The Key to Effective Addiction Care | Charles Neighbors, MBA, PhD

What makes addiction treatment truly effective? Behavioral scientist Charles Neighbors, MBA, PhD, shares groundbreaking research on the importance of therapeutic relationships, harm reduction, and human connection—love!—in treating substance use disorders. Dr. Neighbors is an Associate Professor in the Departments of Population Health, and Psychiatry at NYU Grossman School of Medicine.

💡 Topics Covered

00:00 Introduction to Dr. Charles Neighbors
01:37 The biggest challenges in addiction treatment
02:24 The Importance of Therapeutic Relationships
05:59 Defining “good treatment” and why love matters
08:05 The role of therapeutic alliance in patient outcomes
14:06 Barriers to change in addiction treatment systems (incl. stigma)
22:04 Harm reduction and safe injection sites: What does the science say?
30:36 Future directions in addiction policy and treatment

📚 Related Resources

• Charles J. Neighbors, MBA, PhD (official bio)
• Dr. Neighbors’ Lab - Health Evaluation & Analytics Lab (HEAL)
• Addiction Treatment at NYU Langone
• Understanding Harm Reduction: National Institute on Drug Abuse (NIDA)
• "Motivational Interviewing" by William R. Miller and Stephen Rollnick
• Community Reinforcement and Family Training (CRAFT)
• SAMHSA’s National Helpline for Mental Health, Drug, Alcohol Issues
• New York State Office of Addiction Services and Supports (OASAS)

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Executive Producer: Jon Earle

Transcript

DR. THEA GALLAGHER: Hello and welcome to the Insights on Psychiatry podcast. Today I have the pleasure of interviewing Dr. Charlie Neighbors who is an associate professor in the Department of Psychiatry, the Department of Population Health, and the Wagner School of Public Service. He's also the director of the Health Evaluation and Analytic Lab HEAL.  Dr. Neighbors, thank you so much for being with us today.

DR. CHARLES NEIGHBORS: Thank you. I'm flattered to be invited. 

DR. THEA GALLAGHER: We're excited to get into this topic but can you start maybe by telling us a little bit about the overview of the work that you're currently doing? 

DR. CHARLES NEIGHBORS: So in my work in our lab I wear two hats. One of them is really working with many other investigators who want to ask questions of these very large data that come from Medicaid, questions that are going to help the New York State Medicaid program run more effectively and more efficiently. 

Then the other side of the work that I do—where a lot of my research is—is working on the system of care for people who are getting treatment for addictions throughout the state of New York and in that work I partner very, very closely with the state agency that regulates addiction, OASAS, on thinking through what can we do to improve the care that people get in these treatment programs.

DR. THEA GALLAGHER: Your research examines the quality and efficiency of the current treatment system for substance use disorders. So what do you see as the most significant shortcomings that you've identified and how can they be addressed to improve patient outcomes?

DR. CHARLES NEIGHBORS: I think broadly for some time now the statistics have shown that there's a lot of room for improvement within the treatment system. One example of that is that there are medications that are very effective for opioid use disorders that traditionally there was a reluctance to use these medications.  Many people who could have benefited from them were not getting them. 

There have been a lot of efforts to increase the likelihood that somebody will take those medications and that has been improving over time. So it's one easy indicator. There's still a need to improve on that, but we're seeing improvements and there's efforts on the behalf of many different people.

DR. THEA GALLAGHER:  Your research is also focused on defining and measuring like high quality patient care. As part of your research, you've spoken with many substance use disorder patients and caregivers. What conclusions have you come to about the importance of the therapeutic relationship for these substance use disorder patients?

DR. CHARLES NEIGHBORS: So if it's okay I'm going to  talk about a specific project that we have going on. 

DR. THEA GALLAGHER:  Yeah, that'd be great. 

DR. CHARLES NEIGHBORS:  I'm very excited about it. I'm going to mention the word love in this when I talk about what's the secret sauce, but I promise that there's science involved. 

