Carrie Wilkens, PhD: The Science of Motivating Change

Carrie Wilkens, PhD is a psychologist who is attempting to change the way we think about and address recovery and treatment—specifically by simply presenting evidence for what motivates change. After all, she is the co-president and CEO of CMC: Foundation for Change, a not-for-profit with the mission of improving the dissemination of evidence-based ideas and strategies to professionals and loved ones of persons struggling with substance use. 

As you’ll hear in this conversation—and throughout the entire series—we have not collectively been served by the mono-myth of addiction, that it’s only solved through harsh intervention and confrontation, that addicted people must hit rock-bottom, and that any involvement from concerned family and friends is inherently co-dependent or enabling.

As Dr. Wilkens explains, this simply isn’t true: In fact, evidence overwhelmingly suggests that harsh confrontation and intervention works AGAINST recovery, and that there is a very specific and meaningful role for family to play in what can often feel like a family illness.

The CMC:FFC team’s Invitation to Change approach is an accessible set of understandings and practices that empower families to remain engaged and be effective in helping their struggling loved one make positive changes. The approach has been widely used across the country and is utilized in trainings with laypeople and professionals. 

She is co-author of the award-winning book Beyond Addiction: How Science and Kindness Help People Change, a practical guide for families dealing with addiction and substance problems in a loved one based on principles of Community Reinforcement and Family Training (CRAFT), and co-author of The Beyond Addiction Workbook for Family and Friends: Evidence-Based Skills to Help a Loved-One Make Positive Change.

Dr. Wilkens is also the Co-Founder and Clinical Director of the Center for Motivation and Change, a group of clinicians serving all ages in NYC, Long Island, Washington, DC, San Diego, CA, and CMC:Berkshires, a private, inpatient/residential program for adults.

Dr. Wilkens has been a Project Director on a large federally-funded Substance Abuse and Mental Health Services Administration (SAMHSA) grant addressing the problems associated with binge drinking among college students. And she is a member of the Association for Behavioral and Cognitive Therapies and the American Association of Addiction Psychiatrists.

MORE FROM CARRIE WILKENS:

Beyond Addiction: How Science and Kindness Help People Change

The Beyond Addiction Workbook for Family & Friends

CMC: Foundation for Change

Further Listening on Pulling the Thread:

PART 1: Holly Whitaker, “Reimagining Recovery”

PART 2: Carl Erik Fisher, M.D., “Breaking the Addiction Binary”

PART 3: Maia Szalavitz, “When Abstinence-Only Approaches Fail”

ADDICTION: Anna Lembke, M.D., “Navigating an Addictive Culture”

TRAUMA: Gabor Maté, M.D., “When Stress Becomes Illness”

BINGE EATING DISORDER: Susan Burton, “Whose Pain Counts?”

TRANSCRIPT:

(Edited slightly for clarity.)

ELISE LOEHNEN: Thank you for your work. I know you co founded CMC, right? Or were you the sole founder?

CARRIE WILKINS: No, my partner, Jeff, but and I co founded 20 years ago now we are 20 years old for the outpatient and 10 years old for the rehab and about five years old for the nonprofit. So those are my three CMC children.

ELISE: So what brought you to this work?

CARRIE: Well, that's a complicated question full of unconscious and conscious reasons, I assume. I was in graduate school, you know, like, 25 years ago now, and went to a pretty traditional learn to be a psychologist graduate program. And you get your clients that you work with. And 1 of my clients that I worked with for a whole year, I had supervision with her and so these are the conscious reasons why I've gotten to this work, I was working with her in her last session with me she told me, and all the supervision had been about trauma and her avoidance and her relationship with her family and all these kinds of things. And all those were relevant. Her last session with me, she told me she was drinking two bottles of wine a day. So the whole time she was with me, she was in alcohol withdrawal. And at that time in that program, I had never been trained to ask about, evaluate, understand the impact of substances.

It just felt so horrible to me to have just not treated the most impactful thing that was happening for her. And so I just said, I'm never going to let that happen again and was on my way to internship and happened to land in a program that the postdoc was an addiction program. And so I landed there for a year and just fell in love with the work. And at that time, 25 years ago, there was a real split between psychiatry and the, what used to be called the chemical dependency programs. And, you know, if you had a mental health issue, the addiction program couldn't help you very much. They could help you stop using substances, but they couldn't really talk about or deal with the trauma. The other things that might have been driving that. And then the mental health programs would rule out people with addiction problems. They'd say you have to go get sober before you can come here. So there was this real bifurcated system that really just didn't make any sense to me.

So Jeff and I tried to change the addiction program and tried to kind of get it a little bit more sophisticated and it was just hard to change a big old hospital system. So we just decided to break off and do our own thing and prove that you could develop a program that was psychologically very sophisticated and met people where they're at, because that was the other thing that was happening 20 years ago. And it's still happening in lots of parts of the country where addiction programs have an abstinence only, you know, like that can be your only goal in order to be in treatment. And that's not where most people start. So we really wanted to be able to meet people where they are and work with people at all levels of kind of motivational readiness.

