Helping families with addiction – Residential treatment is not the gold standard; Intervention, Tough Love or CRAFT?; Exercise training is hard work. How do those athletes do it?
In SAVVY, STUMP THE SHRINK and SKILLS, I share a colleague’s request for recommendations for a residential program on behalf of a family affected by addiction. The family wanted their son in long-term residential treatment. But is residential treatment the gold standard? We have to use the whole continuum of care to give long-term, life long addiction treatment if necessary.
What should be done for a son who the parents are financially supporting and who doesn’t follow through with treatment?
In SOUL, I recently started strength and core exercise training. Better late than never, but it is hard. I have a new found admiration for all those athletes who workout everyday to reach their peak performance
savvy, stump the shrink, & skills
Recently a colleague asked for suggestions on how to help a family that was suffering from the affects of addiction through their son. The son had all kinds of negative consequences of addiction and the family was searching for a long term residential program. Here is the sad, but typical story of this family with details changed to protect confidentiality.
Tip 1
Residential treatment is not the gold standard and only treatment for addiction. Use the full continuum of care.
Here is the colleague’s request on behalf of the family:
I am seeking a recommendation for a long term residential treatment facility for a 40 year old male photographer. He is mainly struggling with alcohol use; has been to many inpatient “detox” programs for 6 days every few months and has refused residential after each one. He typically goes to Intensive Outpatient services (IOP) for a week then stops going to Alcoholics Anonymous (AA) and his treatment sessions and relapses and returns about 6 times in the last two years. When he engages with IOP/AA he does not drink.
Multiple consequences – unable to work, wife won’t allow him home (needs to breathalyze to see his children – which he seldom passes), parents are supporting him financially, etc.
He is very intelligent and thinks he can outsmart his addiction. He knows all the things he should do but is unable/unwilling to follow through. He says he suffers from depression and anxiety.
He may be swayed to enter a treatment facility that he deems “worthy” of his intellect(?). I think he would benefit from a 90+ day residential facility that can work through his barriers. He will likely need sober housing and robust continuing care, etc.
My response:
Before assuming that residential treatment is the key to helping this family and their son, I recommend a family meeting with the parents who financially are subsidizing their son’s addiction to help them understand what addiction is and what they can best do and not do to help.
- Educate the parents and the rest of the family to understand family recovery.
- Even if the identified patient, their son, never achieves recovery, you have helped four or five of the family members live better.
- What we know about family systems is that changing even one part of the system increases the likelihood that the identified person in the throes of addiction will change.
Residential treatment isn’t the gold standard. Treating the whole person, which includes all affected by addiction, improves outcomes. That might also save more lives and preserve their precious money and resources to fund a broader continuum of care. This then allows for longer treatment services to increase lengths of stay not in residential treatment only, but within the whole continuum of addiction services.
Tip 2
Failure to engage is ongoing addiction treatment after “detox” is not proof that the client needs residential treatment. It may speak more to a failure of clinicians to use Motivational Enhancement to engage and attract the son into recovery.
Competent addiction counselors and services can address the following common perspectives and beliefs of people suffering with addiction. Such motivational engagement strategies can be effectively provided throughout a continuum of ongoing care, not all concentrated and focused on residential treatment.
This client’s history indicated:
Problem – He has been to many inpatient “detox” programs for 6 days every few months and has refused residential after each one. He is very intelligent and thinks he can outsmart his addiction.
Competent approach – Use Motivational Interviewing and motivational enhancement to start where the client is at. Engage him in a plan to prove to himself and family that he does not have an alcohol problem needing residential treatment. He could demonstrate that by showing he can cut back his alcohol use and/or have a negative breathalyzer result so he can see his children.
Problem – He typically goes to Intensive Outpatient services (IOP) for a week then stops going to Alcoholics Anonymous (AA) and his treatment sessions and relapses. He knows all the things he should do but is unable/unwilling to follow through. When he engages with IOP/AA he does not drink.
Competent approach – This pattern underscores the need for this young man to be engaged in a “Discovery” Drop-out Prevention approach about which I have written since 2003. Here are some of those editions:
July 2003 – When people aren’t interested in treatment for recovery, they need “Discovery” dropout prevention work.
November 2017 – Example of “discovery” motivational work for a teen who doesn’t think he has a drug problem because “I can stop any time I want”
July 2015 SKILLS – Sample Strategies for Treatment Plans
Problem – He may be swayed to enter a treatment facility that he deems “worthy” of his intellect(?). I think he would benefit from a 90+ day residential facility that can work through his barriers.
