Treating Addictive Behaviors. Processes of Change

Transcription

1 Treating Addictive Behaviors Processes of Change

2 APPLIED CLINICAL PSYCHOLOGY Series Editors: Alan S. Bellack, Medical College of Pennsylvania at EPPI, Philadelphia, Pennsylvania, and Michel Hersen, University of Pittsburgh, Pittsburgh, Pennsylvania Current Volumes in this Series BEHAVIORAL ASSESSMENT AND REHABILITATION OF THE TRAUMATICALLY BRAIN DAMAGED Edited by Barry A. Edelstein and Eugene T. Couture HANDBOOK OF ASSESSMENT IN CHILDHOOD PSYCHOPATHOLOGY Applied Issues in Differential Diagnosis and Treatment Evaluation Edited by Cynthia L. Frame and Johnny L. Matson HANDBOOK OF BEHAVIORAL GROUP THERAPY Edited by Dennis Upper and Steven M. Ross ISSUES IN PSYCHOTHERAPY RESEARCH Edited by Michel Hersen, Larry Michelson, and Alan S. Bellack A PRIMER OF HUMAN BEHAVIORAL PHARMACOLOGY Alan Poling THE PRIVATE PRACTICE OF BEHAVIOR THERAPY Sheldon J. Kaplan RESEARCH METHODS IN APPLIED BEHAVIOR ANAL YSIS Issues and Advances Edited by Alan Poling and R. Wayne Fuqua SEVERE BEHAVIOR DISORDERS IN THE MENTALLY RETARDED Nondrug Approaches to Treatment Edited by Rowland P. Barrett SUBSTANCE ABUSE AND PSYCHOPATHOLOGY Edited by Arthur I. Alterman TREATING ADDICTIVE BEHAVIORS Processes of Change Edited by William R. Miller and Nick Heather A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual ship ment. For further information please contact the publisher.

3 Treating Addictive Behaviors Processes of Change Edited by William R. Miller Univmily of New Mexico Albuquerque, New Merico and Nick Heather Universily of Dundee Dundee, Scolland Plenum Press New York and London

4 Treating addictive behaviors. Library of Congress Cataloging in Publication Data (Applied clinical psychology) Based on papers presented at the 3rd International Conference on Treatment of Addictive Behaviors, held at North Berwick, Scotland in Aug Includes bibliographies and index. 1. Compulsive behavior-treatment-congresses. 2. Substance abuse-treatment -Congresses. I. Miller, William R. II. Heather, Nick. III. International Conference on Treatment of Addictive Behaviors (3rd: 1984: North Berwick, Scotland) IV. Series. [DNLM: 1. Compulsive Behavior-therapy-congresses. 2. Substance Dependencetherapy-congresses. WM 176 T J RC533.T ' ISBN-13: e-isbn-13: : / Plenum Press, New York Softcover reprint of the hardcover 1 st edition 1986 A Division of Plenum Publishing Corporation 233 Spring Street, New York, N.Y All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

5 To Lillian and Richard W. R. M. In loving memory of Nicholas Heather N.H.

6 Contributors Helen M. Annis, Addiction Research Foundation, and University of Toronto, Toronto, Ontario, Canada Claus-Peter Appel, Department of Applied Psychology, University of Lund, Lund, Sweden Geir Berg, The Hjellestad Clinic, Hjellestad, Norway Gerhard Biihringer, Addiction Research Group, Department of Psychology, Max-Planck Institute for Psychiatry, Munich, West Germany Sabine Dehmel, Addiction Research Group, Department of Psychology, Max-Planck Institute for Psychiatry, Munich, West Germany Carlo C. DiClemente, Texas Research Institute of Mental Science, Houston, Texas Dennis M. Donovan, Department of Psychiatry and Behavioral Sciences, University of Washington, and Alcohol Dependence Treatment Program, Veterans Administration Medical Center, Seattle, Washington Christopher P. Freeman, Department of Psychiatry, University of Edinburgh, and Royal Edinburgh Hospital, Morningside Park, Edinburgh, Scotland Marcus Grant, Division of Mental Health, World Health Organization, Geneva, Switzerland vii

