By Dr. Richard Juman via The Fix
In an historic moment for the fields of addiction medicine and psychology, Harvard Medical School has appointed psychologist and SMART Recovery Research Director, Dr. John Kelly, to hold a newly-created Professorship in Addiction Medicine. An important milestone in the history of addiction medicine, it’s also a seminal moment for psychology in the implicit recognition of psychology’s contributions to the understanding and treatment of the complex and multifaceted biopsychosocial phenomena of addiction …Richard Juman
Richard Juman: My first reaction to hearing this wonderful news was that Harvard’s creation of a Professorship in Addiction Medicine represents a seminal moment for the field, especially regarding how it might reflect a more widespread societal acceptance of addiction as a true disorder. Do you agree?
John Kelly: Relatively speaking, the field of addiction medicine is a fledgling one, but one that is growing in prominence and stature. I think this designation of the first endowed Professorship in Addiction Medicine at Harvard Medical School sends a message nationally as well as globally that addiction should be, and increasingly will be, a part of medicine. As a result, it implicitly communicates also the notion that substance use disorders are true medical disorders that deserve and require a serious clinical devotion of time, expertise, long-term monitoring and recovery management- analogous to the way we treat other high volume, high burden, chronic diseases like hypertension or diabetes.
My second reaction, and perhaps this is because I am a psychologist but I think it goes beyond that, was to the fact that this pivotal position is going to a psychologist, not a physician. Medicine in general, and addiction medicine specifically, are physician-driven, so I think the fact that you’re a psychologist is meaningful. It aligns with the true spirit of integrated care- that health, disease, treatment and recovery are complex phenomena that require an interdisciplinary approach and that a psychologist might be the right person to lead that kind of process. So I think this is an important moment for the field of psychology with respect to our role in the developing integrated care system of medicine.
As a clinical psychologist, I was particularly pleased that the first endowed Professorship in Addiction Medicine was awarded to me and not to a physician. Physicians have played, and continue to play, a crucial role in understanding and treating addiction, but arguably, psychologists have played an equal if not more influential role. In particular, we have helped to clarify and explicate the nature of addiction, including its etiology, typologies, onset, clinical course, and predictors of remission and recovery. Additionally, we have developed, tested and implemented most of the behavioral interventions that comprise the majority of the evidence-based intervention approaches in addiction treatment.
You point out that addiction is a complex biopsychosocial phenomenon with respect to etiology, clinical presentation and treatment options. But is there a tendency to ignore that complexity when it comes to addiction? There seems to be something about addiction that is very polarizing, in that both those who’ve suffered with addiction and those who treat it can become vehemently associated with a particular school of thought or a concept. One example of a highly polarizing issue is this: Is addiction a “brain disease” in which the drug “hijacks” you, or is it better understood as a behavioral response to underlying psychological issues? Another example: Is abstinence from all mind-altering substances the only sane approach to addiction, or is harm reduction/moderation more likely to produce good outcomes? Another: Are 12-step meetings an essential part of stable recovery or are they harmful, “cult-like” entities that do more harm than good? I don’t tend to see this kind of “passionate bifurcation” in other areas of healthcare and medicine. Is there something particular about addiction that inherently pressures those involved to be drawn into these almost political camps?
Interesting question. The American journalist Henry L. Menken once remarked that for every complex problem there is a solution that is clear, simple, and wrong. We would all like there to be a simple solution – a single injection, a vaccine, or a pill that could cure addiction. The solutions for addiction are actually quite clear, but multifaceted and complex. Ignoring this complexity and the dynamic nature of addiction, relapse, remission, and recovery is doing a disservice to those we want to help. I think also that most of the impassioned arguments that we may read in the media can be assuaged by more careful attention to the science in these areas. Often, writers will only pick pieces of the scientific literature that appear to support their opinion while ignoring those parts which don’t fit their position. This can be very misleading and dangerous when we are talking about something as lethal as addiction.
The efficacy of non-professional support groups has been a strong research interest for you. The variety of fellowship options now available- beyond 12-step programs that are based on a “higher power”- suggests that the 12-steps themselves or a belief in a higher power may not be critical elements in the efficacy of these groups. Would you agree that the shared fellowship and support that these groups all provide is the mutative element behind the success of support groups?
Yes, most of the research has been conducted on 12-step mutual-help organizations, like AA. I have been surprised how helpful these peer-led recovery support organizations can be in aiding recovery. From sophisticated mechanisms of behavior change research, we have found that the majority of the beneficial effect conferred by these organizations is carried by the power of the social changes that they facilitate. These recovery-supportive social changes, in turn, help reduce exposure to alcohol/drug cues, help people reinterpret and cope with stress, maintain and enhance recovery motivation, and boost skill and confidence in individuals’ ability to cope with relapse risks. Although, most of this research has been conducted on 12-step mutual-help organizations, I think we can make an educated guess that there is likely to be similar therapeutic processes operating in these other groups as well. More specifically, all mutual-help organizations create a feeling of identification, universality, cohesion, and belonging; they facilitate expression of emotion and imparting of knowledge regarding the true and tested lived experience of staying sober. It is important that we support an array of these mutual-help organizations because people have different histories and preferences and there are many pathways to recovery. Different mutual-help groups attract different folks. For some, 12-step is not spiritual enough – so they may gravitate toward more explicitly religious mutual-help organizations, such as, Celebrate Recovery; for others, 12-step is too spiritual, and so SMART Recovery or LifeRing, Secular Organization for Sobriety, or another group may be a better fit.