Competent approach – All of the “barriers” some of which Alcoholics Anonymous calls “stinking thinking” can and should be worked through in outpatient treatment if there is no imminent danger that requires 24 hour treatment. In fact, it is only in outpatient treatment that the client has a chance to “do the research” on cutting back or proving they can be abstinent…or not. Only in outpatient treatment in the real world can they have the opportunity to “discover” whether they are as skilled as they think they are to avoid the negative consequences of addiction without intensive addiction treatment.
Residential treatment does not allow this motivational enhancement work to be done and can give the false impression that he is more stable than he really is because of the structure of the supportive environment. How many times have you seen clients “complete” residential treatment and “graduate” only to have a flare-up and use, sometimes within days or weeks of discharge. We usually blame the client, not anything that we did or did not do to fully engage the person in a self change, “discovery” dropout prevention plan.
Tip 3
Community Reinforcement and Family Training (CRAFT) is intended to help family members of people with a substance use disorder learn how to steer their loved one away from addictive substance use.
My colleague:
I did speak with the parents last night and discussed the family aspect of the situation as you suggested. I asked them to consider that paying his rent and buying food is of course compassionate but it may not be helpful at this time.
We did discuss setting boundaries on what behaviors the parents would expect if they were to continue to support him financially. There is a tentative plan to have a family meeting this weekend.
My response:
I can understand the family wants relief, but respite in a residential program may not change things if the family system doesn’t change. And it isn’t about just setting limits, tough love and consequences.
Community Reinforcement and Family Training (CRAFT) is a great method for helping someone who is refusing treatment or who is having difficulty seeing that they are no longer in control of how much they consume.
“Instead of an old-school intervention where the family and friends get together and confront the person in an attempt to enroll them in a rehabilitation program, the CRAFT method encourages close significant others (which the program calls CSOs) to reward their loved one when they choose sobriety or show control.”
- “A skills-based program for families of people who struggle with addiction.
- It is designed to support family members across multiple areas, including self-care, pleasurable activities, problem-solving, and goal-setting, while at the same time teaching behavioral and motivational strategies for interacting with their loved one and addressing resistance to change.
- Participants learn, for example, the power of positive reinforcement for healthy behavior (and of withdrawing it for unwanted behavior).
- How to use communication skills to improve interactions and maximize their influence.”
Tip 4
Books and resources to learn more on Community Reinforcement and Family Training (CRAFT).
1. In SHARING SOLUTIONS in the September 2018 edition, I shared three CRAFT resources
2. One of the books is “Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening”
This book:
- “Describes a multi-faceted program that uses supportive, non-confrontational methods to engage substance abusers into treatment.”
- The program, “Community Reinforcement and Family Training” (CRAFT), uses scientifically validated behavioral principles to reduce the loved one’s substance use and to encourage him or her to seek treatment.
- Equally important, CRAFT also helps loved ones reduce personal stress and introduce meaningful, new sources of satisfaction into their life.”
3. It is worth listening to the July 27, 2018 edition of the National Public Radio show Here & Now, when there was a program on “Coaching Helps Parents Whose Children Are Addicted To Opioids”.
“Parents whose children who are addicted to drugs are routinely advised to be tough with their kids — even cut them off, if necessary. But a new video produced by the Partnership for Drug-Free Kids promotes compassion and understanding instead of punishment.”
soul
Better late than never…… I have said for years that I needed to do some exercise strength training to support my core and improve balance especially in my ripe old age. I was chatting to a neighbor who said his mother introduced him to her trainer. Once a week, my neighbor works remotely on WhatsApp with a trainer in Los Angeles and said he would recommend and connect me.
I did connect and now 10 sessions later, I am stronger. However, there are several ‘Buts”.
- It’s no walk in the park. It takes daily commitment and work.
- Like recovery, it’s a day at a time. I want to be that trim, buffed healthy guy, but it really is Progress, not Perfection.
- I’m committed to having joy in this. But joy isn’t always being all smiles, lying on the beach. There is joy in knowing I am building wellness even if it feels hard right now.
All this has brought me new admiration and respect for all those athletes who do a 1,000 times more work-out effort than me everyday to reach their peak performance on the court, slopes, waves and rinks game after game, event after event.
I’m just trying to stay firm on my feet and head-off any debilitating mobility problems. Athletes have to excel every game or event or soon be out of a job. But then that’s why they get the big bucks.