The Only Free Man in America
Sometimes I feel like the only free man in America.
That is, although many question – and some virulently oppose – the disease theory of alcoholism and addiction, only I can speak my mind freely on this topic.
I was a forensic expert to an attorney for a successful physician in a major medical center. This physician was accused by his soon-to-be-ex-wife of alcoholism and was forced to enter a prominent treatment center. There, he refused to concede that he was an alcoholic or to accept the “spiritual,” 12-step program. Negative consequences ensued, and he sued. His lawyer – who was extremely dedicated and smart – moved for and was granted a summary judgment against the medical board. This attorney argued that it was a violation of the doctor’s right of privacy for a medical board to punish him for actions which – if true – occurred in his private life and never impacted his medical practice.
When I asked whether the physician wanted to sue the board or the treatment center to make this case public, he declined. Why endanger a highly successful – and lucrative and satisfying – medical career to make a point? This, from a man who felt so strongly that his rights were being violated that he refused to simply go along with the 12-step principles he was force fed.
I work with a prominent cleric, a man with connections reaching into the highest levels of government. His religious orientation of self-determination was threatened when he entered the intensive outpatient program (IOP) at Morristown Memorial Hospital, which was typically completely 12-step oriented and run by a recovering AA automaton. He described incredulously the insensitivity of this woman when a female group member reported having a glass of champagne at a wedding. The woman running the program sarcastically asked for reactions from the group, who took turns lambasting the female participant. She left crying and never returned. Another successful outcome!
I asked this man, a gentleman and a scholar who couldn’t be more opposed to the 12-steps and this IOP on fundamental ethical grounds, whether he could communicate his feelings to those he knew in political power. He demurred. “I have a very visible public position to maintain,” he reminded me.
I know a woman who has bravely moved from her own 12-step recovery to become a motivational interviewing (MI) and a harm reduction (HR) therapist and teacher. (These are non-12-step treatment approaches that respect personal determination and recognize continued use but seek to minimize potential dangers of this use.) She encountered a major Hollywood actor who was wrestling with “recovery” issues. When I asked her if she mentioned her own journey and current views, she said, “No, it didn’t seem appropriate to force my experience on him.” Yet, this woman had previously told me she fantasized about some Hollywood figure rejecting the standard treatment programs in favor of seeking MI or HR treatment!
This, of course, reminds me of the most prominent 12-step quisling of all – James Frey. When Frey’s book A Million Little Pieces was first published, he appeared with me in 2002 on a John Stossel special, “Help Me, I Can't Help Myself.” There he declared AA and the 12 steps bullshit – as he did throughout his book. But by the time he appeared on Oprah, and was selected for her book club, there was no trace of his anti-12-step views – people who saw him with Orpah thought he was a standard recovery story. Amazingly, despite the best sellerdome of his book, no one (except Amy McCarley and I ) has ever noted this.
So I guess America will go on for a few more decades in its perfect ignorance that AA and the 12 steps are not the only – or even often the preferred – option.
Stanton’s new book, Addiction-Proof Your Child tackles these issues for young Americans.
Original Articles from DPFT News
First in a Series
We're pleased this month to be able to feature an original full-length article written expressly for the newsletter by Stanton Peele. Dr. Peele has long been an iconoclast in the addiction field, beginning with the publication in 1975 of his classic work, "Love and Addiction." Since that time he has been a thorn in the side of policy makers, scientists, and – as some readers are about to find out – reformers as well, because of his propensity to point out the continuing irrationality of our attitudes towards drugs, drug users, and addiction. He is both a psychologist and an attorney. In his various articles and books such as "Diseasing of America," "Meaning of Addiction," "The Truth About Addiction and Recovery," and most recently, with co-authors Archie Brodsky and Charles Bufe, "Resisting 12-Step Coercion," he has explored how most drug users do not become addicted, how most addicts recover without treatment, how addictive patterns characterize many compulsions aside from drug use, how treatment in America is often more about moralism and zero-tolerance than on actually improving the lives of substance users and addicts, and how various American perspectives towards drugs share the same erroneous assumptions about human beings, about society, and about the effects of drugs. His work can be explored in more detail at his website, www.peele.net.
