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Issue Price:. Subscription Price:. Editorial Focus For over a decade, Relief has helped shape the landscapes of faith and imagination for readers around the world. Tips From the Editor Above all, we want to be surprised, even thrilled, by work of artistic excellence—writing that shows the highest embodiment of craft while having something of deep importance to say. Reade Ave. Somewhere we know that without silence words lose their meaning, that without listening speaking no longer heals, that without distance closeness cannot cure.
Print Journal. Learn More. From the Blog. Joanna ES Campbell. Aug 29, Tuesday in Nelson, British Columbia. Hillary Jo Foreman. Aug 15, Making Islands. Shemaiah Gonzalez. Jun 17, A Friendship Formed in Silence. Feb 25, Rather than intensive and often prolonged treatment as used in PHPs, in HOPE participants may choose whether or not to attend treatment and only a small proportion do so at the outset.
The remainder are monitored without treatment but those who fail monitoring are then referred to treatment. The programme can last up to six years. This is aimed at Driving While Intoxicated DWI offenders nearly half of whom have three or more DWI convictions and who are therefore likely to include many individuals meeting standard diagnostic criteria for substance dependence.
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However, to accurately monitor alcohol use, participants must either undergo twice-daily alcohol breath tests at a local police station or wear continuous transdermal alcohol monitoring bracelets. Participants also undertake regular drug urinalyses or wear drug patches to detect drug use. According to Dupont and Humphreys , the unique aspects of PHPs and similar programmes, and those responsible for their success, are: i they last for years rather than weeks; ii they carefully monitor use of alcohol or other drugs; iii they employ swift, certain, and meaningful consequences for use and non-use of substances.
Such consequences are contrasted with those applying to substance use or other non-compliance in conventional treatment programmes for offenders which are typically unpredictable, slow and harsh. The remarkable success rates from all three programmes are incompatible with a view of addiction that sees addictive behaviour as compulsive and in which relapse is seen as an unavoidable feature of the disorder.
The new perspective on addiction treatment based on the CM approach suggests that the key to long-term recovery lies in sustained changes in the environment in which decisions to use and not to use substances are made. As with the evidence from experimental studies of addictive behaviour, it is very difficult to see how these CM-based programmes could be aimed at the treatment of OCD and achieve anything like the same rates of success; indeed, it would probably and rightly be regarded as unethical to make rewards contingent on the non-appearance of symptoms of OCD.
The idea of compulsion implies that addictive behaviour is inflexible, stereotyped, unreflective and unresponsive to changes in personal or environmental circumstances. But is this depiction of addictive behaviour accurate? We have already seen that evidence on the operant nature of addictive behaviour casts considerable doubt on this depiction of addiction but we can also address the question by examining what addicts tell us about their own behaviour. Joanne Neale reported the results from interviews she conducted with drug users, mostly heroin users, in Scotland.
The overall picture of addicts' behaviour emerging from this research is very different from its characterisation as inflexible and compulsive.
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While drug users' lives could reasonably be described as highly structured and narrowly focussed, owing to the demands of obtaining an expensive supply of drugs on a daily basis, the means by which those demands were met were themselves varied and flexible, not to say innovative and highly ingenious on occasion. The idea of compulsion also implies that addicts are obsessionally focussed on obtaining and using drugs and that their lives are overwhelmingly dominated by it. However, although most people would consider addicts' daily existence limited in scope and exhausting given the time and effort required to obtain drugs, Neale found that they continued to live ordinary lives in many ways:.
Individuals who become addicted to heroin and other opiates do not stop being children, parents, siblings and friends to other members of society. Likewise, some still have business to attend to, hobbies and interests to participate in, and obligations as employees or students to fulfil.
Thus, with greater or lesser degrees of success and failure, drug users must juggle the risks and dangers associated with opiate use alongside very ordinary daily behaviour and life roles Neale, , p. Neale's description of the realities of drug addiction, based on her meticulous qualitative research, is supported by many ethnographic studies and autobiographical accounts of addiction see, e. Ethnographic studies are based on direct, participant observation of behaviour and are not therefore susceptible to any biases that might be present in addicts' self-reports.
However, it most clearly applies to drug-seeking behaviour as opposed to drug-taking. Depending on the kind of addiction in question, the idea of stereotyped and automatic behaviour may apply in some respects to acts of ongoing drug consumption. If this were all addiction consisted of, then compulsive, stereotyped and automatic might well be appropriate descriptors.
Unfortunately for this point of view, it is the seeking of drugs or of opportunities for addictive behaviour that is essential to any satisfactory description and explanation of addiction. It could be that the idea of compulsive addictive behaviour owes much to laboratory studies of non-human animals on which most neurobiological theories of addiction are founded, a point that will be returned to below. Robinson and Berridge , whose own theory of addiction does not require drug-seeking behaviour to be compulsive in the automatic sense, agree:.
