Do values pay a role in addiction?

 

Dear Chris:

I noticed with great interest and appreciation your chapter incorporating values in motivational interviewing in the latest edition of Motivational Interviewing. Values is often the missing link, in my view, in both clinical research and therapy. What, after all, motivates people to change? For me, as you point out, motivational interviewing has always been about flipping people to examine their behaviors in line with their values.

Stanton

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Hi Stanton,

I think your website is one of the greats in the addiction field – stimulating and thought-provoking. Actually, your moral vision of addiction article is required reading in my introductory substance abuse course and was discussed in an earlier version of the MI values chapter before the editing process required some trimming down. I have used your question “why do the same people do so many things wrong?” as a launching point for classroom discussion. The longer I can keep students thinking about that question, the more they seem to have to re-examine the things they’ve come to believe based upon what they have been told by others or have seen on the TV. They have to think for themselves in order to answer the question without resorting to slogans and unexamined handed-down ideas. This is one of my primary interests in teaching – not to lead students to any one view of addiction, because I think all of the major perspectives on addiction are incomplete, but to help them to more critically think about the array of information available on substances and substance use and come to their own conclusions.

My thoughts on values in counseling relate to helping people figure out what they really want and how they can get it or something close to it. It seems to me that when people know who they are and what they want, and have some opportunity to achieve it, many of the problems they experience go away on their own rather naturally. It just seems a lot easier to give up a habit that is getting in the way of something else that is more important to you than to give up a habit because it is bad for you or because it bothers other people. The focus becomes not “what do you need to quit or escape from” but “what do you want, what are you going toward.” Counseling becomes a process for helping people become centered, clear, and empowered to live a life that is satisfying and of which they can be proud.

I have found that a lot of the time I previously spent with people figuring out what’s wrong and how it got that way was inefficient, and that a better way for me to help toward change is to get excited about people freeing themselves from all sorts of chains and do my best to help make change a low-key, relatively non-threatening experience.

All the best,
Chris Wagner

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Dear Chris:

I do think we are traveling much the same territory – I love your using my question, “Why do some people do so many things wrong?” In Diseasing of America (on page 135), it actually reads, “Why do some people – and their families and everyone they know – do so many things wrong,” which recites the foibles of Detroit Lions football player Reggie Rogers and his family. In an interview Rogers reviewed his disastrous previous year – including his brother’s death by drug overdose, his sister’s disappearance, his being charged with aggravated assault and begin sued by his agents. Less than three months after the first interview, Rogers was charged with killing three teenagers while driving drunk and recklessly.

Of course, when you think about that story (as you force your students to do), you immediately are forced to think about how some people, and their families and their social milieus, have bad values. Not that they can’t recover from that, but it indicates how important it is to inculcate values – like responsibility for your actions and concern for others – from the start. And behaviorists, disease proponents, and all politically correct people shy away from recognizing the role of values in much of what we identify as addictive and other dysfunctional behavior.

Of course, values are thus a key tool for changing behavior, since most people do somewhere subscribe to bedrock values, and some rather strongly, which their behavior belies. My favorite educational device is to talk about how my Uncle Ozzie quit smoking when a co-worker told him that he, a labor activist, was a sucker for the tobacco companies (that one’s on page 189 of Diseasing). I extend the story and then finally ask, “Why did Ozzie quit smoking permanently that day, based on a single chance remark by a co-worker?” I point out that if we could package that technique (of course, it requires people who are as focused on key values as my uncle), then we could become miracle workers as therapists.

Of course, I agree completely with your description of therapy – indeed, I have lately become aware that people are marketing something called “coaching” which follows what you and I practice. That is, it shifts from the past and trying to put labels on experience to the future and problem solving.

Chris, it’s great to make contact with you and to know my work resonates so well with your own take on motivational interviewing – which I practice and which I admire so much as it has been developed by Bill Miller and you and other of his colleagues.

Stanton Peele

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Hello again,

Like you, I think this is an important topic that is often overlooked. My response is quite long, but I think this is a complex topic and appreciate the opportunity to engage in a dialogue with someone who agrees that the topic is important and has given the issues considerable thought. I’ll share some of my views on some of the larger issues surrounding values and motivation, with the confidence that you understand that these remain open to input and change and that my efforts to express my views sometimes fall short of explaining what I actually intend to express.

