A Swift Kick in the Pants

May 15, 2018

If you read our newsletter you hear us talking all the time about the science behind behavior change. And the science shows that working with motivation and using reinforcement strategies are two of the most effect ways to help a person abusing substances decide to change while direct confrontation is often experienced as aggressive and moves people away from change.

So why do we hear so much about tough love and confronting denial? When someone is abusing substances, they are typically having a negative impact on someone who cares about them (along with themselves!). Family members struggle with disappointment, fear (oftentimes terror), anger, financial strain, and sometimes verbal/physical abuse. People with substance use disorders also have an impact on our health care and prison systems and oftentimes are not able to contribute to the workforce. All of these outcomes understandably lead people to get mad and just wonder, “don’t these people just need a swift kick in the pants?!

Culturally, we are set up to believe that if you’re engaging in a behavior that is optional, like using/abusing substances, and that behavior is impacting yourself and others, the solution is to “try harder.” This is a country that has embodied the concept of picking oneself up by the bootstraps, that if you work hard enough, you can overcome anything. So there is a cultural component to the concept of tough love and confrontation; if you’re forced to look at the issues in your life, then you can fix them!

If there was any evidence, however, that a “swift kick” to the backside worked, we would not have the drug and alcohol problem we have in this country! All you have to do is look at our prison systems (which are bursting at the seams with substance users) and poor treatment outcomes using traditional methods to see that confrontation and aggressive measures do not work when it comes to engaging substances users in treatment or helping them change. In fact, confrontation and coercion are some of the least effective strategies and can predict relapse rates.

People use substances because they work, they have some effect that is “reinforcing” (e.g., “if I use cocaine, I feel less depressed” or “If I have a few drinks, I feel less pain”). A significant amount of the reinforcing effect is due to activation in the reward centers of the brain, which after a certain point of using substances become pretty automatic and routine. Things just feel better when using substances (either due to the direct euphoric effect or due to a reduction of negative effects like withdrawal symptoms). Punishment and aversive measures like yelling (or kicking) don’t tend to compete very well with these “positive effects,” and in fact may inadvertently become reasons to use (i.e., “if smoke a joint I can tune my dad out, he is so overreacting, “ “if I have a few drinks I can numb out the horrible thoughts I am having about myself because I know I’m such a screw up”).

Watching a loved one hurt themselves through the use of substances is maddening, so yelling, punishing and lecturing are completely normal attempts to address the problem. The reality, however, is that they seldom work and most family members we work with end up agreeing that trying something new is the best step forward. Typically, attending to self-care and setting consistent boundaries can start to have a positive effect!

The other variable that is often overlooked is the power of letting naturally occurring consequences play a real role in influencing change. Family members often try to use their anger, dismay, terror, or worry as a negative consequence (i.e., “if I show you my raw feelings, maybe you will feel the desire to change”). The problem is that by taking this approach you may be setting yourself up to “be the negative consequence” (i.e., “my mom is such a nag, she worries too much” or “my spouse is such a nightmare, she is angry all the time, I can’t win”). If you’re seen as a negative consequence, you’re significantly reducing your ability to help influence the change process!

At the same time, by expressing yourself in a way that makes you the focus of the negative attention, you may inadvertently or even purposefully be shielding your loved one from the naturally occurring consequences that would be the direct result of their substance use. If they can easily blame the family disruption on you (“everything would be fine if dad just chilled out some”), they don’t have to look at how their actions have impacted the system.

Learning CRAFT (Community Reinforcement Approach and Family Training) skills will help you tease apart ways that you can get out of the way of naturally occurring consequences and let them play a role in shifting your loved one’s behavior. CRAFT will also teach you how to use positive communication strategies so that you can express your feelings with greater effectiveness (even when you are angry!). While none of this is particularly “swift,” it is more effective.

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