7 viii CONTRIBUTORS Nick Heather, Department of Psychiatry, Ninewells Medical School, University of Dundee, Dundee, Scotland Reid K. Hester, Behavior Therapy Associates, Albuquerque, New Mexico Joanne R. Ito, Department of Psychology, University of Washington, and Health Services Research and Development, Veterans Administration Medical Center, Seattle, Washington Frederick H. Kanter, Department of Psychology, University of Illinois, Champaign, Illinois Franz Klett, Addiction Research Group, Department of Psychology, Max-Planck Institute for Psychiatry, Munich, West Germany Simonne LeBreton, Addiction Research Foundation, Toronto, Ontario, Canada Gloria K. Litman, Addiction Research Unit, Institute of Psychiatry, London, England Barbara S. McCrady, Center of Alcohol Studies, Rutgers University, Piscataway, New Jersey William R. Miller, Department of Psychology, University of New Mexico, Albuquerque, New Mexico Jim Orford, Department of Psychology, University of Exeter, Exeter, England James O. Prochaska, Department of Psychology, University of Rhode Island, Kingston, Rhode Island Howard Rankin, St. Andrew's Hospital, Northampton, England Martin Raw, Department of Psychology, St. George's Hospital Medical School, London, England Bruce Ritson, Department of Psychiatry, University of Edinburgh, Andrew Duncan Clinic, Royal Edinburgh Hospital, Edinburgh, Scotland lan Robertson, Department of Psychology, Astley Ainslie Hospital, Edinburgh, Scotland

8 CONTRIBUTORS ix David Robinson, Addiction Research Centre, University of Hull, Hull, England Arvid Skutle, The Hjellestad Clinic, Hjellestad, Norway Stephen Sutton, Addiction Research Unit, Institute of Psychiatry, London, England D. Adrian Wilkinson, Addiction Research Foundation, Toronto, Ontario, Canada

9 Preface About a decade ago, psychologists began exploring the commonalities among alcohol and drug abuse, smoking, and obesity. The term substance abuse evolved into the current concept of addictive behaviors, which recognizes similarities with other behaviors that do not involve consummatory responses (e.g., pathological gambling, compulsions, sexual deviations). Professional societies and journals now have been founded in both Britain and the United States with the purpose of focusing on research and treatment in the area of addictive behaviors. As the field has evolved, new models have emerged to address the questions and puzzles that face professionals. This volume examines some of these current issues and, in particular, explores common processes of change that seem to cut across the addictive behaviors. The chapters are based on papers presented at the Third International Conference on Treatment of Addictive Behaviors, which was held at North Berwick, Scotland, in August of The conference was organized around an integrative model of stages and processes of change that has been useful in organizing new knowledge about how to intervene with addictive behaviors. This model is set forth by its authors, Jim Prochaska and Carlo DiClemente, in Chapter 1. In Chapter 2, Fred Kanfer expounds his own model of self-regulation, which overlaps nicely with the Prochaska-DiClemente framework and provides a behavioral-theoretical context. The remainder of the book is organized around stages at which clients come into treatment, and at which professionals are called on to intervene. Part II addresses issues of motivation for change. Marcus Grant opens this section with a commentary on the roles of the World Health Organization in engendering change in the addictive behaviors. Claus-Peter Appel explores applications of experimental social psycholxi

10 xii PREFACE ogy in general, and decision-making models in particular, to problems of individual client motivation. Jim Orford discusses research on the critical minimal conditions for change, and Steve Sutton reviews data on how smokers decide to quit. Part III, the largest section of this volume, is a compendium of theory and research on how people change once they begin taking action to alter addictive behaviors. Miller and Hester, in two chapters, first survey current knowledge on the effectiveness of alternative treatments for alcohol abuse, then review research on matching clients with optimal intervention approaches. Geir Berg and Arvid Sku tie present the results of an early intervention program for Norwegian problem drinkers. Chris Freeman discusses the eating disorders and raises controversial questions as to whether all of these should be classed with the addictive behaviors. Two chapters describe and evaluate behavioral treatment programs for drug abusers in Toronto (Wilkinson and LeBreton) and Munich (Dehmel, Klett, and Biihringer). The literature on smoking cessation methods is summarized by Martin Raw. The remaining six chapters in Part III explore important aspects of treatment and change that transcend particular intervention approaches. David Robinson traces the history and role of mutual-aid groups. Barbara McCrady discusses family involvement in addictive behaviors and the change process, reporting the results of a study and incorporating the larger literature on social support. Ian Robertson explores the applicability of cognitive theory and research in understanding and treating addictive behaviors. Nick Heather expounds on the use of self-help manuals to assist individuals in changing their behavior, clarifying the most common method by which people change: self-directed change without the aid of a therapist. The transtheoretical issue of dependence remains important for addictive behaviors, and Howard Rankin presents theoretical perspectives and recent experimental evidence relevant to treatment. Finally, Bruce Ritson commends "the merits of simple intervention," pointing to data that suggest that we have been making treatment and change altogether too expensive and complicated, bypassing some relatively simple interventions that suffice for a large percentage of clients. Any professional working in this field recognizes that initial change is only a beginning and is no guarantee of long-range success. One of the more important insights of the past decade has been increased awareness of the need for special measures to prevent relapse. Gloria Litman provides an exegesis of her "survival" model for predicting and preventing relapse in addictive behaviors, and Helen Annis presents a comprehensive approach by which relapse risk can be assessed and reduced. In the final chapter of this volume, Joanne Ito and Dennis