Many aspects of addictive drug pursuit are flexible and not habitual.
Human addicts face a situation different from rats that merely lever-press for drugs. We suspect that if animals were required to forage freely in a complex environment for drugs the picture seen in animal neuroscience might look more like the situation in human addiction, and automatic habit hypotheses would be less tempting. An addict who steals, another who scams, another who has the money and simply must negotiate a drug purchase—all face new and unique challenges with each new victim or negotiation.
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Instrumental ingenuity and variation are central to addictive drug pursuit in real life… Thus, the formation of S-R habits may explain the rituals addicts display in consuming drugs, but they do not account for the flexible and deliberate behaviors involved in obtaining drugs p. Like addicts, the lives of suffers from OCD are no doubt ordinary in many ways, notwithstanding the interference with daily routines arising from their disorder. But is it realistic to attribute to OCD sufferers the same kind of flexibility and ingenuity in response to the demands imposed on them by their condition, in the same way that heroin users respond to the demands of their addiction?
This seems doubtful. If addiction entails compulsive behaviour, it must be expected that addicts would take a long time to recover, if they ever did. Linked to the understanding of addiction as a chronic, relapsing disease, compulsion implies that, in medical terms, the prognosis of the condition is bleak, as for other disorders involving compulsion such as OCD. But, since this is presumably an empirical issue, what is the evidence on the natural history of addiction? Does it confirm the postulation of a chronic, compulsive condition with a protracted or lifelong course?
Fortunately, the answer to this crucial question is at hand. It should also be noted that all these surveys were sponsored by prestigious, government-funded bodies, such as the National institute on Drug Abuse ironically the most powerful advocate of the view of addiction as a chronic relapsing brain disease and were designed and carried out by the some of the leading psychiatric epidemiologists in the USA.
The evidence gathered by Heyman from this impeccable data-source mostly concerns the description of addiction as a chronic relapsing disease but it is also highly relevant to the related concept of compulsion as the central feature of addiction. Further, for the great majority of participants, remission was achieved without the benefit of treatment. It is surely incompatible with the notion of a compulsive, chronic disease that over three-quarters of those who had ever suffered from it no longer did so, and despite never having received treatment.
Heyman then examines possible objections to this finding - reasons that it might be spurious. First, owing to the relapsing nature of addiction, it is possible that many of those who did not show symptoms over the past year would relapse in future, thus reducing the true proportion of those in remission. This is shown to be false simply by the demonstration that relapse rates are roughly stable over time, i. It is also possible that rates of remission are biased by the over-inclusion of drugs from dependence on which recovery is thought to be relatively easy, like marijuana.
This too is false because, when drug types are separated, remission rates for marijuana dependence were no higher than those for opioids and stimulants.
Indeed, a remarkable finding of the analysis is that illicit drugs like opioids and cocaine that are generally reputed to be the most addictive substances available, and therefore the most compulsive, showed significantly earlier remission than alcohol and nicotine which might be conventionally thought to be less addictive. Heyman and Mims , p.
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This is not to deny, of course, that addiction is never long-lasting but it is to assert that protracted histories of addiction are the exception rather than the rule outside the treatment context. A predictable objection that respondents to the survey were not telling the truth about their dependence status was also contradicted by the existence of relationships between self-report data and other variables that were very unlikely to have occurred if self-reports were invalid. Finally, the possibility that the findings were affected by the existence of a large number of addicts who were missing from the surveys is highly unlikely because, for such a thing to occur, the number of missing addicts would have to have been improbably large see Heyman, , p.
In view of the clear demonstration by these findings that addiction in the general population is not the chronic, relatively intractable condition it is purported to be, how did such a notion arise? One possibility is that, before the large epidemiological studies Heyman relies on, the majority of statements about the nature and course of addiction were based on treatment samples. For one thing, they are more likely to suffer from other conditions that increase the chance of a poor outcome. On the other hand, addicts in the community seldom seek treatment for addiction. For all these reasons, it is essential to base an understanding of addiction on large, random samples that mirror the demographic and other characteristics of the general population.
When this is done, as we have seen, the true picture of addiction that results is very far from that of a chronic, compulsive disease. The treatment and non-treatment populations do clearly differ in the extent of comorbidity they show and it is this that Heyman believes is mainly responsible for the poorer outlook among the former see Heyman, , pp. It could still be argued, however, that the longer course of addiction among those in treatment is because they represent the more severe end of the spectrum of severity and are therefore more likely to be compulsive addicts assuming that there are also non-compulsive addicts.
Segal b has proposed the existence of a subset of addicts, typified by the majority of those who attend Narcotics Anonymous , who show more severe levels of addiction than others p. The drug use of these addicts, claims Segal, is not nearly as responsive to normal incentives as the less severely affected individuals.