Michael Provines, MD

Chief Operating Officer

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INTERVENTION

MOTIVATING SUBSTANCE ABUSERS TO ENTER

TREATMENT

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TREATMENT PROVIDERS• We are not law enforcement, we provide treatment to the patient and family

system

• We do not judge our patients for having the disease

• We base our decisions on the facts of the case we are treating

• We are not involved in the morality (concern with the distinction • between good and evil or right and wrong) of addiction

• The “disease model” of addiction describes addiction as a lifelong DISEASE involving biologic and environmental sources of origin.

• Justice Department involvement is a symptom of the disease and may not be avoidable

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Disease Model of Addiction

• A disease causes an interruption, cessation, or disorder of bodily function, systems, or organs

• And is characterized by:– A recognized etiologic agent (or agents)– An identifiable group of signs and symptoms– Consistent anatomical alterations of known body systems

• Treatable with medications and cognitive, behavioral interventions.

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Alcoholics Anonymous

• Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.

• Described as an “allergy” to alcohol.• First edition of “big book” published in 1939.

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Primary Illness

• Addiction is a primary illness

• Must be treated before other “problems” can be managed (legal, social, financial).

• Oftentimes treated concurrently with other mental health and medical issues

• Chronic mental health and medical issues are unlikely to improve unless addiction is treated simultaneously

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Chronic and Progressive• Addiction is a chronic and progressive

disease. – Can be arrested but not eliminated– Tends to worsen over time

• Increase use of the substance• Worsening of consequences (symptoms)

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Fatal

• Fatal from direct or indirect actions of the substance– Production of organ system disease

• i.e. alcoholic hepatitis leading to chirrosis, cocaine induce cardiomyopathy

– Behaviors• Accidents• Trauma• Neglect of body (eating, sleeping, hygiene, sexual health)• Suicide• Violence• Overdosage

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12-Steps (AA, NA, CA, MA)

• State that chronic addiction ends in, “jails, institutions, and death.”

• Self-help groups that offer support and encouragement to its fellows

• Offer practical, real-life advice on coping skills• Spiritually based, not religious• Do not treatment medical ailments, psychological or

psychiatric problems, and do not offer clinical advice

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Treatable

• Successful treatment is available– Medical interventions– Cognitive and behavioral interventions– Social interventions– Support groups

• But the disease is characterized by……

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Denial

• Denial is a state of being that places the person out of touch with reality

• The most difficult aspect of treatment for addiction• The support network and the patient can be in denial• Caused by multiple factors

– Distortions of memory (blackouts and euphoric recall)– Psychological defense mechanisms (projection, repression, etc.)– Social factors (enabling, environment of origin, normalizing the

lifestyle)– And……..

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Enabling

• AA– doing something for someone that they should or

could be doing for themselves

• CODA– putting someone elses needs above your own

• Clinical– doing something for someone that prevents them

from experiencing consequences

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Enabling• Often misunderstood

– Not as simple as buying drugs or alcohol for a patient, or supporting the addict financially

– Can be as simple as accepting the behavior without addressing it

– The reduction of enabling DOES NOT mean that the goal is to give additional consequences to the addict, the consequences will come naturally

• Reduction of enabling leads to the cessation of the prevention of consequences

• Is not meant to induce “tattle-telling” in family members– AA and AL-ANON slogan “live and let live”

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Enabling

• Examples– Making excuses for the addict– Paying bills– Bailing them out of jail– Making rationalizations– Ignoring problems cause by use (financial, employment, legal)– Cleaning up messes– Not discussing the problem of chemical use– Not getting help for “yourself”

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Consequences

• The severity of consequences for addict and for family will determine the willingness to intervene

• Consequences can be completely internal (emotional collapse, depression, anxiety, sleeplessness, guilt, fear, etc.)

