relapse, we gotta go detox, we have to send you back to residential and let's start over. 0:06:06 William Moyers So are you incorporating recovery management techniques while people are still in a residential setting? Or are you waiting until they get out? 0:06:13 Michael Tkach Great question. What we wanna do is we wanna start getting people used to it early on. So when people are in residential, one of the things that we're doing is we're shifting the mindset. And so, one of the great things that's been happening in the field is that we're looking at addiction as part of the medical model of addiction. We realize that there are psychological components, there's physiological components, all of these work together towards creating this atmosphere of addiction. And what we look at is how do we help change that attitude about things so that people start feeling more supported and more engaged? When people are engaged in their treatment, they tend to wanna sustain it. So we start early. We have people that are going through what we have is our, at Hazelden for example, Hazelden Betty Ford, we have our online patient portal. Like most places are doing. And what we do is we allow them to engage with their counselors in a certain type of a way that they have that access. But there's also different things that we're moving into doing. We're using feedback-informed treatment in other ways to communicate with their counselor to say like let's keep this conversation going. We're getting people used to that. So that they're used to checking in. It's kind of like when somebody goes ahead and they get the diagnosis of diabetes. You don't get set up with insulin and then it says okay there you go, you're on your own. Instead, they get trained in how do you check your blood sugar, how do you go ahead and manage it, what happens if you do have a hypoglycemic or a hypoglycemic event; what do you do? And so we start trying to do that training early on so that when people are transitioning through the various levels of care, there's that support there. They're recognizing that that transition through levels of care are part of this journey. And the journey doesn't stop when they stop attending, technically treatment, or whatever we wanna call it. And they go back into their daily lives. By then, it should be these patterns of behavior, these habits, these things that they have found as supportive. These communities, these environments that they've been in that help transition into their daily life so that they can have that increased engagement and support. 0:08:13 William Moyers One of the things I love about being in this role and this chair is that I get to sit across the room right here from somebody in that chair who is a lot smarter than I am. And by that I mean colleagues who have a remarkable background, educational background, and a passion, like you do Michael, for these issues. I know that you are a clinical psychologist. You are—was—were or are teaching in our graduate school. And—and—and tell me where your own passion for these subjects comes from. 0:08:45 Michael Tkach Yes. So, I grew up around addiction. I saw addiction throughout my life. And it's been something that's been on my radar. And friends, family, people that I've seen struggle with addiction. And often I see the same pattern over and over again. People go in and they get—they go through, have this transformative event. And then they go back to their daily lives and they're trying to incorporate. And that's the struggle. Is to say how do you sustain it? It's as you mentioned it's even when you're within those four walls and you've got all those things reminding you. But once life creeps back in, people tend to drift back to what they'd known before. And it's—change is difficult. And if you don't have that support there, it's really hard to sustain. And I think one of the things when I work with families and I've talked to families about this is it's a way that we can kind of gain some compassion and empathy for it—is any of us who've ever tried to start an exercise routine, I can talk about for myself personally—you start it and it's—it's something that you have a lot of motivation, you know, all this is great. And then all of a sudden you have a slip-up. And then what happens? I'll start again on Monday. With exercise though, people don't say hey those couple of days that you did of exercise before you got off track, those don't count. With exercise people don't say you failed at exercise. You're not gonna make it, you might as well just give up. Or, we've lost all faith in you. However, when we look at addiction, what I hear over, and over, and over again is why should I trust you, what's gonna be different now? And thinking about that and seeing so many people struggle with that. And trying to find hope and trying to find that support. And recognizing that if change was easy, there wouldn't be fields like mental health. There wouldn't be addiction treatment. There wouldn't be any of the stuff there. This is a life change. And so having seen so many people struggle with that over and over. And trying to—trying to help, and trying to be there and trying to be supportive in that. And recognizing that good intentions can bring you part of the way there. But you need the training, you need the support, you need the structure, you need other people there because inevitably, no matter how passionate one person is about trying to support another person, you've gotta sleep, you've got other obligations that you need to do, you need social support. 0:11:04 Michael Tkach [continued] Which again feeds into why recovery management is such an important part of it. We wanna make sure that there is this well-rounded area of support around anybody. And I've seen that throughout my life. By seeing what happens when you go from saying I'm gonna be the one person that tries to help this person. To saying instead let's bring a team in, and unfortunately, there is a lot of sad stories that had happened along the way that taught me how important it is to say okay, there needs to be a lot more people involved. But luckily I'm a part of a great team now, I'm a part of a great institution where we have that. and we're growing in awareness and how to continue to expand that so that more and more people have those supports. That they're there and they have that ability to go on this journey. And not feel alone with it. 0:11:51 William Moyers I have come to appreciate the role that relapse can play in recovery management. Relapse is not a dirty word. 0:11:53 Michael Tkach Right. 0:11:53 William Moyers Talk more about what your perspective is and the messages that our recovery management emphasizes as it relates to relapse in the context of a chronic disease. 0:12:00 Michael Tkach So and it's exactly that. 