Change is natural. You no doubt
act very differently in many areas of your life now compared with how you did
when you were a teenager. Likewise, over time you will probably overcome or
ameliorate certain behaviors: a short temper, crippling insecurity.
For some reason, we exempt
addiction from our beliefs about change. In both popular and scientific models,
addiction is seen as locking you into an inescapable pattern of behavior. Both
folk wisdom, as represented by Alcoholics Anonymous, and modern neuroscience
regard addiction as a virtually permanent brain disease. No matter how many
years ago your uncle Joe had his last drink, he is still considered an alcoholic.
The very word addict confers an identity that admits no other possibilities. It
incorporates the assumption that you can't, or won't, change.
But this fatalistic thinking about
addiction doesn't jibe with the facts. More people overcome addictions than do
not. And the vast majority do so without therapy. Quitting may take several
tries, and people may not stop smoking, drinking or using drugs altogether. But
eventually they succeed in shaking dependence.
Kicking these habits constitutes a
dramatic change, but the change need not occur in a dramatic way. So when it
comes to addiction treatment, the most effective approaches rely on the
counterintuitive principle that less is often more. Successful treatment places
the responsibility for change squarely on the individual and acknowledges that
positive events in other realms may jump-start change.
Consider the experience of American
soldiers returning from the war in Vietnam, where heroin use and addiction was
widespread. In 90 percent of cases, when GIs left the pressure cooker of the
battle zone, they also shed their addictions—in vivo proof that drug addiction
can be just a matter of where in life you are.
Of course, it took more than a
plane trip back from Asia for these men to overcome drug addiction. Most
soldiers experienced dramatically altered lives when they returned. They left
the anxiety, fear and boredom of the war arena and settled back into their home
environments. They returned to their families, formed new relationships,
developed work skills.
Smoking is at the top of the charts
in terms of difficulty of quitting. But the majority of ex-smokers quit without
any aid—neither nicotine patches nor gum, Smokenders groups nor hypnotism. (Don't
take my word for it; at your next social gathering, ask how many people have
quit smoking on their own.) In fact, as many cigarette smokers quit on their own,
an even higher percentage of heroin and cocaine addicts and alcoholics quit
without treatment. It is simply more difficult to keep these habits going
through adulthood. It's hard to go to Disney World with your family while you
are shooting heroin. Addicts who quit on their own typically report that they
did so in order to achieve normalcy.
Every year, the National Survey on
Drug Use and Health interviews Americans about their drug and alcohol habits.
Ages 18 to 25 constitute the peak period of drug and alcohol use. In 2002, the
latest year for which data are available, 22 percent of Americans between ages
18 and 25 were abusing or were dependent on a substance, versus only 3 percent
of those aged 55 to 59. These data show that most people overcome their
substance abuse, even though most of them do not enter treatment.
How do we know that the majority
aren't seeking treatment? In 1992, the National Institute on Alcohol Abuse and
Alcoholism conducted one of the largest surveys of substance use ever, sending
Census Bureau workers to interview more than 42,000 Americans about their
lifetime drug and alcohol use. Of the 4,500-plus respondents who had ever been
dependent on alcohol, only 27 percent had gone to treatment of any kind,
including Alcoholics Anonymous. In this group, one-third were still abusing
alcohol.
Of those who never had any
treatment, only about one-quarter were currently diagnosable as alcohol abusers.
This study, known as the National Longitudinal Alcohol Epidemiologic Survey,
indicates first that treatment is not a cure-all, and second that it is not
necessary. The vast majority of Americans who were alcohol dependent, about
three-quarters, never underwent treatment. And fewer of them were abusing
alcohol than were those who were treated.
This is not to say that treatment
can't be useful. But the most successful treatments are nonconfrontational
approaches that allow self-propelled change. Psychologists at the University of
New Mexico led by William Miller tabulated every controlled study of alcoholism
treatment they could find. They concluded that the leading therapy was barely a
therapy at all but a quick encounter between patient and health-care worker in
an ordinary medical setting. The intervention is sometimes as brief as a doctor
looking at the results of liver-function tests and telling a patient to cut down
on his drinking. Many patients then decide to cut back—and do!
As brief interventions have evolved,
they have become more structured. A physician may simply review the amount the
patient drinks, or use a checklist to evaluate the extent of a drinking problem.
The doctor then typically recommends and seeks agreement from the patient on a
goal (usually reduced drinking rather than complete abstinence). More severe
alcoholics would typically be referred out for specialized treatment. A range of
options is discussed (such as attending AA, engaging in activities incompatible
with drinking or using a self-help manual). A spouse or family member might be
involved in the planning. The patient is then scheduled for a future visit,
where progress can be checked. A case monitor might call every few weeks to see
whether the person has any questions or problems.
The second most effective approach
is motivational enhancement, also called motivational interviewing. This
technique throws the decision to quit or reduce drinking—and to find the best
methods for doing so—back on the individual. In this case, the therapist asks
targeted questions that prompt the individual to reflect on his drinking in
terms of his own values and goals. When patients resist, the therapist does not
argue with the individual but explores the person's ambivalence about change so
as to allow him or her to draw his own conclusions: "You say that you like to be
in control of your behavior, yet you feel when you drink you are often not in
charge. Could you just clarify that for me?"
Miller's team found that the list
of most effective treatments for alcoholism included a few more surprises. Self-help
manuals were highly successful. So was the community-reinforcement approach,
which addresses the person's capacity to deal with life, notably marital
relationships, work issues (such as simply getting a job), leisure planning and
social-group formation (a buddy might be provided, as in AA, as a resource to
encourage sobriety). The focus is on developing life skills, such as resisting
pressures to drink, coping with stress (at work and in relationships) and
building communication skills.
These findings square with what we
know about change in other areas of life: People change when they want it badly
enough and when they feel strong enough to face the challenge, not when they're
humiliated or coerced. An approach that empowers and offers positive
reinforcement is preferable to one that strips the individual of agency. These
techniques are most likely to elicit real changes, however short of perfect and
hard-won they may be.
By Stanton Peele
Publication:
Psychology Today Magazine
Publication Date: May/Jun 2004
Last Reviewed: 10 Jul 2006
(Document ID: 3453)
SOURCE:
http://www.psychologytoday.com/articles/pto-20040712-000003.html
