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BeyondAddictionHOW S CIENCE AND KINDNESSHELP PEOPLE CHANGEA Guide for FamiliesJEFFREY FOOTE, PHD, CARRIE WILKENS, PHD,AND NICOLE KOSANKE, PHDWITHSTEPHANIE HIGGSS C R I B N ERNew YorkFoote Addiction i-306 PTR.indd 3LondonTorontoSydneyNew Delhi12/11/13 12:44 PM
S C R I BN ERA Division of Simon & Schuster, Inc.1230 Avenue of the AmericasNew York, NY 10020Copyright 2014 by Psychological Motivation and Change Group, PLLC.All rights reserved, including the right to reproduce this book or portions thereofin any form whatsoever. For information, address Scribner Subsidiary Rights Department,1230 Avenue of the Americas, New York, NY 10020.First Scribner hardcover edition February 2014and design are registered trademarks of The Gale Group, Inc.,used under license by Simon & Schuster, Inc., the publisher of this work.S C R I BN E RFor information about special discounts for bulk purchases,please contact Simon & Schuster Special Sales at 1-866-506-1949or business@simonandschuster.com.The Simon & Schuster Speakers Bureau can bring authors to your live event.For more information or to book an event, contact the Simon & Schuster Speakers Bureauat 1-866-248-3049 or visit our website at www.simonspeakers.com.Manufactured in the United States of America135 79108642Library of Congress Control Number: 2013032603ISBN 978-1-4767-0947-5ISBN 978-1-4767-0949-9 (ebook)Clients and cases discussed are based on composites.Foote Addiction i-306 PTR.indd 412/10/13 4:35 PM
For everyone who is hoping and working for change.Foote Addiction i-306 PTR.indd 512/10/13 4:35 PM
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In a gentle way, you can shake the world.—Mahatma GandhiFoote Addiction i-306 PTR.indd 712/10/13 4:35 PM
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ContentsForeword by Robert J. Meyers, PhD, andJane Ellen Smith, PhDxiiiWhere to StartIntroduction: Hope in Hell3PA RT ON EWhat to Know1. What Is Addiction?272. Motivation: Why Do People Change?443. Change: How Do People Change?69PA RT T WOHow to Cope4. Start Where You Are895. Self-Care I: Damage Control1026. Have Your Limits119ixFoote Addiction i-306 PTR.indd 912/10/13 4:35 PM
xCONTENTSPA RT THR EEHow to Help7. Start Where They Are1338. Goals (and Problems)1429. Positive Communication15710. Reinforcement: The Driver of Change17411. Consequences19112. Treatment Options20713. Suggesting Treatment23614. During Treatment247PA RT FOURLive Your Life15. Self-Care II: Building a Life269Acknowledgments285Appendix: When Is It an Emergency?287Resources291Notes293Index307Foote Addiction i-306 PTR.indd 1012/10/13 4:35 PM
BeyondAddictionFoote Addiction i-306 PTR.indd 1112/10/13 4:35 PM
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ForewordIt is with the greatest pleasure that we write this preface. Jane and I haveknown and worked for more than a decade with the directors and staff ofthe Center for Motivation and Change (CMC), and we have conductedworkshops and staff trainings in CRAFT (Community Reinforcementand Family Training) at CMC with Jeff Foote. The first workshop drew aninternational audience from three continents. CMC’s absolute commitment to change the way family treatment is done, and their determination to do whatever it takes, are unsurpassed, and it is also significant thatCMC had been using and promoting evidenced-based treatments longbefore they became popular.CMC has embraced the task of working with families—not just theindividual with the substance use problem but the whole family. Manytreatment centers in the United States still use old-school treatmentsthat have not been tested by rigorous randomized clinical trials, whereasCMC has developed several programs for substance-abusing individuals and their families based on solid evidence-based treatments. Withoutquestion, CMC has been innovative and progressive in their evaluationand treatment of people suffering either directly or indirectly (i.e., familymembers) from substance use.I can personally attest to the pain caused by having a family memberwho abuses alcohol or drugs. I came from one of those families and Iunderstand the anguish firsthand. As my father’s out-of-control drinking continued, I also witnessed my mother suffering incredible pain. Asa result of her frustrations, my brother and I also suffered. My motherpassed away at the young age of forty-five. It is because of this troubledhistory that I carved out my path of investigating humane and positiveways to help substance users and family members. My early years in thefield brought me to the stark reality that there was no reliable or reasonable treatment for family members at the time. “Family Days” at treatmentcenters typically centered around viewing a film on the effects of alcohol.xiiiFoote Addiction i-306 PTR.indd 1312/10/13 4:35 PM
