Adolescent Risk Taking: They May Be More Rational Than We First Thought
A truism in the field of alcohol, other drug, and violence prevention, at least historically, has been that adolescent risk taking is the result of impulsive choices driven by an under developed capacity to think rationally. This belief has driven the work of AODV prevention professionals for years...up to and including the present. But recent research coming out of Temple and Cornell Universities is suggesting that this staple of conceptualizing prevention programming for high school and college adolescents may need to be revisited...if not rethought.
" Decision research shows that adolescents make the risky judgments they do because they are actually, in some ways, more rational than adults. Grownups tend to quickly and intuitively grasp that certain risks (e.g., drunk driving, unprotected sex, and most anything involving sharks) are just too great to be worth thinking about, so they don't proceed down the "slippery slope" of actually calculating the odds. Adolescents, on the other hand, actually take the time to weigh risks and benefits — possibly deciding that the latter outweigh the former. (It is during adolescence, in fact, that the parts of the frontal lobe that govern risk/reward calculations undergo significant maturation.)" This is a quote from a piece published in the Association of Psychological Science's Observer - see http://bit.ly/aJBUr3 for the full piece.
This is a very intriguing piece of information. If this is true--and the science appears to exist to suggest that it is--this may mean that we involved in the prevention of "high-risk" drinking and other drug use by high school and college students may need to rethink our approach to prevention, not to mention the term used to refer to the type of drinking these students do. Most of us involved in the prevention of "high-risk" collegiate drinking are aware of the controversy that has existed in the field regarding how to refer to collegiate drinking since the Harvard School of Public Health coined the term "binge drinking" in 1994 to refer to the consumption of 4+ drinks for women and 5+ drinks for men during an outing. The field has been divided as to the utility of this term when discussing the phenomenon of collegiate drinking ever since - see my essay on the subject -- http://bit.ly/aT3UgS
In that 2003 essay I suggested referring to this type of collegiate drinking as being "high-risk," but it would appear that this too may be no better a moniker for this type of collegiate imbibing than is "binge drinking." If, as I suspect, Drs. Reyna at Cornell and Farley at Temple are correct, we in the prevention field need to not only rethink how we approach adolescents with our prevention messages, but revisit the language we use when doing so as well. If there is a "Type-T" personality (Thrill-seeking) as these researches proffer, this type of student may actually be titillated by our messages designed to reduce "high-risk" consumption. Perhaps Linda Lederman's suggestion to refer to this type of collegiate drinking as dangerous is the more appropriate way to proceed.
What do you think?
Robert
27 January 2010
18 January 2010
Your Cerebral Cortex Can't Overcome Your Nucleus Accumbens...
...or so a physician friend tells me. The point he was making is that we--practitioners treating addictive disorders or individuals experiencing them--cannot change addictive behavior with information and knowledge alone. True, information can be useful in motivating an individual to move from a pre-contemplative stage of readiness to change to a contemplative stage, but this is movement as regards "readiness to change" and does not directly translate into change per se.
It is true that one will never move from a point of seeing alcohol or other drug use as a solution to a life problem until and unless able to recognize his or her substance use as a problem--the cost of continuing is greater than the cost of changing. It is likewise true that the first step in this metamorphosis is beginning to question the substance use as a "solution" to one's life problems. This happens as individuals step back and can see the bigger picture, thereby beginning to recognize that, "what cause a problem is a problem because it causes a problem."
The cerebral cortex is that part of the brain responsible for much of the higher functioning that separates us humans from other creatures in the animal kingdom. It is our ability to think and reason, to problem solve and to learn as the result of our experience that builds the bridge from the past through the present to the future where change can take place. This earns us our cherished position at the top of the evolutionary ladder. But the physiological and neurochemical rewards that are associated with substance use, rewards that can be connected to a much more primitive but nonetheless necessary function of the human brain, that helps explain addiction.
