Journal of Substance Abuse Treatment, 2:225-229, 1985
What Treatment for Addiction Can Do and What It Can't;
What Treatment for Addiction Should Do and What It Shouldn't
For the past 10 years, I have been writing about the experience of addiction (cf. Peele, 1985; Peele with Brodsky, 1975). "Experience" in this formulation refers both to the subjective state the addict undergoes, and to the fact that the object of addiction is an experience. That is, people become addicted to a particular state of body and mind. Addiction is not a chemical side effect of drug use but is rather a primary result of the appeal of the drug's effects and of the place the drug experience has in the individual's personal ecology.
Drugs or alcohol are very direct ways for creating addictive experiences, but by no means are they the only ways to do so. Any powerful involvement holds out the possibility of compulsive, self-destructive engagement. On the other hand, no substance is inherently addictive. Nor does any body chemistry or personality type inevitably predispose an individual to addiction. The only meaningful way to describe addiction is to identify the destructive experiences people welcome from drug or other involvements, experiences that they find necessary to their existences but that they have no alternative means to create.
To say addiction occurs with regard to an experience is not the same as saying psychological and social factors contribute to addiction, or to some addictions. Rather, all addiction takes place at an experiential level. One set of authors, borrowing rather heavily from my writings in How Much Is Too Much (Peele, 1984b), listed the experiential components of addiction, and of healthy habits, and the personality traits that predispose people to be addicted. At the same time, in order to round out their presentation, they discussed the idea that "a true addict must have an abnormal chromosome" (Hafen & Frandsen, 1985, p. 3).
To combine such an idea with an experiential model of addiction is to mix the metaphor so as to make it incomprehensible. There is no "addictive" gene or chromosome. A person, and some groups of people, can have an extreme reaction to alcohol or any other substance. This may mean that, for such a person, these substances are powerful mood modifiers. This falls so short of specifying that an addiction will occur as to risk being almost irrelevant to a description of the person's addictive formula. We still need to know why the person welcomes this experience, can find no more suitable means than a drug to obtain it, continues to accept the drug involvement as its costs outweigh its experiential benefits, and so on (see Peele, 1986b, for my analysis of genetic models of alcoholism in this regard).
In The Meaning of Addiction (Peele, 1985), I outline the personal needs, situational constraints, and characteristics of involvements that contribute to the addictive interaction of person, situation, and involvement. The following summarizes these elements in addiction:
|1. a sense of self-worth|
|the Involvement provides||2. a feeling of control over the environment|
|the Person Needs||3. a sense of intimate contact with others|
|the Situation discourages||4. a feeling of accomplishing something valuable|
|5. the elimination of pain or other powerful negative feelings|
That is, a person who suffers from low self-esteem and whose environment does not provide esteem-building opportunities is susceptible to an involvement which offers the experience of being valued by and valuable to oneself and others. What eventuates in addiction is the continued reliance on the involvement to provide an experience of self-worth in a way that makes it less likely the person can obtain this experience naturalistically, through the ordinary course of his or her life. As the drug use in fact undercuts the person's self-esteem, the self-exacerbating cycle of addiction takes form.
Are the numbered items in the chart characteristics of a particular drug experience or other involvement, personality traits, or situationally induced needs or deficiencies? It depends. Only some people find narcosis or alcohol to be esteem-boosting or confidence-building. Nor is it possible always to declare that someone has low self-esteem. Some people are confident in some settings but not in others. Vietnam was an extreme example of an addiction encouraging setting, where the environment deprived American soldiers of intimacy and opportunities for accomplishment while subjecting them to unusual discomfort. Most important, soldiers were deprived of a necessary degree of certainty and control over their lives. Under these conditions, men ordinarily not prone to welcome narcosis found its reassuring predictability to be addictively attractive. Some other people, on the other hand, show this heightened need for predictability, or a low tolerance for uncertainty, and cannot achieve intimacy, have difficulty accomplishing goals, and experience regular discomfort, under normal, or non-war zone, conditions.