– Al Robison, Executive Director, DPFT
DPFT News (newsletter of the Drug Policy Forum of Texas) 7(2), pp. 1; 3-4, 2001
The New Consensus – "Treat 'em or Jail 'em" – Is Worse than the Old
A liberal consensus is emerging that American drug policy is wrong-headed in as much as it emphasizes interdiction and criminal prosecution of users, and that it should focus on treatment of drug abusers. This consensus is apparent in the cover of the February 12 Newsweek, "Fighting Addiction," and embraces the Steven Sonderbergh film "Traffic" and the recent victory of Proposition 36 in California. But this new consensus in fact recycles outdated and disproved notions, is fundamentally reactionary and antagonistic towards drug users, and stands no chance of reversing either the extent of drug abuse in America or the repression of drug use and users.
A series of linking stories in Newsweek indicated broad agreement on the fundamental tenets of how we should approach drug use in the United States. The lead story, "Abuse in America: The War on Addiction," by Jonathan Alter, opened with a reference to "Traffic." The subtitle for this story was: "Fresh Research And Shifting Views Of Treatment Are Opening New Fronts In A Deadly Struggle." According to a banner across the body of the story, "Even hard-liners in the war on drugs like to say that we can no longer incarcerate our way out of the problem." Barry McCaffrey is a part of the new consensus. McCaffrey, it seems, believes that "the phrase 'drug war' should be retired in favor of 'drug cancer.' The straight-talking military man has little to say about interdiction. His No. 1 recommendation on leaving office last month was that insurance companies offer the same level of coverage for mental-health and drug disorders as they do for any other illness."
Yet, in practical terms, this consensus rejects the forward-looking harm reduction approaches practiced throughout much of the rest of the Western World, including needle exchange and methadone therapy. "Even so," Alter intoned, "a 'third way' consensus between liberals and conservatives is emerging, especially at the local level where the real money is spent." This third way "combines flexible enforcement with mandatory treatment." The epitome of this approach in these articles are the drug courts which have emerged across the United States. According to Alter, "Drug-court judges use carrots (gift certificates; the promise of fewer court dates) and sticks (return to jail) to change behavior."
It is in this regards that Newsweek exposed the first word of opposition to the new consensus. Oddly, it came from Ethan Nadelmann, architect of California's Proposition 36. Alter stated, "Drug-policy reformers like Ethan Nadelman of the Lindesmith Center don't buy the approach: " 'Alcoholics don't have coerced treatment,' Nadelman says. 'So why should drug abusers?' " Ethan faced a number of problems in the article and in his statement (in addition to the misspelling of his name, which was apparently too European for Newsweek editors). Alcoholics – and a host of others – are regularly forced into alcoholism treatment in the United States – according to my recent book with Charles Bufe and Archie Brodsky, Resisting 12-Step Coercion, 1.5 million people a year face this fate.
Indeed, America keeps in place the largest private and public substance abuse treatment system in the world with regard to alcohol almost wholly by coercion. Drunk drivers and other probationers, parents, employees, social service recipients, prison inmates, doctors, pilots, nurses and other professional license bearers, et al. are all forced into alcoholism treatment as a matter of course – even where the person's alcoholism is questionable (as it is for many drunk drivers and parents accused of alcohol abuse by a divorcing spouse) and even though state coercion of people into 12-step treatment (virtually the only kind available) has been ruled unconstitutional by every higher court which has considered the practice.
Most important, the consensus announced by Newsweek that drug use must be treated out of people continues the fundamental orientation of Americans towards drugs as an irresistible but nonetheless reprehensible, punishable, and remediable affliction.
The Treatable Disease
Newsweek links the new consensus to fresh scientific discoveries: according to Alter, "In an attempt to break the vicious cycle, drug addiction is increasingly being viewed more as a disease than a crime." But Alter has missed a few centuries in American history. In the eighteenth century, Benjamin Rush, the American physician who signed the Declaration of Independence, claimed that drunkards and inebriates (not then called alcoholics) were suffering from a disease. By the mid-nineteenth century, the temperance movement had popularized this idea and a large proportion of Americans (although few immigrants) viewed chronic drunkenness as a disease. The modern treatment movement has largely obscured the degree to which temperance views and those of Alcoholics Anonymous coalesce in regarding alcoholism as an inexorable and irreversible process that can be halted only by complete abstinence.
It was only later in the nineteenth century – a hundred years after Rush labeled drunkenness a disease – that the German physician Eduard Levinstein determined that compulsive narcotics use was likewise a disease. Although the Germans and British pioneered in the discovery of the disease of narcotic addiction, Americans rapidly took this discovery to new heights early in the twentieth century – so much so that American psychiatrist David Musto could call his history of heroin addiction The American Disease, referring both to the view of narcotics use in the U.S. and the prevalence of this malady here.
