Ideas

The end of hitting rock bottom

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Shortly after 1 a.m. on March 27, Susan Knade awoke to the sound of her cellphone ringing. It was her 21-year-old daughter, Caroline, calling. She was crying.

Please, Caroline said. Please, come pick me up.

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Nine hours before, the woman running the halfway house had told Susan that Caroline could stay so long as she passed a drug test after the weekend. But something had happened. Caroline had been kicked out. She was calling from a 7-Eleven, she said, and entering heroin withdrawal.

Susan instinctively reached for her keys, then stopped herself. Her Al-Anon group had a phrase for intervening like this — standing in the way of miracles. What if this was the moment Caroline was supposed to hit bottom and turn her life around? But Susan couldn’t shake the darker image: her little girl, at a convenience store counter, alone in a strange city. Afraid.

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Susan fumbled through her dark driveway, got in her car, and drove 50 rainy miles to Annapolis.

She booked a motel room for the two of them, and when they checked out the next day, Susan considered her options: In eight months, Caroline had checked into seven rehabs and three halfway houses. She had quit or been kicked out of all except one. Susan believed if she took Caroline home, she’d immediately begin using again. She could call homeless shelters — she’d already phoned several — to find one with a free bed. Instead, she decided to try something she considered radical: She asked Caroline what she wanted to do.

Knade had been reading a book called “Beyond Addiction: How Science and Kindness Help People Change.” Published in 2014, the book is a guide to a decades-old approach for addicts’ families called Community Reinforcement and Family Training, or CRAFT. CRAFT suggests conversational techniques, helpful questions, and ways of responding to a substance abuser’s (often bad) behavior. It’s like an etiquette guide for dealing with addicts. Yet its goals are much more ambitious: By making loved ones feel listened to, empowered, and supported, CRAFT’s proponents say, family members can motivate them to seek help. And it appears to work.

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The CRAFT approach, while still not widespread, has gained some influential adherents. The Partnership for Drug-Free Kids, the antidrug advocacy group originally known for the “This is Your Brain On Drugs” advertising campaign, introduced a program called the Parent Support Network in 2013, where parents coach peers in CRAFT techniques over the phone. In Sweden, the government’s health department added CRAFT to its 2015 guidelines for how health professionals should treat family addiction problems. In September, a startup company called Cadence Online introduced an online CRAFT course aimed at parents featuring video segments and interactive training developed with Robert J. Meyers, the psychologist who originally developed CRAFT, and A. Thomas McLellan.

“I was skeptical at first. I worked in the field, both of my kids were addicted,” said McLellan. “But CRAFT is among one of the most potent ways to change people’s behavior.”

CRAFT takes aim at one of the most puzzling problems in addiction treatment: Of the 20 million people in the United States who suffer from a substance abuse disorder, 19 million of them — 95 percent — say they don’t need help, according to the 2013 National Survey on Drug Use and Health. That is remarkably high regardless of symptoms or their severity. Even 90 percent of the over 8 million people who experience substance-related withdrawal symptoms — trembling hands, seizures, hallucinations — don’t believe they need addiction care.

In the popular understanding of addiction, these treatment-resistant people are “in denial.” No one can help them get sober, the prevailing wisdom says, until they experience profound personal loss — hit rock bottom, to use the phrase from Alcoholics Anonymous — and declare themselves addicts and get clean. For family members, that’s a heartbreaking prognosis. For the United States, it’s breathtakingly expensive. As these people spiral downward, they run up hospital bills, damage property, and get arrested — a 2009 Columbia University study estimated the damage of alcohol, drug, and tobacco costs the government $468 billion a year.

The notion that substance abusers are in denial and beyond help informs aspects of US social policy and health care, too. At least 13 states won’t provide welfare support to those who test positive for drugs, assuming it’s wasted money until they clean up. The most popular family support group in the United States, Al-Anon, recommends family members “detach with love” until their loved one enters recovery. Even in many rehab centers, patients caught using drugs — the very reason they are in treatment in the first place — get kicked out and told to return when they are ready.

Psychologists who advocate CRAFT argue that family members can play a meaningful role in helping their loved ones — that the ideas of “in denial” and “hitting bottom” have no basis in empirical science, and no place in health care policy.

