Hope in Hell
To accept the things you cannot change . . . to change the
things you can . . . to know the difference.
—Adapted from the AA motto
This book is different.
You may have picked up this book in desperation, you may be afraid nothing will help, but we are optimistic we can change that.
Maybe your husband’s drinking increased after the kids went to college and you worry it’s only going to get worse. Maybe your grown son doesn’t return calls anymore, seems uninterested in working, and smokes a lot of pot. Maybe your daughter has stopped eating, or maybe she can’t seem to stop. Maybe your elderly mom sounds slurry every time you call her in the evening, but never remembers it the next day. Maybe your brother is back in treatment, again, for methamphetamine abuse. Substance and compulsive behavior problems*can take endless shapes and vary in terms of severity, scariness, and heartbreak.
Families come to our program every day with these and many other serious problems. Still we are optimistic. We don’t mean that maybe you’ll be lucky or that it’s no big deal. We are optimistic because we know change is possible. If your own optimism has gotten shaky in recent months or years, we invite you to borrow ours for now. Take this book like a steadying hand. And know that you can make a difference.
As researchers and clinicians, we’ve seen the evidence over the past forty years that families and friends make a difference in helping someone who struggles with drinking, drugs, eating, or other compulsive behaviors. Often, it is the critical difference.
*From this point, we use “substance use” or “substance problems” as shorthand for addictive disorders and compulsive behaviors. The principles and strategies in this book apply to any kind of compulsive behavior problem, from drugs and alcohol to binge eating, shopping, gambling, and Internet pornography.
We also know that people get better, and there are many reasons to be hopeful. However, you’re probably more familiar with the popular notions of intractable character defects and progressive, chronic disease. There’s widespread pessimism about the possibility of real change. Addiction can be terrible—at times life-threatening. But change is possible, and there are clear paths leading to it.
This is why, ten years ago, we created a new treatment program, the Center for Motivation and Change (CMC), in New York City, where we are part of a revolution in addiction treatment based on evidence and on a new model for change.
We built our practice on optimism, not because it made us feel good, though it does, but because it works. We base our optimism, our clinical practice, and now this book on forty years of well-documented research on how substances and other compulsive behaviors affect people, why people use them, and how and why people stop self-destructive behavior and start on paths toward health and happiness. In turn, our experiences with thousands of clients bear out the research findings.
There is in fact a science of change.
Every day at CMC we see clients put it into practice, using the knowledge, attitudes, and skills you’ll find in this book. It takes time, and it is not usually a straight or smooth path. But it is a better way. Things can and do change. The process already started when you picked up this book.
The Science of Change
It’s been five hundred years since the scientific revolution, and we’ve had modern medicine for at least a century. Yet shockingly, the understanding and treatment of substance use in the United States has been exempt from scientific standards and separate from mainstream healthcare until quite recently.
Researchers in America only began to collect evidence in earnest in the 1970s. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) was established in 1970, followed by the National Institute on Drug Abuse (NIDA) in 1974. Finally, after years of folk wisdom running the gamut from truly helpful to ineffective to harmful, federal money flowed toward scientific studies of what works, including what family and friends like you can do to help. The increasing number of controlled studies, including our own, over these forty-odd years, has created a mountain of evidence—scientists have separated the wheat from the chaff, revealing that certain approaches and treatment strategies are more successful than others. That’s good news, and we hope that it will help you find your own optimism.
Most people equate treatment with intensive, residential “rehab” and believe rehab is the starting point of all change. In fact, there are many treatment options and substantial evidence that outpatient treatment is at least as effective in most cases and often a better place to start. Since 1996, the American Society of Addiction Medicine recommends starting with the least intensive treatment that is safe. Dr. Mark Willenbring, former director of the Treatment and Recovery Research Division of NIAAA, describes how the vast majority of people who could benefit from help don’t get it, in part because the system is designed to treat the most severe problems, while the culture dictates waiting until someone “hits bottom”—in other words, waiting until problems become severe. Family members and friends are left with few options other than to stand by and watch things get worse, then get their loved one into rehab if they can. This despite strong evidence that reaching people early, when their problems are less severe and more treatable, leads to better outcomes. Thankfully, the treatment system is starting to change.
The evidence supports many ways to address substance use disorders, as many ways as there are reasons people have them. Treatment is not always necessary; it turns out that many people get better without ever seeking professional help. There is also clear evidence that certain treatment approaches consistently outperform others. Cognitive-behavioral and motivational approaches, for example, which treat substance abuse like any other human behavior, are significantly more effective than confrontational approaches aimed to challenge a person’s “denial” about his “disease.”
Research has demonstrated that the popular belief that if someone “just stops” using a substance, then the rest of his problems will take care of themselves is simplistic and untrue. Substance problems are complex and multidetermined, often driven by underlying psychiatric disorders such as depression, anxiety, bipolar disorder, or attention deficit disorders that require specialized attention over and beyond just treating the substance problem. In other words, good treatment often includes psychiatric care, which has historically been overlooked or even discouraged in some drug and alcohol treatment settings.
Science has also given us a better understanding of the brain’s role in substance use and compulsive behaviors. With that science, there are new medications that reduce cravings and compulsivity, block drug effects, ease withdrawal, and treat underlying issues. Neuroimaging research provides new insights into the effects of substances on the brain; and recent discoveries in neuroscience have shown the power of neuroplasticity in the brain’s healing itself.
