Transcript 1. - Pacificcmc-Pacific Centre for Motivation and Change

The Nature of Addiction: Beyond Brain Disease
William R. Miller, Ph.D.
Melbourne, July 2008
CACTUS Participants
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Warren Bickel
Robert Carlson
Kathleen Carroll
Anna Rose Childress
Carlo DiClemente
Deborah Hasin
Victor Hesselbrock
Harold Holder
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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. Punishment
2. Interdiction
Blind Alleys
1. Punishment
2. Interdiction
3. 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
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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
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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
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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
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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
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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
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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
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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
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5. Drug problems are affected
by social context
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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
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Address social-community factors in
prevention
Involve the family in treatment
Understand, use, and change the client’s
community context