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 written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. 9 8 7 6 5 4 3 2 1 springer.com 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).
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