Dr. Michael Ascher invited Dr. Elana Rosof and Dr. Carrie Wilkens to coauthor this piece with him.

For people in the early stages of making changes in their use of substances, engaging with loved ones is almost always challenging. Joy, relief, and the hopefulness of a fresh beginning often intermingle with shame and worries about an uncertain future. The excitement of making the decision to change is often countered by the sadness, hurt, and anger that arises when family members continue to focus on the problematic past.

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Similarly, family members often feel uncertain about how to engage with their loved ones when they are trying to change their relationship to substances. Hope and excitement are tempered by fear and caution. While they are curious and desperate to know what is happening for their loved one, they can find themselves tiptoeing around the topic of drug or alcohol use and unsure whether and how to address it. Every moment together can feel unnatural and strained.

The dynamics around family relationships often consume a great deal of session time in our work with patients who are trying to make changes in their substance use.  We’ve learned that when our patients gain a better understanding of the potential issues they may face, they wind up with a much better chance of avoiding some of the most predictable problems they might encounter with their loved ones. In addition, when family members understand that behavior change is truly a learning process, they are better equipped to manage the ups and downs that come along with it.

Everyone wants to be understood and appreciated by their families as the unique and multifaceted persons that they are. This includes people who struggle with substance use. Unfortunately, if a person’s substance use has been causing pain, loss, stress and anger within a family system, those feelings are often center stage for a very long time. In addition, communication patterns within the family are likely to be deeply entrenched and resistant to immediate change.

In the early stages of change, managing both internal and external family expectations, while difficult, is imperative in setting the stage for open and positive communication and building trust. Helping our clients manage their expectations for each other also creates greater potential in turning the family system into a resource rather than a stressor. We find that it is best to have these issues clearly spelled out at the start of the process as everyone involved will be better served if they have more compassion for what their loved one is going through as they face the change process.  

7 Tips for the Individual in Early Stages of Substance Use Change

For the person trying to change their behavior around substances, it can be crucial to slow down and acknowledge that your previous relationship with substances may have pulled you away from your loved ones in ways that you have not fully appreciated. It’s likely that your family has missed you. It’s also likely that they are really angry or disappointed with you. And it’s likely that your family is scared about your future and for their own. The following suggestions are things to consider as you try to repair your relationships and build back trust. 

1- Mindfulness: When people are using substances they are often absent or neglectful of their relationships with loved ones- physically, mentally, and emotionally. The practice of mindfulness can help you to settle down and be more present with others. Mindfulness training can have a profound influence on the regulation of your internal emotions. While there is no universally agreed-upon definition of mindfulness, it is helpful to understand the concept as embracing humanness and accepting one’s body, thoughts, feelings and emotions without any judgment. Practicing mindfulness can lead to greater awareness, attention, openness, and insight, and can help you steady yourself as you try to meaningfully engage with your loved ones.

2- Self-care: Self-care is essential in order to be able to respond effectively to all of the various stressors that are common for people as they try to change their relationships with substances. Many people use substances to alter their sleep, eating and energy levels. As you try to make changes, you will need to shift from using a substance to using behavioral strategies. Making sure that you’re getting enough sleep, eating a balanced diet and getting plenty of exercise can minimize the frequency of setbacks in your efforts to change. Making sure you take better care of yourself physically will also keep you more balanced emotionally and help you be more equipped to deal with any ruptures in your relationships with family members. If you are well rested, you will be able to stay more emotionally regulated and therefore better able to resolve conflict or talk about highly charged emotional topics. If you are exhausted, it’s likely you will just lose your cool and either be at risk for relapsing to old behaviors or returning to old communication patterns that are not productive. 

3- Withdrawal: Understanding protracted withdrawal from a substance is important. Just because you’ve made it out of the acute period of withdrawal doesn’t mean that your brain isn’t still undergoing change. This healing period can make you more vulnerable to anxiety and depression that are symptoms of a syndrome called protracted withdrawal. As you go through this process you may not function emotionally, physically or cognitively as well as you would like. You may also be more emotionally reactive than you would like. It is not at all likely that your loved ones will understand what you are going through and as a result may not be as compassionate or understanding as you need. As you attempt to change, it may fall on you to discuss the concept of protracted withdrawal with loved ones so that they understand how it might impact your ability to make changes and your overall functioning during the early stages.

4- Patience: When you start to make changes it can be tempting to immediately apologize or seek overwhelming affirmations from loved ones for previous hurts or wrongdoings. It’s not uncommon to feel compelled to make promises like, “I’ll never hurt you again” or “I’ll never use again." Slowing down and realizing that you have a lot to learn can help you pace yourself and set more realistic expectations for your loved one. Try to empathize with your loved one’s experience and resist making promises that you can't keep. When people you care about are upset with you, it can be difficult to tolerate and there is an understandable impulse to “make it all go away.” It is critical, however, to let the people in your life have their emotional reactions and to try to give them the space they need to process them.

5- Patience (again!): Trust falls along a spectrum. Just because you are trying to make changes, doesn’t mean that you have regained the full trust of the people who love you and have been hurt, stressed or wounded by your decisions around substances. One of the hardest things for our patients to accept when they are working hard to change their behavior and goals, is that their loved ones continue to harbor resentments and engage with them as if they were still using. We hear this common refrain: “Sometimes, I wonder why I should continue trying to change when my family thinks I'm still using.”  As you embark on the change process, it is crucial to remember that it takes time to rebuild trust.

6- Empathy: As you try to make changes, it can be helpful to anticipate the various possible sources of discord between you and loved ones, and make a plan for how you will respond in the most effective way. The first step of being effective is being able to have compassion and empathy for your loved one’s reality.  Being empathic means imagining what your substance use must have been like for your loved one. This might include validating that you know they have been scared, frustrated, angry or confused. By explicitly communicating that understanding to them, you will promote mutual empathy and bonding.

