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Alcoholism Treatment Quarterly

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Sacred Cows and Greener Pastures: Reflectionsfrom 40 Years in Addiction Research

William R. Miller PhD

To cite this article: William R. Miller PhD (2016) Sacred Cows and Greener Pastures: Reflectionsfrom 40 Years in Addiction Research, Alcoholism Treatment Quarterly, 34:1, 92-115, DOI:10.1080/07347324.2015.1077637

To link to this article: http://dx.doi.org/10.1080/07347324.2015.1077637

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PERSPECTIVES

Sacred Cows and Greener Pastures: Reflections from 40Years in Addiction ResearchWilliam R. Miller, PhD

Emeritus Distinguished Professor of Psychology and Psychiatry, University of New Mexico,Albuquerque, New Mexico, USA

ABSTRACTIn this invited editorial, Prof. William R. Miller reflects on les-sons learned through 40 years in addiction research and treat-ment on topics including evidence-based treatment, client-treatment matching, waiting lists, brief intervention, therapisteffects, empathy, polydrug use, relapse, diagnostic labels, man-ual-guided treatment and standard care, abstinence and mod-eration, acute treatment and case management, residentialand outpatient care, concomitant disorders and integratedcare, motivation for change, and spirituality. Concluding thatthere are ample reasons for humility about our professionalexpertise, he offers recommendations in nine areas for improv-ing the care of people with substance use disorders.

KEYWORDSAddiction; treatment;substance use disorders;outcome; relapse; empathy

“Look how far we’ve come; how can we have so far to go?” This line from asong by Santa Fe singer/songwriter Don Eaton captures well my currentsense of addiction treatment. On one hand I am heartened by how much haschanged, mostly for the better, since 1973 when I was drawn to this work. Iam also frequently reminded of how much more change is needed to betterserve those suffering with substance use disorders (SUDs). As KathleenCarroll once quipped regarding our field, “The glass would be half full ifonly we had a glass” (Carroll & Rounsaville, 2006).

At the invitation of the editor I offer here some reflections on the historyof addiction treatment along with some suggestions for further growthemerging from research of which I have been privileged to be a part acrossfive decades. My focus is specifically on treatment, having spanned broaderswaths of addiction science elsewhere (Heather, Miller, & Greeley, 1991;Miller & Carroll, 2006). As shorthand I use the term addiction genericallyto refer to the full range of SUDs (American Psychiatric Association [APA],2013), much as Jellinek (1960) used the term alcoholism.

CONTACT William R. Miller, PhD wrmiller@unm.edu Emeritus Distinguished Professor of Psychology andPsychiatry, University of New Mexico, Albuquerque, NM 87131, USA.The author approved the manuscript and this submission. The author reports no conflicts of interest.

ALCOHOLISM TREATMENT QUARTERLY2016, VOL. 34, NO. 1, 92–115http://dx.doi.org/10.1080/07347324.2015.1077637

© 2016 Taylor & Francis Group, LLC

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Evidence-based treatment

From our first reviews of treatment outcome research, Reid Hester and Iwere struck by the wide gap between science and practice: that what researchsupported as effective approaches seemed to overlap very little with what wasusually delivered in U.S. treatment systems (Miller & Hester, 1980, 1986a).There was no requirement at the time to offer science-based treatments withevidence of efficacy, even though within health care more generally a failureto do so could be grounds for malpractice.

Gradually this began to change with the publication of hundreds of clinicaltrials and ever-improving researchmethodology. States started requiring the useof “evidence-based treatment” (EBT) to be reimbursed for service delivery(Miller, Zweben, & Johnson, 2005). The era of “anything goes” in addictiontreatment was, it seemed, coming to an end (Miller & Moyers, 2015).

Yet in practice, at least so far, the de facto requirement has been just to say thatone is delivering EBT, because services are typically delivered behind closeddoors with content that can be difficult to audit (Miller, 2007; Miller & Meyers,1995). A federally funded National Registry of Evidence-Based Programs andPractices (NREPP) began compiling allegedly science-based approaches forprevention and treatment but set the bar so low—essentially one positive trialregardless of the number of negative trials—that as of this writing the listincludes 350 “evidence-based” interventions. Imagine if you had cancer andwere handed a list of 350 possible treatments. In other words, the NREPP list ispractically useless to consumers and agencies alike in identifying those treatmentapproaches with the best evidence of efficacy.

In a series of systematic reviews with Paula Wilbourne we evaluated thestrength (amount and quality) of evidence for each of 90 different interventionsfor treating alcohol use disorders (AUDs), eventually encompassing more than200 clinical trials (Miller, Andrews, Wilbourne, & Bennett, 1998; Miller &Wilbourne, 2002; Miller, Wilbourne, & Hettema, 2003). Treatments rangedfrom some with strong evidence of efficacy across multiple clinical trials toapproaches found in many studies to be ineffective. The good news emergingfrom these reviews is that there is an encouraging menu of about a dozentreatment alternatives with reasonably strong scientific evidence of efficacy.