DR. THEA GALLAGHER: There’s science involved in love so we can talk about it all. 

DR. CHARLES NEIGHBORS: That's very true and very much in that therapeutic relationship that folks come with, and I'll come back to that. So yes, we have a large research project funded by the National Institute on Drug Abuse and it's a research center, so it has multiple components to it.  But the goal is to work very closely with OASAS, the state agency, to come up with a system of quality measurement but then also a way of using those data to help the system evolve. The idea here is to be open to new kinds of quality measures.  There are not enough quality measures in the field of substance use disorder treatment.  Also to work with OASAS…what do you do with those data?  So there’s many components to this.  

We did, and you’re alluding to this, we started the project by going around and asking people, what is good treatment? How do you know it's happening?  So we had multiple focus groups with providers. We talked one-on-one with patients. We talked with government agencies like local government, county governments that oversee like in behavioral health within their jurisdictions.  We talked to health plans. We talked to family members and one very consistent theme, and this led to a surprise for us, was they knew quality treatment by the way they were being treated. That the patient was being treated, it was a welcoming environment, an environment where the treatment was tailored to what the person's needs were, and what the person's wishes for how to engage in treatment.  Ways in which often you don't see in the treatment system. Often you come in and you go through a process that the whole clinic uses for individuals and it's not all that tailored. A lot of people really focus on the relationship they had with their treatment team. 

We took all this sort of feedback that we were getting and with OASAS, had an internal meeting to really explore what OASAS felt was what are the things that they thought were important about treatment quality and use of medications was important. Having enough resources was important. Having what they call person-centered care, which is really tailoring treatment. A focus on something called harm reduction, which is a philosophy that's emerging now in the treatment system of saying we are more focused on keeping people safe than really pushing them that if you use substances then we find it difficult to work with you, to sort of like really be engaging with people and really emphasize that maintaining of a connection.

All these things were important but as we were having this conversation about what is good treatment and we had a lot of things on the board and there were a lot of clinicians in the room, somebody said, Bill Miller, who's this famous researcher who developed a lot of very important ways in which to engage with people and meet them where they are. This is a person who's done a lot of research on what's the secret sauce in psychotherapy, particularly for substance use disorder, and Bill Miller talks about this language of love, and it's kind of a trend. I have to be careful because sometimes when I use the word love…some of this language that has sort of like mystical meanings to it, some people are kind of like, whoa, that's not serious enough. That's not measurable. It’s not like romantic love. It's not love for your family members or your community. It's not love like in the erotic sense. 

It's a love that sort of—and this is the mystical word transcendent—that you really have a special regard for other people around you, whether you know them or not.  You have sort of a genuine sense that there's goodness in them and as a therapist I want to connect with that goodness.  And I believe in that person. 

These special qualities of therapists…there's been many studies that really have looked at that.  At like, what is it that's the most effective in getting best outcomes? There's been research that tries to compare different schools of thought of treatment and at the end of the day, there's always something that’s sort of special about certain therapists and when you look closer at that, it is that ability to make a connection. A connection where there's trust, where there's like a sense of compassion, there's a sense of I really care. And this is what family members are looking for, this is what patients are looking for and so this was a surprise for us. Like that should be a big component of what we're looking for in quality measurement. 

So now we're going to build into the project a way to ask questions of patients to get at this idea, is there a therapeutic connection happening in the care that they're providing?

DR. THEA GALLAGHER: Is there a way that you're operationalizing that or measuring that? 

DR. CHARLES NEIGHBORS: Such a scientist’s question, which is great. So yes, we're drawing on an area…there's been a lot of in clinical psychology  broadly, a lot of research on these aspects of treatment and a lot written about something called therapeutic alliance, which has many components to it. But there are a lot of measurements that have been developed on like trying to get at that sense of, are we connecting in this therapeutic relationship? So we're going to  draw some questions on that. 

