Podcast: Supporting Loved Ones Struggling With Addiction

Jeff talks to Dr. Julie McCarthy about how to best support those we care about who are struggling with addiction. Julie shares ways to remain compassionate in difficult times, explains the external factors that can help or hinder the recovery process, and provides advice on facing the ups-and-downs of addiction that all members of the family can benefit from.

Julie M. McCarthy, PhD, is a clinician-scientist in McLean’s Division of Psychotic Disorders. Her research aims to identify neurobiological and psychosocial treatment targets and develop/evaluate treatments. She is a clinical psychologist specializing in evidence-based treatments for a wide-range of populations.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Hello and welcome, my name is Jeff Bell, and on behalf of all of us at McLean Hospital, I want to thank you for joining us for this installment of our educational webinar series.

Our topic today, “Supporting Loved Ones With Addiction.” We know, as so many of you know, from experience, that helping someone who is misusing drugs or alcohol can pose all kinds of problems, challenges, the options and considerations are many, and they might feel well overwhelming at times.

So how do loved ones best support someone struggling with addiction? Whether that’s learning how to identify the problem, helping that individual engage in treatment, or providing a conducive home environment during and after treatment, the experts have some suggestions, and fortunately we have one of those experts with us today.

Dr. Julie McCarthy is a clinician scientist at McLean Hospital. Her expertise includes evidence-based treatments for families interested in helping someone with addiction. Julie, thanks so much for joining us today.

Julie: Thanks so much for having me.

Jeff: Well, before we get into specific considerations for helping a loved one struggling with addiction, can you paint the big picture for us when it comes to the family dynamics of addiction and recovery? What do you most want us to know?

Julie: Alright, that’s a great question. So, you know, I think for many of us, you know, if you’re on this call, chances are you have had experience with your own lived experience or with someone who you care about in your own life as I have, who has dealt with a substance use problem.

And so, I think the first thing that I would really want to say is that you’re not alone, you know, so many of us have encountered this and it can feel like a very isolating experience. And a lot of the families that I’ve worked with have really kind of felt at one point or another, like they knew something was wrong and they didn’t necessarily know what to do or where to turn.

So, I just want to normalize that experience and how this impacts some of the family dynamics can really depend on, you know, who in the family is the person struggling with addiction? And then, you know, what kind of changes you’re noticing for yourself because everyone is different.

I think that, you know, a lot of family members feel like they have some level of anger that might come up, perhaps guilt in some ways, or shame about even experiencing some of these challenges.

Even though we know it’s a very common phenomenon, it can still feel really uncomfortable to think, gosh, how did I get here, or, you know, am I the only person in my family going through this or the only person in my friend group or neighborhood going through this?

What that can lead to with the stigma around substance use disorders and addiction is the tendency to not necessarily talk about it with folks, and so that can, that can make it really tough to deal with some of the tensions and stress that can come up with a family, you know, that we’re all trying to deal with in addition to pandemic our normal jobs, our childcare responsibilities, you know, our own personal wellbeing. And so, I think that can bring a lot of challenges.

What I would say though is when you feel frustrated about having a loved one with a substance use problem, I would say, you know, it’s chances are you’ve already done a lot of good things so far, sometimes people feel though that, you know, you’ve quote tried everything and it feels like quote, nothing’s worked, and I would just want to say, you know, I think there are still things that you can do.

On the one hand, you know, if we could completely control a loved one’s substance use, we wouldn’t even be having this conversation, right? It would be a non-issue.

So what I really encourage families to think about is how they can shift their focus or their responsibility to the realm of things that you can control, which is how you are in a relationship with a loved one who has addiction, how you respond to situations that come up around substance use and your role in the communication, with that person knowing that, well, we can’t change the past and we can’t necessarily completely prevent all substance use from happening for everyone out there.

What we can do is use evidence-based skills to create an environment that increases the likelihood of a loved one changing when they’re ready to make that change. And also realizing that this is much more of a marathon than a sprint, and so some days it might feel like you’re losing at this game per se.

I would just really encourage a lot of hope in that the people who I’ve worked with have really been able to show progress, change, even if it seems incremental.

Over time, if you use different skills, you can really rebuild trust in a relationship that can sometimes kind of go out the window in this process and really create relationships where people feel open to be honest with you, and where you can feel supportive to that other person in a way that makes sense for them.

Jeff: You have touched on so many important issues, Julie. I want to drill down on some of them. Starting with identifying the problem itself. It’s not always easy to know when a loved one is actually battling an addiction. Can you walk us through some of the warning signs, perhaps starting with the physical ones?

Julie: Sure, you know, so I think that for any of us, we know that lots of substances these days are legal, like alcohol, cannabis in many states. And so just because someone’s using doesn’t necessarily mean it’s completely a problem for them.

And so, this is a great question about where do we draw the line between, you know, someone using where it might just be for social purposes and using where it can become more of a problem for folks.

So, you know, we have a big book in psychology or in psychiatry called the DSM 5 which helps kind of clue us into when things might be rising to the level of a problem. And so, some of those things might include, you know, even just kind of patterns about how someone is using.