xivFOREWORDThe addiction field as a whole has struggled to find effective ways tohelp distraught family members. During my long tenure in the substanceabuse field, I developed a program called Community Reinforcementand Family Training. CRAFT is designed specifically to empower familymembers. It teaches them how to take control of their lives, and as part ofthis process to change their interactions with the substance user in waysthat promote positive behavioral change. Clinical trials on CRAFT haveshown that when family members use these positive, supportive, nonconfrontational techniques, not only do they find ways to get their loved oneinto treatment, but the family members themselves feel better—specifically showing decreases in depression, anger, anxiety, and medical problems—when they participate in CRAFT. Clinical trials also have shownthat the family members benefit emotionally even if their loved one doesnot enter treatment.The Center for Motivation and Change has taken CRAFT, motivationalinterviewing, and cognitive behavioral therapy and woven them into apowerful treatment system under the expert guidance of its directors, Drs.Jeff Foote and Carrie Wilkens. Jane and I became fans of CMC years ago,due to their kindred spirit and their commitment to doing the right thing.It is a true honor to know and work with such dedicated people.We believe this book will have a huge positive impact on the addictioncommunity, beginning with therapists and researchers. But we also hopeit opens the eyes of directors, legislators, and families to a novel way ofthinking about how to approach and address the family’s substance useproblem.—Robert J. Meyers, PhD, Emeritus AssociateResearch Professor of Psychology, Universityof New Mexico, and Director of Robert J.Meyers, PhD & Associates—Jane Ellen Smith, PhD, Professor and Chair,Department of Psychology, University of NewMexico, Albuquerque, NMFoote Addiction i-306 PTR.indd 1412/10/13 4:35 PM
Where to StartFoote Addiction i-306 PTR.indd 112/10/13 4:35 PM
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I N TR O DUCTI ONHope in HellTo accept the things you cannot change . . . to change thethings you can . . . to know the difference.—Adapted from the AA mottoThis book is different.You may have picked up this book in desperation, you may be afraidnothing will help, but we are optimistic we can change that.Maybe your husband’s drinking increased after the kids went to collegeand you worry it’s only going to get worse. Maybe your grown son doesn’treturn calls anymore, seems uninterested in working, and smokes a lot ofpot. Maybe your daughter has stopped eating, or maybe she can’t seemto stop. Maybe your elderly mom sounds slurry every time you call herin the evening, but never remembers it the next day. Maybe your brotheris back in treatment, again, for methamphetamine abuse. Substance andcompulsive behavior problems*can take endless shapes and vary in termsof severity, scariness, and heartbreak.Families come to our program every day with these and many otherserious problems. Still we are optimistic. We don’t mean that maybe you’llbe lucky or that it’s no big deal. We are optimistic because we know changeis possible. If your own optimism has gotten shaky in recent months oryears, we invite you to borrow ours for now. Take this book like a steadying hand. And know that you can make a difference.As researchers and clinicians, we’ve seen the evidence over the pastforty years that families and friends make a difference in helping someone*From this point, we use “substance use” or “substance problems” as shorthand foraddictive disorders and compulsive behaviors. The principles and strategies in this bookapply to any kind of compulsive behavior problem, from drugs and alcohol to binge eating,shopping, gambling, and Internet pornography.3Foote Addiction i-306 PTR.indd 312/10/13 4:35 PM
4BEYOND ADDICTIONwho struggles with drinking, drugs, eating, or other compulsive behaviors. Often, it is the critical difference.We also know that people get better, and there are many reasons to behopeful. However, you’re probably more familiar with the popular notionsof intractable character defects and progressive, chronic disease. There’swidespread pessimism about the possibility of real change. Addiction canbe terrible—at times life-threatening. But change is possible, and there areclear paths leading to it.This is why, ten years ago, we created a new treatment program, theCenter for Motivation and Change (CMC), in New York City, where weare part of a revolution in addiction treatment based on evidence and ona new model for change.We built our practice on optimism, not because it made us feel good,though it does, but because it works. We base our optimism, our clinicalpractice, and now this book on forty years of well-documented researchon how substances and other compulsive behaviors affect people, whypeople use them, and how and why people stop self-destructive behaviorand start on paths toward health and happiness. In turn, our experienceswith thousands of clients bear out the research findings.There is in fact a science of change.Every day at CMC we