White Paper - Addictions
KEYS TO A SUCCESSFUL INTERVENTION
When many lay people talk about having an intervention with someone about their behavior, they tend to bring up scenes of verbally abusive behavior that is expressly prohibited by the ethical guidelines of the APA. Obviously there must be something wrong with this idea of ambushing a person with their bad behavior and beating them over the head with their flaws. Such behavior sounds more destructive than therapeutic. And indeed, described that way it is, this model of intervention sounds far more satisfying to the participants than useful to the recipient.
But then why do we have interventions and confrontations still in use? The answer is that professional interventions have developed a great deal since the Synanon program and its "attack therapy" as developed by Chuck Dederich in 1958 (Polcin, 2003). At that time, it was believed that the release of emotional energy would release tension and break down denial, thereby allowing a more honest discussion about the addiction and the behavior that resulted from it. The goal at the end was to reaffirm the confronted person's importance to the group. However, many criticized this technique as a replication of the abuse many of these clients experienced in their past. The same criticism could be applied to the early therapeutic communities that use humiliation and punishment to change the addict's behavior. Faced with the alienation by the respected mental health professionals, some therapeutic communities began to use group feedback methods in the 1970s and 1980s. This moved the focus from "breaking down the denial" to confronting the dysfunctional behaviors caused by the addiction. Other factors that brought about this transformation in methodology were: the increasing number of dual-diagnoses of addiction and mental illness, the desire to be allied with 12-step programs, and the research showing that addictions were fueled by core emotional issues.
While there are still disagreements as to what one means by "confrontation", some researchers and program directors prefer to define it, more or less, as "someone being approached, in a realistic but not punitive way, that 'bad things' might happen if they don't make changes in regards to their addiction" (Polcin et al, 2006). Personal attacks are discouraged, as well as other forms of disruptive confrontation. Perhaps the term "therapeutic confrontation" should be used more often to distinguished from the more hostile versions of confrontation, such as the "beat them into submission" type.
Studies show that successful interventions usually generate gratitude and good feelings towards the confronters by the confronted (Polcin, 2006). Given the all too human reaction to be offended when someone tells us we're wrong, how is this created in a confrontation?
One element is the relationship of confronters to the client. The closer the relationship, the more successful the confrontation because the information given is seen as more valid (Malis & Roloff, 2007). Among not so close peers, a great deal of face work has to be done to create enough of a valid bond for their views to be considered. In fact, that bond often has to be there before a peer will even consider confronting someone with their addiction. With therapists, this would be the creation of a therapeutic alliance. While some practitioners claim that this is not necessary, research shows that is does help and never hurts. A study by Miller, Brown, Simpson, Handmaker, Bien, Luckie, Montgomery, Hester, and Tonigan found that there was a strong positive correlation between supportive and empathic approaches and positive outcomes (Polcin, 2003).
To up the odds of an effective confrontation, many current professional intervention programs first educate those of the confrontation team how to phrase their concerns in "a realistic but not punitive way". Alanon facilitation and Johnson Institute interventions are ways that this is done (Polcin, 2003). While the Johnson Invention has high relapse rates, it has a higher rate of getting clients into treatment and still retains clients (Loneck et al, 1996). A more effective training program for the family and friends of a client is the Community Reinforcement and Family Training (CRAFT) program, which teaches behavioral change skills. According to Bob Poznanovich, CEO of Addiction Intervention Resources, they go even further and assess the situation of the family (Conan, 2008). In fact, Poznanovich claims that they work more with the family than with the addict, because family can often enable addictive behavior without realizing it. He calls it a "family illness" and points out that many people are given bad advice about how to deal with addiction, such as it is just a matter of will power or that there is nothing that can be done.
Another important element is the timing of the confrontation (Polcin, 2003). Light to moderate drinkers gain less from interventions than problem drinkers, probably because the concerns seem less valid. However, light to moderate drinkers do respond favorably to the more empathic therapies. Addicts with major cognitive impairment from the drug they're taking, respond better after a period of detox. Addicts already in being treated in a facility benefit more from a therapeutic confrontation after they have been there long enough to emotionally stabilize. Otherwise, they will flee or regress in response to the confrontation. In many programs, the client is educated about the positive role confrontation can play in their recovery. This preparation not only makes the confrontation less traumatic, but also puts the client in a mindset prepared to make the most of the information given to them during the confrontation.
It should be noted that some addicts, because of comorbid conditions, may not be good candidates for intervention. One cannot expect a paranoid or antisocial personality disorder to respond favorably to confrontations. Nor can one expect someone with diminished cognition to fully comprehend what they are being confronted with.
The most important element is the focus of the confrontation. According to a study by Polcin, Galloway, and Greenfield (2006), when the message was on the behaviors and potential problems, clients consistently said that they were more likely to have a positive experience with confrontations. Remarkably, the more frequent the confrontations, the more individuals involved, and the more sources involved, the more positive was the views of the confrontations. Thinking distortions can also be addressed as part of the confrontation.
An element of choice also makes an intervention more successful (Conan, 2008). When the addict is allowed the choice of whether to get better or suffer from their own behavior, and then chooses to get better, they are more committed to the change. Even if the addict chooses not to change at first, some will change their minds later as the "bad things" they had been warned about happen to them.
A skilled counselor should be directing the therapeutic confrontation, in case emotions run too high or a deep issue is triggered (Polcin, 2003). The counselor should be able to switch from a confrontive stance to a clinical exploration of the issues exposed. A far cry from the "beat them until they see the errors of their ways." Modern interventions are more about support for reducing dysfunctional behaviors, than they are about making the recipient admit that they are an addict.
In summary, a successful intervention requires: a trusting and supportive relationship between the client and the intervening group; focusing on the dysfunctional behaviors and possible bad outcomes from the addiction; the client and interveners to be prepared to make the most of the situation; and a facilitator to handle any problems. Education for the family, friends, and client increases the chances that the intervention will be more effective as does the number of confronters and interventions. While old fashion interventions might make for great television drama, forcing the client to admit that they are an addict or otherwise personally attacking them, is more likely to impede than to help the situation.
Conan, N. (2008). Addicted Loved Ones: When to Intervene?. Talk of the Nation (NPR), Retrieved April 17, 2009, from Newspaper Source database.
Loneck B; Garrett JA; et al (1996). The Johnson Intervention and relapse during outpatient treatment. American Journal of Drug and Alcohol Abuse, 22(3):363-375. Retrieved April 17, 2009, from Academic Search Premier database.
Malis, R., & Roloff, M. (2007, January). The effect of legitimacy and intimacy on peer interventions into alcohol abuse. Western Journal of Communication, 71(1), 49-68. Retrieved April 17, 2009, doi:10.1080/10570310701199186
Polcin, D. (2003, January 15). Rethinking Confrontation in Alcohol and Drug Treatment: Consideration of the Clinical Context. Substance Use & Misuse, 38(2), 165. Retrieved April 20, 2009, from Academic Search Premier database.
Polcin, D., Galloway, G., & Greenfield, T. (2006, February). Measuring Confrontation During Recovery From Addiction. Substance Use & Misuse, 41(3), 369-392. Retrieved April 20, 2009, doi:10.1080/10826080500409118