So for instance, if someone’s using for more than intended, you know, that might be a sign of them developing more of a problem or from a physical standpoint, if people are using a certain amount of substance when they first start, but then over time they actually need to use a lot more to get the same physical effect, you know, that term we might call tolerance.

That can be another sign that someone might be developing, you know, a heavier amount of use or a more problematic use.

In terms of what you might notice in the moment when someone might be intoxicated or high, you might look for things like changes in appearance. So maybe are the eyes looking a little bit redder or are pupils more dilated or are you noticing physical changes in how people are talking, is their speech more slurred? Is it more slowed down?

Are they physically more unsteady on their feet, or is the amount of activity changing over time? So, kind of just noticing that something’s a bit off or not the normal routine or appearance or interaction for people can be some of the signs that you can start to look for.

Jeff: Are there some social situations, subtle signs or maybe some psychological signs to watch for beyond the physical ones?

Julie: Sure, definitely. So for instance, you know, I, as I had mentioned, using alone doesn’t necessarily put you into the category of a substance use disorder, however, when we start to see an impact on the functioning or how well we’re able to carry on in different parts of our life, specifically school or work, recreational activities, social relationships, or taking care of your personal wellness, those are things that we would want to look out for.

So, for example, if someone starts to spend a lot of time using, getting, recovering from substance use in a way that interferes with, you know, how likely they are to say yes to a social invitation or maybe avoiding and even initiating things that maybe they used to initiate in the past.

This could look like maybe letting go of seeing a kid’s sports game or maybe declining that invitation to be with other people.

From a personality standpoint, if this is impacting relationships in the family where it’s leading to more arguments, a lot more distrust or you know, resentment even, it can really disrupt how well that relationship is functioning.

And if people are continuing to use despite that impact, that can be a sign when this is becoming more of a problem as well.

Jeff: Here’s a question, I bet you get asked a lot. What if the subject of our concern insists there is no problem, I’ve got this, back off, but what is the response?

Julie: You know, first of all that is very normal. There are millions of people in the United States who would meet criteria for a substance use disorder according to national surveys. The vast majority of those people do not get treatment.

One of the primary reasons why they don’t get treatment is because they feel like they don’t have a problem. And so, I just want to put that out there that where people might disagree on when there is a problem, that’s a common experience.

And so, what we can think about for families is kind of noticing for ourselves, like what we’re seeing that might be different, and trying to broach that conversation with a loved one and trying to kind of tailor our approach based on the response of that person.

If someone’s easily able to say, yes, I agree, yep, I’ve had a problem too, it’s going to be a much easier go than if someone says, you know, I don’t have a problem at all. And so there, I would say the temptation would be to kind of catch someone using or make them admit that they have a problem.

But sometimes that can really put the person on the defensive. So, I think what I would say is really trying to strengthen the relationship, go into some of those conversations without judgment, with an open mind, with sort of a curious standpoint.

It can really help have a conversation where you, you’re very clearly on the same team rather than feeling like you’re getting into a tug of war or any sort of argument where the person with the substance use is on one side and you are on the other because you’re all part of the same family or the same team.

Jeff: What about this whole concept of enabling someone with struggling with an addiction? At what point does that threshold get crossed and what are some of the concerns around that?

Julie: That’s a great question, so, you know, I don’t tend to use the term enabling because it has a very negative connotation.

And I instead think about it as times when maybe all of us may have unintentionally done something that makes it easier for someone to use, substances or increase the likelihood of them doing so in the future because we were making the best decisions that we could at the time with the knowledge that and resources that we had in the moment.

And so, you know, I never want to place any sort of blame on family members for their loved one’s substance use because typically at no point are you forcing someone to have that sip of alcohol or making them, you know, use that pill or smoke that weed.

And so, I think that many families get to a point though when they realize, huh, looking back, maybe I would’ve done some things differently.

So, some examples of times when families may think, hmm, I’d like to change how things go in the future would be any time where they feel like they have mixed feelings or some ambivalence about something that they’ve done, that can be a good sign where things could be better maybe in the future.

So, one example of that might be financial support of a loved one. So, using substances costs money typically. And so, if a loved one is spending their money on alcohol or other drugs and they run out of money, it’s not uncommon for them to turn to a family member and ask for additional financial support.

Family members want to protect their loved ones from, you know, financial distress, wanting to provide the things that would make them comfortable because they love them. And sometimes what that can do is inadvertently create a buffer or stand in the way of what we call a natural negative consequence of substance use, which would be running out of money.

The same might go for potentially doing things like cleaning up after someone coming home after a night out or doing things like offering them a ride to the dispensary or something like that, which sounds counterintuitive, but you might be surprised by the fact that this comes up with many families that they’ve been in that position.

And so of course, you know, if it’s not our own immediate family or if we’re looking at this in hindsight, it can seem very clear that a different course of action may have been more effective. But those are some of the things that might come up that families experience because they’re concerned about what would happen in terms of the alternatives.

And so, I think that there are different approaches that people can take in terms of creating healthy boundaries for themselves that ultimately really empower their loved ones to make the decisions that they want to make for themselves and live with the natural consequences of those decisions so long as it’s safe to do so.

