Active ingredients within the processes of successful addiction treatment and recovery

IMG_3699“For nearly five decades, Rudy Moos, PhD, has been one of the giants of modern addiction research. I believe he has, more than any other research scientist, focused on questions of the greatest import to addiction counselors and the individuals and families they serve. His published studies have dramatically expanded our knowledge of addiction treatment and the processes of long-term addiction recovery.” William L White

That is one hell of an introduction to Rudolf Moos, in my humble opinion one of the great addiction researchers of our time. Bill White’s comments come at the beginning of a very interesting interview he conducted with Rudolf in 2011.  

In this interview, Bill asks Rudolf if he would summarise the core principles that have been revealed by his research that illuminate the active ingredients within the processes of successful addiction treatment and recovery. Here is what Rudolf had to say (I’ve changed some of the paragraphs and omitted references for clarity purposes):

Principle 1. Treated or untreated, an addiction is not an island unto itself.
People with addictive disorders exist in a complex web of social forces, not on an island unto themselves, free of social context. Formal treatment can be a compelling force for change, but it typically has only an ephemeral influence.

In contrast, relatively stable factors in people’s lives, such as informal help and ongoing social resources, tend to play a more enduring role.

Moreover, a recovery that is sustained after treatment is not due simply to treatment; it is nurtured by the same sets of factors that maintain the resolution of problems without treatment.

This contextual perspective highlights the need for a fundamental shift in thinking about intervention programs and evaluating their effects. Many of the hard-won gains of intervention programs fade away over time.

This is precisely as expected on the basis of our knowledge about environmental impact and the diversity of contexts to which individuals are exposed. An intervention program is but one of multiple life contexts. Other powerful environments also shape mood and behavior; ongoing environmental factors can augment or nullify the short-term influence of an intervention.

The fact that the evolving conditions of life play an essential role in the process of remission from addictive disorders is a hopeful sign. It implies that these disorders need not become chronic, that individuals who are able to establish and maintain relatively positive social contexts are likely to recover, and that treatment directed toward improving individuals’ life circumstances is likely to be helpful.

Principle 2. Common dynamics underlie the process of problem resolution that occurs in formal treatment, informal care, and “natural” recovery.
Individuals trying to resolve substance abuse problems usually begin by using one or more sources of informal help, such as a family member or friend, a physician or member of the clergy, or AA or another self-help group.

If such attempts fail repeatedly, some individuals enter formal treatment. On average, these individuals have more severe problems and more difficult life contexts, and are more impaired than individuals who resolve problems on their own or with informal help; outside help may be especially needed when an individual has few personal or social resources on which to base a recovery.

Nevertheless, it may not be important or fruitful to distinguish between problem resolution that occurs with or without treatment. There is no compelling conceptual reason to distinguish between the influence of an AA sponsor, a spouse or partner, and a relative or friend versus that of a counselor or psychotherapist on an individual’s substance use problems.

The cognitive and social processes that underlie the resolution of addictive problems are common to formal treatment and informal help, and the other dynamics of change are likely to be similar, regardless of the context in which they occur.

In addition, any distinction between life context and informal help or formal treatment is arbitrary: when individuals enter an intervention program, it becomes part of their life context.

Ongoing life settings and intervention programs are comparable in that both establish a context for individual development or dysfunction, both involve person–environment matching processes, and both may be altered by the participants they seek to alter.

Moreover, both are environmental conditions that can be characterized by common social processes, as embodied by the quality of interpersonal relationships, the goals, and the structure of the setting.

Principle 3. The duration and continuity of care are more closely related to treatment outcome than is the amount or intensity of care.
Although patients with substance use disorders who receive more outpatient mental health care tend to have better short-term outcomes, there is growing evidence that the duration of care is more important than the amount of care.

In a sample of more than 20,000 patients who participated in a nationwide program to monitor the quality of care in the Department of Veterans Affairs, we found that patients who had a longer episode of mental health care had better risk-adjusted substance use, family, and legal outcomes than did those who had a shorter episode. These findings held after the intensity of care was controlled.

Drug-dependent patients with longer episodes of residential or outpatient care experience better substance use and crime-related outcomes than do patients with shorter episodes.

In other studies, we found that patients who obtained outpatient mental health care over a longer interval had better 1-year substance use outcomes and were more likely to be remitted at 2 years than were patients who had outpatient care for a shorter interval.

The findings were comparable among patients from community-based residential settings; moreover, after the duration of outpatient mental health care was controlled, the amount of care did not independently predict 1-year outcomes.

The finding that the duration of treatment for alcohol and drug use disorders is more closely related to outcome than is the sheer amount of treatment is consistent with the fact that the enduring aspects of individuals’ life contexts are associated with the recurrent course of remission and relapse.

Thus, low-intensity, telephone-based case monitoring delivered by paraprofessional personnel may be an effective long-term treatment strategy for many patients.

My recent thinking in these areas has led me to speculate that comparable processes underlie successful treatment and self-help groups, as well as long-term recovery.

In this vein, there are four related theories that specify common social processes that protect individuals from developing substance use disorders and may underlie effective psychosocial treatments for these disorders: social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory.

These common social processes include:

  • support, goal direction, and structure;
  • an emphasis on rewards that compete with substance use;
  • a focus on abstinence-oriented norms and models; and
  • attempts to develop self-efficacy and coping skills.

I believe that effective psychosocial treatments for substance use disorders (such as motivational interviewing and motivational enhancement therapy, 12-step facilitation treatment, cognitive behavioral treatment and behavioral family counseling, and contingency management and community reinforcement) incorporate these common processes.

Moreover, I think that self-help groups incorporate these same active ingredients.

Again, these active ingredients are:

  1. bonding, goal direction, and structure (consistent with social control theory);
  2. the importance of abstinence-oriented norms and role models (consistent with social learning theory);
  3. an emphasis on involvement in rewarding activities other than substance use (consistent with behavioral economics and behavioral choice theory);
  4. and the building of self-efficacy and effective coping skills (consistent with stress and coping theory).

A number of studies suggest that the emphasis on these active ingredients underlies some aspects of the effectiveness of self-help groups. In addition, these same active ingredients appear to underlie the process of stable remission and recovery.

Intriguing stuff! What do you think?

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