If your drinker is consistently resistant to the idea of treatment, you might try just discussing treatment with her. That is, instead of recommending it, ask your loved one under what conditions she would think treatment is appropriate. This conversation may go nowhere, but it may also give the two of you an opportunity to calmly discuss your current situation and compare how similarly or differently you perceive it. More important, you learn what button presses will motivate your drinker. For instance, she might say that as long as your marriage is holding together as well as it is, there is no need to make any changes. Or your loved one may think that her drinking really isn't causing anyone great pain. In both situations, you have the opportunity to PIUS-ly give your loved one the straight scoop.
Clients often worry that if they set up everything as we have instructed, finding out that they had prearranged treatment might make their drinkers feel manipulated. This is certainly possible. However, remember that we are encouraging you to be honest with your drinker from the start. You have stopped pretending that life as it has been is acceptable to you. You have told him when you are unwilling to fix his messes and under what circumstances you enjoy being with him. At some point in the process, it is also likely that you have let your loved one know that you are in therapy and are hoping that the personal growth you experience will also help your relationship grow. Tell her that you are in treatment and you have a therapist that is helping work out some problems. You can then ask her to go with you to therapy, and at that point you can have it prearranged that you leave the session and it becomes her treatment, or during therapy it could be suggested that she get her “own” therapist. There are many alternatives of this scenario. If you offer help in the context of loving steps you have taken to make sure your loved one has choices should he want to exercise them, he is not likely to feel manipulated. If he does react angrily, back off and tell him that you did not mean to pressure him—that you were only trying to have options available should he want them.
When the Window Slams Shut
For all your careful planning and patient waiting for that window of opportunity to open, there remains the possibility that your drinker will slam it shut. Everything will be perfect, the two of you will be on a really positive roll, you will lovingly and clearly raise the topic, and your drinker will explode. Or you get your drinker all the way to the waiting room of your therapist's office, and she gets cold feet and stomps out. What do you do? Simple. You do the same things you did to get her there in the first place. You thank her for considering it, remind her how much you love her and enjoy being with her when she is sober, and you plan and wait for another window of opportunity. It happens.
The beautiful thing about windows (of opportunity as well as those that let in fresh air) is that they can open, shut, open, shut, and open again. If you need to back off, that's okay. The fact that the window opened, however briefly, means it can open. Just review your strategy to see if you can improve it and bide your time. Most of the people who use this program get their drinker to at least try treatment. Remember, this is much like a road trip. Change takes time and the path meanders along its way. Getting your drinker into treatment often takes repeated attempts, but it can be done.
Supporting Treatment
When your loved one enters treatment, it is important that you continue to practice the new interaction style you have been working on. In fact, your help will be needed more than ever. You know from your experience how difficult it can be to change long-standing habits and how easy it is to become discouraged and give in to the old familiar patterns. Now imagine how difficult change can be with the added challenge of trying to give up a drug (or drugs) that affect not only the mind but the body as well. In a word—hellacious.
More than a few drinkers have abandoned treatment because it was too difficult to change themselves while their environment remained the same. You have made some excellent changes in your drinker's environment at this point. It is critical that you continue to use rewards, to communicate using the PIUS style, and to pay attention to the triggers and patterns that lead to drinking, arguments, and other difficult situations. Your job from this point on will be to continue working on improving the way the two of you interact and to support treatment. You cannot simply send your drinker off to be “fixed.” You must be an active supporter and, if necessary, an involved participant in treatment.
Depending on the type of program your loved one enters, your role will vary. Our hope is that he becomes involved with an active treatment program that focuses not only on eliminating the drinking problem, but also on replacing drinking with other healthier, more productive behavior patterns. If you are not in couples therapy, get your loved one's okay to talk to his therapist. Ask how you can help. Better yet, ask your loved one how you can help. You may be amazed at the types of help an individual asks for that might never have occurred to you.
Two of the universally appropriate ways to support treatment are to remove obstacles to treatment and to reward your loved one for going. Make it easy to go by ensuring child-care duties are covered, transportation is available, other events are not scheduled for that time, and whatever else you can think of to remove obstacles. Reward your loved one by telling her that you are proud, pleased, impressed, delighted, or otherwise thrilled with her for making the effort. Do not dwell on how bad things used to be. Rather, focus on the positive change and your bright future. Make being in treatment as easy as you can.
When to Involve a Medical Professional
In most cases, your best bet for treatment is a licensed mental health worker (clinical psychologist, clinical social worker, certified alcohol counselor). These people are trained to help the problem drinker find healthier ways of coping with life. However, there are instances in which the assistance of a medical professional such as a physician or psychiatrist is recommended.
