Families Help Addicts Enter Treatment

Ms. A. arrived at the office for a routine medication visit with her psychiatrist. She was visibly tense and dejected, with swollen eyes from a night of crying. "I am so hurt! My son is so bright – he really has potential – but he’s drinking way too much. He took a leave from college after getting bad grades last semester, and now his girlfriend broke up with him!"

She continued, looking down at the floor. "A few years ago, his father died, and they were so close. Now, it’s just the two of us living in our home, as my daughter is out of state. Anyway, my son has distanced her as well. They aren’t as close as they used to be.

©Dmytro Panchenko/iStockphoto.com

"I want to help him so badly but he doesn’t think he has a problem. He’s not in school, but he won’t even look for a job. I feel responsible ... and ashamed. I can’t even tell my family. What should I do?"

Family-Focused Interventions

Most individuals with substance use disorders resist engaging in treatment despite the negative consequences of their addictions. (NIDA Res. Monogr. 1997;165:44-84). People who misuse substances typically have calamitous effects on their families, who then need to reach out to mental health professionals for advice, support, empathy, and direction – yet family members often do not seek help. In the families of addicts, marital distress, social problems, financial woes, legal problems, criminality, aggression, and interpersonal violence commonly arise (Int. J. Addict. 1992;27:1-14), often leading to feelings of intense anger, sadness, anxiety, shame, guilt, and social isolation (Drugs in the Family: The Impact on Parents and Siblings. University of Glasgow, Scotland, 2005). Providing support to families of addicts is crucial, along with getting the substance abuser into treatment.

Family-focused interventions can lead to positive outcomes for both the substance misuser and his or her family members. Alcoholics Anonymous (families group)/Narcotics Anonymous (families group) are good family-support groups. Family therapy, such as the Behavioral Couples Therapy (BCT) of Fals-Stewart, is very effective. But the question often is: How do I persuade my relative to seek help? Two evidence-based treatments designed to help family members persuade their loved ones to seek treatment are profiled here.

Community Reinforcement Approach Family Training (CRAFT)

CRAFT uses a positive approach that doesn’t involve confrontation. This program encourages family members to identify the addict’s triggers, to assist him in breaking the patterns that lead to his drinking. Once these triggers are identified, CRAFT helps the family learn how to reward nondrinking through positive reinforcement.

Family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. In a recent study, CRAFT resulted in three times more patient engagement than do Al-Anon/Nar-Anon, and two times more patient engagement than does the Johnson Institute Intervention. CRAFT also encouraged two-thirds of treatment-resistant patients to attend treatment (Addiction 2010;105:1729-38).

A Relational Intervention Sequence for Engagement (ARISE)

ARISE engages the patient in a family-centered process. The assumption with ARISE is that families are competent and have the capacity to heal. The therapist looks for strengths within family relationships. An "intervention recovery network" within the family functions like a board of directors, so that the addict cannot manipulate people one-on-one.

The process of ARISE is as follows. First, the telephone call: The therapist coaches the caller to include all the family members and as many friends as possible for the intervention. Next, the "identified loved one," or substance abuser, is invited into a conversation that will occur in the form of a family meeting. By the time of the family meeting, each participant has become clear on their "eyewitness account" of how the crisis has affected their loved one and the whole group.

Ideally, before the family meeting, the family members and friends cooperate to plan and write a "change message" that will be shared with their loved one at the family meeting. At the meeting, the group talks, and then signs the change agreement. The individual with substance abuse/dependence also signs the change plan. The therapist’s goal is to get the substance abuser into treatment. If successful, the therapist then collaborates with the treatment provider, and family and friends, through weekly phone calls for 6 months. In an NIH-funded study, ARISE resulted in 83% of substance abusers entering treatment (Am. J. Drug Alcohol Abuse 2004;30:711-48).

Beyond this overall framework, the ARISE program offers tips and guidance for families, to maximize the odds of success:

• Raising the subject. There is no perfect time or place to bring up the issue, but do not do it while the person is drunk or drinking. Wait until he or she is sober. Sometimes, a confrontation is more productive when facilitated by a professional who is knowledgeable about alcoholism and alcohol abuse and who can arrange a therapeutic intervention.

