Changing the Focus of Substance Abuse Treatment

September 30, 2013

This is part 2 of two responses to the New York Times article about Dr. Carl Hart’s research at Columbia University.  You can read Part 1 here and the the original NY Times article here.

Some of the work of Carl Hart, an experimental psychologist at Columbia University, was described in the NY Times recently, and adds to our understanding of motivation in addiction, while challenging one of the myths of addiction.  Many people believe (and it’s often supported by treatment providers) that you can have little impact on a substance users choices, because their brain is wired to choose drugs or alcohol over anything else (“uncontrollability”, the defining characteristic of addiction for many).  The message attached to this myth is “you can’t do anything to help them until they bottom out and have no other choice to make but to change”.  In fact, Dr. Hart’s work appears to support what years of other solid research has found (again and again): if you give people access to alternative resources and behaviors, many will choose these things over substances (in Harts experimental lab work it was the finding that people chose small amounts of money over their drug of choice when given a choice). The foundation of the treatment we use at CMC is the Community Reinforcement Approach (CRA) which is an evidence based treatment (means it’s been studied and proven to be effective). The main objective of CRA is to reduce or eliminate substance use by strengthening “community”. The goal of this treatment model is to identify things (people/relationship, resources, activities) in a person’s environment that reinforce positive behavior and change, then increase attention to those variables and provide access to them.  By building up alternative reinforcers you are establishing alternatives that can compete with what the person gets from their substance use, and ultimately replace substance use as a behavior.

A family intervention based on this idea is called CRAFT, and is designed to help family members identify the ways they can strategically have a positive impact on their loved ones choices. The core point again being…you can influence a substance users choices in a positive way!   Dr. Hart’s point that many substance users choose substances because their communities are depleted and empty of resources for family engagement, employment and health and wellness…is more real than many treatment providers or politicians want to discuss. Building community (through self-help groups like AA, yoga classes, sports groups, book clubs, volunteer organizations, etc.) and family connections can have a positive impact and change the course of addiction.

Dr. Hart points out in the article that in lab studies, when we enrich the environment of lab rats, they make the choice to abstain from highly addictive drugs like cocaine, and instead engage in their environment.  He points out that this process is true for humans as well.  Both CRA and CRAFT encourage the enrichment of one’s environment, making it easier to make the decision to abstain from use.  Whether that enrichment is done on one’s own, or helped along by caring family members and friends, creating positive connections to a “community” can help to change patterns of substance abuse.

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