And science has revealed that teenagers are not simply grown-ups who text a lot; they are neurologically, psychologically, socially, and legally different from adults, and they have different treatment needs. Until about fifteen years ago, most of the services available for adolescents were barely modified adult treatments. Clinical trials have shown us that teenagers respond well to appropriate treatment and just as with adults, some treatments are considerably more effective than others. You might be surprised to learn that they all involve parents as active treatment participants (and often siblings, peers, and school systems).*
Finally, research has shown how you can play a role in change. Our work with families and friends of people with substance problems is informed by CRAFT—Community Reinforcement and Family Training—a scientifically supported, evidence-based, clinically proven approach to helping families of substance abusers. CRAFT grew out of treatment innovations that began in the 1970s. A group of researchers in Illinois, led by behavioral psychologist Nathan Azrin, developed what is still the most effective behavioral treatment for substance users, and called it the Community Reinforcement Approach, or CRA. In the process, they discovered that family involvement was a crucial factor in successful change. Robert J. Meyers, PhD (one of the original Illinois group), expanded the CRA approach to work with families when their loved one refused help, and called it CRAFT. After moving to the Center on Alcoholism, Substance Abuse and Addictions (CASAA) at the University of New Mexico, Dr. Meyers conducted further research and clinical trials (teaming with Jane Ellen Smith, PhD), and they and others investigating CRAFT have given us robust evidence that given the right tools, families can effect change.
*The parent-child relationship is different from other relationships, too, even when the “child” is an adult. This book is for everyone, parents included. However, we recognize that parenting comes with unique challenges, responsibilities, and feelings, and so we partnered with the Partnership at Drugfree.org to offer a supplementary guide for parents. You can download it from our website at http://www.the20minute guide.com.
CRAFT has three goals: 1.) to teach you skills to take care of yourself; 2.) to teach you skills you can use to help your loved one change; and 3.) to reduce substance use, period, whether your loved one gets formal treatment or not. CRAFT is behavioral in that it employs strategies for real-world, observable change. CRAFT is also motivational, drawing its strength from collaboration and kindness rather than confrontation and conflict. This motivational and behavioral approach is the core of our work with families, the substance of the helping strategies in this book, and an opportunity for profound change.
Drs. Meyers and Smith and other research groups have studied CRAFT with family members from a variety of socioeconomic, ethnic, and age groups struggling with a range of different substances, with the following results:
* Two-thirds of people using substances who had been initially resistant to treatment agreed to go to treatment (typically after family members had around five sessions of CRAFT).
* The majority of participating spouses and parents reported being happier, less depressed, less angry, and having more family cohesion and less family conflict than prior to their CRAFT sessions, whether or not their loved one engaged in treatment.
* CRAFT’s effectiveness in engaging substance users and improving family functioning is found across substance types, relationship types, and ethnicities.
Good News: Things get better with CRAFT. Families feel better, substance use often decreases, and people with substance problems usually enter treatment when a family member uses CRAFT.
CRAFT works, first, because it understands substance problems holistically, in the context of family, community, and work. People do not use substances in a vacuum. Their relationships impact their substance use just as their substance use impacts their relationships. CRAFT recognizes that most family members and friends, for their part, have good intentions, good instincts, and a healthy desire to help. CRAFT treats the problems families face as a deficit of skills rather than as a disease of codependence. These skills can be learned.
Second, CRAFT recognizes that “just stopping” is not a sustainable long-term solution. While change depends at first on stopping (or reducing), the $64,000 question is what promotes staying stopped. CRAFT asks you to see what makes substance use rewarding to your loved one, so that you can introduce the “competition”—more constructive activities that serve the same needs—into her world. To this end, CRAFT will feel strange at first. If you have been viewing her substance problem as the cause of all other problems for some time, you may wonder what taking her bike in for a tune-up could have to do with anything. Plenty, as we’ll see.
What We Offer
First, we offer a new perspective on why your loved one does what he does. “Why” is a key to change. Second, we will teach you skills: positive communication, reinforcement strategies, and problem-solving skills to transform your relationship with your loved one and your life. Third, we will help you navigate what is often a one-toned, ideologically tinged treatment system, because there are treatment approaches and settings, medications, and knowledge available that you run a high risk of never encountering through traditional channels. Fourth, we will show you how to take better care of yourself so you’ll have the energy to keep going, keep changing, keep helping. Finally, we will teach you skills to make peace with the things you cannot change.
Motivation: Why Do People Change?
What Is Motivation?
Like addiction, motivation can also be understood to be “in the brain.” Many neurological systems are involved in goal-directed behavior; the outward signs of motivation—for example, taking action—are a result of complex internal neurological processes. In essence, motivation is the link between emotion (“ahh . . . this feels good” or “wow, I could use some relief ”) and action (having another drink), involving the parts of the brain that manage attention, pleasure seeking, inhibition, and memory. In the end, motivation gives us the energy to make a decision and take action and is intimately involved in how we recognize a problem and attempt to solve it.
Remember the discussion of dopamine from chapter 1? Since it is instrumental in the human experience of what is enjoyable and worthwhile, it also plays a significant role in motivational states. For example, do you like camping? Do you hate it? Don’t have strong feelings about it, or much interest? Whatever your feelings, you’d agree that one has to be pretty motivated to take all the steps of planning and organizing to get on the road for a camping trip.
In neurobiological (and simplified) terms, we are motivated to do things that have been associated with dopamine in our experience. So we are motivated to go camping if dopamine flowed the last time we went or, if you have never been, perhaps when you looked at pictures of a beautiful camping spot. As we look forward to the trip, we summon the drive it takes to pack up backpacks, organize maps, plan meals, and forgo our comfy bed for a week. When we’re there, we take in the sounds, smells, and adventure of the experience and dopamine flows and we feel good. In the end, the decision to do all the work associated with a camping trip is motivated by the anticipation and actual reward of smelling pine needles, hearing babbling brooks, and eating s’mores.
