What is Addiction?
Addiction - Substance use disorder (SUD) - is defined by the American Psychiatric Association as a complex condition in which there is uncontrolled use of a substance despite harmful consequences. People with SUD have an intense focus on using a certain substance(s) such as alcohol, tobacco, or illicit drugs, to the point where the person’s ability to function in day-to-day life becomes impaired. People keep using substances even when they know it is causing or will cause problems. The most severe SUDs are sometimes called addictions. Addiction is categorized as a chronic relapsing disorder. There isn't a cure, but approximately 25 million American adults have resolved a serious alcohol or drug problem and live in sustained remission. But it is conservatively estimated that 20 million adults in the US perennially suffer from active use SUD.
There are certain factors that cause addiction. Genetics probably plays the predominant role, specifically the genes that create differences in the dopaminergic neural pathways of the brains of the afflicted. Culture and environment are also critical contributors. There are attributes of the legal profession that create a fertile environment for the manifestation of SUD, and other mental distress disorders. Impulsivity and other emotive characteristics are likely causal factors too.
Fortunately, addiction and other well-being disorders are amenable to treatment, but the culture of the legal profession is a stubborn impediment to its own well-being. That paradigm is beginning to shift and the profession has started to implement measures to address its mental well-being and alcohol problems.
Addiction is diagnosed using clinical criteria. There are three primary tests used to assess the severity of SUD. They have excellent scientific reliability and validity. Once someone is diagnosed with SUD, the focus needs to shift from why did it happen to how to escape active use. We tend to ruminate on the "why." That question is complex, and ultimately far less important than the "how." We know the hows. It's challenging, but millions have found the path out of active use and have gone on to live incredibly rich, productive, and fulfilled lives by embracing the structures and hope that lead to long-term remission.
Why Care
Statistics show that roughly one of every four American adults is either living in active use SUD, or has resolved a serious drug or alcohol problem. Virtually all of us have a family member, friend, or coworker who has struggled with an alcohol or drug problem. SUD affects us all in profoundly negative ways.
Addiction results in desperation and destroys lives. Drug-seeking behavior supplants responsibilities to family, work, friends, and community. Addicts lie, cheat, and steal not because we want to, but because our brains have been hijacked by SUD. At later disease stages, addict behavior often leads to jails, institutions, and early death. Roughly 65% of the two million people incarcerated in the US have SUD, and another 20% are locked up because of offenses committed while under the influence. Conservative estimates place the economic cost of addiction to American society at roughly $1.5 trillion a year.
The legal profession has one of the highest rates of SUD of any occupation, primarily in the form of alcohol abuse. It costs the profession billions of dollars annually, leads to mistakes, ethical violations, and profound suffering. Certain inherent aspects of the practice of law cause higher rates of addiction and mental distress. Effective protocols exist to address mental distress and SUD, but very few lawyers and law firms are aware of these tools.
How is Addiction Diagnosed?
The Diagnostic Manual of Mental Disorders (DSM) is the handbook used by psychiatrists, psychologists and, other clinicians to diagnose a variety of mental illnesses, including SUD (addiction). The current iteration, the fifth revised version, known as the DSM-V-TR, was introduced in 2013. It lists 11 symptoms to determine whether one has SUD and the level of severity - Mild, moderate, or severe. The AUDIT (Alcohol Use Disorders Identification Test) is another commonly used test for clinical assessment of Alcohol Use Disorder (AUD). The DAST (Drug Abuse Screening Test) assesses for problems with drugs other than alcohol. Both of these tests have excellent validity and reliability.
While most with substance use disorder (SUD) struggle with alcohol, it is common for addicts to abuse a multitude of drugs. A person with moderate to severe SUD typically has a psychoactive "drug of choice" (DOC), but will often substitute other drugs when their DOC is unavailable or is impractical to use. A person who is regularly tested for alcohol, but not other substances, will often substitute other drugs, commonly marijuana, benzodiazepines (Valium Xanax, Lorazepam, etc), or opioid pain medications. Virtually everyone who has a drug problem also abuses alcohol. Addiction doesn't discriminate between psychoactive substances. When one has crossed the line into addiction, abstinence from all psychoactive drugs is critical to allow neuroplasticity (brain change) the time to diminish the phenomenon of craving and heal the addict's dysfunctional dopaminergic neural pathways.
