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When I served as the director of Bellevue Hospital's detoxification ward, I often met patients whose lives had been destroyed by addiction. I particularly remember one young man who, in addition to his heavy use of alcohol, smoked more than $100 worth of crack cocaine every day and had been admitted to the hospital in a drunken stupor. Given the life-threatening nature of his addiction, and our experience with individuals with similar stories who had died, our treatment team gave him the "full-court press." In addition to medications, counseling, group therapy, and Alcoholics Anonymous meetings, several of us sat down with him and his family and tried to convince him of how much danger he was in, and how important it was for him to change his behavior. But despite our entreaties, he left after four days, telling us that he appreciated our concern and that he would try to cut down his alcohol use, but that he had no intention of stopping his crack cocaine use. In our staff meeting, we agreed that we'd failed to reach this young man, and prepared ourselves for his readmission or news of his death.
Much to our surprise, however, the next we heard of him was several months later when he showed up, with several others from a local AA group, to lead a meeting on our ward. He told us that after leaving our ward and using crack cocaine a few times, he'd decided to try a few of the relapse prevention techniques we'd taught him and got his best friend to go with him to an AA meeting. From that modest beginning came full-fledged sobriety and the subsequent positive changes in his life.
Ever since then, whenever I find an addict who seems similarly "hopeless," I think back on my own hopelessness in that situation and how misguided it was. It reminds me that no case is hopeless and that the techniques for getting an addict into treatment -- both those professionals use and those families and friends can use -- are more powerful than we sometimes realize and can have long-lasting effects.
I wrote this book because, as a psychiatrist who treats addiction, I've had many similarly difficult and sometimes painful experiences with the friends and families of addicted people. Very early on in my practice I realized that although I could give some solid advice to my patients (such as encouraging them to join a twelve-step program), I had no such recommendations for the often frustrated family and friends of those addicts who would not even consider any kind of treatment. But over the fifteen years that I've worked in this field, I've developed a method for guiding friends and family to help get their loved ones into treatment without getting hurt themselves. That method -- which I call "Creative Engagement" -- is based on what I've learned from my teachers, what I've read in the psychiatric literature, and what I've found works best with the hundreds of patients I've treated. And I've written this book so I can share it with you.
Creative Engagement means, first, being willing to use every available strategy, even those you may be uncomfortable with, to convince your loved one to go into treatment. And, second, continuing to engage with the addict -- to hang in there -- rather than leave the addict to his or her own devices. That can mean trying to push him or her toward a program, looking for ways to help the addict avoid the dangers of the substance use, or simply being there to help as he or she suffers with the addiction. Creative Engagement, then, is essentially about focusing on solving the immediate problem of getting help for your addicted loved one, doing whatever you can to resolve it, and continuing to work on it until you have.
But in order for you to understand why I feel that Creative Engagement is such an effective method, I need to tell you something about how I think of addiction, some of which, frankly, goes against the conventional wisdom. The first and perhaps most important thing for you to understand is that addicts, almost by definition, are "reluctant patients." That is, they're at best ambivalent about and, at worst, in complete denial concerning their addiction. Of course, reluctance is a common enough human feeling. We're all reluctant to do necessary but sometimes unpleasant tasks, like getting out of a cozy bed on a cold winter's morning, or going to the dentist to have a cavity filled. We know we have to face the cold floor or the dentist's drill, but we just don't want to do it, at least not yet. The same is true for addicts -- the problem must be faced, but the addict is invested in putting that moment off for as long as possible.
One reason for this is that, unlike other diseases such as high blood pressure or diabetes, there are actually some "upsides" to remaining addicted. Although people who have become addicted to substances usually feel very little actual "high," some of them need the substance to work effectively, and some are literally unable to function without it. For instance, if an individual addicted to OxyContin was to stop using it, he might find himself experiencing muscle cramps, diarrhea, and insomnia. Faced with a situation like that, taking the drug may seem like a very good idea, and it would be entirely understandable for him to be reluctant to face the uncomfortable effects of withdrawal in order to get back to a sober life. This, though, is where the "creative" aspect of Creative Engagement comes into play. If, instead of disagreeing with the addict when he or she makes such an argument, you acknowledge whatever upside there may be to the substance use, even if it means having to bite your lip, you can keep the lines of communication open and continue working toward convincing him or her to enter treatment.