I agree that individuals’ values can guide their behavior and that an individual value hierarchy that emphasizes self-indulgence over prosocial behaviors can lead to self-indulgent behavior at others’ expense. At the same time, I think that the relationship between values and behavior is complex and so I am hesitant to say that because someone engages in destructive behavior this equates with having “bad values.” I’m not denying that self-oriented values can lead to self-indulgent behavior, just that I think there are a number of other contributors to destructive behavior to consider as well (which I think you agree with from reading your other writings).

I appreciate your view on values and responsibility – and especially turning the issue around to take a look at the responsibilities of society in helping people develop prosocial values and live by them. For my own part, I think that responsibility and choice are opposite sides of the same coin – you can’t have one without the other. Thus, I think social, legal, moral or counseling efforts that emphasize personal responsibility are prone to fail to the extent that they ignore personal choice – and to the less opportunity there is to engage in a range of behaviors, the less there is choice. Of course, there is always individual choice as to whether to engage in specific destructive behaviors or not, but I think there is an important larger issue of opportunity to choose to engage in more prosocial patterns that serve as protective factors against dysfunctional behavior – opportunities to engage in meaningful work, to receive a sufficient wage that increases opportunities to participate in community events and have access to community resources, to live in a neighborhood that one feels comfortable in, and so on.

Drug use and dependence exist across all strata of society, but it seems to me that the greatest problems related to drug use are concentrated in those areas where opportunities for achievement, success, and participation in a community are the most limited. In your email and other writings, you talk about the need for society to inculcate prosocial values. I agree, and also think that the process of developing prosocial values is facilitated by having the experience of living in a society that values you. I would be hard-pressed to look at American society and say that it highly values those of minority and under-privileged backgrounds, who historically do not have adequate supports and resources to compete on an equal footing in a capitalistic society. In my mind, for society to expect differently of individuals who grow up with the experience of being devalued by society, society must behave differently toward them – not leave them to make it on their own or die in the streets, but develop real opportunities for them and provide resources so that they can learn how to make use of the opportunities. We know that behavior is in part a consequence of environmental reinforcement – what positive reinforcement does our culture provide for the majority of those in under-privileged communities to behave in prosocial ways? Very little, it seems to me, unless the individuals are exceptional in some way and can make good on their exceptionalities. It seems to me we need much more than the threat of punishment or removal from society to sort things out at the societal level.

Some may misperceive what I am saying as excusing individuals for engaging in behaviors that harm others. Holding individuals responsible for engaging in behavior that harmed others is a different subject than examining societal factors that inhibit development of prosocial values and behaviors – related perhaps, but different. Of course we need to have systems in place that hold individuals accountable for their harmful behavior – otherwise we would have chaos. However, at the same time I think we invite future destructive behavior if we ignore the context in which those behaviors most commonly occur and fail to develop social structures that engage people in prosocial behavior.

There is another aspect of this that I am interested in. I don’t think that drug problems or related problems are necessarily related to having a value system that prioritizes “selfish” values over community values (though I’m not arguing with you that they can). As Frank Sanchez and I mention in the chapter on motivational interviewing and values, there is some fairly convincing evidence that people often do not live by the values they hold when they are in situations that pull for behavior contrary to held values. We touch on some of the famous social psychology experiments – research subjects who continue to follow Milgram’s commands to shock confederates even when those subjects are reduced to “twitching, stuttering wrecks” because of their value conflicts about doing so – seminary students who declare that their faith is based on “caring for others” and then immediately proceed to step over a man lying in a doorway and moaning for help as they rush off to lecture on the Good Samaritan parable, simply because they have been told that they are late and their audience is waiting for them. I think these are good examples of the kinds of evidence suggesting that it is not just drug users and individuals with dysfunctional patterns who do not always behave in congruence with their values – it is many of us, depending on the situation. Regarding the minority and under-privileged communities I mention above, it could be that individuals having problems in these communities do hold prosocial values, and perhaps hold them fairly strongly, but have greater difficulty living by them without the community supports and opportunities available to those in more privileged communities and also simply have environments that exert a stronger pull to engage in dysfunctional behaviors. I happen to live in a middle class community – if I am feeling the need for self-indulgence or pleasure, I have many opportunities available to me – I can walk around a nice neighborhood without fear of being mugged, shot or approached by drug dealers. I have the money to go to a pleasant restaurant. I have neighbors I know and like and can visit. I can work in my garden or go to a movie or watch cable TV. I was encouraged to read for pleasure from an early age and learned to enjoy the benefits of that. And so on. Having these opportunities available decreases the likelihood that I will develop a pattern of reliance on pleasure-producing drugs to make me feel good.