Jeff: Such important points that you’ve raised there. I want to ask you about the family unit itself or the definition of what a family structure is because sometimes that’s an unconventional one, sometimes that family will include friends and colleagues at work, for example.

Is there a way to integrate the most pertinent members of a support system in a family model?

Julie: Sure, that’s a great question. And these days, you know, we can kind of think of family as anyone who would be a concerned, significant other, someone who cares about that person using substances and their wellbeing.

So right, it could be, you know, biological family, it could be chosen family, it could be friends, it could be teachers, coaches. There are lots of different ways that people could seek help to support the loved one that they care about.

And so, one of the evidence-based approaches that works with families in this broad definition of concerned significant others is CRAFT or Community Reinforcement And Family Training.

It’s an evidence-based approach really designed to help people to do a few things, one, to get a loved one into treatment for substance use if they’re not in treatment already.

Two, to help reduce substance use even in the absence of treatment or in the context of ongoing treatment.

And three to really help improve the resilience and wellbeing of that family member or concerned significant other so that they are in the best position to continue to help this loved one with their substance use recovery throughout their process.

And so, the way that can look is a few different ways. One, you can learn about the CRAFT approach yourself and kind of books or online courses, or you can try to find someone trained in the CRAFT model to really work with you one-on-one.

And this is a really unique approach because it doesn’t require that the person with the substance use problem meet with that CRAFT coach or CRAFT therapist.

And this is so important because sometimes when you’ve got a loved one who’s connected to a treatment in some way or another, they may or may not actually give the family member or those other people in their life access to talk to their clinical team.

And so that creates a tough barrier where the family member might be in the wing saying, hi, you know, I’m living with this person or I’d like to help, but I don’t know how. And so, CRAFT is a way to kind of get those skills into the hands of people who need them most.

And anyone can learn these skills, it’s not rocket science, I promise if I can learn it, anyone can learn it. And the research has shown that approximately seven out of 10 family members or concerned folks trained in CRAFT skills have been able to get a loved one into treatment for the first time.

Jeff: What happens, Julie, if different members of the team have different ideas about how to go about doing all of this? Do you find that there are sometimes conflicts within the family structure itself?

Julie: Good questions, yes. It’s tough when everyone thinks that their way is the right way and sometimes those are very complimentary approaches and sometimes not so much.

So, for instance, when I work with family members, I might be working with one member of a family, so this might be one parent of a set of parents concerned about an adult child, for instance, with a substance use problem.

And ideally it would be great if everyone were on the same page, but sometimes people don’t always have the time or the bandwidth and their schedule to actually, you know, all meet with a coach at once or the, there may not be a ton of coaches available in someone’s area. So, one person may be taking the lead in that family to learn different skills or to think about the approach to help their loved one.

So what I would encourage is really having open communication as much as possible about trying to connect about what common ground you can find, even if you don’t agree on everything, maybe it can be one agreement about, hey, this is the boundary that we’re going to set, or hey, this is the type of support that we’d like to offer, or, okay, can we all agree that maybe our loved one would benefit from talking to a professional.

And think about sometimes one person taking the lead with having that conversation with the loved one, or sometimes it can be, you know, taking slightly different approaches to get at the same goal, sometimes that can really benefit, especially when a loved one has a different relationship, maybe with one family member or another.

You can sort of create a, an approach where you can share the similar, a similar sentiment, but deliver it in a way that makes the most sense for that family member, however, if there are conflicts, you know, I often encourage talking to the loved one with substance use issues directly.

And really think about, on the one hand, family members could have all the opinions they want about how treatment might go or what’s useful in recovery, but ultimately, it’s the person with the substance use who’s going to make the decision about what they feel comfortable with.

I would go with first and foremost what they would be open to trying and take their lead.

Jeff: So, beyond conflicts within the team that might arise, what are some of the other major roadblocks when it comes to getting a loved one into treatment and keeping that loved one engaged?

Julie: Oh, sure that, I am glad that you brought that up because just because someone’s in treatment one day doesn’t mean that they necessarily will another day. So, I think some of the roadblocks that come up, particularly in this climate and you know, the healthcare system that we have, are a couple of things.

One factors within the individual who’s using substances and two, are sort of systemic factors or limitations.

So, for the individual with a substance use problem, they may have changes ebbs and flows in their readiness to acknowledge that they may need help or their openness or motivation to actually go meet with a professional.

Another might be past experiences that they may have had having experiences within involuntary treatment for instance, or if they’ve met with a provider in the past that maybe hasn’t felt like the best fit. And in terms of systemic barriers, they may totally agree that they may need help. And also, a family member might think, okay, well I’ll just sign you up for treatment.

And in an ideal world, we would of course love to get someone meeting with a professional within 48 hours of them expressing their willingness to do so, like the strike while the iron is hot, is definitely the way to go whenever possible, however, there are wait lists for people oftentimes, or people you know, may not have folks who are covered by their insurance.

