Promoting Self-Change From Addictive Behaviors: Practical Implications for Policy, Prevention, and Treatment

269 Pages·2007·6.97 MB·English

by  Linda Carter Sobell (auth.)

Promoting Self-Change From
Addictive Behaviors
Practical Implications for Policy,
Prevention, and Treatment
Promoting Self-Change From
Addictive Behaviors
Practical Implications for Policy,
Prevention, and Treatment
Edited by
Harald Klingemann
University of Zurich
Zurich, Switzerland
Linda Carter Sobell
Nova Southeastern University
Fort Lauderdale, FL, USA
Harald Klingemann Linda Carter Sobell
University of Zurich Nova Southeastern University
Zurich 3301 College Avenue
Switzerland Fort Lauderdale, FL 33314
[email protected] USA
[email protected]
Library of Congress Control Number: 2007924715
ISBN 978-0-387-71286-4
e-ISBN 978-0-387-71287-1
Printed on acid-free paper.
©2007 Springer Science+Business Media, LLC
All rights reserved. This work may not be translated or copied in whole or in part without the
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Dedication
To my brother Hans-Dieter Klingemann, who has been supportive in times of
change, on the occasion of his 70th birthday.
H. K.
To my father, Harold A. Carter, who has been a beacon of support over the
years, and to my two daughters, Stacey Sobell Williams and Kimberly Allison
Sobell, who are the joys of my life.
L. C. S.
Acknowledgments
We would like to thank all our colleagues who over the past several years have
participated in the natural recovery conferences and related publications. With-
out their support and research, we would not have been able to prepare this
book. As researchers, we believed that self-change was possible and sought to
study the process. However, this would not have been possible without those
individuals around the world who shared their stories with us. Thank you for
giving your time and graciously consenting to be interviewed. We were willing
to learn and you taught us more than we ever imagined.
In addition, we want to extend a very special thanks to Andrew Voluse and
Kristen Harris who labored over every word in this book to insure that the
final product was perfect. Lastly, we want to thank our publisher, Springer,
who encouraged us to prepare this book.
Harald Klingemann
Linda Carter Sobell
vii
Foreword
Considering the Unimaginable:
Challenges to Accepting Self-Change
or Natural Recovery from Addiction
Howard J. Shaffer
Harvard Medical School;
The Division on Addictions, The Cambridge Health Alliance1,2
So thoroughly and sincerely are we compelled to live, reverencing our life, and denying the
possibility of change. This is the only way, we say; but there are as many ways as there can
be drawn radii from one centre. All change is a miracle to contemplate; but it is a miracle
which is taking place every instant.
—Henry David Thoreau, WALDEN; Or, Life in the Woods (1854, p.14)
The great enemy of the truth is very often not the lie—deliberate, contrived, and
dishonest—but the myth—persistent, persuasive, and unrealistic.
—John F. Kennedy (Yale University Commencement Address, 1962)
During the middle 1980s, Stephanie Jones and I began to consider whether
and how people might escape from cocaine addiction (Shaffer & Jones, 1989).
During that time, cocaine misuse was a widespread and growing activity.
There were many claims that even a single episode of cocaine use would lead
to cocaine addiction. In the midst of this fervor, we speculated that many
people would try this newly discovered drug, but that few would become
addicted. We also suggested that among those who did become cocaine
dependent, many more would stop using on their own than would seek treat-
ment to help them stop. Our logic was that most people who stopped their
nicotine dependence—another short-acting stimulant with many cocaine-like
1 Please send correspondence to Howard J. Shaffer, Ph.D., Director, Division on
Addictions, 101 Station Landing, Medford, Massachusetts 02155.
