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One set of options for the reduction of dissonance consists of modifying appetitive behavior to make it compatible with other needs, with other values or attitudes, or with the desires of other significant figures such as husband, wife and other family members. It is in fact the principal argument of this part of the model that change, in the direction of moderation or abstinence, is a natural consequence of the development of strong appetite. This way of looking at the change process suggests a radical change of focus. Instead of assuming that addictions, like diseases, require expert treatment, we should be assuming that on the whole they do not require treatment, and trying to understand the real world, everyday processes whereby people make their own changes. This point of view was nicely summed up by Lindstrom (1991), who wrote: Perhaps psychosocial treatment research has started at the wrong end. Instead of moving from the top downward, it might be more profitable to move from the bottom up... it is my recommendation that research on treatment for alcohol problems should adopt a diversified strategy, with its main focus reoriented from the effects of specific techniques to natural healing processes, common therapeutic elements and effects of client-treatment interaction (p. 848).
There is every reason for agreeing with Lindstrom that the search for specific 'best' treatments is doomed (his first hypothesis). Expert treatments (as opposed to natural, unaided change) have been remarkably diverse and a strong case can be made for concluding that all credible treatments are effective to a more or less equal degree. This appears to be the case even when treatments differ markedly in intensity (e.g. treatment versus advice: Orford & Edwards, 1977); when treatments have utterly different theoretical rationales (e.g. 12-Step facilitation versus cognitive-behavioral: Project MATCH, 1997a, 1997b); when treatment focuses on the object of the addiction and when it does not (e.g. interpersonal versus cognitive-behavioral therapy for excessive eating: Agras, 1993; imaginal desensitization versus imaginal relaxation for excessive gambling: McConaghy et al., 1988); and even when theory-consistent treatment has been compared with counter-theoretical treatment (e.g. contingent versus non-contingent aversion for smoking: Carlin & Armstrong, 1968). Nor, in the light of the findings from Project MATCH (1997a, 1997b) can we hold out a great deal of hope for the idea of client-treatment-matching (Lindstrom's second hypothesis). Most of the hypothesized matches in that most statistically powerful of all studies to date were not supported, and those that were were mostly not strong nor replicated across the two arms (outpatient and aftercare) of the study. The conclusion was that, 'Despite the promise of earlier matching studies ... the intuitively appealing notion that matching can appreciably enhance treatment effectiveness has been severely challenged' (Project MATCH 1997b, p. 1690, but note the possible shortcomings of Project MATCH as well as its strengths, Project MATCH, 1999).
There is, on the other hand, abundant evidence that people can give up excessive appetites without the aid of expert treatment. The idea that tobacco smokers might make their own decisions to give up or moderate on the basis of the evidence available to them, perhaps with the aid of advice from their doctors or exhortations from their family, comes as no surprise. Despite the fact that tobacco smoking is by many criteria one of the most addictive of all activities, we have no difficulty conceiving of change as a perfectly ordinary, natural occurrence. The evidence that many excessive drinkers, indeed the majority, give up excess unaided by expert treatment (e.g. Sobell, Sobell & Toneatto, 1991) came as more of a surprise. Indeed, the term 'spontaneous remission', originally applied to this phenomenon, implied that change with the help of treatment was understandable, but without it was inexplicable. The excessive appetites model leads to precisely the opposite view. Perhaps because of the central position that heroin addiction has held in professional and lay conceptions of addiction in the 20th century, evidence that large numbers of heroin addicts can be found who have given up without formal treatment is the most challenging of all (Biernacki, 1986).
How might we characterize this natural process of giving up excess? Prochaska, DiClemente & Norcross's (1992) 'transtheoretical' model of change has been very helpful since it enables us to cross the otherwise heavily guarded borders between the separate addiction territories. It is the 'processes' aspect of their model, rather than the better known 'stages' component, which is most useful to us here. Provocative findings have already emerged; for example, that the process they term 'self-liberation' (e.g. a day-to-day commitment to quit) is one of those most commonly endorsed (DiClemente & Prochaska, 1982), and that those in 12-Step and CBT programs change in similar ways during treatment, as assessed by increased use of some of the 'processes', despite the very different treatment rationales (Finney et al., 1998). Another helpful source of ideas was Hunt & Matarazzo's (1970) demonstration that relapse curves following attempts to modify heroin, alcohol and tobacco habits were remarkably similar, with high proportions of people relapsing in the first few weeks, and a flattening-out of the curve well below 100%, leaving perhaps as many as 20-30% having made at least medium-term changes. This figure of 20-30% recurs in a number of unexpected places. That is the proportion, for example, found to give up opiate use after detoxification with herbal medicines and Buddhist rites in Thai temples (Poshyachinda, 1980, cited by Groves & Farmer, 1994). It was also one informed estimate of the proportion of pledge-takers who continued to honor their pledges after committing themselves to abstinence at meetings of the Washingtonian Temperance Society in the 1830s and 40s (McPeek, 1972). This is not to argue that expert treatment never works, but rather to point out that treatment operates within a context and against a background of powerful natural processes (Bacon, 1973; Moos, 1994). When it does work, the prediction would be that it does so because of processes that are non-specific (Lindstrom's third hypothesis). These processes far transcend the fads and fashions of particular groups of experts working at one particular time.
