Beyond Addiction INTRODUCTION Hope in Hell To accept the things you cannot change . to change the things you can . to know the difference. -Adapted from the AA motto This book is different. You may have picked up this book in desperation, you may be afraid nothing will help, but we are optimistic we can change that. Maybe your husband''s drinking increased after the kids went to college and you worry it''s only going to get worse. Maybe your grown son doesn''t return calls anymore, seems uninterested in working, and smokes a lot of pot. Maybe your daughter has stopped eating, or maybe she can''t seem to stop.

Maybe your elderly mom sounds slurry every time you call her in the evening, but never remembers it the next day. Maybe your brother is back in treatment, again, for methamphetamine abuse. Substance and compulsive behavior problemsIcan take endless shapes and vary in terms of severity, scariness, and heartbreak. Families come to our program every day with these and many other serious problems. Still we are optimistic. We don''t mean that maybe you''ll be lucky or that it''s no big deal. We are optimistic because we know change is possible. If your own optimism has gotten shaky in recent months or years, we invite you to borrow ours for now.

Take this book like a steadying hand. And know that you can make a difference. As researchers and clinicians, we''ve seen the evidence over the past forty years that families and friends make a difference in helping someone who struggles with drinking, drugs, eating, or other compulsive behaviors. Often, it is the critical difference. We also know that people get better, and there are many reasons to be hopeful. However, you''re probably more familiar with the popular notions of intractable character defects and progressive, chronic disease. There''s widespread pessimism about the possibility of real change. Addiction can be terrible-at times life-threatening.

But change is possible, and there are clear paths leading to it. This is why, ten years ago, we created a new treatment program, the Center for Motivation and Change (CMC), in New York City, where we are part of a revolution in addiction treatment based on evidence and on a new model for change. We built our practice on optimism, not because it made us feel good, though it does, but because it works. We base our optimism, our clinical practice, and now this book on forty years of well-documented research on how substances and other compulsive behaviors affect people, why people use them, and how and why people stop self-destructive behavior and start on paths toward health and happiness. In turn, our experiences with thousands of clients bear out the research findings. There is in fact a science of change. Every day at CMC we see clients put it into practice, using the knowledge, attitudes, and skills you''ll find in this book. It takes time, and it is not usually a straight or smooth path.

But it is a better way. Things can and do change. The process already started when you picked up this book. The Science of Change It''s been five hundred years since the scientific revolution, and we''ve had modern medicine for at least a century. Yet shockingly, the understanding and treatment of substance use in the United States has been exempt from scientific standards and separate from mainstream healthcare until quite recently. Researchers in America only began to collect evidence in earnest in the 1970s. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) was established in 1970, followed by the National Institute on Drug Abuse (NIDA) in 1974. Finally, after years of folk wisdom running the gamut from truly helpful to ineffective to harmful, federal money flowed toward scientific studies of what works, including what family and friends like you can do to help.

The increasing number of controlled studies, including our own, over these forty-odd years, has created a mountain of evidence-scientists have separated the wheat from the chaff, revealing that certain approaches and treatment strategies are more successful than others. That''s good news, and we hope that it will help you find your own optimism. Most people equate treatment with intensive, residential "rehab" and believe rehab is the starting point of all change. In fact, there are many treatment options and substantial evidence that outpatient treatment is at least as effective in most cases and often a better place to start. Since 1996, the American Society of Addiction Medicine recommends starting with the least intensive treatment that is safe. Dr. Mark Willenbring, former director of the Treatment and Recovery Research Division of NIAAA, describes how the vast majority of people who could benefit from help don''t get it, in part because the system is designed to treat the most severe problems, while the culture dictates waiting until someone "hits bottom"-in other words, waiting until problems become severe. Family members and friends are left with few options other than to stand by and watch things get worse, then get their loved one into rehab if they can.

This despite strong evidence that reaching people early, when their problems are less severe and more treatable, leads to better outcomes. Thankfully, the treatment system is starting to change. The evidence supports many ways to address substance use disorders, as many ways as there are reasons people have them. Treatment is not always necessary; it turns out that many people get better without ever seeking professional help. There is also clear evidence that certain treatment approaches consistently outperform others. Cognitive-behavioral and motivational approaches, for example, which treat substance abuse like any other human behavior, are significantly more effective than confrontational approaches aimed to challenge a person''s "denial" about his "disease." Research has demonstrated that the popular belief that if someone "just stops" using a substance, then the rest of his problems will take care of themselves is simplistic and untrue. Substance problems are complex and multidetermined, often driven by underlying psychiatric disorders such as depression, anxiety, bipolar disorder, or attention deficit disorders that require specialized attention over and beyond just treating the substance problem.

In other words, good treatment often includes psychiatric care, which has historically been overlooked or even discouraged in some drug and alcohol treatment settings. Science has also given us a better understanding of the brain''s role in substance use and compulsive behaviors. With that science, there are new medications that reduce cravings and compulsivity, block drug effects, ease withdrawal, and treat underlying issues. Neuroimaging research provides new insights into the effects of substances on the brain; and recent discoveries in neuroscience have shown the power of neuroplasticity in the brain''s healing itself. And science has revealed that teenagers are not simply grown-ups who text a lot; they are neurologically, psychologically, socially, and legally different from adults, and they have different treatment needs. Until about fifteen years ago, most of the services available for adolescents were barely modified adult treatments. Clinical trials have shown us that teenagers respond well to appropriate treatment and just as with adults, some treatments are considerably more effective than others. You might be surprised to learn that they all involve parents as active treatment participants (and often siblings, peers, and school systems).

II Finally, research has shown how you can play a role in change. Our work with families and friends of people with substance problems is informed by CRAFT-Community Reinforcement and Family Training-a scientifically supported, evidence-based, clinically proven approach to helping families of substance abusers. CRAFT grew out of treatment innovations that began in the 1970s. A group of researchers in Illinois, led by behavioral psychologist Nathan Azrin, developed what is still the most effective behavioral treatment for substance users, and called it the Community Reinforcement Approach, or CRA. In the process, they discovered that family involvement was a crucial factor in successful change. Robert J. Meyers, PhD (one of the original Illinois group), expanded the CRA approach to work with families when their loved one refused help, and called it CRAFT. After moving to the Center on Alcoholism, Substance Abuse and Addictions (CASAA) at the University of New Mexico, Dr.

Meyers conducted further research and clinical trials (teaming with Jane Ellen Smith, PhD), and they and others investigating CRAFT have given us robust evidence that given the right tools,.