So we built CMC with that goal in mind. The unconscious reasons are I grew up in Western Kansas in the middle of nowhere where there was no treatment and have family members and people that I care about who, now that I know what it was, you know, had very severe PTSD and we're Drinking and using substances to manage what I know now were traumatic PTSD symptoms. But nobody talked about that stuff out there in the middle of nowhere. And there were no resources. So I just saw people struggle and saw how addiction impacts all of us in a variety of different ways. And so once I got into the work, I'm like, oh, like, this explains so much. Now, I understand it from a different lens, which is our nonprofits mission is to get these evidence based options further out into the world. And in particular, into the hands of family members, because they're really the ones on the ground. Providing the most support and help and they don't have evidence based strategies to be able to do that well.

ELISE: No. And what's more is we're served such a dominant single story about addiction, right? And some of these parts are true, right? Progressive, lifelong disease, you must hit bottom, abstinence is the only recourse. Not only is abstinence required, but abstinence from all substances and or potentially medications that you need, for ADHD or SSRIs or anti abuse or whatever it may be. You have to work the program and as a family member, not only do you need to work the program, but to help is enabling in some way, that it's none of your business. But you would never not drive your partner to chemotherapy. How are you not allowed to be engaged? In what comes to be a complex family disease and or this idea that like, oh, you're just codependent. It's so pervasive. Right?

CARRIE: No, thank you for laying that out so well, I mean, that stigmatizing restricted frame that people are coached and it's all well intentioned, you know, but again, it goes back to that problem where the mental health and medical system didn't want to have anything to do with people with substance use problems. So they got really split off. And so all the helping systems were, you know, built up by people with substance use problems who predominantly got better in the 12 step community because that's all that there was. You know, so they were helping people through the lens of, The way I got help, what worked for me, I'm doing my best. I'm offering you what worked for me, right? So there's nothing bad about that. I'm like, I'm trying to help you. But there was a, it's been a long road to get the science to match up with what's actually happening in treatment. And it's gotten better for people with substance use problems.

I mean, we're providing more evidence based treatments, you know, more and more programs are offering that, you know, you still have to scratch it and really ask like how are those treatment providers supervised and how are they trained because a lot of people now know what they need to say in order to market their programs as being more sophisticated. But if you really scratch in there, they're still doing pretty old school stuff. So it's important to be an educated consumer and know what you're asking about, but what's provided for families is like even more in the dark ages. And like you said, it's really still from that codependency, any attempt to help labels you an enabler, which is a really shame. I mean, this is a stigmatized problem. People who use substances are full of shame, their family members equally full of shame. So we're talking to them in a way that only perpetuates that. So part of our mission, our entire 20 years and for sure with the nonprofit has really been to just challenge that stuff head on and to say, actually, the reality is there is no one description of a person with a substance use problem. Every single person has a problem. They got it in different ways for different reasons, their process, you know, how they go about it, how it fits in their lives, what they need to do to get better. Every single one of them is different. Literally every one of them and their families are all different.

So we actually have to slow down and be way more thoughtful. Thoughtful about the family and the person with the problem in terms of what we're suggesting Like would help them and the reality is like some studies show that 75 of people who meet criteria For a substance use problem, they never go to treatment and they get better. They get better in their community, in their family, you know. So if we can empower family members with strategies that can speed that process along We're going to be helping so many more people because they're never going to walk. They're never going to walk in the door of a therapist. That's just never going to happen for cultural reasons, access reasons, financial reasons.

ELISE: Yeah. Or they go to AA and they feel like it might not be for them. And all this to say, I know AA is incredibly powerful for so many people, but when it's sort of the only option and it's presented as if you don't do this, you're doomed, which I think is how so many people hear it, then anyone outside of it, I think, lives like on this precipice of I'm not really doing the program, therefore. I'm doomed.

CARRIE: right. I'm doing something wrong or I must not be serious or I must not want to change, you know, and that's what their family members think too, because they're getting the same message. You know, I use an example a lot of this young one when I worked with who had been through multiple treatments and had been told over and over and over again yeah, you're just not ready. You're just not ready to be sober. You're just not ready, you know, cause she just couldn't go to AA meetings for, you know, and her family really thought she's just not taking it seriously, you know, and they were, okay. cutting her off. I did the evaluation with her. She had horrible PTSD.

And she went to AA meetings as a young person and was sexually assaulted. So not only did she have a sexual assault history, but she also got assaulted outside of an AA meeting. So she literally couldn't go. I mean, she was terrified to go and she was terrified to tell anybody about that, you know, but she just kept getting this message of you're doing it wrong. You don't want to be sober. And it was just, it was so painful. And I think that unfortunately happens.

ELISE: Yeah, reading Beyond Addiction, I haven't done the workbook, but I thought it was full of fascinating information to apply to any life or anyone who wants to change along any measure and I thought it was beautifully human because we're sort of conditioned to believe that substance, you know, you're an addict or you're normal, right? Whereas we all live somewhere on that spectrum, certainly. And so I thought the way that you guys took The evidence based approach to what actually fosters change, what motivates people to move their lives in a different direction was widely applicable to everyone in a way that's like, of course, like, I don't want to be confronted personally. I don't want anyone intervening on me aggressively in any part of my life, like all of these things that were this harshness that has been baked into the legal, all of our thinking, right? Historically about substance abuse, it's counter, counterproductive, right? All the evidence suggests it's like the wrong move.