• Explaining the consequences. Convey the following message to the substance abuser, in a kind but firm tone: You need to get help or suffer the consequences. These consequences could include loss of your job, chronic illness, divorce, and breakup of the family or friendships. I will no longer cover-up for you.

• Don’t be brushed off. If you are seriously concerned about a person’s drinking, do not allow her to distract you from your concerns. If you are constantly bailing her out of trouble or giving her another chance, the alcoholic or alcohol abuser is likely to interpret this pattern as permission to keep drinking.

• Blame is counterproductive. Someone with an alcohol problem is likely to feel misunderstood. Try to put blame aside because it only feeds such feelings. Remember that alcohol addiction is a disease, not a moral weakness.

• One on one, the alcoholic wins. It is very common to become isolated in the effort of trying to get the alcoholic to accept help. Once you are isolated into one-on-one confrontations, the alcoholic almost always wins because he has the power to manipulate with promises, short-term efforts to improve, and blaming you as the cause of the problem. It is important to build a support network, such an intervention group, to avoid the pitfalls of getting caught in a one-on-one confrontation.

• Don’t wait until it’s too late. Putting off the discussion or confrontation increases the risk of serious health and social problems. As with any disease, the earlier the person gets treatment, the better. The alcoholic does not have to "hit bottom" in order to get help.

• Don’t neglect your own needs. It’s easy for the alcohol problems of one person to overwhelm an entire family. Family or personal stresses often show up as problems with emotional, economic, physical, and social functioning from living with alcoholism. You may feel anger, resentment, depression, betrayal, and disillusionment.

• Counseling may be necessary. You may need counseling to help you understand alcoholism and learn appropriate actions to protect your own well-being. Intervention is a proven method to both get you support and help a loved one get started in treatment. One way to help the alcoholic or alcohol abuser is to attend to your own needs and those of other family members. Going to alcohol support groups such as Al-Anon can be very helpful.

Psychiatrists see patients like Ms. A. in their clinical practices every day. While the importance of quiet, compassionate, and involved listening with patients is crucial, psychiatrists can also help their patients by providing new psychoeducation and treatment options, such as CRAFT or ARISE. These treatments can have profoundly positive effects and bring relief to the family and the person with substance dependence.

Dr. Heru is in the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic. Dr. Ascher is a resident in psychiatry at Beth Israel Medical Center and a candidate in the postdoctoral program in psychotherapy and psychoanalysis at New York University. He is a Sol W. Ginsburg Fellow in the Group for the Advancement of Psychiatry (GAP) Family Committee.

Ms. A. arrived at the office for a routine medication visit with her psychiatrist. She was visibly tense and dejected, with swollen eyes from a night of crying. "I am so hurt! My son is so bright – he really has potential – but he’s drinking way too much. He took a leave from college after getting bad grades last semester, and now his girlfriend broke up with him!"

She continued, looking down at the floor. "A few years ago, his father died, and they were so close. Now, it’s just the two of us living in our home, as my daughter is out of state. Anyway, my son has distanced her as well. They aren’t as close as they used to be.

©Dmytro Panchenko/iStockphoto.com

"I want to help him so badly but he doesn’t think he has a problem. He’s not in school, but he won’t even look for a job. I feel responsible ... and ashamed. I can’t even tell my family. What should I do?"

Family-Focused Interventions

Most individuals with substance use disorders resist engaging in treatment despite the negative consequences of their addictions. (NIDA Res. Monogr. 1997;165:44-84). People who misuse substances typically have calamitous effects on their families, who then need to reach out to mental health professionals for advice, support, empathy, and direction – yet family members often do not seek help. In the families of addicts, marital distress, social problems, financial woes, legal problems, criminality, aggression, and interpersonal violence commonly arise (Int. J. Addict. 1992;27:1-14), often leading to feelings of intense anger, sadness, anxiety, shame, guilt, and social isolation (Drugs in the Family: The Impact on Parents and Siblings. University of Glasgow, Scotland, 2005). Providing support to families of addicts is crucial, along with getting the substance abuser into treatment.

