August 2018
Helping families with addiction; CRAFT; TSA Precheck and humility
Savvy
Anyone who has treated a person suffering from addiction knows how much family members and significant others are also affected by addiction. Those closest to a person with addiction are often at their wits end to know:
- What to do to “make” their loved one stop using or behaving addictively
- How to cope with their own anger, frustration, fears and despair
- Where to turn to get help, especially when their addicted loved one doesn’t seem to even care to get help.
They may have heard about “tough love” and getting the person to “hit bottom” before treatment and recovery can begin. Reality TV shows about Intervention and “rehab” give some glimpse of what next steps might be, but they also suspect that is all “reality TV”.
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Empathy training for families is more effective to engage people with addiction than tough love and hitting bottom
It is easy to adopt the widespread view that you have to “break through denial”; confront the addicted person; set a limit and if necessary “kick them out” until they “hit bottom”.
But in a program earlier this month on National Public Radio’s “Here and Now”, I was reminded of alternate methods that have been around since about 1986 – Community Reinforcement and Family Training (CRAFT).
The segment was “Coaching Helps Parents Whose Children Are Addicted To Opioids – From Tough Love To Empathy: Coaching For Parents With Opioid-Addicted Children”
Here are some of the highlights:
1. Empathy training helps families proactively support people recovering from opioid addiction (and any other manifestation of addiction e.g., alcohol use disorder).
2. While “many drug users say, in hindsight, they appreciated being forced into treatment,” Kaiser Health News reports studies showing that “a compassionate approach and voluntary treatment are the more effective ways to engage drug users in recovery and keep them alive,” which is a critical consideration amid the rise in overdose deaths linked to fentanyl.
3. According to Nora Volkow, director of the National Institute on Drug Abuse, “The concept of letting their children hit bottom is not the best strategy, because in hitting bottom they may die.”
The program goes on to tell the story of Bea and Doug Duncan at their home in Natick, Massachusetts. At 2 a.m. on a January morning nine years ago their son, Jeff, had been caught using drugs in a New Hampshire sober home and was being kicked out.
On the ride back from picking up their son in NH, the parents delivered an ultimatum: Go back to rehab or leave home.
“Bea Duncan says her son chose the latter. She remembers a lot of yelling, cursing and tears as they stopped the car, in the dead of night, a few miles from the house.”
“It was really, really difficult to actually just drop him off in a parking lot on our way home and say, you made the decision – no rehab – so we made the decision, no home,” says Bea Duncan. “It was exquisitely difficult.”
Jeff returned to rehab, but the Duncans decided their approach wasn’t working. They sought help, eventually connecting with a program which stresses empathy: CRAFT or Community Reinforcement and Family Training.
“There was more compassion and ‘wow, this is really difficult for you,’ more open questions to him instead of dictating what he should and should not behave like,” says Bea Duncan.
The Duncans say the training helped them shift from chaos to calm.
“I started to feel an immense sense of relief,” Bea Duncan says. “I stopped feeling like I had to be private investigator and controlling mom. I could kind of walk side by side with him on this journey, instead of feeling like I had to take charge of it.”
The Duncans credit switching from family consequences, like kicking Jeff out of the house, to outside ones, like losing a job due to drug use, with helping their son stick to recovery. He’s 28 now and has been sober for nine years.
You can hear the rest of the story if you want at: Here & Now: Coaching Helps Parents
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Acquaint or re-acquaint yourself with Community Reinforcement and Family Training (CRAFT)
I am by no means an expert on CRAFT. But it sits in the same ballpark and spirit of Motivational Interviewing about which I know a lot more. There is a brief overview of CRAFT on the website of the Center for Motivation and Change (CMC).
I don’t know any of the Directors or Clinical Staff of CMC, but I do know I was impressed with their description of “Who We Are.” The goal of their existence is so in alignment with what I hope for all the work we do:
“ We are a group of dedicated psychologists…clinicians and researchers, who have been writing books and articles, developing groundbreaking treatments, conducting research studies, training programs and community outreach efforts for years. Our goal? Better, more effective and more respectful treatment for people struggling with substance use, as well as their families. Our even bigger goal? To change the conversation. From the language of stigma to the language of growth. From defects to strengths. From shame to pride and an open heart. From punishment and confrontation to an invitation to truly change. And to change that conversation, we rely on science and kindness.”
Here are some excerpts on CMC’s Overview on CRAFT:
“Community Reinforcement and Family Training (CRAFT) teaches family and friends effective strategies for helping their loved one to change and for feeling better themselves. CRAFT works to affect the loved one’s behavior by changing the way the family interacts with him or her. It is designed to accomplish three goals:
1. When a loved one is abusing substances and refusing to get help, CRAFT helps families move their loved one toward treatment.
2. CRAFT helps reduce the loved one’s alcohol and drug use, whether or not the loved one has engaged in treatment yet.
3. CRAFT improves the lives of the concerned family and friends.
CRAFT is a skills-based program that ……. teaches families behavioral and motivational strategies for interacting with their loved one. Participants learn, for example, the power of positive reinforcement for positive behavior (and of withdrawing it for unwanted behavior), and how to use positive communication skills to improve interactions and maximize their influence.