Matching clients to treatments

If there is a menu of good treatment options, then how should one go abouthelping people find the best approach for them? This process is often calledclient-treatment matching (Miller & Cooney, 1994; Miller & Hester, 1986c)or in statistical terms” attribute by treatment interactions.” Which approachis best for whom? That was the central question in Project MATCH, thelargest randomized trial ever conducted with treatments for alcohol problems

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(Project MATCH Research Group, 1993). The study tested three promisingtreatments with very different theoretical rationales: 12-Step facilitation,cognitive-behavior therapy, and motivational enhancement therapy. Allthree yielded similarly positive outcomes at 1 (Project MATCH ResearchGroup, 1997a) and 3 years after treatment (Project MATCH Research Group,1998a).

The investigator team, highly experienced in clinical practice and research,developed 19 detailed a priori hypotheses about whowould fare best in each of thethree different therapeutic approaches (Project MATCH Research Group, 1997a1997b). Only a few of these hypotheses were confirmed at one or more follow-upintervals, and often in an opposite direction from what had been predicted, withthe authors acknowledging that “Considering the large number of interactionstested, it is entirely possible that all of the interactions observed may be attributedto chance” (Longabaugh &Wirtz, 2001, p. 306). It seems that even acknowledgedexperts in alcohol treatment are not much better than chance at predicting whatapproaches will be best for whom. Similarly, attempts to validate various versionsof the widely-used American Society of Addiction Medicine (2001) criteria formatching clients to levels of treatment intensity have found few and chance-leveloutcome differences betweenmatched and unmatched cases (Angarita et al., 2007;Magura et al., 2003;McKay, Cacciola,McLellan, Alterman,&Wirtz, 1997;McKay,McLellan, & Alterman, 1992; Sharon et al., 2004).

A reasonable alternative is to encourage people to make informed choicesfrom a menu of evidence-based options, as is common in cancer treatment.This assumes the availability of such a range of options rather than a one-size-fits-all approach. It also requires giving people a fair and accurate descrip-tion of available treatment options along with what is known about theiroutcomes and possible side effects.

The limits of horse races

Hundreds of clinical trials for SUDs have been designed like horse races: lineup a stable of two or more presumably different treatments, start them off onequal footing, and see which one wins the race. Whenever bona fide treat-ments are compared, a very predictable result is no clinically significantdifference in outcomes (Imel, Wampold, Miller, & Fleming, 2008; Miller &Manuel, 2008). This can lead to the nihilistic view that the content oftreatment is irrelevant and addiction counselors should therefore be allowedto do whatever seems best to them.

There are, however, systematic factors beyond the theoretical rationale oftreatment that do substantially affect clients’ outcomes (Miller & Moyers,2015; Norcross & Wampold, 2011). To dismiss these as “general” or “non-specific” factors is a frank admission that we have failed to do our homeworkin determining what actually helps clients recover (Duncan, Miller,

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Wampold, & Hubble, 2010). For example, simply placing people on a “wait-ing list” can be pernicious, because the implicit instruction is that they shouldwait and the expected outcome would be no change until they can be treated.Brief and empowering counseling, even a single session and self-help mate-rial, is robustly more effective than no intervention or a waiting list (Apodaca& Miller, 2003; Bien, Miller, & Tonigan, 1993; Harris & Miller, 1990; Miller& Wilbourne, 2002). Rather than just a fact-gathering “intake,” why not offerpeople something that is likely to help them in the very first contact?

Therapist effects

Prominent among determinants of clients’ outcome in addiction treatment isthe particular counselor to whom they are assigned. Even if therapists aretrained together, closely supervised, and are following a specific treatmentmanual, there are usually large differences in the outcomes of their caseloads(Luborsky, McLellan, Diguer, Woody, & Seligman, 1997; Najavits & Weiss,1994; Project MATCH Research Group, 1998b). The clients of nine counse-lors in one clinical trial had positive outcome rates ranging from 25% to100%, with a 60% improvement rate for clients randomly assigned to a self-help condition (Miller, Taylor, & West, 1980). In a natural experimentclients’ outcomes varied substantially by which of four arbitrarily assignedcounselors had treated them, with one caseload growing worse on all mea-sures (McLellan, Woody, Luborsky, & Goehl, 1988).

Nor are these differences among therapists randomly distributed. In aclinical trial of manual-guided behavior therapies for AUDs there were nooutcome differences based on the content of treatment. However counselors’in-session listening skill in accurate empathy (as operationally defined byTruax & Carkhuff, 1967) predicted two thirds of the variance in clientdrinking outcomes at 6 months, one half at 12 months (Miller et al., 1980),and still one third of the variance in drinking 2 years after treatment (Miller& Baca, 1983). Similarly Valle (1981) found that alcohol relapse rates were 2to 4 times higher across 2 years of follow-up when clients were treated bytherapists with low (vs. high) interpersonal skills as described by Carl Rogersand his students (Truax & Carkhuff, 1967). In a multisite trial, counselors’pretrial skillfulness in accurate empathy prospectively predicted their clients’drinking outcomes (Moyers, Houck, Rice, Longabaugh, & Miller, 2015). Itmatters not just what you do, but how you do it!

