Confronting, berating and threatening an addicted loved one to make them get treatment might make for compelling TV, but it’s a lousy way to help. If you’ve heard about interventions and are thinking of staging one for someone you care about, please read this article first. Despite your good intentions, decades of evidence shows that what you’re considering is counterproductive, even cruel.
A Familiar Scene
Thanks to shows like A&E’s Intervention, the scene is familiar to us all. “Take a seat,” it begins. The off-the-rails drug user is encircled by loved ones. “Your family has some things they’d like you to hear,” says a placid stranger
One by one, the loved ones spell out how the subject’s addiction has spread pain and fear. Everyone becomes highly emotional. The family then implores the subject to take immediate help—typically in the shape of a stint at a residential rehab.
This plea is always accompanied by a threatening ultimatum: If treatment is not accepted on the spot, the alternative is exclusion from the family circle, emotional and financial abandonment.
“It hurts to say this,” a crying daughter says to her addicted father in one episode of Intervention, “but if you don’t take this opportunity you will no longer exist in my life.” It’s what’s known as “tough love.”
The interventionist who orchestrates this dramatic confrontation speaks in a calm, caring fashion but irresponsibly ignores 40 years of research. Using threats and coercion to get an unmotivated person into treatment is not helpful, and is likely harmful.
The pernicious effect of intervention-as-TV-entertainment is the further normalization of this approach. Interventions have long been a fixture in the US addiction field—and they’re just one aspect of the broader confrontational approach embedded across the treatment industry.
What Works and What Doesn’t
Confrontational counseling—involving a therapist delivering “reality-oriented feedback” to a client—landed in 45th place out of 48 different treatments ranked in order of effectiveness, according to Professor William R. Miller, a clinical psychologist and emeritus professor of psychology and psychiatry at the University of New Mexico.
Treatments ranked by Miller and his colleagues were given scores based on, among other metrics, the number of studies with positive and negative findings for each approach. Even “Videotape Self Confrontation”—merely showing someone a film of themselves during a binge—ranked one place higher than confrontational counseling. One approach near the top of the list, meanwhile, was motivational enhancement, which seeks to elicit the patient’s motivation to change, rather than forcefully demand it.
Miller and his colleagues also conducted clinical trials comparing three different intervention approaches aimed at getting unmotivated subjects, whose loved ones were concerned about their problematic alcohol use, into treatment.
They found the most effective approach was CRAFT (community reinforcement and family training), an approach based in the ideas of cognitive behavioral therapy (CBT). CRAFT teaches behavior-changing skills at home with the help of a professional. Of the families who used CRAFT in Miller’s comparison, 64 percent succeeded in getting their loved one into treatment. (CRAFT also came in fourth in that earlier ranking of 48.)
The other two approaches were far less successful. Only 13 percent of people made it to treatment when families used “Al-Anon facilitation therapy”—the intervention style favored by rehabs basing their treatment on Alcoholics Anonymous (the vast majority in the US). Of the families using the “Johnson Institute intervention”—a confrontational family meeting most closely resembling the interventions you see on TV—30 percent got their loved one into treatment.
CRAFT also worked better than other approaches when the family member outright refused to get treatment. Another clinical trial found that facilitation therapy based on AA or Narcotics Anonymous only succeeded in encouraging 29 percent of people who initially refused to get help. Families using CRAFT, however, succeeded in getting 58 percent to eventually seek help.
The numbers are clear. Yet the US addiction treatment field overwhelmingly chooses to use less effective methods of engaging and helping people.
And the true picture could be far worse. The research mentioned above doesn’t explore the impact on all those subjects of confrontational interventions who refused treatment—those who therefore received the threatened sanctions, resulting in isolation, poverty or homelessness. Harmful effects of confrontational intervention styles, according to addiction historian William L. White, have included “increased drop-out, elevated and more rapid relapse, and higher DWI recidivism.”
How Did We Get Here? And Why Are We Still Here?
White, perhaps the most revered historian of all things addiction, has authored over 300 scientific articles and the acclaimed book Slaying the Dragon: The History of Addiction Treatment and Recovery in America (1998). He has also written about a “peculiar turn” US addiction treatment took in the mid-1900s.
During this “peculiar turn,” addiction counselors—themselves usually in recovery from addiction—advocated for hitting their clients over the head with harsh realities, in the hope of sparking motivation to change.
“The alcoholic evades or denies outright any need for help whenever he is approached … he is not in touch with reality,” wrote Vernon Johnson, champion of the confrontational Johnson Institute intervention, in his 1973 book I’ll Quit Tomorrow. He advised breaking through to clients with what he called a “dynamite charge.”
In a 2008 article, White and Miller together described this approach as varying from “frank feedback to profanity-laden indictments, screamed denunciations of character, challenges and ultimatums, intense argumentation, ridicule, and purposeful humiliation.”
“It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate,” they concluded.
You might think such tactics would be consigned to history by now, but they persist. You won’t find the aggressive berating of clients advertised on rehabs’ websites. But read between the lines, or listen to the testimony of former rehab clients (I’m one of them), and you’ll find it remains common.
“Confrontational approaches are often used without being intentional,” said Ian McLoone, lead therapist at an outpatient addiction treatment facility in St. Paul, Minnesota. “I hear words like ‘denial’ or ‘non-compliance’ used by therapists to describe patient behavior. But what they really mean is, ‘That guy isn’t doing what I want him to do.’”
When it comes to moving away from confrontation in counseling, McLoone told me, “We have a long way to go. I still see humiliating and shaming assignments being used in ‘world class’ facilities. Few fields have been better at blaming patients for their own failures.”
Can you think of another area of healthcare in which providers “help” their patients via humiliation and threats? Neither can I.
I Was Screamed at in a “Therapeutic” Circle
I had just turned 23 years old inside a renowned residential facility that was treating my heroin addiction. They rapidly tapered me off of buprenorphine, a medication used to treat opioid use disorder. (Not one morsel of evidence in the medical literature suggests that doing this is a good idea; loads of evidence suggests it can be harmful, and more likely to lead to a fatal overdose.)
As a result I suffered through multiple sleepless nights. I couldn’t eat well, so the nurses had me drinking a meal-replacement protein drink. Sleep-deprived and malnourished, I wasn’t able to fully participate in hour upon hour of group therapy and lectures. The staff mistook my lethargy and sickness for a defiant refusal to engage in the process.
So I was summoned to an office where several counselors and staff sat in a circle. One seat was left for me, placed so that that I felt all their eyes on me, and the director of the facility—tall, thick and bald—asked me to take it.
The towering director then asked me to read a portion of the Big Book of AA (never mind that I was in rehab for heroin, not alcohol). The passage described the selfish and egotistical personality traits of someone who drinks too much: “He may be mean, egotistical, selfish and dishonest.”
I asked what this was all about, why I was reading this, and how it applied to me.
The director, red with anger, slammed the book shut. As the other counselors in the room kept their eyes to the floor, I was scolded for being a “lying, selfish heroin addict.” The director proceeded to poke fun at my withdrawal, saying the sickness I experienced was nothing compared to what he’d seen before.
The tactics came straight out of the confrontational counseling playbook. Only, I was already broken, guilt-ridden and ashamed. At a time when I needed encouragement, more shame was heaped onto me.
I was then told to leave and make a list of all the ways that “you keep yourself sick.” My punishment was to compile this list while my fellow patients went to the planetarium for an off-campus activity that evening.
I still think about why the counselors in that room, assembled purely to intimidate me, kept their eyes to the floor. My guess is, they knew that what they were watching was wrong.