CARRIE: There's not a single study that says confrontation is a effective way to motivate somebody. It doesn't exist. In fact, there's studies that show that confrontation sets people back. And there was one study that showed a single confrontational event with a therapist predicted relapse, you know, so it's really it's so profound and what's painful and I think worth everybody reflecting on is just what is it about, and I mean, it's on the surface. It's. It's understandable from a simplistic viewpoint of this is one of the only problems we want to punish, right? Like we really want to punish people with substance use. So we want them to be locked up. We want them to go away. We want to control them. And it's partially because, you know, when somebody's in the active stages of very, very serious substance use, there's a lot of pain, you know, happening around them.

Whether they're harming themselves, harming their families, you know, doing scary things, breaking the law, you know, there's all sorts of stuff that makes people say, Oh, we got to control these people and they're behaving badly. Let's lock them up and punish them and hope that that gets better. Again, the reality is substances work. You know, we engage and we use them for a whole host of reasons. One of the ways we talk about it is behaviors make sense. You know, we don't do things that don't work for us again and again and again. So if somebody's using substances again and again and again, in spite of consequences piling up, it's doing something powerful for them.

And to really be able to kind of shift your perspective and be curious about that, it opens you up to a whole different way of approaching the problem. And I think, unfortunately, for this country, to really examine that forces you to look at poverty, racism, trauma, you know, and all these things that people really don't want to wrestle with on a deep level and think about how do we actually fix this in our community? Because that really is what's driving the problem. People are medicating their pain, at all levels of our society, but we really have to deal with these core issues in order for this problem to be less impactful. And it's complicated. It's really complicated, complex problem.

ELISE: Yeah. No, and that intervention sort of requires kindness, which I think can be terrifying when all you want to do is control the behavior, right? Or make the behavior stop. But that there's this kindness that you guys continue to underline throughout the book of how do you manage yourself?

CARRIE: right.

ELISE: How do you manage yourself and you provide, you know, like a lot of CBT, etc. to sort of help you. I love sort of the breaking before you before breaking analogy of like, how do you process all of your anxiety before you just project it onto the person so that you can be a little bit more productive, I guess.

CARRIE: Well, and effective. Right. I feel more pressure when I'm working with a family member in some ways, because they really want things to change, you know, somebody with a substance use problem may walk into my door and they're wrestling with it. And we're wrestling with the ambivalence and we're working on it and we're working on it. Right. Their family members walk in the door, their family members want things to change, you know, so you've got a really motivated person in front of you. And so a lot of the time that we're doing with the families is actually getting them to slow down and realize, like, just because you want things to change and because things are scary and you're mad and all sorts of understandable things, doesn't mean approaching your loved one with that energy is going to activate it any faster.

Right? In fact, we probably have to slow everything down and give you some skills so that you can have tough conversations and have those conversations go well, you know, so that you can really be strategic and what you reinforce, like, what are you supporting? What are you reinforcing? What are some consequences that you might actually let play out? So that the person realizes like, oh, my substance use isn't working. Right? So there's a lot of strategy involved and there's a lot of communication involved. And if you're on your last nerve and completely dysregulated because you haven't slept or you've been fighting every day for five days. Like those conversations are impossible to have.

So we really have to try to help family members find some space for themselves, take care of themselves, you know, and really kind of think about their own behavior because they are the environment, right. And that is a lot of responsibility. And so, the workbook is the, is a natural progression from the CRAFT, the community reinforcement and family training that we talk about in Beyond Addiction. And what we've done in the last five years is kind of convert that to something that we're calling the Invitation to Change approach. And that's what's in the workbook, which is a and a bigger part of that, what we added to CRAFT is self compassion because like it takes a lot to change, you know, so you're asking your loved one to change.

They're going to struggle. They're going to have fits and starts. They've got a lot of learning to do. We have to have compassion for that learning process and you as a family member or if you're going to be successful, have a bunch of stuff you have to learn to and you're suffering. We're in pain. Most family members are really in pain. You know, whether it's financially emotionally, it's just hard to watch somebody you love struggle, you know, so we've got to help them tend to that pain in a different way. And it's not just bubble bath and going out for dinner with friends, right? It's really bringing some internal compassion to the whole learning process, which is just a new concept for most people.

ELISE: Yeah. Well, there's some really interesting, just even in Beyond Addiction, I sort of stopped at the, like, have you been kind to your partner? Like, that checklist alone, I was like, oh, right, this is something that's very easy to not do.

CARRIE: The reminder to be nice checklist.

ELISE: reminder to be nice, like, have you said, have you offered any support? Have you done anything to help your partner? I think just for any functioning relationship, period. We're going to get into how to not withhold, but like the consequences and all of that. Let's talk about that next, but first you know, pushing past this idea that someone needs to hit quote unquote rock bottom change really only starts though, when the benefits outweigh, there's like some sort of internal push, right, where someone says, okay, I would like to pursue moderation, maybe I'm not ready to embrace abstinence, even if they might eventually get there, but like something has to happen where they recognize they need to change, right?