Family-focused interventions can lead to positive outcomes for both the substance misuser and his or her family members. Alcoholics Anonymous (families group)/Narcotics Anonymous (families group) are good family-support groups. Family therapy, such as the Behavioral Couples Therapy (BCT) of Fals-Stewart, is very effective. But the question often is: How do I persuade my relative to seek help? Two evidence-based treatments designed to help family members persuade their loved ones to seek treatment are profiled here.

Community Reinforcement Approach Family Training (CRAFT)

CRAFT uses a positive approach that doesn’t involve confrontation. This program encourages family members to identify the addict’s triggers, to assist him in breaking the patterns that lead to his drinking. Once these triggers are identified, CRAFT helps the family learn how to reward nondrinking through positive reinforcement.

Family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. In a recent study, CRAFT resulted in three times more patient engagement than do Al-Anon/Nar-Anon, and two times more patient engagement than does the Johnson Institute Intervention. CRAFT also encouraged two-thirds of treatment-resistant patients to attend treatment (Addiction 2010;105:1729-38).

A Relational Intervention Sequence for Engagement (ARISE)

ARISE engages the patient in a family-centered process. The assumption with ARISE is that families are competent and have the capacity to heal. The therapist looks for strengths within family relationships. An "intervention recovery network" within the family functions like a board of directors, so that the addict cannot manipulate people one-on-one.

The process of ARISE is as follows. First, the telephone call: The therapist coaches the caller to include all the family members and as many friends as possible for the intervention. Next, the "identified loved one," or substance abuser, is invited into a conversation that will occur in the form of a family meeting. By the time of the family meeting, each participant has become clear on their "eyewitness account" of how the crisis has affected their loved one and the whole group.

Ideally, before the family meeting, the family members and friends cooperate to plan and write a "change message" that will be shared with their loved one at the family meeting. At the meeting, the group talks, and then signs the change agreement. The individual with substance abuse/dependence also signs the change plan. The therapist’s goal is to get the substance abuser into treatment. If successful, the therapist then collaborates with the treatment provider, and family and friends, through weekly phone calls for 6 months. In an NIH-funded study, ARISE resulted in 83% of substance abusers entering treatment (Am. J. Drug Alcohol Abuse 2004;30:711-48).

Beyond this overall framework, the ARISE program offers tips and guidance for families, to maximize the odds of success:

• Raising the subject. There is no perfect time or place to bring up the issue, but do not do it while the person is drunk or drinking. Wait until he or she is sober. Sometimes, a confrontation is more productive when facilitated by a professional who is knowledgeable about alcoholism and alcohol abuse and who can arrange a therapeutic intervention.

• Explaining the consequences. Convey the following message to the substance abuser, in a kind but firm tone: You need to get help or suffer the consequences. These consequences could include loss of your job, chronic illness, divorce, and breakup of the family or friendships. I will no longer cover-up for you.

• Don’t be brushed off. If you are seriously concerned about a person’s drinking, do not allow her to distract you from your concerns. If you are constantly bailing her out of trouble or giving her another chance, the alcoholic or alcohol abuser is likely to interpret this pattern as permission to keep drinking.

• Blame is counterproductive. Someone with an alcohol problem is likely to feel misunderstood. Try to put blame aside because it only feeds such feelings. Remember that alcohol addiction is a disease, not a moral weakness.

• One on one, the alcoholic wins. It is very common to become isolated in the effort of trying to get the alcoholic to accept help. Once you are isolated into one-on-one confrontations, the alcoholic almost always wins because he has the power to manipulate with promises, short-term efforts to improve, and blaming you as the cause of the problem. It is important to build a support network, such an intervention group, to avoid the pitfalls of getting caught in a one-on-one confrontation.

• Don’t wait until it’s too late. Putting off the discussion or confrontation increases the risk of serious health and social problems. As with any disease, the earlier the person gets treatment, the better. The alcoholic does not have to "hit bottom" in order to get help.