So, there can be a lot of different barriers that come up. What I would say would be strategies to get to minimize some of those barriers to the extent possible would be to think one, if your loved one doesn’t have a provider yet, try to do as much research as you can in advance to think about who’s in your area, who’s using evidence-based approaches for substance use.

Specifically, things like cognitive behavioral therapy or CBT and really think about, you know, if you have your pick, who’s going to be a good match for your loved one, you know, it’s, we’re all people, right?

Just because you’re a trained licensed clinician doesn’t mean you’re going to be the best clinician for every person who walks through your door.

And so, thinking about who you might feel comfortable talking to, you know, with your loved one, depending on demographics or style, that can really go a long way because none of these evidence-based treatments work if a person is not willing to try them or to talk to the person delivering them.

Another is to think about, well, how do you capture or take advantage of the motivation to get help in your loved one? So, we can think about this in two ways.

One window of opportunity, the timing of when to have these conversations. And then two, the motivational hooks or the specific elements that would actually get your loved one to listen when you’re having those conversations.

So, some of the windows of opportunity to keep in mind are one, when there might be some sort of crisis, when a person may feel remorseful about their substance use, like if there’s a hospitalization, a crash car, a legal incident.

People don’t tend to change when things are too comfortable. And so, if you’re catching someone at a time when they really feel like, yeah, gosh, this is not how I was imagining living my life right now, they might be more open to change.

Another might be if they share that someone outside of the immediate family unit, like a friend or a coworker has made some unexpected remark about their loved one’s substance use or how they’re doing it lands very differently than if it’s mom or your dad or your spouse saying for the hundredth time that they’ve seen a problem.

It really helps that person take a step back and think, oh, maybe this isn’t just, you know, an issue with my family member. This is actually something that other people are noticing more objectively.

And then a third would be if a family member is working with say someone on CRAFT skills and they notice that their family member acting differently, maybe not getting into as many arguments, maybe changing how they interact with their loved one, that’s an opportunity to talk about you yourself as a family member, perhaps getting help normalizing that process, sharing some of the benefits that maybe you found.

And then once you’re having those conversations, I must emphasize that you want to have these conversations when you and your loved one are sober. And when you have the time to do so, to really think about, well, what would hook them in and get them to buy in to this idea of treatment at all?

So, one would be to really emphasize what might be obvious, but that they don’t have to do anything they don’t want to do, if they haven’t been in treatment to this point, I mean, they’ve already proven that fact, right?

Unless they’re immediate harm to themselves or others. Really trying to highlight the autonomy and the empowerment of that person to really have a huge say in their treatment because they are the leader of their treatment team. And then also to think about they’re not ready to work on substance use and treatment, that’s okay.

The majority of people I talk to, their treatment goals are not around reducing substance use. It’s more about, I want to get a job, I want to go back to school, I want to move out of my parents’ house. I would like a relationship.

And so, to the extent to which you can center the conversation around what your loved one cares about already, lead with that first. Because naturally the conversations around how substance use is helping or hindering progress toward that goal will come up.

And the third thing that I think most people find helpful is this idea of sampling treatment. It’s very tempting to say, hey, loved one, you need to go to treatment for, you know, this month-long experience or you know, let’s get you hooked up with a therapist.

You meet with them for six months or a year, and then that’ll prove to me, you know, that you’re really making a change. If someone hasn’t had a track record of no treatment and you’re putting in an ask like that, it’s going to feel really intimidating.

And so sometimes taking the foot in the door approach can really help, like, hello, you know, would you be willing to talk to this person for five or 10 minutes, see if you like them. And if you don’t, you don’t have to talk to them again.

But you know, you might be able to see if they might be able to help you and giving them a chance to sample treatment just like we would, this idea of sampling sobriety can help take the pressure off a little bit and give people the opportunity to try and the openness to succeed and also to find somebody else who might be a better fit if needed.

Jeff: So, Julie, quick follow up on that. You ran through a number of windows of opportunity. There is sometimes this notion out there that you have to have someone hit rock bottom before they can really get into help, is that a myth?

Julie: You know, I think that message is out there for a lot of people and every family is different, but the approach that I take is no, we don’t have to wait and kind of sit on our hands until our loved ones hit rock bottom.

There’s such an important role of families when helping a loved one in that they, next to the person who has a substance use problem, know that person probably better than most people. So, they have an incredibly valuable amount of knowledge about that person, about what they’re going through. And to really leverage that position and relationship that they have with their loved one is so key.

And so there are lots of things that people can do to really create a positive relationship with that loved one, to provide consistency, and expectations or type of support that they’re feeling, comfortable offering that loved one and really realizing that, you know, they’re there as a resource and someone for that loved one to turn to whenever they’re ready.

And so, I’d say it’s all about balance. Like, no, I wouldn’t say you should have these conversations about helping your loved one get into treatment every day.

Leaning in too much, you might make that loved one, want to lean back and kind of move away from this idea, but also thinking about that you don’t have to cut ties with your loved one to help them is an important one too, because I think it still gives us hope in that there’s so much that we can do.

And some of the families that I’ve worked with on this idea about how to help without pushing that help on someone else, you know, sometimes people really describe it as life changing for them.