Addiction occurs along a continuum, and even those at the extremes of addictiveness show the capacity to act in other than an addicted way under the right circumstances. In one study where street inebriates were allowed to drink alcohol made freely available in paper cups at a nursing stand, the vast majority did not drink excessively throughout the experiment. The largest group did not drink at all, some drank heavily then stopped, some drank regularly in either an excessive or moderate way or combinations of both (Gottheil et al., 1973). The characteristics of addictive involvements are not solely, or even largely, determined by their pharmacological properties alone. In this case, as is also true of narcotics, changing the means of administering a substance or the setting of administration can alter the addictive experience sufficiently to render it ineffective for accomplishing the addictive goals of the individual.
The above example illustrates changing the person's addictive formula by modifying the reward value of an involvement. A similar approach is represented by aversive conditioning to drug and alcohol effects or by simply convincing the person to abstain. In these cases, the formula will only remain stably balanced and the person nonaddicted if the person is able to develop the personal means and situational opportunities to replace the experience he or she sought in the drug involvement. A more direct approach to shifting this balance is to improve the person's personal and situational resources. Treatment will then succeed to the extent it:
- enhances self-esteem and esteem-gathering opportunities
- enhances the skills that enable people to control their situations and directs people to more manageable environments
- enhances interpersonal skills and helps people become involved in more fruitful relationships
- enhances work habits and encourages people to find manageable tasks and satisfying endeavors
- increases people's tolerance for imperfection and discomfort while removing them from painful circumstances inimical to life.
Therapy for addiction only rarely and very inexactly accomplishes these things, in part because addiction treatment is preoccupied with the nature of the substance involvement rather than with the person's relationship to self, others, and the world. In this form, addiction treatment shares with most therapy an overemphasis on the experience of therapy itself rather than on the person's life structure.
I disagree radically with the point of view sometimes expressed on the pages of this journal that we need more treatment for addiction. We already have too much addiction treatment. We search for innovative new ways to recruit clients for an expanding treatment networksuch as the widespread reliance on mandatory referrals from employee assistance programs and from the courts (Weisner & Room, 1984)but without being able to judge our efficacy. A study designed to determine the effectiveness of therapy referrals for drunken drivers found these offenders had significantly greater recidivism than those who received regular judicial sanctions (Saltzberg & Klingberg, 1983). While more and more people are in treatment, our addiction problems as a society worsen all the time. Mann (1981) estimated that in the 1930s, when Alcoholics Anonymous was founded, there were 3 million alcoholics in America. Today treatment officials claim there are 5 to 8 times this number of alcoholics, at the same time as the number of people undergoing treatment for alcoholism has risen to anywhere from 25 to 50 times the number of those receiving treatment in the 1930s (cf. Peele, in 1986a). In the case of drug abuse and addiction, an even more stark increase in both treatment and abuse has occurred over the past half century. Therapy for addiction has not been able to, it cannot, reduce substance abuse in our society.
The best hope for eliminating addiction is to enhance each individual's personal and situational resources; the single best means yet discovered for accomplishing this is for a person to grow up. This is why most adolescents and young adults leave drug abuse behind as they grow to feel better about themselves, see better paths toward real accomplishment, and learn to discriminate meaningful from insubstantial relationships. Subsequent research has continued to affirm Winick's (1962) discovery that the majority of young heroin addicts "mature out' of their drug habits, although work by Waldorf (1983) and others has emphasized that such maturing out can be rather belated and can take place at any point in the life cycle. A significant goal for therapy, as well as for our ordinary social institutions, is thus to enable people to achieve full adulthood and to develop a mature view of themselves and acceptance of the world.
