Do Drug and Alcohol Interventions Really Work?
By Kate Jackson
Social Work Today
Vol. 5, No. 1, Page 28

When an alcoholic or other substance abuser is spiraling downward, cutting a path of destruction in every direction, marring loved ones’ lives, burning bridges, and headed for certain demise, what’s a family to do? There’s little doubt that loved ones have struggled with this issue since history’s first instance of substance abuse, yet few overwhelmingly effective solutions have emerged. In the early 1960s, an idea gathered steam and took hold—that loved ones could intervene. It’s a concept that’s led, say various experts, to recovery, tragedy, or some point between, depending on their individual points of view.

Rev Vernon Johnson, a recovering alcoholic, organized a church study group in 1962 in Minneapolis to explore ways to encourage alcoholics to accept assistance before the disease wrought havoc on their lives. The group concluded that alcoholics are blinded by denial—an obstacle to recognition of the problem and thus to early treatment. The group’s work to hurdle that barrier led to the concept of the intervention and its first application. Four years later, the Johnson Institute was created to teach the intervention process and devise treatment programs.

In an intervention, as described on the Web site of the Johnson Institute, “the alcoholic’s spouse, children, friends, clergy, and employer come together to give him/her a ‘reality check.’ The hard truth, reiterated by every participant, becomes undeniable. At the same time, the alcoholic can glimpse a positive alternative to continuing physical, emotional, and spiritual pain and isolation.” The procedure was outlined in Johnson’s 1973 book I’ll Quit Tomorrow, revised in 1990, and in Intervention, published in 1986.

By 1991, the institute had trained more than 8,000 professionals. Although it still directs its efforts toward what it views as barriers to treatment, the Johnson Institute no longer trains interventionists. The work of the institute, however, standardized the notion that alcoholics and substance abusers must typically hit rock bottom before being willing or able to accept help, and the intervention took hold as the solution to that paralyzing stalemate.

Over the years and continuing today, interventions might be instigated by friends, clergy, family members, the military, and even coworkers. And the reasons for interventions have also expanded to include any behavior that may be viewed as destructive, such as eating disorders or gambling addictions. Other models have developed over the years, but the Johnson model set the standard. Typically, a family works with a professional trained in intervention to confront the person whose behavior they wish to change. The family lays down the terms the person must abide by—generally involving participation in a treatment program—as well as the consequences they will insist on if those terms are not agreed to and carried out. Most commonly, the method of treatment is decided in advance and arranged by the interveners.

Over time, various styles and models of interventions have grown from this basic premise, and these interventions have come to be viewed by some as an effective and loving way to give a leg up to those disinclined to help themselves and by others as something of a well-intentioned but ultimately damaging intrusion. Consider the points of view of four professionals in the field: two interventionists and two social workers.

Leslie Koralek, PhD
A firm believer in interventions, Leslie Koralek, PhD, a therapist in private practice, approaches them from a slightly different perspective than his predecessors, seeing the procedure of greater benefit to the family and friends than to the substance abuser. Loved ones, he suggests, are often entangled in enabling behavior and fear anger or reprisals if they attempt to persuade the abuser to get help. “I try to teach families not to ask what they need to do so that the person will get help, which is really unanswerable, but to ask themselves what they need to say to the person so that they can go to bed proud of what they’ve said,” he explains. He describes an intervention as a caring way to point a loved one’s negative or destructive behavior and communicate what actions you’re willing to support and those that you are not willing to support.

Koralek, himself in recovery, agrees that a substance abuser generally needs to hit rock bottom before being able to seek help and sees interventions as a means to prevent the fall. “It’s a way for family and friends to say, ‘Listen, we care about you, and because we want you to get better, we’re no longer willing to look the other way.’”

The process, Koralek explains, is intended to set boundaries and delineate consequences in a positive, loving way. One thing that’s not negotiable, however, is the substance abuser’s acceptance of the interveners’ prescription for treatment. “The goal is not to tell the people that they need help but rather that they need the help that’s been arranged for them.” Social workers, he says, can be invaluable in this process because they are well aware of available resources and highly skilled at discussing options with family members.

Using a three-session model, Koralek, formerly clinical director of Springbrook Institute in Newberg, OR, where he developed and operated a 47-bed treatment center focused on the treatment of physicians with addictions, uses the first session to meet with the concerned people to talk about addiction, explain the intervention process, and discuss the range of treatment options. After getting a commitment to proceed if the family feels comfortable with moving forward, Koralek instructs each participant to write a letter to the person for whom the intervention is being planned explaining why they’re intervening, what they’ll do if the person gets the help they’ve arranged, and what they’ll do (or not do) if the help is rejected. “It’s very important that those letters contain only ‘I’ statements so that when the substance abuser says, ‘You’re telling me what to do,’ my response is, ‘No, we’re telling you what we’ll do.’”

