 | Minding Your Mind | | |
Treating Addictions -- Act Sober
September 25, 2008  By Michael Craig Miller, M.D.
Harvard Medical School Addictions — whether to drugs, alcohol or tobacco — are common and difficult to break. Addiction is not a moral problem. Rather, it's a brain problem: Drugs change the brain's self-regulating mechanisms, which means a persistent loss of self-control. Maybe that's why the Alcoholics Anonymous (AA) advice to new members — to "fake it till you make it" or "act as if" — is so well-established. The idea is, follow AA's 12-steps — even if you are initially skeptical — and the program will help you avoid addictive behaviors. In other words, if you want to be successful in your sobriety, you must develop new habits to replace the old ones Research suggests that the AA veterans may be onto something: You're more likely to stop abusing a substance and maintain abstinence by focusing at first on changing your behavior rather than changing your thinking and attitudes. Back to top Evaluating Treatment Approaches The National Institute on Drug Abuse (NIDA) Collaborative Cocaine Treatment Study, which was conducted in the 1990s, enrolled almost 500 patients who were cocaine-dependent. They were randomly assigned to one of four treatments: - Group drug counseling alone consisting of group discussions focusing on patients helping each other solve problems encountered in recovery
- Group drug counseling combined with individual drug counseling that focused on helping patients achieve and maintain abstinence through behavioral changes, such as avoiding situations that trigger drug use
- Group drug counseling combined with cognitive therapy (what they thought or believed about their drug use)
- Group drug counseling combined with supportive-expressive therapy (how their drug use affected their personal relationships)
All of the participants were encouraged to attend 12-step programs like AA or Cocaine Anonymous. Cocaine use decreased no matter which treatment group a person was in: Over the course of a year, drug use dropped from 10 days per month to three days per month. Which one worked best? A combination of individual drug counseling (IDC) and group drug counseling (GDC). After six months, about 4 out of 10 people in the IDC-GDC group reported using cocaine in the previous month, while almost 6 out of 10 people receiving cognitive behavior therapy plus GDC were using. Of those receiving supportive-expressive psychotherapy plus GDC, or GDC alone, about half continued to use cocaine. According to the researchers, combined drug-counseling treatment may have worked better than the alternatives because it delivers the simple and strong message: Stay away from the situations where you use drugs and the people you used drugs with. One unexpected, but significant finding was that the IDC-GDC intervention proved most likely to change drug-related attitudes. This is surprising, because this was the group receiving therapy that did not involve exploring attitudes. Rather, it was focused exclusively on behavior change. The fact that the IDC-GDC combination worked best thus raised a question: Why would focusing solely on behavior be more effective than cognitive-based approaches that focus on changing beliefs? Back to top Why Behavior Before Thought? One way of explaining the results is based on the "reverse causation theory" of behavior change. According to this theory, behavior comes first and thoughts later — the reverse of what we imagine. Some people who are forced by the courts or pressured by family members to attend 12-step meetings stop using drugs. These individuals think their behavior change is a result of their participation in the group rather than as a response to legal or family pressure. In the end, they feel more committed to the 12-step approach, and that in turn helps to reinforce the new behaviors. The second explanation is that addiction exerts such a powerful hold on people, physically and mentally, that an intensive focus on behavior is necessary to give the person a chance to successfully resist using. In contrast, if a person has a disorder that involves distorted thinking — such as depression or panic — he or she may be more likely to benefit from cognitive interventions. Back to top Alternatives to 12-Step Meetings What about people who don't want to attend 12-step meetings? A follow-up analysis of the NIDA study suggests alternative approaches. Investigators analyzed study records to find out which participants had actually gone to 12-step meetings and which ones felt that reading the literature or calling a sponsor for support were all they were willing to do. The researchers found that passive attendance at meetings without participation did not increase the chances of success. Rather, active participation — speaking up in the meeting, for example — resulted in less drug use. This implies that people who are reluctant to attend 12-step support groups might still benefit if they add an active component to their treatment, such as reading literature or getting involved with online meetings. However, more research is needed to find out if this approach would actually work. Back to top The Bottom Line The NIDA study shows that behavior change may need to come before changing thoughts and attitudes if you're trying to overcome an addiction. It seems you don't have to understand why or how changing your behaviors works. But you probably do need counseling, encouragement and support to take a leap and change that behavior. This may seem like too much pretending, but — in the case of addiction — there is at least some evidence now that acting "as if" has merit. Back to top Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.
| 