The thing that's a challenge for us is that—and this is where like implementing stuff in the real world comes out—a lot of these measures are that long, and take a bit for somebody to answer them. We have to compress that so that it can be given to patients in a dynamic way in the workflow of a clinic which is very, very busy. So we have to compress the questionnaire and get the clinics to actually use them. So we want there to be some clinical benefit for the clinician. So it's going to  be a way for us to track quality and improvement in folks, but at the same time they can use the questionnaire results to say, oh, I see that your cravings are increasing this week.  Let's talk about that. 

DR. THEA GALLAGHER: I think we're hopefully getting to a place too, the more that we understand maybe these measures are too complicated and too ornate and maybe there is a way to simplify it. I even know something like the subjective units of a distress thermometer. “How are you feeling?” can be such an accurate way for people to describe how they're feeling and maybe some of these intangibles are maybe more simply assessed. 

DR. CHARLES NEIGHBORS: Yes and in a very practical way where I can see where you pointed on the thermometer. Yeah and we can talk about that.

DR. THEA GALLAGHER: Yeah. My question kind of building on that is that I imagine so many parents who have maybe had children who have struggled with substance use disorder will say, I loved my kids so much, I bent over backward, I sold my car, we refinanced our home. We did whatever we could and so is there something specific about that experience of a patient feeling love or unconditional positive regard from a potential stranger?

DR. CHARLES NEIGHBORS: I was going in a different direction in my head because I have kids and so I imagine the struggle.  So I'm going to  talk a little bit about that first, the pain of the family member, but then pivot to having a third party which is where you were going. I feel there's family suffering and you know this, you've seen this in the work that you do.  So much and they're getting a lot of conflicting advice, a lot of advice to go, cut them off, and I used to be that person to just cut them off. That'll be the best for them until I had my own kids and I realized the special nature of that love that you can't do that. And what we're learning is to heal you need love, and I'm a scientist, I promise you, but, you need that kind of caring compassion in a nonjudgmental way. It's hard to do as a parent because you suffer because they're suffering and you want them to get better. So finding that right balance between, okay, there's limits to what I can do, but I still love you and I want to help you and so let's see how we can work together. And often you need somebody to come in and help referee that because it's so, so difficult. And there are resources for family members. There's something called CART, which is ways in which family members can learn how they can use some of the principles from cognitive-behavioral therapy to work with loved ones. But very often family members are told, now you’ve got to show tough love. And I think where we're drifting to today is saying tough love is probably not the right word for this, not the right way to conceptualize this.

To your point, and it's a very good one, to have that kind of great connection for the person that's affected by the substance use disorder with somebody who they feel that is caring for them in a non-judgmental way can take some of the pressure off the family members, because they're caught in this duality that they, can't get out of because they're inseparable. Whereas having another party where the person feels that can be extremely beneficial. 

DR. THEA GALLAGHER: And I think in what you're talking about, I always think about motivational interviewing is so powerful.  It's such an objective way to talk to somebody about what they're dealing with. And I always think that would be very difficult to do with my children. But it's easier to do with your patients because you care about them in a different way and it sounds like maybe there's some limitations to this word love, but that's someone that people are experiencing really true, unconditional positive regard from their therapist, but it's not enmeshed in the same way that you might be with like a family member that none of us can separate from.

DR. CHARLES NEIGHBORS: A joke I've told too many times, which is, my kids' mom was also a clinical psychologist and we were so confident that we were going to  be the best parents because we were so well prepared and we were just completely overwhelmed. Because you're right, there's another level to this that you can't, you can't be that person that's objective about everything. 

DR. THEA GALLAGHER: Just the nature of the relationship diminishes that. What would you say are the biggest barriers to redesigning substance use disorder treatment infrastructure to support that therapeutic relationship? Or do you feel like there maybe are less barriers and we're tackling those?

DR. CHARLES NEIGHBORS: The first thing I want to start off with is I want to highlight that we do see change happening and one concrete example is more people who go into treatment for opioid use disorders are being introduced to medications and in a substantial way. Not enough yet. There's room for improvement, but things are improving. 