People debate the impact of labeling addiction and alcoholism as diseases. On the one hand, the label removes some of the moral stigma from compulsive drug use by viewing it as an inescapable biological process. On the other hand, the disease notion tends to transfer moral culpability to a different point – the initiation of use ("Why did they ever try heroin, since they were told it was addictive?") and also the failure to abstain (and, in the modern era, to seek treatment). One further modern addition to the disease notion of addiction is that it is marked by "denial," so that addicts and alcoholics need to be confronted and coerced. According to Dr. George De Leon, quoted in Newsweek, "The nature of the disorder is that the client is resistant to treatment," and thus people must be forced into treatment under threat of legal punishment.
The "New" Science of Addiction
At a more elevated level, "scientific" views (or, more accurately, cultural views) of addiction have always fueled drug policy. Narcotics (and cocaine and marijuana, et al.) were outlawed in good part because they were seen to create uncontrollable behavior. Thus, it is not surprising that a large portion of the Newsweek issue is devoted to supposed scientific advances in addiction. These discoveries are largely government sponsored – through funding by the U.S. National Institute on Drug Abuse – and are cheered by the director of the NIDA, Alan Leshner. In large part, these scientific discoveries can be traced to historic views of drugs and addiction, modern government anti-drug propaganda, and assumptions brought by researchers that are contradicted at every turn by the real-world behavior of drug users.
Thus, Newsweek announced, "New Research Reveals How Drugs, Alcohol Affect Parts of Brain: Explains Why Withdrawal Is So Difficult." Leshner lectured, "Drugs of abuse change the brain, hijack its motivational systems and even change how its genes function. . . .This is why addiction is a brain disease. . . . It may start with the voluntary act of taking drugs, but once you've got it, you can't just tell the addict, 'Stop,' any more than you can tell the smoker 'Don't have emphysema'." In the article elaborating this research, entitled, "The Brain: The Origins of Dependence," Sharon Begley claimed that "New Research On How Cocaine, Heroin, Alcohol And Amphetamines Target Neuronal Circuits Is Revealing The Biological Basis Of Addiction, Tolerance, Withdrawal And Relapse."
This is not the place to review all the contradictions in this research, other than to marvel that drugs affecting so many different systems of the brain are all equally addictive. Some (like alcohol) operate in wholly different ways from other drugs, because alcohol does not bind with specific brain receptors. In order to capture the diversity of drugs which people will use compulsively, neuroscientists (or at least Leshner) try to unify all drugs of abuse around their impact on dopamine, which he and some others regard as the mediator of pleasure in the brain. Only, as Begley matter-of-factly points out, "Eating cheesecake or tacos or any other food you love activates it. So does sex, winning a competition, acing a test, receiving praise and other pleasurable experiences." In other words, at this level of generalizability of brain function, drug use cannot be distinguished from a hundred other activities.
What we see in this research is a way of trying to encapsulate prejudices against drugs in a new package. According to Begley, "the more you take an addictive drug, the more dopamine receptors you wipe out. . . .But now the law of unintended consequences kicks in. With fewer dopamine receptors, a hit that used to produce pleasure doesn't. This is the molecular basis for tolerance. Drugs don't have the effect they originally did. To get the original high, the addict has to up his dose." This scientific sounding description is, of course, simply a translation of the temperance model of the inexorable progression of the disease of alcoholism (or addiction) – from tippling to regular drinking to abandonment to the addiction, and the impossibility of ceasing without the help of God – into new, scientific-sounding terms.
But this is all wrong, and we know it is all wrong. Every piece of practical and epidemiological evidence tells us it makes no sense. When hospital patients are allowed to regulate their narcotics intake, they regularly reduce their reliance on the drug rather than increasing it. Narcotics do not hijack their motivational systems; rather, these patients do not seem to be motivated to be addicts, and this ensures they have a wholly different reaction from the pattern that Leshner tells us God intended – when "drugs of abuse change the brain, [and] hijack its motivational systems." After all, do all people have their motivational systems hijacked by cheesecake, sex, and victory – although some people do?
