Previously published with permission by © Robert J. Chapman, PhD, guest blogger for Jeremy Frank Associates
Interventions and Their Role in Addiction Treatment
Addictions treatment has come a long way since Vern Johnson (1973) published his classic, I’ll Quit Tomorrow. In that tome, chapter 5 “The Dynamics of Intervention,” to be precise, he outlines how to conduct what he refers to as an intervention. His thoughts on facilitating change—and this is admittedly a brief, almost passing overview—was that someone with alcoholism did not usually “quit” as the result of a single, large, life-threatening event. Rather, it is numerous smaller confrontations or “untoward consequences” resulting from continued use, often involving family and significant others that result in reaching a point where it becomes clear that, paraphrasing Fr. Joseph Martin (1989), what causes a problem is a problem when it causes problems.
Is a Rose by any Other Name Still a Rose?:A 21-Century Look at the Utility of Interventions in Addictions Treatment
Johnson advocated conducting interventions were family and significant others would gather, unbeknownst to the addicted individual, to present their concerns about the individual’s use behavior, albeit in a supportive and caring way, and then ask that the addicted love one go to treatment. Proposing what could be characterized as a “carefrontation,” chapter 5 suggests preparing these interveners to read, from prepared letters, their concerns for the addicted individual as well as the consequences if he or she was unwilling to pursue sobriety. Unfortunately, such interventions were as likely to end in a cursory commitment to change or, worse, anger and resentment depending on where on the continuum of readiness to change the addicted individual might be at the time of the intervention. However, the purpose of this essay is not to critique Johnson’s approach to conducting family interventions; it is to focus the discussion on a different question — are practitioner-facilitated interventions with individuals or families, consistent with contemporary best practices in the treatment of substance-use disorders?
Turning to the popular culture, cable TV programs such as Intervention and Celebrity Rehab with Dr. Drew further shape our understanding of interventions, suggesting they are appropriate arrows for the practitioner’s treatment quiver. Such programs provide a skewed view of addictions and how best to approach those who have a substance use disorders (SUD). Unfortunately, with audience ratings an issue of primacy for the channel hosting these programs, when intervening with someone in a pre-contemplative stage of readiness to change, there will be ample drama and tension generated by these programs to hold audience interest. Unfortunately, viewers come away believing that addiction treatment is a one-size-fits-all proposition, but interventions are not the panacea of effective addictions treatment and they are not exemplary of best practices in the 21st-Century, especially in one-on-one and group counseling.
The study of addiction and addictive disorders, addictionology, has come a long way in last 50 years. A traditional view of addiction characterized it is a disease of denial. To gain any traction in its treatment, one had to first “break through” that denial in order to affect any meaningful progress towards recovery. It is this belief that prompts interventions, either through a formally orchestrated and professionally facilitated family interaction with an addicted person or when conducted by the individual counselor in individual or group sessions. William Miller, the father of Motivational Interviewing, argues that clients perceive such interventions as attack therapy (White, 2012). Miller further submits that practitioners can either wrestle with their clients or dance with them, and submits that dancing is far more conducive to change. By dancing, motivational enhancement therapists are more focused on what is done “with” individuals when assessing and treating SUDs than they are about what we do “to” them. For this reason, it may be time to revisit the appropriateness of conducting interventions, in particular as part of individual or group counseling sessions and to a lesser degree, as a formal family intervention as proposed by Johnson (1973).
Do We Intervene or Intercede?
The point of this essay is that if addiction educators teach about interventions, this is done from a purely historical perspective and that they refrain from presenting interventions as a best practice. Instead, it is advised that educators instruct students—and that clinical supervisors advise their supervisees—to conduct “intercessions” instead. The rationale for this argument is based on the fact that “to intervene” is a more “reactive” verb and therefore consistent with—not to mention proliferates—aggressive confrontation as the means of interacting with whomever the intervention is conducted. “To intercede,” on the other hand, is more consistent with what contemporary practitioners do when employing brief motivational techniques and is therefore more of a “proactive verb,” one associated with “entreating on one’s behalf.” When practitioners “intervene,” they attempt to do something to the individual thus facilitating what Miller refers to as “wrestling.” When practitioners “intercede,” they insert themselves between the client and the SUD in order to facilitate increasing awareness on the part of the individual regarding the disorder. This facilitates movement through the stages of readiness to change, thereby resulting in more of a “dance” between the individual with a SUD and the practitioner.
By way of fleshing out the merits of this suggestion further, what follow are several points supportive of its adoption:
- To “intercede” is to act as a mediator in a dispute whereas to “intervene” is to involve oneself in a situation so as to alter, hinder, if not stop an action’s continuance. These are very different activities and suggest very different courses of action, particularly in the addictions treatment field;
- The practitioner who intercedes mediates between the individual with the SUD and the SUD itself…it is an experience indicative of enhancing self-awareness and discovery rather than a confrontation as a means of imposed awareness;
- As the professional treatment of SUDs moves farther away from its traditional confrontational style, it increasingly embraces the principles of brief motivational interventions. Evidence-informed practitioners pursue an active role of “involving oneself” in a clinical relationship with an individual or family dealing with a SUD so as to “insert themselves between the client and the SUD in order to facilitate increasing awareness on the part of the individual regarding the disorder“;
- The intent of Motivational Interviewing is to elicit from an individual personal insight that permits movement through the progressive stages of readiness to change until reaching the point of “taking action.” It is more about “drawing something unrealized out” from the individual rather than “forcing something external in”;
- “Intervention” is what physicians do when employing the medical model; this may work wonders when treating strep throat or appendicitis, but “intercession” is what practitioners do when employing the behavioral health model that facilitates movement through the stages of readiness to change;
- Intervention is about doing something TO the individual with a SUD in hopes of changing SUD-related behaviors and therefore is invasive, whereas intercession is about doing something WITH him or her in order to facilitate the same result.
To intervene is all too often an approach that prompts those with a SUD to become intractable in their denial and display what social psychologists call “reactance.” Carl Jung is purported to have once said, that which you resist, persists. Its corollary could well be, what you accept, changes. Intercessions are far more likely to yield acceptance than are interventions, and is that not the issue of primacy for the practitioner working with someone with a SUD?
Conclusion
Interventions pit practitioner against individuals with SUDs in a “tug-of-war” where for one to win, the other must lose. This is what Miller meant by referring to it as “wrestling” with a client. Intercessions pursue a more collegial—although at times nonetheless blunt—relationship, one built on mutual trust and respect; what Miller meant when suggesting “dancing” with a client. As any accomplished ballroom dance team will report, “someone leads while the other follows,” but the team does not win the competition until and unless “its members” enter a state of symbiosis. In essence, as the practitioner guides more than directs or leads in this dance, the partners, together, constitute an intercession in action. When practitioners intercede as opposed to intervene, they appeal on behalf of the individual with an SUD, essentially countering the rhetoric if not polemic historically delivered, non-stop, by none other than—and please pardon the allegory—Al K. Hall, Mary Juana, Herr O’Wynn, Toby Acco, or any of A. Diction’s other minions who continually shout in addicted individual’s ears.
References
Johnson, V. (1973). I‘ll Quit Tomorrow, New York: Harper & Row Pubs., Inc.
Martin, J (1989). Chalk Talk on Alcoholism, Harper Collins.
Miller, W. & Rollnick, S (2013). Motivational Interviewing: Helping People Change, 3rd edition, The Guildford Press.
White, W. (2012). The Psychology of Addiction Recovery: An Interview with William
- Miller, PhD. Posted at www.williamwhitepapers.com; published in abridged form in Counselor (in press).
