Using therapeutic leverage to encourage change and promote recovery
When alcohol and drugs assume a life of their own and begin to influence and, at times, take control of the behavior of the user, family members and advisors wonder how best to respond. The simple answer might be, “Why not ask them to stop?”
But anyone familiar with a substance user knows this request is very likely to be ignored or objected to (sometimes vehemently). The concerned person who is rebuffed or too afraid to ask the question faces three major challenges:
- Understanding what is going on in your loved one’s brain.
- Lack of motivation to change his/her behavior.
- In the face of resistance, deciding on the most effective option to encourage the addict to seek help and be successful in recovery.
This blog will briefly discuss these challenges with an emphasis on why we much prefer “therapeutic leverage” to encourage addicts to seek help, versus other commonly-used approaches. As one parent wrote about her young adult child:
And the truth is without mom and dad forcing change, as some point either the law will force change, or tragically life will.[i]
This the stone cold truth – it is reality in world of addiction. And the purpose here and in the next few blogs is to talk about leverage and compare it to other, less-effective approaches.
Understanding the disease concept.
The first thing those dealing with a substance user need to remember is this:
- It’s not your loved that is rebuffing you, it’s the disease.
With brain scans, we now understand addiction as an “automatism” – a disorder of the central nervous system partially located in the limbic system – the fight-or-flight area of the so-called primitive brain, which tells itself “I need this substance to survive.”
The intensity of the reaction to any request to stop is directly related to the limbic system’s commitment to the drug or drink.
This commitment to use can be for several hours a day, on weekends only, or two-to-three days a month. It’s not the frequency of use – it’s what happens as result that matters.
In order for the limbic system to become less reactive, an addict must abstain from mood-altering substances and learn new responses to the desire to use. This means in discussing change strategies, the idea is to look at the model(s) that provides the best opportunity to achieve abstinence in the long run. (If you, the reader, do not buy into the disease concept, you have an obligation to present credible alternative scientific evidence to support your view.)
Lack of awareness on the part of the addict.
One major hurdle is what we call the “self-perception” problem. A high percentage of people who need treatment do not believe they need it. They do not perceive themselves as having a problem with alcohol or drug use and are resistant to being told they need help or to seeking treatment. For example:
Of the young adults who needed but did not receive substance use treatment in a specialty facility in the past year, 96 percent did not perceive a need for treatment. Of the 4 percent of the young adults who did perceive the need for treatment, less than one-third made an attempt to get treatment.
This holds true even if there is a crisis that outside observers consider to be overwhelming dependence on alcohol or drugs: DUI, low grades or dismissal from school, car accidents, failed relationships, or a consistent pattern of binge drinking.
The addict’s inability to see the need to change is one of the core conditions that an effective approach to encourage the person to seek help must take into account. Addicts are not merely in denial, they are delusional because of lack of awareness regarding behavior or attitudes. Therefore, any change strategy must focus on chipping away at the self-perception problem – the delusion that the addict is fine as-is and you are the problem.
This can take weeks and continues on even after entering treatment. For example, merely because someone agrees to seek help does not mean they fully understand what they need to do to recover – the “learning process” is ongoing. Addictions are different from other illnesses in that the degree of effort is greater for recovery, and it requires a unyielding determination to remain abstinent no matter what.
Choosing a change model.
While there are a number of different approaches used in the treatment field, we firmly believe in the leverage model used by medical boards for substance-dependent physicians because its results are spectacular when compared to other approaches. Let’s look at the numbers:
“The research showed that 78 percent of 904 doctors in the studied programs completed an average of 7.2 years of monitoring without relapse. …
Those are just over-the-top numbers for a chronic, progressive disease that kills people.” – Dr. David Carr, Director, Mississippi Physicians Health Program
Seventy-eight percent rate of continuous abstinence at seven years!
These results are much better than those for other programs. (And the data is reliable because it is based on regular drug testing overseen by medical boards, rather than self-reporting or very small, restrictive samples, as is the case for success rates reported by other programs.)
One reason for their very good outcomes is that medical boards use the license to practice medicine as leverage or pressure to assure that physicians comply with treatment recommendations, including post-treatment plans and reliable drug testing for two or more years.
“A skeptical argument often goes that physicians are a special case because the threat of losing a lucrative profession they have worked so long to pursue gives them extra motivation to stay sober.
But Carr believes most everyone has something similar in their life that they value, and that is what the treatment system must identify and tap into.
‘The plumber has a good job and doesn’t want to lose it,’ he says. ‘Or he’s got a great wife.’
Carr says the field needs to analyze what it is providing to groups such as physicians and airline pilots but not to others. Then it can determine how to overcome barriers to a more widespread application of a treatment model that is based on accountability.”
Our goal, then is to identify and tap into what the addict values and does not want to lose.
Finding and using leverage points.
Parents, family leaders, trustees, and business owners need to find pressure points to encourage their addicts to enter treatment and comply with post-treatment recommendations, via either explicit or non-explicit leverage.
- Explicit leverage includes using continued employment, access to funds, and professional licenses as incentives for compliance.
- Examples of non-explicit leverage include requests to seek help, embarrassing social incidents, and school or employment failure.
Non-explicit leverage is far less effective because it does not provide enough pressure for the addict to engage in recovery activities long enough to sustain stable abstinence.
Using leverage to encourage compliance with treatment recommendations over many months helps make the disease “real.” People with few external consequences – especially those with wealth, status, and power, who are immune to the Average Joe’s “rock bottom” – begin to recognize they do have a problem, particularly when there is accountability and drug testing.
Why leverage works
The primary goal of applying leverage is to modify behavior by encouraging the addict to seek effective treatment and follow post-treatment recommendations. The pilot and physician model is, in essence, forced behavior modification in which the addict is required to engage in recovery activities until they internalize the desire to remain sober.
Internal motivation is a more powerful predictor of recovery than external motivation. Moving from external motivation to internal motivation is a long process. Therefore it is critical for external pressure to continue until this transition is fully underway, if not complete. The failure to follow this advice is a major cause of relapse. (Paraphrased from report.)
Susan Merle Gordon. Relapse and Recovery: Behavioral Strategies for Change. Caron Foundation Report. 2003: p. 18.
As noted in a New York Times article, “The Secret of Effective Motivation,” internal reasons for remaining sober are far more conducive to success. Therefore helping people focus on the meaning and impact of their new life without drugs or alcohol is one of the primary goals of treatment, beginning with initial detoxification and continuing on as a life-long process. We cannot stress enough how important it is to maintain pressure until the addict is motivated to recover for the sake of recovery, and not for the benefits of doing so – or the punishments for failing.
Leverage is a strategy to obtain compliance – it is not treatment.
Leverage is not treatment. It is a technique to get the addict to enter treatment and stay in recovery. So you have to find treatment centers who support your use of leverage and has an abstinence-, 12-step-based program that respects and treats the individual clinical needs of your loved ones.
In upcoming blogs, we’ll discuss other aspects of leverage as well as other approaches to treatment and recovery and why we believe these fall short of the therapeutic leverage model.
[i] Lynn Benson, Star Tribune 8.6.11