Wasted: An Alcoholic Therapist's Fight for Recovery in a Tragically Flawed Treatment System (39 page)

There have been around two hundred randomized clinical trials of motivational interviewing, the largest focusing on alcohol and drug problems, but outside the addiction field it has been widely adopted in health care,
social work, corrections, even dentistry. Dr. Miller says the data indicate it has a small-to-medium effect on average. But in some cases, with the right therapist, the approach gets much better results.

This kind of therapeutic talk differs from what many addicts may have heard in the past. Although one must be a skilled professional to guide someone trapped in a substance abuse cycle
through treatment, Dr. Miller’s examples helped me understand how those of us who love addicts unwittingly contribute to the deepening of their disorder by choosing the wrong words to communicate with them.

“We talk about desire, ability, reasons, need,” says Dr. Miller. “Desire: I want to quit drinking. Ability: I could quit drinking. I don’t want to but I could. Reasons: My wife would
be happy. I’d be spending a lot less money. Need: I’ve got to do something about my drinking. I can’t go on the way I have been.”

This is what motivational therapists call “early change talk.” Next comes willingness.

“What are you willing to do? I’m willing to consider cutting down. I’m ready to stop drinking.” It’s not quite “I will stop drinking,” but it’s getting close.

“Then, there’s commitment language: I will, I’m going to, I promise, I swear. There’s something called taking steps, which is when the person just
does
something. When they come back, they tell you something they’ve done during the week that’s a step in the right direction. ‘I got all the alcohol out of my house. I went to a meeting this week.’ Change talk is like little smoldering coals.
You need to blow on them. That’s what motivational interviewing is like.”

Dr. Miller offers some insight into how motivational interviewing differs from other talk therapies: it demands a certain creativity and lack of ego on the part of the therapist to let the client lead.

“If the client’s beginning to get what we call resistive—I think we shouldn’t use the word resistance because
it blames the person—if the client’s starting to backpedal and make arguments for not changing and so forth, that’s your client saying, ‘Why don’t you try something else.’ But in addiction treatment, what we taught therapists to do, is if you start getting resistance,
you push harder.
But in reality, it just increases resistance all the more. That’s not denial, that’s just one side of ambivalence.
It signals that the relationship isn’t going well.”

If you keep pushing you get into what Dr. Miller calls “discord” in the relationship. “Those words from clients have
you
in them. ‘
You
don’t understand how hard this is for me. Who are
you
to tell me what to do?
You
don’t know how I feel.
You
’re no expert on me.’ Those
you
statements are something other than the ambivalence. They’re saying,
‘We’re not dancing together.’”

According to Dr. Miller, this predicts a poor outcome for therapy. The solution, he says, is to listen closely and respond appropriately to what your client is telling you
in the moment.
So if your client is giving you change talk, that’s the client saying, “You’re doing this well.”

Current trends in talk therapy suggest motivational interviewing
is best used in tandem with other therapies. For instance, cognitive behavioural therapy can be delivered in the style of motivational interviewing, with “lots of listening and lots of collaboration,” according to Dr. Miller. “And if you’re doing twelve-step the way I think Bill W. would have done it, you know it has that same quality to it.”

When we interviewed Dr. Miller, we asked him
how he can be a supporter of Alcoholics Anonymous
and
motivational interviewing when one’s success is founded on admitting powerlessness and the other relies on a belief that individuals have an intrinsic power to change. Dr. Miller smiled like the sage he is, and after a pause for reflection said, “Many truths are paradoxes. I think both of those things can have a role in recovery. Some people
find that accepting powerlessness is very helpful to them in recovery. Others, particularly those who have been disempowered historically, such as women, may need something that is more empowering. So I think offering a variety of approaches is the best way to go.”

• 47 •

THE EXPERTS WE
talked to routinely compared substance use disorder to cancer, heart disease and diabetes in an attempt to underscore the severity of the illness and to get us thinking about how we treat those suffering from other conditions. We don’t heap abuse on them, even though in the case of heart
disease and diabetes, there may well be an element of choice in why the sufferer is so ill.

