The most recent report from the Substance Abuse and Mental Health Services Administration (SAMHSA) states that approximately 24 million Americans are dependent or addicted to some type of drug. This may include alcohol and prescription opiates, or illegal substances such as heroin. As astoundingly high this number already is (9.5 percent of the US population over the age of 12), it does not include non-addicted individuals whose lives are profoundly affected by substance abuse. The decisions and actions of someone who compulsively uses drugs inevitably affect the lives of their family, friends and colleagues. Moreover, these affected individuals contribute and get caught up in a cycle of rage, enabling and confrontation. This only serves to deepen the addiction, alienate the person who’s using and add to the intense suffering all around.
Characteristics of the Individual with Addiction
A person who has become dependent has made it to a state where s/he will choose short-term goals (i.e. taking drugs) over long-term values (eg. family or work). They depend on the drug to manage emotions, be those positive or negative. At a calm and satiated moment, someone who is using may feel utterly committed to valued and shared goals. However, factors such as stress, exposure to people, places or things associated with the drug, withdrawal, or exposure to the drug itself, usually result in a sacrifice of those values for drug use. For example, they end up using rather than studying or spending quality time with their family, often with dreadful shame after. Over time, they develop an identity and self-understanding that becomes intricately linked to the drug-related experience. This takes precedence over family relationships, links to the community or the promise of an exciting and successful career. If pain was a trigger for drug use, then the relief and avoidance are highly rewarding and compulsive with an erosion of distress, tolerance and coping skills. Once the drug is gone, everything is worse and solutions once again seem more narrow.
Typical addiction treatment protocols focus on withdrawal and detox, as well as surrender to a higher power and limit-setting. They often advocate an ‘all or nothing’ approach. This means treatment goals are set around complete abstinence or withdrawal. Anything less than this is unacceptable and seen as a form of enabling the drug user and condoning use. Failing to meet these goals often leaves the individual that’s using feeling stressed, ashamed and isolated, and without alternatives. They may feel resentful of the pressure and expectation placed upon them; and the lack of understanding for their distress and pain. To the outside world, this can look like denial. But it is actually a dogged holding on to the one solution that their brain and experience has shown them to work – even if they get it that it sucks for them and everyone else.
Effect of Addiction on Family Members
The toll that addiction takes on the people whose lives are inextricably linked to the individual who is using can be tremendous. Family members often report feelings of anxiety, helplessness, guilt, despair, and anger. Some are ashamed to have a family member wrestling with addiction, while others feel responsible for the addiction of their loved one. It is not uncommon for family members to take sides against one another in terms of how to deal with the addicted member. For example, some would insist on bailing the family member from any problematic situation caused by their drug habit, like being sent to jail for drug possession. Some family members go out and buy the drugs, protecting their using child from the dangers of copping drugs directly, whilst ignoring the risks to themselves. This is driven by a loving desire to protect but clearly enables the use by shielding the user from natural consequences that may dissuade them. On the other hand, other family members insist on ‘tough love,’ in order to push the using family member to hit a ‘rock bottom’ and suffer the consequences of their drug-centered actions. But such approaches, fueled by anger and rigidity, can extinguish feelings of love, cause harm to the user, and breed resentment that can last forever.
Without timely and effective intervention, addiction can tear families apart and cause irreparable harm to relationships. It’s ironic that drug addiction breaks families apart, just when the addicted member needs his or her family around them the most. Alienation often extends to friends and professional colleagues as well. The drug can serve as the strongest attachment for the user: reliable, soothing and compelling, when other bonds may have been lacking, inconsistent or painful. Ultimately, of course, the drug has no reciprocity, no reliability and causes deep pain. Addiction erodes even the strongest bonds of relationship, leaving the addicted individual more alone and vulnerable. Without the support of their family and community, they become even more susceptible to the lure of the drug experience. A vicious cycle gradually emerges where the user falls deeper into addiction and farther away from the very connections that can keep them tethered to what makes life meaningful. At the same time, the family becomes burned out, angry and split.
It is not only the person using whose health and physical well-being are threatened by addiction. Constantly dealing with contradicting and negative emotions can affect the physical and mental health of family members as well. Insomnia, eating disorders, high blood pressure and other stress-induced conditions are often reported by people living with individuals deep into their compulsive use. This may not be all caused by the addiction, of course. Genetics and shared developmental experience and trauma may be expressed in different ways in different family members. Impulsivity may cause some to use drugs early and others to be more violent or antisocial. A hyporesponsive stress system may lead some to seek novelty and find drugs more compelling, and others to be less emotionally responsive, contributing to a sense of aloneness in the user as a child. Drug addiction costs America roughly $484 billion every year. But this only pertains to healthcare for the addicted individual, lost earnings, and costs associated with accidents, crime, and jail maintenance. If the cost to affected family members is factored in, this amount will undoubtedly be much higher.
