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CHAPTER 1

Why Treat Addiction?

There are several good reasons why treating addictions should be of vital concern, not just for specialists in this area, but to all professionals who work in health care, behavioral health, and social services (Miller & Weisner, 2002). One of these is how common addiction problems are. In the United States, for example, current alcohol use disorders alone are diagnosable in about 7% of the general adult population (Secretary of Health and Human Services, 2000). An overlapping 15% of the population remains addicted to nicotine (Hughes, Helzer, & Lindberg, 2006), and about 2% meet diagnostic criteria for an illicit drug use disorder (Compton, Thomas, Stinson, & Grant, 2007). Still others have significant problems with addictive behaviors that do not involve a drug, such as pathological gambling, which afflicts up to 5% of the population, particularly in areas with a high concentration of legalized gaming (Petry & Armentano, 1999). Thus the sheer prevalence of these problems and the suffering they cause to the afflicted and those around them are reason enough to attend to them.

A second reason is that addictions are closely intertwined with the problems that bring people into the offices of medical, mental health, social service, and correctional workers. In most populations seen by such professionals, the prevalence of substance use disorders can be much higher than in the general population. If 1 out of every 12 people in the general population has an alcohol/drug problem (without even counting their family members and others they affect), the proportion is greater still among health care and mental health patients, as high as 20 to 50% depending on the setting (Weisner, 2002). Thus, aware of it or not, most health and social service professionals are already treating the sequelae of addictions without directly addressing a significant source of the problems.

Why not just refer people with addictions to specialist programs? There is a role, of course, for specialist treatment of addictions, particularly when it is closely integrated with other needed services. Yet there is a downside to regarding clients' disorders as separable, to be treated by different specialists. A majority of people with alcohol or other drug dependence also have concomitant mental and/or physical disorders that need attention. The presence of concomitant disorders complicates the treatment of addictions, and vice versa. Furthermore, if addictions are chronic conditions, there is wisdom in continuous care and not just acute specialist treatment. People often get lost in the referral process, and there are well-known problems with the coordination of care when various parts of the person are being treated in separate services (Shavelson, 2001). For all these reasons, there is a trend toward integrating the treatment of addictions within a larger spectrum of health and social services.

By the time people accept specialist addiction treatment (or are compelled to do so), their problems have often reached a severe level. Often they had been seen earlier in health care, mental health, social service, or legal and correctional systems for conditions directly or indirectly related to their substance use. Yet their alcohol/drug problems were either not recognized or not addressed effectively at these times. It is clearly possible to recognize and treat alcohol/drug problems in more general practice settings. It may even be easier to treat them there because people tend to turn up in health care and social services at earlier stages of problem development, long before they may accept referral to a specialist addiction treatment program.

Perhaps the most persuasive reason for addressing addictions, however, is the one that attracted and has held each of us in this field over the years: addictions are highly treatable, and a variety of effective treatment methods are available. When people who have developed alcohol/drug dependence recover, they really get better. You don't need subtle psychological measures to see the change. They look better. They feel better. Their family and social functioning tends to improve. They are healthier and happier. They fare better at work, school, and play. And, contrary to public opinion, most of them do recover. With the array of effective treatments now available, it is rewarding indeed to treat addictions in practice. Furthermore, substance use disorders — particularly tobacco and alcohol — are by far the leading preventable cause of death in the Western world. Treating addictions is quite literally a matter of life and death.

Why Not Treat Addictions?

So why, then, have so many professionals chosen not to address this very common, life-threatening, and highly treatable class of disorders that are so intertwined with other problems? The answer lies, in part, in several misconceptions.

First, some practitioners believe treating addictions requires a mysterious and highly specialized expertise that is entirely separate from their own. In fact, as will become clear in the chapters that follow, the psychosocial treatment methods with strongest evidence of efficacy are often familiar to behavioral health professionals who treat other disorders, and are commonly part of the ordinary training and practice of many professionals: client-centered listening skills, behavior therapies, relationship counseling, good case management, and motivational interviewing. Effective medications are available to aid in treatment and long-term management of these chronic conditions. The major professional health disciplines have already contributed and will continue to contribute much in understanding and treating addictions (e.g., Miller & Brown, 1997). To be sure, there are some facts and particular skills you need to know when addressing alcohol/drug problems. Providing that background is one primary purpose of this book.