Where that analogy falls down for me is that the behaviour of loved ones battling heart disease or cancer doesn’t put the rest of us through such an emotional wringer. Anyone who has loved someone with a substance use disorder knows what a unique hell it can be. What less known and understood is
how a concerned significant other—husband, child, best friend—can actually make a substance use disorder worse by interacting with the sufferer in certain ways. When we traveled to New Mexico on our first filming road trip, we met Dr. Robert Meyers, who has developed a program that helps not only families who struggle with a problem substance user, but the problem substance user too. The Community
Reinforcement and Family Training model, or
CRAFT
, is built on a radically simple principle.

“We try to look at what’s positive about a human being, use positive reinforcement, and find out what we can build on, as opposed to calling you names and saying you’re no good, and you didn’t do this, you should have done that, you should have done this. We’re always upbeat. Even if you make a
mistake, we say that’s okay—it’s a learning experience. How can I help you learn better how to deal with that problem?”

Dr. Meyers says an element of
CRAFT
evolved out of marital therapy. “As I was working with couples, I started to see that the spouse had more power or more influence than I thought he or she might have. So as I thought about all that over the years, I kept thinking, I
wonder if we could actually work with the spouse, because she or he does influence the partner with a substance use disorder.”

But
CRAFT
also evolved from Dr. Meyers’s own damaging experience with substance abuse, both as the child of an alcoholic and then as a drug abuser himself, self-medicating to control his
PTSD
as a Vietnam War veteran.

“My father was a heavy drinker and
that caused lots of problems. My mother, we would say she had bipolar disorder now. She was very depressed a lot of time. She took a lot of her anger out on my brother and myself. She would beat us pretty good. And I got involved in drugs when I was in Vietnam—I did a lot of drugs. When I came home from the military, I was doing drugs and my parents kicked me out of the house. They said, ‘We don’t
want you around here, you’re a drug addict.’ So I was on the streets.” Getting rejected by the people who were supposed to love and support him the most convinced Dr. Meyers there had to be a better way. And to Dr. Meyers, “that’s
CRAFT
.”

For the
CRAFT
model to work, there’s a degree of self-control required from the family members of those battling addiction. “Lots of spouses do things
unintentionally that support drinking or drug use. When the drinker gets angry, or when the non-drinker gets angry in response and starts yelling at the drinker and calling him or her names and so on, it doesn’t do anything but exacerbate difficulties. So what we’re gonna do is start learning how to just back away and then figure out times to talk to her or him in different ways.” This is not the
same as walking on eggshells around the drinker. It’s about being strategic, and interacting with them when it will be most effective.

We asked Dr. Meyers to reimagine how a drinker facing conflict with a non-drinking spouse might look different if the spouse was using
CRAFT
.

“The wife might say, when her drinking spouse comes through the door, ‘Oh, I’m glad you’re home, I’m glad
you’re safe, I worry about you because I do love you. But right now, I think I’ll go take a shower and go to bed. Maybe we can talk tomorrow morning. I’m glad you’re home.’ And just walk away. And if he says ‘Hey, where the hell are you going, what’s going on,’ the spouse could say, ‘It hurts me too much to see you like this because I love you,’ as opposed to saying ‘You’re drunk and a slob, I
can’t take it anymore.’” By learning to communicate effectively with an individual with a substance use disorder, we rebuild trust—and become partners in them getting well.

Therapists who use
CRAFT
say it, like motivational interviewing, is about letting the client lead. “We never say, you’ve got to do this, or you’ve got to do that. We let it come from them. And eventually if you do the
right stuff and you talk to him or her in the right way, they’ll come back and make those choices,” assures Dr. Meyers.

