The conclusion of the two-parter. Part one is here. Professor Selman’s last five essentials:
6. Different therapies appear to produce similar treatment outcomes. Project MATCH, a huge psychotherapy trial showed similar outcomes for the techniques of motivational enhancement therapy, twelve step facilitation and cognitive behavioural therapy. Other trials including British ones have shown the same results. The key thing for me is always around the quality of the therapeutic relationship and what represents best value for money. One more thing; there’s been an important addition to the evidence base since this which changes things. Find it here.
7. “Come back when you are motivated” is no longer an acceptable therapeutic response. The old idea that you need to reach rock bottom before change is possible has been challenged (most clearly by Bill Miller). In a recovery oriented treatment service the workers take on some of the responsibility for helping to generate hope and motivation. In a therapeutic community, the other community members do this very effectively. Motivational interviewing is a useful tool and the importance of the quality of the client/professional alliance is stressed. The old response to blame the client when treatment fails just doesn’t do it any more: we need to hold ourselves to account too.
8. The more individualised and broad based the treatment a person with addiction receives, the better the outcome. The professional and the client developing a care plan together focussing on meeting needs and reaching goals is the ideal. There is plenty of evidence that this makes a difference. If this focusses on building recovery capital across a range of domains, clients are likely to do better. Do enough people in addiction treatment understand the key components of building recovery capital?
9. Epiphanies are hard to manufacture. One way of defining an epiphany is that it is a sudden intuitive realisation of the truth of something. One of the fascinating things about working in the field of addiction, writes the prof, is coming across people who have had dramatic and sudden life changing recovery experiences. Bill Wilson, the co-founder of AA was one example. Part of the process is overcoming self deception. Hearing others’ stories of recovery experiences is probably important here and, of course, this takes place in mutual aid groups.
10. Change takes time. Who could argue? He gives a rather neuro-scientific description of this, but wins me over in the end when he points out (from the viewpoint of a medic of course) that clinical management gives way to personal management as people move through the stages of treatment; rehabilitation; aftercare and self-management. Of course this is not the route of all to recovery, but it does reflect collective experience to some degree.
And if these are the ten most important things about addiction, then what are the ten most important things known about recovery? I think the language and tone of addiction treatment has changed to focus more on the positives that accrue with recovery than the negatives that are removed or diminished by traditional treatment approaches. This is a good thing, but it’s clear the scientific study of recovery lags well behind the scientific study of addiction. Let’s do some catching up!
Sellman, D. (2010). The 10 most important things known about addiction Addiction, 105 (1), 6-13 DOI: 10.1111/j.1360-0443.2009.02673.x