And what, exactly, supports Leshner's claim that: "Starting may be volitional. Stopping isn't"? Let's first consider the most universally addicting substance known to Americans – cigarettes. Surveys of multiple substance abusers tell us that nicotine is at the top of the list of addictive substances that are hard to quit – harder than crack or alcohol. Yet, national surveys have revealed what most of us could ascertain by surveying our co-workers and dinner companions – a large percentage (half or more) of people ever addicted to smoking have quit. Moreover, in the 1980s, these surveys showed, from 90% to 95% quit smoking without formal treatment of any kind (although current research will reveal that more people – although still a minority – quit smoking through relying on widely marketed pharmacological aids). To say that quitting smoking is the same as willing away emphysema distorts the data so badly that, if not intentionally meant to be misleading, it can only indicate that the speaker is psychotic.
Consider the results of the largest survey of drinking ever conducted – involving face-to-face interviews with nearly 45,000 Americans (this study, called the National Longitudinal Alcohol Epidemiologic Survey, was conducted by the National Institute on Alcohol Abuse and Alcoholism). Of all Americans who were ever dependent on (addicted to) alcohol, about a quarter had been treated. Nonetheless, a large majority of untreated alcoholics (a higher percentage than of those who were treated) were no longer alcoholic, even though more than half continued to drink!
Table: National Longitudinal Alcohol Epidemiologic Survey Data on Ever-Alcohol-Dependent Americans
|Currently drinking alcoholically or with problems||26%||33%|
|Currently drinking without problems||58%||28%|
Finally, think of the Vietnam experience, where, among those GIs found to have been addicted in Vietnam, only one in eight became re-addicted in the U.S., although half used narcotics at some point stateside.
What we see is that Leshner is a government functionary selling us a bill of goods as though it were science, while his assertions are violated at all points by the most readily accessible data and daily experience.
Only Treatment Can Save Us from Universal Addiction
Based in good part on the Leshner et al. model that addiction is now scientifically proven to be a unique, inexorable, irreversible process limited to certain drugs of which the government disapproves, the conclusion becomes unavoidable that our only salvation is to treat more and more people for their drug use, even if we must drag them kicking and screaming into the psychiatric ward (like political dissidents in the Gulag). But, just as interviewing our dinner companions or examining data from government surveys proves that Leshner's claim that people cannot free themselves from addiction on their own is false, so too does the most casual examination show universal compulsory treatment for drug users is no reform in drug policy at all. For, even Leshner and his minions must agree (as the U.S. government's National Household Survey on Drug Abuse proves for every category of drug), the large majority of even current drug users (let alone those who have ever used any drug) are NOT addicted to their substance of choice, but rather use it casually, intermittently, or occasionally. For what, then, are such people to be treated – doing bad things?
With this in mind, we need to return to the entire Newsweek enterprise. From its cover through all of its articles, Newsweek's assumption is that illicit drug use is a function of addiction. Its cover boy is Robert Downey Jr. – the man who can't quit drugs. But why would we base our drug policy on him, any more than we should base our national cheesecake and taco policies on a six-hundred-pound person? Among other things, Newsweek's article on Downey described how he has been through treatment innumerable times! Furthermore, Newsweek selected, along with Downey, one other named drug user to prove its points: Jennifer Capriati, who seemingly used drugs briefly in her early adolescence, who was sent to treatment but who never announced that she was addicted and embraced recovery, but who returned to the tennis circuit and eventually worked her way back into championship form. Consider this odd paragraph from Alter, which is supposed to prove the prevalence and intractability of addiction:
After leaving drug rehab, Jennifer Capriati stages an improbable tennis comeback to win the Australian Open. Robert Downey Jr. relapses once again, a haunting symbol of the limits of treatment. The departing president of the United States appears to have been addicted to sex, while the new president – by his own account – once had a drinking problem. (Note how none of these cases actually supports the idea that addiction requires and responds to treatment.)
What is the Point of "Traffic"?
"Traffic" – a widely viewed; entertaining movie – depicted U.S. drug policy as badly misguided. Its view of addiction comes primarily from its screenwriter, Stephen Gaghan, who contributed a guest essay to the Newsweek issue on addiction. Gaghan is a recovering addict who himself recognizes that his experience is singular among his peers: "I wasn't much different from my peers. Except where they could stop drinking after three or six or ten drinks, I couldn't stop and wouldn't stop until I had progressed through marijuana, cocaine, heroin and, finally, crack and freebase. . . ." Still, Gaghan does not exactly conform with popular notions of addiction: in Newsweek he revealed that, "I won an Emmy for an episode of 'NYPD Blue' composed while on heroin," after years of serious drug use.