Polydrug use as the norm

Treatment was once quite segregated for alcohol versus other drug problems.Programs were geographically and often ideologically isolated: a client waseither an alcoholic or a drug addict. I recall vividly the organizing meeting in

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the early 1970s for an Oregon Substance Abuse Professionals Association.The meeting hall in Bend, Oregon, had an aisle down the middle. On oneside sat neatly dressed alcohol counselors, often with crewcuts and ties.Across the aisle were the drug counselors with long hair, jeans, and tattoos.We didn’t speak the same language or attend the same meetings, but it was abeginning.

These days, of course, it is difficult for clinical trials to find clients who use onlyone chemical, and treatment programs have responded to the population’s poly-drug use by combining alcohol and other drug treatment. This further compli-cates the evaluation of outcomes, particularly when adhering to a binary relapsemodel. It is quite possible to quantify the use of multiple drugs (Tonigan &Miller,2002), but if there are only two possible outcomes—“clean” or relapsed—thenwhere is the dividing line? Does any use of any psychoactive substance constitutefailure? If so the rates of “success” will be demoralizingly low even one year afterany particular treatment episode. Are there “slips” that don’t constitute a relapse?If so, how much and for how long?

The problem, I believe, is in the black-or-white thinking about outcomesthat is inherent in the concept of “relapse” (Miller, 1996; Miller, Forcehimes,& Zweben, 2011). Few chronic illnesses are treated in this manner. Peoplewith asthma or diabetes who turn up in the emergency room are seldom toldthat they have “relapsed.” Episodes of elevated blood pressure do not con-stitute failure of antihypertensive treatment. A goal and common pattern inchronic disease management is to have longer spans of remission and toreduce the length and severity of symptomatic episodes. That is also a patternin alcohol outcomes: gradually longer periods of abstinence interspersed withshorter and less severe episodes of drinking (Miller, Westerberg, Harris, &Tonigan, 1996).

One review summarized 1-year posttreatment drinking outcomes for 8,389clients across seven clinical trials (Miller, Walters, & Bennett, 2001). Onaverage, 24% of clients had abstained from alcohol throughout 12 months.By binary standards that is a 76% treatment failure rate. Among the drinkers,however, alcohol consumption had decreased by 87% throughout follow-up(from an average of 77 to 10 standard drinks per week). For any otherchronic illness, 24% complete remission and an 87% reduction in symptomsfor the remainder would constitute dramatic success (McLellan, Lewis,O’Brien, & Kleber, 2000). Why not use more realistic standards than perfec-tion when evaluating outcomes?

Treatment as usual

Most of the outcome studies in the above-mentioned review (Miller et al.,2001) did not standardize the content of psychosocial treatment that wasdelivered. It was treatment as usual or standard care that had yielded such

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good outcomes. Nor is there empirical reason to believe that people receivingstandardized manual-guided treatment will automatically have better out-comes. In a meta-analysis of 72 outcome studies of motivational interview-ing, the effect size when no treatment manual had been used was twice aslarge as when treatment had been manual guided (Hettema, Steele, & Miller,2005). At the Albuquerque site in Project MATCH we compared the out-comes of clients enrolled in the MATCH study with those for clients treatedduring the same period in the same treatment agency (the University of NewMexico Center on Alcoholism, Substance Abuse and Addictions, or CASAA).The latter group of clients were assigned to whichever CASAA counselor wasavailable and received usual care at the discretion of counselor and client.MATCH clients came from the same clinical population but received highlysupervised manual-guided treatments. Drinking outcomes for the two groupswere virtually identical (Westerberg, Miller, & Tonigan, 2000), averaging 88%reduction in drinking over one year, though the standard care groupattended fewer treatment sessions and had somewhat more severe pretreat-ment drinking.

The National Drug Abuse Clinical Trials Network (Tai, Sparenborg, Liu, &Straus, 2011) has conducted an impressive array of randomized trials com-paring standardized treatments with treatment as usual, with both beingdelivered by the regular clinical staff with the usual clients of front-linecommunity treatment programs. The manual-guided treatments being testedwere usually chosen because they had shown efficacy in prior clinical trials.Yet most of these trials have failed to find a clinically (Miller & Manuel,2008) or even statistically significant advantage of manual-guided treatmentsover standard care (Miller & Moyers, 2015; Wells, Saxon, Calsyn, Jackson, &Donovan, 2010). It appears that, on average, treatment as usual is a toughstandard to beat, at least in programs that participate in clinical trials (Roman& Johnson, 2002). This does not obviate the important influence of othertreatment factors (such as therapist effects) on treatment outcome, nor is itjustification for “anything goes” in addiction treatment. There are largedifferences in the weight of evidence for (and against) particular treatmentmethods (Miller & Wilbourne, 2002; Miller et al., 2003) and some approachesappear to inflict harm (Moyers & Miller, 2013; White & Miller, 2007).