CARRIE: well, yeah, it's kind of realizing like, oh, this just isn't working for me, right? You know, part of it's working for me. I'm getting most likely short term benefits from it, but I don't like how I feel the next day, you know, really reduces my stress at night, helps me deal with the end of the day. I hate how I feel the next day, or I'm not available to my kids or whatever we have to help them make that connection. And part of what we do as therapist is talk to clients in a way that open that conversation up. Right? So, one of the things I say to people is like, I can make you defensive in a nanosecond, depending on how I talk to you. I can back you into a corner. I can make you feel defensive. I can make you shut down all in how I ask you questions. And if I approach you with curiosity, if I approach you with open ended questions, if I approach you with validation and some empathy for what you might be getting from whatever it is that you're doing, even though I might find it problematic, you're going to step into a conversation with me and in that space where we're actually talking about things is where we can potentially have an influence on somebody. If somebody's just jammed in a corner, shut down, nothing's happening. Right? So that's true in therapy and that's true in families. So, if we can help partnership, you know, like a spouse with a spouse or a parent with a child, if we can help them have richer conversations where they can express themselves in a way that they're actually heard then you can start to give your loved ones some feedback, or you can start to ask some things of them, or you can start to give some advice that they might actually take, right? If the conversations are all just fraught with lecturing or, you know, how upset I am. You're just not going to get anywhere. So that's part of what we really are trying to shift. Most of the change, I think, happens in how do you connect,

ELISE: Yeah. Well, you have this, you know, short list, the things that can change motivation: feeling acknowledged, understood and accepted as you are not contingent on doing something or not doing something, getting information without pressure, having options, having reasons that make sense for a particular choice, having a sense of competence about how to change, steps to take, and getting positive feedback for positive change. Like, even just the optionality, right? Of like, well here are five paths. Any of them appealing?

CARRIE: Yes, menu of options is always helpful. Really like constantly be thinking, like, am I jamming my loved one in the corner or am I giving them multiple doors to walk through? Most people will always appreciate the multiple door option. The other thing, though, is the reinforcement. So part of also what happens is, you know, when a family starts to try to deal with this, they're usually locked in like a pretty negative spiral where there's really nothing, but I'm telling you everything that you're doing wrong. I'm telling you all the ways that you're upsetting me. I'm telling you all the ways that you're disappointing me. You know, so there's a really negative feedback loop in there, cause just giving somebody a compliment, and noticing what they've done in the kind of positive change vein, even if it's the smallest thing, just shining a little light on that and saying, Hey, I noticed maybe a bunch of other stuff over here I don't like, but there's this one thing over here that you did really well. And I just want to notice that is simple, put some positivity in the water, right? And then you're helping the person realize like, Oh, when I do this, there's less conflict when I do this, I get a compliment, you know, and that feels good or I feel connected or whatever. So we're trying to help family members think like, what can I reinforce, you know, that my loved one is doing that's not destructive. So I can build that up. And then how do I actually talk about some of the stuff that is hurting the family or hurting them or things that I'm worried about? And can I talk about that in a way that doesn't make them defensive?

ELISE: Talk about consequences. And you offer a lot of examples in the book, whether it's a child or a parent or a partner, but do you have any general advice for thinking through consequences that keep kindness present?

CARRIE: Those two things are hard, right? When you kind of think about naturally occurring consequences, it goes right at that enabling idea, because a lot of family members will start to think as they hear it so much, like you can enable, don't enable, you're an enabler, right? So they hear that message so much that they start to feel like, if I do anything, I'm enabling. What we want to help them differentiate is like, okay, I can actually positive, positively reinforce a whole bunch of stuff and I can support a whole bunch of stuff that is not enabling. There may be some things that I'm doing that is kind of preventing my loved one from connecting those dots of when I engage in this behavior, this is what happens in the world, right? And me as a loved one, I'm getting in the middle of there because we don't want our loved ones to suffer, you know, but you end up kind of shaving the rough edges off of the natural outcome of some of their choices, this is just a overly simplistic example, but, you know, like, if your kid is staying up all night on their phone and smoking pot, and they don't get up for school or for squash practice or whatever it is, you know, if a parent's getting them out of bed and they're showing up to that practice on time and not having any trouble, and their mom's just mad at them all the time. They're not connecting that dot. If the mom's like, you know what? You don't get up. I'm not taking you. And they have to deal with the coach or the teacher or the principal because they're missing, that's more impactful, right?

So that's them realizing like, oh, I do this and I have to deal with this authority figure in my life that's not my parent. And that's a little more meaningful to me. I don't want to have that happen again. You know, there's other natural consequences that you don't want to have happen, right? Like not letting your loved one drink and drive, it may be that your loved one is a primary provider. And you really can't let them lose their job because your family would be in dire straits if you didn't have their income, you know, so it's also helping family members and, you know, unfortunately with substance use, there is a risk for domestic violence and it may be that having your loved one experience some consequences escalates their anger or escalates their out of control behavior in a way that puts you in harm's way. So we don't want to have that happen either. So there's, these are serious, hard Decisions that loved ones have to, you know, that loved ones have to make, which is why, you know, getting some support as you make them can be really helpful. But also just going back to that idea of self compassion, being able to be like, okay, for my family, I can't actually let these consequences play out because it's just too dangerous for my family. So I'm going to find a way to take care of myself in other ways or I'm going to work on reinforcement or I'm going to work on, you know, just removing myself a little bit to take care of myself, whatever it is. So those are hard discussions.

I use this example where I worked with a woman who was really, really upset with her husband and mad at him all the time because he would pass out at the end of every night, and he'd kind of have beer cans around him and everything, because he'd stay up drinking after the kids went to bed. The kids were like 12 and 10 and she would clean it up, she'd take him upstairs, she'd put him to bed, and she'd be furious with him in the morning, and he wouldn't remember really anything, because he was kind of in a gray blackout, right, and she was mad all the time, so he just thought she was a nightmare when she was actually just, she didn't want the kids to see him. And part of what we worked through was she's like, they're old enough. He actually really cares about being a father. I think if the kids came down and saw him, that would actually really, that would matter to him. So she let it happen a couple of times.