Once addicted, there is a demonstrable process by which the use of substances results in the activation of a "pleasure pathway" of sorts, and the nucleus accumbens is an integral part of that pathway. Once activated, mere information and knowledge about addiction, substance use disorders and/or consequences associated with the continued use of my drugs of choice are not going to supersede the physiological rewards associated with continued substance use.
To be succinct, logic and reason are no match for the physiology of addiction or, to reiterate my friend's quip, "your cerebral cortex can't overcome your nucleus accumbens." That said, the prevention of substance use disorders requires a concerted effort that addresses a number of factors. As individuals with addictions are able to move along the continuum of readiness to change from a pre-contemplative stage of readiness where the substance use is actually perceived to be a solution to life's problems to the next stage on the continuum, "contemplation," where change is not yet a perceived option, but the use is no longer viewed as a solution. It is this ambivalence that is actually welcomed by those practicing motivational interviewing rather than viewed with disdain and attacked as indicative of denial.
This movement along the continuum of readiness to change comes as practitioners resist the temptation to confront the user, which historically has been predicated upon the belief that a refusal to change behavior, even when willing to change perspective, is tantamount to denial. The traditional approach to counseling addicted individuals, even in a contemplative stage of readiness to change, has been to confront the user directly in an attempt to "break through" the denial and, as William Miller, the father of Motivational Interviewing has written, "wrestle" the addicted individual into submission. This is tantamount to the bully on the playground that engages his adversary and does not stop until the victim cry, "uncle!"
Miller goes on to suggest that counselors therefore have two choices when engaging an addicted individual: (1) to wrestle with that client in an adversarial relationship where counseling’s success necessitates client failure, or (2) to dance with the client. Notice the difference in these two metaphors; both clearly cast the counselor in the lead position, but as any ballroom dancer will tell you, the pair collaborate in a symbiotic relationship built on mutual respect for the other and his or her role in accomplishing the end goal..
To return to my opening admonishment; knowledge may appeal to the cerebral cortex, but it does not hold sway over the nucleus accumbens. Yet historically, prevention programs have been heavily if not exclusively steeped in delivering information in the misguided belief that rational beings will make good choices, avoiding high-risk and dangerous behaviors, if only they are given the information and knowledge on which to base those decisions. And as if this placement of all the prevention eggs in the knowledge enhancement basket were not enough, the information presented has tended to be at the same time negative--"this is your brain...this is your brain on drugs..." and steeped in scare tactics, as if the combination of knowledge and fear would be sufficient to void the activation of the pleasure pathway in the brain.
So the next time you are tempted to intervene in the high-risk behavior of a client, acquaintance, or loved one with a lecture or information about the risks and consequences associated with substance use, remember, "Your cerebral cortex can't overcome your nucleus accumbens."
What do you think?
Robert
...or so a physician friend tells me. The point he was making is that we--practitioners treating addictive disorders or individuals experiencing them--cannot change addictive behavior with information and knowledge alone. True, information can be useful in motivating an individual to move from a pre-contemplative stage of readiness to change to a contemplative stage, but this is movement as regards "readiness to change" and does not directly translate into change per se.
It is true that one will never move from a point of seeing alcohol or other drug use as a solution to a life problem until and unless able to recognize his or her substance use as a problem--the cost of continuing is greater than the cost of changing. It is likewise true that the first step in this metamorphosis is beginning to question the substance use as a "solution" to one's life problems. This happens as individuals step back and can see the bigger picture, thereby beginning to recognize that, "what cause a problem is a problem because it causes a problem."
The cerebral cortex is that part of the brain responsible for much of the higher functioning that separates us humans from other creatures in the animal kingdom. It is our ability to think and reason, to problem solve and to learn as the result of our experience that builds the bridge from the past through the present to the future where change can take place. This earns us our cherished position at the top of the evolutionary ladder. But the physiological and neurochemical rewards that are associated with substance use, rewards that can be connected to a much more primitive but nonetheless necessary function of the human brain, that helps explain addiction.