Jeff: We have a lot of questions I want to get to about addiction and other forms of mental health concerns as well. But first I want to continue walking through the family’s roles during and after treatment. So, let’s kind of talk about some of the various forms that addiction treatment can take and the roles that loved ones can play during that treatment process, starting with detox or inpatient care.

Julie: Sure. So, there are all types of different levels of care depending on the person’s need. And this may be in some ways tied to the types of substances that they’re using. And in other ways it may be the amount of acuity, or the severity of that substance use disorder.

So, when someone has a substance use problem, the first line of defense may not necessarily be detox or inpatient care, but that is a perfect setting for people who might be in the position where they are using a substance where cutting down or stopping using that substance would put them at medical risk for harm.

And so, things like, you know, alcohol for instance, if someone is using a lot of alcohol and they need to detox doing so in a safe way where they have the medical support available in case they have withdrawal induced seizures or other concerns like that is really important.

And so sometimes we don’t always think about that, or the idea of detox or inpatient care can be scary for folks, but it can actually be the most appropriate level of care for some people, that being said, detox or inpatient care is typically a much shorter stay than some other forms of treatment.

And so, it’s really all about stabilizing that person in a medical or psychiatric crisis to then continue work in a lower level of care.

Jeff: What about when a loved one is in residential treatment? What can family members do to support him or her?

Julie: Sure, so, you know, in a time like that, by definition, their residents or their living location is outside of this home.

And so, I think that can be really beneficial for a couple of reasons, one, for the person with a substance use problem, it takes away a lot of the environmental stressors or triggers that might increase their likelihood of using substances.

For the family members, it gives them breathing room to say, okay, what’s the state of affairs, what does my loved one need? What do I need right now? And it gives you a chance to kind of regroup and come up with an effective plan, you know, going forward.

And so, I really think taking that time when someone’s in a residential treatment program to work with their team if possible, to come up with a good aftercare plan is really, is really key because I think sometimes in the moment of a crisis, it’s really hard to think clearly if there isn’t already a plan in place.

Emotions are running high, and so it can be really tough in that moment to manage as a family, but during residential treatment, you get to learn a bit about what your loved one’s working on, ideally in that program.

And then that program may include family members as part of family meetings or consultation about what’s possible and what’s recommended after on an outpatient basis. And so, I think it’s really a time of planning and thinking about putting pieces in place to be successful in recovery after.

And one thing that I would just note about is both for detox and inpatient and residential programs, sometimes there is this sense of if my loved one just goes to treatment, they’ll be cured, or they will be fixed. And so here I would just say that these are all important pieces of the recovery process and also it is a process.

So, I do just want to set expectations that there is definitely work to be done outside of those contexts as well.

Jeff: What about mutual help programs? So, my loved one is in one of those, how do I help them there?

Julie: So interestingly, you know, a lot of times people think about some mutual help programs where you know, you’re working with other people who have also gone through a substance use concern. You might think, okay, well that’s something that just they’re working on. But some of these programs also have kind of corresponding groups or services for family members and friends as well.

So, for instance, something like Smart Recovery where it incorporates, you know, recovery-oriented approaches to care also including some CRAFT elements as well, can be really helpful for folks. And there’s, you know, for instance, Smart Recovery Family And Friends, that is a service that you can go to when you’re in the position of supporting a loved one.

And so I think that finding ways to kind of work on learning more, to educate yourself about a loved one substance use is really key, and figuring out, you know, from people who also have lived experience in this area about what’s been helpful for them can be helpful to figure out what works best for you and your family.

Jeff: Let’s keep walking through this process here, Julie. So, if someone has just come out of treatment and is back in the home, what are some of the dos and don’ts for supporting that person?

Julie: Sure, definitely. Well, having talked to some people on one of our inpatient units for substance use, I’ve asked actually, you know, what they feel like would be helpful for them and their families, you know, upon discharge or to support them in the programs that they’re in.

And one of the things was really educating themselves. You know, it’s tough to get all of the information about substance use disorders and addiction, but I really would say to the extent possible as a family member, try to learn what you can about, you know, substance use disorders as a disorder. It’s not necessarily a choice.

I have yet to meet anyone who is woken up and said one day I want to have a substance use disorder. It’s not something that people choose, and so yes, people can make choices that can improve their chances of recovery, but this is really something that can have a biological component too, it is very difficult, you know, to just make some of these changes overnight.

Even if you think about anyone quitting smoking cigarettes, which can be a process that can take multiple attempts. And so, I would really encourage families to learn what they can to have empathy for their loved one who’s trying to make these changes.

If it’s hard for the family member to see a loved one go through that, just imagine how difficult it might be for that loved one to have this personal experience themselves and to know that it’s perhaps impacted the family as well. And to think about, you know, some of the best approaches in supporting a loved one.

Oftentimes family members are very cautious, you know, about what should I do, shouldn’t I do? And sometimes it can lead to almost feeling like you’re walking on eggshells with a loved one. And what that can do is sometimes need families to say, well, I don’t know what to say so I’m not going to say anything.

