The Likely Cause of Addiction Has Been Discovered, and It Is Not What You Think

http://www.huffingtonpost.com/johann-hari/the-real-cause-of-addicti_b_6506936.html

There is much to be said about the merits of Hari's argument outlined in the essay.  First—and foremost—the War on Drugs is, at best, an antiquated response to the drug problem and, at the worst, a monumental disconnect from the real problem of understanding SUD.  It is essentially based on the 18th-19th Century Moral Model of addiction that suggests that drugs are bad and therefore so are the people who use them.  Consequently, this view of addiction suggests that the way you deal with “bad people” is to punish them, and in our culture you punish “bad people” by incarcerating them.  As noted in the article, this not only does not deter use, it likely reinforces it. 

Next, we have long understood that boredom is highly correlated with both use and, for those pursuing recovery, relapse.  AA addresses this with its famous acronym, H.A.L.T.  When someone is “hungry,” “angry,” “lonely,” or “tired,” that individual is standing on the slippery slope of relapse.  It is tempting to infer that the Alexander “Rat studies” seem to indicate that the results of rats living in isolation vs. residing in “Rat Park” “explains” their penchant for consuming drugs and is somehow transferable to explaining human drug use, but we all know this is a spurious connection at best – correlation is not causation…and rat behavior, although informative, does not necessarily equate with human behavior.

I do believe, however, that the basic premise of this article—and I must confess that I have not read its author’s book nor those referenced in the article—that “drugs” do not cause addiction. I suspect that the etiology of addiction is more readily explained by social science than biological science.  It will not surprise me, for instance, to see our understanding of addiction move away from the current mainstream argument that addiction is a brain disease and that for those with this disease, that drugs "hijack the brain."  This does not mean that there is no physiological/genetic predisposition to addiction, as I suspect that there may well be, but I am becoming less convinced that addiction will ever be something that can be predicted via a simple blood test added to the mandated screen panel conducted on newborns labeling them at birth as “one of them."  I suggest this for many of the reasons Hari outlines in his article, namely that there are more likely socioeconomic and psychological variables that increase or decrease the one’s susceptibility to a SUD.

What the article does not seem to address is how do we explain the absence of addictive behavior in individuals who are exposed to the same isolated or socially dystopian environment yet do not turn to drugs?  Just as the argument that alcohol, tobacco, and marijuana are “gateway drugs” is questionable because it does not consider all users of these substances, including those who experimented with these substances, but do not go on to use these drugs let alone become addicted; we must be cautious about claiming that living in The Hunger Game’s “district 12-type” environment is the "cause" of addiction.

That said, it is not a new argument to suggest that the environment to which a recovering person returns affects the prognosis for sustained recovery.  We have known for decades that an unsupportive and/or drug using environment all but guarantees relapse.  What is interesting and worthy of further study, however, is the extent to which such environments affect the etiology of addiction.  What is it about/in those individuals who do not “turn to drugs” although exposed to the same environments that precludes their becoming SUD? (NOTE: I have raised a similar concern regarding high-risk collegiate drinking when suggesting that we can learn much to prevent such behavior by studying moderate drinkers and abstainers in order to understand why they make the choices they do when exposed to the same collegiate environment as the “binge-drinkers.” We spend way too much time and money studying the problem drinker rather than those who seem immune to it, but this is another discussion).

Frankly, I believe that there are multiple variables associated with “becoming addicted.”  These include the drugs themselves, but although drugs may be necessary for "drug addiction” to occur, they are not likely sufficient to explain its etiology.

Lastly, in this brief reaction to the article, a large area concerning addiction goes unaddressed and this suggests, at least for me, a potential “fly in the ointment” of Hari’s argument: what about the process addictions?  I suspect that individuals may seek refuge or relief from the boredom of a socioeconomically deprived existence, one with no access to job, education, adequate housing, etc., by turning to sex or gambling or other “addictive” behaviors, but this too requires more study :)

What do you think?

Robert

Cognitive-Behavioral Counseling and Effective Treatment

With any technique, there are a number of variables that affect the clinical outcome.  For example, a practitioner’s level of proficiency in employing a particular technique is a significant variable, as is

the individual’s basic prowess as a counselor.  Add to this the variables that can affect an individual’s ability to respond to counseling, for example, personal expectations of counseling, the propensity for optimism or pessimism, family/community support, etc., and you begin to see how the significance of a particular therapeutic approach can quickly  when considering “what works.”

Scott Miller, Mark Hubble, and Barry Duncan wrote an article entitled, No More Bells, and Whistles (to download a copy, visit http://bit.ly/1INZHhh) that reviews the sources of efficacious counseling.  They suggest that there are “4 common factors” that determine the outcome of counseling: (1) Therapeutic Technique (accounts for 15% of the outcome of counseling), (2) Expectancy and Placebo (15% of outcome) , (3) Therapeutic Relationship (30% of outcome), and (4) Client Factors (40%).  I will skip reviewing each of these 4 “factors,” but suffice it to say that in affecting but 15% of the outcome of counseling, debating the merits of a particular therapeutic approach while stimulating may be more of a footnote in the discussion than than issue of primacy.

It seems to me—and CBT-related techniques and cognitive theory (I always liked George Kelly’s Personal Construct Psychology) are frequently used tools in my counseling toolbox—that IF there were a theory of counseling that truly outperformed all the others, we would at least have a clear indication of its existence by now.  Rather we find practitioners employing various approaches claiming success in their work and the individuals they counseled reporting symptom relief.  This would seem to confirm, albeit unscientifically, what Miller et al. suggest in their article; that it is the therapeutic relationship itself and the individual factors the client brings to therapy that contribute the lion’s share of efficacious outcome in counseling.

There is no doubt that CBT has passed the rigors of scientific scrutiny regarding its efficacy.  What this suggests, to me however, is not so much that it should be used exclusively or even predominantly, but rather that it is deserving of consideration as an evidence-informed, best practice to which our students should be exposed.  So the issue for me is not that CBT is used “too much” or that it has taken on “rock star” status.  The issue is, does CBT—or any other counseling theory for that matter—enable me, as the practitioner, to understand my client’s presenting problem(s) in such as way that I can: (1) design an appropriate treatment strategy to affect symptom relief, (2) assist my client in understanding the nature of the presenting problem and its origin, and do so in such a way that ensures that the client recognizes that she or he has a problem rather than is the problem, and (3) can accomplish this in a reasonable amount of time with non-invasive and cost-effective strategies.

What do you think?

Robert