Diagnostic labels

Diagnostic labels and criteria have undergone major changes over the dec-ades. Alcoholism and drug abuse were classified as personality disorders inthe first two editions of the Diagnostic and Statistical Manual of MentalDisorders (DSM) (APA, 1952, 1968). The diagnosis of “alcoholism” wasdisplaced in DSM-3 and DSM-4 (APA, 1980, 1987, 1994) by a distinctionbetween abuse and dependence. There was no substantial evidence, however,

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that substance abuse and dependence represented different disorders, and soeven this distinction was removed in DSM-5 in favor of continuously dis-tributed SUDs (APA, 2013).

These diagnostic changes parallel corresponding shifts in public and pro-fessional understanding of alcoholism. The early binary “disease concept” ofalcoholism (Milam & Ketcham, 1984; Moyers & Miller, 1993) provided asatisfying remedy to the cognitive dissonance that followed the U.S. repeal ofprohibition. During prohibition alcohol education had emphasized theharms of drinking as medically damaging, potentially lethal, and difficult tocontrol. Then in 1933 alcohol was again made freely available. It was anappealing solution (particularly to the alcohol industry) to conclude that itwas only certain unfortunate individuals who are at risk: alcoholics, who arequalitatively different from other people who can drink as they please withimpunity. The logical course then was to identify these rare individuals andpersuade them to accept that they are alcoholic and incapable of drinking atall. Treatment thus began placing a premium on “admitting” one’s alcohol-ism or drug addiction, although Bill W., the cofounder of AlcoholicsAnonymous, advised against imposing this label on other people (AAWorld Services, 2001; Miller & Kurtz, 1994).

In spite of a “quest for the test” and a plethora of screening instruments(e.g., Selzer, 1971) research failed to reveal any qualitative distinction orcharacteristic personality or defense mechanisms of “alcoholics.” Alcoholinstead emerged as a public health issue much like smoking (Babor et al.,2010; Institute of Medicine, 1990), and even the distinction between “abuse”(or problem drinking) and “dependence” (or alcoholism) turned out to be anarbitrary cut-point on continuously distributed dimensions of use andimpairment (Miller et al., 2011). There is growing public and professionalawareness that alcohol is a danger for anyone who uses it immoderately or inhazardous situations (Babor et al., 2010).

Moderation goes mainstream

With increasing awareness of drinking as a public health issue, U.S. percapita alcohol consumption decreased by one half from a mean of 20standard drinks per week in the 1960s (Cahalan, 1970) to fewer than 10 inthe first decade of the 21st century (LaVallee & Yi, 2011). Physicians are nowurged to assess their patients’ frequency of heavy drinking and counsel themto reduce their consumption (National Institute on Alcohol Abuse andAlcoholism, 2005; Whitlock, Polen, Green, Orleans, & Klein, 2004). Evenalcohol manufacturers urge customers to use their products “responsibly.”

Effective treatment and self-help strategies for moderating alcohol usehave been available for decades (Bien et al., 1993; Hester, 2003; Miller &Muñoz, 1976, 2013; Sanchez-Craig, 1980) but have been slow to find their

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way into the U.S. continuum of care. Up through the 1980s Americantreatment for alcohol/drug problems almost exclusively focused on depen-dence and required clients to accept a goal of total and lifelong abstinencefrom psychoactive substances (with the notable exception of tobacco). Thiswas linked in part to the postprohibition disease concept that moderationwas either impossible (for alcoholics) or unnecessary (for normal people). Atleast 35 clinical trials of behavioral self-control training and 48 of briefinterventions have yielded ample evidence that it is possible to help heavydrinkers moderate their alcohol use (Miller & Wilbourne, 2002). Perhapsmore importantly, research indicates that moderation is a feasible goal forpeople with less severe alcohol use and problems, whereas in moving up thescale of severity, abstinence emerges as the more stable outcome (Miller,Leckman, Delaney, & Tinkcom, 1992). The relative feasibility of each goalcan be evaluated via at least two assessment instruments: the MichiganAlcoholism Screening Test and the Alcohol Dependence Scale (Miller &Muñoz, 2013). For some, moderation is the more likely outcome; for otherswith higher severity, abstinence is the better choice. Why not address the fullcontinuum of alcohol problems rather than focusing only on those mostimpaired (Institute of Medicine, 1990)? My early interest in moderationstrategies was to intervene farther upstream before drinking engendersworse consequences. That appears to be precisely where such strategies areuseful, in targeted or indicated prevention.

