A Controversial New Way To Think About Addiction | Carrie Wilkens
Dr. Carrie Wilkens, Co-founder, Co-president and CEO of the Center for Motivation and Change: Foundation for Change, discusses the pervasive stigma around substance use disorder, exploring alternatives to abstinence and the crucial role of meditation in recovery. She advocates for compassionate, evidence-based approaches like CRAFT for loved ones and encourages individual assessment of one's relationship with substances.
Deep Dive Analysis
16 Topic Outline
Current State of Addiction and Overdose in the US
Stigma and Language Around Substance Use Problems
Defining Substance Use Disorder and its Brain Impact
Abstinence vs. Alternatives in Substance Use Recovery
Assessing a Healthy Relationship with Substances
Personal Journeys and Natural Recovery from Substance Use
Nuance in Substance Use and Harm Reduction
Role of Mindfulness and Self-Compassion in Recovery
Understanding Motivation for Behavior Change
Motivational Interviewing for Loved Ones
Myth-Busting: Interventions, Tough Love, and Rock Bottom
CRAFT: An Effective Strategy for Family Members
Importance of Self-Care for Supporting Loved Ones
Positive Communication Strategies for Families
Reinforcement and Consequences in Behavior Change
Why Change is Often a Slow Process
5 Key Concepts
Substance Use Disorder
This is the formal medical term, preferred over 'addiction' to reduce stigma and encourage open conversation. It is diagnosed based on 11 symptoms, with 2-3 indicating mild, 4-5 moderate, and 6+ severe problems. Individuals can cycle in and out of problematic use and may shift substances or behaviors.
Motivational Interviewing
A communication strategy designed to help people explore and resolve ambivalence about change by activating their internal motivations. It involves creating a safe, non-judgmental environment, asking open-ended questions, and reflecting back what the person has said to strengthen their own insights and desire for change.
Harm Reduction
An approach in the treatment field that acknowledges the need to meet people where they are, working with varying levels of motivation to change. It allows individuals to address specific problematic substance use while potentially maintaining a relationship with other substances, rather than demanding complete abstinence from everything.
CRAFT (Community Reinforcement and Family Training)
An evidence-based strategy for family members of loved ones with significant substance use problems who are resistant to treatment. It teaches families how to reinforce positive changes, allow natural consequences to occur, use effective communication strategies, and prioritize their own self-care.
Natural Consequences
These are the direct, unmanipulated outcomes of a person's substance use choices. Allowing these consequences to play out (e.g., not shielding someone from the repercussions of missing work due to drinking) can increase the individual's motivation to change by making them realize the behavior is not working for them.
10 Questions Answered
The numbers are dire, with one in 10 Americans struggling with a significant substance use disorder. Over 100,000 people die of overdose annually, and it has become the single biggest cause of death for teens and young adults, surpassing suicide.
Stigma arises because people perceive those with substance use issues as 'out of control,' 'scary,' or 'destructive,' leading to anger and a desire to push them away. The use of stigmatizing labels like 'junkie,' 'addict,' or 'alcoholic' further dehumanizes individuals and shuts down open conversation, making it harder to understand and help.
Substance use disorder is a medical condition diagnosed based on 11 symptoms. Having 2-3 symptoms indicates a mild disorder, 4-5 a moderate disorder, and 6 or more a severe problem. The term is preferred over 'addiction' to be more inclusive and less stigmatizing.
For many people, there are alternatives to abstinence, and individuals often try different approaches before committing to full abstinence. People can cycle in and out of problematic use, and a substantial percentage naturally recover without formal treatment, often by finding alternative strategies or dealing with underlying issues.
Mindfulness helps individuals stay in the present moment, reducing rumination about past mistakes or anxiety about the future, which is crucial for facing the challenges of behavior change. Self-compassion helps individuals be kind to themselves during setbacks, preventing the inner critic from paralyzing them with shame and encouraging persistence in the learning process.
People are motivated to change when the costs of substance use outweigh the benefits, and they have personal reasons that tip them towards change. This often involves wrestling with ambivalence and identifying environmental factors, emotions, or thoughts that pull them back to old behaviors, which then need to be addressed or shifted.