Motivation works in the same way with the decision to use a substance. Substance use increases dopamine in the brain (or the substance itself acts like dopamine). If someone who is struggling with depression uses cocaine and feels more alert, engaged, and less tired, they may be motivated to use cocaine to “feel better” again, even though going on a camping trip would also make the person feel better. Camping is a lot more work. According to what we’ll call the zero-to-sixty rule, the quicker a substance (or experience) affects the brain, the more powerfully the brain is motivated to use it. And it’s relative: if the brain’s reward system has learned to release dopamine in response to a drug, it might not get excited by nature, the smell of a campfire, s’mores, and so on. In other words, the benefits of camping will pale in comparison to those of using the drug. For someone using substances, cocaine is rocket fuel, while camping is a can of Sterno.
Thankfully, as we discussed in chapter 1, some of the most exciting and hopeful research in neurobiology is revealing how psychological and social factors like medications, therapy, and family involvement can, in turn, change our brains and motivational states. The brain and the world in which it operates are inextricably intertwined; we literally take in substances, people, and other stimuli, and they affect the very structure and functioning of our brains. Our brains in turn affect our behavior toward substances, people, and other stimuli in the world. Understanding the interactive nature of motivation, you can see the value in staying engaged. Your loved one is affecting his brain chemistry with substances; you can affect his brain chemistry with the way you interact.
In other words, don’t leave your loved one’s brain alone! You can affect those covert systems with strategically planned overt actions; you can influence your loved one’s choices by helping him associate positive experiences with positive actions (“I feel better when my wife . . . ” instead of “I feel better when I use . . . ”). The “How to Help” section (Part 3) will show you how to do this.
Neuroscience is not the only science supporting the idea that we influence others’ motivation. One of the most robust, evidence-supported theories describing human motivation is Self-Determination Theory (SDT), developed by Edward Deci and Richard Ryan, psychologists at the University of Rochester. In explaining the impact of the interpersonal, social environment on human motivation and behavior, SDT identifies two types of motivations behind people’s choices: internal, or autonomous, and external, or controlled motivation.
When we are internally motivated to do something, we have reasons for making a choice or taking action that make sense to us, to our values, desires, and thinking. External motivation comes from reasons outside of us, as in the law, company policy, school rules, parental rules, or anyone else’s reasons for why we should do something. While their influence and power tend to fade over time, external forces are often the reasons we do things in the first place (“I don’t want to get arrested,” “I want to get an A,” “I want my coach to be proud of me”). But imagine if the only reason you had to show up for work every day until you retire was “because I’ll get fired if I don’t.” Hopefully you have a number of more positive, internal motivations for doing your work.
Self-determination applies to the whole range of human behaviors and relationships, from children at play to athletes’ performance, from parent-child to boss-employee to doctor-patient relations. Within these relationships, the way one person interacts has proved to affect the type of motivation the other person experiences. In other words, your behavior toward your loved one can help to foster her internal motivation.
Some clients who over time made great changes working with us at CMC wouldn’t have come through the door in the first place if they hadn’t been compelled by external motivators. They were told—sometimes with kindness and a rationale appealing to their point of view; sometimes with-out—that they needed to choose between their marriage and cocaine, between graduating and getting stoned, between their job and drinking every night. The external motivation added a sudden weight to the costs of continuing the behavior, moving the person to seek help in the moment. However, maintaining changes in behavior beyond that first decision usually requires a shift, at least in part, from external motivators to internal ones. Research has shown time and again that it is essential that people develop their own reasons or “buy in” to change.
We need to find our own reasons for doing things. We need internal motivation to change our behavior if we’re going to continue caring enough to stick with it. The traditional treatment mandate to “come back when you’re ready” partly got it right: maintaining change usually requires that people develop their own reasons for wanting that change. What this mandate did not get, however, is that a person’s internal motivation is directly influenced by external factors, including treatment providers. Our mandate has become How do we help you shift your motivation?
A husband could strategize to make dinner for his wife and be affectionate toward her when she comes home sober. When she comes home intoxicated, he can tell her he is going to the den to read and let her make dinner for herself. At first, her husband’s withdrawal and having to cook dinner for herself would be an external motivator for the wife not to drink. But after they’ve had some nice dinners together (when she has come home sober) and she’s enjoying his company and feeling good about her marriage, the reasons to skip the drinks after work start to become important to her, and she internalizes the motivation. Now she values this time with her husband and knows that if she drinks it won’t happen, and she will miss it; this becomes her reason to not drink, and as such it will more likely hold over the long haul. In terms of self-determination theory, the husband’s behavior contributed to an environment where his wife felt motivated to change.
As we’ve stressed before, everyone is different, but for most people a combination of external and internal factors has the strongest effect on their motivation and actions. A classic example is the case of physicians, who have one of the highest recovery rates among categories of people struggling with substance abuse. They have tremendous external pressures and structure: urine testing, close monitoring, appearances before the state board, and their careers to lose if they fail. But they also like their lives as doctors—that’s why they went to medical school in the first place. They understand their substance use to be incompatible with the life they want. When the external controls are removed, they have enough internal reasons to maintain the changes.
What We Know about Motivation
Motivation is a state, specific to a given behavior, not a general trait inherent in a person.
Everyone is motivated, just not always in the ways other people would like us to be. Teenagers may be highly motivated to hang out with their friends, though their parents wish they were more motivated to do schoolwork. Someone may be more motivated to do the Sunday crossword than clean the house. Another person finds a clean house more rewarding than a completed crossword puzzle. When it comes to housecleaning and crosswords, most people shrug off those differences as “different strokes for different folks.”
When it comes to substance problems, however, it’s easy to lose objective distance and let the problem taint our view of the whole person. The more unacceptable, frightening, or disturbing a person’s behavior seems to us, the more it pulls us to make judgments about the whole person (“loser,” “freak,” “bum,” “addict”). Such labels imply that the motivation behind the behavior is based on innate characteristics (weakness, weirdness, laziness). The reality is that the motivation to use a substance rather than engage in some other behavior is based on how the outcome of that choice feels to the person—smoking pot feels relaxing, for example, and doing a crossword feels boring. By understanding the different motivations behind each choice your loved one makes, you will be better equipped to look at the problem clearly without judging, writing off, or hating the person for it.
