Treatment Takes Two to Tango

By Dr. A. Tom Horvath 03/13/13

What actually takes place in addiction treatment? In the first of a three-part series, Dr. Tom Horvath shows motivational interviewing in action.

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He loved cocaine. As he described getting high, his glowing face and the animation of his body expressed more than his words. He welcomed the release coke provided from life’s mundane affairs. But most of all, he relished the entirely different world coke could send him to for days on end.

Benjamin (a composite case based on several clients) was quite successful in his profession. His intelligence and curiosity led him to gain extensive technical knowledge, which was the foundation of his financial success. However, his upbringing had been traumatic, and his self-knowledge was limited. He avoided self-exploration because it was painful. When he thought about his past, he blamed himself, incorrectly I later learned, for the many problems in his family when he was growing up. He deeply valued the escape cocaine could provide.

As an addiction psychologist, I firmly believe in a collaborative approach—as opposed to a confrontational one. By “collaborative,” I mean that my clients and I work together to come up with ways to address their problems. My job is to help my clients make their own decisions about substance use (and other life issues), helping them to identify and better understand the contradictory motivations we all have. I assume that with sufficient discussion the deeper reasons to pursue a meaningful life will emerge.

Benjamin was rather far from living a meaningful life. However, it’s not my job to dramatize the negative consequences of substance use. Rather, I help my clients to perceive these consequences accurately and to consider them in light of what’s most important to them. In some cases, clients may choose to continue using or to cut back but not stop. 

In Benjamin’s case, it was initially a challenge for me to maintain a neutral position. The facts were compelling: He was about to lose his girlfriend, who apparently was devoted to him—not just to his money and success; he had already lost his job, despite the fact that his employer really liked him; his health was starting to suffer; and he was losing friends.

Over time, these issues would enter our discussions in a serious way. But in that first session all he really wanted to talk about was how much he loved coke. At such times part of me wants to scream! To be clear, I don’t scream or criticize. But inside me is a negative voice, a collection of criticisms and commands directed at me or others over the course of life: “Don’t you see that you’re being an idiot? What is wrong with you? You are destroying yourself. Quit it!”

Our clients say they have been addressed this way so many times by family, friends and addiction professionals that they expect criticism from us as well. The client is upset with me even before I say anything! From my side, it’s scary to realize how close someone might be to “going over the edge.” Often the client’s family, friends and possibly a referral source want this one interview to have a big impact. Under these circumstances, it is tempting to criticize or command. If the client doesn’t follow my advice, it won’t be my fault.

The TV show Intervention adds to this problem. Many people think that the way to change an “addict” is through the kind of relentless confrontation featured on the show. Ironically, one of the most well-established findings in addiction treatment is that confrontation makes people worse, not better. Criticism begets defensiveness. A struggling client won’t be able to make good decisions if he is defending himself from my criticism.

In our sessions, my client was free to explore both sides of his coke use without having to defend it.

There are no quick fixes for motivation or for recovery. Although everyone (except the client) may be hoping or demanding instant success, recovery is an educational process that often takes time. The place to begin is with a thorough understanding of how valuable the substance experience is to the user. The following exchange between me and Benjamin illustrates how a collaborative technique works.

Dr. Horvath: You love coke. You don’t see that much harm in using for a few days at a time. The price you’ve paid for using does not seem that great given the pleasure you get. Any problems you might experience in the future you expect to be able to cope with. You think you’ll easily find another job. You also believe your girlfriend could eventually accept your coke use. Am I accurately summarizing what you’ve said?

Benjamin: Yes, that’s it.

Dr. Horvath: OK. What would happen if you got your girlfriend’s agreement, and maybe once a month went to a hotel room for a few days and used? 

Benjamin: Huh?

Dr. Horvath: You said the pleasure from coke is worth the cost. You also stated earlier that it was possible to use too much. I’m asking, What if you tried controlled use. It doesn’t seem like doing a line or two on occasion would appeal to you. Rather, you like the full-on experience, several days alone with your coke.

The discussion of how he might have a time-limited binge took the rest of that session and another one. What emerged was his own conclusion that he would not be able to limit his binges to once a month or even once a week. Coke use, as he enjoyed it, was incompatible with employment. Although he had once had enough money not to work, the reality of now needing an income was asserting itself. He began to weigh the value of having adequate money against the value of the cocaine experience. He was confronting himself, without my being in the way.

Almost no one can think well when it seems the other person is waiting to pounce. With this client I had quickly acknowledged that coke was very valuable to him, that he had a right to use it, that the price he had paid for it was worth it to him, and that he could continue to use if he wanted to. In our discussions he was free to explore both sides of his coke use without having to defend it.

A friend or family member can actually try this approach at home with the troubled person. The crucial question to ask her is, What do you like about coke (alcohol, gambling, etc.); the crucial behavior for the friend or family member is to listen actively and without judgment to her answers. However, it’s easier for a professional to listen and converse in this way, because we don’t have to live with the consequences of a slow learning process. In many situations the family needs to stay focused on setting and enforcing limits, as well as rewarding non-using behavior. Whatever the case, criticism is not going to help.

The collaborative approach work that I’m describing is known as motivational interviewing. How well does it work? In scientific studies, motivational interviewing works about as well as other effective (evidence-based) treatments for addiction.

A collaborative approach is in tune with reality because: 1. Clients do have choices; 2. Most truly want a better life; 3. They have a hard time seeing how to get to a better life; and 4. They won’t let go of what seems to work until they’re confident about a new direction. Consequently, helping the client make changes can take effort and patience.

Perhaps you think a good solid confrontation would do the job faster. Confrontation can lead to superficial compliance that is soon followed by rebellion. Or the rebellion starts right at the beginning and is followed by a long standoff and possibly further deterioration of the client. The only benefit for the provider is that this approach makes it easy to blame the client for being “noncompliant.” But in fact the provider has ignored two fundamental realities of human psychology: Almost everyone wants the freedom to make his own choices, and almost no one thinks clearly when on the defensive.

After we had had many conversations, Benjamin realized that he did not completely want to stop using coke. However, he eventually chose to give it up because other aspects of life were more important to him. He began appreciating the less compelling, but more meaningful, satisfactions of love and work.

A. Tom Horvath, PhD, ABPP, is the founder and president of Practical Recovery in San Diego, CA, a self-empowering addiction treatment system including sober living, outpatient services and two residential treatment facilities for alcohol and drug abuse. He is also the president of SMART Recovery, an international non-profit offering free, self-empowering, science-based, mutual help groups for addiction recover. A past president of the Society of Addiction Psychology (Division 50 of the American Psychological Association), he is the author of Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions.

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A. Tom Horvath, PhD, ABPP, is the founder and president of Practical Recovery in San Diego, CA, a self-empowering addiction treatment system including sober living, outpatient services and two residential treatment facilities for alcohol and drug abuse. He is also the president of SMART Recovery, an international nonprofit offering free, self-empowering, science-based, mutual-help groups for addiction recovery. A past president of the Society of Addiction Psychology, he is the author of Sex, Drugs, Gambling & Chocolate: A Workbook for Overcoming Addictions. Follow Dr. Horvath on Linkedin.