Diagnostic Manual of Mental Disorders - DSM-V
The DSM-V SUD criteria are:
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Taking the substance in larger amounts or for longer than you're meant to.
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Wanting to cut down or stop using the substance but not managing to.
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Spending a lot of time getting, using, or recovering from use of the substance.
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Cravings and urges to use the substance.
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Not managing to do what you should at work, home, or school because of substance use.
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Continuing to use, even when it causes problems in relationships.
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Giving up important social, occupational, or recreational activities because of substance use.
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Using substances again and again, even when it puts you in danger.
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Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
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Needing more of the substance to get the effect you want (tolerance).
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Development of withdrawal symptoms, which can be relieved by taking more of the substance.
Two or three symptoms indicate a mild substance use disorder. Four or five symptoms indicate a moderate substance use disorder, and six or more symptoms indicate a severe substance use disorder.
The AUDIT, DAST, and DSM-V are the three most common diagnostic SUD tests. The trend in clinical diagnosis in recent years has been to define SUD as a spectrum severity disorder. SUD is considered to be progressive, For those of us who can't stop, it gets worse over time. Yet about half the population who have had a drug or alcohol problem manage to quit without assistance, or go into remission without maintaining strict abstinence. Most in this group are thought to fall into the less severe category of SUD, or they may lack the genetic propensity to develop SUD. However, It is dangerously clear, that once the "line" into severe addiction has been crossed, the disorder progresses, with profoundly negative consequences that will ultimately result in premature death unless arrested. The vast majority of this group cannot stop and maintain abstinence without treatment and recovery support.
Fortunately, SUD has a very good prognosis if treated correctly. Recovery is challenging, especially at the outset where relapse is the rule rather than the exception, which is why those in early recovery must have a structured aftercare and monitoring program.
Nomenclature
Admittedly, we violate the new protocol used in describing SUD. We use descriptive nomenclature that has fallen out of favor with clinicians. We use terms like: Addict, alcoholic, addiction, alcoholism, etc. These words are considered pejorative phraseology that reinforces negative stereotypes and stigma. The older terms are also considered to impede the establishment of uniform clinical diagnostic criteria.
We are exceptionally mindful of these concerns, but we feel the older terms are understood by the greatest number of people in a way that emphasizes the seriousness of the disorder. We are recovering addicts. Our disease took everything from us, and nearly killed us. We don't care what we're called. We do care that people get the help they need.
SUD is a complex disorder. Causation is multifaceted, but there are primary factors believed to play a role:
Genetics - Genes are likely the most important factor in determining whether one will become an addict. Evidence shows between 50% to 80% of the causal component of SUD is biologically heritable. Some of us inherit genes that create brain biochemistry that makes us more susceptible to becoming addicts. Recent research indicates that there may be differences in the D2 dopamine receptors in the brains of addicts. Other research implicates certain proteins in the dopamine system, while some research suggests that the way the liver processes drugs of misuse is involved. More study needs to be done. It is likely that there are a multitude of genetic/biochemical variables involved that science doesn't yet fully understand. Currently, there is no determinative genetic test to predict addiction.
What we do know is that a statistically significant number of addicts and alcoholics have parents or other close relatives who are also addicts or alcoholics. Addiction is very much a multi-generational disorder that runs in families.
Environment - Living in an environment that is stressful, filled with trauma, or characterized by negative affect states causes people to seek ways to relieve their negative emotional states. Drugs of misuse are the most efficacious way to immediately salve negative emotional feelings induced by stress/trauma.
Culture - Culture is a primary determinant of whether one will develop SUD. An adherent Mormon who follows the strictures of his Church's teachings prohibiting the use of alcohol or other drugs won't become an addict, even if all other predisposing factors are present. There is no fuel to create or sustain SUD. In contrast, a person who joins a fraternity out of high school becomes enmeshed in a culture where it is virtually impossible to escape heavy drinking is at greater risk of developing SUD if other predisposing factors exist. Early-life exposure to drugs or alcohol is also a predictor of later development of SUD.