The other thing that we're seeing when we have these conversations with practitioners in these clinics, they are talking about being person-centered and embracing the sense of we want to keep people safe.  But there's still a way to go in really embracing those concepts and really fully…sort of the practice really reflecting the principles that were behind it. So I want to make that very clear that things are changing but we think there's more room for improvement.

I work very closely with this professor at the Wagner School of Public Service, Tom D’Aunno, and he's very much a systems level thinker and he's very big in the field of organizational management. We have lots of conversations about how that each one of these organizations, each one of these clinics, is reflective of a social entity. It's comprised of people and the interpersonal dynamics that happen within the organization. And out of that is forged a certain culture that has certain ways of thinking, what is right and what is wrong, and those things, that culture of the organization, gets forged during a certain period when the organization was just forming. A lot of the organizations we're working with were formed during a different period where there was a different concept about what substance use disorders were and what was right for treatment for substance use disorders. 

So that cultural change takes time.  And you can imagine like in our societies how cultures do change, but it's a gradual evolution.  So that's one of the things that I think is foundational. How do you get people to really think about what's right and wrong in a fundamentally different way? And we're working on that to really help accelerate that. 

The other thing that I really…I don't think we've spent enough time just yet talking about is the amount of stigma that people who have substance use disorder suffer.  For so long they've been condemned as morally bankrupt and just lacking sufficient will to really do what everybody else can do. And there's been a lot of through the decades, a lot of stereotyping that is linked to racial stereotypes and that still persists and it's reflected in the amount of funding that these programs get.  They're trying to do heroic work with limited resources. They're often because of a reluctance to have people who get treatment visible in communities, these treatment programs often get sequestered in areas where it's imposed on certain communities that don't have the political power to push back.  And the stigma itself is a barrier even for family members because now they feel shame and this makes it more difficult for them to seek help.

I think this is one of the areas where I've seen lots of improvement, but we have a ways to go to really get the whole communal society to think about people with substance use disorders as people with a health condition, with a medical condition, that need to be treated with compassion rather than—and with air quotes here—degenerates.

DR. THEA GALLAGHER: Do you have an idea of why this kind of sequestering initially happened because we were talking about it even with diagnosing ADHD earlier, that it became so complicated or you have to have a neuropsych eval to get to that point. And I think substance users, you have to have a formal evaluation or only people licensed to do the work can do it and so let's say a practitioner in their office has somebody who's navigating substance use disorder and with co-morbid depression and they're like, do I have to send them out to some sort of rehab that's specifically focused on substance use disorder? Do you have a sense of how that happened and what are your thoughts about that being like you have to handle that almost separately?

DR. CHARLES NEIGHBORS: This notion that—and let's pull it apart—there's been a push-pull on this. There's a general sense that a lot of people in the medical community don't feel very comfortable with this. Part of that is the stigma. Part of this is the sense that there's a specialized knowledge that your primary care physician might not feel that they're capable of  contending with. There are people here at NYU that are doing a lot of work in trying to bring in to medical settings that capacity for dealing with substance use disorders. And it would be a great setting to first address this because it normalizes substance use disorder, kind of takes a little bit of the stigma away from it.  But also if that's where people are getting care, that's where they should receive care. 

So there's a piece of this where people are leery of it and then there's this treatment infrastructure that's been built out over time that have been driven by people who are really committed to the community of folks that have been given….and there has been in that community a lot of…it’s affected people who are building up the system. Because they have a sense of what it entails and also the lack of available help that's out there. So that's been another part of it.

And then there's been socioeconomic things. One of them is the relatively lower levels of funding. And I should say that substance use disorder treatment in the United States, three-quarters of it is paid by government, between states, local government and federal, which is that mix in medical care is a little bit different where you have more commercial insurance paying for medical care. But then there's a lot of this thing NIMBY-ism where “not in my backyard” which is like a community saying, we don't want that around here.  We're not that kind of community, air quotes again. And so it often gets pushed to areas that make it even more marginalized. 