Gaghan's proxy in "Traffic" seems to be the high school girl played by actress Erika Christensen, who progresses from a straight-A student to prostitution in a matter of weeks after she freebases cocaine. The point Gaghan – and "Traffic" – made is that everyone is susceptible to addiction, and indeed everybody has his or her own monkey, just as the girl's father, played by Michael Douglas, liked to relax by drinking Scotch. But the Douglas character completed law school and became a state supreme court judge, suggesting that he limited his drinking appropriately. Indeed, the boy who introduced the judge's daughter to freebase cocaine does not seem to be disoriented by his drug experiences. The girl's character has a very different experience – but what does that tell us about drug policy?
Worse, "Traffic" is misleading about the epidemiology of addiction. Consider that people in lower socioeconomic groups are less likely to drink alcohol, but more likely to develop a drinking problem. It is true that some well-to-do people succumb to substance abuse. But they are less likely to do so than disadvantaged individuals, even though they are at least as likely to use psychoactive substances, while they are also more likely to recover should they ever abuse any substance – including becoming addicted to it. The point is the common-sense one that people with social and psychological advantages are more protected from addiction. For parents to know this is to be aware of something practicable that they can use in rearing children. It is also something that makes addiction and drugs appear less magical – and less threatening. But, then, it makes less good copy and subject matter for an attention-grabbing film.
Thus, this supposedly iconoclastic film, by focusing on a well-off person who is instantly reduced to utter degradation (Gaghan took decades to trace his addictive path), by minimizing the impact of social forces in creating and sustaining addiction, by proposing that treatment is both necessary for overcoming addiction and a winning social policy (the Douglas character, his wife and daughter enter a family-oriented treatment program), perpetuates popular misconceptions about drugs, addiction, and treatment – the same misconceptions that are being carried over whole-cloth from the old, bad drug policies to the new, Newsweek-promoted consensual policies of the 21st century. Of course, we may have to wait to see the results of the new "consensus" – one person who hasn't signed on is Attorney General John Ashcroft. On "Larry King Live" (February 7), Ashcroft indicated, "I want to escalate the war on drugs."
Addendum Not Published in DPFT News
by Dr. Stanton Peele
Before identifying treatments that work, let me make the following five points:
- Allowing the person to select a treatment — and treatment goals — is critical to treatment success, with people showing superior results when they feel engaged in the treatment and the options it offers and when these are consistent with their values and self-image;
- Treatment is not necessary — indeed, most people recover on their own from every variety of addiction, including alcoholism , without formal treatment or support groups, although they often rely on informal resources for assistance;
- The nature of treatment is not usually the critical ingredient in treatment outcomes — the characteristics of the treated person are critical, such as whether they are married, have stable social supports, have work skills and a job, etc.;
- Also critical is the follow-up to treatment — even very brief, informational sessions can have a strong impact on addiction if the person is tracked and knows he or she is to be contacted regularly about progress;
- Treatment outcomes, as above, occur in a social milieu — the best treatment outcomes will occur in environments which offer the most practical assistance (e.g., housing, work, legal and medical assistance, et al.) and social support.
Having made these critical points about treatment choice, natural recovery, the person in treatment, the follow-up to treatment, and the environment in which the treated person lives, there are treatments which make use of these principles and offer more successful outcomes for the treatment buck.
Among these useful treatments are the following:
Community Reinforcement Approach (CRA)
This is the therapy best supported by research. It's a moderately low-cost form of outpatient treatment; it was devised and first tested over a quarter-century ago; every study of its efficacy — with alcohol and a variety of drugs — has shown extremely positive results; and it is not in regular use at a single treatment center in the United States.
The basic premise of the community reinforcement approach — most often a one-on-one therapy, although it can be used in group settings — is that substance abuse does not occur in a vacuum, that it is highly influenced by marital, family, social, and economic factors. CRA attempts to help the client improve his or her life in all of these areas, in addition to giving up drinking or using drugs. Thus, a CRA program will typically include at least the following components: (1) communications skills training; (2) problem-solving training; (3) help finding employment; (4) social counseling (that is, encouraging the client to develop non-drinking relationships); (5) recreational counseling (that is, encouraging the client to find rewarding non-drinking activities); and (6) marital therapy. Other treatment components are sometimes used — for example, rewarding the client materially for abstinence or use of disulfiram or other drug therapy to reduce, substitute for, or eliminate drug use — but these six above-listed components form the core of the very successful CRA approach.