11 PREFACE xiii Donovan evaluate research on approaches to aftercare following the active treatment or change phase. We are enthusiastic about the progress that is represented in this volume. The convergence of work from a wide variety of settings is obvious. Our contributors represent the nations of Canada, England, Norway, Scotland, Sweden, Switzerland, the United States, and West Germany. Their professions include psychiatry, psychology, public health, and sociology. The participants in the conference itself represented a still broader range of nations and professions. We are encouraged not only by the increasing international interest in addictive behaviors, but also by the consistency of findings that emerge from welldesigned research across diverse settings. Clear progress is being made toward more efficacious and cost-effective treatment of these costly, perplexing, and often devastating problem behaviors. The editing of an international volume of this kind poses special challenges. English represents a second or third language for some of the contributors, and we express our admiration for their multilingual skills. In conventions of spelling, we have for consistency adhered to U.S. forms, and referencing in all chapters conforms to the publication standards of the American Psychological Association. WILLIAM R. MILLER NICK HEATHER

12 Acknowledgments We wish to express our gratitude to those who made special contributions to the quality of this volume. We particularly express our appreciation to Ian Robertson for his help in organizing and arranging the Third International Conference on Treatment of Addictive Behaviors. We also thank Eliot Werner, our editor at Plenum Press, for his encouragement and assistance in the publication process. We acknowledge with appreciation the assistance of the following organizations, which provided partial funding for the conference while allowing us complete freedom to determine speakers and content: the Alcohol Education and Research Fund, the Brewers' Society, and the Scotch Whisky Association. Both the conference and the preparation of this book were supported in important ways by the New Directions in the Study of Alcohol Group, the University of Dundee, and the University of New Mexico. Finally, we are grateful to the many colleagues who participated in the Scottish conference, bringing their enthusiasm and expertise to the task of taking one more step toward the alleviation of the human suffering surrounding the addictive behaviors. xv

13 Contents PART I. CHANGE IN THE ADDICTIVE BEHAVIORS CHAPTER 1. Toward a Comprehensive Model of Change 3 James O. Prochaska and Carlo C. DiClemente CHAPTER 2. Implications of a Self-Regulation Model of Therapy for Treatment of Addictive Behaviors 29 Frederick H. Kanfer PART II. CONTEMPLATION: MOTIVATION FOR CHANGE AND PREVENTION CHAPTER 3. From Contemplation to Action: The Role of the World Health Organization 51 Marcus Grant CHAPTER 4. From Contemplation to Determination: Contributions from Cognitive Psychology 59 Claus-Peter Appel CHAPTER 5. Critical Conditions for Change in the Addictive Behaviors 91 Jim Orford xvii

14 xviii CONTENTS CHAPTER 6. Trying to Stop Smoking: A Decision-Making Perspective 109 Stephen Sutton PART III. ACTION: ASPECTS AND PROCESSES OF CHANGE CHAPTER 7. The Effectiveness of Alcoholism Treatment: What Research Reveals 121 William R. Miller and Reid K. Hester CHAPTER 8. Matching Problem Drinkers with Optimal Treatments 175 William R. Miller and Reid K. Hester CHAPTER 9. Early Intervention with Problem Drinkers 205 Geir Berg and Arvid Skutle CHAPTER 10. Strategies of Change in Eating Disorders 221 Christopher P. Freeman CHAPTER 11. Early Indications of Treatment Outcome in Multiple Drug Users 239 D. Adrian Wilkinson and Simonne LeBreton CHAPTER 12. Description and First Results of an Outpatient Drug- Free Treatment Program for Opiate Dependents 263 Sabine Dehmel, Franz Klett, and Gerhard Biihringer CHAPTER 13. Smoking Cessation Strategies 279 Martin Raw CHAPTER 14. Mutual Aid in the Change Process 289 David Robinson

15 CONTENTS xix CHAPTER 15. The Family in the Change Process Barbara S. McCrady 305 CHAPTER 16. Cognitive Processes in Addictive Behavior Change 319 Ian Robertson CHAPTER 17. Change without Therapists: The Use of Self-Help Manuals by Problem Drinkers 331 Nick Heather CHAPTER 18. Dependence and Compulsion: Experimental Models of Change 361 Howard Rankin CHAPTER 19. Merits of Simple Intervention 375 Bruce Ritson PART IV. MAINTENANCE: PREVENTING RELAPSE CHAPTER 20. Alcoholism Survival: The Prevention of Relapse 391 Gloria K. Litman CHAPTER 21. A Relapse Prevention Model for Treatment of Alcoholics 407 Helen M. Annis CHAPTER 22. Aftercare in Alcoholism Treatment: A Review 435 Joanne R. lto and Dennis M. Donovan Index 457