Magazine article Psychotherapy Networker

From Reasearch to Practice, Addictions Treatment: Myth vs. Reality: Effective Interventions Often Don't Match Stereotypes

Magazine article Psychotherapy Networker

From Reasearch to Practice, Addictions Treatment: Myth vs. Reality: Effective Interventions Often Don't Match Stereotypes

Article excerpt


Addictions Treatment: Myth vs. Reality Effective interventions often don't match stereotypes

Substance-abuse treatment used to bring to mind a no-holds-barred, in-your-face engagement, such as the notoriously confrontational rap groups of the '70s and '80s, often led by tough former addicts, or the Johnson intervention, in which family members and close friends came together to overwhelm the abuser's denial with stories of the harm done and to insist on treatment. It was widely accepted that the best therapists for addicts were former addicts. Many thought intense, confessional, 12-step programs, such as Alcoholics Anonymous (AA), were necessary adjuncts to any treatment. Long-term inpatient treatment, which removes addicts from the stresses of everyday life, was considered the treatment of choice, for those who could afford it, and still is even today.

While treatment approaches to substance abuse have continued to evolve, a clear, new picture of what works in addiction treatment hasn't emerged. Clinicians and the public continue to rely on a hodgepodge of old and new approaches, unsure what works when. Fortunately, two recent landmark reviews of the research on adult substance-abuse treatment give us a much more coherent picture of what the literature tells us about effective substance-abuse treatment.

Psychologist Rudolf Moos of the Department of Veterans Affairs and Stanford University, widely considered the dean of researchers in substance-abuse disorders, prepared one summary of the research. A panel of experts in substance-abuse treatment and psychotherapy research, including Peter Nathan of the University of Iowa, Barbara McCrady of Rutgers University, and myself, assembled the second. This was part of a larger project to assess principles of change in treating a wide range of clinical problems.

For their reviews, the researchers combed through hundreds of studies to distinguish which assumptions about how to treat substance-abuse disorders are supported by research and which are empirically unfounded. So what, then, do these reviews tell us about what's effective in the treatment of substance-abuse disorders?

* The core processes of change for overcoming substance-abuse disorders are the same whether addicts participate in psychotherapy self-help programs, or recover without treatment. For instance, Tom, who wants to reduce his drinking on his own, Harry, who's in AA, and Steve, who's in outpatient therapy with a therapist who uses Motivational Interviewing, experience more or less the same process of change. Each was initially unwilling to acknowledge his problem with alcohol; each moved through a process of facing the detrimental effects of alcohol, learning more about its dangers, discovering ways to diminish his exposure to situations in which he was likely to drink, and figuring out ways to say "no" when offered drinks. Each was mired in negative cycles with their families around their alcohol use, and each received considerable support from family members when he stopped drinking. All three negotiated these processes that led to their successful recovery.

* Not only are the processes of change the same across groups, so are the stages of change. The research summaries highlight the work by psychologists James Prochaska of the University of Rhode Island and Carlo DiClemente of the University of Maryland, Baltimore, identifying the predictable stages of change. Although research is beginning to show that stages of change apply in other disorders, most of the research has been done in substance-abuse disorders.

In the first stage (precontemplation), addicts typically don't recognize their problems with substances. In the words of singer Tom Waits, "The piano has been drinking, not me." In the next stages, they recognize the problem, but aren't ready to change (contemplation), they take action to try to change (action), and finally they work to maintain the changes they've made (maintenance). …

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