Bill, a thirty-four-year-old lawyer, a big bear of a man, came to see us after his doctor recommended he start exercising, lose weight, and drink less. He was not interested in starting an exercise program and he wasn’t bothered by his weight. He did want to cut drinking out of his life. He was highly motivated in this specific arena (and many other specific arenas, including work, bluegrass fiddle playing, and marrying his fiancée the following year), just not when it came to exercise. There were reasons he was not motivated to start exercising, just as there were reasons he was motivated to stop drinking. He hated waking up feeling headachy. He hated worrying, when he’d been out with coworkers the night before, that he might have said or done something inappropriate. He hated how after a night of drinking he didn’t feel up to speed until midafternoon the next day. Meanwhile, he couldn’t imagine having time to exercise. The little spare time he could find he devoted to music and doing things with his fiancée. She was a runner, but he had never enjoyed running, and there was no form of exercise he could think of that he would like as much as he liked playing his fiddle. Plus, he knew his fiancée liked his size the way it was; his drinking, however, bothered her. Whether we agree with his reasoning, we can see that there was reasoning, which needed to be understood in order to help him change.
Was this man “unmotivated,” or “in denial”? Maybe you would say no, since he wanted to tackle his drinking. Or maybe you would say yes, since he did not choose to target his weight and cardiovascular fitness, which were probably the issues putting him most at risk for health problems down the road. Either way, though, you can see that he had specific motivations to address one behavior and not another. And his motivations mattered to him. They are also subject to influence. Our client might have been less motivated to stop drinking if his girlfriend drank wine with dinner every night, and maybe he would have been more motivated to exercise if his doctor told him he must lose fifty pounds or have a heart attack. The point? Motivation is specific to a behavior and a context, and you can be an influence for good when you understand that.
Motivation changes over time.
As anyone who has ever made a New Year’s resolution knows, motivation is not fixed in place by one decision. Motivation is not a threshold that one crosses over into “being motivated.” It’s a shifting balance over time, with many contributing factors. It can fade, it can gather strength; it can make a lot of sense in the morning and a lot less by the evening; it’s a moving target.
When we start working with someone, we encourage the person to identify every reason (or motivation) to change but we also suggest that they not get too attached to any given one. We want them to be prepared for the shifts in motivation that will inevitably come with time. For example, the decision to stop drinking might initially come from motivation to appease a spouse. A few months later, after a few squabbles with the spouse, that reason for changing may not carry as much weight and the person will need other reasons why the decision to stop drinking makes sense to her. Because the short-term reasons for taking an action may differ from the reasons that hold for the long haul, people must periodically reexamine their motivations for change along the way.
While accepting that motivation changes over time might feel unsettling, this awareness can help you and your loved one learn to work with motivation, even—or especially—as it changes. Knowing that shifts in motivation are natural, you may feel less threatened by them. You can endorse different reasons for making a change, rather than assuming that your loved one has forgotten the one you talked about. He probably didn’t forget, but his focus may have shifted to other, now more compelling, reasons. This is different from his cycling through reactive motivations that flame out (“I gotta stop this bingeing!” “I will never go out again!”). Reactive motivations tend to be emotion-based (guilt, shame, anger), superficial, and not clearly thought through. As a result, they don’t hold after those reasons change or those emotions subside. For example, Oscar in the earlier example could decide to stop drinking because Janie threatened to leave him. When Janie was more relaxed, he might decide she wouldn’t really mind if he went out. The short-term, reactive motivation doesn’t ultimately sustain change—and causes pessimism and discouragement in family and friends.
Motivation to change can occur whenever the costs of a behavior outweigh the benefits.
People who have decided to change their use of substances without ever consulting a professional (which, you’ll recall, is most people) most frequently cite as their reason for changing some version of “the costs outweighed the benefits.” This realization can strike like an epiphany or it can develop over time, but it does happen, often. In fact, in the context of motivational therapies, this cost-benefit analysis (or “decisional balance” in therapy-speak) is one of the most powerful techniques in the therapist’s motivational arsenal.
Of course, people’s perceptions of costs and benefits can change over time for the same behavior, and it can be maddening when your loved one does not see the equation in the same light you do. You may not want to acknowledge the benefits your loved one perceives in his behavior. And it may be painful and scary to be aware of how much he relies on a substance to get things done, unwind or relax, or just feel okay in his own skin.
If, however, you can understand how your loved one has constructed his ledger—the cost-benefit balance inherent in his behavior—it can help you understand your potential to influence his costs, benefits, and perceptions, which in turn will affect his motivation for change. Specifically, you can change your behavior in a way that shifts the costs of your loved one’s behavior back to him so you aren’t carrying them on your shoulders. Instead of getting him up in the morning and enduring the fight you usually have, you can let him sleep in and miss his meeting and feel his boss’s frustration. You can help your loved one define the costs of his behavior more sharply for himself, and with less conflict between you.
One of our clients made dinner for his wife every night. Often she would come home drunk, they’d fight, and she’d take her plate into the TV room. This made him furious. He would either lash out at her or give her the silent treatment. But he kept making dinner for her, out of habit and because in spite of his anger he wanted to take care of her somehow. His CMC therapist suggested he consider his wife’s motivations. He saw that not having dinner made for her could be a cost for her of drinking and, conversely, having dinner made for her could be a benefit of not drinking. He strategized to wait to make dinner until his wife was home and he knew she wasn’t intoxicated. They both experienced the difference. As he described it, “Now when she comes home sober she watches TV while I make dinner, and then we eat together, which is really nice for both of us. If she is drinking, I let her make her own food while I read a book by myself.” One change like this may not tip the scales, but a number of them will add up; positive change often starts to happen well before the biggest issues are resolved. However long his wife took to weigh the costs and benefits, their fighting and his resentment had already decreased dramatically. Meanwhile, as their relationship improved, his wife felt closer to and more considerate of him, which was intrinsically motivating to both of them.
