What should we be aiming for in the treatment of addiction?

For decades, treatment for addiction to drugs such as alcohol, cocaine and heroin was largely separated from broader concerns of physical and mental wellbeing. Addiction was conceptualized and treated as a distinct illness, to which many other problems were secondary and would probably resolve once the primary disorder had been addressed. Addiction treatment systems in many western nations thus developed in relative isolation from primary health care and mental health treatment, and have focused almost exclusively mainly on alcohol/ drug use. While this may be appropriate for some drugs, such as tobacco, or some drug users, we argue that such an approach is outdated for the mainstream treatment for addiction to drugs such as alcohol and heroin. Among the things that we know about addictions with reasonable scientific certainty is that they come intertwined with a host of other health, social, economic, family and mental health problems [1]. The conception of ‘dual diagnosis’ as a special minority population has given way to the recognition that concomitant problems are the norm when treating addiction. Even when entering specialty treatment, people bring with them a vast array of other concerns, some of which are often of higher subjective priority than stopping substance use. There is also a growing consensus that concurrent treatment of these concomitant problems is the way forward [2]. It is no longer adequate to tell people that the rest will resolve when they quit drinking or using, or to have each problem addressed separately by isolated treatment systems. Treatment ideally should address the person’s range of inter-related needs. Not doing so is one reason why addiction services never see most of those they were designed to help. More than three-quarters of people with addiction-related problems never enter specialist treatment. Of those who do, many more leave treatment soon after their initial contact. While some may gain what they are looking for in a brief contact, this attrition rate suggests that what we are offering is not very attractive or not relevant to their needs as they see them [3]. Further, while addiction treatment makes an impact, it is focused mainly on a single outcome: the absence of addiction. The cessation or reduction of addictive behavior is often a good starting-point, but if that is where treatment ends, it may be finishing just when a person needs help the most. One area of study that holds worthwhile insights for addressing addiction is research on quality of life and more specifically, subjective wellbeing (happiness), which has been pondered even longer than the desire for intoxication. Philosophers such as John Stuart Mill and Jeremy Bentham built their concepts of the good society on the maximization of subjective wellbeing [4]. If addictive behavior is often a quest for pleasure or release from unhappiness, surely this is a relevant consideration in addiction treatment. Dimensions of happiness are assessed specifically and addressed in the community reinforcement approach to addiction treatment, with the rationale that in order to be stable, a life of sobriety should be happier (more reinforcing) than one of inebriety [5]. Assessment of life quality often begins with a broad question such as: ‘How satisfied are you with life as a whole? ’. A long tradition of contemplation and research has identified at least eight subdomains of subjective wellbeing: standard of living; personal health; achieving in life; personal relationships; personal safety; community–connectedness; future security; and spirituality–religion [6]. Others have included elements such as creativity, self-esteem and a sense of meaning or coherence in life [7]. Notably, objective health is not a strong predictor of subjective wellbeing (e.g. [8,9]), suggesting that the dominance of a health approach for addiction treatment may not be reflective of an addict’s main concerns. In practical terms, identifying people’s satisfaction with each dimension of wellbeing can provide tangible directions for intervention, providing a true means for individualizing treatment goals and plans. Clearly, some elements are more important than others, and Maslow’s hierarchy of needs [10] may provide guidance as to which areas of a person’s life should be addressed first. More importantly, clients themselves have priorities, and the extent to which we address them is likely to influence our success with engagement, retention and outcomes. There is wisdom in viewing clients’ lives respectfully through their own eyes. (This flies in the face of a tradition that dismisses clients’ perspectives as hopelessly distorted, irrational and out of touch with reality.) In one study, people entering in-patient addiction treatment were asked, via a questionnaire with a broad range of items, what they wanted from treatment. Then at follow-up again they were asked, using the same items, what they actually gained from treatment. The extent to which they had received what they wanted from EDITORIAL doi:10.1111/j.1360-0443.2008. 02514.x