'Cause when we think about it as a chronic disease, there is this old mentality. That it's all or nothing thinking. And we've really applied that historically to addiction. And if there's any type of flare-up or any type of expression of symptoms, that suddenly there's this failure. And that's luckily no longer the way that we're looking at it. If we break it down and to oversimplify it just for a moment, we're gonna talk about dopamine in the brain. And what happens here. And we start thinking about this that when dopamine is—is in our brain what its use is to help reinforce learning. A little bit of dopamine makes you feel uneasy, a lot of it makes you feel rewarded, satisfied, and what not. And we use this in learning because like let's say you're hungry. Your brain will release a little bit of dopamine. Say I go eat a sandwich. My brain says congratulations you did the right thing. It will release a lot more dopamine and that'll help reinforce that so that next time I'm feeling hungry I know what to do. When we start talking about addiction, what happens with the brain is that all addictive behaviors affect the way that our brain processes dopamine. And so, when we start looking at that and there are certain substances like cocaine and methamphetamines that directly work on the dopaminergic pathways. And so suddenly instead of a small spike for eating a sandwich, dopamine levels that somebody would get from using cocaine or methamphetamines, are these really large spikes. Now the brain recalibrates itself then to start recognizing that, you know, this is a lot more. And I need to be able to process this without feeling overwhelmed which is where we start seeing tolerance. And what happens though is now, all of these other blips, these things that we need to do. Relationships, obligations, or what not, become blips on the radar that the brain's no longer calibrated to recognize. So we start looking at this from a biological perspective and we realize it's not about moral choice, it's not about just choose better. The brain is recalibrated and it's not really recognizing some of these other obligations. So, we need to provide an environment where the brain has time to re-adjust, to heal, to recalibrate. And in order to do that we have to start thinking long-term. 0:14:25 Michael Tkach [continued] And just like with most other biological conditions, once something has happened, once the brain has recalibrated itself, the likelihood of it reverting back is—is fairly great. 'Cause the brain says hey I remember this. Here we go again. Let's jump back in and so relapse becomes this great teacher because we learn how is the brain processing it? And we recognize that it has taught us that this long-term view of addiction is essential. The brain doesn't just change back. And I don't think that we would have gotten to this place of understanding addiction from a biological, from a medical model without understanding relapse a bit better. And so, it becomes this important part. And instead, what we wanna start doing from a clinical point of view, is start recognizing when there's those markers. When cravings start going up higher, when people are starting to revert back to old patterns of behavior. When all these things— 0:15:18 William Moyers Stress. 0:15:19 Michael Tkach Stress. All of that stuff. Mental health plays a huge part of this. And when people are at this place, the brain's trying to be as efficient as possible. It's gonna say what did I do last time when I was in this circumstance. And if we think about it short-term, it takes us a while to learn new behaviors. So, once we're just kind of put on the spot, we tend to revert to what we've done before. You can have a great treatment experience, but if you don't have that long-term support reinforcing when you have your day-to-day life stressors, that this is what you choose now and this is what you do now, your brain's gonna try to be helpful and revert to what did I do before. 0:15:59 William Moyers We have about two minutes left. What would you wanna leave our audience with today as it relates to the—from your perspective, as a professional in this field, all the experience you have, what are the three essential elements that anybody in recovery needs to focus on or emphasize as it relates to the management of their recovery? 0:16:19 Michael Tkach Yes. I would say if we're gonna really summarize it down, it would be meaningful engagement through meaningful structure, meaningful support, and then also, self-compassion. And so when you're looking at this, let's talk about self-compassion for a moment. 'Cause this is usually where people understand meaningful support. Like you have to have that support system where it's meaningful and has this resonance with you. Where you're feeling supported and you feel that you have that confidence to engage. And in terms of meaningful structure, you wanna make sure that the people that you're working with know what they're doing. And that they have these structures set up that are unique and individualized to you. But that self-compassion part is such a big thing to consider. Because often when somebody gets to this place where they're not feeling hopeful and they're saying okay fine, we'll go ahead, I need—I hit rock bottom, I need to go through treatment. That lack of self-compassion could be the thing that stops them from showing up in the morning. And instead when you realize what somebody is accomplishing by overcoming and really overcoming that negative voice and showing up and engaging day to day, they're reprogramming their brain. They're recalibrating stuff. They're going ahead and they're changing time and time again of choosing one thing and choosing something else. And giving their brain that support and that space to do that. And it takes that self-compassion because you're really doing something really quite amazing. And it's easy to instead fall into those old narratives. And so, that's what I would encourage. 0:17:50 William Moyers So it's okay to be good to ourselves? 0:17:54 Michael Tkach It is. And it's important too. In fact, things change faster when we tend to be accepting and being supportive of ourselves. And have that self-compassion. Because then we're going ahead and we're supporting it. There was this old approach that we used to take towards addiction where there was this confrontation. 0:18:10 William Moyers Yes. 0:18:11 Michael Tkach And what we found from the research was that confrontation makes the people doing the con—the confronting feel good, but it's not a lasting change for most people. 0:18:21 William Moyers Sure. 0:18:22 Michael Tkach Fear is not a good motivator that anger is not a good motivator for sustained change. And instead it's that acceptance, that self-compassion, that engagement, and somebody feeling I can do this that makes the difference. 0:18:33 William Moyers Progress, not perfection. 0:18:34 Michael Tkach Exactly. 0:18:36 William Moyers Doctor, thank you very much for taking the time. [they shake hands] 0:18:38 Michael Tkach My pleasure. 0:18:39 William Moyers Dr. Michael Tkach the director of recovery management at the Hazelden Betty Ford Foundation. Emphasizing that treatment is the beginning of the journey but that the rest of the journey includes taking care of ourselves and forgiving ourselves one day at a time. Thanks for being with us today. [to Michael Tkach] Thanks to our listeners and to our viewers for tuning in to on behalf of our executive producer Lisa Stangl and the gang. I'm William Moyers thanks for being here and we'll see you again.