When people see their behavior as inconsistent with their self-image or goals, their motivation to change can increase.
We can find potential energy for change in any gap between how we see ourselves now and who we want to be. We may look at our current state of affairs and think, This is not who I am! and the balance can shift toward making a change. Sometimes this happens organically, as when someone becomes a parent and decides something they used to do or not do is no longer compatible with what it means to them to be a parent. For instance, a couple may have stopped attending synagogue for years, then realize, as they plan for the birth of their first child, that they want their new family to be part of that community and spiritual life. So they start going to synagogue again. Other times the assessment requires soul-searching, trial, and error as we clarify our values and goals and figure out the steps we need to take to realign our lives.
It takes courage for any of us to examine ourselves, to step back and ask, Is this who I want to be? It turns out that the right kind of encouragement from others can prompt this type of questioning and self-reflection, and depending on other people’s feedback, we can feel hopeful and galvanized by the possibility of change, or we can feel demoralized and dismayed by our failings.
A client told us the balance shifted for her when she took her six-yearold for a playdate at the home of another first grader. As she sat having coffee with the other mom, she overheard her son say to his friend, “Your house is really fun because your mom plays games with us.” While it was a passing comment to everyone else, the woman was mortified; since she had been taking painkillers for her back pain she hadn’t had the energy to do much with her son, and she felt terribly guilty about this. Her back seemed to be hurting more frequently, and she wondered if it had anything to do with the added stress she was under since they had let go of the babysitter and she’d cut back her job. For days she thought about what her son said, reeling from her embarrassment. She felt almost too ashamed to bring it up with her husband, but when she did he gave her a hug and joked that at least their son hadn’t mentioned her fondness for reruns of Dallas. In seriousness, he asked what she thought about the pill use and her back pain, and offered to help in any way he could. As they talked she relaxed and felt more comfortable, and changing her behavior seemed more doable knowing he was on her side. She attended one of our skills groups to learn how to handle the issues—boredom, restlessness, worries about her career—that all seemed to be adding to her stress. Eventually, she decided to start physical therapy to strengthen her back and learn mindfulness meditation skills to address her stress. The pills no longer seemed like an acceptable coping strategy to her, as she didn’t want her son to feel she was unavailable or “out of it.” That was not the mom she wanted to be.
Ambivalence is a normal part of motivation and the change process.
Motivation waxes and wanes. We need not panic in the face of ambivalence when we know that fluctuating is just what motivation does; it’s in its nature, and we can work with it. When we waver in our own resolutions to “exercise more” or “eat less fried food” or “read poetry” or “stop smoking,” we feel this to be frustrating but normal. When our teenager was convinced last week that he wanted to give up pot, but now seems not so sure, it may seem intolerable. But ambivalence is normal, and learning to roll with it is the best way through. One of the great insights of the motivational therapies developed for substance problems has been just this: that ambivalence is integral to change, not an unfortunate feeling to be quashed or avoided, or a failure to “get with the program.”
If using substances were like putting a hand on a hot stove, all downside and no upside, you wouldn’t be reading this book, because your loved one wouldn’t need help. There would be no ambivalence; he would have stopped a long time ago.
But we’re not dealing with burning-hot metal; we’re dealing with behavior that has an upside, often multiple upsides, at least for the people doing it and often for others as well. “I drink because it lets me relax with my friends”; “I am funnier when I’m tipsy”; “I lose weight with cocaine”; “I focus better for my SATs with lots of Adderall”; “I am less depressed about my arthritis when I use OxyContin”; and so on. There is a counterargument to every one of these reasons, but that is precisely the point: ambivalence is the pull in two directions at the same time, both of which can seem like good directions. The more this can be accepted as normal, the less people have to cling to the unrealistic idea that there’s no looking back, and the more openly and effectively they can deal with their ambivalence.
When clients tell us what they think we want to hear—their unswerving commitment to change—we’re wary. We actually want to hear all about their ambivalence, the reasons pro and con for continuing the status quo or for changing. We know that if we are only hearing the cons of their behavior we are only hearing half the story, and unacknowledged pros have a way of ambushing people. Similarly, if you can’t tolerate ambivalence in the change process, your loved one will sense this and probably tell you only what he knows you want to hear, if he tells you anything at all. If he knows you won’t go berserk, on the other hand, he’ll be more likely to tell you when he’s wavering. When you know about it, ambivalence can be a huge opportunity for you to help.
This is important because holding to a black-and-white notion of unwavering commitment to change is often a setup for excessive disappointment and destroyed confidence about lapsing. Many people (and their loved ones) believe that if a person returns to old behavior patterns, he must not really want to change, or even worse, is just an “addict” who can’t change. A lapse is in fact much more productively understood as the benefits of using outweighing the costs at that time. By understanding the benefits we can help find competing beneficial behaviors, or ways to reduce the benefit’s pull. It may also be that there is a cost to changing that is exerting more influence than the benefits of changing at that time. Perhaps the loss of contact with familiar friends and a mild depression are outweighing the value of stopping cocaine use. If you can tolerate thinking about his perception of the downside to changing, you will be better equipped to help alter the environment and your behavior to counter this downside. If you know he is struggling with newfound loneliness, you could plan social events that bring him together with supportive friends and family or new peers whom he does not associate with using.
Allowing for people’s ambivalence does not mean biding our time until they snap out of it. Understanding and appreciating why your loved one does what she does will help you have more empathy and identify how you can modify your behavior, your relationship, and her environment so you can help to support long-term change.