A culture with lax values on consumption will produce a greater number of people who suffer from SUD. The power of the peer plays an extremely large role. The cultures we belong to are our most influential peer groups. The culture in the United States is relatively permissive regarding alcohol consumption but harshly oppressive with most other drugs of misuse.
The culture of the law is a profession that is far more laissez-faire with regard to alcohol use when compared to the rest of society. We don't yet have entirely reliable data detailing the prevalence of other drugs in the legal profession, but it appears as though lawyers could be somewhat less inclined than the general population to use illicit substances, with the potential exception of opioids and sedatives. Evidence suggests that legal professionals use these drugs at rates higher than estimates of use in the general public.
Drug of Choice - A person's drug of choice plays a large role in the development of SUD. Certain substances are more likely to lead to addiction over a shorter amount of time. The vast majority of people who use alcohol will never develop an alcohol use disorder. For those who do, it typically takes years, even decades in some instances, to become addicted to alcohol. Marijuana is another drug that isn't as physically addicting as other substances. Opioids, cocaine, nicotine, and amphetamines tend to result in higher rates of addiction that develop over shorter periods of time in those who have an affinity for these substances.
Co-Occurring Mental Health Issues - The presence of other mental health conditions is a driver of SUD. The two most common mental health problems are anxiety and depressive disorders. It is a vicious cycle. People use psychoactive drugs to relieve anxiety and depression, which causes greater levels of anxiety and depression, that leads to greater substance use.
Lawyers, as a cohort, have extraordinarily high levels of anxiety, stress, and depression. Addressing these conditions, and any other co-occurring mental health issues is critical to relieving the suffering and dysfunction they cause directly, and to eliminate their role as drivers of SUD.
Impulsivity - The concept of the 'addictive personality" is frequently raised as a predominant causal factor in SUD. But there is not a correlation between SUD and the various personality subclassifications delineated in the psychology field. There is one behavioral characteristic that does correlate with addiction, and that is impulsivity. Addicts tend to be impulsive. Impulsivity is acting without planning or considering the consequences of an action. It is the behavioral characteristic at the root of the delay-discounting phenomenon, where people prefer a smaller, immediate reward at the expense of a larger, delayed reward. Addiction is the manifestation of dysfunctional delay-discounting run amok.
Impulsivity is generally thought to be a bad attribute. Who wants to be described as someone who just acts without thinking things through? But impulsive behavior is vital to survival. We all need to make quick decisions without having a good sense of the outcome, using only our general framework of experience as our guide. The caveman who ate the strange berry and found a new source of nutrient-rich sustenance not only enhanced his survival, but also benefitted his clan by impulsively taking the chance on the berry. People who quit their jobs with good salaries, benefits, and security to create a start-up are acting impulsively. Most will experience the negative consequence of failing, but some will change the world, get rich in the process, and be rewarded in other desired ways.
Our behaviors are motivated almost entirely by our desire to seek rewards and avoid negative consequences. The caveman runs the risk of being poisoned by the berry, but impulsively desires the potentially large reward of finding a new source of food. Those who tend toward impulsive behavior place a higher value on the chance of a reward, over avoiding a negative consequence. The impulsive are less behaviorally risk averse. Their mindset is "I am going to get the reward, and I'll deal with any negative consequences later." Addicts exist in this dysfunctional delay-discounting paradigm. We need the immediate neurological reward provided by psychoactive substances. We minimize the negative consequences of using and will engage in dishonest and manipulative behaviors to attempt to later minimize the negative consequences. Substance abuse alters the brain structures that modulate healthy risk-reward cognitive assessment that often leads to destructive behavior. Those of us who reach the later stages of SUD become overly concerned with pursuing behaviors that will ensure our ability to continue to use rather than engaging in behavior that results in healthy rewards.
