Constructing a Theory and Evidence-Based Approach to Promote and Evaluate Autonomy in Addiction

ABSTRACT

In this article we use theory and empirical evidence to synthesize a model for the analysis of autonomy in people with addictions. We review research on motivation and denial as accepted addiction constructs that need to be replaced with non-stigmatizing and autonomy-supportive language when seeking to ‘treat’ addicts. We present three main factors involved in relational autonomy in addiction (mentalizing, positive self-concept, and stigma), and illustrate our model by examining variations on these parameters in two case studies of heroin addicts. We conclude that a growth perspective is needed to assess functioning in populations believed to be ‘addicted’ and make suggestions for assessment.

Acknowledgements

This article was supported by the Norwegian Research Council through a Postdoctoral Fellowship awarded to the Norwegian Centre for Addiction Research, as well as a grant awarded to the Centre for Study of Mind in Nature for the project Personal Autonomy, Addiction and Mental Disorder. The production of the DVD Mindfulness—A Resource for Life Betterment was supported by the Norwegian Directorate of Health, and Stavanger University Hospital. We are grateful to Edmund Henden and Dag K. Wennesland for discussion of the ideas contained within.

Notes

¹Ryan and Deci, ‘Self-Determination Theory’; Mackenzie and Stoljar, Relational Autonomy.

²Corrigan, ‘How Stigma Interferes’.

³Vanagas, Padaiga, and Subata, ‘Drug Addiction Maintenance Treatment’.

⁴Owen et al., ‘Mental Capacity and Decisional Autonomy’.

⁵Peele, ‘Review’.

⁶Jellinek, Disease Concept of Alcoholism; Leshner, ‘Addiction is a Brain Disease’; Weinberg, ‘Embodiment of Addiction’.

⁷Davies, Myth of Addiction; Pickard, ‘Purpose in Chronic Addiction’.

⁸Klingemann, Sobell, and Sobell, ‘Continuities and Changes’; Heyman, ‘Is Addiction a Chronic Relapsing Disease?’.

⁹Sobell and Sobell, ‘Individualized Behavior Therapy’; Dawson et al., ‘Transitions’.

¹⁰Klingemann, Sobell, and Sobell, ‘Continuities and Changes’; Orford, ‘Asking the Right Questions’.

¹¹Levy, ‘Autonomy and Addiction’, 131.

¹²See DiFranza et al., ‘Measuring the Loss of Autonomy’; Hughes and Shiffman, ‘Conceptualizations of Nicotine Dependence’.

¹³Rasinkski, Woll, and Cooke, ‘Stigma and Substance Use Disorders’.

¹⁴Copeland, ‘Qualitative Study’; Corrigan, ‘How Stigma Interferes’.

¹⁵Luoma, Hayes, and Walser, Learning ACT.

¹⁶Link et al., ‘On Stigma and its Consequences’.

¹⁷Frischknecht et al., ‘Vicious Circle’.

¹⁸Larkin, Wood, and Griffiths, ‘Towards Addiction as Relationship’; Orford, ‘Addiction as Excessive Appetite’, Excessive Appetites.

¹⁹Orford, ‘Addiction as Excessive Appetite’.

²⁰Ibid.

²¹Anderson, ‘Cultural Identity Theory’, ‘Drug Identity and Identity’.

²²Anderson, ‘Drug Identity and Identity’.

²³Matto, ‘Applying an Ecological Framework’.

²⁴Cramer, ‘Defense Mechanisms’.

²⁵Baumeister, Dale, and Sommer, ‘Freudian Defense Mechanisms’.

²⁶Howard et al., ‘Denial in Addiction’.

²⁷Clancy, ‘Procrastination’.

²⁸Miller and Rollnick, Motivational Interviewing; Miller and Rose, ‘Toward a Theory of Motivational Interviewing’.

²⁹Khanlou, ‘Post-Migratory Experiences’.

³⁰Alexander, Globalization of Addiction.

³¹Ravndal and Vaglum, ‘Self-Reported Depression’.

³²Schwartz, ‘New Identity’.

³³Ryan and Deci, ‘Self-Determination Theory’.

³⁴Deci and Ryan, Intrinsic Motivation.

³⁵Wagner and Ingersoll, ‘Beyond Cognition’.

³⁶Mackenzie and Stoljar, Relational Autonomy.

³⁷Henden, ‘Addictive Actions’.

³⁸Davies, The Myth of Addiction.

³⁹Mackenzie and Stoljar, Relational Autonomy.

⁴⁰Bateman and Fonagy, ‘Comorbid Antisocial and Borderline Personality Disorders’; Savov and Antanassov, ‘Deficits of Affect Mentalization’; Fonagy et al. Affect Regulation, Mentalization and the Development of the Self.

⁴¹Liotti and Gilbert, ‘Mentalizing, Motivation, and Social Mentalities’.

⁴²Briñol and DeMarree, Social Metacognition.

⁴³Wells and Matthews, Attention and Emotion, ‘Modeling Cognition’; Wells, Emotional Disorders and Metacognition.

⁴⁴Hill et al., ‘Dynamics of Threat, Fear and Intentionality’.

⁴⁵Rothbaum, Weisz, and Snyder, ‘Changing the World’; Skinner, ‘Guide to Constructs of Control’.

⁴⁶Harrington and Loffredo, ‘Relationship’.

⁴⁷Rosenberg, Society and the Adolescent Self-Image.

⁴⁸Bandura, Social Learning Theory.

⁴⁹Rotter, ‘Generalized Expectancies’.

⁵⁰Judge and Bono, ‘Relationship of Core Self-Evaluations Traits’. Neuroticism, considered one of the ‘big five’ personality variables, has also been considered for inclusion in the core-self construct. Judge et al., ‘Are Measures of Self-Esteem..?’. This variable has been consistently linked with addiction, and is a term with a longstanding history in the study of various psychopathologies. However, since measures of neuroticism involve impulsiveness, a temperamental cognitive factor believed highly heritable and stable, we argue neuroticism should not be included in core-self. We would suggest that impulsiveness, which has its own bearings on autonomy, be considered as a separate construct within an assessment.

⁵¹Brandon et al., ‘Cognitive and Social Learning Models’.

⁵²Rosenberg et al., ‘Global Self-Esteem’.

⁵³McKellar et al., ‘Predictors of Changes’.

⁵⁴Moos, ‘Theory-Based Active Ingredients’.

⁵⁵Lovejoy et al., ‘Patients’ Perspective’.

⁵⁶Corrigan and Watson, ‘Paradox of Self-Stigma’.

⁵⁷Goffman, Stigma, 2–3.

⁵⁸Buchman and Columbia, ‘Stigma and Addiction’.

⁵⁹Orford, ‘Addiction as Excessive Appetite’.

⁶⁰Myers et al., MBTI Manual.

⁶¹Orford, ‘Asking the Right Questions’.

⁶²Antonovsky, ‘Salutogenic Model’.

⁶³See, for example, Holmes, ‘Evidence for Repression’.

⁶⁴See Keren and Schul, ‘Two is Not Always Better’.

⁶⁵See Evans, ‘In Two Minds’.

⁶⁶Escher, Relativity.

⁶⁷Mackenzie and Stoljar, Relational Autonomy.