And that can be tricky too, because when we’re starting to shut down conversation, it opens up the doors for assumptions which may or may not be accurate in terms of what a loved one’s going through and what they need.

And so, I would really say if you start to notice that you’re feeling like you’re avoiding some of the interactions or conversations with a loved one, trying to think about ways that you can be honest, like, it’s okay if you don’t completely know what your loved one’s going through or that you don’t understand.

And you can say that if you have a loved one in that situation, you could say something like, you know, I don’t completely understand, you know, what you’re going through and I want to, what would be important for me to know?

So, finding ways to get that line of communication open, hear what’s going on with a loved one, so you don’t have to make assumptions about what they’re needing or not needing can really go a long way.

And also, really taking care of yourself in the process is so key, when we’re under times of stress, it’s the easiest time to let go of, you know, eating well, sleep, exercise, et cetera. And it sounds very basic, but it’s, if we’re taking care of ourselves, we are modeling how to be healthy and take care of, you know, ourselves for our loved ones.

And then also it really can help us de-stress, get ourselves into a state where we can be the most effective in communicating and supporting a loved one in the way that is most consistent with our values.

Jeff: Yeah, I definitely wanted to circle back to self-care is such an important topic, very specific question for you. Should the home environment be entirely free of drugs and alcohol for somebody post-treatment?

Julie: That’s a great question. So, I think that from my experience in research with substance use, I’ve learned a lot about what’s called kind of cues for using substances. So, cues are any types of things that you might see or associate with using substances.

So, this could be things like seeing a bottle, a brand, even the store where you might buy or drugs or alcohol or the people who you would use with or even kind of, you know, the smells associated with that use.

All of these cues can be incredibly powerful for someone who has a substance use disorder. So much so that when you put someone in an FMRI machine and you show them these cues of their substance of choice, their brain will respond differently to those cues usually in a way associated with reward or pleasure.

That’s different than someone who does not have that association with using substances and these cues and that type of reactivity can persist far after someone has stopped using substances.

So, I say that provide some context for how cues or drugs or alcohol in the home or in the environment that someone is in can really impact someone even if they’ve chosen not to use anymore. So, what it does is typically increases the amount of creating or desire to use that drug or alcohol again.

And so, I think to the extent that the home can be free of or minimize those types of cues, it will give your loved one a better chance of success. That being said, no one lives their life in a bubble, so they will be in a position where they will be out in the world and encounter these cues or triggers as well.

And so, I think that none of this is entirely on a family member, you know, to do everything in their power that would necessarily guarantee that a loved one would stay sober or continue to reduce their substance use.

I think the loved one in treatment ideally would also be working on strategies to minimize their exposure to some of these cues and also think about ways to respond to those cues or remove themselves from those high-risk situations as we might refer to them whenever possible.

So, if drugs or alcohol are in the home, at least making sure that you’re kind of trying to minimize that interaction or certainly not offering that to a loved one would definitely help.

Jeff: So, I suppose a natural follow up to that question would be this one. Do you find sometimes that resentment develops over recommended changes to the home environment?

Julie: Hmm, sure, of course. I think that it’s natural that families might experience some level of resentment because this is not typically the type of situation that they had imagined themselves being in.

And so sometimes even frustration around the expectations and the reality and the discrepancy between those two can be, can be tough for families understandably. And when they may be asked or feel like they, they’ve got to make changes that they don’t a hundred percent want to make, that can be difficult too.

So, every family is different and thinking about what makes sense for an individual and that family is going to be the way to go. And also, it’s okay to experiment about what works for your family, you know, the holidays are coming up. This is something that is often front of mind for people when you’re inviting a lot of family over, you know, do we want to serve alcohol or not?

When you know you have a family member for whom that’s been a problem. And so you can think about the fact that it’s normal to feel some resentment toward this and also think about your choices, you know, what happens if you take this approach versus what might happen or be most likely to occur if you take that approach and only you or that family member can decide what they feel most comfortable with.

It’s okay to try something out and also change tactics later.

Jeff: Julie, I want to shift gears here a little bit and explore with you the connection between substance misuse and other diagnoses. Whether those diagnoses include depression, anxiety, trauma disorders, what should we know about this?

Julie: Yeah. So, I think it is very common for people who have a substance use problem to also have other types of mental health challenges or experiences as well.

So, for instance, you know, it could be anything from depression or anxiety, ADHD, psychosis, all of these types of things may increase the likelihood that someone may have difficulties with using substances.

So, a few things to keep in mind would be like for instance, if you have a loved one with psychosis, and that’s one of my backgrounds of expertise as well, a smaller amount of substance may affect that person a little bit differently than someone who does not have a psychosis experience in their life.

Another would be to think about, well how does this impact how family members might use some of the skills that I’ve mentioned when helping their loved one in their recovery with substance use?

So for some people, and not everyone, but on average, you know, certain groups, if they have additional mental health challenges, there may be difficulties with concentration, attention, other cognitive issues, even by definition, you know, for depression and anxiety, troubles with concentration or attention can be one of the symptoms that would lead to a diagnosis of major depression or anxiety disorder.

