Question 1

What is motivation to seek substance abuse treatment?

Jeff Foote · Accepted Answer

Good question!

Sometimes change happens due to external factors which influence motivation (a sudden illness, a legal mandate).  External motivators, however, are usually not that great at really shifting internal motivation  -  which is what needs to be in place for change to be maintained over the long haul.  Even very serious external motivators don’t always work (i.e., “I keep smoking even though I have a spot on my lung,”  “I keep going to the bar at night to drink even though my wife says she is talking to a lawyer”).

In order to stay motivated, it is best to really work on accepting that change is a process.  Just like you don’t gain 30 pounds in a week, you won’t lose 30 pounds in a month (without some other potentially serious consequences). Change takes time and returns to old behavior are the norm.  It’s all part of learning.

Unfortunately, many people (addiction treatment providers, family members, people struggling to make changes) feel that slips (returns to old behaviors) are a sign of low motivation (a personality trait, as a character defect, as a reflection of their moral compass).  In other words, many people think that if you return to an old behavioral habit then it is a sign that you are “unmotivated”, “not ready”, “in denial”.

The reality is, a significant portion of the time slips are an example of a skills deficit.  I “don’t know how to do this”...so “I’m going to go back to what I know is comfortable”.  Slips are often a sign that the person trying to change has run into unanticipated obstacles, and does not know how to cope.  If you find yourself meeting slips with anger, despair, or pessimism...try to slow down and reflect on the events, feelings, and thoughts that preceded the slip.  Is there something about the change process that your loved one did not anticipate?  Something they did not know how to handle?  Was their motivation to keep changing shakier than they were aware of  - and can you help them  identify what was knocking them off course?

Slips require self reflection and a return to planning for next steps with hopefully increased awareness.  And making changes over the long haul requires your loved one to have a fine tuned attention to their internal motivation.  What are the variables (people, places, things, feelings, situations) that increase their desire to make changes?  What are the variables that pull them back to the old behaviors or cause their motivation to lag?

Whatever you do, try not to respond to a shift in their motivation as simply a sign that they are “unmotivated”...it is almost never that simple.

Helping them do the work to understand what is happening to their motivation will go a long ways toward helping them decide how to keep it steady and stable.

Question 2

Does it work to confront someone about their addiction?

Jeff Foote · Accepted Answer

When someone you love is using substances or engaging in a host of other risky behaviors, it’s natural to feel afraid, angry, betrayed, ashamed, and confused. It’s also normal to find yourself expressing these emotions by yelling, lecturing, shutting down, and maybe even throwing a few things.

The problem with this approach? It tends to take attention away from the problem at hand (”you drank too much last night”) and put it back on you (“you’re yelling and are always so negative”). Even worse, direct confrontation leads to increased resistance when it comes to asking a person to make a change. This we know from a number of studies on motivation.[Confrontation In Addiction Treatment, William R. Miller and William White October 2007)

Then why do so many of us still hold ideas like this: If I don’t confront him and show him how upset he is making me, why would my loved one ever decide to change?

Welcome back all that anger, fear, and confusion. When you have a loved one who is struggling with behaviors that are dangerous, like alcohol and drug use, it’s normal for parents and loved ones to do anything that feels like it might effect some change. Unfortunately, while it might feel that directly hitting your loved one with the harsh facts would jolt them into a desire to change (“you look like a drunk”), there is a significant chance that you are likely driving your loved one further away both from your goal, and from you! And, most people actually feel worse after acting on their negative emotions because they escalate a variety of negative responses in others.

So then, how are you supposed to address the issue that feels like it is changing your loved one into someone you don’t know and harming your family?  How do you handle that next morning, when you’re so angry and afraid, and just want to lash out? How do you help them (and you!) start to move to a place that feels safer and more manageable?

Start by managing your negative emotions. The goal is not to banish or “solve” these feelings — that’s impossible — rather to manage them so you don’t act on them with your loved one. For most, the first step to managing negative emotions more effectively is to shift the focus onto your own self-care.  Being well-rested, practicing relaxation techniques, blowing off steam through exercise, staying connected to outside friends and interests can all help you keep your balance.  Engaging in good self-care can also keep your negative emotions from bursting out of you in the form of confrontational or hostile behaviors that push away your loved one and take you further from your ultimate goals.

