Cognitive Evaluation

So treatment doesn’t work, where does that leave you?  What should you do if you want to end your substance abuse problem?  The statistics in the last chapter revealed an important fact- most people end their substance abuse problems on their own.  It’s not just most people- three quarters of people who end their substance abuse problems have never been to treatment programs or 12-step groups.  Naturally then, we should look at those people and follow their lead.  We should ask these self-changers how they did it, and then do the same.  Luckily, there are researchers out there asking these very questions of these very people.  This knowledge can give us direction on how to proceed.

As in our last section, I want to look first at research that has a wide scope.  In 2001 a team of researchers gathered 3 separate studies of self-changers.  These included heroin, alcohol, and cocaine abusers from Canada and Switzerland who had resolved their substance abuse problems without treatment.  These self-changers were interviewed about how and why they stopped abusing substances.  As you can imagine, they offered up many reasons from health scares and “rock-bottom” experiences to feeling that something needed to change or simply thinking about the pros and cons of their habits and making a decision.  Their stories were analyzed with a computer program which categorized and counted the number of times they mentioned words or phrases that fit into 11 different categories of reasons for change.   So in other words, this study set out to find the most common reasons for change by measuring how much the self-changers talked about different factors that led them to change.  The results- when self-changers are asked to explain what made them change, by far the most common reasons they cited fit into the category of Cognitive Evaluation, as you can see in the chart below.

A cognitive evaluation is a decisional process of weighing pros and cons.  In other words it’s a fancy way of saying that these self-changers thought about what they were doing, whether it was worth it, and then decided to change.  They made a choice.  Not a choice that they took lightly, and not one that was necessarily arrived at quickly, but nevertheless they did make a choice.  They got to the point of making the choice by thinking about the costs and benefits of their substance abuse habits, they thought about how things might get better if they stopped abusing substances, or worse if they continued abusing substances.  They thought about change.

Here’s some examples of quotes that fit into the cognitive evaluation category in this study.  One alcohol abuser said “it was a process”, “I had thought about it for a while”, “I came to grips with it and realized something was wrong”.  A heroin abuser said “I made a decision…in favor of life, that gave me strength”.  Another alcohol abuser said “I looked at myself as being dirt, that I had not achieved more”, and “you begin to draw kind of a balance sheet”.  In this analysis of self-changers’ stories about how and why they changed, they used words and phrases indicative of a cognitive evaluation an average of 14.9 times.

The next most common reason for change according to this study has to do with emotions- the category of Affect-Related Statements. Many self-changers mentioned fear, angst, love, or happiness as reasons for change in this study.  Words and phrases related to emotions were mentioned on average 7.3 times.  This is significant, indeed, emotions are the catalyst for all kinds of changes we make in our lives.  But ultimately, at 7.3 the score for this category was less then half the score for cognitive evaluations which weighed in at 14.9.  But in the end, emotions are just another factor that feed into the cognitive evaluative process.  Emotions are factors people weigh when making decisions.

The least significant reason for change in this study fit into the category of Dramatic Events.  What are Dramatic Events?  They’re nothing less than the typical “rock bottom” story- this is a common theme found at 12-step meetings, where people say that some horrible event woke them up and caused them to change e.g “I woke up in the hospital after the car crash and realized I would never drink again”.  With Dramatic Events scoring 1.8 and Cognitive Evaluations weighing in more than 8 times greater at 14.9 on our chart above, we can see that in reality you’re much more likely to end your substance abuse problem by thinking about it and making a choice, than you are likely to end it by “hitting rock bottom”.  It’s ironic that we’re often told in treatment programs and 12-step groups that the only way we’ll change is by hitting rock bottom, but when you look at self-changers (who make up 3/4 of the people who successfully end a substance abuse habit) this reason for change has the lowest rating.  Thinking about your behavior and it’s effects is much more powerful, but what is a “rock bottom” experience if not just another factor to consider when one makes a “cognitive evaluation” about whether or not to continue the behavior of substance abuse.

In fact, when we look at how other reasons for change scored relative to Cognitive Evaluations we can see that most of what we’re told about ending a substance abuse problem is directly contrary to the evidence.

We’re told that we must have “support” and while positive social groups and family support are shown in many cases to have a positive effect on substance abusers, it’s just not as significant a factor as cognitive evaluation- as can be seen in the low score (3.3) of the “references to others, support statements” category.  We’re also often told that “finding God” or a “higher power” is a necessity for substance abusers.  Again, with a score of 2.5 this study shows that it doesn’t factor in highly for most self-changers.  And the “health-related statements” (2.4) category is almost the same as “rock bottom”.  Meaning that these would be statements in which references to health or health scares are mentioned as a reason for quitting.  It is a powerful reason to quit when you’re health is in danger, but it just doesn’t happen to be a factor that self-changers mention as often as they mention factors fitting into the “cognitive evaluation” (14.9) category.

And finally, there’s the “Problem Related Reasoning” category in this study.  This category’s low score of 2.9 on the scale would seem to contradict the prevalence of Cognitive Evaluations as the top category of reasons for change.  Isn’t “problem related reasoning” thinking about a problem?  Yes, but responses categorized as cognitive evaluation fit more into a weighing of pros and cons, they imply a decisional “balance sheet”, and mention a decisional process directly, whereas examples that fit into the problem related reasoning category seemed to only reference avoiding negative consequences.  Quitting as a means to avoid a particular negative consequence is not the same as a decision making process that takes a wider view of the situation which considers the negatives and the positives.  Either way, it’s still indicative that self-changers for the most part get to a point of change by thinking about change, and that’s the most important point in our discussion.  When we look at the stats we can see that a rock-bottom experience, religious experience, health-scare, or presence of social support aren’t nearly as significant factors for self-changers as is the process of cognitive evaluation.  The total sum score of all these factors together is 10 which is still considerably lower than the 14.9 score in the single category of cognitive evaluation.  (This isn’t to say that these factors can’t be important, they are proven to be significant for many people, but our goal is to stay focused on the most prevalent reason for change right now.)  Self-changers decide to change.  They think about what they want in life, and whether or not their current behavior is getting them what they want.  This is the most important lesson we can learn from them.

From: What Works? – By Steven Slate, Untitled Addiction Workbook, Copyright 2005

Citation:

1. Sobell, L.C.;  Klingemann, H.K.; Toneatto, T.; Sobell, M.B.; Agrawal, S.; Leo, G.I. Alcohol and Drug Abusers Perceived Reasons For Self-Change in Canada and Switzerland: Computer-Assisted Content Analysis.  Substance Abuse & Misuse, 36(11), 1467-1500 (2001)