Common myths include the belief that people must 'hit rock bottom' to change (which is cruel and can be fatal), that interventions are always effective (they have high dropout rates and can fracture family relationships), that 'tough love' is a clear strategy (it's often confusing and creates friction), and that any understanding or support is 'enabling' (which discourages connection, a vital resource).
The most effective strategy is CRAFT (Community Reinforcement and Family Training), which teaches family members how to reinforce positive changes, allow natural consequences to play a role, use communication strategies that lower defensiveness, and prioritize their own self-care. Studies show it gets loved ones into treatment 60-70% of the time, improving both the loved one's substance use and the family member's mental health.
Caring for someone with a substance use problem is incredibly stressful, maddening, and confusing, leading to burnout. Prioritizing self-care (like managing stress and ensuring sleep) allows family members to stay regulated, use communication skills effectively, and remain an effective helper rather than being overwhelmed by their own emotions.
Change is slow because it requires a lot of new learning, especially in regulating emotions, changing relationships, and establishing new social connections, which takes time and trial-and-error. The brain and body are affected by substances, leading to cravings and discomfort that must be tolerated and coped with, rather than avoided, in a society that often seeks quick fixes.
32 Actionable Insights
1. Honestly Assess Consequences & Values
Regularly and honestly evaluate the personal consequences of your substance use and determine if your actions align with your values and the person you want to be.
2. Be Curious About Substance Use
Pause and be curious about how substance use makes sense for you, understanding what draws you to it so you can explore alternative ways to meet those underlying needs.
3. Identify Benefits & Alternative Skills
List the perceived benefits you gain from substance use, then learn and develop different skills to achieve those same positive effects without relying on the substance.
4. Develop Emotional Regulation Skills
Learn and practice alternative ways to deal with your emotions and thoughts, rather than using substances as a primary coping mechanism.
5. Practice Mindfulness & Self-Compassion
Develop mindfulness strategies to stay in the present moment and practice self-compassion to manage emotions and thoughts, which can reduce the desire for substances and aid in learning.
6. Practice Self-Compassion During Setbacks
When experiencing a slip or setback in behavior change, respond with kindness and understanding towards yourself instead of self-criticism, which helps you stay on the path of learning and persistence.
7. Lean into Discomfort (ACT)
Utilize Acceptance and Commitment Therapy (ACT) principles to learn how to relate to pain and discomfort differently, understanding that leaning into these feelings is necessary to achieve your end goals.
8. Address Avoidance with Discomfort Tolerance
Recognize that substance use often serves as avoidance; when removing the substance, actively learn to lean into, cope with, tolerate, and move through the discomfort it previously masked.
9. Embrace Slow, Incremental Change
Understand that significant behavior change is an incredibly slow process that requires extensive new learning, patience, and tolerance for trial and error.
10. Recognize New Learning Requirements
Understand that giving up substances necessitates learning new skills, such as how to socialize or deal with feelings, which takes considerable time, practice, and acceptance of setbacks.
11. Modify Your Environment
Actively identify and change aspects of your environment that contribute to old behaviors, such as temporarily distancing yourself from certain friends or situations that trigger substance use.
12. Cultivate Sober Relationships
Invest in and experience relationships and social interactions without relying on substances, recognizing that camaraderie and connection can be achieved without them.
13. Run Personal Substance Experiments
Experiment with substances to understand their effects on you personally, helping you determine if they are truly beneficial or if they are not working well for you.
14. Utilize CRAFT Strategies
Learn and apply Community Reinforcement and Family Training (CRAFT) strategies, an evidence-based approach designed to help family members positively influence loved ones who are resistant to treatment.
15. Prioritize Self-Care as a Helper
Engage in self-care to manage the immense stress of caring for someone with a substance use problem, ensuring you remain emotionally regulated and effective in your support.
16. Allow Natural Consequences to Play Out
Let the direct, natural consequences of a loved one’s substance use choices occur, as experiencing these can activate their motivation for change.
17. Maintain Connection with CRAFT
Use CRAFT strategies to stay connected with a loved one struggling with substance use, as positive relationships compete with substance use, while doing so effectively without inadvertently supporting the use.
18. Approach with Compassion & Curiosity
Engage in conversations about substance use with compassion, understanding, and curiosity, rather than judgment, to foster open dialogue and exploration.
19. Practice Motivational Interviewing
Create a safe and comfortable environment for open conversation by approaching without a personal agenda, allowing the other person to express their thoughts and feelings freely.