Emotive Characteristics - There are certain psycho-emotional themes that those with SUD seem to experience to a greater degree than the non-afflicted populace. The following are common attributes: Fear, anger, isolation, avoidance, need to control, interpersonal sensitivity, self-reliance, perfectionism, and conflict orientation. The SUD prone seem to dwell in a construct where these characteristics are at the forefront of thoughts and feelings, both conscious and subconscious. Each of these emotive states is necessary for survival, but when one or more becomes out of balance, one's perspective and belief system tends to become negative affect oriented. This causes extremely discomforting feelings - Angst, anxiety, depression, etc. that lead to a lack of joy and purpose in living and feeling overwhelmed by life.
Psychoactive substance misuse is a very efficient way to quickly repress negative emotional states, without devoting the energy required to work through them in a healthier manner. For addicts, expending the effort to appropriately deal with negative emotions is overly painful, when contrasted with the immediate, reliable relief more easily obtained through substance misuse. But the benefit of repetitive short-term relief gradually results in ever greater dysfunction, unless and until healthy behavioral and emotional coping strategies are substituted.
Emotive Attributes of Law Practice - Our environments, particularly our vocational environments, are strong influencers of our emotional states, and wire our brains to perceive the world in a particular construct. The practice of law involves spending large blocks of time in situations that evoke the very emotional themes inherent in addicts. Conflict, fear, perfectionism, need to control, self-reliance, and especially anger. Anger is strongly correlated with alcohol abuse.
A lawyer is expected to always be in control of complex, uncontrollable variables in order to be perceived as successful. The practice of law is most often a zero-sum game, where effectively utilizing hostility to control complex variables is a structurally ingrained attribute of the profession. A person who is expected to be in control of the uncontrollable, in a win or lose paradigm, inevitably feels fearful and emotionally isolated. Living in fear in an environment that promotes hostility leads to anger. Living in near constant fear and anger creates a desire to diminish the discomfort these negative emotional states create. Humans didn't evolve to thrive while being constantly subjected to profound feelings of fear, anger, and isolation for extended periods of time. Drinking or using drugs effectively provides temporary avoidance of distressing emotions, but repeated resort to psychoactive substances as a refuge from emotional turmoil cycles into ever-increasing turmoil and dysfunction.
The law is also exceptionally time demanding. For many, there is little time allocated to engage in a balanced life with family, hobbies, exercise, and other self-care activities that counteract negative emotional states and stressful career demands. Anxiety, depression, and SUD too often manifest as a result of this imbalance. Fortunately, there are several strategies that can be implemented to effectively ameliorate this dynamic if the individual and the organization are simply willing to do some work.
The wonderful outcome of doing recovery work is the development of new, healthy perspectives and belief systems. The person in recovery from SUD redefines his relationship with himself and the world around him in a way that promotes a healthy outlook and productive behaviors. Over time, this emotional and spiritual growth quells negative emotional states. Angst, anxiety, depression, and other unhealthy emotional constructs give way to a more serene perspective that promotes healthy engagement with the world.
Organizations that implement programs to prophylactically reduce environmental factors that contribute to SUD in individuals invariably find their overall organizational well-being improves dramatically. Anxiety and depression decrease, the financial bottom-line increases, turnover rates fall, and the people who make up the firm have far greater life satisfaction.
Why Versus How - Historically, the scientific and medical communities have tended to focus much of their SUD research resources on seeking the answer to the causation question, "What causes addiction?" Presumably in the hope of finding the elusive magic bullet to cure SUD. A "pill to replace all pills," or a brain operation to eliminate the phenomenon of craving. Great strides have been made with medically assisted treatment (MAT) in the last decade, especially in the treatment of opiate/opioid disorders, but there is no medical panacea as a cure for SUD on the horizon.
SUD is a complex, chronic affliction. The "how" to change is more important than the "why" did it arise. Fortunately, systems exist that allow us to leverage proven behavioral change protocols to significantly reduce SUD. The great irony is that the vast majority of the efficacious "how" systems have been developed not by the medical and scientific communities, but by the afflicted. Millions have escaped the crushing cycle of addiction by adhering to the hows discovered by addicts figuring out what works and then helping other addicts to find the path out of active use.
We're also now on the cusp of great improvement in the one area where the traditional treatment model has failed. We can now leverage external change motivators to ensure compliance with abstinence and aftercare, allowing sufficient time for the brain to develop healthy dopaminergic neural pathways. These modalities bolster brain healing and the development of entirely new belief systems that break the bonds of addiction.