Another helpful technique for managing your emotions is to be more aware of them. While it might feel backwards, being more aware of your negative feelings can help you manage them. For example, instead of walking around trying not to be mad until your reach the point your head is going to explode, if you know you are about ready to boil over into a confrontation, you can choose another path (https://the20minuteguide.com/parents/helping-self-care/managing-your-emotions/). You can walk away to cool off and take care of yourself so you can return later with the potential for a productive conversation. Additionally, if you learn positive communication skills (https://the20minuteguide.com/parents/helping-with-words/positive-communication/) you will improve the odds that you express your feelings in a way that your loved one can hear and may be interested in acting on.

Question 3

How can you show compassion towards a loved one without enabling the substance misuse?

Jeff Foote · Accepted Answer

We know that using positive reinforcement as a helping strategy probably goes against some advice you have heard. It’s not uncommon to be told that in order to help someone with a substance use problem, you need to confront the problem head on, challenge their denial, punish bad behavior, or distance yourself until they find rock bottom and decide to change on their own. You have probably also heard that if you do anything to directly support your loved one then you are enabling them.

Think of positive reinforcement as watering the flowers in your garden, or catching your loved one being good, as rare as that may seem at times. Try to step back and look at the larger picture to find positive behaviors you can reinforce. For example, if you notice a rare day that your loved one is sober, or that they got up in the morning and went to work without your prodding, tell them that you appreciate it. Strategically reinforcing your loved one’s constructive behaviors has the potential to help change the tone of your relationship and informs your loved one that you see a positive or healthy behavior. It gives you permission to stay connected and deliver positive messages instead of always being the negative, avoided person in their life, which can help both of you feel better. It will also help sustain motivation over the long haul, as a strong behavioral garden takes time and ongoing watering is needed to allow it to continue to grow. 
Positive acknowledgement and reinforcement of positive behaviors is a great thing to try to do! It is not “enabling”!

Question 4

How do I show compassion for my loved one when I feel angry at their lack of motivation to change their substance misuse behaviours?

Jeff Foote · Accepted Answer

The first step is to gain perspective on your own feelings and the problems you are facing.  These may include some of the following common feelings:
Disappointment that your family isn’t “normal,” that your dreams for your loved one (your child, your spouse, your sibling) and your family life elude you; more specifically disappointment that your loved one relapsed again, lied again, cut classes again, got fired again…
Anger that your loved one is putting you and your family through this, that they don’t seem to care about your suffering or appreciate what you are trying to do for them...
Fear that your loved one is blacking out, driving drunk, dropping out, ruining their life, maybe even going to accidentally kill themselves...
Discouragement when your loved one doesn’t change after a long heart-to-heart, a scary incident, a second time in rehab…
Shame over your loved one’s choices, the suspension from college/lost job, their rudeness or anger in public, their choice of friends, inappropriate clothes, not taking care of themselves… 
Sadness that you can’t talk to your loved one, that you talks always turn into fights, that your loved one doesn’t seem to want a happy life that you always wanted them to have…
Guilt because you blame yourself for causing or contributing to the problem or at least for not preventing it. Wondering whether you give your loved one enough attention or too much, have been too demanding or not demanding enough into infinity.  You wonder if your divorce, temper, or tendency to drink one too many drinks caused the problem…

There are two things to remember about these emotions: 1) it is totally reasonable and normal that you are feeling some or all of them, and 2) it is very helpful to moving forward constructively if you can acknowledge them to yourself, but not have them play out in your discussions with your loved one. If they are, they will likely drown out any other message you are delivering.

We list some of what you may be going through emotionally as almost a gruesome, “greatest hits” list of how hard this all can be. We also list them for another, totally practical reason as well: Your feelings are valid and are a direct result of the complicated, painful problem that you face if your loved one is dependent on substances.  At the same time they need to be managed if you are going to be successful in instigating change.

Strategy Session: Don’t Take It Personally - How can you keep that confusion and fog of emotion from knocking you off your course as you try and help your loved one make changes? We suggest that you try and understand going into any given situation that it has the potential to be emotional for you (often), and work to stay calm.  A major help in this? Don’t take your loved ones decision to use substance personally. This may seem like a very odd way to interact with your loved one, but it is critical to keeping your balance and not sinking when the going gets tough, like when they are snippy, they are lying, they are late, they are doing any number of things you feel insulted/hurt/disregarded by.