“I hope in the next 10 years, we take ‘hitting bottom’ out of the lexicon,” said Dr. Carrie Wilkens, coauthor, along with psychologist Jeff Foote, of “Beyond Addiction.” “I want to eradicate it. It doesn’t need to happen, ever.”

What if kindness, not suffering, leads addicts to get help?

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Foote and Wilkens run a substance abuse and mental health treatment center based in the Berkshires and New York City, the Center for Motivation and Change. They tell family members that they are a crucial part of their loved one’s recovery.

“You can both take care of yourself and take care of them at the same time, you don’t have to detach,” said Foote. “Family is a very powerful force. It can be incredibly constructive.”

CRAFT starts with a provocative premise: Most substance abusers aren’t in denial, but rather are ambivalent and guarded. They know their drug use causes problems, but they don’t want to admit it because doing so risks the loss of all sorts of things: their dignity, possibly their freedom, not to mention access to the benefits of the drug itself.

With CRAFT, family members learn ways to lower loved ones’ defenses and encourage them to speak candidly. The advice essentially boils down to simple steps like asking open-ended questions, complimenting positive behaviors, and echoing the person’s concerns in a nonjudgmental way. Next, they learn to devise ways to improve their home life (without fixing or minimizing the ill effects of the drinking or drug use). When the struggling loved one feels understood and safe, the reasoning goes, he or she will be more willing to be vulnerable, to seek help.

Gentle as the CRAFT method sounds, research indicates it is effective. In a study of 130 families published in 1999, nearly two-thirds of the participants who took CRAFT classes saw substance-abusing family members who had resisted treatment change their minds and get help — more than three times the rate of families who attended Al-Anon meetings and twice the rate of those who planned a traditional intervention (in the intervention group, several families decided not to go through with the final confrontation, lowering the rate). Similar results were repeated in another study published later that year, and again in 2002.

CRAFT was originally developed in the 1980s and 1990s by Meyers, then a therapist and clinical researcher at the University of New Mexico. When Meyers was growing up, his father was an alcoholic who disappeared for days at a time. His mother suffered depression. “She would sit in this one chair, just staring at the door, like a dog,” recalled Meyers. When his mother died of complications following a hospital procedure at age 45, Meyers blamed his father’s drinking. After leaving the Navy, he got a degree in social work and decided to focus on treating addiction.

Meyers’s early clinical work focused on alcoholics themselves. He became interested in treating addiction with elements of operant conditioning — the concept that people respond better to positive reinforcement than punishment — and also motivational interviewing, where a therapist uses open-ended question and reflecting statements to help patients develop plans to solve their own problems.

He also performed couples therapy, and, too often, the addict wouldn’t come to treatment. Meyers began to wonder if he could coach their wives instead.

“I saw all these women sitting around being tortured. I felt like, I’ve got to do something about this. Who wants a ma who dies at 45 years old?” Meyers said.


The downside of CRAFT is that it’s difficult for families to implement in normal circumstances, let alone in the chaos of a home ravaged by drug or alcohol. It asks parents and spouses to change habits of speaking and behaving that have been ingrained for years, if not lifetimes. Then, consider the circumstances: How does one remain nonjudgmental and ask level-headed questions when a child is stealing a sibling’s money to buy drugs, or be patient with a spouse who is struggling to hold down a job?

Southwestern Behavioral Healthcare, an addiction treatment center with 500 outpatients and a 36-bed residential rehab program based in Evansville, Ind., began offering CRAFT classes in 2013. But currently just 16 or so family members attend the weekly night classes, and another 20 come to weekend family days, said Katy Adams, director of addiction services. “When the family is angry, and understandably so, it’s hard to say, let’s look at the things you can change” said Adams. “The response is, ‘I’m not doing anything. They’re the ones with the problem.’ ”

Susan Knade’s decision to try CRAFT came at the end of a difficult year. Susan had suspected Caroline smoked marijuana and sometimes took pills ever since high school. But it wasn’t until a morning the previous August, a year after graduation, when she discovered Caroline’s heroin. The girl had come home after being out all night and passed out on the sofa in the sun room, shoes still on her feet. When Susan looked in Caroline’s purse she found pill capsules filled with off-white powder. Susan and her husband insisted Caroline go to rehab the next day.

