Love Wins: A Compassionate Approach to Addiction Treatment

One of the hardest things a person with an alcohol or substance use disorder does in their life involves treatment. For some, the hard part is the decision to seek treatment. For others, the hard part is accepting they have a drug or alcohol problem. And for still others, the hard part is the treatment process itself.

For some people, it’s all hard.

But the truth is that it’s different for everyone.

Some people wake up one morning and, with no external influence at all, make a rational, clear-eyed choice to quit drinking or quit doing drugs. For them, the decision is the easy part — but finding the right treatment program or support group is the hard part.

Some spend years waging an internal battle around whether they really have a problem, and when they finally accept that they do, the next steps — finding treatment and support — may offer challenges, but those challenges are typically not nearly as tough to overcome as admitting to themselves they have a problem that needs to be resolved.

Some people make the decision without too much drama, find treatment and support relatively easily, and arrive on day one ready, willing, and able to change — and find that making those changes is the hardest thing they’ve ever done.

Then there are those who won’t admit they have a problem. They don’t consider seeking treatment or support. They don’t know how treatment would go for them because they never get to that point. For those people, it often falls to family, friends, and loved ones to convince them they have a problem and need to do something about it.

For most of us, that last sentence conjures up one word: intervention.

And that word, in turn, conjures up a phrase: tough love.

Tough Love Interventions

I know all about tough love interventions. I’ve seen them succeed and fail. They typically follow what’s known as The Johnson Model, which achieved widespread public notoriety through television shows like “Intervention,” which is currently in its 21st season on the A&E Network.

Here’s how the American Psychological Association (APA) describes a Johnson-style intervention:

“The approach is to plan and implement a confrontation of the substance abuser by one or more caregivers…[and]…family members who are actively involved in the lives and care of the person with substance use disorder and/or are impacted by the disorder. Intervention includes planning and the confrontation session which follows, with the goal of engaging the person in treatment.”

Here’s how the Substance Abuse and Mental Health Services Administration (SAMHSA) describes the effectiveness of confrontational approaches to treatment-resistant individuals:

“Adversarial confrontation is one of the least effective methods for helping clients change substance use behaviors, can paradoxically reduce motivation for beneficial change, and often contributes to poor outcomes.”

The latest data on confrontational models — the ones I call tough love models — show that a majority of the time, they don’t work. In a study comparing three intervention models — one involving confrontation, one involving non-confrontational, detached persuasion, and one focusing on compassion and collaboration — researchers found that the confrontation model (Johnson) resulted in the loved one seeking treatment in 30 percent of cases, the detached persuasion model (Al-Anon) resulted in the loved one seeking treatment in 13 percent of cases, and the compassion/collaboration model resulted in the loved one seeking treatment in 64 percent of cases.

That data brings me to the third model — the compassionate, collaborative one — when helping a treatment-resistant individual with an alcohol or substance use disorder. It’s called CRAFT: Community Reinforcement and Family Training (CRAFT).

About the CRAFT Model

The origins of the CRAFT model appear in the work of psychologist Nathan Azrin. In the early 1970s, Azrin explored approaches to treating alcoholism that, rather than relying on conflict and confrontation to convince alcoholics to seek treatment, instead focused on helping friends and family create an atmosphere of positive reinforcement and support for choosing sobriety and engaging in non-drinking behaviors. Azrin prioritized improving the relationships, environment, and conditions that surrounded the individual instead of focusing solely on the problem behaviors associated with the problem drinking. He worked on devising strategies to help the individual develop coping skills, engage in activities unrelated to drinking, and create a support network of positive, recovery-oriented friends, family, and recovery peers.

This work on what was then known as the Community Reinforcement Approach (CRA) formed the foundation for what we now call the Community Reinforcement and Family Training (CRAFT) model of treatment. Over the past 40 + years, dozens of studies involving thousands of participants have verified the values of the CRA model and its derivatives — including the CRAFT model — for the treatment of both alcohol and substance use disorders (AUD/SUD).

The core components of the CRA/CRAFT approach include:

· Restructuring the circumstances surrounding the person in recovery. This primarily involves the positive reinforcement of abstinent and/or non-drug using behaviors and negative reinforcement of drug or alcohol use.

· Helping the person in recovery to recognize and prioritize positive reinforcement through taking steps to avoid alcohol and/or drug use.

· Facilitating direct participation of Concerned Significant Others (CSOs) in the recovery process.

· Educating CSOs about addiction treatment and the science of addiction.

· Teaching CSOs about enabling behavior. Enabling refers to actions that remove or diminish the natural negative consequences associated with the disordered use of alcohol or drugs.

· Teaching CSOs how to positively reinforce alternatives to alcohol and/or drug use.

· Training CSOs about collaborative, non-confrontational approaches to communicating with the person in, or considering, recovery.