see clients put it into practice, using the knowledge, attitudes, and skills you’ll find in this book. It takes time, and it is notusually a straight or smooth path. But it is a better way. Things can and dochange. The process already started when you picked up this book.The Science of ChangeIt’s been five hundred years since the scientific revolution, and we’ve hadmodern medicine for at least a century. Yet shockingly, the understanding and treatment of substance use in the United States has been exemptfrom scientific standards and separate from mainstream healthcare untilquite recently.Researchers in America only began to collect evidence in earnest in the1970s. The National Institute on Alcohol Abuse and Alcoholism (NIAAA)was established in 1970, followed by the National Institute on Drug Abuse(NIDA) in 1974. Finally, after years of folk wisdom running the gamutfrom truly helpful to ineffective to harmful, federal money flowed towardscientific studies of what works, including what family and friends likeyou can do to help. The increasing number of controlled studies, including our own, over these forty-odd years, has created a mountain of evi-Foote Addiction i-306 PTR.indd 412/10/13 4:35 PM
Hope in Hell5dence—scientists have separated the wheat from the chaff, revealing thatcertain approaches and treatment strategies are more successful than others. That’s good news, and we hope that it will help you find your ownoptimism.Most people equate treatment with intensive, residential “rehab” andbelieve rehab is the starting point of all change. In fact, there are manytreatment options and substantial evidence that outpatient treatment isat least as effective in most cases and often a better place to start. Since1996, the American Society of Addiction Medicine recommends starting with the least intensive treatment that is safe. Dr. Mark Willenbring,former director of the Treatment and Recovery Research Division ofNIAAA, describes how the vast majority of people who could benefit fromhelp don’t get it, in part because the system is designed to treat the mostsevere problems, while the culture dictates waiting until someone “hitsbottom”—in other words, waiting until problems become severe. Familymembers and friends are left with few options other than to stand by andwatch things get worse, then get their loved one into rehab if they can.This 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 address substance use disorders,as many ways as there are reasons people have them. Treatment is notalways necessary; it turns out that many people get better without everseeking professional help. There is also clear evidence that certain treatment approaches consistently outperform others. Cognitive-behavioraland motivational approaches, for example, which treat substance abuselike any other human behavior, are significantly more effective than confrontational approaches aimed to challenge a person’s “denial” about his“disease.”Research has demonstrated that the popular belief that if someone “juststops” using a substance, then the rest of his problems will take care ofthemselves is simplistic and untrue. Substance problems are complex andmultidetermined, often driven by underlying psychiatric disorders suchas depression, anxiety, bipolar disorder, or attention deficit disorders thatrequire specialized attention over and beyond just treating the substanceproblem. In other words, good treatment often includes psychiatric care,which has historically been overlooked or even discouraged in some drugand alcohol treatment settings.Science has also given us a better understanding of the brain’s role insubstance use and compulsive behaviors. With that science, there are newFoote Addiction i-306 PTR.indd 512/10/13 4:35 PM
6BEYOND ADDICTIONmedications that reduce cravings and compulsivity, block drug effects,ease withdrawal, and treat underlying issues. Neuroimaging research provides new insights into the effects of substances on the brain; and recentdiscoveries in neuroscience have shown the power of neuroplasticity inthe brain’s healing itself.And science has revealed that teenagers are not simply grown-ups whotext a lot; they are neurologically, psychologically, socially, and legally different from adults, and they have different treatment needs. Until aboutfifteen years ago, most of the services available for adolescents were barelymodified adult treatments. Clinical trials have shown us that teenagersrespond well to appropriate treatment and just as with adults, some treatments are considerably more effective than others. You might be surprisedto learn that they all involve parents as active treatment participants (andoften siblings, peers, and school systems).