You have done work examining stigma and terminology in addiction; you’ve presented your work at the White House and have worked with the national Office of Drug Control Policy (ONDPCP) to change policy around addiction. Why is this important to you?
This has been a fascinating area of research for me. I was interested particularly in how certain commonly-used terms in the addiction field may perpetuate negative stereotypes and stigmatizing attitudes toward those suffering from addiction. More specifically, I began to get disturbed by use of the term “abuse” and in describing individuals with substance-related conditions as “substance abusers”. To me, these terms convey a notion of purposeful and willful misconduct that may lead to perceptions of the need for punishment as opposed to treatment. In contrast, describing someone as having a “substance use disorder” conveys the notion of the medical malfunction that is inherent in the functional and structural brain changes observed in addiction and may increase perceptions of a need for treatment. I conducted experiments wherein I randomly assigned two vignettes describing the exact same individual in trouble with alcohol and drugs to 561 doctoral level mental health and addiction providers. In one of these vignettes the person was described as a “substance abuser”, in the other, as having a “substance use disorder”, otherwise they were identical. The clinicians that completed the survey who were exposed to the “substance abuser” term were substantially more likely to rate that person as more to blame for their condition and more deserving of punishment than the exact same individual when described as having a “substance use disorder”. This indicates that even among well-trained and experienced clinicians, use of and exposure to terms like “substance abuser” may induce punitive implicit cognitive biases whether the person is aware of it or not. We replicated this study in a general population sample and found even bigger differences. I am working with various organizations and national agencies as well as the International Association of Addiction Journal Editors to try to eradicate this potentially stigmatizing language from use in our discussion and reporting of addiction science as we move away from the rhetoric of the war on drugs and toward a broader public health approach.
I don’t think anybody would agree with the idea that trauma is a prerequisite for addiction, but there is a lot of evidence for a high correlation between trauma, especially Adverse Childhood Events (ACE), and addiction. What are your views on the role of trauma in the etiology of addictive disorder?
Adverse childhood events, unusual stressors, and traumatic events are documented risk factors for the onset of alcohol and other drug-related problems and disorders. Adverse childhood events in particular, can have life-long impacts through their effect on cognitive and emotional development that can have lasting ramifications. This doesn’t mean that they always lead to substance-related problems, but they are a risk factor. Early detection and intervention is key in this regard to help prevent poor developmental trajectories. It should be noted too, however, that alcohol and other drug-related problems and substance use disorders are documented risk factors for the occurrence of unusual stressors and traumatic events. The nature of substance-related conditions means that individuals are at high risk for traumatization, regardless of their prior trauma history.
Although you are most well-known as a researcher, you also have a clinical practice. Can you give readers a sense of your approach, and whether you would identify certain essential elements of effective psychotherapy with clients with addictive disorders?
Yes, I enjoy my clinical work immensely. In general, I try hard to foster a warm, upbeat, and welcoming atmosphere to create a strong therapeutic alliance and sense of trust in me as someone who is willing and able to help. Creating the right conditions is key for therapeutic engagement; without it little good can happen. I try to treat patients with the utmost respect and dignity; so many addiction patients have lost their self-respect and are overly harsh on themselves. I try to instill hope that change is possible and that recovery is likely, and to bolster self-efficacy. I bring in research findings to help support these approaches whenever possible. I use ongoing measurement to assess my patients’ responses to treatment and I believe that this kind of outcome measurement is essential to good quality practice. If we were treating hypertension we would never not get a blood pressure reading before each health check-up; the blood pressure reading forms the basis for discussion and intervention. Analogously, I use standardized, non-proprietary, psychometrically validated measures to assess patients’ clinical response, in a variety of life areas, to the treatment I provide. The results are fed back to the patient graphically and inform collaborative treatment planning, decision-making, and recommendations.
There are several overarching theoretical frameworks which guide my clinical approaches, as well several specific clinical technologies which strongly influence my practice in treating individuals with substance use disorders and related conditions. I am influenced by the general psychotherapy model of Howard and colleagues (i.e., remoralization, remediation, rehabilitation) and the life-course model of Hser and Anglin, which acknowledges different life stages (e.g., childhood, adolescence, young adulthood, adulthood etc.) as conferring different risks and protective factors that influence the probability of onset and offset of different diseases and disorders, including substance use disorders. In particular, this model is useful for sensitizing me to the social context and roles that individuals face at different stages of life, and how these may differ across men and women. The stages of change model of Prochaska and DiClemente also influences my clinical approach, since it makes good sense to acknowledge and respect individuals where they are currently located in the change process, and go from there. My clinical interventions specifically are influenced by the work of William R. Miller (Motivational Interviewing), G. Alan Marlatt (cognitive-behavioral relapse prevention therapy), as well as the relapse warning signs model of Gorski and Miller. I also use Twelve-Step Facilitation interventions to link patients to social networks of recovery. I take a long-term view of recovery management for substance use disorders that is similar to chronic care for diabetes and hypertension. In this way, I use recovery management check-ups based on the work of Mike Dennis and Christy Scott. I always discuss and make recommendations for patients to consider medications for substance use disorder or other co-occurring psychiatric conditions, and in this regard I work closely with addiction psychiatrist colleagues who prescribe and work collaboratively with me to coordinate care.
Congratulations on this really ground-breaking appointment, and thank you for spending time with me and The Fix.
Many thanks. My pleasure.
Richard Juman—a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings—is the Editor of Professional Voices on The Fix. He is also former President of the New York State Psychological Association. [email@example.com] Find him on twitter—@richardjuman
Interview & story via The Fix
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