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Wednesday, November 22, 2017

Rina was desperate to help her son David. Always anxious and withdrawn, David got into drugs during his sophomore year in college. Things went down hill and David dropped out of college and returned home to live with his parents. Life became one long saga of anger, yelling, frustration and worry for Rina as she tried again and again to coax, prod and bully her son to acknowledge he had a problem and accept help. She is desperate for guidance but the advice from friends and relatives is confusing and contradictory...

Some of the most difficult encounters I have had as an addiction psychiatrist occurred not with those suffering from addiction but from family members desperate to change a loved one’s behavior. Substance use disorder and behavioral addiction can ravage a family on many levels and loved ones often feel powerless to change the destructive course of the individual suffering from addiction.

How can one respond in such a situation? Is there anything the community can do to maximize the chance that things end well? Below, we will review the advice given by practitioners of three approaches to dealing with this problem and discuss the benefits and drawbacks of each and then come to develop a healthy approach.

Approach #1: Al Anon

Rina, you need to let go and cut all ties from David. Ask him to leave your home, change the locks, don’t trust him until he has proven he can live drug free. If he asks you for support or money you need to say no and just focus on taking care of yourself. He will only come into treatment once he hits rock bottom. As long as you are helping him you are enabling his drug use.

Among the earliest approaches to this problem was that prescribed by the wife of one of the founders of the Alcoholics Anonymous movement. She founded a mutual support group for individuals in her situation in 1951. This group, called Al-Anon, defined themselves as suffering from “codependency,” a term used to describe the unhealthy relationship between an individual suffering from substance use and a close relation. The theory was that the close relation unconsciously facilitated the loved one’s addiction because they themselves were psychologically “addicted” to the struggle itself. The answer, according to Al-Anon, is to accept that the loved one must continue on his or her own chosen path and generally must hit rock bottom in order to turn their lives around. Thus, loved ones should cut themselves off from the addict to extricate themselves from their own facilitating behavior and focus on themselves.

Approach #2: The Interventionists

Rina, the way to deal with the problem is to stage an intervention. Get everyone whom David has ever cared about to surprise him at home one night. Corner him and tell him how worried and concerned you are and tell him to go to rehab. If he still refuses, bully and shame him into agreeing. This is your best shot to getting him into treatment.

A new approach to dealing with the problem of addiction in loved ones was developed, that of the intervention. In the 1960s and 70s the field of addiction treatment developed a “tough love” approach for addicts, believing that individuals could only change if confronted, shamed and berated into changing their behavior. The Johnson intervention approach is still used by some today and involves all significant members of an addict’s life using this confrontational approach in an attempt to motivate a move toward treatment.

Sadly, both the Al-Anon approach and the confrontational approach fail both the addict and the loved ones in fundamental ways. While it is true that a family member may be facilitating their loved one in some way (for example by providing food and shelter) the best approach to dealing with this issue is not necessarily cutting the family member off. Such an approach breaks all communication and may push an individual farther into drug or alcohol use. A loved one may have a calmer and more peaceful life but we should not delude ourselves that such an approach will likely lead to the addicted individual seeking treatment.

A more nuanced approach is possible, one that acknowledges the problem of “codependency” but attempts to correct the mistakes in the relationship as opposed to ending it altogether. The loved one might be able to function and live a happy life even if their relative does not change their behavior, but this does not mean that the situation is not sad or upsetting or that the relationship must end.

Approach #3: The CRAFT Approach

Rina, there are a couple of things you can do to try to make things better for both yourself and your son. Learning to talk to David in a way that avoids the circle of confrontation and conflict but that encourages healthy behavior can really help. You can also sit down and think about ways in which you can encourage good behavior by providing positive reinforcement and discourage the negative behavior by allowing David to experience the natural consequences of his actions without protecting him. Finally, you can make sure to take care of yourself so you will remain in an emotional and physically healthy place so if the time comes when David tries to make a change you will be there to help him.

The newest approach, community reinforcement approach and family training (CRAFT), asks family members to change their behaviors in a way that facilitates their own psychological health and their loved one engaging in treatment. To test this approach against the first two approaches we mentioned, a large clinical trial was performed in which participants were divided into three groups, each receiving one of the above approaches. The results were striking. In the first six months of the trial, among those in the Al-Anon approach, only 13 percent of individuals entered treatment. Among those in the interventionist approach, only 30 percent engaged in treatment. In the CRAFT approach, 64 percent engaged in treatment, making the chances more than double that a loved one will engage in treatment if this approach is used!

This approach involves three distinct areas for improvement: communication, contingency management and self care.

Communication: Family members are taught the basic skills used by addiction specialists to help foster change in their loved ones. Instead of nagging or attacking, which leads to defensiveness and more rigidity, they are encouraged to keep lines of communication open; be open, non-judgemental and roll with resistance; and encourage and praise any positive behavior.

Contingency management: In working on this skill, loved ones are encouraged to provide support for a drug user in a way that is likely to support their sobriety. For example, not providing money to support a loved one because they are low on cash, but agreeing to pay for healthy non-drug activities the drug user is willing to take on, like a yoga class or gym membership. Although each case is different, family members can remain connected and helpful to their loved one in a way that facilitates sobriety, not their drug use.

Self care: The final element of CRAFT works with loved ones to be sure they take care of themselves during this process. A spouse might be encouraged to take a night out or treat herself to a bath if her husband is out late drinking, instead of waiting up and fretting. This approach helps avoid the explosive confrontation that will occur when the spouse gets home later and allows the couple to have a conversation about the night’s events at another time when tempers are less likely to flair.

Conclusion

Although dealing with a loved one who abuses drugs or alcohol can be frustrating and feel hopeless, there are things we can do to maximize the chances that the individual suffering gets the help they need. As a community it is important to appreciate and utilize the wisdom of medical research in this area. In this way we can help others in a manner that is both empathetic and conducive to long-lasting change.

By Matisyahu Shulman

 Matis Shulman, MD, is an addiction psychiatry fellow at Columbia University Medical Center and has a private practice in Teaneck, where he treats individuals with a range of psychiatric issues. He also has semicha (rabbinic ordination) from Yeshiva University. He can be reached at [email protected]