We know this is difficult, and actually feels artificial and unnatural. “I should be able to speak my mind”, “I can’t let them get away with this crap”, “they need to know how much they hurt our feelings”. All valid feelings, but not necessarily valid strategies  - and we are in the strategy business of trying to most effectively encourage positive change.

This text comes from an article, “Don’t Take It Personally”. You can read the rest of the article at https://cmcffc.org/article/dont-take-it-personally

Question 5

What is the most helpful way to react when finding out a loved one has relapsed and has been lying about it?

Jeff Foote · Accepted Answer

Lying is a tool that almost everyone uses at one time or another to try and mitigate negative reactions and emotions in others. It’s a human communication strategy that is as old as time itself. When you know that telling the truth is going to cause the other person to react negatively, it can be tempting to change your story in order to keep things running smoothly and maintain the relationship. We’ve all done it, and we’ve all seen it work.

When you have a substance use problem, odds are someone in your life has negative feelings about what you are doing.  They are at the very least confused, and more likely frightened or angry (most likely both!). When people you care about are upset with your behavior, it can feel like all eyes are on you and that’s a lot of pressure, especially when you are engaged in a behavior pattern that you may very well be ambivalent about! Maybe you have told them you want to change (and you actually do want to!) but keep getting faced with situations that you were unprepared for and you have old habits kick in. There may be other times where they really want you to change and you just don’t have the same concerns.  Regardless of the reason, if you have friends and family watching your behavior closely, there can be a very normal impulse to lie and try to convince everyone there is nothing to look at!

And when you think about the issue of lying you cannot discount the effect of stigma.  When you’re really struggling with a behavior problem that is stigmatized, like abusing drugs, there is the added component of shame.  The temptation to lie about behaviors you feel ashamed about can be really strong. And, once you’ve lied, it can hard to resist telling more lies in order to maintain the story you’re trying to portray. Because not lying will often put you in direct contact with shaming responses from the outside world.  Hence, the cycle continues.

So, if your loved one is struggling (and struggling to tell the truth!), how are you supposed to talk to them and get them to tell you what is actually going on so that you can support them?  Or help them want to change their behavior? How should you communicate with someone that you suspect is in a cycle of lying described above? How do you have a conversation when you can’t trust what the other person is saying?

You can begin by thinking through what your goal is for the conversation.  What do you want to get out of it? Do you want them to just hear your thoughts and concerns? Are there specific behavior changes that you’d like to see? What are you hoping they will share with you and why?  How will having that information help you? Are you hoping to open up a line of communication that will continue over time?

Each one of those topics may require different ways of communicating. By figuring out where you want to end up, you can focus on managing your part of the communication, regardless of what the other person is saying. For example, if you heard that your daughter got fired from her job, and she’s saying that she was only late once but they just “have it out for her” (and you don’t believe that she’s being honest with you about her tardiness), it helps to think about what you want to achieve in this conversation. Perhaps your goal is to help her think about what she needs to do to get a new job, or to help her think through strategies for being on time regularly. Neither of those topics require her to “fess up” and be more honest, instead they circumvent the lying and steer the conversation toward topics that can help her do better moving forward. Focusing on the lie can move you away from your end goal of trying to support positive behavior change.

Sometimes however, the lie must be addressed. In these cases, it can be helpful to step back and try to understand the “function” of the lie.  Try to hold the idea that the lie (“I’m not using”) is probably not meant to be hurtful, rather it is an unsuccessful attempt to maintain the relationship and avoid the discomfort of a fight or confrontation. See if you can speak to the function of the lie, (e.g., “I imagine it’s hard to be honest when you know I am upset and you are ambivalent about stopping”).  It can also be helpful to tell them you will try to manage your response so that a honest conversation can actually happen (“I am going to try and stay calm while we talk so that you can maybe tell me what is going on.”). And most important, try to spell out your overall goal for the conversation (e.g., “I want to understand what you are experiencing and try to be helpful if I can be”).  And if you do happen to get a response that feel like an honest one, don’t forget to reinforce them for being honest (“thank you so much for sharing that with me, I really appreciate your honesty.”)