At the second session, the letters are reviewed and the logistics of the proposed treatment are discussed. The intervention itself, which takes place at the third meeting, takes roughly 15 minutes, says Koralek, because it’s not a negotiation—merely a discussion. He has the subject join the group and listens to the interveners read their letters. He then explains the treatment program that’s been arranged and asks for a commitment. “Part of my role at the intervention is to deflect their objections. When they say, ‘I can quit on my own,’ I say, ‘Maybe you can, but you need to go to treatment.’ When they say, ‘You’re overreacting,’ I say, ‘Maybe we are, but you need to go to treatment.’” It’s not unusual, he says, for the individuals to reject the help because they’re angry and hurt, but they often return one week later when they discover that the family actually plans to carry out the consequences described in the letters. Whether or not the person consents to treatment, Koralek considers the intervention a success if the loved ones who intervened can feel that they did a loving thing and can then go about reconstructing their family.

Bruce Cotter
A graduate of the Johnson Institute, interventionist Bruce Cotter has broken from tradition and developed his own model of intervention. He started out the usual way, he says, because he didn’t know any better. He did what he was taught and told to do, gathering groups of concerned people to confront an impaired loved one. They wrote and read letters and stated their terms, and the impaired person most often capitulated and went off to the selected treatment.

Cotter, author of When They Won’t Quit: A Call to Action for Families, Friends and Employers of Alcohol and Drug-Addicted People, a primer on interventions, became increasingly aware that although the people went to treatment, they did so only to get their friends and family off their backs, and the process made them extremely angry. This anger, he says, impeded their progress and stood in the way of their ability to process treatment. “They were furious, and many of them would just put in their time or leave in five days or a week. They felt verbally bludgeoned because it’s a humiliating and embarrassing kind of confrontation.” The whole process, he says, only exacerbated the pain of people already in bad shape.

Circumstances forced Cotter to intervene alone with one client, and the success convinced him to change his approach to a one-on-one intervention. Now, he says, those intervened upon are far less angry, tend to stay in treatment, and do far better than those who participate in the more traditional sort of intervention. Treatment for Cotter, as for Koralek, is not negotiable.

However, Cotter says, “I firmly believe, to encourage others to wait until a person ‘hits rock bottom’ is totally and dangerously irresponsible and will serve to keep morticians busy and cemeteries full. When people tell me they want to wait until the person ‘hits rock bottom’ before they step forward to offer help, which they do daily, I simply tell them when a person hits bottom, one of two things will happen: They will either bounce or go splat. Then I ask, ‘Why wait to find out which it will be?’

“There really aren’t many choices because by the time they call me in, the person is in a very late stage and usually needs inpatient treatment badly,” says Cotter. He makes them feel that the choice is theirs, however. His goal when he sits down with someone is for it to become their idea to want to do something about the problem. “No one likes to be told what to do, deep down, least of all alcoholics or drug abusers. So I have to make it their idea.” His version of an intervention, he insists, is a conversation, not a confrontation, because he wants to engage them in the process. “I want them to start telling me things, and when they do, they’ll eventually come around to seeing that the prudent thing to do is to get some help and go to treatment.”

A recovering alcoholic, Cotter believes he understands the needs as well as the denial behaviors of his subjects, and by sharing his experience, he’s convinced that he can make a connection based on mutual understanding. “They’ll talk to me differently than they will to their spouse, child, boss, brother, clergyman, or physician,” he explains. “They can open up with me because I’ve ‘been there, done that.’ I know what they’re feeling.” This knowing, empathetic ear, he suggests, helps him build a bridge for the client that will illustrate the damage they so vociferously deny. They’ve got their life problems on one side and their drinking on the other. Good, solid treatment, he says, lets them see that connection between the two.