Many people are highly ambivalent about stopping use. Even when they already derive less pleasure from using, they still turn to drugs to manage their emotions and relieve stress. In contrast, the family is usually in action phase, seeing all the downsides of compulsive drug use and being more than ready for an immediate intervention. This discrepancy can drive the addicted person to protect their addiction or maintain that the addiction is only the perception of the people around them. This can cause the family to focus entirely on the drug use as the problem, ignoring their contribution to the evolution of the drug use and perpetuation of the cycle. Both sides dig in. This dynamic blocks everyone from feeling and exploring their own ambivalence and grief. In place come shame and rage, resentment and name-calling. The interpersonal interactions get lost and the addicted person is labeled as being ‘in denial.’ This is a simplistic and dismissive label that shuts down collaboration. This makes it even harder to engage the person in treatment.
While it may be too strong to say that drug use is caused by family relationships, they exert a huge influence. Warm, positive, encouraging and open relationships encourage cohesiveness and permit discussion of worrisome behaviors. In contrast, strained, angry or weak connections can foster avoidance behaviors like drug use. Once established, the drug habit and associated alienation and impulsive thoughtlessness of the addicted individual acts like acid on the bonds that hold families together. It destroys relationships and corrodes the values and shared experiences that typically bind family members. In such a fragmented state, it can be nearly impossible for any single family member to exert a positive influence on the addicted member to seek treatment.
An important frame to understand relationships in and between the individual and his or family is the attachment lens. A user may be (or become) avoidant, withdrawing from their alcohol or drug use. Often this is to fend off unbearable feelings of rejection, guilt or aloneness. However, the effect on caring others is often contrary to their wishes, in that they may become anxious and pursue the withdrawn person, which can feel nagging or punitive.
Other times the alcohol or drugs may make the person more demanding and connection-seeking, though in a maladaptive way. They may be clingy, desperate, aggressive or demanding – for the duration of intoxication perhaps. This might drive the other away, causing them to withdraw, thus perpetuating the cycle. Often, the cycle becomes disorganized so that people switch between anxious and avoidant attachment styles, between pursuing and withdrawing. Eventually, both parties may get exhausted and burn out, both withdrawing in different ways – to other sides of the bed, to affairs, or their drugs. Different family members may take different roles – one being anxious and desperately imploring, the other aloof, punitive and protective.
Community Reinforcement Approach – Family Training (CRAFT)
One treatment option has been proven to be highly effective in bringing addicted individuals to therapy, keeping them in the program, and helping family members assist them in reaching their goals. The program is called CRAFT, which stands for Community Reinforcement Approach – Family Therapy.
CRAFT draws on behavioral therapy, motivational interviewing and stage-of-change models. Rather than focusing exclusively on the individual who is addicted, the program engages the family, partner or friends who are woven into the actions and decisions of the patient. CRAFT has consistently been shown to succeed in getting individuals to engage in treatment and reduce their use of other drugs, far in excess of standard intervention models, whose outcomes are frankly dismal. (I am not aware of studies specific to opiate-addicted populations but we, and the few other programs that also utilize this treatment, see vastly improved rates of engagement and family satisfaction.)
Rather than attempt to figure out the feelings and teach effective communication in the midst of the swirling storm of attachment styles, the family or partner is seen apart, separately from the using person. Their emotions can be teased out, validated, softened and then their responses are amenable to teaching. If they are withdrawn, they can be re-engaged. If they are reactive pursuers, they can be softened. Identifying and validating their feelings and attachment needs is the first step that will hopefully lead them to later understand, empathize, and reach the person that is using. It is important to note that the person that is actually using can often be left out of the treatment at this stage. It is essential to first interrupt the cycle of avoidance and reactive pursuit or burned-out withdrawal. This makes working with the non-using parties much easier. Once things are calmer, or drug use is eased, there is a renewed capacity for empathy and connection, and greater resilience in everyone, permitting more traditional couples or family approaches to stick.
The program equips family members with the knowledge and skills to identify and modify their own reactions and expectations towards the person who is using. It breaks the cycle of ineffective enabling and reactive pursuit of connection that is felt as nagging, punitive and exhausting by the using party. Family members are encouraged to set limits for themselves, which certainly requires a degree of acceptance of the things they cannot change, but also asks them to acknowledge that their interventions have been at best useless and at worst contributory. There is a focus of self-care and self-compassion and grieving, which softens the desperation and interrupts the cycle while opening the possibility of empathic engagement with the suffering and loneliness of the using person.
As an added bonus, education of the family facilitates medical decision-making, including options to use medications such as Suboxone or Vivitrol. Patients are often ambivalent and need someone they trust to bounce ideas off. Families, picking misinformation up from the internet, can deter patients from making sound choices. Often the family wants them to be completely ‘medication free’ without appreciating the length and severity of the drug use. In pursuit of this goal, families often disregard the data on recovery rates with medication assistance versus without medication assistance.
For more information on how we approach CRA-FT, please see our family therapy page.