The Family Factor

"I know about my son and his addiction better than he does,” a tearful mother in my office stated several years ago.

I remember the power of her statement. Although she was crying, the woman was calm and incredibly self-assured. As therapists are so fond of saying, “She had done the real work.” She sat before me, and the years of enabling now dissolved and distilled into her next simple, powerful statement:

“Maybe he's not responsible for his disease, but he is responsible for his recovery.”

“So how do we help him?” I asked.

“Actually, Jim,” she said matter-of-factly, “we can't. What we have to do is to find ways to help him help himself.”

This conversation took place some 20 years ago, and yet I somehow have never forgotten it. It helped me to begin a personal and professional process that I am still involved in—using the addict's family as a therapeutic tool for recovery.

This article is based on excerpts from my book The Family Factor. It is based on thousands of hours of interviews and hundreds of client cases. The book's goal is to present clinicians and families with practical, “how-to” ideas and activities that families can use in helping an addict help him/herself toward a genuine and sustained recovery.

Family's critical influence

The Family Factor is based upon the premise that of all the people involved with an addict, it is the natural support system that almost always constitutes the most decisive and powerful outside influence.

No one knows the addict and is invested in that person's success like the addict's family. Family members are the ones who have watched the disease's progression. They have enabled and have been “ripped off” countless times. They know the specific and unique components of the addict's relapse pattern and can predict, with uncanny certainty, what's going to happen next.

Historically, they are the ones who have provided money (what I refer to as the lifeblood of the addict), usually a whole lot of it. They don't just know the games—many times they have helped create them.

For the addict, almost without exception, the most necessary, influential, and dependent persons in their life are their family or “natural support system” (I use the two phrases interchangeably here). For right or wrong reasons, the addict always seems to gravitate back to the family. For the addict, the family often represents a primal source of comfort, blame, predictability, anger, resources, and insulation from an outside world that the addict simply cannot negotiate in any long-term sense.

We in the field talk a great deal about “enabling” in the family. But enabling should not be a dirty word, and doesn't need to be a dysfunctional process. Enabling is a high-energy expression of love for the addict. It takes two very distinct forms:

• “Dystonic” enabling, or dysfunctional enabling that advances the addict's disease

• “Syntonic” enabling, or functional enabling that advances the addict's recovery

Members of the natural support system typically arrive at the threshold of syntonic enabling only after they have passed though the dystonic phase and have given up in a healthy way. Borrowing from the 12 Steps, they have “come to realize they are powerless” and are ready to work with the therapist in treatment approaches based upon trust, realistic expectations, and natural consequences. This is the conceptual framework.

Potentially useful approaches

There are several practical approaches and activities therapists can add to their skill set in working with the addict's family.

The trust contract.

When in doubt, write it out! The centerpiece for real recovery with the family is the trust contract. It is conceived, written out, and signed by all parties involved. The trust contract involves rules (expectations), along with consequences for noncompliance. It is a living document that can be revised daily if necessary. It creates accountability and a concrete way to measure progress. It also greatly reduces the chance for misunderstanding and/or manipulation.

The kick-out.

This is sometimes politely referred to as “environmental manipulation.” It simply means the family demands that the addict leave their home. This major event should be used only under the following conditions:

• It is the result of a major violation of the trust contract, such as using substances or stealing.

• It is not done in an angry, impulsive fashion but rather in a matter-of-fact presentation.

• It utilizes successive approximations. For example, the first kick-out may be for two to three days. The second may be for five days to a week, and the third may be for two weeks to a month. It is hoped that the family never has to go beyond the first two efforts, if the next condition is met.

• The kick-out is utilized with the same intent as any therapeutic activity—namely, to facilitate a change in behavior. If the addict realizes that stealing $45 from Mom's purse will result in his expulsion from the home, and that experience is far worse for him than not having $45, he will (hopefully) reassess his behavior. I hedge here because any seasoned therapist knows there are so many variables in working with addicts (i.e., punishing the family for being kicked out, etc.). But this approach at least puts the addict in a position of real accountability and natural consequence for change.

