What should we be aiming for in the treatment of addiction?
1 NHMRC Howard Florey Fellow, School of Psychology, Faculty of Health, Medicine, Nursing and Behavioural Sciences Geelong Waterfront Campus, Deakin University, Geelong, Vic, 3217 Australia
2 Distinguished Professor of Psychology and Psychiatry, Center on Alcoholism, Substance Abuse, and Addictions, The University of New Mexico, Albuquerque, NM, USA.
For decades, treatment for addiction to drugs such as alcohol, cocaine and heroin was largely separated from broader concerns of physical and mental wellbeing.
addiction was conceptualized and treated as a distinct illness, to which many other problems were secondary and would probably resolve once the primary disorder had been addressed.
Addiction treatment systems in many western nations thus developed in relative isolation from primary health care and mental health treatment, and have focused almost exclusively mainly on alcohol/drug use.
While this may be appropriate for some drugs, such as tobacco, or some drug users, we argue that such an approach is outdated for the mainstream treatment for addiction to drugs such as alcohol and heroin.
Among the things that we know about addictions with reasonable scientific certainty is that they come intertwined with a host of other health, social, economic, family and mental health problems .
The conception of 'dual diagnosis' as a special minority population has given way to the recognition that concomitant problems are the norm when treating addiction. Even when entering specialty treatment, people bring with them a vast array of other concerns, some of which are often of higher subjective priority than stopping substance use.
There is also a growing consensus that concurrent treatment of these concomitant problems is the way forward . It is no longer adequate to tell people that the rest will resolve when they quit drinking or using, or to have each problem addressed separately by isolated treatment systems. Treatment ideally should address the person's range of inter-related needs.
Not doing so is one reason why addiction services never see most of those they were designed to help.
More than three-quarters of people with addiction-related problems never enter specialist treatment.
Of those who do, many more leave treatment soon after their initial contact.
While some may gain what they are looking for in a brief contact, this attrition rate suggests that what we are offering is not very attractive or not relevant to their needs as they see them .
Further, while addiction treatment makes an impact, it is focused mainly on a single outcome: the absence of addiction. The cessation or reduction of addictive behavior is often a good starting-point, but if that is where treatment ends, it may be finishing just when a person needs help the most.
One area of study that holds worthwhile insights for addressing addiction is research on quality of life and more specifically, subjective wellbeing (happiness), which has been pondered even longer than the desire for intoxication.
Philosophers such as John Stuart Mill and Jeremy Bentham built their concepts of the good society on the maximization of subjective wellbeing .
If addictive behavior is often a quest for pleasure or release from unhappiness, surely this is a relevant consideration in addiction treatment. Dimensions of happiness are assessed specifically and addressed in the community reinforcement approach to addiction treatment, with the rationale that in order to be stable, a life of sobriety should be happier (more reinforcing) than one of inebriety .
Assessment of life quality often begins with a broad question such as: 'How satisfied are you with life as a whole?'. A long tradition of contemplation and research has identified at least eight subdomains of subjective wellbeing: standard of living; personal health; achieving in life; personal relationships; personal safety; community-connectedness; future security; and spirituality-religion .
Others have included elements such as creativity, self-esteem and a sense of meaning or coherence in life . Notably, objective health is not a strong predictor of subjective wellbeing (e.g. [8,9]), suggesting that the dominance of a health approach for addiction treatment may not be reflective of an addict's main concerns.
In practical terms, identifying people's satisfaction with each dimension of wellbeing can provide tangible directions for intervention, providing a true means for individualizing treatment goals and plans. Clearly, some elements are more important than others, and Maslow's hierarchy of needs  may provide guidance as to which areas of a person's life should be addressed first.
More importantly, clients themselves have priorities, and the extent to which we address them is likely to influence our success with engagement, retention and outcomes. There is wisdom in viewing clients' lives respectfully through their own eyes. (This flies in the face of a tradition that dismisses clients' perspectives as hopelessly distorted, irrational and out of touch with reality.)
In one study, people entering in-patient addiction treatment were asked, via a questionnaire with a broad range of items, what they wanted from treatment. Then at follow-up again they were asked, using the same items, what they actually gained from treatment. The extent to which they had received what they wanted from treatment predicted greater post-treatment abstinence. The extent to which they gained what they did not want was unrelated to outcome .
To attract, engage and retain people more successfully with addiction-related problems, addiction services and the interventions they use need to be more welcoming, attractive and focused broadly towards their clients' actual needs.
This has clear implications for the qualifications and training of providers. We believe that the era of specialist alcohol/drug counselors is coming to an end. The interlinked psychosocial and health problems that commonly accompany addiction require professionals trained and skilled to treat them, as well as closely integrated systems of care.
To what extent is your program making peoples' lives better, rather than simply suppressing alcohol/drug use? Structured assessment using appropriate brief wellbeing measures could facilitate discussions about broader life needs to be addressed.
Further, insights from the literature on subjective wellbeing may inform services and interventions to help people establish happier, more meaningful lives within which addiction holds less attraction.
WRM is a senior consultant to The Change Companies, which publishes resource materials for addiction professionals, and also receives royalties from books that he has published in this field.
Peter Miller is funded by an Australian government NHMRC Howard Florey Research Fellowship. This paper arose from discussions held at The Addiction Summit in Melbourne in 2008. We would like to thank Joel Porter for organizing a forum which encouraged such an exchange of ideas.
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Copyright Journal compilation ? 2009 Society for the Study of Addiction
Addiction, Volume 104 Issue 5, Pages 685 - 686
Published Online: 7 Apr 2009