Interventions are essential, he insists, because the substance abusers are unable to recognize that they have a problem, despite the depth of their suffering. “Addiction is an incredible thief,” says Cotter. “It steals your money, your home, your job, your self-esteem. The addicted are people with great self-loathing who are 99.9% suicidal, if not by the act of actually picking up a weapon, then to the extent that they’re drinking themselves to death. They’re living on the edge, and they don’t really mind a hell of a lot. That’s when I’ve got to bring them back from that brink.” He’s convinced, however, that the majority of interventions—those that are confrontational—merely degenerate into family arguments and end poorly. The impaired, he says, are already sick, and in a typical intervention, they’re verbally beat up.
Speaking as a former substance abuser, Cotter says, “We don’t need to hear that. Our self-esteem, our pride, confidence, and ego are shattered, and then the people that are most important in our lives come and tell us that we’re even worse than we thought we were. It’s fraught with negatives.” His method, he insists, is full of positives. “I come around and sit on the same side of the desk, so it’s the two of us addressing this problem. Now they’re not doing it alone. It’s always we: ‘We can get this thing done.’”

Shulamith LaLa Ashenberg Straussner, MSW, DSW
A professor at New York University School of Social Work, Shulamith Lala Ashenberg Straussner, MSW, DSW, who runs the Post-Master’s Program in the Treatment of Alcohol and Drug Abusing Clients and is the founding editor of the Journal of Social Work Practice in the Addictions, claims to be neither a supporter nor an adamant critic of interventions. She concedes that interventions work for some people but believes that the traditional model of the Johnson Institute is less used these days because the outcomes have not been as promising as once believed. She acknowledges that there have been some great success stories but suggests that interventions often lead to a conflict in the family. She points out that when the first edition of her book Clinical Work with Substance-Abusing Clients was published 10 years ago, there was an entire chapter on intervention. The new edition, just out, has only a small section on the practice, reflecting her view of its fall from favor.

Interventions, Straussner indicates, were initially carried out with typically high-functioning individuals—people with jobs and very involved families who were quite capable of carrying out the consequences. It’s not successful, she says, for people who no longer have involved families or who are less able to function. In addition, she says, we live in a society with a less punitive perspective, so the notion of this “either or” approach—either one does what the family wants or one suffers the consequences—is less tenable.

There’s far more focus now, Straussner explains, on motivational interviewing—trying to motivate people to change as opposed to controlling them and forcing them to change. She doesn’t quarrel with a family’s desire to intervene but cautions that less recrimination and more choices would better serve substance abusers and their families. “It’s a field in which there are no easy solutions because if you don’t do anything, the person will get worse,” Straussner cautions, “and if you try to do something and it doesn’t work out, that’s going to result in tragedy too.” She advises social workers and other professionals to seek specialized training before considering participating in interventions and to be mindful that there’s more potential for harm than good when an intervention is performed by someone without adequate skills.

G. Alan Marlatt, PhD
Less equivocal about interventions is G. Alan Marlatt, PhD, professor and director of the Addictive Behaviors Research Center at the University of Washington, department of psychology. To illustrate his views, he points to the tragic death of musician Kurt Cobain, which came on the heels of an intervention arranged by his wife, Courtney Love, and the members of his band, Nirvana, in Seattle. Cobain came home one day, explains Marlatt, to find everyone there, insisting that he immediately enter a treatment center in Los Angeles to deal with his heroin dependency. A company executive that produced the band’s work told Marlatt that Cobain, who claimed to use opiates to control severe stomach pain, repeatedly asked his wife and fellow musicians to meet him halfway—to work with him rather than thrust him into total abstinence. They refused to listen and instead threatened to withdraw their social support. “They put him on a plane and flew him to the abstinence-only center, from which he later checked out against medical advice. He flew back home to Seattle and killed himself.” It’s an extreme example, says Marlatt, but it demonstrates how easily this direct approach backfires, at a minimum leading to guilt, shame, helplessness, and feelings of being stigmatized.

Adamant in his belief that interventions shouldn’t be performed under any circumstances, Marlatt, like Straussner, points to the more promising movement toward motivational interviewing, which meets people where they are—an approach he insists is more effective than confronting and punishing individuals. He points to research demonstrating that confrontational tactics increase resistance and denial, making people more defensive and less willing to discuss what the interveners have in mind.

Marlatt makes a case for harm-reduction approaches that don’t seek to take away a person’s coping strategies until other skills and strategies are in place. Choice works, he insists, and research supports that notion. In motivational interviewing and other nonconfrontational approaches, a wide range of options are offered and the person who needs help is given choices. “Once you have the person on board and involved and you have a good continued care program, things will happen in a good way,” maintains Marlatt. “But if you say, ‘Do this or else,’ you take away a person’s choice and the consequences are negative.”

— Kate Jackson is a staff writer for Social Work Today.