And the 12 year old was like, dad, I saw you in your chair. That was weird. You know? So it wasn't like horribly traumatic for the kids. You know, the kids were like, well, what happened? And that feedback mattered to him and he stopped doing. So that was just an example of where she was kind of enabling him by picking up that mess. And then she was hoping that her anger would be the consequence. It wasn't having any impact, so she got out of the way of that behavior and let him deal with his kid being confused. And that mattered, you know, so that was a meaningful, natural consequence that she let play out that really changed the situation a lot.

ELISE: Yeah. Or you gave a couple of examples, similarly, you know, a wife letting a husband sleep through his child's soccer game repeatedly, Instead of getting him up or a husband who would make a nice dinner when his wife would come home directly from work sober versus like removing himself to go read. I think those are like highly accessible because I would imagine a lot of what you get is sort of this like, not gray area necessarily, but you probably see a lot of families where it's like a lot of anxiety about kids and a lot of partners who are like, I'm convinced that my wife or husband Is an alcoholic or, you know, has a problem. I'm sure they're in denial, right? Or unclear whether it's crossed a line, although it's clearly crossed a line for the partner. It's hard, right?

CARRIE: Yeah. And I usually tell people like, whether or not your loved one's an alcoholic or not like labels, again, there's not, there's no evidence that labels help either. And in fact, it's probably just causing you to have a battle that is wasting your time, you know, like stick to the behaviors, can you describe the behaviors that are problematic? You know, I don't like it when you wake up and you're really kind of cranky and you're hard on the kids and you don't smell so great. Right. That's not you being an alcoholic. That's three things that are kind of hard to deny because you're cranky and you're hard on the kids and you don't smell great, right?

So labeling things you know, and describing the behavior is way more impactful than trying to get somebody to accept what they are because they may never take that on in this identity. And another thing that I say to people is if you self identify as being an alcoholic or an addict, because you're part of the 12 step community, and that joins you to a community that you want to be a part of, that's really powerful. And that can be really helpful to people and an important part of how they decide to change. Right? That's them taking on that themselves. Me saying to somebody you're an alcoholic like that's me doing something to another person that probably isn't helpful. So it just I just try to get that stuff out of the way because it just doesn't ultimately matter and I've never had anybody change because...

ELISE: yeah.

CARRIE: Or somebody told them, that's just not how it works.

ELISE: Yeah. Well, I think there's just so much fear, understandably around, like, if you have the label and the line is clear and you're part of 12 Step and you're professing your days and your months and your years. Then there's something that you're defending that's at incredible stake, and I get that. And then also, as you write, most people have a lapse or a relapse, right? Like that is part of this process not that you want to invite it, but it's just the reality of change, right? Change is hard. and I thought you did a great job in the book of just, of exploring that too, because I think with friends of mine who have gone through this process too, they're always like, I thought everything would be different, but they're maybe contending with a partner who is like a quote unquote dry drunk, or there's still a lot of hard behavior, right?

CARRIE: Well, it's another, thing that we don't think about. So in the invitation to change part of one of those elements of it is this idea of practice, practice, practice because that's the other thing that we don't really think about when it comes to addiction problems. If you're asking somebody to give up a substance, Right, that works for them in some way. So it helps them with their anxiety. It helps them with sleep. It's they've been doing it since they were a kid. And so it's part of their identity. It's in their friend network, whatever. It could be very deeply a part of somebody's life, right? That behavior. So if we're going to ask them to give that up. So there's a lot of behaviors they have to learn. to give that up. And then there's a lot of behaviors they have to learn to replace all that space that the substance use was picking up. And we expect them to do it quickly, right? Like, Oh, you got out of rehab. You're going to be sober now. They don't know how to do that.

No idea how to do that. They're going to have to practice it. They're going to have to be in different environments. They're going to have setbacks. And we really set people with substance use up for this like incredibly high standard in terms of what they should have figured out just because they decided to change instead of actually giving them the time and you know that it takes to practice these new behaviors and you know, anybody who's been sober for a period of time, one of the ways I describe that is like, they learned how to do that. Like, it's a learned behavior. And you would never expect your kid to play a Chopin etude, right? You'd be like, Oh, you need a, you need a teacher who can teach you some scales and you're going to learn some pieces. And then maybe you're going to have to get a new teacher along the way, because you outgrew that person, you know, you're going to learn stuff wrong and you're going to have to go back and relearn it. We have so much compassion for all these other things that we have to learn. Not when it comes to substance use, we expect it to get sorted out very quickly. And that's a setup for everybody. It's a setup for everybody.

ELISE: Yeah. Not to mention, you guys explore this at length, but that there's like a fair amount of rebalancing in the brain that has to happen chemically after, that we don't really accommodate for or necessarily understand.

CARRIE: I'll just go with what you said, which is like the dry drunk. Right. So that's somebody who has maybe, I mean, just describing it for listeners who may not understand what that means, but it's like, okay, so there's a person who's quote unquote, not drinking, but they're still raging or they're still gambling or they're still doing some other destructive behavior, you know, that's having a negative impact on their life, so they're people will kind of judge them and say, you're not really, you're dry drunk. You're not really sober. All that says to me is like, okay, here's a person who gave something up that was working for them in some way, and they haven't replaced it with something else.