DR. THEA GALLAGHER: It is hard to grow an empathy if you're never faced with the situation that is in your backyard and I think that's another thing, if there's a way to also, maybe to educate people on the stigma that exists and on how these disorders develop and are perpetuated. I think it gives you a lot of understanding for people and their struggles which I think we need more of. 

DR. CHARLES NEIGHBORS: Yes. I completely agree. 

DR. THEA GALLAGHER: We talked a little bit about harm reduction and that could mean things like reducing the amount that you're using but also something like injection sites are considered a part of harm reduction model. That is thought of to be controversial. So what are some of your thoughts about things like safe injection sites and what does the evidence show about it?

DR. CHARLES NEIGHBORS: It's a great question. Let me talk a little bit about harm reduction and then get to the safe injection sites. Harm reduction can mean many, many different things to many different people. So I think it's good to really establish some working definition for the conversation.

For many, it's a real focus on reducing risk of overdoses.  Let’s distribute Naloxone kits, or let's allow people who are injecting, self-injecting, drugs, let's give them new, fresh needles so that they don't share the needles and pass along infectious diseases.  So there's strategies that you can do that sort of help to reduce the risk of poor health outcomes or even death. 

But there's also a way of thinking about harm reduction as a philosophy, which is, starting from the precept that what matters most is keeping somebody safe. And once we start with that premise, then we can move on to seeing if we can engage that person in ways that move them along to where they want to go in a safe way. And often that means finding a way to live a life as a fully productive and self-actualized person.

So in treatment often the difference is…in some treatment programs what you'll see is that if somebody is showing signs of using substances while they're in treatment there is a lot of discussion between the team and that person of saying, hey, this is not working for you.  And sometimes that leads to the treatment program saying this is not the right treatment for you and the person ends up leaving treatment altogether. And that's a more traditional model in this evolving, more harm reduction principled way of thinking about treatment.  If a person's in treatment and they're using substances, the idea there is that we want to keep this person engaged with us because that is the best way that we're going to have opportunities to help them move to a safer and more self-actualize life. So if they're using substances, that's a clinical moment to talk about it, rather than saying, this ain't working. You don't seem to get it. Like you probably need to go somewhere else. 

So it's a philosophy and if you follow through on that philosophy of we want to do everything we can to really keep people safe in the hopes that that'll give them the moment where they can make the next step in a way that for them rings true, then that leads to many different kinds of options and one of those options is to say, people are using substances, many people are dying from overdoses, particularly now where the supply of drugs that's out there that people are obtaining, through whatever markets that they're getting the drugs from, there's no quality control to really understand what's in the drugs and there's some really powerful and dangerous adulterants or things that are being added to those medications, and it's killing a hundred thousand people a year.

So if you follow through on that and your sense is let's keep people safe because we have humanistic values, then these safe injection sites, or opioid prevention centers (the political lingo that they…overdose prevention centers), they make sense even from a public health perspective.  

There are controversial things about it. Part of that comes from the traditional sort of like law and order perspective that we have in this country when it comes to drugs and drug use. And also where these overdose prevention centers are being placed, which is often in communities that don't have the political clout to fight back.  So you're getting pressure, political pressure, from different ends on the other side of things and it really catches public officials in a very complicated bind. I think the evidence, and there's some preliminary evidence that this just saves lives, fewer people are dying because they're…so in that regard it's something that it's easy to support.

DR. THEA GALLAGHER: I think when you look at the bigger picture, the broader picture, it makes more sense and it's less of again, a fear-based or out-of-context idea when you understand the larger context of people dying and how important it is to save a life. 

DR. CHARLES NEIGHBORS: Absolutely.

