Science and Kindness Working with Substance Abuse

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Approaches You Don't Know About

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If you are a therapist working with a client who is in a relationship with someone who seems to have a substance problem...  or if you are a family member of someone with a substance problem, you have probably heard suggestions that include distancing yourself, using tough love or detaching until your loved one bottoms out and decides to change. You can turn on the TV and hear about interventions and celebrity rehab stays. What you probably have not heard is that families can be tremendously helpful, can influence change in their loved one, and can influence positive change in themselves. There are strategies for helping that have been proven in studies to be very effective but have been very poorly disseminated into the public and into the professional treatment world... but they exist!

Family members who are worried about a loved one's substance use understandably feel everything from annoyance to terror and desperation. And there's a huge range in what might provoke worry: maybe there's concern about a wife's increased drinking after the kids went to college; maybe a friend is looking more disheveled and could be using pills; maybe an adult son doesn't return calls anymore and smokes a lot of pot; maybe a brother is back in treatment, again, for methamphetamine abuse.

As a psychologist working in the field of substance abuse treatment, I am in direct contact with families every day with a full range of serious problems. I know that substance abuse problems vary in terms of severity, fright and heartbreak, and yet I am optimistic! Not because I'm naïve or think these problems are no big deal, but because I know change is possible. In research and clinical work alike, I've seen the evidence over the past 40 years that families and friends make a difference in helping someone who struggles with drinking, drugs or other compulsive behaviors. Often, it is the critical difference.

There is in fact a science of change: methods like Motivational Interviewing, family and individually-based cognitive behavior therapy (CBT), Community Reinforcement and Family Training (CRAFT), and certain medications, all have clear rates of success in both getting people into treatment and also achieving successful outcomes. Unfortunately, these approaches are only recently becoming more widely used and the culture and many programs continue to operate under a "belief" system rather than what scientists, researchers and doctors have worked so hard to give us -- options for change that are effective with a wider range of people struggling with substance use disorders.

One myth about substance abuse that prevents people from getting help -- and inhibits people from trying to help them -- is that treatment is equated with intensive, residential "rehab" and believed to be the starting point of all change. But in fact, there are many treatment options and substantial evidence that outpatient treatment is at least as effective in most cases and often a better place to start. Since 1996, the American Society of Addiction Medicine has recommended starting with the least intensive treatment that is safe. Dr. Mark Willenbring, former director of the Treatment and Recovery Research Division of NIAAA, describes how the vast majority of people who could benefit from help don't get it, in part because the system is designed to treat the most severe problems, while the culture dictates waiting until someone "hits bottom" -- in other words, waiting until problems become severe.

Family members and friends are left with the assumption that they must wait until things get worse, then get their loved one into rehab if they can. They get this message from the media and from certain treatment providers despite strong evidence that reaching people early, when their problems are less severe and more treatable, leads to better outcomes. Thankfully, the treatment system is starting to change. The evidence supports many ways to effectively help people with substance use disorders and help their loved ones as well.

One of those approaches is called CRAFT (Community Reinforcement Approach and Family Training), which is a scientifically supported, evidence-based, clinically proven approach to helping families of substance abusers. Dr. Robert Meyers at the University of New Mexico developed CRAFT over 20 years ago, and all the subsequent research on this approach has concluded the same thing: given the right tools, families are a powerful engine for positive change: two-thirds of substance-abusing people who were initially resistant to treatment agreed to go to treatment (after an average of five family sessions).

Additionally, the vast majority of participating family members (spouses and parents typically) reported being happier, less depressed, less angry, and having more family cohesion and less family conflict than prior to their CRAFT sessions, whether or not their loved one engaged in treatment. CRAFT's effectiveness in engaging substance users and improving family functioning is found across substance types, relationship types, and ethnicities, and is starting to be used in broader contexts like in parent-to-parent peer coaching (see video below). This is an approach that does not require family members to disengage -- which to most parents feels plain wrong! -- but rather helps them utilize the strength of their love and healthy desire to help by honing communication skills, reinforcement strategies, self-care and problem-solving, which transforms relationships for the better.

Substance abuse can be devastating, but more people need to hear the good news: Things can get better. Families can feel better and the motivation of people abusing substances can be affected by their relationships in a very positive way.

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I am the Director of Family Services at the Center for Motivation and Change in NYC where we utilize evidence-based treatments for substance abusing clients and their families. I have worked in both therapeutic and research settings and have specialized training in Community Reinforcement and Family Training (CRAFT) which is an effective and unique treatment approach designed to help family members take care of themselves while also helping to motivate their substance abusing loved ones to be engaged in treatment.

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