They just took something out and they don't actually have something in there that is replacing it effectively, and they're actually having a hard time. And so what we really need to help them with is like, all right, so how are you regulating your emotions? You know, how are you building your community? How do you manage intimacy? How do you connect with other people or the 10 million other things that could be, right? But again, it's easier to just label them than to be curious on a very deep level of What's going on with that person. They're still struggling. And why? You know, like, how can we help them take that next level of help in so that they can really change.

ELISE: Yeah. Do you guys treat sex addiction too at CMC or is that its own thing?

CARRIE: I mean, the reality is all of these kind of compulsive behaviors, whenever somebody is like engaging in something and it can be like, I'm binge eating. I'm on my phone. I'm on my social media. I'm having sex out there in the world or I'm on porn, you know, too much. So like we do all sorts of compulsive things, right? They all have little different special things that you got to figure out in terms of like, what are you going to change in your environment so that you don't engage in that behavior. But they all respond to the same principles in terms of like it's a behavior that you're engaging in that is working for you in some way. We have to respect that and we have to unpack that. You know, we actually really have to understand what is it about that behavior, what function is it serving for you so that we can then identify what are the skills you need to be working on instead so that you don't turn to that.

And a lot of people who engage in sexual compulsive behavior have really serious trauma. They have trauma in some way and they don't actually have ways to understand their bodies and Be connected in their bodies or connect with other people because of trauma. So it's a lot to figure out. So again, you can just look at it as like, Oh, you have a sex addiction or you can go deeper and be like, yeah, you actually don't know how to connect with people a authentic, intimate way. Or however you want to call it. And again, it's different for different people.

ELISE: Yeah. So, and I'm sure this is highly individual, so just putting this out there, but when someone comes to you, either a family or a client who needs change or is like ready to engage in this process, how much of your work at CMC is sort of the tactical, helping that person figure out goals, doable goals, treatment plans whether they're going to go to treatment or don't need to go to treatment. I know it's highly variable. And then how much of it is sort of going into the family system and addressing trauma, or do you guys partner with other trauma therapists? Or do you do the whole person?

CARRIE: We're trying to do the whole person. But sometimes we can't do the whole person, right? So, yes, it's very individualized and, you know, we really do try to partner and really the other part of the invitation to change approach is one size doesn't fit all. So we really have to, like, Maybe you need an executive functioning coach, you know, maybe you need a family therapist where everybody's in the room. Maybe your family, your spouse or your parent needs to do some of their own work. So we're going to get them on their own path, and then maybe down the road, bring you all together. Or maybe you need to see a psychiatrist and be on medication. Maybe you need to go to your Synagogue or your faith based leader and like reconnect, maybe you need to find a yoga class, you know, like, it's just many different things that are going to be helpful to people in their change process. And we definitely try to involve the family because it always goes better when the family is involved. You know, sometimes they don't want to be so.

ELISE: Yeah. But that, I thought you gave really great concrete advice on that side, too, of like how to facilitate involvement, maybe you can never demand it, but if you're paying for it, how you can increase communication or be involved without again, like overreaching, right? You can't solve this for your child.

CARRIE: No. And, you know, and sometimes unfortunately, you know, treatment providers are bound by HIPAA. So we have confidentiality limitations, so there's all too many times where we'll be working with somebody and we're desperate for their family to be involved and we're desperate to share information with their family and the person's not giving us permission to be in touch and they're not doing stuff that's risky enough that warrants us breaking their confidentiality. We just can't, you know, so making a plug out there for people to understand the treatment providers we get in boxes ourselves that we wish were different. We're typically doing our best. And maybe your loved one's not given us permission to include you which is a a drag for everybody. And it happens, you know, so, but I really like to empower family members of like I may not be able to call you, you can call me and leave me a message about what's happening, you know, so that I can say, Hey, I heard from your parent. I may not be able to call you back or acknowledge anything that's happening, but you can give me information. That can be really helpful. And yeah, if you're paying for treatment, you can say, Hey, I'm not going to, I'm not actually going to pay for things if you don't allow me to be involved in some ways. And unfortunately there's treatment providers who don't involve families enough, that actually get really locked in with a client and don't think about everything that's around them, you know, so it goes both ways, but the confidentiality limits can be hard for providers and families.

ELISE: Talk about lying because I feel like that's another big part of the mythology and maybe it's also slightly true, right, of addiction, that there's like a lot of sneaking around and lying and that you can't really trust, quote unquote, an addict. I'm just using language, words out in the culture. But let's talk about that because it feels like healing or crossing that bridge or changing the way that everyone is thinking about that, that they, are completely trustworthy, that sometimes the lying makes sense as they're defending something that maybe they are relying on for their sanity. How do you coach people through that?

CARRIE: Most human beings lie, right? So we have a hard time with full honesty all the time. So that's wish we would all do better, but it's just human nature. Most of us lie because we have something that we're ashamed about, we have something that we're hanging on to that we feel like somebody is going to judge us for or something that somebody is not going to understand. So to actually just kind of strip it down to like, It's an all too common behavior when somebody is like wanting somebody to be honest about their substance use again. We bring a lot more energy and expectations to that. And the reality is substances are having a big impact. And typically somebody is hanging on to something for dear life and they feel like they're not going to be understood. There you feel like you're gonna want me to give it up. You're going to tell me how bad it is. I know you're going to be disapproving of it. So I'm going to hide it potentially to protect you I'm going to try to protect myself, but I might actually be trying to protect you too, because I know you're going to get even more scared if you really know what's going on, right?