DR. THEA GALLAGHER: And I know we hear this statistics get thrown around that it takes individuals seven times getting treatment before they can get better, I want to know your thoughts on that and then also is that kind of a way to think about this is an iterative process with a therapist and a patient navigating this journey together and understanding that.  So just some of your thoughts on that statistic itself and then on how to look at the therapeutic relationship. 

DR. CHARLES NEIGHBORS:  No, that's a great question. To begin with, it's important to understand the substance use disorders are often just like other chronic conditions like diabetes is the example that we often use, which is you don't expect to be cured of diabetes.  You have diabetes and what you try to do is manage it and with that you need a certain amount of sense of what you hope to achieve and then, and that's a decision that the person with a condition needs to make on their own. And then go about putting in place all the things that you need to do to, reach your goals.  You know and things get easier over time, but it's always there and that is the case with substance use disorders where if you are a person that using substances is leading to things that are less healthy for you, or causing such disruption in your own life that you're very unhappy, moving to a place where you manage your substance use or stop using substances, requires vigilance over time and people often need to iterate over time to figure out for themselves what is the right strategy to get there. 

So many people end up going through multiple episodes of treatment. My sense is that a lot of that, the data that you're talking about, is within a system that really pushes people like, “The only thing we will accept here for a goal is you quitting altogether.” If we move to this emerging model which says, “I want to stay connected to you, but I want to figure out what you really want out of this.” In most cases that's going to mean at the end of the day you're going to stop using substances because that's how you get to the goals that you have. But if you're not there yet or you're not going to  be there, I still want to stay connected to you and help you get to whatever goals that you have. 

And if you can build a system that sort of has that mindset of saying, what's important here is staying connected and helping people navigate that journey, you'll have the, go in, leave, go in, leave, it becomes more evened out.  Is my sense of things. 

DR. THEA GALLAGHER: And just my final question, anything you're excited to see, kind of research and policy push things forward in the next 10 years?

DR. CHARLES NEIGHBORS: It's interesting because I'm so excited about what we're doing right now. I do think we need to maintain this vigilance on the suffering that people have because it'd be so easy to just…there's been a lot of attention and investment in substance use disorders. We need to continue to evolve in this sort of like a conversation between public safety and public health approaches to substance use disorder. One example is in the treatment using methadone as a medication. The system there, there's a lot of DEA oversight over what the treatment programs have with that medication. And the DEA, their role is public safety. So there's a lot of restrictions that they employ that sometimes lead to ways in which the providers are engaging with the patients that are not necessarily the best therapeutic approaches.  Because there's this heightened concern about, are the patients going to use this medication in a way that is not therapeutic? So trying to resolve these inherent paradoxes of how we think about what's happening within the field I think is very important.

I will pivot a little bit for a second. There's another area that's emerging that I think is super interesting, but there's a big dearth of really good research on and it's gambling. And there can be a debate about is gambling the same thing as substance use disorder and in the phenotype of them. There are some differences, but there's some similarities and everybody knows we have an explosion going on right now in this online gaming, gambling. My son's a young adult and I see how caught up he is in it I think in a fine way. But we don't have the toolkit to know what to do with the folks that really get caught up in this kind of gambling. We don't know the topography of it. We don't know how people…like what predicts that they're going to lead to things that are ruinous for themselves or like how to intervene with them.  So I think that's on the horizon, something that we should be thinking about. 

DR. THEA GALLAGHER:  I think the concept of understanding the crossover with behavioral addiction and then substance use disorder and where they differ but where they are the same, I think it is really important and especially with gambling addiction and the risk of suicide.  Again going back to saving lives, what are we doing to intervene and to make sure that we know that this is a population that could be at risk.

DR. CHARLES NEIGHBORS: Absolutely. And often it’s tied to substance use disorders. 

DR. THEA GALLAGHER: Yeah, absolutely. Thank you so much for being on our podcast today.  And thank you to all of our listeners and viewers who have heard or watched this podcast.  If you liked this podcast you can rate and subscribe anywhere that you watch or listen to these podcasts and from everyone here at NYU Langone Health, thank you so much for listening.