Addicts as People

William R. Miller, Ph.D. Center on , Substance Abuse and (CASAA) The University of New Mexico (USA) A Conflict of Interest

The speaker is ambivalent about treatment in the U.S. Origins of Stigma

U.S. Prohibition 1920

• Education During Prohibition

• Alcohol is a medically and socially dangerous drug • Drinkers inflict great harm and cost on society • Alcohol cannot be used for long in moderation • Those who drink are headed for insanity or death • Abstinence is the only sane choice and then . . . End of Prohibition 1933 National Cognitive Dissonance 1935 The Seed of a Solution

• It is only certain people who are at risk • Alcoholics are different from normal people • Non-alcoholics can drink with impunity Alcoholics/Addicts as “Other” An American Disease Model

1. Alcoholics have a disease that renders them constitutionally incapable of drinking in moderation 2. Their loss of control is permanent and irreversible 3. Therefore lifelong abstinence is essential for alcoholics 4. They have immature defense mechanisms and personality 5. Particularly a high level of “denial” and 6. Therefore alcoholics are out of touch with reality “The quest for the test”

Miller, W. R. (1986). Haunted by the Zeitgeist: Reflections on contrasting treatment goals and concepts of alcoholism in Europe and the United States. Annals of the New York Academy of Sciences, 472, 110-129. This model justified “treatments” that would constitute malpractice for any other disorder

“When the executive tried to deny that he had a drinking problem the medical director came down hard: ‘Shut up and listen.’ he said. ‘Alcoholics are liars so we don’t want to hear what you have to say.’” (Greenberger, Wall Street Journal, 1983. p.1)

“Now Buster, I’m going to tell you what to do. . . That’s the way we operate in Synanon; you see, you’re getting a little emotional surgery. If you don’t like the surgery, fine, go do what you have to do. Maybe we’ll get you again after you get out of the penitentiary or after you get a drug overdose. ‘Nobody tells me what to do.’ Nobody in the world says that except dingbats like dope fiends, alcoholics and brush-face-covered El Gatos.” (Yablonsky, 1989 quoting Chuck Dederich, founder of Synanon)

“Addiction counselors” with low educational standards, low salaries and status What about scientific evidence?

• Addictive behavior responds to normal principles of behavior and social influence • No scientific evidence for inherent loss of control • Most recovery happens without formal treatment • No consistent addictive personality; wide diversity • Normal defense mechanisms in alcoholism (Donovan et al., 1975, 1977) • 100 % negative trials of confrontational treatments (Miller & Wilbourne, 2002) • Client belief in disease model predicts relapse (Miller et al., 1996) • No qualitatively different group of “alcoholics” or “addicts” (DSM-5) i.e., “Alcoholics”/”addicts” are not a separate class of people People are not Perfect

• Perfect symptom-free life is a peculiar standard for treatment success! • Combined results for 8,389 people in treatment for alcohol use disorders in seven multisite trials: • 1 year outcome • 1.5% mortality • 24% continuous abstinence for 12 months • Among those who drank, alcohol consumption decreased by 87% and alcohol-related problems decreased by 60% • These outcomes have not changed substantially in 40 years

Miller, W. R., Walters, S. T., & Bennett, M. E. (2001). How effective is alcoholism treatment in the United States? Journal of Studies on Alcohol, 62, 211-220.

Pieces of a Puzzle When compared with other bona fide treatments, theoretically different therapies tend to have identical outcomes (Imel et al., 2008)

Project MATCH COMBINE Study

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60 60 50 50 40 40 30 30 20 20 Intake 4 Months 16 Months -2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15

CBI + Placebo CBT MET TSF Naltrexone, No CBI Placebo, No CBI CBI + Naltrexone Therapist Effects in Addiction Treatment

• But the therapist to whom a client is assigned often has a large effect on: • Treatment retention vs. drop-out • Clients’ in-session satisfaction and collaboration (working alliance) • Clients’ post-treatment substance use outcomes • The assigned therapist often has a much larger impact than the treatment approach being delivered Therapist Effects on Client Outcome

Percentage of variance in 12-month drinking outcomes predicted by therapist factors in random assignment designs

Miller, Taylor & West 1980 Valle 1981 Miller et al., 1993

52% 65% 42%

What therapist factors improve or hinder client outcome? Therapist

• Accurate empathy is a well-specified, learnable, reliably measurable therapist skill – the ability to understand and reflect clients’ meaning

• Originally defined and studied by Carl Rogers and his students

• It is not identification with your client My Staff 1978

An unexpected finding All Nine Counselors

• Were delivering the same manual-guided behavior therapy (behavioral self-control training) • Were trained both in behavior therapy and accurate empathy • Had sessions independently observed and rated by three supervisors, including the Truax & Carkhuff scale for accurate empathy • Were then rank-ordered (1-9) for empathic skill while delivering behavior therapy • And when we examined 6-month client outcomes . . . . Therapist Empathy and Positive Outcomes Miller, Taylor & West (1980) JCCP 48:590-601