Unfortunately, it is not at all clear whether therapy as an institution contributes to these aims. In what I found to be a remarkable document, Vaillant (1983) strongly affirmed the medical model for treating alcoholism while noting that his own hospital based, and AA based, treatment of alcoholics produced results no better than did the ordinary passage of time. That is, just as many people recovered from alcoholism on their own over 8 years as did under his medical regimen! Meanwhile, a recent study by Helzer et al. (1985) has been greeted by many as having proven that alcoholics cannot return to moderate drinking, since only 1.6% did so in a 5 to 8 year period following hospital treatment. Further results of this study were that 4.6% alternated moderate drinking with abstinence, while an additional 12% drank heavily at some point during the previous 3 years but did not demonstrate any alcohol-related problemsthis leaves 18% who drank without demonstrated problems compared with 15% who abstained, a summary of the results that completely reverses the widely propagated impression of the research. We need to be careful about greeting each new study like this one as having lain to rest all debate about current treatment approaches (see, in this regard, an editorial entitled "Rx-abstinence: Anything less irresponsible, negligent," 1985).
Thus the Helzer et al. study has been cast as definitive support for hospital treatment that discourages all attempts at moderating drinking. Yet what was most outstanding in Helzer et al.'s resultswas the ultimate futility of conventional alcoholism therapy. Of the four cohorts of subjects, the one receiving inpatient alcoholism treatment had the lowest remission rate, one half that for alcoholics who had been seen in a medical/surgical hospital. A total of 7% of the patients treated specifically for alcoholism survived and were in remission five to eight years later! That undergoing surgery offered a better prognosis for alcoholism than receiving treatment is not surprising: Vaillant (1983) reported that natural forces, such as illness and job and family considerations, were the major factors in recovery from alcoholism. Vaillant further noted that the best predictor of treatment outcomes was how much the patient had to lose by not recovering.
Vaillant also studied alcohol problems over the course of 40 years in a population of men who went by and large untreated. At their last assessment, 20% of those who had abused alcohol were drinking moderately while 34% were abstaining; in addition to nearly all the controlled drinkers, the large majority of abstainers had not gone to AA. Furthermore, there were indications in Vaillant's data that those attending AA were more likely to relapse than were those who abstained on their own, apparently because those in AA needed to keep up AA attendance in order to sustain their remission. This finding is reminiscent of New York Met baseball player Keith Hernandez's testimony before a federal jury. Hernandez testified that perhaps 40% of baseball players were using cocaine in the peak year of such drug use (1980). Most, like himself, had cut back and stopped on their own, claimed Hernandez. This contrasts markedly with some of the stories of repeated relapse among the very small group of cocaine-using baseball players who placed themselves, or were coerced, into treatment.
Of course, therapy of every sort should always be available to those who want it (although controlled drinking therapy is not available in the United Statesalone among western nations; Peele, 1984a). While treatment will not reverse our drug problems, it is a humane and reasonable part of any ameliorative package. What we need most, however, is not more drug and alcohol therapy, but better therapy: i.e., that which is directed at the fiber of the person's life. Instead, I believe our current chemical dependence treatment boom is having a harmful impact overall. It does so first by misdirecting our attention to the chemical effects of drugs, and second by creating a therapeutic milieu, a patient identity, and a treatment regimen which act to convince the abuser of his powerlessness and his need for a permanent attachment to therapy. It is interesting in this regard that Hernandez rejected the idea that "once an addict, always an addict" in rehabilitating himself.
Disease-oriented treatment for substance abuse becomes more and more inappropriate and counterproductive the younger the clients and the less severe the substance abuse problems to which it is applied. Yet this expansionism, fueled by third-party payments and the increasing profits to be made in treatment, is typical of the field (Peele, 1986a). Since my aim here is to improve drug treatment and since I think it is now doing more harm than good, I will end by indicating what I think such therapy should not do. It should not convince people that they are lifelong addicts who can never enter the ranks of normal people; it should not tell them that any exposure to psychoactive substances holds out the distinct possibility they will relapse; it should not undermine their self-reliance by indicating that it is only the therapy which enables them to stay healthy; it should not retard the process, already under attack in our world, through which people assume responsibility for their actions and their impact on others; and, lastly, it should not forcibly lay claim to infallibility and to more knowledge about a person's drug problems and how to cure them than the person himself or herself has. It is this last aspect of substance abuse treatment, marketed under the therapeutic label of denial, which is America's greatest danger to civil rights today, especially for the young (Peele, 1986a).
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