*Finally, research has shown how you can play a role in change.Our work with families and friends of people with substance problems is informed by CRAFT—Community Reinforcement and Family Training—a scientifically supported, evidence-based, clinically provenapproach to helping families of substance abusers. CRAFT grew out oftreatment innovations that began in the 1970s. A group of researchersin Illinois, led by behavioral psychologist Nathan Azrin, developed whatis still the most effective behavioral treatment for substance users, andcalled it the Community Reinforcement Approach, or CRA. In the process, they discovered that family involvement was a crucial factor in successful change. Robert J. Meyers, PhD (one of the original Illinois group),expanded the CRA approach to work with families when their loved onerefused help, and called it CRAFT. After moving to the Center on Alcoholism, Substance Abuse and Addictions (CASAA) at the University ofNew Mexico, Dr. Meyers conducted further research and clinical trials(teaming with Jane Ellen Smith, PhD), and they and others investigatingCRAFT have given us robust evidence that given the right tools, familiescan effect change.CRAFT has three goals: 1.) to teach you skills to take care of yourself; 2.) to teach you skills you can use to help your loved one change;*The parent-child relationship is different from other relationships, too, evenwhen the “child” is an adult. This book is for everyone, parents included. However, werecognize that parenting comes with unique challenges, responsibilities, and feelings,and so we partnered with the Partnership at Drugfree.org to offer a supplementaryguide for parents. You can download it from our website at http://www.the20minuteguide.com.Foote Addiction i-306 PTR.indd 612/10/13 4:35 PM
Hope in Hell7and 3.) to reduce substance use, period, whether your loved one gets formal treatment or not. CRAFT is behavioral in that it employs strategiesfor real-world, observable change. CRAFT is also motivational, drawingits strength from collaboration and kindness rather than confrontationand conflict. This motivational and behavioral approach is the core of ourwork with families, the substance of the helping strategies in this book,and an opportunity for profound change.Drs. Meyers and Smith and other research groups have studied CRAFTwith family members from a variety of socioeconomic, ethnic, and agegroups struggling with a range of different substances, with the followingresults: Two-thirds of people using substances who had been initially resistant to treatment agreed to go to treatment (typically after familymembers had around five sessions of CRAFT). The majority of participating spouses and parents reported beinghappier, less depressed, less angry, and having more family cohesionand less family conflict than prior to their CRAFT sessions, whetheror not their loved one engaged in treatment. CRAFT’s effectiveness in engaging substance users and improving family functioning is found across substance types, relationshiptypes, and ethnicities.Good News: Things get better with CRAFT. Families feel better, substance useoften decreases, and people with substance problems usually enter treatmentwhen a family member uses CRAFT.CRAFT works, first, because it understands substance problems holistically, in the context of family, community, and work. People do not usesubstances in a vacuum. Their relationships impact their substance usejust as their substance use impacts their relationships. CRAFT recognizes that most family members and friends, for their part, have goodintentions, good instincts, and a healthy desire to help. CRAFT treats theproblems families face as a deficit of skills rather than as a disease of codependence. These skills can be learned.Second, CRAFT recognizes that “just stopping” is not a sustainablelong-term solution. While change depends at first on stopping (or reducing), the 64,000 question is what promotes staying stopped. CRAFT asksFoote Addiction i-306 PTR.indd 712/10/13 4:35 PM
8BEYOND ADDICTIONyou to see what makes substance use rewarding to your loved one, so thatyou can introduce the “competition”—more constructive activities thatserve the same needs—into her world. To this end, CRAFT will feel strangeat first. If you have been viewing her substance problem as the cause of allother problems for some time, you may wonder what taking her bike in fora tune-up could have to do with anything. Plenty, as we’ll see.What We OfferFirst, we offer a new perspective on why your loved one does what hedoes. “Why” is a key to change. Second, we will teach you skills: positive communication, reinforcement strategies, and problem-solving skillsto transform your relationship with your loved one and your life. Third,we will help you navigate what is often a one-toned, ideologically tingedtreatment system, because there are treatment approaches and settings,medications, and kno
The addiction field as a whole has struggled to find effective ways to help distraught family members. During my long tenure in the substance abuse field, I developed a program called Community Reinforcement and Family Training. CRAFT is designed specifically to empower family members.
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