When Caroline quit rehab and returned home, it marked a turning point: Susan refused to give Caroline any money and started policing her every move. Caroline, already prone to angry outbursts, became more vicious. She got into screaming fights with her mom, slamming doors so frequently the Knades had to have all the hinges on three doors replaced. Caroline stole her father’s power tools and pawned a gold bracelet of her mother’s for drug money. When her brother brought a friend home from boarding school for Thanksgiving, Susan had to tell the boy to keep an eye on his wallet.

Knade felt like she didn’t recognize her own family. She works as an interior designer on the Eastern Shore of Maryland, catering to the families of affluent doctors and executives. Her husband is a financial adviser. Together, they live next to a country club golf course in a four-bedroom house with walls painted coral and green and floral print curtains dressing the windows. This wasn’t the family of a junkie.

Susan had begun attending Al-Anon meetings at the beginning of 2013, when she thought Caroline’s problem was limited to Percocet and marijuana. While she found great solace and support from the other family members there, she had trouble with the idea that she should kick Caroline out and let her find her own way, like several others in the group had done with their kids.

“Al-Anon was about handing it all over to your higher power and letting things happen the way they’re going to happen,” Knade said. “But the idea of letting her hit bottom went against every grain of my being, everything I believed about how you’re supposed to love another person. ”

Knade began searching the Internet for alternatives to the tough love approach and eventually found Foote’s book.

The morning in Annapolis, when Susan asked Caroline what she wanted to do, the two decided to go to Caroline’s grandparents’ house in Pennsylvania. For the next week, she detoxed there, alternately sleeping and crying on the couch. “She kept saying ‘I’ve ruined my life!’ ” Susan recalled. Susan held her — and asked her to talk about what the addiction was like.

“It was the first time in a long time I asked her what she felt, instead of sitting there being the expert,” Knade said. “I felt such a huge amount of compassion for her. Before, I just felt like she was rebelling. But I said, you know what? She’s not rebelling. It’s deeper than that.”

At the end of the week, they decided Caroline would go to a halfway house that Caroline picked in Cambridge, Md., a 15-minute drive from home. In May, Susan attended a weekend-long CRAFT seminar for the Parent Support Network in New York City. After Caroline was three months sober, Susan agreed to let her move home.

Her parents and Caroline agreed to some ground rules: Caroline would get a job, do her own dishes and laundry. If she wanted a cellphone, she would pay her own bill. She would agree to take a drug tests whenever Susan wanted to administer one. She would attend an outpatient rehab program and 12-step meetings. If she stayed clean by the fall, her parents would pay for her community college.

Susan agreed to stop policing her daughter in the house and presuming her guilty. That was difficult. She had to stop herself from putting her ear to the bathroom door when Caroline was inside, fearful she was using. When Caroline texted with her old boyfriend — the one who first introduced her to freebasing Percocet up in her room back in high school — Susan would hold her tongue. It was even harder not to complain or intervene when they got back together. (Caroline says he hasn’t used for years, and helps her stay clean.)

And as it turned out, Caroline had relapsed. “One of the girls I waitressed with had a Percocet. I sniffed it. Pretty soon I was snorting dope again,” Caroline said. She tells this story sitting in her kitchen on a recent day in November. Susan sits on the other side of the counter, listening thoughtfully.

“It started to become habit again. . . I was like I can’t believe what I’ve just ruined,” Caroline said. But rather than continuing to hide her using, Caroline told her mom she was struggling. She asked if she could start taking Suboxone, a maintenance medication that helps alleviate cravings and also negates the “high” effect of heroin. Susan dispenses it.

There is still a long way to go. But Caroline says she feels like her mother is on her side, like they are working toward the same thing.

“Before, you were so mad at me, I never wanted to open up about anything,” Caroline said, turning to her mom. “I felt like you were never ever going to forgive me, because I was a junkie.”

She takes a breath. “But when they started treating me with compassion, trying to understand what I was going through. . .” She paused again, and then turned to Susan. “I feel like you’re the best-prepared person for me to talk to about my addiction. You’ve been here, seeing what I’ve been through, and you’ve learned how to communicate with me. It’s such a help,” Caroline said. “Thank God you care about me enough. That you had the time to do that.”

Burt Helm is a freelance writer living in New York City.

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