And so, because of that, if you’re going into a conversation talking to a loved one, trying to keep in mind some of the specific communication skills, like being brief, being specific and clear can be incredibly helpful. And it can lead to less frustration than if you feel like you’re having the same conversation over and over or you feel like your loved one’s not listening to you.

It might not be on purpose; it might really be because it is more difficult to pay attention. You know, if you’re distracted by your own negative thoughts or if you’re distracted by hearing voices, it will be physically more difficult to hear what a loved one or a family member is saying to you.

And so, for that, I think really focusing on your main goal for a conversation with someone, what’s the number one thing you want to express or the number one thing that you want to accomplish or ask in that conversation can really help?

Because it can be difficult when you’ve had a track record where a loved one’s not talking to you, all of this, you know, a laundry list of items to discuss may be building up and it can feel so tempting to say, oh, I’ve got an opportunity to talk to you. Let me talk about the 10 things that I’ve been meaning to talk to you over the past number of weeks or months.

And so, I would say to try to focus in on one of those topics at a time, and that can also help as well to get across whatever you want to say about concerns around substance use or encouragement around seeking treatment so that your message isn’t getting lost in a lot of other topics of conversation.

Jeff: Yeah, this could be really confusing and challenging for a family member to figure out, and you touched on this Julie, but if someone has a co-occurring mental health condition, how do you determine which symptoms or changes are attributable to substance use versus the other diagnosis?

Julie: That is a really, you know, tricky kind of differential diagnosis point.

I think that sometimes you might be able to tell, so for instance, if someone’s using a substance and you notice that it exacerbates their level of depression or anxiety, or for instance with cannabis, we know if people use cannabis, that increases the likelihood of developing psychosis or risk of rehospitalization.

You know that if you see those changes and then you stop using that substance and then those symptoms go away, that can be a sign that yes, those mental health symptoms were more so driven by that substance versus coming up just on their own. However, it can be a little bit trickier when you might not see such clear patterns of symptoms coming on and symptoms coming offline.

And sometimes you may not entirely know and sometimes people feel like they might use substances in a response to experiencing certain symptoms, however, the self-medication hypothesis doesn’t always play out for a lot of people.

And so, I think that this is a long answer to say that it can be unclear for some folks. The important thing is to think about how people can get help or ideally, an integrated approach for their mental health and substance use problems.

Because typically if you’re making progress or improvement in one area, the other areas will also improve as well.

Jeff: And it’s worth noting that addiction is itself a mental health condition.

Julie: Exactly, yes. I’m glad that you brought that up, you know, sometimes I phrase it in a couple of different ways because that’s often how people talk about it, but I completely agree it’s all part of mental health, you know, umbrella.

And so, to think about the fact that everyone, you know, when a mental health concern, you know, deserves treatment, deserves to get help, I think in, can help to destigmatize the stigma that is especially pertinent when it comes to substance use disorders.

Jeff: We have talked at several points in this conversation today about the role of compassion. How do you cultivate compassion? What if a family member is really having trouble with the best of intentions, finding compassion for a loved one, struggling with addiction?

Julie: Oh, for sure. You know, this comes up for so many reasons, whether it be, you know, feeling personally impacted by the things that a loved one said when they’ve been intoxicated or having been through the process of trying to find treatment and having a loved one decline that treatment.

It can be a really frustrating feeling like you’re putting in all this time and effort trying to help someone, and you may not feel like that effort is being reciprocated.

And so, you know, I think taking a step back and reminding ourselves why we’re doing all this in the first place, you wouldn’t go through all of that effort, you wouldn’t be attending this webinar if you didn’t care so much and love this person in your life.

And so really trying to keep that in mind why you’re trying to do this, the fact that you value that relationship or why that relationship is important to you can help keep your personal motivation out, right?

I think of course it would be easier if the person with a substance use disorder were able to take care of all of this on their own, but they may not be the person, you know, attending this webinar today or the person meeting with me in my virtual office, you know, to work on these different skills with CRAFT.

And so, I think that if it’s worth it to you, to work on rebuilding, preserving, or improving the relationship with your loved one and knowing that even if they’re not making the progress that you might like yet, they are doing the best that they can help keep that compassion into play.

One of the specific exercises that we do with CRAFT is something called a functional analysis where we actually walk through and try to put ourselves in the loved ones shoes about what do they get out of using substances, what’s great about it for them because there’s always a reason or a set of reasons why people continue to use substances.

And by going through this process of identifying the short-term positive consequences of use can help us understand why our loved ones do what they do, even if we don’t agree with it.

It can also serve as the framework for what alternative healthier activities we might be able to encourage or support that might be able to replace that substance use and serve as similar function in terms of helping them relax or have fun or escape in some ways that are healthier.

And so, I think that process can sometimes sound counterintuitive, like what’s so great about using heroin for instance? And also, it can help us build that empathy by just trying to understand where a loved one is coming from because they’re making choices in a logic system that makes sense for them at that time.

