Addiction and change: how addictions develop and addicted people recover

336 Pages·2003·2.41 MB·English

ADDICTION AND CHANGE
THE GUILFORD SUBSTANCE ABUSE SERIES
Howard T. Blane and Thomas R. Kosten, Editors
Recent Volumes
Addiction and Change:
How Addictions Develop and Addicted People Recover
Carlo C. DiClemente
Seeking Safety: A Treatment Manual for PTSD and Substance Abuse
Lisa M. Najavits
Substance Abuse Treatment and the Stages of Change:
Selecting and Planning Interventions
Gerard J. Connors, Dennis M. Donovan, and Carlo C. DiClemente
Introduction to Addictive Behaviors, Second Edition
Dennis L. Thombs
Psychological Theories of Drinking and Alcoholism, Second Edition
Kenneth E. Leonard and Howard T. Blane, Editors
New Treatments for Opiate Dependence
Susan M. Stine and Thomas R. Kosten, Editors
Couple Therapy for Alcoholism:
A Cognitive-Behavioral Treatment Manual
Phylis J. Wakefield, Rebecca E. Williams, Elizabeth B. Yost,
and Kathleen M. Patterson
Clinical Guide to Alcohol Treatment:
The Community Reinforcement Approach
Robert K. Meyers and Jane Ellen Smith
Psychotherapy and Substance Abuse: A Practitioner’s Handbook
Arnold M. Washton, Editor
Addiction and Change
How Addictions Develop
and Addicted People Recover
Carlo C. DiClemente
THE GUILFORD PRESS
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© 2003 The Guilford Press
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All rights reserved
No part of this book may be reproduced, translated, stored in a
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Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
DiClemente, Carlo C.
Addiction and change: how addictions develop and addicted people
recover / Carlo C. DiClemente
p. cm. — (Guilford substance abuse series)
Includes bibliographical references and index.
ISBN 1-57230-057-4 (alk. paper)
1. Addicts—Rehabilitation. 2. Substance abuse—Treatment. I. Title.
II. Series.
RC564.D535 2003
616.86′03—dc21 2002015477
To
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About the Author
CarloC.DiClemente,PhD,isProfessorandChairoftheDepartmentof
Psychology at the University of Maryland, Baltimore County. He re-
ceivedhisMAinPsychologyattheNewSchoolforSocialResearchand
hisPhDinPsychologyattheUniversityofRhodeIsland.Dr.DiClemente
is the codeveloper with Dr. James Prochaska of the Transtheoretical
Model (TTM) of behavior change. He is the author of numerous scien-
tific articles and book chapters on motivation and behavior change and
the application of the TTM to a variety of problem behaviors. Dr.
DiClemente is coauthor of a self-help book based on this model of
change—Changing for Good—and several professional books—The Trans-
theoretical Approach: Crossing Traditional Boundaries of Therapy, Sub-
stance Abuse Treatment and the Stages of Change: Selecting and
Planning Interventions, and Group Treatment for Substance Abuse: A
Stages-of-Change Therapy Manual. For the past 20 years, he has con-
ducted funded research in health and addictive behaviors. He has
directed an outpatient alcoholism treatment program and serves as a
consultant to private and public treatment programs. Dr. DiClemente
was recently given the 2002 Distinguished Contribution to Scientific
Psychology award by the Maryland Psychological Association and was
oneoffivewinnersofthe2002InnovatorsCombatingSubstanceAbuse
award given by the Robert Wood Johnson Foundation.
vi
PPrreeffaaccee
Preface
How a society views individuals who engage in addictive behaviors has
animportantinfluenceonaddictionandrecoveryfromaddiction.Ifad-
dictionisseenasamoralfailing,itwillbecondemned.Ifseenasadeficit
inknowledge,itwillbeeducated.Iftheaddictionisviewedasanaccept-
ableaberration,itwillbetolerated.Iftheaddictionisconsideredillegal,
itwillbeprosecuted.Ifviewedasanillness,itwillbetreated.Socialpol-
icies mirror these different views with strategies ranging from prohibi-
tion and criminalization to hospitalization and mandated treatment.
TheUnitedStateshasusedaneconomicviewofsupplyanddemand
with which to frame its policies. However, supply reduction has coex-
isted uneasily with demand reduction, and interdiction with treatment.
For many policymakers addiction is viewed predominantly as a legal
problem, and so interdiction and zero tolerance are considered the ap-
propriatepolicies.Increasingly,then,themajorresponsibilityformanag-
ing addictive behaviors and addicted individuals is given to the police,
thecourts,andthelegalsystem.Atthesametime,thereareanumberof
illness-oriented policymakers who see addictions as social epidemics or
chronic medical or psychological conditions. They, along with the treat-
ment community, promote policies to provide interventions to assist the
individual addict and reduce the harm from addictions on society.
There are serious shortcomings in current perspectives and the ef-
fortsatinterdiction,prevention,criminalization,andtreatmentthatthey
support.Interdictionandeliminationofthesupplyfeedingaddictivebe-
haviors appear impossible as long as the demand from current and new
consumers remains high. Attitudes about legal and illegal addictions
vary significantly, causing confusion in messages and approaches to ad-
diction and recovery. Punishment has become closely linked to treat-
ment, mixing external pressure with internal motivation that often in-
creases attendance at treatment programs but makes personal recovery
more challenging. Attempts to reduce harm for addicted individuals are
vii
viii Preface
often banned because they are seen as supporting addictions. Inconsis-
tenciesinattitudesandapproachestowardaddictionsabound.Thereal-
ity is that it is difficult to balance concern for the individual who be-
comes addicted and the welfare of the society and its other citizens.