So to actually be thinking like, okay, there's a function. So as behaviorists, we're just always looking for like, what's the function of this behavior? What purpose does it serve? The line serves a purpose. What is it? And again, when we look at the stigmatizing cultural lens of like, of course they're lying, they're an addict and all addicts lie, like that's just overly simplistic, just whitewashing the whole problem versus being like, all right, am I approaching these conversations in a way that is causing my loved one to feel like they can't be honest with me. And so part of what happens when we do these trainings with family members and parents in particular, is we almost have to inoculate them of like if you get better at these conversations where you're creating an environment where your loved one is actually telling you what's going on, that might be harder than itself. So you're having success. You're having success because they're telling you what's going on. You might get more scared. You might get more mad.

Can you still be like, and I'm getting information that I can then potentially use to be helpful to them, right? Because lying is a complex dynamic. And it's not as simple as they just do it because they're addicts. They're doing it because it works in some way. And yes, maybe it's denial, but I tend to not even use that word because every person who I've worked with, which is hundreds and what feels like thousands, they feel really bad about their behavior. And they are struggling. They know on some level it's not working. They just don't know what else to do, you know? So they just keep hanging on to that as the way that they're coping. They don't want to be doing it. Nobody wants to be somebody with a serious substance use problem. Nobody wants to be addicted to a substance. I mean, it doesn't feel good. Dependency doesn't feel good. And we end up in there anyway, right?

So I think if we can bring compassion and understanding to, wow, it must really be working in a way that's really powerful for them to keep pursuing it. And then you've got the physical effects of substances, right? So then our bodies physically get dependent, you know, so it starts out as like, it's probably working for an emotional or something in our life and then we become physically dependent on it. And then it's a whole nother host of things in terms of how do you stop it? And people don't fully understand treatment in terms of there's medications available. There's all sorts of things that are available now that weren't available even 5, 10 years ago that are really helpful to people. And we've also had this stigmatized idea that people with substance use problems shouldn't be on medications, you know, they're self medicating.

ELISE: yeah. No, Suboxone saves lives. Yeah.

CARRIE: Yeah. They may need another medication.

ELISE: Yeah. no, it's interesting. As much as we profess our desire for the truth, we have little tolerance for the truth, really so much of our just daily conversation with each other, right, is softening how we actually feel to make it acceptable.

CARRIE: Well, it's typically pain under there. Like when you're dealing with a compulsive behavior, you know, like whether somebody is overeating, binge eating, gambling, you know, if you go all the way to the core of it, for most people, it is I'm lonely. I don't know how to cope with it another way. I'm in pain in some way. I'm anxious. I'm depressed. You know, there's something in there that is pain driven, and there's different types of pain for all of us. It might be physical pain, but I think part of what we resist in really talking. About substance use on a deep level is that it's hard for us to actually stay with. Wow. This person's really suffering, you know, this is really hard. You know,

ELISE: So, thinking about the families that you see and parents with children or you know, often these are intergenerational issues, right? There's theoretically genetic component, right? But they don't really know what the genes are or what would turn those genes on. But when you see sort of a complex family with a lot of addiction and with children, what is the science about sort of the propensity for that next generation to develop addiction? Or do you think that that's sort of overstated? Or do you have any advice on that?

CARRIE: I just we just go back to this idea of like, and it's different for every family. And that's what's hard about this. Right. You know, like your genetics might set you up for you've got a little more anxiety in your system, so you like alcohol because you've got anxiety in your system, or it could be that you've got a family tree of heavy drinkers. So you have a really high tolerance for alcohol and you can drink a lot of alcohol before you feel an effect, which puts you more at risk for being physically dependent. So yeah, there's different genetic things that can get turned on or off depending on the environment. And then you've got all the learning, you know, so if you grow up in an environment where you're seeing your parents or other family members over drink in response to X, Y, and Z, or at every family event, or, you know, get intoxicated on the weekends or whatever binge drink, you're going to learn that that's what people do. And you're going to start engaging those behaviors too. So again, I just want to go back to this idea of like we learn to do this. People learn that substances work in a particular way through experience and through observing people around them. And then we can learn to change too by what's around us and the people around us. So I think just everybody being super conscious of what impact am I having and what message am I sending to my kids? If you happen to be a parent who's concerned about this, they're watching every single thing you do.

ELISE: Right.

CARRIE: You know, which is what's hard about being a parent, right?

ELISE: It's like, avert your eyes, children.

CARRIE: Yeah.

ELISE: What I don't understand, Carrie, is all I do is read and I'm like, how am I modeling so much reading and nobody in my family wants to read. What gives?

CARRIE: I know, I know.

ELISE: Honestly. Ugh. Is there anything that you feel like we didn't touch on that you Want to get to?