Once addicted, there is a demonstrable process by which the use of substances results in the activation of a "pleasure pathway" of sorts, and the nucleus accumbens is an integral part of that pathway. Once activated, mere information and knowledge about addiction, substance use disorders and/or consequences associated with the continued use of my drugs of choice are not going to supersede the physiological rewards associated with continued substance use.
To be succinct, logic and reason are no match for the physiology of addiction or, to reiterate my friend's quip, "your cerebral cortex can't overcome your nucleus accumbens." That said, the prevention of substance use disorders requires a concerted effort that addresses a number of factors. As individuals with addictions are able to move along the continuum of readiness to change from a pre-contemplative stage of readiness where the substance use is actually perceived to be a solution to life's problems to the next stage on the continuum, "contemplation," where change is not yet a perceived option, but the use is no longer viewed as a solution. It is this ambivalence that is actually welcomed by those practicing motivational interviewing rather than viewed with disdain and attacked as indicative of denial.
This movement along the continuum of readiness to change comes as practitioners resist the temptation to confront the user, which historically has been predicated upon the belief that a refusal to change behavior, even when willing to change perspective, is tantamount to denial. The traditional approach to counseling addicted individuals, even in a contemplative stage of readiness to change, has been to confront the user directly in an attempt to "break through" the denial and, as William Miller, the father of Motivational Interviewing has written, "wrestle" the addicted individual into submission. This is tantamount to the bully on the playground that engages his adversary and does not stop until the victim cry, "uncle!"
Miller goes on to suggest that counselors therefore have two choices when engaging an addicted individual: (1) to wrestle with that client in an adversarial relationship where counseling’s success necessitates client failure, or (2) to dance with the client. Notice the difference in these two metaphors; both clearly cast the counselor in the lead position, but as any ballroom dancer will tell you, the pair collaborate in a symbiotic relationship built on mutual respect for the other and his or her role in accomplishing the end goal..
To return to my opening admonishment; knowledge may appeal to the cerebral cortex, but it does not hold sway over the nucleus accumbens. Yet historically, prevention programs have been heavily if not exclusively steeped in delivering information in the misguided belief that rational beings will make good choices, avoiding high-risk and dangerous behaviors, if only they are given the information and knowledge on which to base those decisions. And as if this placement of all the prevention eggs in the knowledge enhancement basket were not enough, the information presented has tended to be at the same time negative--"this is your brain...this is your brain on drugs..." and steeped in scare tactics, as if the combination of knowledge and fear would be sufficient to void the activation of the pleasure pathway in the brain.
So the next time you are tempted to intervene in the high-risk behavior of a client, acquaintance, or loved one with a lecture or information about the risks and consequences associated with substance use, remember, "Your cerebral cortex can't overcome your nucleus accumbens."
What do you think?
Robert
11 January 2010
Motivating Physicians to View Treating Addictions Differently
I suspect that an important part of having an impact on an audience composed of medical students and physicians is being able to invite them to see beyond any individual case of effective treatment, e.g., "the case of Brad," and focus on a more generic patient with an addictive disorder. They will all know of or at least heard of patients who “quit.” For them to become motivated to consider doing something different, however, they are going to have to see beyond "Brad" and recognize that “these patients,” that is, "addicted patients," can change and the way they change is by my doing “more of this” and “less of that.” This is the challenge I believe we face when inviting physicians to rethink the treatment of patients with addictive disorders. I suspect physicians may be more motivated to consider changes in their treatment strategies if seeing the “The case of Brad” as the result of an effective process to which "Brad" responded rather than something idiosyncratic about him as an individual that resulted in, for lack of a better term, a spontaneous remission.
