“He’ll just have to hit bottom.”
That bit of outdated advice terrifies the family and friends of the person with an addiction who refuses treatment, because they know that “bottom” may be serious injury, overdose, or death. Although well-described methods are available for managing the person with an addiction who agrees to come into treatment with a support group of family members and/or friends, sometimes an in-office evaluation is refused out of hand.1,2 So how do we, as clinicians trying to help the person with an addiction who refuses to set foot in our office, render assistance?
First, the message to the concerned family and friends should be that the time to act is now—whether or not the person with addiction comes in to the office. Second, we should model for loved ones of the person with an addiction an attitude of urgency combined with an acknowledgement of the situation’s complexity, because barring an immediate threat, there is little possibility for legally coerced treatment. Those who care can push the person with an addiction towards treatment, while still maintaining an attitude of respect for his or her autonomy, life choices, and preferences.
Psychiatrists can teach the family and friends how to recognize an immediate danger and access the appropriate level of care for a threat to the life of the person with an addiction. For instance, helping loved ones understand what an opioid overdose looks like, how to use naltrexone, and when to call 911, would be the first orders of business for someone with an opioid addiction. Or, for the individual who may or may not be in withdrawal from alcohol, informing the family about the signs and symptoms of alcohol withdrawal and alcohol poisoning educates them about what a true emergency is, and what presentations may be dealt with less urgently. The bottom line, however, is that any immediate threat to the person’s life should result in a call to 911.
Once the immediate threats are delineated, family and friends should be educated about the typical course of addiction, available treatments, and the best way to convince their loved one to accept an evaluation and eventual treatment. It is usually helpful to find out how those who care about the person with an addiction think about the addiction problem, and what they have tried up to this point. Often, families will have unrealistic or simply inaccurate views about addiction, or express (understandable!) anger if the person with an addiction has lied to them. Once these matters are on the table, the clinician can support any productive strategies already in place, counter any mistaken understandings, and suggest a specific plan for advancing treatment.
Family members who have been manipulated by a person with an addiction for money or other support are often angry and resentful. But by providing the family with psychoeducation—specifically, approaches that are likely to be helpful but also protect the family from being further abused—one can reassure family members and bring them into a makeshift “treatment team.” For example, offering to drive a family member to AA, or arranging insurance for a detox stay, or simply providing a hot meal and a chance to talk are all effective in supporting a recovery-focused view, but do not endanger the giver. By contrast, handing the person with addiction cash, allowing him or her to stay in one’s home, or even paying for an expensive treatment stay can all lead to families feeling taken advantage of and needing to protect themselves.
The “Intervention” model
Families sometimes believe that the best, and sometimes only, way to confront the person with addiction is via the “Intervention” model they have seen on television.3 Although based on the influential work of Vernon Johnson,4 this model is hardly the only way to address an addiction problem in the family and can be counterproductive. Rather than using the dramatic and sometimes complicated “Intervention,” family and friends can be coached to ask about the particular problems they observe and explore possible avenues for help.
Dr Westreich is Clinical Associate Professor, Department of Psychiatry, NYU Langone Health, New York, NY. He is the author of A Parent’s Guide to Teen Addiction, Skyhorse Publishing, 2017.
1. Galanter, M. Network Therapy for Alcohol and Drug Abuse. New York, NY: Guilford Press; 1999.
2. Meyers RJ, Wolfe BL. Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening. Center City, MN: Hazelden Press; 2004.
3. A&E Network. Intervention, 2005-2013. https://www.aetv.com/shows/intervention. Accessed January 17, 2019.
4. Johnson V. Intervention: How to Help Someone Who Doesn’t Want Help. Hazelden Foundation: Center City, MY; 1986.
5. Miller WR, Rollnick S. Motivational Enhancement: Helping People Change. New York, NY: The Guilford Press; 2013. ❒