An unexpected finding in our longer-term follow-up (Miller et al., 1992) wasthat many of those who came to us for help in moderating their alcohol use hadactually stopped drinking, and not for the expected reason. Onemight anticipatethat they would try moderation, fail, and thus conclude that they had to abstain.Instead these were people who did get their drinking down to a moderate leveland then told us one or both of two things: (1) “This is really hard! I feel like I amon a tightrope and could fall off at any time” and (2) “What’s the point indrinking so little?” Thus they decided that it simply wasn’t worth all the work todrink moderately. Incidentally, if they did then drink after a year or two ofabstinence, we found that it was typically one or two drinks for a day or two, thenback to long-term abstaining. It reminded me of these words from Bill W’s“working with others” (AA World Services, 2001):

Be careful not to brand him as an alcoholic. Let him draw his own conclusion. If hesticks to the idea that he can still control his drinking, tell him that possibly hecan – if he is not too alcoholic. (p. 92)

Concomitant disorders as the norm

“Dual diagnosis” was once thought of as a small and special subpopulation:those having a SUD as well as a diagnosable mental disorder. What has sincebecome apparent is that SUDs seldom occur alone but are usually

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accompanied by other psychological and/or medical problems. In the earlydays of addiction treatment these were thought to be secondary conse-quences of alcohol/drug use that would recede with abstinence. Indeed,concomitant problems often do improve when people stop or reduce theirdrinking (Miller, Hedrick, & Taylor, 1983). It is also clear, however, that notall problems are secondary to addiction; they can also persist or worsen assubstance use is addressed. Mood and thought disorders, anxiety and per-sonality disorders, learning and attentional disorders, neuropsychologicalproblems, family conflict, sleep, and sexual disorders all occur at elevatedrates among people with addictions.

A somewhat unique American problem is that we have trained a genera-tion of addiction counselors who have been prepared only to treat SUDs. Yetit is increasingly clear that integrated treatment of concomitant disorders isthe preferred approach, rather than referring people back and forth betweenaddiction and mental health services and arguing about which should comefirst (Mueser & Drake, 2007; Mueser, Drake, Turner, & McGovern, 2006). Ina career of treating addictions one may encounter the entire DSM. This trendtoward integrated treatment is reflected in the concept of “behavioral health”professionals who are prepared to address a broad spectrum of psychosocialproblems.

Integrated care systems

A related aspect of addiction treatment in America has been its segregationfrom mental health and health care services more generally. Mainstreammental health and medical professionals have often been given the impres-sion that addiction is “not my problem” and should be referred out fortreatment in specialist clinics that are isolated socially, politically, and oftengeographically from other health services. Health professionals often receivevery little training in how to treat SUDs even though these constitutethe second-most-common mental health diagnosis (after depression) andcommonly present with a host of concomitant medical and mental healthproblems (Miller & Brown, 1997; Miller & Weisner, 2002).

A sea change in this segregation is occurring as providers are beingencouraged not only to screen for but also to treat SUDs within the contextof health care (Blount & Miller, 2009; Butler et al., 2008). This can be donedirectly through brief interventions by nurses and physicians (E. Bernsteinet al., 2009; J. Bernstein et al., 2005; Fleming & Manwell, 1999; Senft, Polen,Freeborn, & Hollis, 1997) or perhaps more feasibly by colocating behavioralhealth providers in medical settings (Ernst, Miller, & Rollnick, 2007). Theavailability of effective pharmacotherapies has also increased the feasibility ofmanaging SUDs in medical clinics (Garbutt, 2009; O’Malley & Kosten, 2006;Pettinati et al., 2004). Most people with SUDs never darken the door of a

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specialist treatment program but do appear regularly in health care, socialservice, mental health, and correctional systems. It makes sense to be treatingaddictions where they are most likely to be found (Miller & Weisner, 2002).

Acute treatment

Although widely recognized as a chronic condition, SUDs have often beentreated as if they were acute illnesses. In the 1970s and 1980s it was commonto treat alcohol problems in inpatient or residential settings of 28 days’duration. Any incident of substance use following a treatment episode wasregarded to be a relapse (Miller, 1996). Yet there are no 28-day treatmentprograms for diabetes, heart disease, asthma or hypertension, and the recur-rence of symptoms of a chronic illness is seldom dismissed as patient failure.SUDs are, in essence, the sole “chronic disease” for which there has been onlyspecialist care, no ongoing primary care (McLellan et al., 2000).

Given that about three fourths of clients have a recurrence of use after anyparticular treatment episode, it would seem more appropriate to think ofongoing monitoring and case management with stepped-care treatment asneeded, as is common in managing other chronic conditions (Alexander,Pollack, Nahra, Wells, & Lemak, 2007; Kakko et al., 2007; Sobell & Sobell,2000). It would also be appropriate to dispense with vestiges of an acute caremodel such as a “graduation ceremony” that implies that treatment has beencompleted.

Studies have long reflected no aggregate difference in client outcomesfrom more intensive (such as inpatient or residential) versus less intensive(such as day treatment or outpatient) treatment settings for adults (Altermanet al., 1994; Miller & Hester, 1986b), and as discussed above attempts toidentify patient correlates of differential success at different levels of intensityhave borne little fruit. There is enduring consensus that “aftercare” (i.e.,outpatient treatment and mutual help groups) is crucial following a residen-tial treatment episode (Ito & Donovan, 1986), but the very term aftercare is aremnant of an acute care model and implies that the “real” treatment hasalready happened. Residential treatment remains a useful part of a conti-nuum of care, but it is not a place to start unless there is some otherpersuasive reason for intensive supervision such as suicidality or acutemedical or psychiatric illness. If anything, a period of residential treatmentconstitutes a form of “fore-care” stabilization after which the ongoing workof recovery and maintenance begins in the community (Miller et al., 2011).

