Addiction and the Road to Damascus

Rev. Alexander E. Sharp Drug Education, Harm Reduction

William R. Miller, psychologist and Co-founder of Motivational Interviewing

Dear Friends and Colleagues,

If asked to name the American thinkers of the past 150 years whom I most admire, I would place the great pragmatic philosopher William James at the very top of the list. Starting as a professor of physiology at Harvard in 1873, James virtually created psychology as an academic discipline. His Varieties of Religious Experience, published in 1890, endures as a religious classic.

William R. Miller, distinguished professor emeritus of psychology and psychiatry at the University of New Mexico, should be considered among James’ most worthy successors. While he may not have created an academic discipline, Miller did, along with colleague Stephen Rollnick, develop a new therapeutic technique – Motivational Interviewing (MI) – now used worldwide to treat individuals suffering from alcoholism and addiction and more broadly seeking personal change.

 It is easy to forget that until about 40 years ago, many people believed a confrontational “boot-camp” approach was an effective treatment for alcoholism and other addictions, The concepts of MI have helped to expose this misguided view.  

Miller’s experience in working with addicts also led him to explore with academic rigor the notion of sudden personal conversion. He is the first scholar since William James to do so. In his book Quantum Change, he documents what he finds to be the reality and surprising frequency of such experiences. He is now exploring the ways MI and such “change” experiences might be related. 

I am delighted to introduce Dr. Miller to you here, for two reasons. First, Clergy for a New Drug Policy is devoted to ending the so-called War on Drugs. The tenets of Motivational Interviewing make clear why criminalization as the primary weapon in this war, as currently fought, is a tragic response to drug possession and addiction. More broadly, these same principles offer the potential for human change regardless of the arena.  

Dr. Miller recently participated in a webinar broadcast by the Center of Addiction and Faith (CAF), a Minneapolis-based organization that engages clergy and churches in responding to addiction. A selection of Dr. Miller’s comments under key issues is provided below.  


On the origins and key tenets of Motivational Interviewing:  

Early in my education, I was on an internship in Milwaukee, Wisconsin working on an alcoholism unit. It was run by a psychologist who was compassionate and scientifically oriented, so I felt very at home. I knew nothing about alcoholism, really, but had been trained in Carl Rogers’ person-centered and behavioral approaches.

It was the patients who taught me about alcoholism. I began reading the literature on alcoholism from the 1970s, which said, “Alcoholics are pathological liars, completely in denial, out of touch with reality, and horribly difficult and defensive.” And I said, “Gee, those aren’t the same people I was talking to.”

This puzzle was the beginning of Motivational Interviewing. I realized that that picture of people being very difficult, defensive, and dishonest was a function of the way we were treating addiction at that time — in a very confrontational, authoritarian, shut-up-and-listen kind of way.

The spirit behind Motivational Interviewing is partnership rather than “I’m the expert and you’re only a recipient.” It’s two people talking to each other as peers. I have expertise, but so does my client. My client knows more about him- or herself than anybody else in the world. If we’re talking about a change in that person’s behavior, I need their expertise, as well as my own.

Rather than saying “I have what you need, and I’m going to give it to you,” the communication in Motivational Interviewing is more “You have what you need, and together we’re going to find it.”

A central principle is that it should be the person, the client, the patient, the student, who’s making the arguments for change and not me. If I’m arguing for change and they’re arguing against change, I’m in the wrong chair.

On the importance of “self-acceptance” in personal change:

Here was one of Carl Rogers’ interesting discoveries: that when you experience yourself as unacceptable, it’s very, very difficult to change. It’s paralyzing. And when you experience acceptance, profound acceptance — as you are — whether from a therapist, or a friend, or your family, or God, then it becomes possible to change.  Now, I don’t know why we’re wired that way, but we seem to be. 

On the role confrontation and punishment in response to addictions: 

Punishment suppresses behavior. It doesn’t teach anything new. It doesn’t say, “This is the way to go, … this is the way forward.” I began a very different approach to working with addiction accidentally and [found] very different outcomes.