In randomized controlled trials, the
CRAFT
model was three times as effective as Al-Anon, the twelve-step recovery program for the families and friends of alcoholics, and twice as effective as classic interventions, the kind you see on reality
TV
.
1

Dr. Meyers
asserts
CRAFT
gets a drinker or drug user into treatment about seventy per cent of the time. “But here’s the deal. Even if the partner doesn’t get the drinker or drug user into treatment, they feel better. We empower them. If they go to Al-Anon, they’ll be told they’re powerless to help. What we do is say we want to give you back your power, and we want you to be the person that you want to be,
regardless of what he or she does.”

CRAFT
is one of the approaches used at the Center for Motivation and Change in New York. About a month after Mike’s relapse, with cameras rolling, Mike and I sat down for a session with the Center’s director and co-founder, Dr. Jeffrey Foote. Dr. Foote recalls how he bought into the mental health training culture surrounding addiction to the point that
he tried to get out of studying it when he was a student.

“When I was trained almost thirty years ago, I was going be assigned to an addiction facility for my first rotation, and I wrote a letter to the training director asking her if she would please not assign me there because I had no interest in having anything to do with addiction-related issues. So she, of course, realizing my arrogance,
said, ‘Go to hell, that’s where you’re going.’ That was my first exposure to addiction treatment, and despite the fact that it was totally traditional, straight-on disease model treatment, I loved it.”

Our session with Dr. Foote helped us both understand how much we were perpetuating our anxieties about Mike’s relapse by not talking about them. After Mike got his Vivitrol shot, even though
I saw how it erased his cravings and returned his sense of wellbeing, all I thought about was him drinking again. But I didn’t feel comfortable revealing this to him, as I was worried he’d get angry and think I didn’t trust him anymore. Which, at the time, I didn’t!

A transcript of our therapy session illustrates how the
CRAFT
approach helped both Mike and I navigate what could have been
a particularly volatile discussion.

Maureen: Mike got a haircut two days ago, and I was away having coffee with a friend. I phoned him after it should have been done and I couldn’t reach him. The phone rang for a bit. And then the next time I called, it was off. My thinking? It’s pretty early but I wonder if he’s in a bar. And if he’s in a bar, what will I do about that? I’ve got this
new level of parallel thinking in my brain about what’s happening and I don’t feel I can share that kind of thing with him. Which is a concern now.

Mike: Well, this is the first I’ve heard that you thought you couldn’t reach me so maybe I was in a bar.

Maureen: That’s now my default when...

Mike: Well, what could I have done? What would have helped with that?

Maureen:
I—I don’t think that you could have done anything. You were getting your hair cut.

Mike: Yeah.

Maureen: But because the phone went off I worried you were going to drink somewhere. But if I went and told you that, I thought you’d be mad at me.

Mike: No. No I wouldn’t be mad at you at all.

Maureen: Are you just saying that ’cause there’s a camera rolling?

Dr. Foote: This is a great discussion, so please continue, because it’s incredibly important.

Mike: No, I wouldn’t have been mad at you, not given what’s happened. I would experience that as legitimate concern.

Maureen: My fear is you would have gotten reactive and said, “Well why don’t I. I might as well just go and drink then, if that’s what the expectation is.”

Mike:
It would be okay if you’d say it to me the way you said it here, which was, this is what was going on for me, and this is what I was thinking, instead of you coming to me accusing, “Were you drinking? You weren’t answering your phone. Were you drinking?” You’re worried and you’re anxious and I don’t want you to be worried and anxious.

Maureen: So I guess because I don’t really know the
words to use, I’m saying nothing.

Dr. Foote: And your experience has been that he gets reactive or defensive, right? And I’m sure that that’s true. You’re not making that up. Mike, your position: Well if you come at me, I get defensive. One of the things we talk about in
CRAFT
is the seven steps of positive communication. The steps include things like being very specific, putting a feeling
word or a feeling into the statement that you’re making, taking partial responsibility, using an understanding statement. Maureen, you said, I get really scared inside, and this is my default setting now, and it’s hard for me.