Fertile though the 'processes of change' (Prochaska, et al., 1992) idea has been, it does not go nearly far enough in exploring the naturalness of addictive behavior change. It leaves out, in particular, three vast domains of human experience that can not be ignored: the social, the spiritual, and the moral. Bacon (1973) saw the importance of the social when he wrote, 'The recovery personnel of prime significance are the associates, the significant others ... crucial for recovery are the daily life associates through time, not the specialists during formal "treatment periods"' (p. 25). Much more recently ways have been found of deliberately harnessing the concern of 'significant others' in order to encourage excessive alcohol or drug users into treatment and to support them once they are there. These include the 'pressures to change' approach of Barber & Crisp (1995), and 'social behavior and network therapy' (Copello et al., 2000) being used in the UK Alcohol Treatment Trial (UKATT Research Team, 2000).
The possibility that conventional, expert formulations of the change process may have omitted some of the more profound elements has been recognized from time to time by some of the more thoughtful commentators. For example, Drew (1990) observed, 'We have produced a psycho-bio-social model of drug dependence that excludes the essence of human existence--options, freedom to choose and the centrality of value systems.' Miller (1998) has written of the neglect of the spiritual component in the theory and practice of addictive behavior change despite its clear presence in the philosophy of Alcoholics Anonymous and other 12-Step programs. The continued prominence and growth of such mutual help organizations in the spectrum of modem forms of help for people with excessive appetites (Makela, 1991), and the evidence of successful outcomes following attendance at AA (Tonigan, Toscova & Miller, 1996; Humphrey, Moos & Cohen, 1997; Miller, 1998), strengthen the argument that the change process is not to be understood most readily by accepting the supposed rationales of modem physical or psychological treatments, or by taking too seriously their techniques, but rather by an appreciation of the factors that are common to a variety of forms, whether religious, medical, psychological or unaided.
Is it too fanciful, then, to go one step further and conclude that giving up an excessive appetite is essentially a process of moral reform or, as Gusfield (1962) put it, one of 'moral passage out of deviance'? Some of the processes of change identified by observers of AA, and highlighted in AA's own teachings, relate to character change: acceptance, selflessness, humility, surrender, forgiveness, ego-reduction (Tiebout, 1944; Alcoholics Anonymous, 1955; Miller, 1998). Sarbin & Nucci (1973) believed that all programs of conduct reorganization, whether these be religiously, politically or therapeutically motivated, involved a common process of symbolic death, surrender and re-education. Although the processes were thought to be essentially the same, the form and language in which they were couched needed to be acceptable to the place and times. In mid-19th century Britain and the United States change might often have been brought about by evangelical religious means. Later, in the era of the purity campaigns in Britain, a period running roughly from 1880 until the outbreak of the First World War (Mort, 1998), morality was part of a dominant discourse regarding drinking, gambling and sex. This was the era of the Salvation Army, whose purpose was to rescue large numbers of the 'sinking classes' from a sea of misery and temptation to excess in which drunkenness, gambling, adultery and fornication figured large. Early psychologists of that time, such as Emile Coue and William James, had no hesitation in using the language of 'will-power'.
Half a century or more later aversion therapy was popular in the treatment of almost all the excessive appetites. The commitment to carrying out such a 'treatment' and the process of going through the aversion routine repetitively could scarcely have been better arranged for enhancing a newfound attitude towards the at-one-time attractive appetitive object. It contained all the ingredients necessary for inducing dissonance (see Kelman & Baron, 1974) or self-liberation (Proschaska et al., 1992). Right up to the present day, some of the more thoughtful behaviorally orientated psychologists have pondered the nature of the appetitive change process, and come up with challenging ideas. Premack (1970) concluded that the experience of some sort of 'humiliation' (e.g. in the case of smoking, realizing that one was putting money into the pockets of cigarette manufacturers, or that one was encouraging one's children to smoke) was crucial. Kanfer & Karoly (1972) concluded that in order to bring about a reduction in the occurrence of a high probability behavior involving actions that were usually run off smoothly, automatically and without self-monitoring, some form of 'editing' of behavior was necessary, often involving a kind of 'performance promise' or 'contract'. Heather (1994) argued that we should take more seriously the lay view that addiction was, in essence, a problem of 'weakness of will', addiction being characterized by repeated breaking of strong resolutions to desist from harmful behavior.
Orford, Jim; Addiction as excessive appetite; Addiction; Vol. 96 Issue 1; Jan 2001
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