• Don’t neglect your own needs. It’s easy for the alcohol problems of one person to overwhelm an entire family. Family or personal stresses often show up as problems with emotional, economic, physical, and social functioning from living with alcoholism. You may feel anger, resentment, depression, betrayal, and disillusionment.

• Counseling may be necessary. You may need counseling to help you understand alcoholism and learn appropriate actions to protect your own well-being. Intervention is a proven method to both get you support and help a loved one get started in treatment. One way to help the alcoholic or alcohol abuser is to attend to your own needs and those of other family members. Going to alcohol support groups such as Al-Anon can be very helpful.

Psychiatrists see patients like Ms. A. in their clinical practices every day. While the importance of quiet, compassionate, and involved listening with patients is crucial, psychiatrists can also help their patients by providing new psychoeducation and treatment options, such as CRAFT or ARISE. These treatments can have profoundly positive effects and bring relief to the family and the person with substance dependence.

Dr. Heru is in the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic. Dr. Ascher is a resident in psychiatry at Beth Israel Medical Center and a candidate in the postdoctoral program in psychotherapy and psychoanalysis at New York University. He is a Sol W. Ginsburg Fellow in the Group for the Advancement of Psychiatry (GAP) Family Committee.

Ms. A. arrived at the office for a routine medication visit with her psychiatrist. She was visibly tense and dejected, with swollen eyes from a night of crying. "I am so hurt! My son is so bright – he really has potential – but he’s drinking way too much. He took a leave from college after getting bad grades last semester, and now his girlfriend broke up with him!"

She continued, looking down at the floor. "A few years ago, his father died, and they were so close. Now, it’s just the two of us living in our home, as my daughter is out of state. Anyway, my son has distanced her as well. They aren’t as close as they used to be.

©Dmytro Panchenko/iStockphoto.com

"I want to help him so badly but he doesn’t think he has a problem. He’s not in school, but he won’t even look for a job. I feel responsible ... and ashamed. I can’t even tell my family. What should I do?"

Family-Focused Interventions

Most individuals with substance use disorders resist engaging in treatment despite the negative consequences of their addictions. (NIDA Res. Monogr. 1997;165:44-84). People who misuse substances typically have calamitous effects on their families, who then need to reach out to mental health professionals for advice, support, empathy, and direction – yet family members often do not seek help. In the families of addicts, marital distress, social problems, financial woes, legal problems, criminality, aggression, and interpersonal violence commonly arise (Int. J. Addict. 1992;27:1-14), often leading to feelings of intense anger, sadness, anxiety, shame, guilt, and social isolation (Drugs in the Family: The Impact on Parents and Siblings. University of Glasgow, Scotland, 2005). Providing support to families of addicts is crucial, along with getting the substance abuser into treatment.

Family-focused interventions can lead to positive outcomes for both the substance misuser and his or her family members. Alcoholics Anonymous (families group)/Narcotics Anonymous (families group) are good family-support groups. Family therapy, such as the Behavioral Couples Therapy (BCT) of Fals-Stewart, is very effective. But the question often is: How do I persuade my relative to seek help? Two evidence-based treatments designed to help family members persuade their loved ones to seek treatment are profiled here.

Community Reinforcement Approach Family Training (CRAFT)

CRAFT uses a positive approach that doesn’t involve confrontation. This program encourages family members to identify the addict’s triggers, to assist him in breaking the patterns that lead to his drinking. Once these triggers are identified, CRAFT helps the family learn how to reward nondrinking through positive reinforcement.

Family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. In a recent study, CRAFT resulted in three times more patient engagement than do Al-Anon/Nar-Anon, and two times more patient engagement than does the Johnson Institute Intervention. CRAFT also encouraged two-thirds of treatment-resistant patients to attend treatment (Addiction 2010;105:1729-38).