2 Preparation of this foreword was supported, in part, by current grants and contracts
from The National Center for Responsible Gaming, bwin.com, Massachusetts Fam-
ily Institute, National Institute on Alcohol Abuse and Alcoholism (NIAAA), National
Institute on Mental Health (NIMH), National Institute on Drug Abuse (NIDA), the
Massachusetts Council on Compulsive Gambling, and the Nevada Department of Pub-
lic Health. I extend special thanks to Debi LaPlante, Sarah Nelson, Chris Reilly, and
Chrissy Thurmond for their helpful comments on earlier versions of this manuscript.
ix
x Foreword
effects—had quit on their own, so the same pattern might hold for cocaine
users. Nicotine dependence is widely accepted as one of the most difficult cir-
cumstances to change; this is partly due to how people weave its use into the
fabric of their everyday lives. Illegal and more expensive, cocaine use arguably
was less integrated into the day-to-day activities of most people who used
it. Therefore, we expected that people should be able to stop cocaine use on
their own at rates similar to nicotine quitting. We also reasoned, however,
that people who used cocaine would not be willing to talk about their natural
recovery experience because the community view was that they could not stop
on their own and would require treatment—at the time, the treatment most
often prescribed was inpatient care. To many people this pathway to recovery
was unacceptable. So, they kept their quitting strategy a secret. We opened the
floodgates for these people by soliciting their participation with flyers posted
in public areas around Boston. When people came to tell us their story, they
often began by saying, “I thought I was the only one.” Interestingly, though
they were unwilling to talk about their self-directed cocaine quitting in gen-
eral, they were very willing to talk about it with us—perhaps because they
knew that we already accepted the idea of natural recovery.
Earlier, as Stephanie and I were preparing to undertake our quitting cocaine
project, we received lots of advice from colleagues. Unfortunately, the advice
usually was that people could not recover from cocaine dependence without
formal treatment, and that we were wasting our time. Norman Zinberg, one
of the pioneers in the addiction field who demonstrated that self-control
was possible even with the most frightening of illicit drugs (Zinberg, 1984;
Zinberg & Harding, 1982; Zinberg, Harding, & Winkeller, 1977; Zinberg &
Jacobson, 1976), encouraged us to see the project through. That was all we
needed to keep going.
More recently, I have been working to better understand the similarities
and differences between substance (e.g., cocaine) and activity (e.g., gambling)
addiction. In both cases, treatment seekers are different from people in the
community who might have addiction but do not seek treatment (e.g., Berk-
son’s bias; Berkson, 1946); more specifically, very few people seek treatment
compared with the number who struggle with either type of problem on their
own. Yet, many people recover. With both types of addiction, more people
recover on their own, without treatment, than with formal care. What makes
it so difficult for people to accept the idea that people struggling with addic-
tion can change their behavior on their own?
In addition to the cynical but unfortunately real concerns about turf and
economic issues that treatment providers fear, for example losing treatment
opportunities to natural home remedies for addiction, there are other pow-
erful social psychological forces that make it very difficult for people to
accept the idea of self-change. When talking about human foibles, Norman
Zinberg often quipped, “Consider it projection until proven otherwise.”
This aphorism is useful when trying to understand the challenges to accept-
ing self-change.
Foreword xi
People tend to view the world as they experience it. People tend to think
that others experience the world as they do. People think that others require
treatment to change because they think their own behavior change is the
result of external forces. “I had to stop smoking because my doctor said….”
The tendency to project is compounded by the “fundamental attribution
error.” Ross (1977) first described this error as the tendency for actors to
see their own behavior as determined by forces external to them, and for
observers to see the very same behavior as determined by the actor’s internal
dispositions. This “fundamental attribution error” increases the likelihood
that observers will think that others who are struggling with addiction are
stuck because they “want” to be stuck—that they are not sufficiently moti-
vated to change, for example. Once observers perceive people with addiction
to be absent the intrapersonal resources necessary for change, they then
deduce that people with addiction need some external force to change. Simi-
larly, they tend to view their own behavior changes as the consequence of
external forces.
