This post was written with Alan Cudmore, who is a program consultant with the Centre for Addiction and Mental Health in Ontario, Canada (CAMH). The views expressed here are the authors' and do not necessarily reflect those of CAMH.
The Emmy-award winning A&E reality show Intervention begins each episode with ominous music -- and an even scarier message -- "Millions of Americans struggle with addiction, most need help to stop." How did A&E decide most people can't eliminate an addiction without help (like, for instance, the large majority of smokers do)? According to the National Institute on Alcohol Abuse and Alcoholism's NESARC study, about three quarters of alcoholics recover without professional help. A little over 10 percent of people with substance dependencies ever receive any specialty addiction services, yet according to the study, most people mature out of their alcohol addictions on their own over time.
So why do we as a society continue to promote the idea that we need to employ confrontational strategies against people with addiction problems? We don't do this in other areas of healthcare. Although the mental health field has its own dark history of coercion, would the mental health professionals who frequent HuffPost's pages consider for a minute using with mentally ill people the confrontational strategies that are considered de rigueur on Intervention? For example, would they (would you) bombard with abuse a person living with schizophrenia who refused their medication?
The logic behind this inhumane -- and counterproductive -- approach is expressed by one of my fellow bloggers at Psychology Today, Sarah Allen Benton, author of the The High Functioning Alcoholic. Benton recommended such interventions in her post, "The Challenges of Dealing with an Alcoholic Loved One," because she reckons that adding to people's misery hastens their recovery (actually, only their getting treatment):
By allowing the active alcoholic to experience negative consequences as a result of their addiction, they are helping to speed up the "cause and effect" connection for that individual. This is imperative in helping this person to reach some type of bottom (i.e., emotional, physical, situational) and leading to a better chance that they may seek help. (italics added)
It is easy to see how this interventionist approach might appeal to exhausted family members desperate to find a way to help a loved one who is struggling with addictions (even as everyone either of us has ever spoken to about the process has been extremely uncomfortable engaging in it). But simply thinking through the rhetoric of helping the person "to reach some type of bottom" should make clear how abuse is not a helpful technique. Would you use it with a child, for instance? In fact, aggressive confrontation is a regular feature of addiction treatment for adolescents, the fastest growing -- and most vulnerable -- segment of the rehab market.
All of this has been worked through by clinical psychologist and researcher Bill Miller and his colleagues at the University of New Mexico. Miller developed the technique, called motivational interviewing, that is now most widely used by addiction professionals in assisting addicts to buy into their treatment -- which then reflects their own choice.
Bill was struck when he observed that interventions and similar dehumanizing and coercive practices typical in the addiction field were at total odds with the therapeutic approaches employed throughout psychology. In their classic work, Motivational Interviewing, Miller and Stephen Rollnick noted the traps that interventions set up:
- The Confrontation - Denial Trap: Circular arguments about the nature and extent of the person's problem.
- The Expert Trap: Telling someone that you are the expert about their problem.
- The Labeling Trap: Forcing someone to accept a label (i.e. addict, alcoholic) before they are ready to do so -- or when they don't really need to.
- The Premature Focus Trap: Deciding for the person what the problem issue is. (Substance abuse may be secondary to other problems, for instance.)
- The Blaming Trap: Telling someone that all of the family's problems are their fault. (Problematic substance use most often occurs in the context of troubled families.)
The show succeeds by manipulating viewers so that we lose all of our compassion for the unwitting victims -- but it should sicken us. The televised cruelty is usually justified because the subject is guilted into entering a residential treatment facility. Of course, in a sequelae, when that doesn't work, the threats escalate -- "We won't talk to you," "You won't see your children," "We'll call the police," etc. The person's already deflated sense of themselves is further ground into dust, the goal being to remove any idea that he or she can exercise choice. Who thinks of submission as therapy -- other than perhaps the Marquis de Sade? This approach may work to fill beds in rehab, but it defies everything we know about encouraging psychological growth.
* Bill Miller and Bill White reviewed the efficacy of confrontational counseling: "Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations." Overall, the research indicates, confrontational approaches to substance abuse lead to higher drop-out rates, quicker and more severe relapse, and -- when used with DWI's -- higher recidivism.
But who's counting? In fact, the approach endorsed by Intervention has become so popular that is being spread to all sorts of other problems, as well as appearing in imitation shows in other countries, like Canada, where one of us (Cudmore) works.
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