This text comes from an article, “How To Talk When You Think They’re Lying”. You can read the rest of the article at https://cmcffc.org/article/how-to-talk-when-you-think-theyre-lying

Question 6

What do you do when your partner acknowledges they have an issue and still continues the same pattern of behavior?

Jeff Foote · Accepted Answer

One of the key ideas we train parents in is that ambivalence is normal. Your loved one was using substances for reasons that make sense (even though they may also be causing problems), and those reasons  don’t necessarily go away just because I also want to change. In other words, if I smoke pot to reduce my anxiety and help me sleep and I start to change that pattern, I know that returning to pot will still provide that benefit! So, it can be really helpful to be able to encourage open discussion of this tension: the pull to change, the pull back to doing things that “worked” in some real ways.  Providing an understanding aren to talk can allow some real problem solving; otherwise, they may go underground when that pull back to old behaviors occurs.

Question 7

Like with some complex trauma can an addiction/person to a substance be resistant to treatment and is once an addict always an addict ?

Jeff Foote · Accepted Answer

NO! But it is also helpful to be aware of language and its impact: terms like “addict” convey the idea that all people struggling with substances or other compulsive behaviors are the same..the entity called “addict”, and this has then become a stigmatized, “one size fits all” pejorative term, one that adds to stigma and shame and people not seeking the help they may need. Last, people change over time...all the time!

Question 8

What is your opinion on 'tough love' approaches to kids using substances?

Jeff Foote · Accepted Answer

If there was evidence that tough love worked, we might recommend it. But studies show that confrontation and aggressive measures don’t engage substance users in treatment or help them change. In fact, confrontation and coercion have been shown to predict relapse in clinical research studies – that is, they make things worse. And why? The overarching concept is that increasing a person’s internal motivation to change will provide a path to sustainable, robust change; when it matters to them, they will engage in the work of changing, which really is work! “Tough love” approaches tend to do the opposite: they underline that the reasons for change are mine, not yours: “if you don’t stop, I will force you to”!

People use substances because, in one way or another, they work for them (e.g. ‘If I use cocaine I feel more confident’ or ‘if I have a few drinks I feel less pain’). Punishment and aversive approaches like yelling don’t compete very well with the powerfully reinforcing effects of substances. They may even become reasons to use if substances help your loved one to tune out or forget about your reactions.
What makes things better? The evidence supports understanding, positive reinforcement, problem solving, and allowing the natural negative consequences of substance use to occur. Communication also helps, and the communication skills in the 20-Minute Guide and the Invitation to Change Approach can help you express your feelings more constructively (even when you’re angry!). These strategies aren’t always as ‘swift’ as kicking – but they are more effective.

Question 9

Hi Jeff, what is your opinion on doing "an intervention" to motivate a loved one to go to treatment for their addiciton?

Jeff Foote · Accepted Answer

Again, the data on “interventions” as a way to produce change are abysmal: in the few controlled research studies investigating this method or approach, the rates of successfully engaging people into treatment ranges from 0% to the mid-30s%! In head to head studies comparing “intervention” to CRAFT (the leading evidence-based approach for engaging loved ones who are struggling), CRAFT was found successful between 60-70% of the time, while interventions were successful around 30% of the time. And this does not measure the after effects: we cannot tell you the number of times we have treated people post-intervention who were still struggling with feeling betrayed and angry at those who had orchestrated their intervention.

Does this mean there are no intervention success stories? Of course not, but again, if we are comparing apples to apples, we need to see that 1) they have a low engagement rate and 2) they have carry on effects that can be long lasting and negative.

We generally and strongly recommend using motivational approaches rather than confrontational ones to get people to consider substance use treatment (or any other path to change that seems appealing and accessible to them). There will also be situations in which you feel that waiting for your loved one to decide to go into treatment on their own is dangerous for you or them, and that an intervention is the only option. This is also understandable and at times warranted, and certainly could be something to consider in those situations. We would also point out that in the realm of ‘interventions” there is an intervention method called ARISE that is much more collaborative and user friendly for everyone; if you feel an intervention is critical, we might recommend starting there.

Question 10

What tips can you provide to help with the frustration of seeing a loved one making progress with drug addiction yet frequently relapsing?

