"He'll just have to hit bottom." That bit of outdated advice can be terrifying. How do clinicians trying to help the person with an addiction who refuses to set foot in our office render assistance?
“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That bit of outdated advice terrifies the family and friends of the person with an addiction who refuses treatment, because they know that “bottom” may be serious injury, overdose,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.
Teaching a non-confrontational communication style can be a revelation for family members bound up in hardened patterns of blaming/shaming interactions with their loved one. Role-playing is often helpful in a situation like this, as families and friends often question how they should respond to specific retorts from the person with an addiction. One example:
Roger: I don’t need your help. You know I’ve been using a lot less lately, and I’m going the right direction.
Angela: I can see, that, and I’m very glad about it. But given the heroin out there that’s laced with fentanyl, I worry about you overdosing even as you’re starting to turn the corner.
Roger: Nah, I’m really careful. And anyways, you’re my sister, not the hall-monitor!
Angela: I know, I know! I won’t even bother trying to twist your arm, but I can still worry about you! And we found a treatment program that accepts your insurance and can see you this afternoon.
Angela has been coached to acknowledge the strides that Roger has made in cutting down his use, but also remains realistic about the remaining dangers of his heroin use. And, she has learned to reassure her brother that she has no ability or intention of controlling him but does have a very specific recommendation for getting help. This sort of respectful but persistent pressure for treatment will be better received than demands or directives.
The essential point for family members to understand is that they are trying to build a therapeutic alliance with the person with addiction-and this is a skill that can be taught, even to non-clinicians, and even in the heat of a deteriorating clinical situation. Family members and friends can be coached to approach the person with addiction as non-judgmentally as possible, with initial offers of a listening ear, and with particular treatment goals in mind. The attitude must be that “we are together and we’re going to get through this,” rather than “you need to stop acting like a child,” or (even worse!) “Just say NO!”
After this initial approach is discussed, family members and friends can be coached on using basic elements of the Motivational Enhancement model.5 This is the key to most successful communications between human beings. The skills of fostering empathy, waiting for their loved one’s expression of reasons to stop using, avoiding arguments, and adjusting for resistance can all be taught as the most effective means possible for convincing the person with an addiction to get help. The most challenging aspect of this interaction style is helping the family and friends manage the resistance that they see as illogical or laughably inconsequential. The clinician can often help them prepare for this common resistance by practicing a role-play like this:
Edward: Mom, I can’t go to rehab and live there. I just don’t agree with all that God-stuff they talk about in AA. It’s not me. I’m not religious.
Sally: Well, I certainly understand that, and you’re a grown-up who can decide what you believe and what you don’t.
Edward: Good. You get it. The whole thing is ridiculous and there is no way I’m going to go into that place. Those freaks can’t help me with my relationship with Lexi and the kids.
Sally: Your relationship with Lexi and the kids?
Edward: Yeah, you know. She won’t let me see them any more until I stop drinking.
Sally: Oh honey, I know you love those kids.
Edward: I do. It’s messed up.
Sally: We have to figure out a way for you to get back into their lives.
In this role-play, Sally has been coached to avoid the bait of arguing about AA philosophy, or confronting directly Edward’s dislike for the treatment facility. Rather, she waits for Edward to give his own personal reason to stop drinking, which he quickly does: his love for his children. This should be the driving force in his desire for sobriety and can be used by Sally and the rest of the family for motivating him to enter treatment. The family can now emphasize Edward’s reasons, rather than their own, for beginning treatment and the eventual goal of sobriety.
Of course, in real-life situations, attempts to motivate the person with an addiction rarely go quickly, or smoothly. Families should be coached to focus on the eventual intended goal, with the understanding that the path will likely include setbacks and relapses. While keeping the safety of the person with an addiction in mind, families and friends can learn to accept-although not like-giving up ground in the service of remaining engaged and ready to help. For instance, a family may have to accept their child dropping out of school, or moving out of the house, or taking public assistance funds, all in the hopes of pushing the goal of treating the underlying addictive disorder.
The most painful situations occur when a family must withdraw resources from their loved one, in the form of declining to underwrite a drug-using lifestyle, and/or asking the person with addiction to leave the family home. If the family is unintentionally supporting the drug or alcohol use, these painful decisions must be made. However, barring any actual danger to those who love the person with addiction, family and friends can remain available to arrange treatment, help with applying for Medicaid, or driving to an AA meeting.
Clinicians should disabuse the family and friends of the fantasy that they can control whether their loved one enters treatment. Instead, a realistic understanding of their abilities can allow the group to function as effectively as possible, without the fantasy that they are omnipotent and can force the person with an addiction to accept treatment.
Families and friends often misperceive the range of available addiction treatments and venues. Contrary to public perception, a standard 28-day rehab is not the only, or even the best treatment available for addictive disorders. Families should learn about, and be able to promote, a wide variety of possibilities for their particular loved one, such as intensive outpatient programs, individual therapists, Medication-Assisted Treatment (MAT), and a range of peer-led support groups such as AA. It is important that all persons involved know that addiction treatment at a reasonable cost is becoming increasingly available, although it may not seem so from the glossy ads for high-end inpatient treatment centers.
Finally, families and friends should be coached to remain optimistic, persistent, and unwavering in their support for their loved one, and in their loving confrontations of the destructive alcohol or drug use. By helping the family and friends keep themselves emotionally and physically safe, while still promoting treatment, a clinician can advance the cause of treatment and an eventually solid recovery.
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. â