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The Cost of Sobriety

Interventions are not the only, or the best, way bring an end to addiction.

My advice column, Unconventional Wisdom by Hara Estroff Marano, in the November/December 2012 issue of Psychology Today, has generated considerable interest and commentary, both pro and con. Because it is on a subject of importance to many, it is being reprinted here, so that it may be widely available.

A FRIEND OF 30 YEARS recently celebrated one year of not drinking. She was a "functional alcoholic". Every night, she drank at home by herself to the point of intoxication, but managed to hold down a job and pay her bills. She finally got into a rehab program after her family staged an intervention. Even though she says she doesn't want to drink anymore, she frequently voices anger at her family and, more indirectly, at me for confronting her about her drinking in the past. I was not part of the intervention, but I did tell her at times that I was worried about her drinking. It seems to me that a person who's really sincere about staying sober would be grateful to the people who cared enough about her to encourage her to get some help. She is not involved in any aftercare or AA meetings, and I really don't understand her continued anger toward her family and me.

CONFRONTATIONAL GANG-UPS are not the way most people like their encouragement served. Real encouragement reinforces what is best in a person, not shoves her nose in what is worst.

Your friend perceived the intervention—but not its goal—as negative and dehumanizing, and considerable evidence supports her view. A look at the psychological realities of interventions clearly suggests why any self-respecting person might experience lingering anger over being force-fed unasked-for advice.

How might you react if a bunch of people cornered you and insisted that you are unacceptable as you are, defective in some profound ways, blind about yourself, and everybody else in the room is more enlightened than you are about yourself? Most interventions proceed by labeling someone an addict or alcoholic; to sum up a person's being in one pejorative label not only diminishes the whole of a life but makes the problem behavior feel eternal and inescapable.

Confrontational methods are practiced nowhere else in the world—for good reason. Interventions are deeply humiliating. They imply a moral and psychological superiority among those staging the intervention. They remove a person's autonomy, and removing the opportunity for choice is thoroughly dehumanizing. They deflate a person's already deflated sense of self. Further, interventions also induce shame, guilt—feelings that actually reduce the likelihood of change.

In 2007, psychologist William Miller and consultant William White reported that "decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects." Those harmful effects? Interventions actually increase dropout rates from treatment programs and precipitate more and faster relapse.

Interventions generally rest on a series of mistaken beliefs about drinking and about how people change. One mistaken assumption is that a person would never stop drinking on her own, most likely because of a pathological personality—when, in fact, government data show that three quarters of alcoholics recover without professional help. Another mistaken assumption is that drinkers are always defensive about their problem, so that gentler methods of approach would never work. Interventions rest on mistaken assumptions that everyone knows better than the drinker what she is doing—in fact, there is the assumption that the drinker is out of touch with reality and deluded about the nature of her "problem." The implication that others are authorities on the drinker and on drinking compounds the humiliation of this method.

Research clearly points to a better approach that evokes and beefs up a person's own motivation for change. Motivational interviewing is one such approach. it's gentler, more empathic—more in keeping with established knowledge about how people change.

Your expectations about gratitude are misplaced. Your friend has demonstrated her sincerity about being sober by stopping drinking—the only measure that matters. Further, despite the shame and humiliation to which she was subjected, she may be feel grateful about not drinking in her own, silent way.

AA is hardly the benchmark of being "sincere about staying sober." It might be the best-known program, but failure rates are high. Nor do many people feel comfortable subscribing to powerlessness, a foundational tenet of AA. Further, AA views drinking as a lifelong disease, a concept not endorsed scientifically. In fact, people always have the power to change.

One of the elements that makes friendship so rewarding is the equality of the relationship. Anything that unbalances that equality is bound to have lingering effects on the relationship. Caring about a friend can be expressed in many ways, including research about the best approach to a person who drinks too much. Offering unsolicited advice is dicey under the best of circumstances. Caring might have been better demonstrated through methods of approach that maintain a person's dignity and sense of choice. Humiliation never communicates caring.

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