What Causes Someone to Become an Addict?
Dopamine
SUD dwells in the dopaminergic neural pathway of the brain. Dopamine is a critical neurotransmitter, influencing many aspects of mood, motivation, learning, memory, focus, energy, cognition, perseverance, habituation, and the ability to experience pleasure in pursuing naturally healthy and rewarding behavioral objectives.
Dopamine is released when we experience something that feels pleasurable. Our brains are wired to find experiences that enhance survival to be both biologically and psychologically pleasing. As an example, food that is calorie-dense tends to taste good, giving a sense of pleasure because these foods release greater levels of dopamine compared to food that is less caloric. A slice of chocolate cake contains approximately 400 calories. A comparable volume of celery contains about 45 calories. If a person is hungry and is given the choice of chocolate cake or a plate of celery, virtually everyone will choose the chocolate cake.
This cake versus celery choice isn't a fully conscious decision. It's rare that we cognitively analyze the relative calories of chocolate cake versus celery and arrive at the conscious conclusion that the chocolate cake has more calories and therefore increases our odds of survival. In our modern world, where food scarcity is rare, and over-consumption of calories too common and detrimental to health, the opposite is probably true. The chocolate cake is likely to decrease our odds of survival. Yet, most people will still choose chocolate cake. The celery stands no chance, even when it is the more rational choice to enhance survival.
Why? Because dopamine makes virtually all of our choices for us, and most of those choices are made at the subconscious level. Even when we can pull our choice behavior out of the subconscious and evaluate the relative cost-benefit of pursuing a pleasurable reward that is also potentially harmful, we have little decisional ability (willpower) to alter behavior in contravention of what dopamine dictates. Eating the chocolate cake releases dopamine that floods the nucleus accumbens in the brain, giving us the pleasure that we crave. We bargain with our higher order cognitive personas and tell ourselves, "I know I probably shouldn't eat this because it contributes to weight gain, but what's one little piece going to hurt? I'll start eating better tomorrow!" We engage in the same delay-discounting phenomenon that addicts use to rationalize immediate satiation of craving - "i know this is destroying my life, but just one more time, and I'll stop using tomorrow." Weight gain doesn't occur immediately, it happens gradually and imperceptibly, usually without much conscious awareness. Addiction also develops gradually and imperceptibly, without much conscious awareness, until suddenly one can't stop or control using.
In the cake versus celery example, it is craving that drives the choice to consume the cake over the celery. Craving also fosters active use in SUD. Craving starts with a cue. In the chocolate cake example, that cue is likely a combination of many different things. The internal biological processes that indicate we're hungry and need sustenance are cues. It may be that the chocolate cake is fresh out of the oven, and we smell it, which triggers a memory associating the smell of the cake with eating the cake with the pleasure experienced by dopamine release.
It may be that the cake is presented to us at a restaurant that we've eaten at in the past, where we laughed and bonded with friends, so our brain subconsciously associates eating the cake, not only as pleasurable for the dopamine it releases, but we subconsciously recall the pleasure of being with good friends at the restaurant when we ate the cake, which also released dopamine. The subconscious memory of bonding with friends over chocolate cake creates an expectation (cue) of the release of an even higher level of dopamine when we consume the cake because it is subconsciously associated with the fun we had with friends. The expectation of added pleasure creates an even stronger craving driving our behavior to consume the cake. We don't crave the cake so much as we crave the dopamine released by consuming the cake.
Humans evolved in environments where scarcity of calorie rich food was often the norm. We are hardwired by our dopaminergic neural pathways to crave calorically dense foods because they enhance survival. The brain evolved a craving system to provide a large reward - The pleasure felt when eating high calorie comfort food - to motivate behaviors to find and consume calorie dense foodstuffs. But the human environment changed, most radically just in the last generation. Since 1980, the per capita amount of calories in the US food supply has quadrupled. Calorie rich foods are now cheap and widely accessible in large quantities, resulting in an obesity epidemic. In 1970, 15% of adults in the US were obese. Now, over 40% of American adults are obese, and the trend is upward. The obesity epidemic has occurred during a period where the cultural ethos in the US has placed increasing value on a thin, fit body type. Cultures are humanity's greatest behavioral modulators, so why has there been an unprecedented explosion of obesity coincident with rising cultural pressure to maintain a thin body type? The answer is the profound power that our dopaminergic neural pathways have in dictating our behavioral choices. Our ancient biological brain wiring is a more potent driver of consumptive behavior than the overwhelming cultural preference for thinner body typology. Our dopaminergic driven behavioral urges prevent us from resisting the chocolate cake even when we are cognitively aware that eating too much calorie rich food will lead to obesity, causing negative health and social consequences.
