Dr. Michael Ascher invited Dr. Jeff Foote and Dr. Elana Rosof to coauthor this piece with him.
It’s an intensely emotional experience to watch a family member in the throes of addiction. It’s at once confusing, maddening, sad and frightening. You see your loved one act in ways unfamiliar, secretive and unsafe. You wonder why they can’t see how much they are hurting themselves and everyone around them. The truth is, they do see this. And they usually feel awful about it, but that doesn’t automatically mean they can stop using. Whatever the substance is, they are in its grip.
As mental health clinicians, we spend a great deal of time working with family members in their journey to help the identified patient (IP) to enter treatment. They come to us having exhausted many of their coping mechanisms and resources to influence the IP in the direction of change. At this point, pleading, threatening, arguing, confronting and avoiding have all been tried with limited success. Feeling alone, stigmatized, and devastated, families are left with many questions. “How did my loved one get to be like this?” “What could I have done differently?” “Why does he/she continue to hurt themselves and us so recklessly?” “Am I an enabler?" “Should I just cut the person off or administer tough love?” “What is their rock bottom?”
While many families are convinced that the IP doesn’t want to change, we regularly point out that they may not feel they currently have the skills to do so. When looking at motivation to change substance use, we initially look at two factors—how important it is to the person to change and how confident the person feels that they can make the change. Just because a person may feel some degree of desire to change, it doesn’t mean they know how or that they feel they can.
We feel incredibly lucky and privileged as clinicians to work with these inspiring and resilient families because individuals and families can and do change. While good outcomes are attainable over time, it is imperative for families and the IP to recognize that the management of substance use disorders is a process like any other chronic medical condition (e.g. diabetes, hypertension and obesity). So often the IP experiences so much shame that admitting they need help feels too demoralizing. They believe they have to figure out how to undo the addiction on their own. Sometimes they can. Sometimes they need help.
Regrettably, there is an abundance of misinformation available to the general public regarding the treatment of substance use disorders. Reality television shows often portray dramatic and provocative “interventions” that claim to result in radical change. Unfortunately, these types of approaches rarely work and can serve to alienate and shame the individual, often leaving him or her with lower self-esteem, self-hatred and hopelessness. Furthermore, inpatient rehabilitation is not always necessary. Twelve-step treatments have dominated the treatment literature until fairly recently and while twelve-step is helpful to some, it is by no means the only treatment approach. There is much evidence to support behavioral, pharmacological and motivational approaches to treating addiction. This can be done on an outpatient basis and, when needed, at a residential facility. Invite your loved one to be part of the process of finding a clinician and treatment philosophy that most speaks to them.
As you discuss treatment as an option with your loved one, explain that the expectation isn't that they have to stop using the day they walk in the door. Treatment begins as an exploration into understanding the reasons for use and typically this first means addressing depression and anxiety.
Empathize with the dilemma of ambivalence that the IP faces. Remind your loved one that making an initial appointment doesn’t have to mean that they have decided to stop using. Ambivalence really is normal and treatment is a place to help your loved one sort out their individual reasons for both wanting to change and not wanting to change. A skilled clinician helps the IP find what holds value to that person and works alongside the IP to create a meaningful path forward.
In cases where physical withdrawal is of concern, there are many medications that help. The IP doesn’t have to suffer and they don’t have to go through that part alone. Actually, entering treatment can feel quite relieving for people especially if they discover that treatment isn’t about being controlled. Education about the impact of drugs and alcohol on the brain helps people understand why they are feeling many of the things they do.
As the loved one of the IP, if you can see how your behavior influences the ambivalence one way or the other, you have information that can be extremely useful. There will be times when the IP seems more amenable than others. Give them room to express the shifts in their motivation. Listen to him or her. Try to understand their point of view. This can be an extremely frustrating time because you might have felt some hope that they were ready to get help and then they change their mind. You may have even made the appointment for them. This start and stop is normal and may also have to do with where they are in their substance using cycle. Even when you are at the height of feeling frustrated, be careful of using terms that carry stigma such as “addict,” “enabler,” and “co-dependent.” Stay away from threatening or begging. Establish your own personal limits and understand when it is important for you to walk away.
Learn to communicate in a nonjudgmental way. Own your piece of the struggle. Make a commitment to addressing your own issues—maybe even seeking your own treatment—with the IP. Learn to control the way you deliver a message. There are simple things to remember for effective communication that include being brief and specific, owning a piece of the blame, stating what you would like rather than what you don't like, and being empathic. Our patients have told us, after the fact, that much of what their ones were saying to them fell on deaf ears because when they were approached they were high or drunk or withdrawing. So, remember to time these communications during sober periods.
And to you—the one trying to help—self-care is critical to your well-being. Your life has to be more than just depending on your loved one to get better. Take time to do the things that strengthen you. Seek outside consultation from a clinician you trust. Learning how to communicate in ways to potentially positively influence your loved one takes time and practice. Be patient and remember this is a process.
Dr. Foote is a cofounder and director of the Center for Motivation and Change and a coauthor of “Beyond Addiction: How Science and Kindness Help People Change” (New York: Scribner, 2014). Dr. Rosof is a clinical psychologist in Philadelphia with a specialty in addiction and extensive training in motivational approaches.