7- Defend The Use Of MAT’s (Medication Assisted Therapies): There is an incredible amount of misinformation on the therapeutic use of medications (e.g., Naltrexone, Buprenorphine, Methadone, Antabuse) when it comes to changing substance use patterns. If you and your doctor decide that they’re helpful in your personal recovery, be prepared for criticism. It is still all too common in our culture that people question “using a drug to treat a drug problem.” Dealing with misinformation and stigmatized views about medication from your loved ones can be one of the hardest challenges to overcome.

7 Tips for Family Members

If you are someone who loves someone with a substance use problem, please know that you can play a crucial role in their change process. All too often, family members are told that they need to “distance with love” or let their loved one “bottom out.” These two phrases have contributed to confusion, loss and self-blame on the part of family members. Instead, we recommend that as a family member or friend, you consider the following:

1- Patience: As you witness your loved one trying to change, try and keep in mind that it is a process of learning. Peoples don’t just “get sober,” they learn to be sober. And just like any other learning process, it takes trial and error. If you can, try to trust that your loved one is at least engaged in the learning process and are trying to change their behavior choices. This may be terrifying given all the damage that has been done to the trust system. People want to trust...that is human nature and likewise, people want to be trusted. As your loved one works to make changes, it can be crucial to learn effective communication skills so that you can talk about things as they come up through the learning process. 

2- Increase Your Awareness: Read up on how substance use affects the brain and how habits (both healthy and unhealthy) are formed. Understanding what has been going on in your loved one’s brain may inform your responses and help you not take the things that happen during the learning process personally. Relapses and slips to old behavior patterns do not mean they are starting back at the beginning or that treatment has not worked. We look at relapse as something to address as quickly as possible, as helpful data about what the person needs, and an opportunity to learn about more subtle triggers and where to fortify coping strategies.

3- Show Interest: Your loved one has been through a lot and has probably gained a better understanding of why they use drugs or alcohol. They are also probably finding ways to deal with things differently. Get to know them how they are now. Ask about their discoveries but also respect if they prefer to be private about it.

4- Educate Yourself About Treatment Options: As your loved one begins the change process, they are hopefully getting support from addiction informed treatment professionals or self-help groups and it is important to reinforce these efforts. It is hard to ask for help and navigating the treatment landscape can be difficult and you will likely witness a fair amount of trial and error as they figure out what works for them.  Additionally, as they go through this process, they may decide to go on medications that greatly reduce the possibility of relapse such as Extended-Release Naltrexone, Buprenorphine, or Antabuse. They may also decide to try other psychiatric medications like antidepressants.  While you may have some concerns, try and be supportive as it is imperative that underlying issues are addressed. If your loved one goes to individual treatment, group therapy, or twelve-step meetings, be encouraging and understanding of the time commitment and support that they receive.

5- Offer To Help: Ask your child, partner, parent what they need from you. It may be to do less of something or it may be to do more. See what they ask for and brainstorm ways that you can be supportive of their efforts.

6- Manage Your Own Anxiety: Family members can gain a great deal by learning to manage their own anxiety. Self-care, entering their own therapy, and getting support can provide family members with useful ways to deal with fears of a loved one using again. There are helpful and not so helpful ways of harnessing these anxieties and worries. We often recommend an evidence-based program that helps families use a positive approach to communication called Community Reinforcement and Family Training (CRAFT). CRAFT helps family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. It also teaches families how to impact their loved ones in a positive way, while avoiding both detachment and confrontation.

7- Optimize Your Communication Strategies: If you feel your family member is relapsing, it is normal to feel anything from panic to rage. Responding with either of these hot emotions will not likely help you, or your loved one feel better. By learning effective communication skills (this is a part of CRAFT), you can increase your odds of talking about the issue in a constructive manner. By practicing self-care you will be better equipped to manage your emotions and think clearly as you try to problem solve. And finally, by understanding how to reinforce healthy, sober behavior and letting naturally occurring consequences have an impact, you can have an influence on your loved one’s choices (these are all skills learned in CRAFT). Finally, while you may not be directly involved in their treatment, you can always call or email the therapist and/or psychiatrist with your concerns. They may not be able to respond to your call unless they have a release of information, but at least they will have your observations and concerns. This is also a time to check in with yourself about best ways to care for yourself and other members in your family.

Deciding to change your relationship with substances (or any compulsive behavior pattern) can be a very difficult process with periods of enthusiasm and hopefulness, ambivalence, all the way to intense frustration and wanting to give up. It is important for the person with the problem and everyone who cares about them to fully appreciate that the process of change for most is like running a marathon through rocky terrain and in inclement weather. It is not a quick, fast sprint on a sunny day. We have found that people going through it and their loved ones do best when there is open and positive communication, respect for one another’s perspectives and needs, patience with the process, and safe places to retreat to when things get heated or overwhelming. Whether you are the person with the problem or someone who loves them, by educating yourself and embracing the need to learn new skills for living, you will be more likely to thrive during the process and come through with a stronger sense of self and family bonds. 

Dr. Rosof is a clinical psychologist in Philadelphia with a specialty in addiction and extensive training in motivational approaches. Dr. Wilkens is a Cofounder and Clinical Director of the Center for Motivation and Change in New York City and the Berkshires, a coauthor of “Beyond Addiction: How Science and Kindness Help People Change” (New York: Scribner, 2014) and Co-Executive Director of the CMC:Foundation for Change, a non-profit focused on training family members in evidence-based skills to help their loved one using substances.
 

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