Recent research indicates that obesity and SUD dwell in the same dopaminergic neural pathways of the brain, with many of the same biological mechanisms implicated as drivers of aberrant consumptive behaviors. This is not to say that chocolate cake and heroin are the same thing. Many different biochemical processes come into play when consuming either substance, but both do activate the reward driven mechanisms of the brain's dopamine system, which is a primary driver of human behavior.
Drugs of abuse release far more dopamine into the brain's pleasure centers than naturally rewarding behaviors like eating chocolate cake, sex, making money, being deeply connected with others, etc. While all rewards that drive behavior have their own complexities that differ, and modes of satiation that also influence behavior, the crux to much of behavior, both healthy and dysfunctional, is rooted in dopamine. A balanced, healthy dopaminergic system is critical to a balanced and healthy existence. Addiction is the greatest disruptor of a balanced dopaminergic system.
Dopamine also influences the prefrontal cortex. This is the area of the brain that last evolved in humans and that part that makes us human. It is where our higher-ordered cognition and rational decision-making ability dwell. It regulates our behavior by delineating the probability of benefit or harm flowing from behavioral choices.
A lower level of dopamine in the prefrontal cortex is linked to impulsivity, which is a driver of addiction. Research indicates that dopamine released when drugs of misuse are ingested has a greater effect of stimulating the striatum of the brain, where euphoric reward increases impulsive behavior. The striatum, flooded with dopamine, motivates impulsive behaviors and diminishes the frontal cortex's behavioral inhibitory function. The power the striatum gets from a dopamine rush overpowers the frontal cortex's modulating effect on behavioral choice. This is why those who are intoxicated are more apt to engage in highly risky behavior while under the influence. The behavioral "stop button" of the frontal cortex is effectively tuned down. Even when someone hasn't progressed to the level of SUD, if he or she gets intoxicated, the disinhibitory effect of using psychoactive substances leads to a much greater probability of poor behavioral choices and dangerous behaviors leading to potentially profound consequences.
The frontal cortex is also the area of the brain where our cognitive ability resides. Addiction causes damage to this area of the brain, and to structures in the mid-brain responsible for memory. The brains of addicts do recover, but recovery of brain function takes time and doesn't occur without abstinence.
There are protocols that restore balance to the dopaminergic pathway in the brains of addicts. The process takes effort, proper structure, and time, but the millions who have recovered from SUD prove that recovery is feasible. There is hope. Instilling that hope is the first step to righting the addict's dysregulated dopamine system.
Living a life where existence is defined by the loss of the ability to make healthy, connected choices causes one to lose hope. Active addiction is very much a disease of lost hope. Without hope there is little motivation to change. This lost hope profoundly impacts the addict, loved ones, friends, and colleagues. Hope is restorable, but finding hope requires action, support, and the rebalancing of neural structures and brain chemistry.
There are now as many addicts and alcoholics in long-term recovery as there are who remain trapped in active use. With the recent availability of cost-effective modalities to reinforce aftercare compliance and abstinence, we can turn the tables and bring hope to realization. Instead of 80 plus percent of people returning to active use following treatment, we can reverse those numbers, helping 80 plus percent to achieve long-term, sustained remission by implementing efficacious aftercare monitoring protocols.
Hope builds each day that one in recovery stays clean and sober. Hope leads to the restoration of trust bonds and leads to a wonderful new way of living. Hope is powerful. Hope is taking the right action. That right action is not at all as daunting as it may seem. It is simply reaching out and finding the help that is out there, just waiting.