Many in the political, legal, prevention, and treatment systems believe
that new approaches are needed.
This volume offers such a new approach in the form of an alterna-
tive, integrative perspective for understanding addiction and recovery.
Mypremiseisthataddictionandrecoveryshouldbeviewedasaprocess
of behavior change. Research colleagues and I have followed thousands
ofindividuals,examininghowtheybecomeaddictedandrecover.Inthat
research it is clear that addictions are not static states turned off and on
with a switch. Addictions are multidetermined and take hold over time.
Thereisapathtoexperimentationandthroughcasualusetoabuseand
dependence. Recovery is also a journey that takes time and effort and is
often filled with false starts and failed attempts. While the factors that
lead a particular individual into addiction and out of it are unique to
thatindividual,theprocessofbecomingaddictedandofrecoveryfollow
acommonpath.Thepathisalsocommonacrossindividualsandacross
addictive behaviors. In this volume I want to illuminate that common
path and illustrate how multiple factors and experiences can influence
an individual’s movement along that path. More specifically, this book
isolatesimportantdimensionsoftheprocessofchangeinvolvedinstart-
ing and stopping an addictive behavior; it highlights similarities in the
process across addictions; and it sees both addiction and recovery in a
largerlifecontext.Whenviewedasaprocessofbehaviorchange,addic-
tions can be managed more effectively.
This book views addiction through the dimensions of the Trans-
theoretical Model (TTM) of intentional behavior change that James
Prochaska and I have been refining in research and writings over the
past 20 years. The TTM emerged from our seminal research examining
how smokers were able to free themselves from their nicotine addiction
and has been primarily applied to recovery from addictions. Although
themodelasdescribedhereissimilartodescriptionsinpriorworks,this
is the first time I offer as complete, detailed, and precise a version. This
book is also the first full application of the model to the process of be-
coming addicted. Other specific adaptations and changes to the model
presented in this book include the following: a detailed explanation of
thetasksforeachstageofchangeandillustrationsofhowthestagesand
processesofchangeinteracttoproducemovementthroughthestagesof
addiction and the stages of recovery. I have incorporated an extensive
consideration of the context of change and how issues in multiple areas
oflifefunctioninginteractwithaddictionandrecoverytobothhelpand
Preface ix
hinder change. I hope the views offered in this volume will empower
communitiesandenrichprogramsandpoliciestopreventaddictionand
promote recovery.
This book is organized into four parts. Part I introduces addiction
and recovery as a process of change. It begins in Chapter 1 with a brief
reviewofperspectivesthathavebeenusedtounderstandaddictionsover
thepast100years,highlightingtheirinsightsandblindspots.Thesedif-
ferent models point to biological, psychological, and social influences
andattempttounderstandhowriskandprotectivefactorscreateaddic-
tion or promote recovery. Some are unsatisfactorily one-dimensional.
Many are multidimensional but fail to explain how diverse dimensions
interact over time to produce addiction or recovery. Most are rather
staticinhowtheyseeaddictionsstartorstopandofferalimitedviewof
thepathintoandoutofaddictions.Chapter2describesourcurrentun-
derstandingoftheprocessofbehaviorchangeasembodiedintheTTM.
This dynamic, developmental, and multidimensional change perspective
offersanintegrativeframeworkforunderstandingchangeandtheprob-
lems of addiction and recovery. The stages of change highlight the spe-
cifictasksofContemplation,Preparation,Action,andMaintenancethat
mark the individual’s progress toward addiction and the addicted per-
son’s pathway to recovery. Ten processes of change derived from differ-
ent behavior change theories describe key mechanisms that move indi-
viduals through the stages. Five areas of functioning comprise the
contextofchangethatcontaintheriskandprotectivefactors,resources,
and barriers that influence process activity and movement through the
stages.Finally,criticalmarkersofchangetrackanindividual’sdecisional
balance and self-efficacy/temptation as he or she moves through the
stages of change. This multidimensional, integrative TTM offers a pan-
oramic view of addiction and recovery. In Chapter 3, Part I concludes
withadescriptionofthefullydeveloped,establishedaddictionthatrep-
resentsthefinalstageinthepathtoaddictionand,atthesametime,the
starting point of the stages of recovery.
Part II, comprising Chapters 4 and 5, goes back to the beginning
anddescribestheroadtoaddiction.Iproposethatasimilarprocessand
thesameTTMdimensionsmarkthepathtoaddictionastheydoforre-
covery.Stagesintheprocessofbecomingaddictedincludemovingoutof
Precontemplationforengaginginanaddictivebehaviorandintoserious
considerationandexperimentationwiththatbehavior,thentopreparing
toengageregularly,andfinallytodevelopingaregular,problematicpat-
tern of engagement. Stage transitions that lead to addiction also involve
shifts in the processes and markers of change as well as in contextual
risk and protective factors. The end point of these stages of addiction is
the well-maintained addiction described in Chapter 3.