Motivation for change

Client motivation for change is widely acknowledged as a crucial factor intreatment and recovery. Prior to the 1980s it was largely assumed that low

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motivation was the client’s deficiency, and people were sometimes told, “Comeback when you’re motivated” or “You haven’t suffered enough yet. We’ll seeyou when you hit bottom.” A breakthrough on this issue was the emergence ofthe trans-theoretical model of change (Prochaska & DiClemente, 1984), thebest-known aspect of which is its stages of change. A key insight of this modelis that clients need different things from providers depending on where theyare in the change process. Most treatments had assumed readiness for change(the action stage) as a prerequisite. The revolutionary shift was to see facilitat-ing readiness for change as an important part of the provider’s job. Whenpeople are ambivalent about change (contemplation stage) they need helpresolving that ambivalence in the direction of change. Charging directly intoaction-focused interventions is likely to evoke resistance when someone isambivalent. Motivational interviewing (MI) fit with a trans-theoretical per-spective precisely because it was designed to promote readiness for change,helping people advance from contemplation to preparation and action(DiClemente & Velasquez, 2002).

An early surprise in our research was how often MI appeared to besufficient to trigger a significant change in drinking (Miller, Benefield, &Tonigan, 1993; Miller, Sovereign & Krege, 1988). Comparisons of MI-basedinterventions with longer treatment alternatives have usually yielded similaroutcomes (Hettema et al., 2005; UKATT Research Team, 2005). CombiningMI with other active treatments, however, often yields an enduring additiveeffect (Bien et al., 1993; Brown & Miller, 1993; Hettema et al., 2005), perhapsby increasing treatment retention and adherence. A combined approach likethis seems more sensible than a horse race pitting treatment approachesagainst each other (Anton et al., 2006; Longabaugh, Zweben, LoCastro, &Miller, 2005).

MI also represents a fundamental shift in helping roles (Miller & Rollnick,2013). Addiction treatment of the 20th century was often highly authoritar-ian, working from a deficit model that people lacked insight, skills, knowl-edge, reality, or wisdom that had to be installed by the experts. MI is aboutevoking from people their own expertise about themselves, their own wisdomand motivations for change. It involves a shift from “I have what you needand I’m going to give it to you,” to “You have what you need and togetherwe’re going to find it.”

Spirituality and addiction

For much of the history of psychology, psychiatry, and other mental healthprofessions, religion was a taboo topic derided by vocal critics from SigmundFreud (1928/2010) to Albert Ellis (1988). It is no coincidence that my ownpublications on spirituality and psychology did not begin until after the yearI received academic tenure. Clinicians could ask clients about their sex life,

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money, fantasies, family secrets, emotions, irrational beliefs, and drug use butnever about their religion. Spirituality has since become a more acceptablesubject among American psychologists, who nevertheless remain far lessreligious than the people they serve (Delaney, Miller, & Bisono, 2007). Theaugust American Psychological Association now publishes volumes on spiri-tuality (Miller, 1999; Richards & Bergin, 1997) and religion (Miller &Delaney, 2005; Shafranske, 1996).

At least in the United States, addiction treatment is one field in whichspirituality never got lost, largely because of the 12-Step programs (AA WorldServices, 2001). In Alcoholics Anonymous as in psychology a difference is oftenemphasized between spirituality and religion, a distinction that would have beenalien to William James (1902). Studies do support an inverse relationshipbetween spiritual/religious factors and addiction. Religiousness predicts lowerrisk for current and future SUDs (Miller, 1998, 2003) and spiritual changes areassociated with recovery from addiction (Jarusiewicz, 2000; Kelly, Stout, Magill,Tonigan, & Pagano, 2011; Robinson, Cranford, Webb, & Brower, 2007).

Although there is wide acknowledgment of the importance of spiritualityin recovery, few treatment programs employ religiously trained professionalsor place much emphasis on spiritual development except to encourage 12-Step meeting attendance. Two randomized trials did evaluate the impact ofspiritual direction when added to addiction treatment (Miller, Forcehimes,O’Leary, & LaNoue, 2008). Clients in a residential program who agreed toparticipate were randomly assigned to receive or not receive counseling froma professional spiritual director in addition to standard care. We predictedthat spiritual direction would yield changes on spiritual measures that in turnwould be associated with decreased substance use. In fact, neither occurred.In retrospect we realized that these people were down at the bottom ofMaslow’s (1943) hierarchy of needs, concerned about food, housing andsafety, whereas our intervention was focused up at the top of the hierarchy:spirituality and meaning. Perhaps after stabilization of sobriety and casemanagement to address immediate concerns there would be opportunity tofocus on spiritual practices. As it was, we were on Step 11 (“Sought throughprayer and meditation to improve our conscious contact with God as weunderstood God, praying only for knowledge of God’s will for us and thepower to carry that out”) and not attending to our clients’ immediate needs.Acute treatment intervention is a limited model for addressing both addic-tion and spirituality.