When presented with the opportunity to speak with physicians or medical students, my goal is to impress upon at least some in the audience that: (1) change is an inside job, i.e., “physicians do not change patients (at least those with addictive disorders), but patients change patients,” and (2) the physician’s job with addicted patients is almost counter intuitive when considering what physicians generally do when treating “real” diseases. Historically, physicians conduct a differential diagnosis, prescribe a course of medical treatment, administer that treatment, follow-up on that treatment, and then discharge the patient...end of story. At best, the patient is a passive participant in the change process. With addictive disorders, however, nothing changes until and unless the patient makes that internal decision—choice, if you will, to change...the “inside job” mentioned earlier. Basic factors in the “keys to success” when treating an addictive disorder are: (1) recognizing that the addicted individual has progressed from a pre-contemplative stage of readiness to change to an action stage and eventually on to a maintenance stage, and (2) this happened because the individual realized he or she wanted to change rather than felt obligated or manipulated or forced to do so...again, the “inside job.”
I do not believe that the way to motivate physicians to think about treating addiction differently is to charm them into doing medicine with addicts differently—they will have 100 examples of how treatment does not work and even more reasons why this is so. Rather, it is to present them with a way to lessen their personal frustration when working with addicted patients. Put another way, we cannot push them into treating addicted patients differently, but we might be able to lure them into reducing their personal frustration when interacting with such a patient. It is sort of like Tom Sawyer getting his buddy to paint Aunt Polly’s fence...he entices the buddy to want to have the experience rather than talk him into doing his work for him.
As Sandra Anise Barnes has suggested in her poetry, "It is so hard when I have to (change), and so easy when I want to."
What do you think?
Robert
I suspect that an important part of having an impact on an audience composed of medical students and physicians is being able to invite them to see beyond any individual case of effective treatment, e.g., "the case of Brad," and focus on a more generic patient with an addictive disorder. They will all know of or at least heard of patients who “quit.” For them to become motivated to consider doing something different, however, they are going to have to see beyond "Brad" and recognize that “these patients,” that is, "addicted patients," can change and the way they change is by my doing “more of this” and “less of that.” This is the challenge I believe we face when inviting physicians to rethink the treatment of patients with addictive disorders. I suspect physicians may be more motivated to consider changes in their treatment strategies if seeing the “The case of Brad” as the result of an effective process to which "Brad" responded rather than something idiosyncratic about him as an individual that resulted in, for lack of a better term, a spontaneous remission.
When presented with the opportunity to speak with physicians or medical students, my goal is to impress upon at least some in the audience that: (1) change is an inside job, i.e., “physicians do not change patients (at least those with addictive disorders), but patients change patients,” and (2) the physician’s job with addicted patients is almost counter intuitive when considering what physicians generally do when treating “real” diseases. Historically, physicians conduct a differential diagnosis, prescribe a course of medical treatment, administer that treatment, follow-up on that treatment, and then discharge the patient...end of story. At best, the patient is a passive participant in the change process. With addictive disorders, however, nothing changes until and unless the patient makes that internal decision—choice, if you will, to change...the “inside job” mentioned earlier. Basic factors in the “keys to success” when treating an addictive disorder are: (1) recognizing that the addicted individual has progressed from a pre-contemplative stage of readiness to change to an action stage and eventually on to a maintenance stage, and (2) this happened because the individual realized he or she wanted to change rather than felt obligated or manipulated or forced to do so...again, the “inside job.”
I do not believe that the way to motivate physicians to think about treating addiction differently is to charm them into doing medicine with addicts differently—they will have 100 examples of how treatment does not work and even more reasons why this is so. Rather, it is to present them with a way to lessen their personal frustration when working with addicted patients. Put another way, we cannot push them into treating addicted patients differently, but we might be able to lure them into reducing their personal frustration when interacting with such a patient. It is sort of like Tom Sawyer getting his buddy to paint Aunt Polly’s fence...he entices the buddy to want to have the experience rather than talk him into doing his work for him.
As Sandra Anise Barnes has suggested in her poetry, "It is so hard when I have to (change), and so easy when I want to."
What do you think?
Robert
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