20. Ask Open-Ended Questions
Engage in conversations using ‘how,’ ‘what,’ and ‘why’ questions to encourage deeper sharing and understanding, rather than yes/no or agenda-driven questions.
21. Frame Requests Positively
Phrase requests in terms of what you do want (e.g., ‘I’d love it if you came home sober’) rather than what you don’t want, to shift the conversation’s tenor and improve relationships.
22. Use Permission-Based Requests
When making requests, first ask permission to share your idea, respect a ’no,’ and follow up with reflection and validation to ensure understanding and maintain connection.
23. Validate & Reinforce Positive Changes
Actively validate emotions and notice and reinforce any positive changes or efforts made by the individual, no matter how small, to encourage further growth.
24. Reinforce Alternative Behaviors
Provide practical support (e.g., gym membership, app access, childcare, treatment payment) to reinforce and facilitate engagement in alternative, healthier behaviors.
25. Set Limits on Undesired Behaviors
Strategically set limits and withhold support for behaviors you want to discourage (e.g., not providing cash that could be used for substances), while still offering support for other positive areas.
26. Time Difficult Conversations Strategically
Express anger or concerns when you are regulated and the loved one is not high or crashing, choosing a time when you can handle the conversation effectively and minimize negative outcomes.
27. Reject “Hit Rock Bottom” Myth
Discard the belief that a loved one must ‘hit rock bottom’ to change, as this notion is cruel, untrue, and can have fatal consequences, especially with opioids.
28. Eliminate Stigmatizing Labels
Avoid using labels like ‘junkie,’ ‘addict,’ or ‘alcoholic’ unless the individual self-identifies with them, as these terms can be judgmental and push people away from help.
29. Understand Behavior Makes Sense
Recognize that a loved one’s substance use behavior, even if problematic, makes sense to them in some way (e.g., self-medicating underlying issues), and be curious about these reasons.
30. Investigate Underlying Mental Health Issues
Be curious and seek to understand any underlying mental health issues that might be contributing to a loved one’s substance use, as these are often worth exploring.
31. Talk Openly for Support
Overcome the shame and judgment around discussing a loved one’s substance use by talking openly with trusted individuals to gain support and brainstorm solutions for yourself.
32. Interfere with Dangerous Consequences
Actively intervene to prevent dangerous natural consequences, such as a loved one drinking and driving, as some risks are too high to allow to play out.
5 Key Quotes
Overdose has become the single biggest cause of death in teens and young adults. It surpassed suicide.
Carrie Wilkins
People don't want to talk about it, and families don't want to talk about it. And I think there was enough activation around the opioid crisis from white people and people with privilege that the conversation got into the media in a completely different way than it has in other epidemics.
Carrie Wilkins
I've never met anybody who just said, you know what, I want to abstain. There's a lot of learning that got them to that point where they were like, this just is not working for me.
Carrie Wilkins
people get to make their own bad decisions. Like that's actually just something we humans get to do, but can we create an environment where people can openly talk about it instead of going underground and feeling ashamed?
Carrie Wilkins
If you can help me eliminate people saying they got to hit rock bottom, that phrase just makes me crazy. It's cruel. It's not true. And people are really dying because that's the belief.
Carrie Wilkins
2 Protocols
CRAFT (Community Reinforcement and Family Training) for Family Members
Carrie Wilkins- Reinforce positive change and keep relationships positive to maintain connection, which competes with substance use.
- Allow natural consequences to play a role, stepping back to let the loved one experience the direct outcomes of their substance use choices.
- Utilize communication strategies that lower defensiveness, keep conversations going, and provide more information.
- Prioritize self-care to manage stress, stay regulated, and remain an effective helper throughout the process.
Positive Communication Strategies for Loved Ones
Carrie Wilkins- Ask open-ended questions (how, what, why) to encourage the person to share their thoughts and feelings.
- Frame requests positively, stating what you want instead of what you don't want (e.g., 'I'd love it if you came home sober tonight').
- Ask permission before making a request or offering an idea (e.g., 'Are you open to hearing about it?').
- Use reflection and validation to show understanding of their emotions and experiences, strengthening their own insights.
- Notice and reinforce positive behaviors, even small ones, to encourage their growth and motivate further change.