Reasons for humility

One way of summarizing what I have learned over 40 years working in thisfield is that we have ample reasons for humility. Most recovery happenswithout any professional treatment. A cherished therapeutic approach does

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not turn out, on average, to yield superior results when compared with othertreatments. We are no better than chance at predicting which treatmentapproach will be best for our clients. Often people may need far less ther-apeutic help from us than we think they do. And the effectiveness of what wedo appears to depend more on how we relate as people than on the contentof the treatment manual we keep on the shelf. These learnings also point toways in which we might better serve people with addictions.

Directions for growth

Drawing together the developments and learnings discussed above, hereare some recommendations for how treatment for addictions might beimproved in the decades ahead. It is a progress report based on what isknown from research so far, necessarily subject to revision as new knowl-edge emerges.

Evidence-based care

As we learn more about what treatment approaches offer the most promise,it is appropriate to expect that this knowledge will be reflected in practice.This is what we expect in health care more generally, and given the volume ofresearch available it is not plausible to argue that we do not yet have enoughscience to guide practice. The blessing of an approved list of brand-nametreatment methods is a very limited and problematic way of accomplishingthis. “What works” should encompass therapeutic relationship and systemicfactors (like waiting lists) as well as addressing obstacles in access to care.Clinical research should move away from simplistic horse race trials towardidentifying what actually promotes change.

It is a reasonable and testable question whether retraining current clinicalstaff in newer treatment methods is a cost-effective way to improve clientoutcomes (Miller & Moyers, 2015). A reasonable step forward would be totrain the next generation of behavioral health providers from the outset inaddiction treatment approaches with the best evidence of efficacy.

A menu of options

Treatment cannot be individualized when only one approach is available. Ananalogy would be a cancer treatment system that offers only radiation.Providing a range of treatment options requires having staff who are properlyqualified and trained to deliver them. Within a single program this maymean hiring staff with varied expertise in evidence-based treatment methods.A larger menu of options may be possible within a community treatmentsystem comprised of multiple programs (Martin, 1995).

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Given our demonstrably limited wisdom about what treatment is best forwhom, a reasonable approach is to provide clients with a fair and accuratedescription of the options that are available and to help them make aninformed choice, a process termed “shared decision making” in medicine.Given a natural bias for programs and providers to recommend their ownservices, one possibility is a “core/shell” model with an independent assess-ment and referral service to help clients consider their options (Martin, 1995;Pierce, 1995).

A continuum of care

Most disorders are easier to treat at earlier stages of development. Yetservices, at least in the United States, have been focused primarily on thesevere end of spectrum of SUDs, in part because of the isolation andstigmatization of specialist treatment programs. “Broadening the base” oftreatment (Institute of Medicine, 1990) involves screening and early detec-tion of emerging problems (indicated prevention) and offering an appropri-ate continuum of services. Screening for at-risk drinking and drug use inhealth care services is a good start. The same can be done in other socialservice and correctional settings where earlier detection is feasible.

Such broader screening also involves moving away from a binary (yes orno) model of detection toward risk assessment. Cut-points for diagnosinghypertension and diabetes have decreased over the years, recognizing thatblood pressure and glucose are continuously distributed and any cut-point issomewhat arbitrary. People one point above the cut-point are not verydifferent from those one point below it. The practical question is when andwhat treatment is appropriate.

As discussed earlier, drinkers with lower levels of consumption anddependence are more likely to stabilize with moderation than with lifelongabstinence. Targeted and indicated prevention of AUDs should includemoderation-oriented interventions within the menu of options, and theseneed not be limited to formal treatment. Brief interventions and some self-help materials (“bibliotherapy”) have been shown to reduce alcohol use andrisk. Counseling for moderation is uncontroversial in primary care but is lessoften available within specialist treatment.

A stepped care approach is also sensible, starting with interventions thatare least intrusive, disruptive, and expensive. This again is common practicein treating chronic medical conditions. Brief intervention, motivational inter-viewing, and self-help materials may be enough to trigger change. If not, acontinuum of care provides other options for stepping up intensity oftreatment.

Finally, we need to shed acute-care thinking. Addressing SUDs is a processthat occurs over time, as is the case with chronic illnesses. An episode of

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specialist treatment is usually insufficient and should not be thought of as acompleted course of care. Monitoring, case management, stepped care, andan open door for ongoing consultation should be the norm.

Fidelity of care

People cannot benefit from a treatment to which they have not been exposed(Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005). A hard lesson from myclinical research was that therapists do not necessarily deliver the treatmentsthey say or believe they are providing. Even with thorough training in anevidence-based approach there is large variation in fidelity of practice. In avariety of evidence-based treatments, fidelity of practice matters and predictsoutcome (e.g., Miller & Rollnick, 2014). Yet if practice is unobserved, there islittle chance to reliably assess fidelity.