As you read this, please understand that although the CRA/CRAFT approach emphasizes the role of the family and community in helping an individual move away from addiction and toward recovery, it does not transfer personal accountability for drinking and/or drug use from the user to the family and community. Within the CRA/CRAFT model, the primary work of recovery is the responsibility of the person in recovery. What the CRA/CRAFT model advocates — and what sets it apart from other treatment models — is creating an environment that promotes sobriety and recovery. The idea is that when a person is surrounded by life-affirming and sober-friendly people, and has access to positive and enriching activities, they have a greater chance at sustainable health and wellness.

CRAFT in Action

In 2011, a group of psychologists developed a set of data-driven, evidence-based procedures based on CRA/CRAFT principles. They published a manual designed to help counselors, therapists, and other addiction professionals apply CRAFT in their work with individuals with AUD/SUD.

Here are the key elements of that manual.

CRAFT: The Community Healing Process

1. Functional Analysis of Substance Use. Therapists examine the causes of addictive behavior with CSOs first, then with the person with the AUD and/or SUD, with the goal of recognizing the consequences of disordered alcohol or drug use.

2. Sobriety Sampling. Therapists propose the idea of sobriety to the person with AUD/SUD, with the idea that telling them they can never drink or use drugs ever again might backfire. They collaborate on a plan to try sobriety on a limited basis — a trial run.

3. CRAFT Treatment Plan. The recovery team — including therapists, CSOs, and the person with AUD/SUD — generates a list of realistic goals along with practical approaches to achieving those goals.

4. Behavioral Skills Training. This involves three things:

a. Problem-solving: Therapists teach people with AUD/SUD to break big obstacles, challenges, or issues down into workable, constituent components that aren’t as intimidating.

b. Communication: Therapists coach CSOs and people with AUD/SUD on productive strategies for interacting around and talking about potentially contentious topics.

c. Alcohol and substance refusal training: Therapists teach people with AUD/SUD to recognize high-risk situations and relapse triggers, then practice specific techniques for being assertive and saying “No” when offered alcohol or drugs.

5. Job Skills Training: Azrin identified consistent employment as “incompatible with problematic substance use” and therefore prioritized job skills training and work itself as a buffer against AUD/SUD and relapse to AUD/SUD.

6. Social and Recreational Counseling: The goal of social and recreational counseling is to help people with AUD/SUD find interesting, fun, productive, and fulfilling ways to spend their time that do not involve drinking or using drugs.

7. Relapse Prevention: This involves three things. The first is alcohol and substance refusal training, the second is identifying triggers and high-risk relapse situations, and the third is how to handle a relapse. In the CRAFT model, CSOs are critical in managing risk for people with AUD/SUD.

8. Relationship Counseling: This involves restoring and improving the core relationships in the life of a person with AUD/SUD. Friends, spouses, and any CSOs can participate in this phase of counseling. Relationship stability is important in establishing and maintaining a new normal for a person in recovery.

Studies on CRAFT reveal another important outcome: it reduces stress and enhances quality of life for family, friends, and CSOs as well for the person in in recovery. This changes the game for many families who live with a loved one with AUD/SUD. When they’re less stressed, they’re better able to offer the support and unconditional acceptance a person in recovery needs.

Community, Family, and Recovery

Human beings are social creatures. We’re hard-wired to thrive in circumstances where we have daily contact with others. We communicate, we participate, we collaborate. That’s one thing that makes the isolation associated with addiction so painful. A person with AUD or SUD may be surrounded by people who love them — and who they love — yet the reality of their addiction means they don’t communicate with complete honesty, participate fully, or collaborate wholeheartedly in the open and productive give-and-take that characterizes functional human communities.

This situation — this condition of feeling alone while surrounded by people — can foreground their isolation and exacerbate their symptoms, which can lead them deeper into addiction. That’s the reason I find the CRAFT approach so appealing: it acknowledges the fact that humans need connection to feel complete. They need to feel like they’re part of a group that understands who they are and values their contribution to this collective effort we call life.

The CRAFT approach also considers the recovery process from soup to nuts in a way that other approaches don’t. Look back the pre-treatment and pre-sobriety phase of CRAFT. It enlists loved ones and CSOs in helping a person with AUD/SUD realize they need to change, introduces the concept of sobriety as an option, and encourages them to choose that option because it has the greatest likelihood of leading to an outcome they agree is beneficial: overall health and wellbeing. There’s no confrontation. There’s no ambush. There are no tough love ultimatums. It allows the family and the person with AUD/SUD to work together. It creates a practical roadmap for the family — or community of CSOs — to bring the person in recovery back into the full give-and-take of life that makes the human experience both sustaining and fulfilling.

It gives a person deep in the isolation of addiction a real chance at reconnecting — and real connection is critical to a successful recovery.

It also shows me that these words, which bring me to tears almost every time I hear them, written by a songwriter who publicly shared the pain of his alcohol addiction with the world, were more than the words to a song. They were an insight on recovery:

“Shower the people you love with love
Show them the way that you feel
Things are gonna be much better

If you only will”

• James Taylor