Jeff: Let’s segue from compassion for our loved ones to self-compassion, which is again, is something you touched on earlier in our conversation. It’s so important for caregivers to take care of themselves. Talk about some strategies, if you would, for doing so.

Julie: Yeah, so I think that this is an important piece that I try to work with folks on every session that I meet with them. And I think that one thing that I mentioned in the beginning is this idea of shifting one’s focus to the realm of influence that you can control.

And so starting with yourself first is where you can start to see progress and you can build up your own wellbeing and patience and resilience and do things for you in a way that you can create a life and a level of fulfillment that yes may be related to your loved one and their wellbeing, but is not completely dependent on your loved one and their wellbeing.

And so I think that one way we can do this is to really think about taking stock of how things are going in different areas of life, you know, thinking about how things are going at work, how things are going in your marriage or family relationships, how things are going with your own personal alcohol or drug use, how things are going in terms of your personal habits.

And once you take a bit of an inventory about what’s going well and what could be better, focusing in on your top priority area of what could be better is a great place to start. If you feel like all of my life areas really could use some change, that’s okay too.

We would just focus in on one area to start with first, knowing that those other areas are also important.

And then once you focus on what’s important to you right now, for instance, for a lot of people it might be their personal habits with exercise or sleep, things that physically give them, you know, the resources to carry on day to day.

We would really think about setting very specific and achievable, you know, measurable goals to really think about what they can do, what would allow them to be successful, and really trying to set a goal week to week.

And what’s interesting about this process is that not only can it help a family member improve their own happiness, and there’s been research to show that using this in the context of the CRAFT approach that I had mentioned can improve family member’s depression and anxiety levels increase their own happiness and their happiness with their loved one.

It can also build empathy in some ways for when a loved one’s trying to work on their own goals with substance use or recovery related goals because it highlights, you know, that it’s not always easy and that it can take patience in progress.

So, I think it can be useful in so many ways and it really helps people build up their confidence regardless of what’s going on with their loved one, and in doing so, it allows them to put their best foot forward every time they interact with that loved one with substance use.

Jeff: What about support groups for those who are providing this care?

Julie: Sure, support groups are a wonderful way to connect with a community of people who have been through something very similar to yourself, if not the same thing, and that’s so important because we had talked about earlier the role of stigma and isolation in this whole process, the tendency to maybe want to hide what’s going on, but we all need someone to talk to about this, whether it’s an individual therapist or a group of people.

And there are definitely support groups of people with lived experience with a loved one who you can connect with. So that can be through a lot of different options.

It might be through, you know, Smart Recovery for Family and Friends, Al-Anon, Na-Anon or it could be through a NAMI family support group.

Or you can look to connect with people through something like the Partnership to End Addiction, which is a nonprofit that offers even individual connections with other family members who have been through a similar situation but have been trained in skills to kind of help you get through that too.

So, there are definitely options to seek out where you can connect with folks who have been through something very similar to yourself.

Jeff: So, before we wrap up and let you go, let’s talk about any additional resources for family members supporting somebody living with addiction. Can you pass along a few?

Julie: Yeah, definitely.

Locally at McLean, if you have a loved one with a substance use problem and you’ve come through our McLean programs, we have a Wednesday night group led by Angela Hakkila, a social worker who really leads a wonderful group, a support group for family members of people with a loved one with a substance use disorder.

There are also plenty of books and resources online.

So, for instance, I’ve mentioned CRAFT several times. This was an approach created by Robert Myers and Jean Smith, and they have a book called Get Your Loved One Sober, which is written for the public. That can be really helpful to kind of walk through some of these skills and how you can use them with a loved one.

Another book kind of related to that is Beyond Addiction by Jeff Refa and others at the Center for Motivation and Change.

If you’re looking more for a podcast of someone who’s, or a group of family members who’ve been through this, typically with children with a substance use disorder, Steven D’Antonio had started this podcast with some other family members and he also has a great website, Addictionlessons.com.

And if you’re looking more for an online course also with some options to get additional group or one-on-one coaching, We The Village is a great resource out of New York, but really serves people internationally using CRAFT-based skills.

For folks who have a substance use problem and early psychosis, I’m actually leading a research project that is comparing CRAFT for early psychosis compared to treatment as usual. So if folks are interested in potentially getting involved in that they could email me directly.

And I think that there’s also a wonderful book written by some folks at McLean called The Complete Family Guide to Addiction by Thomas Harrison and Hillary Connery, and that can be a great place to start as well.

One other thing that I would mention would be Helping Families Help is a resource on how to find different folks who use the CRAFT approach across the nation. And the Invitation to Change approach is something sort of CRAFT related and there’s some free resources from the foundation for change on that as well.

I know that was a lot, but I would just encourage people to look into some of those if it might be of interest and also your local NAMI resources as well. There are some great family to family programs that people can look into too.

Jeff: And we’ll add some links along with this webinar, Julie, I’m afraid we’re out of time, this hour has just flown by. You’ve given us such great information, thank you. Dr. Julie McCarthy, we very much appreciate your time and for those of you who have tuned in today, we want to thank you as well.

On behalf of all of us with McLean Hospital, wishing you a very good day.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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