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The Nature of Addiction: Beyond Brain Disease

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

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The Nature of Addiction: Beyond Brain Disease

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  1. The Nature of Addiction: Beyond Brain Disease William R. Miller, Ph.D. Melbourne, July 2008

  2. 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

  3. Blind Alleys 1. Punishment

  4. 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

  5. Blind Alleys • Punishment • Interdiction

  6. Blind Alleys • Punishment • Interdiction • Quest for the Flaw

  7. That humanity at large will ever be able to dispense with artificial paradises seems very unlikely Aldous Huxley The Doors of Perception

  8. “Criminogenic Needs” Personality Attitudes and beliefs Low self-control Peers Substance abuse Dysfunctional family

  9. Criminogenic Needs Poverty Homelessness Unemployment Untreated addiction Meaningless life

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

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