by Stanton Peele
Change is natural. You no doubt act very differently in many areas of your life now compared with how you did as a teenager. Likewise, over time you will probably overcome or ameliorate certain behaviors; 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 addiction than do not. And the vast majority does 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 dramatic treatment, the most effective approaches rely on the counter-intuitive 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 addiction – 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 new work skills.
Smoking is at the top of the charts in terms of difficulty of quitting. The majority of ex-smokers quit without any aid. 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’re shooting heroin. Addicts who quit on their own typically report that they do 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 18-25 constitute the peak period of drug and alcohol use. In 2002, the latest year for which data are available, 22 percent of Americans between 18 and 25 were abusing or were dependent on a substance, versus only 3 percent of those 55-59. These data show that most people overcome their substance abuse, even though most of them do not enter treatment.
How do we know the majority aren’t seeking treatment? In 1992 the National Institute on Alcohol Abuse and Alcoholism conducted one of the largest surveys of substance abuse 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 alcoholic abusers. This study, known as The National Longitudinal Alcohol Epidemiologic Survey, indicates first that treatment is not a cue-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 those who were treated.
This is not to say that treatment can’t be useful. But the most successful treatments are non-confrontational 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 cu 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 meetings, 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 method of 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 agree 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 (like 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 pressure to drink, coping with stress 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 Psychologist Stanton Peele
Author of “Love and Addiction” (with Archie Brodsky), 1975 and
“7 Tools to Beat Addiction” Random House/Three Rivers Press
Also recommended, “Calling it Quits” by Neil Parmar, Jammie Salagbang and Susan A. Smith