A forty-five-year-old construction manager came to us to follow up a twenty-eight-day rehab stay. Sol was committed to abstinence, and as part of his plan he attended three AA meetings a week, as well as working with his AA sponsor (a more senior member of the group who acts as a kind of mentor). Sol liked many aspects of his AA group, but he noticed over time that when someone discussed a lapse to drinking, the elders, as he referred to them (people with many years of sobriety), would invariably question the person’s level of commitment. Sol realized that if he were to lapse, he would not feel comfortable disclosing it in this group. His uneasiness grew over time until he felt he could not bring up even his intermittent cravings to drink. He feared “letting the guys down,” as he put it, thinking that they wouldn’t accept his ambivalence. In this case, the group became useless to him, as he was presenting an incomplete and thus unhelpable version of himself: What’s to help? Everything’s fine.
Motivation is interactive, affected by the environment, and YOU are the environment!
Motivation is, in a word, malleable. Interactions with other people affect our motivation. In social psychology, Deci and Ryan’s self-determination theory shows us that our interpersonal environment has a huge impact on how much we feel like starting, end up sticking with, and enjoy a particular action along the way. In parenting, teaching, managing employees, and many other arenas, what we do (and don’t do) deeply affects other people’s motivation to act or change.
In Sol’s case, his therapist helped him find a different AA meeting, one where for a variety of reasons—members his own age, a warmer feel, and most particularly a group where people spoke openly about lapses and cravings—he felt he could be completely honest, and where Sol felt supported and encouraged even when he’d slipped, which is of course when he needed it the most. (We helped alter his environment—trying a different meeting—in an effort to keep his motivation high for going to meetings. We encourage clients looking to join a support group to try several for the best fit. Many people benefit from 12-step involvement, but ultimately this model isn’t for everyone, and there are other options. Even within AA, groups vary from one to the next, and multiple groups in any given area can accommodate many people.)
One big thing in your loved one’s environment that you can change is, very specifically, YOU. You are malleable too! If you’ve been told a thousand times that you’re supposed to stay out of it, because it’s up to your loved one to change, then it may sound like we’re saying it’s all up to you. It may even sound like the job of changing is your job or that your loved one’s resistance to change is your fault.
It is not your job or your fault. We can’t make other people change. What we can do is learn to provide an environment that lets them be less reactive to what we’re doing (such as yelling or judging) and more concerned with their own behavior and its consequences. You can’t make someone want to change, but you can help him realize that he wants to change, and help reduce his need to defend his current behavior, which can get him stuck there. You’ll be in a position to do this if you stay connected. You won’t if you detach.
Good News: No matter how stuck things seem to be, motivation can change. You don’t have to be a therapist to encourage your loved one’s motivation in a positive direction.
The Things That Can Change Motivation
In practical terms, how can you positively impact another person’s motivation to change? Here’s what enhances people’s motivation to do something, and keep doing it, according to the evidence:
* Feeling acknowledged, understood, and accepted as you are (not contingent on doing something or not doing something)
* Getting information without pressure
* Having options
* Having reasons that make sense for a particular choice
* Having a sense of competence about how to change/steps to take
* Getting positive feedback for positive change
Conversely, here’s what tends to crush our motivation to do something:
* Feeling misunderstood and judged
* Other people pushing you to do it
* Having only one option
* Not having reasons for change that make sense to you (the person doing it)
* Not believing you can do it
* Getting yelled at
Acknowledging someone’s point of view, truly listening to her perspective, and being as empathic as possible are what cultivate motivation. Telling her she’s wrong (or crazy or lazy or fill in the blank), because all we can see is how we’re right, tends to drive motivation straight down. We can say I can’t believe you would do this. Can’t you see how irresponsible you are?! Or we can say You’re not a terrible person for drinking too much. You drink that way because you get depressed and drinking makes you feel better, helps you sleep, and that makes sense to me. It doesn’t mean this is how you want things to stay, but it does make sense to me. The former undermines motivation; the latter promotes it.
Providing information about choices, with a minimum of pressure to have to act on that information, helps people hear and be open enough to take in what we are saying. Trying to force someone tends to increase push-back. Easier said than done in a fraught or scary situation, but— counterintuitively—the less pressure, the more likely action will occur. That is, the difference between this: If you don’t admit you’re an addict and go to Narcotics Anonymous, you’re going to die or I’m going to leave you. And this: I’m going to start taking a meditation class because I think it could help me with my stress. It seems like you’ve been drinking more than usual lately, since that disappointment about the promotion, and I’m scared about what could happen now that we know you have the beginnings of pancreatitis. I know that I worry a lot, but maybe it would help us both to talk about it? I also want to show you this website I found . . .
Exploring options and letting any and all reasonable paths be part of the discussion are ways to engage motivation. Giving ultimatums makes people defensive, angry, and skeptical. Allowing choice lowers defensiveness and gets people invested in the process. On the one hand there’s something to be resisted; on the other, choices to be made. And choice depends on having options. You’re going to rehab or I’m kicking you out of the house is much less helpful in the short and long runs than, say, There are a variety of options. These two seem to me to be the best, but there are other things you could do too. What do you think?
Suggesting a rationale based on the other person’s perspective also promotes motivation, because we know that when people are considering doing something different, it’s useful for them to have reasons that make
sense to them. In contrast, assuming someone should do something and assuming no explanation is needed because the reasons should be obvious tends to leave people feeling more skeptical. These are fighting words: You shouldn’t party every Friday and Saturday night; I won’t allow it. These words invite someone into a conversation: It seems to me that when you party every Friday and Saturday night you’re hungover the entire weekend, and that doesn’t leave you any time to do schoolwork. You said you’ve been really worried lately about falling behind in math.
