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Addictive Disorders in Context: Principles and Puzzles of Effective Treatment and Recovery

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Addictive Disorders in Context: Principles and Puzzles of EffectiveTreatment and RecoveryRudolf H. MoosVeterans Affairs Health Care System, Palo Alto, California, and Stanford University Medical CenterTo consider key issues in understanding effective treatment and recovery, the author reviews selectedprinciples and unresolved puzzles about the context of addictive disorders and the structure, process, andoutcome of treatment. The principles focus on the process of problem resolution, the duration andcontinuity of care, treatment provided by specialist versus nonspecialist providers, alliance and the goalsand structure of treatment, characteristics of effective interventions, and the outcome of treatment versusremaining untreated. The unresolved puzzles involve how to conceptualize service episodes and treat-ment careers, connections between the theory and process of treatment, effective patient–treatmentmatching strategies, integration of treatment and self-help, and the development of unified models toencompass life context factors and treatment within a common framework.There has been an expanding cornucopia of research on addic-tive behaviors in the past 30 years. We have formulated conceptualmodels, measured key constructs, examined salient theoreticalissues, and made substantial progress in understanding the ebb andflow of addictive disorders. An integrated biopsychosocial orien-tation and a theoretical paradigm of evaluation research havesupplanted earlier adherence to an oversimplified biomedicalmodel and reliance on a restrictive methodological approach totreatment evaluation. And yet, in an ironic way, more remains tobe done than before, in part because of our increased knowledgeand in part because of new clinical perspectives and treatmentprocedures and the evolving social context in which we ply ourtrade. Here, I set out seven principles that exemplify advances inour effort to understand the processes involved in effective treat-ment and recovery. I then describe some unresolved puzzles andimportant questions for future research.Principles: What We Know or Think We KnowThe first two principles of effective treatment and recoveryaddress the context of addictive disorders, the next two principlesfocus on the structure of treatment, and the following two princi-ples consider the process and content of treatment. The finalprinciple addresses treatment outcome.Principle 1: Treated or Untreated, an Addiction Is Not anIsland Unto ItselfPeople with addictive disorders exist in a complex web of socialforces, not on an island unto themselves, free of social context.Formal treatment can be a compelling force for change, but ittypically has only an ephemeral influence. In contrast, relativelystable factors in people’s lives, such as informal help and ongoingsocial resources, tend to play a more enduring role. Moreover, arecovery that is sustained after treatment is not due simply totreatment; it is nurtured by the same sets of factors that maintainthe resolution of problems without treatment (Biernacki, 1986;Moos, Finney, & Cronkite, 1990; Vaillant, 1995).This contextual perspective highlights the need for a fundamen-tal shift in thinking about intervention programs and evaluatingtheir effects. Many of the hard-won gains of intervention programsfade away over time. This is precisely as expected on the basis ofour knowledge about environmental impact and the diversity ofcontexts to which individuals are exposed. An intervention pro-gram is but one of multiple life contexts. Other powerful environ-ments also shape mood and behavior; ongoing environmentalfactors can augment or nullify the short-term influence of anintervention.The fact that the evolving conditions of life play an essentialrole in the process of remission from addictive disorders is ahopeful sign. It implies that these disorders need not becomechronic, that individuals who are able to establish and maintainrelatively positive social contexts are likely to recover, and thattreatment directed toward improving individuals’ life circum-stances is likely to be helpful.Rudolf H. Moos, Center for Health Care Evaluation, Veterans AffairsHealth Care System, Palo Alto, California, and Department of Psychiatryand Behavioral Sciences, Stanford University Medical Center.Preparation of this article was supported by the Department of VeteransAffairs Health Services Research and Development Service and by Na-tional Institute on Alcohol Abuse and Alcoholism Grant AA12718. Thework was conducted in part under the auspices of the Substance UseDisorders Module of the Veterans Affairs Quality Enhancement ResearchInitiative. Penny Brennan, John Finney, John Kelly, Jennifer Ritsher,Kathleen Schutte, and Christine Timko made helpful comments on a draftof the article. An adapted version of this article was presented as an invitedaddress at the 110th Annual Convention of the American PsychologicalAssociation, Chicago, August 2002. The views expressed here are mineand do not necessarily represent the views of the Department of VeteransAffairs.Correspondence concerning this article should be addressed to RudolfH. Moos, Center for Health Care Evaluation (152-MPD), Veterans AffairsHealth Care System, Menlo Park Division, 795 Willow Road, Menlo Park,California 94025. E-mail: [email protected] of Addictive Behaviors In the public domain2003, Vol. 17, No. 1, 3–12 DOI: 10.1037/0893-164X.17.1.33Principle 2: Common Dynamics Underlie the Process ofProblem Resolution That Occurs in Formal Treatment,Informal Care, and “Natural” RecoveryIndividuals trying to resolve substance abuse problems usuallybegin by using one or more sources of informal help, such as afamily member or friend, a physician or member of the clergy, orAlcoholics Anonymous (AA) or another self-help group. If suchattempts fail repeatedly, some individuals enter formal treatment.On average, these individuals have more severe problems andmore difficult life contexts, and are more impaired than individualswho resolve problems on their own or with informal help; outsidehelp may be especially needed when an individual has few per-sonal or social resources on which to base a recovery (Finney &Moos, 1995).Nevertheless, it may not be important or fruitful to distinguishbetween problem resolution that occurs with or without treatment.There is no compelling conceptual reason to distinguish betweenthe influence of an AA sponsor, a spouse or partner, and a relativeor friend,


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