Social Skills Training (SST)
This form of group therapy is another very well supported approach. The basic premise of social skills training is that alcohol/drug-abuse clients lack basic skills in dealing with work, family, and other interpersonal relationships, as well as in dealing with their own emotions. Thus, they benefit from skills training in communications, anger management, conflict resolution, dr ink and drug refusal, assertiveness, relaxation, expressing feelings constructively, et al.
Behavioral Marital/Family Therapy
The single most frequent request/complaint I receive begins, "My boyfriend/husband. . ." Thus, marital counseling with an emphas is on altering behaviors related to drinking and drug use is important, particularly helping the non-substance-abusing spouse to aba ndon futile nagging about drinking and drug use and instead begin to reward sober behavior. This requires that the couple lear n constructive marital negotiation techniques, so that the non-substance-abusing spouse will also make modifications/concessions in her behavior. The remainder of the therapy involves typical couples counseling, the goal being to repair substance-abuse-cause d damage to the relationship, as well as dealing with non-substance-based problems.
Brief Intervention/Motivational Enhancement
Brief intervention (in many ways similar to motivational enhancement) was rated the most effective treatment in the Miller et al . (1995) analysis of alcoholism treatment research, while motivational enhancement was ranked the third most effective form of treat ment. At the same time, they were also among the most inexpensive therapies, with only a self-help manual being lower in cost . Because brief intervention is used often in a conventional medical setting, and because it is not abstinence-oriented, its u se with drugs is somewhat problematic. However, the principles remain valid with drugs as well as alcohol.
Brief intervention shares elements with motivational enhancement in that the patient and the therapist create a mutually agreed-u pon goal based on an objective assessment of the person's drinking habits, perhaps involving a medical (such as liver-function) test or a comparison of the individual's drinking levels with community standards or with optimum levels of drinking for health purposes . In brief intervention, the goal is usually reduced drinking; in motivational enhancement, it is either reduced drinking or t otal abstinence. The key is to allow patients to select a goal that is consistent with their own values and that they thus &qu ot;own" as an expression of their genuine desires.
In a brief-intervention session, the health-care worker simply sums up the goal: "So, we agree you will reduce your dr inking from 42 drinks a week to 20, no more than four on a given night." Motivational enhancement is a bit more subtle:&n bsp; the therapist nudges the client, without directing them, by responding to and building on the person's own values and desire fo r change. Here is a highly encapsulated version of a motivational-enhancement session:
THERAPIST: What is most important to you?
PATIENT: Getting ahead in life. Getting a mate.
T: What kind of job would you like? What training would that take?
T: Describe the kind of mate you want. How would you have to act, where would you have to go, to meet and deal with a person like that?
T: How are you doing at achieving this?
P: Not very well.
T: What leads to these problems?
P: When I drink, I can't concentrate on work. Drinking turns off the kind of person I want to go out with.
T: Can you think of any way to improve your chances of succeeding at work or with that kind of mate?
Here we see that the goal of therapy is to draw the connection between what people genuinely want — their own goals — and the institution of helpful behaviors, or the elimination of behaviors that interfere with achieving their goals. In brief intervention, in addition, drinkers know that they and the helper will be regularly assessing progress towards the agreed-upon goals in systematic but nonjudgmental meetings. (To examine these nondirective approaches, see Horvath, Sex, Drugs, Gambling and Chocolate: A Workbook for Overcoming Addictions; Miller & Rollnick, Motivational Interviewing: Preparing People to Change Addictive Behavior; and Peele et al., The Truth About Addiction and Recovery: The Life-Process Program for Overcoming Destructive Habits.)
Hester, R.K., and Miller, W.R. (1995). Handbook of alcoholism treatment approaches (2nd Ed.). Boston: Allyn and Bacon.
Horvath, T. (1998). Sex, drugs, gambling, & Chocolate: A workbook for overcoming addictions . Atascadero, CA: Impact Publishers.
Miller, W.R., and Rollnick, S. (1991). Motivational interviewing: Preparing people to change ad dictive behavior. New York: Guilford.
Peele, S., Brodsky, A., and Arnold, M. (1991). The truth about addiction and recovery. New York: Fireside.