60 Client Drinking Outcomes Accounted for by Therapist Empathy

6 months 1 year 2 years r = .82 r = .71 r = .51

26% 67% 52%

Miller & Baca (1983) Behavior Therapy 14: 441-448 Counselors’ Interpersonal Skill (Rogers) and Clients’ Drinking Relapse Rates Valle (1981) J Studies on Alcohol 42: 783-790

• Patients in treatment for alcoholism were randomly assigned to counselors with: • LOW levels of empathy and related interpersonal skills • MEDIUM levels of empathy and related interpersonal skills • or HIGH levels of empathy and related interpersonal skills

• What percentage of their patients relapsed? Rogerian Skill and Client Outcomes

OR=4.0 OR=2.6 OR=2.3 OR=2.0

Valle (1981) J Studies on Alcohol 42: 783-790 Variance in Client Drinking at 12 months Accounted for by Clinician Confrontation

Confront (r = .65)

42%

Miller, Benefield & Tonigan (1993) JCCP 61: 455-461 Motivational Interviewing

• Based on Rogers’ client-centered approach • A conceptual opposite of confrontational therapy Add MI as a Prelude to TAU Randomized Trial Outcomes at 3 months Bien et al 1993 Brown & Miller 1993 Aubrey 1998

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0 Inpatient Adult VA Outpatient Adolescent Outpatient TAU TAU + MI

How you deliver a treatment matters: Same Counselors, Same Treatment, Different Styles

Miller, Benefield & Tonigan (1993) JCCP 61: 455-461 % Change Talk and Sustain Talk Glynn & Moyers (2010) J Subst Abuse Treatment 39:65-70

2.0 1.6 1.2 0.9 A Modest Proposal

Hire Empathic Therapists!

• Accurate empathy is an observable and reliably measurable therapist skill • Therapists’ empathic skill predicts better client outcomes, even when doing behavior therapy • It is an evidence-based practice to hire addiction treatment staff based on the demonstrated skill of accurate empathy

Moyers, T. B., & Miller, W. R. (2013). Is low therapist empathy toxic? Psychology of Addictive Behaviors, 27, 878-884 Compassionate Treatment Affects Whether Clients Come Back

20 minutes in ER One handwritten note

Hire Compassionate One telephone call Counselors! Systematic encouragement 100 100 90

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70 60 50 40 30 %Attending AA 20 10 0 0 Systematic Encouragement Standard Procedures Leake & King (1977) Clients’ Recovery Potential

• Psychologists tested patients in three different treatment programs

• They identified patients with particularly high alcoholism recovery potential (HARP)

• HARP vs. non-HARP patients did not differ from each other on prior treatment history or severity of alcoholism Counselor Ratings During Treatment Showed HARPS to be:

• More motivated for counseling • More punctual in meeting appointments • Showing greater self-control • Neater and more attractive in appearance • More cooperative • Trying harder to stay sober • Showing better recovery Throughout 12 months of Follow-up HARP Patients Showed:

• Higher rates of abstinence • Longer spans of abstinence • Fewer slips • More employment The Psychologists’ Secret:

“HARP” patients were selected at random.

Leake, G. J., & King, A. S. (1977). Effect of counselor expectations on alcoholic recovery. Alcohol Health & Research World, 1(3), 16-22 How do we look at our patients? Counselor expectations matter a lot. Waiting Lists

Common in practice when treatment programs are full and Delayed treatment as a control condition (randomly assigned)

1. Group 1: Immediate treatment by a counselor 2. Group 2: 1 session with self-help instructions 3. Group 3: Waiting list (10 weeks)

Harris & Miller (1990)

Waiting List Control Group

Harris & Miller (1990) Psychology of Addictive Behaviors, 4, 82-90

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45 40 35 30 Drinks per Week Drinks per 25 20 15 10 Intake 10 weeks 20 weeks 15 Months

Self-Directed Therapist-Directed Waiting List

What you see is what you get Expectations are self-fulfilling prophecies Hire optimistic counselors! Some implications at least for U.S. treatment

It’s time . . . to retire unprofessional and moralistic language to stop treating substance use as a crime to end punitive confrontational treatment that would be unacceptable in any other area of health care to end waiting lists to retire isolated, segregated, stigmatized treatment settings to treat the full spectrum of substance use disorders to require that like other health care providers, those treating substance use disorders have science-based professional education preparing them to treat a range of disorders, and are appropriately compensated to retire stigmatizing stereotypes

and accept that people with substance use disorders are people just as different from each other as snowflakes

who deserve and respond just as others do to empathy, compassion and respect