A second challenge is time. Counselors and psychotherapists may have 50-minute hours, but health care appointments are often brief, with many other tasks to be accomplished. Those who work in contexts such as primary health care, family medicine, and dentistry may understandably see substance use disorders as "not my job" — falling outside the realm of possibility within time constraints. Yet many other chronic conditions are followed and treated within the scope of routine care, and it's possible to do what you can within the time that you have. Medical professionals may have only a few minutes to address substance use concerns, but it is clear that even this amount of time when used well can make a difference (see Chapter 9). Similarly, those who work in mental health or probation services have other issues to address and may view addictions as beyond their professional responsibility or expertise, but alcohol/drug problems are intertwined with mental health and correctional concerns.

A third possible obstacle is the belief that in order to be effective in treating addictions, one must be in recovery oneself. Although a substantial minority of professionals who treat addictions are themselves in recovery, ample evidence indicates that therapeutic effectiveness is simply unrelated to one's own history of addiction. Those who are in recovery are neither more nor less effective than other professionals in treating addictions, even when delivering 12-step-related treatments (Project MATCH Research Group, 1998d). Rather, effectiveness is related to other factors of therapeutic style (see Chapter 4).

Then there is, for some, a social stigma associated with addictive disorders, sometimes linked to pessimism (among the public, professionals, and clients themselves) about the possibility of change (Moyers & Miller, 1993; Schomerus, Corrigan, et al., 2011; Schomerus, Lucht, et al., 2011). This was exacerbated by writings in the mid-20th century suggesting that people with substance dependence are pathological liars, sociopaths, and highly defended by chronic immature defense mechanisms. We also see moralizing and blaming related to the perception that these disorders are self-inflicted (overlooking that other chronic health problems are also closely linked to personal behavior and lifestyle). In truth, people with substance use disorders represent a full spectrum of personality, socioeconomic status, intelligence, and character. Research provides no support for the belief that these individuals differ from others in overusing certain defenses, and they surely have no corner on dishonesty. One reason we, the authors, have remained in this field is that we have genuinely enjoyed treating people who are struggling with addictions, and also working with their loved ones. It is rewarding, lifesaving work.

AN INTEGRATIVE APPROACH

The approach we describe in this book is integrative in at least four ways. As the chapters to follow reveal, this approach is (1) comprehensive and evidence-based, (2) multidisciplinary, (3) holistic, and (4) collaborative.

Comprehensive and Evidence-Based

Our integrated approach is first of all grounded in available clinical science. Professional and public opinions abound regarding addictions. Such opinions, including our own, have often proved inaccurate when carefully examined in well-designed scientific research. In this book we have sought as much as possible to differentiate opinion from science, and given primary emphasis to the substantial base of scientific evidence that is now available to guide practice.

The approach we describe is also comprehensive in that it places treatment within a larger context of scientific knowledge about the nature of addictions, motivation for change, assessment and diagnosis, mutual help groups, case management, and prevention (McCrady & Epstein, 1999; Miller & Carroll, 2006). We address the full spectrum of addiction treatment, from crucial aspects of the first contact to long-term maintenance, as befits the management of a complex and often chronic condition.

Multidisciplinary

Second, we draw upon a range of professional perspectives including those from counseling and family therapy, medicine and nursing, pastoral care, psychology, and social work. In an ideal world, treatment might be delivered by a collaborative team of professionals representing these differing areas of professional expertise. In reality, treatment often relies upon a single or primary therapist whose role includes providing or serving as liaison with this range of services.

Holistic

Third, we seek in our integrated approach to consider the whole person: biological, psychological, social, and spiritual. Some think of going to a specialist for treatment of addiction, much as one goes to a dentist for care of one's teeth. Yet addictions involve and affect the whole person and those around him or her. They are biological and psychological and social and spiritual. By nature of disciplinary training, you may be prepared to deal best with one of these dimensions. Those who treat addictions, however, will meet all of these aspects of the person, and treatment will not be optimally effective if it is limited to only one of them.