A Relational Intervention Sequence for Engagement (ARISE)

ARISE engages the patient in a family-centered process. The assumption with ARISE is that families are competent and have the capacity to heal. The therapist looks for strengths within family relationships. An "intervention recovery network" within the family functions like a board of directors, so that the addict cannot manipulate people one-on-one.

The process of ARISE is as follows. First, the telephone call: The therapist coaches the caller to include all the family members and as many friends as possible for the intervention. Next, the "identified loved one," or substance abuser, is invited into a conversation that will occur in the form of a family meeting. By the time of the family meeting, each participant has become clear on their "eyewitness account" of how the crisis has affected their loved one and the whole group.

Ideally, before the family meeting, the family members and friends cooperate to plan and write a "change message" that will be shared with their loved one at the family meeting. At the meeting, the group talks, and then signs the change agreement. The individual with substance abuse/dependence also signs the change plan. The therapist’s goal is to get the substance abuser into treatment. If successful, the therapist then collaborates with the treatment provider, and family and friends, through weekly phone calls for 6 months. In an NIH-funded study, ARISE resulted in 83% of substance abusers entering treatment (Am. J. Drug Alcohol Abuse 2004;30:711-48).

Beyond this overall framework, the ARISE program offers tips and guidance for families, to maximize the odds of success:

• Raising the subject. There is no perfect time or place to bring up the issue, but do not do it while the person is drunk or drinking. Wait until he or she is sober. Sometimes, a confrontation is more productive when facilitated by a professional who is knowledgeable about alcoholism and alcohol abuse and who can arrange a therapeutic intervention.

• Explaining the consequences. Convey the following message to the substance abuser, in a kind but firm tone: You need to get help or suffer the consequences. These consequences could include loss of your job, chronic illness, divorce, and breakup of the family or friendships. I will no longer cover-up for you.

• Don’t be brushed off. If you are seriously concerned about a person’s drinking, do not allow her to distract you from your concerns. If you are constantly bailing her out of trouble or giving her another chance, the alcoholic or alcohol abuser is likely to interpret this pattern as permission to keep drinking.

• Blame is counterproductive. Someone with an alcohol problem is likely to feel misunderstood. Try to put blame aside because it only feeds such feelings. Remember that alcohol addiction is a disease, not a moral weakness.

• One on one, the alcoholic wins. It is very common to become isolated in the effort of trying to get the alcoholic to accept help. Once you are isolated into one-on-one confrontations, the alcoholic almost always wins because he has the power to manipulate with promises, short-term efforts to improve, and blaming you as the cause of the problem. It is important to build a support network, such an intervention group, to avoid the pitfalls of getting caught in a one-on-one confrontation.

• Don’t wait until it’s too late. Putting off the discussion or confrontation increases the risk of serious health and social problems. As with any disease, the earlier the person gets treatment, the better. The alcoholic does not have to "hit bottom" in order to get help.

• Don’t neglect your own needs. It’s easy for the alcohol problems of one person to overwhelm an entire family. Family or personal stresses often show up as problems with emotional, economic, physical, and social functioning from living with alcoholism. You may feel anger, resentment, depression, betrayal, and disillusionment.

• Counseling may be necessary. You may need counseling to help you understand alcoholism and learn appropriate actions to protect your own well-being. Intervention is a proven method to both get you support and help a loved one get started in treatment. One way to help the alcoholic or alcohol abuser is to attend to your own needs and those of other family members. Going to alcohol support groups such as Al-Anon can be very helpful.

Psychiatrists see patients like Ms. A. in their clinical practices every day. While the importance of quiet, compassionate, and involved listening with patients is crucial, psychiatrists can also help their patients by providing new psychoeducation and treatment options, such as CRAFT or ARISE. These treatments can have profoundly positive effects and bring relief to the family and the person with substance dependence.

Dr. Heru is in the department of psychiatry at the University of Colorado at Denver. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic. Dr. Ascher is a resident in psychiatry at Beth Israel Medical Center and a candidate in the postdoctoral program in psychotherapy and psychoanalysis at New York University. He is a Sol W. Ginsburg Fellow in the Group for the Advancement of Psychiatry (GAP) Family Committee.