The Nature of Addiction: Beyond Brain Disease

William R. Miller, Ph.D. Melbourne, July 2008

CACTUS Participants Warren Bickel Robert Carlson Kathleen Carroll Anna Rose Childress Carlo DiClemente Deborah Hasin Victor Hesselbrock Harold Holder

Keith Humphreys George Koob Barbara McCrady Thomas McLellan William Miller Rudolf Moos Kim Mueser Stephanie O’Malley

Blind Alleys

1. Punishment

19th century convict song Cut yet name across me backbone Stretch me skin across a drum Iron me up to Pinchgut Island From today till kingdom come I will eat your Norfolk dumpling Like a juicy Spanish plum Even dance the Newgate hornpipe If you’ll only give me rum

Blind Alleys

1. Punishment2. Interdiction

Blind Alleys

1. Punishment2. Interdiction3. Quest for the Flaw

That humanity at

large will ever be able to dispense with artificial paradises seems very unlikely

Aldous Huxley The Doors of Perception

“Criminogenic Needs”

Personality Attitudes and beliefs Low self-control Peers Substance abuse Dysfunctional family

Criminogenic Needs

Poverty

Homelessness

Unemployment

Untreated addiction

Meaningless life

1. Drug use is chosen behavior, a volitional choice among alternatives

Responds to the same principles of learning and motivation that shape other animal and human behavior

Society holds people responsible for drinking and drug use – i.e., they could have done otherwise

Intentional/decisional change is prominent, the norm

Intention and commitment predict behavior change

Motivation for change is malleable

Enhancing personal motivation for and commitment to change should be a

key component of treatment

Involve clients as active, choosing agents Effective treatments tip the balance of

motivation away from drug use Enhancing motivation improves client

retention, adherence, and outcomes

2. Drug use responds to social reinforcement

Expectancies of reinforcement from alcohol predict early drinking, relapse

Positive reinforcement for abstinence works

Drug use is associated with shortened time perspective

Competing reinforcers promote long-term change

Ergo: Enhance positive reinforcement for non-use, and enrich access to alternative

sources of reinforcement

Stopping drug use interrupts one important source of reinforcement

Initially, competing reinforcers should be immediate, not delayed

Teach families to reinforce sobriety Dependence involves progressive

isolation from non-drug reinforcement Sobriety is about developing meaningful

and rewarding lives not reliant on drugs

3. Drug problems rarely occur in isolation, but rather as part of complex problem clusters

In adolescents, drug use is part of a larger cluster of dysregulated behavior

In adults, comorbidity is the norm Drug abuse is correlated with a host of

health and psychosocial problems

Ergo: Don’t treat addiction as an isolated specialist problem

The era of the “addiction counselor” is coming to an end

Time to end low-pay, low-status isolated specialty care

Professionalization: Competence in behavioral health care more generally is needed

“Mainstreaming” substance abuse treatment into primary and integrated care

4. Therapeutic relationship matters

One of the largest determinants of client outcome is the therapist who provides the treatment

Empathy is a strong predictor Working alliance predicts outcome Some counselors have outstandingly poor

outcomes Confrontation is associated with poor

outcomes

Ergo: Pay attention to the relational process of treatment

Hire counselors who are already skilled in accurate empathy and evidence-based treatment methods

Monitor retention and outcomes by counselor Bring treatment out of the closet – make

observed practice the norm Time to stop funding confrontational

treatment practices

5. Drug problems are affected by social context

Regional differences in prevalence Social norms have important impact Availability promotes use/problems Availability of competing reinforcers is

protective (as is meaningful social role) Social modeling affects use/nonuse Parental monitoring is protective

Ergo: Look beyond the individual for the causes of and solutions to

drug use and problems

Address social-community factors in prevention

Involve the family in treatment Understand, use, and change the client’s

community context