Human beings don’t generally take well to being told what’s wrong with them and what they should do. If you take a different, person-centered approach, you get a very different outcome. You find that you are working with a very different kind of person.

When we also looked at the literature on confrontation, it is completely negative. There’s not a single clinical trial of a confrontational approach that produced a positive outcome. It was the norm at that time. We thought that that’s what those people needed.  But there never was any science to the notion that if you can just make people feel bad enough, they’ll change. And nor is that my faith.

On the debate over addiction as a disease or a choice: 

It’s an old idea that people with substance use disorders just can’t enter into a therapeutic relationship. There never was any science to that. Quite to the contrary, person-centered approaches like Motivational Interviewing have a very, very good track record.

When we have this black-and-white way of thinking about things, there are only two possible outcomes, perfection or disaster. I’ve done outcome research for 40 years. Outcomes don’t look like that. They’re all over the map. It used to be alcohol dependence and alcohol abuse were different disorders. They’re not. It all lies along a continuum. Outcomes look the same way.

We know that with chronic illnesses, we don’t expect people with diabetes to never taste sugar again. We don’t expect people with hypertension to abstain totally from salt in all forms. The main thing is to be moving in the right direction. 

What is meant by the disease model is that you are completely different, incapable of controlling what you are doing.  For some people that’s helpful.  Identifying with that is the way they stay sober, and that’s good. However, if you don’t remain perfect, it can be discouraging. 

We have a study in which we found that an endorsement of the disease model actually increases the relapse rate. People were more likely to not just use, but use catastrophically, when they believe that if one drinks one is a drunk. For some people, that’s helpful. For others, it’s not. That’s human nature and there’s not one solution, one answer for everybody.

On the seemingly contradictory approaches to recovery (some evoking a “higher power,” others “personal agency”):

One of the wonderful things about addiction treatment is we have a terrific menu of different science-based approaches that can help people. There isn’t one approach you should always do.  

One of those is the 12-step program. It’s very nicely scientifically documented. (Alcoholics Anonymous itself is harder to document, although there are a lot of studies of it.) But a 12-step facilitation treatment works on average just as well as cognitive behavior therapy or Motivational Interviewing on average. So, if one thing isn’t working, try something different.  

For Bill Wilson (founder of Alcoholics Anonymous), who was a banker and at the top of his game, learning powerlessness might have been the key. But if you’re working with individuals who have experienced deep trauma, they might need to focus on methods that will draw out personal agency.

Feminist theology has questioned whether women in general need more powerlessness. Women for Sobriety and SMART Recovery and other kinds of approaches were developed as reasonable alternatives. Humility and ego busting and powerlessness doesn’t seem to be the path for them.

On how churches and other communities can respond to addiction:

First, make it a topic of conversation. So often there’s so much shame around this topic in the United States that you just don’t talk about it. You can change that norm in a church by preaching about it if you’re the pastor, by sharing stories in prayer time.  Bring it out of the closet. In this country we have made it a shameful thing.

Albuquerque is an interesting example. The University of New Mexico Hospital operates the largest addiction treatment program in the state. But it’s not located at the University of New Mexico Hospital. It’s in a warehouse district out by the airport. Now, why is that? It’s because we don’t want “those people” around the hospital. Except guess what? They’re already there being treated for all kinds of other things.

That’s not right. We have science-based, perfectly reasonable treatment methods that are rather like what therapists are doing anyhow with other kinds of clients. And yet, we’ve somehow come to believe that this is somebody else’s work. We should mainstream it in churches, in healthcare, in psychology, in social work, in homeless services. It’s just a really common part of life and not one to be shunned.

On the importance of “small interventions:”

Most of the things in my career that were most important were unexpected. And I learned early that when you don’t find what you predicted, that’s when you should get interested, become curious, and follow that, believe your data and follow your data. 