This is important because, reluctant though they may be, addicts are desperately in need of treatment, and just as desperately in need of someone to help them get that treatment. And this is one example of how Creative Engagement conflicts with the conventional wisdom. Much of what's been written on addiction argues that, as a friend or family member, it's best for you to divorce yourself from the problem of your addicted loved one and simply do what you can to protect yourself. Of course, it's true that those who care about addicts have to work to keep from being taken advantage of by them, both emotionally and financially. But it's equally true that friends or family who take an active role in trying to save an addict from the wreckage of his or her life can have an enormous influence. And that's what Creative Engagement is all about -- being proactive and positive instead of reactive and negative. It's also exactly what this book will teach you to do.
Conventional wisdom also says that you can't get people to make even beneficial changes in their lives unless they want to. In terms of addiction, this would suggest that, regardless of how much of an effort you make to convince, cajole, or demand that the addict you love deal constructively with his or her addiction, unless they're ready, it won't happen. And there is some truth in that. In my opinion, though, while you can't physically or legally force an addict into a treatment program, as his or her friend or family member, you have the right to encourage the addict to enter treatment. And whether or not the addict in your life is completely ready to change, there are still effective and potentially lifesaving steps that you can take.
If, for example, your loved one is a cocaine addict, you can absolutely refuse to be around her when she's using or intoxicated, but welcome her when she's not. Similarly, you can spend as much time as possible helping her do positive things like looking for a job or an apartment, but refuse to help when she needs a ride to pick up drugs. In other words, you can encourage those aspects of her thinking that are positive and aimed toward getting into treatment, and discourage those that aren't.
A third bit of conventional wisdom is that addicts have to "hit bottom" before accepting treatment and sobriety. But "bottom" for many addicts is death. So if you wait for that to happen, it may be too late. What you can do instead is help them "raise the bottom" to a more acceptable level, such as embarrassment, job loss, or even ill health. There are a number of ways you can do that, and I discuss several of them in this book.
At the same time, it's important for you to understand that your power to prevent an addict's use of drugs or alcohol is limited. You also have to let go of any unrealistic guilt feelings you may have for having caused or encouraged the addictive behavior. No one other than the addict him- or herself is responsible for the substance use, and no one other than the addict can stop it. That's the bad news. The good news is that once you have a realistic understanding of the limits of your power, you can focus that power on the problem at hand and become really effective. I've seen families unite to convince an alcoholic parent -- a woman who had been in denial for years -- to address her alcoholism. I've seen groups of friends band together to help a member of the group stop dangerous cocaine or heroin use. Pulling together, family and friends can act as powerful change agents in an addict's life.
One of the ways you can do this is through what I call "Constructive Coercion." The term Constructive Coercion essentially covers a number of different strategies that you and other friends and family members can use that are more forceful than those used to just convince an addict to enter treatment. This may sound like the well-known technique called intervention, but it's actually very different. Intervention is, essentially, a group of the addict's friends and/or family members getting together to surprise the addict, confront him or her about the addiction, and threaten to cut him or her off unless he or she goes into a treatment program. What distinguishes intervention from other methods is that element of surprise. Someone who doesn't want to deal with his or her addiction can avoid going to a therapist's office or an AA meeting but has no way of avoiding a confrontation that he or she isn't even expecting.
While I recognize that there may be some benefits to surprising an addict in this way, I don't recommend using this technique for a number of reasons, not the least of which is that it often doesn't work. Even more important, though, to my way of thinking the whole idea of a "surprise attack" is misguided. I think it's better -- from both the emotional and practical standpoints -- to frame the interaction with the addict as an attempt to help rather than as an attack. Constructive Coercion accordingly focuses on the friends' and family's concern for the addict rather than on whatever threats they may make. And while it also makes use of ultimatums to coerce addicts into treatment, those ultimatums are presented by different people over a period of time, instead of all at once, and don't include threats to cut off the addict unless he or she enters a program.