Bolstering someone’s sense of competence, giving him positive feedback, and helping figure out doable, “bite-size” changes that feel accomplishable enhances motivation. People really don’t like to (and then don’t) embark on new behaviors if they think they can’t do them. Suggesting an AA meeting to someone with bad social anxiety, and then being upset that they repeatedly don’t go, would not be so helpful. Suggesting that AA could be helpful, and offering to find someone to go with for the first three meetings, could really help. We spend a lot of time helping people gauge what is accomplishable and starting there; when people present us with a laundry list of the things they are going to change, we tell them to slow down, consider how much they can actually chew, and give themselves time to chew it. And we make sure they know how to do something, not just that they “should” do it.
Last, “yelling” versus “not yelling” (concretely and metaphorically) may be one of the biggest variables in your control for facilitating internal and positive motivation for change. Tone matters. Volume matters. In fact, these may matter more than anything else. Our families tell us that not yelling is the hardest change to make because they are often so upset. But when we yell, people don’t hear us. They become defensive and flooded with emotion. The conversation becomes a fight; the fight escalates. Also, when we yell we model yelling, that is, we “teach” other people to yell back. The only upside to yelling is letting off steam. While we might feel better for an instant, there are other ways to let off steam (or cool down before we come to a boil) that don’t sabotage communication and damage relationships. In addition to all the things we’ve discussed so far about motivation, there is one other thing we know from research studies and clinical experience: confrontation is the archenemy of motivation.
Confrontation: The Biggest Motivation Killer
The evidence gathered in almost every study of therapeutic techniques is that resistance to change increases with confrontation. Confrontation undermines motivation. It’s fascinating and sad that for decades, traditional treatment for substance abuse enacted a self-fulfilling prophecy with harsh approaches like interventions (and boot camps and “hot seats” and so on) that induced and strengthened the very defenses (denial) they intended to break through. (Some treatment providers still take this approach—we will help you ask the right questions to avoid them.) Confrontation in therapy leads to client resistance, which leads to more confrontation. Only recently, this flawed strategy has been challenged by the fundamental insight of motivational thinking and all the evidence for it that research has provided. Treat people with respect and present them with a range of options, and their resistance will decrease. Nobody likes to be bossed around.
Why does it seem to work on TV? Because it’s TV. Confrontation doesn’t work on shows like Intervention and Celebrity Rehab either, but it does make for great drama because it meets all the criteria for a reality TV show (secrets, betrayals, tears, confessions, redemption, and so on). In reality (real reality), this version of helping people is ineffective and at times harmful. Respectful, collaborative approaches like CRAFT have a 64 percent or greater success rate for getting reluctant people into treatment, while confrontational interventions succeed about 30 percent of the time. Some evidence indicates that even when successful—defined as getting the person into rehab—the aftereffects of some confrontational interventions linger on in a damaging way; those who have been subjected to an intervention are more likely to relapse after their initial treatment episode. Anecdotally, this is our experience as well, as we are often left with angry, resentful, and betrayed clients who no longer want to allow their families or friends to be involved.
Choosing to be nonconfrontational does not mean doing nothing. Nor does it mean you approve of the problematic behavior or tiptoe around it. By understanding and working with your loved one’s motivations, you can be a collaborative helper, and there are specific strategies that we will teach you to instigate change in yourself, your loved one, and often the whole family system. Staying involved has the power to help your loved one change course. Remember what the evidence says: your skillful involvement has a positive impact on your loved one’s motivation and is usually more influential than any other factor. At the same time, specific, temporary, strategic detachment when your loved one is intoxicated or hung-over is something you can do to influence your loved one’s motivation. Recall the husband earlier in this chapter who, when his wife was drinking, stopped making dinner for her and secluded himself with a book.
Remember that there is a sweet spot of engagement that keeps us connected but at the same time gives the other person room to consider information, make decisions, and learn from mistakes, as opposed to us being on his back all the time and nagging. Ultimately, we can help people change, though we can’t do it for them.
What’s hard about this . . . It may seem counterintuitive, especially when the stakes are high and emotions deep, that it helps people to change if they feel understood and accepted as they are. It will become easier to hold the paradoxical truth in your mind as you practice and see it working, but for now just try to be inquisitive and aware. The more aware you are, the more choice you will have to respond in motivation-enhancing ways, and the better you will become at promoting motivation for change. Remember that you are learning, so please try to be patient and kind to yourself if you lapse and find yourself yelling, or if empathy doesn’t come easily. You deserve to feel acknowledged, understood, and accepted too.
The way you understand motivation profoundly affects how you think and feel about your situation. Other people’s behavior is more comprehensible when you realize that the same principles of motivation apply to all of us, in whatever we’re trying to do. Before you learn to use the specific skills and strategies that come later, before any changes in behavior on the part of you or your loved one, you can feel more hopeful and in control, for good reason. In fact, you may find yourself acting differently already, because you are seeing things differently, and your loved one may respond differently in turn.
Have Your Limits
Braking Before You Break: Setting Your Limits
Ignore the signs to your limits and you may be on your way to a breaking point. Hitting that point can set you or your loved one back by adding to hurt feelings, confusion, and a variety of other unhelpful emotional states. In the moment that you break, your reaction feels justified—that’s the nature of being overwhelmed and not thinking straight. If you can see your breaking point a half mile down the road, however, you can slow down, pull over, adjust your expectations, and set a limit. You can tell yourself don’t go there, and find a safer way around. You can brake before you break.
Here are some examples to help you get a feel for the difference between braking and breaking.
Breaking point: This is the third night in a row he’s going to come home late and disappoint the kids, and I’m going to hand him his head!
Braking point: I’ve been stewing all day and I need some time off. I’m going to take the kids to a movie so we can have fun.
Breaking point: I’m tired and cranky, but I can’t stand letting him get away with going to bed early again. I’m going to insist he clean the kitchen even though he has been drinking.