In 1983, I was thinking of Motivational Interviewing as a kind of priming the pump or getting people ready for what would be real treatment. The unexpected thing that popped up was that after a conversation in this way, people often began changing without additional help. 

My training as a therapist had been “the longer you spend with me, the better you’ll get.”  But I began to find that even after a relatively brief conversation, people seemed to turn a corner on what had been very longstanding destructive patterns.  It didn’t make sense to me, but we kept pursuing it. That has held up over time.

If you look at the stories of healing and in writings about Jesus, they’re not long interactions. They are relatively brief encounters. He almost always touches the person, which is interesting. But these things are not long-term psychotherapy sessions. Something is happening that powerfully changes the person.

On the possibility of personal conversions:

Some people don’t know that the author of the hymn Amazing Grace was a slaver. His last trip was not the one on which he wrote Amazing Grace. He had a couple more exchanges. And so, it doesn’t necessarily happen all at once. It’s not always like Ebenezer Scrooge, where you’re totally transformed in the moment.

But sometimes people are. I wrote a book called Quantum Change. The last psychologist I could find who was interested in this was William James, for whom psychology and religion naturally fit together at the beginning of the 20th century. 

He was fascinated by people who are suddenly transformed and tells some of their stories in Varieties of Religious Experience.  I wondered, “Is that real? Does that actually happen in real life?” Well, the stories are found in biography and autobiography.  We found that it was not difficult at all to find people who had had such “turning point” experiences in their lives. They hadn’t told anybody. They often didn’t talk about it, because the experiences sometimes sound pretty crazy. 

I just went into the study asking, “Does this even exist? Is there such a thing as an experience that happens within a few minutes or hours that permanently changes the person, like a one-way door?” It is real and it’s common. (For more on this aspect of Dr. Miller’s work click here.)

On the relation of psychology and religion: 

Psychology in the middle of the 20th century was phobic about religion. Psychology arose in the 19th century out of philosophy and religion. Those are the parents of the field. But somewhere in the middle of the century, psychology just drew back from that, almost like an adolescent rebellion, really, I think.

And when I was in graduate school, I was told, “If you have to believe that kind of thing, just keep it to yourself.” I wondered, “Why is that? That doesn’t make sense to me.” I kept my mouth mostly shut about my faith during the graduate training.  But those worlds have always fit together for me. Toward the end of the 20th century, books began appearing on spirituality and psychology and religion and psychology as well in the journals of the American Psychological Association.

It was almost like we had passed the adolescent rebellion and begun to say, “You know, maybe my parents did know something.” Openness to spirituality and religion has really begun to take hold in psychology. But I think we had to get through that rebellion period.

These are only a few of the humane and enlightening insights from this interview with a gifted psychologist and man of faith. If you would like to hear the full interview as conducted by Timothy McMahon King, digital organizer and author of Addiction Nation, click here.

Sincerely, 

Rev. Alexander E. Sharp, 
Executive Director, Clergy for a New Drug Policy


P.S. The following two pieces provide a broader understanding of topics included in the above interview. 

DO CHURCHES CARE ABOUT ADDICTION?

In the above interview, Dr. William Miller comments on the critical role churches and health care institutions can play in combating the stigma associated with substance abuse and other forms of addiction. The current issue of Reflections, the online magazine of the Yale Divinity School, includes a piece I have written on this theme, along with thoughts about the role of the church in public life. I include my article here. It is drawn from the webinar offered by the Center of Addiction and Faith in January, 2021.

WILLIAM R. MILLER SPEAKS AT THE UNIVERSITY OF CHICAGO

In 2014, Professor Miller was invited to give the Ruth Knee Lecture on Spirituality and Social Work at the University of Chicago School of Social Service Administration. The first half of his lecture focused on Motivational Interviewing, the second on the notions of personal conversion as addressed in his book Quantum Change. I bring this lecture to your attention here, especially for those who seek to know more about this second topic, and the relation between the two.