• External consequences (financial, legal, employment, medical) are more likely to lead to intervention, but not necessarily.– Dependent on the stage of the disease

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Intervention

• A formal or informal process to aid in motivating a person to seek treatment

• Many different styles of intervention• Older styles relied more upon threatening

the addict with consequences• Newer styles rely on treating the family

system and prevention of enabling behaviors

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Intervention Models

• Major categories are direct and indirect– Direct is a direct confrontation with the addict

• First direct model was the Johnson Model, originating in the 1960s

– Indirect is working with a co-dependent person in the addict’s support network

• Allows co-dependent person to be more effective in working with the addict (AL-ANON)

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Johnson Model

• Originated in 1960s with Dr. Vernon Johnson• Taught at the Johnson Institute• Very effective in treatment entry rates• Method

– Family meets with a counselor (or interventionist)– Family prepares letters to addict– Intervention rehearsal meeting takes place– List of consequences if addict does not enter treatment is

developed– Intervention takes place and is usually a rapid process– Addict agrees to treatment or accepts consequences

Confrontational vs. Motivational Approaches

• Confrontational approaches may work more quickly

• Confrontational approaches tend to address the addict, rather than the entire family unit

• Confrontational approaches may lead to higher treatment drop-out

• Confrontational approaches are more stressful for the family unit and addict

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Forcible Intervention

• Civil liberty issues arise with forcible interventions

• Interventions that use physical force to capture or even confine the addict

• Addict has not been allowed to attend court nor have they been served with legal action

• Deprives the person of liberty without due process

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Underlying Themes of Modern Interventions

• Utilize motivation rather than confrontation

• Are invitational in nature, rather than by surprise

• Decreases the focus on the addicted individual

• Focuses on need of entire family system to grow towards increased health

• Focus on dignity and respect for the addict and the family

• May be effective in helping the addict decrease use without their direct participation

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Modern models

– Motivational Interviewing– Systemic– A.R.I.S.E. (A Relational Intervention

Sequence of Engagement)– CRAFT (Community Reinforcement and

Family Training)

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Motivational Interviewing

• Open-ended questions• Utilizes mirroring• Reflective listening• Affirmations• Summaries• Reframing• Takes the burden of motivation away from the family• Patient eventually accepts the consequences of their

actions

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Systemic Approaches

• Can help the family return to a state of health, even if the addict continues to use

• Rewards sober activities• Discourages activities that include drugs or alcohol• Eventually reasons not to use outweigh the reasons

to use, the addict seeks treatment• Avoids nagging, pleading, and threatening• Addict gradually develops insight into the

consequences of their actions

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A.R.I.S.E.( A Relational Intervention Sequence of Engagement)

• Divided into phases– Phase A

• Level 1—first call and first meeting of intervention team• Level 2—Continue intervention meetings• Level 3—Formal ARISE intervention takes place and

consequences are given if patient has not entered treatment

– Phase B• Individual and family healing, individual and family get treatment

– Phase C• Relapse prevention and long-term recovery

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CRAFT

• Designed for others who need assistance in getting help for their loved one

• Utilizes positive communication• Rewards sober activities• Discourages using activities• Could lead to a lower rate of relapse b/c entire family unit

is motivated• Goals:

– Increase happiness of family members– Decrease addict’s use– Motivate addict to seek treatment

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CRAFT

• Uses positive communication styles to encourage the family and addict– Brief sessions to describe problem– Positive and hopeful– Use I statements and stick to fact– Indicate hopes for future outcome

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Treatment of the Family

• Help is available for the family, even if the addict is unable to gain motivation for change

• Self help groups such as AL-ANON and CODA are helpful tools and offer support at no cost

• Individual and family therapy• Help from an interventionist• Help from a treatment facility to guide family

through process

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Choosing a technique

• A “one size fits all” approach does not work• You must match the technique with the family

and patient’s needs• The urgency of the situation may dictate your

approach• If one approach is unsuccessful, try another• Reminder that working with the family or

employer who initiated the intervention is of utmost importance

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Interventions are initiated by

• Family• Friends• Employers• EAPs• Professional licensing agencies• Law enforcement and legal means• Child protective services• Physicians• Therapists or counselors

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Recovery Connection

• If you are looking for assistance, please call our 24 hour helpline, free of charge

• 800-673-1847, Recovery Connection

• Guidance is available in looking at options

• Staff here receive 30,000 calls per month and are experts at interventions

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