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In trying to make sense of the many different
self-injurious paths people take, we use words such as:
addiction, which gives the
misleading impression that different individuals suffer the same malady. In fact,
there are as many versions of addiction as
there are versions of the Psyche.
Substance abusers, overeaters, sex addicts, money losers,
etc. often make a serious commitment to change their ways, yet
relapse rates are high.
Only a small minority of graduates of alcohol, drug, nicotine,
and weight loss treatment
programs have achieved
their treatment goal and maintained it for one year.
Because of the high relapse
rates, it is often assumed that it doesn't matter which strategy is
selected because treatment doesn't work. In fact for any
individual, different treatment approaches produce vastly different
outcomes. Some strategies can do some individuals more harm than
good.
Meta-analysis of published data suggests that in
general the more intensive and rigid the treatment the worse the long-term outcome.1
The very notion of receiving treatment fosters dependence.
The patient's role is passive; the agent of change is external. Initially, the
presence of external controls can facilitate behavior
change, but when the external controls are not
available relapse is often the consequence.
Everyone is different,
and a life long involvement
with external support, such as a 12-Step support group is
truly the best
solution for many individuals.
I hope there is information here that will be useful to individuals well
matched with the philosophy, traditions, and social support that the
12-Step
movement offers.
However, this web site is specifically
designed for those interested in self-determination - that is using
one's own cognitive resources intentionally to have a
beneficial
influence on how one's biography unfolds.
Because of the differences among Psyches, selecting
the best treatment strategy for a given individual is the most important
clinical decision. Consider a 55-year-old unemployed,
chemically dependent, head injured alcoholic and a 22-year-old,
cognitively intact college student who just got her 3rd DUI.
A
treatment strategy that is most likely to promote good
outcome for one might be harmful for the other. Nevertheless, it would
surprise few clinical professionals to learn
that both received the same treatment program.
Addiction is a complex interplay of factors and is different for each
individual. For those whose addictions are serious enough to
require external assistance, the selection of
treatment strategy is of crucial importance.
Currently, the most popular way to treat chemical abusers is short term,
intensive, group programs. The typical
4-6 weeks of intensive outpatient treatment, or the even
more intensive and expensive inpatient
programs do not protect against relapse after the graduate has returned
to the high risk environment.
Within the first year of discharge the vast majority of the participants
of such programs relapse. The external behavioral controls
provided by the intensive program are no longer present, and
program participants have not developed the
internal controls to manage the stressors and
temptations they encounter. There is insufficient
attention to matching individuals to the treatment strategy best suited
to the individual participants. Consequently, many individuals get too
much or too little.
Impaired individuals need an
externally imposed structure for a much longer time than they are
currently getting. For some there is a need for permanent
supervision. However their are many substance abusers for whom
heavy handed treatment does more harm than good.
As a rule of thumb, the
more impaired the individual, the greater the
external control required to maintain addiction free periods.
Some operational definitions of "impairment" are listed below:
·
Cognitive impairment resulting from chronic substance abuse
·
Cognitive impairment due to other factors – eg. Head injury other
organic causes, low native intelligence.
·
Physical dependence on drug
·
Psychiatric impairment – e.g., mood disorder, thought disorder,
psychopathy
However some strategies work very well for one kind of patient and
very poorly for another. For example, high intensity
treatment produces better outcomes for more impaired individuals; the
opposite is true for higher functioning individuals. In one study,
Rychtarik and his colleagues found that clients high in drinking problem
severity or low in cognitive functioning benefited more from inpatient
than outpatient care; higher functioning individuals with
less severe drinking problems had better outcome with outpatient
treatment. Surprisingly, but consistent with the findings of other
studies, there was no difference between high intensity and low
intensity outpatient treatment. 1
There are many ways to respond to an addictive disorder, and for a given
individual some paths are much better than others. Those with the
intellect to have made it through this dense material are self-selected
as high functioning and may respond well to a
self-determination strategy - one with
minimal external influence.
Paradoxically, self-determination requires more effort than accepting
the passive patient role.
Footnotes
1..
Robert G. Rychtarik Gerard J. Connors Robert B. Whitney Neil B.
McGillicuddy James M. Fitterling Philip W. WirtzTreatment Settings for
Persons With Alcoholism Evidence for Matching Clients to Inpatient
Versus Outpatient Care Journal of Consulting and Clinical
Psychology April 2000 Vol. 68, No. 2, 277-289 |