Collaborative Care

Finally, we advocate the integration and coordination of addiction care with the broader range of health and social services. Sequestering addiction treatment in isolated programs has served in some ways to sustain stigma and discourage treatment. We favor involving a broad range of professionals in direct care for people with alcohol/drug problems. In truth, most health and social service professionals are already seeing people with addiction problems, though they may be unaware of it or regard such problems as someone else's concern. In complex disorders like addictions, where attention is needed in so many spheres, care can begin with almost any area.

Taken together, the 23 chapters of this book represent pieces of a puzzle, the building blocks of an integrative approach to addiction treatment. They describe a system of care that is comprehensive, evidence-based, multidisciplinary, holistic, and collaborative. That's a tall order for us in writing this book, and for you in practice. Taking the attitude of "My way or the highway" and offering only one brand of treatment is much simpler, but does a disservice to clients in failing to make use of the vast amount that has been learned about how to help people with addictions. An integrative approach is a challenging goal, a direction in which you can keep growing throughout your professional career. That has certainly been our continuing experience, and we are grateful for this opportunity to pass on, for your consideration, what we have learned along the way.

KEY POINTS

* Substance use disorders are prevalent i ???n the general population, and even more so among people seen in health care, social service, and correctional settings.

* Substance use disorders are highly treatable. A majority of affected people recover.

* An encouraging armamentarium of effective, evidence-based treatment methods is available, no one of which is best for everyone with addiction problems.

* People with alcohol/drug problems c ???ommonly have other significant psychological, medical, and social problems, and coordinated treatment of these problems is needed.

* Treating addictions should be a normal part of general health care and social service systems and not limited to specialist programs.

REFLECTION QUESTIONS

* Of the people you normally serve (or anticipate serving), what percentage would you estimate have alcohol or other drug problems?

* What most encourages or motivates you to work with people whose lives are affected by addiction, and with their family members?

* In your community, where are people with alcohol/drug problems most likely to turn up seeking help or services? (Hint: It's not in addiction treatment programs.)

What Is Addiction?

Just about everyone has some notion of what addiction is. The website www.dictionary.com offers this general definition: "The condition of being habitually or compulsively occupied with or involved in something." This definition concisely reflects three aspects of the term that are found in most popular conceptions of addiction: (1) it is something done regularly, repeatedly, habitually; (2) there is a compulsive quality to it that seems at least partly beyond the individual's conscious control; and (3) it does not necessarily involve a drug, although that is the most common association.

In everyday speech, people are said to be "addicted" when they relentlessly pursue any sensation or activity, be it sex, gambling, alcohol or other drugs, work, food, shopping, or love. Peele (2000) argued that the concept of addiction has expanded to describe so many behaviors that it has almost lost its meaning. Something becomes an addiction when it increasingly dominates a person's life and, as a result, harms or detracts from other aspects of life. In this broad colloquial sense, addiction is not unusual.

For purposes of science and health care, however, a more precise meaning is needed. This meaning is usually expressed in the form of a diagnosis that is defined by a particular pattern of signs and symptoms. Diagnostic criteria are typically developed by consensus within a professional organization such as the World Health Organization, which is responsible for the International Classification of Diseases (ICD). The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has been the standard for classification by behavioral health professionals in North America. The DSM is revised every decade or so, which means that the names and criteria for diagnosing addictions have evolved over time.

UNDERSTANDING DIAGNOSES

A formal classification system such as the ICD or DSM is a way to help health professionals mean the same thing when making diagnoses. It is a bit like the biological taxonomy of life forms classified by genus and species. Such classification systems tend to become larger and more complex over time as new species and subspecies are recognized, and this has certainly happened with the DSM. What was once a single diagnosis of "alcoholism" or "drug addiction" has been differentiated into dozens of more specific categories.

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Excerpted from "Treating Addiction"
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