Specifically, CRAFT teaches several skills, including:
- Understanding a loved one’s triggers to use substances
- Positive communication strategies
- Positive reinforcement strategies – rewarding non-using behavior
- Problem-solving
- Self-care
- Domestic violence precautions
- Getting a loved one to accept help
CRAFT is not a quick fix, but rather an approach to benefit both the substance user and the family in the short and long terms with a holistic plan of action and a more optimistic view.”
skills
Reflecting on Bea and Doug Duncan’s experiences, I realized there are a number of lessons which apply to professional addiction treatment too. They apply, because:
- Treatment teams are affected by addiction in the same ways families and significant others are affected by addiction.
- Treatment providers and drug court and treatment court teams can fall into the same attitudes, beliefs and behaviors as family members.
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Consider the parallels between what families and treatment teams do when affected by addiction. Can you embrace lessons learned to improve addiction treatment?
Let’s revisit the Duncan’s story in the radio program:
At 2 a.m. on a January morning nine years ago their son, Jeff, had been caught using drugs in a New Hampshire sober home and was being kicked out.
- Just like families, some treatment providers believe in tough love and kicking people out of treatment to teach consequences and ensure safety for the home.
Learning Opportunity #1
Jeff’s flare-up of addiction could have been a learning opportunity for Jeff to find out what went wrong in his recovery journey and to fix his treatment plan in a positive direction. If he was willing to take responsibility for his mistakes and learn from them, he should stay and not get kicked out.
His sober home roommates could have learned what to do when triggered by someone else’s use or having drugs in the environment; and how to prevent a flare-up.
On the ride back from picking up their son in NH the parents delivered an ultimatum: Go back to rehab, or leave home.
- Just like families, some treatment providers believe setting ultimatums will “break through denial” and confront a person into sobriety: Sign this behavioral contract: if you break the rules of the program again, or get another “dirty” urine, you will be discharged from the program and can’t reapply for another 30 days at least.
Learning Opportunity #2
When clients and participants struggle with cravings to use or impulsive behaviors, that is the time to assess what is not working in the client’s life, treatment plan or attitudes. If the person is not interested in learning what to do about cravings, triggers, impulsive or antisocial behavior, then they have the right to choose no further treatment and leave.
However, if they are willing to examine what is not working and incorporate strategies in their treatment plan to improve attitudes, thoughts and behaviors, then there is no need to leave. Ultimatums don’t create change; they usually just end up losing the client.
Jeff returned to rehab, but the Duncans decided their approach wasn’t working. They sought help, eventually connecting with a program that stresses empathy: CRAFT or Community Reinforcement and Family Training.
- Just like families, some treatment providers and treatment court teams are realizing just sanctioning, suspending, discharging, and applying consequences for addiction flare-ups isn’t working. Clients keep revolving through “detox”, treatment programs and the courts without establishing lasting change.
Learning Opportunity #3
“There was more compassion and ‘wow, this is really difficult for you,’ more open questions to him instead of dictating what he should and should not behave like,” says Bea Duncan.
What the Duncans learned worked was the Spirit of Motivational Interviewing which promotes Partnership, Acceptance, Compassion, Evocation using open-ended questions rather than closed-ended mandates and dictates.
The Duncans say the training helped them shift from chaos to calm.
“I started to feel an immense sense of relief,” Bea Duncan says. “I stopped feeling like I had to be private investigator and controlling mom. I could kind of walk side by side with him on this journey, instead of feeling like I had to take charge of it.”
- Just like families, treatment providers can be calm, prevent compassion fatigue, burnout and secondary trauma and quit feeling like a private investigator or law enforcement to catch and control clients who may be using.
Learning Opportunity #4
Zero tolerance for substance use shifts the responsibility to staff, treatment and court teams to detect and expose addiction flare-ups and substance use. Instead, each participant in treatment should take responsibility to watch for any urges to use or actual drinking or drugging in themselves or others. They are the ones who need to know how to protect themselves from triggers, cravings and flare-ups rather than avoiding being a “snitch” or sharpening their antisocial lying and conning skills to prevent detection.
soul
For over 22 years of full-time training and consulting, commuting to work has usually meant catching a plane to some state or country. If you’ve caught a plane lately, especially since 9/11, you know how it can go with the Transportation Security Administration (TSA) and those long snaking lines.
For six years, I’ve had Global Entry, which allows you to avoid all those long customs and immigration checkpoints when re-entering the USA; and a bonus – it gives you automatic TSA Precheck, allowing me to skip long lines and zip through security.
How superior I feel, having a special entrance to breeze through security and not have to wait in line with all those people!
Suddenly my TSA Precheck stopped. Nowhere to be seen on my boarding pass. I was incensed. Who took that away; and without notifying me too? Well actually they did notify me because there is an expiration date on my Global Entry card which was this month, this year. I was the one who didn’t renew my application in time.
Now, as I’m standing in those long lines with all those people, waiting to have to take off my shoes, my belt, empty my pockets, place my computer, toiletries, shoes and coat in the security trays, stand in that machine with my arms in hold-up position, I am bemoaning my fall from specialness.
I know not having TSA Precheck doesn’t compare to the challenges of being a woman in a man’s world; or a person of color in a white person’s world; or being homeless and penniless in a society that rewards the rich and famous. But it did take me down a peg or two and remind me of the value of humility.
Over the weekend, I received notice my Global Entry renewal application was “Approved”. I will soon have TSA Precheck again on my boarding pass every time. I will soon have that special security entrance again.
I hope I will not soon forget the value of humility.