Okay/no way.

The main reason why someone's residential rehabilitation stay may not succeed is because of a lack of continuity of care from rehab back to the addict's real-life environment. A concrete plan must be in place to translate what the addict has learned in rehab to day-to-day life. An okay/no way written document is a key component of this plan. It calls for all parties involved in the addict's recovery to list who, where, and what is allowable for the addict to experience, and what should be strictly avoided. The latter category includes but is not limited to old friends, places, and situations that could place the addict's precious recovery at risk. Like the trust contract, the okay/no way list is a living, breathing document and should be revisited frequently.

Understanding and arresting SAAS.

SAAS is an acronym for “Stunted Adolescent Addiction Syndrome.” It essentially means that whatever the addict's age, he/she is stuck or “stunted” in the adolescent stage of development as a result of active addiction.

The causative factors involved in SAAS relate to the idea that because the active addict is completely obsessed with using, he/she has not experienced the normal developmental patterns into adulthood. For years, the SAAS addict has been used to having a drug of choice immediately remove the normal stress from life's problems. Simply put, the addict does not know how to wait. Anyone who has witnessed the addict minutes before getting the drug knows about this high-anxiety anticipation.

SAAS can be characterized by the following behaviors:

• a near insatiable need for immediate gratification;

• poor impulse control;

• a strong sense of entitlement (i.e., Mom and Dad owe them and are supposed to “bail them out,” literally or figuratively);

• nonexistent or poor planning skills;

• a distorted view of money and money management;

• exaggerated evidence of some of the more common defensive behaviors in recovery (blaming others, minimizing, punishing family members, etc.);

• superficial compliance with treatment as evidenced by little or no real integration of the therapeutic message (i.e., always telling the therapist, parents, and other authority figures what they want to hear); and

• mental/physical lethargy and procrastination.

One of the most powerful treatments for overcoming SAAS is the introduction of a realistic, structured schedule for the addict. So much of the addict's anxiety is rooted in not knowing when or how the next high is going to come. A daily set of positive and predictable activities gradually serves as a meaningful substitute for the anxiety-producing, impulsive, and frenetic activities of active addiction. The therapist needs to work with the addict and his/her family to introduce a daily schedule commensurate with the addict's ability to handle it. Insight-oriented therapy with all parties involved, explaining SAAS in a nonjudgmental way, can set the stage for both acceptance and execution of a daily, structured schedule.

Catch them being good.

This use of positive reinforcement with specificity can help facilitate a genuine and sustained success for the previously mentioned approaches. Most addicts are sharp and can see right through the therapist's and family's superficial attempts to try to provide positive reinforcement. If the addict actualizes these attempts as being phony or patronizing, the entire recovery process can be inhibited.

One answer is for the therapist and family to do the work of carefully identifying situational reinforcers that are very client-specific. A former client of mine was a chef who took great pride in his culinary skills. His father had decided to buy his wife (the client's mother) a set of cutlery as a gift. Rather than just go out to buy the item, the father saw this activity as an excellent opportunity to defer to his son's expertise in this area. This became a genuinely reinforcing experience for the family, as the reinforcer was specific to the client.

By examining the client's preaddiction history, with past vocational, athletic, and academic skills and accomplishments, the therapist can guide the family toward situational reinforcers that are at once authentic and specific to the addict.

Stop the world.

The final technique to mention is a mental activity, but is not unlike physical exercise for muscular development in the sense that it requires repetition in order to be successful. “Stop the world” means that whenever someone in the addict's family is confronted with an activity or behavior about the addict (i.e., requests for money, use of car, visitors, etc.), the family member should ask him/herself the following question: Will this enable my loved one's addiction or will it enable his/her recovery? I would encourage the family member to explain the decision to the addict.

It is the therapist's job to help the family move beyond the guilt and compunction so often associated with the misperception that enabling is a bad thing. Enabling is a high-energy expression of love for the addict and should be reevaluated, then redirected, toward behavior that enables recovery, not addiction.