I won’t get into all of my reasoning for why I define values as I do, but my definition is somewhat broader than a typical definition that limits the meaning of the term values to “ideals.” I start with the premise that to study values, it is useful to move beyond preconceptions regarding values that are rooted in religious and cultural traditions – not to throw out the conceptualizations of values that come from these traditions, but to free ourselves to think about values in a rational fashion without having to rely only on traditional views. From my point of view, I start by recognizing that valuing something is a process – and that people can value things that are often not included in typical definitions of the term “values” – such as excitement, relaxation, adventure, comfort, pleasure, and so on. So my use of the term is fairly broad, and I see close relationships between the concepts of values, motivations, preferences, desires, and needs. As you know, motivational interviewing is focused on helping people resolve ambivalence about competing options, and part of my focus is on helping people resolve the ambivalence that results from holding multiple values that are in conflict with one another (e.g., “Is it more important to live an exciting, fast-paced life or to spend time helping my kids learn to read even though the school will eventually teach them that anyway?” I also sometimes focus on helping people resolve ambivalence that results from holding values that are different from their surrounding culture (e. g., “Should I quit smoking marijuana because it is illegal and I have been arrested, even though I don’t find smoking it to be a problem otherwise and don’t think it is anyone’s business but my own?”).

In our chapter, we discuss some ideas regarding values conflicts between different levels of values, such as those represented in Maslow’s seven-level motivational pyramid, Robert Pirsig’s five-level system of values or in any of the simpler three-level versions (W. James, E. Mathes, C. Alderfer) that focus on the levels of physiological/material/existence, social-belongingess/relatedness and spiritual-growth/actualization. The basic prediction from these theories, especially Maslow’s, is that people are motivated to behave in ways that meet needs/values at all levels, but when there is a conflict between levels, it is natural for people to sacrifice the “higher” levels in order to meet needs/values at the lower levels. Thus, if a person must choose between behaviors that meet either physiological needs/values or actualization needs/values, but not both, it is natural for that person to choose the behavior that meets the lower needs/values (e.g., problematic drug use that brings pleasure, but sacrifices achievement or personal growth). If giving up a drug means sacrificing physiological pleasure or comfort, the person must then transcend the natural hierarchy of motivations to do so, which can be a difficult venture. If the drug use also is related to a sense of belonging in a peer group, then the attempt to change behavior is likely to be even more difficult, as the drug using behavior fulfills values at two “lower levels.” Thus, the person must give up not only physical pleasure or comfort, but also a sense of social belonging in his or her peer group, all in favor of more abstract “higher” values related to achievement, responsibility, personal growth or contributing to the community.

As Bill Miller and Janet C’de Baca have described in their “Quantum Change” book and I think as you are describing with your Uncle Ozzie, sometimes people have sudden “upward” shifts in their values hierarchy, but these kinds of changes often are slow, gradual, tentative and difficult. Some of the ideas we propose in the chapter include using MI strategies and techniques to help people explore their value conflicts and increase awareness of the extent to which certain behaviors may fulfill certain values at the expense of fulfilling other values. It seems to me that a good general counseling strategy, from a values perspective, is one that helps people initiate and maintain behaviors that fulfill values at all levels of the motivational hierarchy. Thus, my focus often is not on giving up behaviors that serve the “lower” values at the expense of the higher values, on trading in pleasurable behaviors for more prosocial behaviors. Instead, the focus is on helping people think about their values in all of these areas, and try to find a combination of behaviors or habits that feel good, that include others and lead to their support and respect, that help achieve personal goals and societal rewards, and that lead toward actualization or personal growth. When people conceive of a way to have this kind of success, the attachment to addictive or other problematic behaviors can dwindle rather quickly and naturally, as the behaviors are no longer seen as either helpful or necessary. It may be that the level of excitement, relaxation or comfort produced by drug use is not quite duplicated in the new way of living, but these needs/values can be met to a lesser extent through other behaviors and any loss in them is compensated by gains resulting from increased social support and belonging, achievement of goals, and growth. But an important point in my mind is that people should not be poisoned against seeking excitement or relaxation or other pleasurable experiences as I have seen happen in some treatment settings, but instead encouraged to find less problematic ways to have these experiences that do not threaten the possibilities of having a more deeply satisfying life overall.

More than you asked for, and probably far more than you wanted to know about what I think on all this, but these are some of my thoughts at this time. I am sure that you can find areas where we differ somewhat in our thinking, but also anticipate that you appreciate the effort to think through such issues “outside the box” and look forward to any further dialogue you wish to engage in…

Best wishes,
Chris Wagner