Breaking point: I’m so tired and cranky that I am going to order takeout so I don’t have a mess to clean up. I will talk to him about cleaning up tomorrow when he is sober and I am rested.
Breaking point: He spends so much money on cocaine, I can’t stop worrying about our finances, and I have a stomachache all the time.
Braking point: If I got a separate bank account, I could at least protect my income from going toward his habit.
Have Your Limits
Notice how breaking tends to happen to you, in reaction to something you can’t control. In order to brake, you will need to be at the controls: your hands on the steering wheel, your feet on the pedals. Knowing the difference depends on awareness. To build awareness and acceptance of your limits, you can ask yourself these questions:
What exactly is it that I dread?
How can I prepare myself for the best and worst outcome?
What can I do with this anger (or other emotion) before it gets out of control?
How can I settle my anxiety/other emotions enough to think straight and make good decisions?
What parts of this situation can I control?
Any of the awareness exercises from chapter 4 can help bring the signs of your limits into view. The “Self-Care Checklist” in chapter 5 is meant to encourage you to take care of yourself, but it can also help you respect your limits and breaking points, since they partly depend on tolerance and resilience.
Living Your Limits
Determining a limit and living with it are not the same thing. You may be hugely relieved by your decision not to pick him up at the train when he has been drinking; he can walk or find a ride home. You may celebrate the prospect of no more good-night phone calls when she’s drunk. But actually following through can bring on a new, challenging mix of anxiety and guilt. Living with the limits you set requires conviction in their validity, plus tolerating your loved one’s reaction when you stand by them.
This chapter introduces limits as guidelines for self-care. In the next part of the book, we’ll present the goal-setting, communication, and reinforcement strategies you can use to solve more complicated problems with limits, when it isn’t as simple as turning on the stereo in your car. This chapter is meant simply to give you permission to have limits, to help you see the value in knowing where they are, and to encourage you to pay attention to the relationship between your limits and how you take care of yourself. If you’re not sure how to talk to your loved one or anyone else affected by your limits, you can keep them to yourself for now.
Be patient while you get the hang of your limits. If you are used to losing your temper when he chooses that glass of wine over you, it might be enough for now to just notice that and take care of yourself. Practice setting and communicating lower-stakes limits in situations that are less charged—ordering in instead of cooking, having your mom babysit so you can stay later at work—where your boundaries will more likely be honored. Start smaller, set out a plan, and practice getting comfortable with your limits. Pick the lower-hanging fruit.
What’s hard about this . . . Family systems are like any organic system that tends toward a homeostatic state. When one person in a family (or couple or friendship) changes, everyone around him may try, consciously or unconsciously, to pull him back to the old routine (because that’s where they still are). As we’ll see in chapter 11 (“Consequences”), a “burst” of reaction is natural from others when we set new limits and their behavior doesn’t elicit the result they have come to expect. However, if you can tolerate an unpleasant reaction a few times in a row, the behavior will likely burn out.
Evie’s husband was trying to stop drinking by checking in with his addiction psychiatrist a couple times a month while he powered through long days at his all-consuming job. Evie took care of their three kids and cooked everything from scratch while she tried to run a small business. When her husband wasn’t relapsing, Evie was pretty happy with the fullness of their life. When he decided to drink for a weekend, she was devastated. She knew her husband and their household were doing better on the whole, but she was always ready to snap, and snap she did when she found out he had been drinking.
As she educated herself on how people make behavioral changes, she came to understand that lapses were a likely part of the process for her husband. So, she decided to focus on minimizing the effects of his lapses on her, so that she wouldn’t break. She served leftovers more often. Her husband helped by getting up with the kids one morning each weekend. She made a point of taking five quiet, uninterrupted minutes each day to just breathe. She trained her nine-year-old daughter to ask her how she was doing as they drove home from school—not that Evie would unload everything on her daughter, but because it helped to remind her to ask the question to herself. Paying more attention to her own limits and reactions, she noticed that not only did she keep her temper in check on more occasions, but when she did lose it, she was able to get her equilibrium back more quickly than she used to.
Have Your Limits
Living life always at the edge of your breaking point is like a game of Jenga. The players take turns pulling out blocks one by one from the tower of blocks, hoping at each turn that this will not be the block that makes the whole thing collapse. We try to help families dealing with substance problems stack the blocks of their lives differently, so that a single block does not make the difference between a standing tower and a pile of rubble. The elements of self-care in this part—awareness, acceptance, distress tolerance, rest, nourishment, exercise, getting help when you are physically or psychologically ill, and setting limits—are the materials for a stable foundation and earthquake-proof building. Stability doesn’t depend on nothing going wrong. Rather, it depends on your ability to weather problems and mistakes, making sure the regular demands of life do not wear on the whole system too much, and repairing damages when they occur.
Take our suggestions with your own limits in mind. The research is clear about the power of family involvement, but there is no master checklist of things every family should do. The quality of your involvement matters, as you will see, and a big factor in quality is whether you are involved in ways that make sense to you. Let your limits guide you in deciding what you will do and when you will do it.
IN CASE OF VIOLENCE: A SPECIAL CASE OF LIMITS
It’s a sad and well-documented fact that when domestic violence occurs, alcohol and other substances are often involved. If you think you are at risk for violence in your relationship, the principles in this chapter apply all the more urgently, with some additional considerations specific to domestic abuse. Please take your feelings seriously if you are worried that your loved one may become violent—either in general or specifically in response to a change you plan to make. When we recommend making changes, our hope is for things to improve, but if you feel you are in danger or physically at risk, please get more information on how to protect yourself. This section is not meant to be a complete resource on this matter. We suggest where you might turn for more information and help and a few steps you can take toward greater safety:
If you are in immediate danger, call 911.