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

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Presentation on theme: "The Nature of Addiction: Beyond Brain Disease William R. Miller, Ph.D.Melbourne, July 2008."— Presentation transcript:

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

2 CACTUS Participants Warren Bickel Warren Bickel Robert Carlson Robert Carlson Kathleen Carroll Kathleen Carroll Anna Rose Childress Anna Rose Childress Carlo DiClemente Carlo DiClemente Deborah Hasin Deborah Hasin Victor Hesselbrock Victor Hesselbrock Harold Holder Harold Holder Keith Humphreys George Koob Barbara McCrady Thomas McLellan William Miller Rudolf Moos Kim Mueser Stephanie OMalley

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5 Blind Alleys 1. Punishment

6 19th century convict song Cut yet name across me backbone Cut yet name across me backbone Stretch me skin across a drum Stretch me skin across a drum Iron me up to Pinchgut Island Iron me up to Pinchgut Island From today till kingdom come From today till kingdom come I will eat your Norfolk dumpling I will eat your Norfolk dumpling Like a juicy Spanish plum Like a juicy Spanish plum Even dance the Newgate hornpipe Even dance the Newgate hornpipe If youll only give me rum If youll only give me rum

7 Blind Alleys 1.Punishment 2.Interdiction

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10 Blind Alleys 1.Punishment 2.Interdiction 3.Quest for the Flaw

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

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14 Criminogenic Needs Personality Personality Attitudes and beliefs Attitudes and beliefs Low self-control Low self-control Peers Peers Substance abuse Substance abuse Dysfunctional family Dysfunctional family

15 Criminogenic Needs Poverty Homelessness Homelessness Unemployment Unemployment Untreated addiction Untreated addiction Meaningless life Meaningless life

16 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 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 Society holds people responsible for drinking and drug use – i.e., they could have done otherwise Intentional/decisional change is prominent, the norm Intentional/decisional change is prominent, the norm Intention and commitment predict behavior change Intention and commitment predict behavior change Motivation for change is malleable Motivation for change is malleable

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18 Enhancing personal motivation for and commitment to change should be a key component of treatment Involve clients as active, choosing agents Involve clients as active, choosing agents Effective treatments tip the balance of motivation away from drug use Effective treatments tip the balance of motivation away from drug use Enhancing motivation improves client retention, adherence, and outcomes Enhancing motivation improves client retention, adherence, and outcomes

19 2. Drug use responds to social reinforcement Expectancies of reinforcement from alcohol predict early drinking, relapse Expectancies of reinforcement from alcohol predict early drinking, relapse Positive reinforcement for abstinence works Positive reinforcement for abstinence works Drug use is associated with shortened time perspective Drug use is associated with shortened time perspective Competing reinforcers promote long-term change Competing reinforcers promote long-term change

20 Ergo: Enhance positive reinforcement for non-use, and enrich access to alternative sources of reinforcement Stopping drug use interrupts one important source of reinforcement Stopping drug use interrupts one important source of reinforcement Initially, competing reinforcers should be immediate, not delayed Initially, competing reinforcers should be immediate, not delayed Teach families to reinforce sobriety Teach families to reinforce sobriety Dependence involves progressive isolation from non-drug reinforcement Dependence involves progressive isolation from non-drug reinforcement Sobriety is about developing meaningful and rewarding lives not reliant on drugs Sobriety is about developing meaningful and rewarding lives not reliant on drugs

21 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 adolescents, drug use is part of a larger cluster of dysregulated behavior In adults, comorbidity is the norm In adults, comorbidity is the norm Drug abuse is correlated with a host of health and psychosocial problems Drug abuse is correlated with a host of health and psychosocial problems

22 Ergo: Dont treat addiction as an isolated specialist problem The era of the addiction counselor is coming to an end The era of the addiction counselor is coming to an end Time to end low-pay, low-status isolated specialty care Time to end low-pay, low-status isolated specialty care Professionalization: Competence in behavioral health care more generally is needed Professionalization: Competence in behavioral health care more generally is needed Mainstreaming substance abuse treatment into primary and integrated care Mainstreaming substance abuse treatment into primary and integrated care

23 4. Therapeutic relationship matters One of the largest determinants of client outcome is the therapist who provides the treatment One of the largest determinants of client outcome is the therapist who provides the treatment Empathy is a strong predictor Empathy is a strong predictor Working alliance predicts outcome Working alliance predicts outcome Some counselors have outstandingly poor outcomes Some counselors have outstandingly poor outcomes Confrontation is associated with poor outcomes Confrontation is associated with poor outcomes

24 Ergo: Pay attention to the relational process of treatment Hire counselors who are already skilled in accurate empathy and evidence-based treatment methods Hire counselors who are already skilled in accurate empathy and evidence-based treatment methods Monitor retention and outcomes by counselor Monitor retention and outcomes by counselor Bring treatment out of the closet – make observed practice the norm Bring treatment out of the closet – make observed practice the norm Time to stop funding confrontational treatment practices Time to stop funding confrontational treatment practices

25 5. Drug problems are affected by social context Regional differences in prevalence Regional differences in prevalence Social norms have important impact Social norms have important impact Availability promotes use/problems Availability promotes use/problems Availability of competing reinforcers is protective (as is meaningful social role) Availability of competing reinforcers is protective (as is meaningful social role) Social modeling affects use/nonuse Social modeling affects use/nonuse Parental monitoring is protective Parental monitoring is protective

26 Ergo: Look beyond the individual for the causes of and solutions to drug use and problems Address social-community factors in prevention Address social-community factors in prevention Involve the family in treatment Involve the family in treatment Understand, use, and change the clients community context Understand, use, and change the clients community context

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