The dynamics of addiction and the need to attribute causes for both addic-
tion and recovery have important implications for clinicians and public policy
makers alike. Sometimes treatment providers and public policy makers inter-
vene with addictive behavior patterns when it is unnecessary, calling too much
attention to issues that have limited adverse consequences. These patterns of
drug misuse tend to resolve without treatment. Alternatively, if policy mak-
ers or treatment providers think that addictive behaviors will resolve without
intervention, they might act too slowly. Research must determine the latency
of self-change, which problems require policy or treatment interventions to
help people change, and which expressions of addiction fall somewhere in
between.
To illustrate, while working on the quitting cocaine project, it was common
to see public service announcements that touted, “One puff of crack and you
will be hooked.” This announcement might have kept some people who were
ambivalent about whether to try smoking crack from doing it. But, I wonder
what effect this message had on the people who already tried smoking crack?
This message might have encouraged them to believe that they were doomed
to a life of addiction and would not be able to stop. A better, and more scien-
tifically accurate, message would be “one puff of crack and you can stop, just
like most of the people who have used it.” This public health message and its
consequences likely would be very different from the other message and most
users would recognize that there were others who understood the nature of
drug use and that they were telling the truth.
Understanding natural recovery holds fundamental benefits for treatment
providers and treatment protocols. People who have recovered from addiction
without formal treatment often have discovered—on their own—some of the
essential elements of behavior change. For example, our cocaine quitters often
identified loss of health, work, or family to be primary factors that encour-
aged them to change. Similarly, they identified more healthy substitutes that
xii Foreword
could take the place of the addiction they wanted to stop. It is very important
for treatment providers to learn about the building blocks of natural recov-
ery so that they can integrate or enhance these elements in their treatment.
Natural or self-directed changers have learned—on their own—exactly what
treatment seekers need to know to help others: how to change behavior for the
better and then maintain those changes.
The earlier book of Promoting Self-Change From Problem Substance
Abuse was a landmark in the field, and this book updates, integrates, and
solidifies the best science on this topic. Klingemann and Sobell have pro-
vided a fundamental service to the field that is destined to become a water-
shed event. As more research has become available, they have identified the
central perspectives essential to understanding self-change from addictive
behaviors and woven them into a coherent explanation of recovery. Yet,
despite this vital contribution, the idea of self-change is still likely to face
stout challenge: this is because, as I suggested earlier, the idea that people
can direct their own escape from addiction is anathema to many observers.
In the struggle between (a) what people are disposed to perceive by cultural
myth and the dynamics of social perception and (b) what is possible, this
volume makes its most important contribution. It shifts from unimagina-
ble to imaginable the process and possibility of self-directed changes from
addiction. This shift in perspective holds the potential to revolutionize treat-
ment and recovery. This book can change treatment because it identifies the
central elements of human change; it can transform recovery because, in
addition to revealing the most fundamental and efficient treatment tactics,
it makes clear to people struggling with addiction that they have the capac-
ity for change. If we cannot imagine the possibility of self-directed change,
not only will our science be limited unnecessarily to studies of externally
directed change, but it also is likely that people will not change without
external influence. Just as software lags behind hardware, clinical practice
tends to lag behind science. This circumstance suggests that clinicians do not
access some of the change options that are available to them. The conven-
tional cultural wisdom lags even further behind clinical protocols, making
it difficult for people with addiction to even imagine that they can change
without formal treatment or self-help. Yet, some do recover by self-directing
their change. Consequently, I suspect that natural recovery is a more power-
ful force than even self-change proponents now recognize.
In context, the challenges associated with considering self-change inher-
ently limit the full range of change options. This book makes a very special
contribution and provides a portal to things yet unimagined and undiscovered
about change. Yet, for this book to achieve its full potential, it will be neces-
sary for addiction science to mature. Currently, the field of addiction reflects
an underlying belief that change is either not likely or must be coerced. But,
Jean Rostand (1962) reminds us, “It is sometimes important for science to
know how to forget the things she is surest of…. Nothing leads the scientist so
astray as a premature truth” (A Biologist’s Thoughts, Chapter 7).