How, then, do you get the addict in your life to agree to enter a treatment program? This book lays out a plan for you to follow. Of course, I can't promise that, even if you follow it exactly, you'll be able to control the addict's substance abuse or get him or her into a program. But I know from experience that the power of Creative Engagement and, if necessary, Constructive Coercion, can help the addict in your life. I've seen many examples of the strategies contained in these pages tilting the balance toward sobriety, and am confident that, regardless of what efforts you've already made, I'll be able to show you some that you've never even thought of. More important, if you follow the plan, you can be sure that you'll have done the best you (or anyone) could do to help the addict you love end his or her dependence on drugs or alcohol.
In order to help you achieve this goal, the book is divided into four sections. The first -- An Addiction Primer -- helps you figure out whether or not your loved one is an addict, answers basic questions about the nature of addiction, and shows you both how addicts avoid dealing with the problem and what you can do about it. The second part -- Strategies for Getting the Addict into Treatment -- provides detailed suggestions for how, using Creative Engagement, you can gather information about addiction and addiction treaters and use that information to convince your loved one to go into treatment. It also explains when and, if necessary, how to use both Constructive and Legal Coercion. The third part -- Treatment Options -- explains what treatment is and what types of treatment are available, what to look for in evaluating a treatment facility, why and when detoxification may be necessary, the uses of psychotherapy in rehabilitation, the benefits of organizations like Alcoholics Anonymous, and some of the popular but, in my opinion, misguided strategies that you should avoid. The last part -- When Addiction Is Just One of the Problems -- discusses how to handle situations that can present special difficulties, such as dealing with addicts who have also been diagnosed with mental disorders.
As you read through this book, and work toward helping your loved one achieve sobriety, there's one other thing I'd like you to keep in mind. There's a wide range of treatments available for addiction, and even if one method doesn't work, that doesn't mean another won't. Too often those trying to help addicts give up out of frustration before exploring all the possible avenues. Sometimes they give up because they don't know there are other possibilities. More often, though, it's because they're unfamiliar or uncomfortable with other methods and afraid to try them, or because they're afraid of getting their hopes up for yet another "failure."
But the "failure" of any one particular addiction treatment doesn't mean that you should give up hope. It can mean that the treatment was ill-advised, that the addict wasn't ready for the particular treatment, that no treatment would have been effective at that particular time, or all three. In fact, even if the addict opts out of any treatment, or if multiple treatments have been tried and failed to help, the only disaster in addiction treatment is to stop trying without reassessing the situation and trying another strategy. We human beings can't tell the future, so we have to maintain our self-confidence and persevere through our doubts. Nowhere does this idea apply more powerfully than in addiction, where the addict's life can become a misery of suffering and self-doubt. So, too, for the family and friends of the addict, who must face down the strength-stealing loss of morale common in such a drawn-out battle against a resourceful enemy.
As someone whose profession is helping addicts, I am buoyed in my work by my memories of addicts who have "turned the corner" to a new life free from the agony of their addiction. Although I once thought that some addiction problems should be considered "terminal," as you've seen, I've learned over time that some of these seemingly hopeless individuals can -- and do -- find their way to sobriety and a better life. Although these transformations are due to the addict's own courage and faith, they serve to remind me that I must never abandon hope myself.
All the ideas presented here are based on my work with the friends and families of addicted people, and represent the techniques I've found to be the most effective. My primary goal is to provide hope and encouragement to people like you who are engaged in a battle to help their loved ones stop dangerous use of drugs and alcohol -- to offer you tools and information that will make your difficult job a little easier.
Laurence M. Westreich, M .D.
New York, N.Y.
Copyright © 2007 by Laurence M. Westreich