Jeff Foote · Accepted Answer

One of the main things to understand about using substances is that the person using is using for a reason (or many reasons), and that these not only “make sense” to them, but will not magically disappear. So even when they are engaged in wanting to change, the pull back to old ways will remain: this is natural and to be expected, and will be part of a process that might well be “one step forward and one step back”. While this can be frustrating, it may help in realizing it is normal to then be able to not take it so personally.

Question 11

What can be done when a loved one is not motivated to deal with their addiction?

Jeff Foote · Accepted Answer

Perhaps the best advice we can give you here comes in one word: “listen”. Communication often breaks down in the face of frustration and the lack of apparent movement toward change. If you can slow down and realize that often each person has gone to their defensive corner, and start to counter that, you might be able to have an impact on motivation, or at least start to create conditions of possible change. And here, the most basic but often forgotten communication tool in the toolbox is helpful: just slow down, and let yourself listen; ask open ended questions (part of Motivational Interviewing), try to come at them from a genuinely inquisitive position instead of starting with an agenda, and see what happens! Often this is the beginning of more open talk, and all you can ask for at that time: the possibility of considering something new.

Question 12

What factors contribute to substance abuse?

Jeff Foote · Accepted Answer

There is a lot of ideology around this question unfortunately, with a very common idea in the U.S. culture being the idea that substance struggles are best characterized as a “disease”. There is not enough space here to comment on this idea/ideology, but the evidence around substance use seems to best support the idea of the “bio/psycho/social” model. That is, for any given person who ends up struggling with substances or using them in a destructive way (a MUCH smaller number of people than the number who use alcohol and other drugs), what contributes to that person’s struggle could come from biological predispositions (“my dad was a very problematic drinker”), from psychological issues (“I have PTSD”; “I struggle with anxiety”), or social factors (“all my friends drink”). Most importantly, the contribution for each person is a mix of these, and in that sense, this way of understanding this struggle allows for helpers to examine what factors might be most relevant for their loved one, instead of assuming a monolithic idea that there is a “disease”, a concept that is both factually untrue as well as practically unhelpful.

Question 13

What makes a person prone to substance abuse?

Jeff Foote · Accepted Answer

The current scientific evidence supports an understanding of substance use and substance use disorders as involving psychological, biological, and social factors, and the mix of what is included for each person is different. The evidence also supports the idea that substance use disorders fall on a continuum of severity and can be positively influenced at any time. People can be helped, but their individual reasons for using substances need to be understood as part of the helping process. Black and white assumptions of what “addicts” and their families all need are stigmatizing and harmful.

Question 14

How does your approach view the disease model of alcoholism? Is abstinence necessary or is moderation a realistic goal for some people?

Jeff Foote · Accepted Answer

The United States treatment system (and public), unlike many other countries’, has traditionally held a black-and-white view of substance abuse as a “disease” for which abstinence is the only treatment. The data about how people really behave and change contradicts this view. For most people use falls somewhere on a continuum between unproblematic, problematic in varying ways and degrees, and destructive; and for most people change is gradual, a process of weighing the costs and benefits and then deciding to make change, usually incrementally until the problem behavior has changed enough. For some, this can result in successful moderation; for others, abstinence is required to eliminate the negative effects of their use. The bottom line? It’s different for different people.
Often by the time people seek professional help they are experiencing substantial problems. They may feel that abstinence is what they need, and that is how we focus their therapy. If, usually after a period of abstinence, someone wants to test the waters and see if controlled use is possible, he or she must take on this question in an honest and responsible manner: “Either I can use in a controlled way or I can’t, but fooling myself is no longer a useful option.” Clients collect data that we help them interpret, and they may conclude they are not reasonable candidates for moderation. Each client realizing this for him- or herself is a powerful predictor of positive outcome and sustainable change.
Studies have demonstrated a fascinating fact: when we collaborate with the person who is struggling, that is, ask them what they feel is important to them, their chances of positive change increase enormously...whatever their goals are!
Our approach is based on respectful, non-shaming, non-judgmental ways of relating to clients. This has been shown repeatedly to result in clients being open and truthful about their struggles, as opposed to hiding them and “faking good.” In this setting, whatever their goals, we can openly explore and track with clients how well they are doing.

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