Quality assurance thus means bringing treatment out of the closet, out frombehind closed doors (Miller, 2007). Accountability is only one reason for doingso. Fidelity of practice generally improves client outcomes. Furthermore,practice in isolation restricts feedback that is vital to clinician learning andpractice improvement. For skill development in motivational interviewing wehave been encouraging the development of collaborative learning commu-nities where practitioners meet to observe each other’s practice with the solegoal of getting better at what they do (Miller & Rollnick, 2013).

Integrated Care

There is already a trend toward delivering addiction treatment within the contextof ongoing health care, through interventions by medical staff (such as briefcounseling, motivational interviewing, or pharmacotherapies) and via colocationof behavioral health providers in medical settings. Treatment for substance useand other behavioral health problems should also be integrated within mentalhealth, social service, and correctional settings. The sheer prevalence and con-comitance of SUDs in these settings are reason enough. It follows that prepara-tion to competently assess and treat SUDs should be a routine part ofmainstream training in medical and behavioral health professions.

Holistic care

Patient-centered care and the “medical home” movement encourage provi-ders to treat people, not disorders. Although one need not explore everyaspect of clients’ lives, effective treatments for SUDs often address far morethan substance use. The community reinforcement approach, for example,focuses on family, social skills, and developing a drug-free life that is toogood to give up (Meyers & Miller, 2001; Meyers & Smith, 1995). Treating

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clients as whole people includes at least openness to their spirituality, whichcan be central to their identity and relevant in recovery (Toni, Toscova,Connors, & Miller, 1999).

Providers of care

Addiction treatment is not solely a matter for specialists, but a concern to beaddressed by health care providers more generally. Some additional knowl-edge is needed by generalists (Miller et al., 2011), but most health profes-sionals will be seeing many people with SUDs throughout their careers,regardless of their preparation to recognize and treat them.

But what of specialist providers? One implication of research to date is toscreen for and hire professionals who already show a high level of skill inaccurate empathy, in the ability to listen to, accept, and understand theirclients. It is an evidence-based practice. High-empathy providers have betteroutcomes, and low-empathy providers have worse outcomes in addictiontreatment (Moyers & Miller, 2013). Accurate empathy is a learnable skill thatcan improve with practice, but we have found it far easier to hire clinicianswho already have a reasonable level of skill than to teach it afterward (e.g.,Miller, Moyers, Arciniega, Ernst, & Forcehimes, 2005).

Obstacles to care

McLellan (2006) averred that treatment should ideally be perceived as“attractive, easy to access, potent, rapid, and delivered at a price that isaffordable” (p. 291). We have a long way to go for this to be an accuratepublic perception of addiction treatment. Besides tinkering with the contentand providers of treatment, however, there are structural aspects of care thatcould be changed to move in this direction.

One example is the “waiting list” in many public service systems. Commonpractice has been to conduct a fact-gathering “intake” and then ask people towait for weeks or months until they can be seen for treatment. Often arelatively small percentage of people make it through the intake gauntlet andwaiting period. Achieving treatment on demand would require a huge infu-sion of resources, but there is at least a better alternative than telling peopleto wait. Why not offer them something immediately that is likely to benefitthem in the very first contact? That way, even if they do not return they havereceived a helpful service. An intake can gather whatever minimal informa-tion is essential, but begin with an open invitation: “After a while I will needto ask you some questions that we ask everyone, but first tell me somethingabout what is happening and how you hope we might be able to help.” Ahalf hour of quality listening and MI may yield more information than a listof questions and can strengthen motivation for change.

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Then a second component is to communicate that the client does not justhave to wait. What steps might this person take to get started on the road torecovery? There are research-based bibliotherapy materials that can offer self-help guidelines (Apodaca & Miller, 2003). 12-Step and other mutual helpgroups are probably available. The message is one of activation and empower-ment rather than implying that nothing can happen until “treatment” begins.The delayed consultation thus becomes not passive waiting, but a follow-upconsultation: “We’ll check back with you in _____________ and see howyou’re doing, then take it from there.” In our earliest studies we assumedthat people would be disappointed when assigned to a self-help bibliotherapy,and some were, but just as often they were pleased that there were things theycould do on their own and by the time we saw them again (8–12 weeks later)they had, on average, managed as much change in drinking as those who hadbeen treated immediately.

Collaborative care

Whenever you sit in counseling with someone there are two experts in theroom. You have some potentially helpful expertise by virtue of your training,experience, and keeping up to date on new developments in addictiontreatment. When what is needed is a change in the person’s lifestyle andbehavior, however, no one knows more about your clients than they dothemselves. They have a lifetime of experience in what works for them andhow to manage change. Research shows that one of the best predictors ofsuccessful counseling is deep, empathic listening with acceptance and respectfor the person’s own wisdom—precisely what Carl Rogers and his studentswere teaching half a century ago. Why listen? Because the answers are alreadythere within your clients and your task is to call them forth. Addictiontreatment is necessarily a partnership of expertise, a collaborative processof finding together (rather than prescribing) what works. This also lifts aburden from your shoulders. You don’t have to make people change. Intruth, you can’t. You don’t have to come up with all the answers. The personwho has them is sitting right there across from you.

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