CARRIE: No, I mean the foundation is trying to make it so that there are free resources for family members, you know, because again, not everybody can afford treatment and that's the unfortunate part of what's happening out there it's a complicated landscape. But we're trying to train lay people in the invitation to change approach so that they can start groups in their communities and, you know, groups for each other, where they're sharing these evidence based ideas with each other precisely to start to challenge all these stigmatized messages that get shared around, right? And I would love to have ITC invitation to change groups right next to every Al Anon group because you get different messaging and some of our families go to both, you know, they go to Al Anon and get like, Peer support for taking care of themselves. But most family members really want to help their loved one change. That's not what Al Anon does. So to be able to have another support group where you're hearing from other family members and really getting advice from other family members because peer support and the narratives that we share really that's what helps people change, right? So there's a whole host of resources on our website that are free for family members if they want help. It's cmcffc. org. So just your listeners knowing that there might be...

ELISE: so people could yeah and start their own support groups and obviously there are therapists in this network and you guys train therapists.

CARRIE: Yeah.

ELISE: It seems like there it's it co mingles with CBT and DBT and lots of other therapy modalities.

CARRIE: Yes. Yeah. All the evidence based treatment models. I mean, the invitation to change is all of those in one approach, you know, so we took CBT, we took motivational interviewing, we took craft, we took acceptance and commitment therapy, and then Kristen Neff's work on self compassion, which is really powerful, it used to be just a great idea, Kristen, and Her colleagues have really, like, done studies of it actually really helps people change. So, it creates a lot of self compassion into the approach, both for the person with the problem and for their family members, because, you know, just even your joke of, like, I'm reading a ton. Why is my family not reading? Because change is hard and learning takes time and takes repetition and, you know, to really stay on for as long, stay on this ride for as long as we need for behavior change to really happen, that can be a long process. Right? And people give up, but that can people give up quickly because they're overwhelmed. And we also are becoming a society that wants quick fixes.

ELISE: This is all true.

CARRIE: we don't want to do that hard work.

ELISE: yeah, and I thought that the very clear articulation in the book and the method too, just that rehab came out of this 28 day, like Minnesota model, not to say that it's not an amazing place for people to refresh and restart and practice and get support and obviously there's a lot of variability in rehabs and variability in approaches, but most people, right, don't get treatment and recover.

CARRIE: Yes. And most people don't need rehab. I own a rehab and I talk people out of rehab all day long. Like, we get calls from family members. I'm like, I don't think that's what your family, I don't think that's what they need. I think you should start here. And there's studies that show starting at the least intensive level of treatment has the best effects, you know, and so you start at the least intensive and work your way up, if you need. You watch intervention, you do an intervention, you go to rehab, right? Again, these cultural messages of like, this is how you do it, they don't bear out in the evidence. And family members becoming more educated consumers, we wrote Beyond Addiction, How Science and Kindness Help People Change to try to help family members become more educated consumers, because they really are often driving their loved one into treatment and knowing and putting options in front of them, so them really knowing like, hey, I could, maybe put a rehab in there, but I could also put a therapist that just has a nice connection or I'm going to give my kid an executive functioning coach because they're really struggling with ADHD and smoking pot to cope. I mean, it's like, let's just look at it from all the different angles.

ELISE: yeah, particularly because, I mean, people go into debt or dipping into college funds, etc. to pay for these programs, which can be like 80, 000 a month.

CARRIE: Yeah.

ELISE: I also, I think This idea that people can walk themselves toward potentially abstinence, but by trying sobriety, trying moderation, and convincing themselves in the process, Oh, actually, like, I just need to be abstinent feels much more durable than being walked off a plank where they're forced into that.

CARRIE: Yeah. And the whole harm reduction approach is like, let's just, cause you know, their substance use may not change that much, but maybe they're employed. Maybe they're eating better. Maybe their marriage is better because their communication is better. Their substance use maybe hasn't changed that much, but these other things are better. That's still better. That's still better. Right. There are less consequences, you know, so we get all locked in on the only goal is being abstinence and it's preventing us from being able to say, like, there are lots of ways to improve people's lives, yes, I would like to reduce substance use because it's hard on our bodies and it would be good if you're not using in a problematic way, but if you're not willing to talk to me about that, but you're willing to talk to me about these five other things that you're willing to make changes around, I'm going to start there. I'm going to start there. And we're going to work on that. And maybe if you make some progress in these other areas, maybe you actually won't need that drink so much. Right? So, you may actually reduce the need for substance use by helping people make improvements in these other areas of their life. And lo and behold, we never even really talked about the substance use, but it changes.

ELISE: Yeah. Well, thank you for your work.

CARRIE: Anytime you want to talk about this stuff, I love it.

I think for anyone listening who has a loved one struggling with substances or who struggles themselves, this is a great book I think for anyone who is contemplating change and these are certainly great therapists to help manage the process. It’s just a great read in general for I think parents and for partners, this is the checklist that I have mentioned which is just a basic exercise: “Daily reminder to be nice: Did you express appreciation to your loved one today? Did you compliment your loved one today? Did you give your loved one any pleasant surprises today? Did you visibly express affection to your loved one today? Did you spend some time your complete present attention to pleasant conversation with your loved one today? Did you make any effort to help your loved one today before being asked?” Basic, but I think so easy to skip. They also offer a lot of ideas for both consequences and re-enforcers, which is what they call them, which really underlines how easy it is in someways: providing a favorite snack, give a ride somewhere, allow use of car (these are for kids) allow to sleep in, pay for a special hair cut, or mani-pedi” so full of ideas, full of example, and hopefully full of reassurance.