If your loved one is drinking large quantities of liquor (more than five or six drinks per day for many weeks), he may need medical detoxification (detox) to help with withdrawal symptoms. Past experience is your best guide; if your loved one had withdrawal symptoms when giving up alcohol or drugs in the past, it is likely that she will need medical detox this time. Typically, medical detox takes three to five days and can be done either on an inpatient or outpatient basis, depending on the severity and on the resources available in your community. During detox, medical personnel will monitor your loved one and provide medications to help him get through the delusions, tremors, seizures, and other withdrawal symptoms that may begin a number of hours after the last drink. Beware, though, that psychological withdrawal will take considerably longer than physical. Psychotherapy is essential to deal with the emotional stress of giving up liquor and adjusting to a new lifestyle. Getting past the physical withdrawal is only the first step.
Other instances in which a medical professional should be involved include the presence of liver problems (clues to this include a distended stomach, yellow tint to the skin and eyes, and wounds that refuse to heal), multiple drug use, or a history of emotional or psychiatric problems requiring medication. This list is by no means definitive. If you have any doubt as to the health status of your loved one or her ability to handle the stresses of giving up alcohol, consult a physician.
Help for the Rest of the Family
Most likely, other family members have also been adversely affected by alcohol, and it's important to seek family therapy or individual help for those family members. Al-Anon is a good resource for family members who need the support and empathy of others who have lived, or are living, through similar situations. Most communities have several Al-Anon chapters listed in the phone book.
Roll with the Punches
As thrilled as you are when your loved one enters treatment, keep in mind how difficult the process may be for him. Once the initial self-satisfaction of having taken this step wears off (possibly within hours or days), your loved one will be hit with the reality of giving up an old, dearl
y loved friend. It will be tough, and there are surely going to be times that your loved one takes it out on you. After all, it was your dissatisfaction with the drinker's life that started the whole change process. Accept that responsibility (secretly pat yourself on the back) and keep your goal in mind. You can put up with his temporary resentment to eventually live the life you deserve. As long as you keep yourself safe—it is too early to toss your safety plan yet—and continue to use all the strategies you have been practicing, you can get through this. So can your loved one.
Another warning we must give you is that more drinkers drop out of treatment than stay in—at least initially. It is very common for people to go in and out of treatment a number of times before they really begin to make lasting changes. Do not lose heart if your loved one enters treatment only to drop out after a short time. All the changes you have made figure into the success equation and even a treatment drop-out cannot negate them. Keep on working to make your life more pleasant and to reward your loved one for nondrinking behaviors. Continue to take care of yourself and to avoid making it easy for your loved one to drink without consequences. It may take a number of tries, but eventually there is a very good likelihood that your loved one will come around. In the meantime, keep your eye on the positive changes you have accomplished and enjoy them.
At some point you may decide that you have done all you can and tried as many times as you care to. You will have to decide whether to pull the plug on the relationship if your drinker does not change. At that point, you may want to use this decision as one last attempt to motivate your drinker into treatment by telling her that you are leaving unless changes are made. However, if you do so, make sure you are ready to follow through on your threat. Otherwise, you lose future credibility. Idle threats just give the drinker more power.
Action Summary
As we said earlier, the most critical piece of what you accomplish in this step is to have treatment ready to go as soon as your loved one indicates he is open to the idea. You must be able to get the drinker to a therapist within twenty-four to forty-eight hours of his agreeing to the idea. In our experience, this is about the maximum length of time the window will remain open. In fact, minutes after your loved one says, “I do need treatment,” motivation may begin to slip away. If you think of it as a wave that rolls in and out, you can see how briefly it crests. Don't waste an instant of that time—have a treatment program lined up and waiting. The sooner you catch that wave, the more likely it is your loved one will ride it to success.
Use the drinking maps you have made to figure out when your drinker is most likely to accept treatment and be alert for those windows of opportunity. Then, when the window opens, use your PIUS communication skills to lovingly but firmly present the treatment option. Do so with the expectation that your loved one will agree, but be prepared to back off if you see resistance or anger. Keep that wave image in mind and rest assured that even once the wave has slipped back out to sea, it will eventually return to where you sit waiting for it. Just as each time you fall off a surfboard teaches you a little more about how to stay on it, each time you broach the subject of treatment without an argument, you get a little closer to the time your loved one accepts and enters treatment.
Recap
Seek treatment programs that have strong empirical support for their effectiveness. We recommend those that use methods described with phrases such as “behavioral,” “cognitive behavioral,” or “skills training” and that involve the drinker's loved ones in the change effort.
Have treatment for your loved one lined up and ready to go the minute she agrees to try it.
Use your road maps to identify the windows of opportunity in which you can suggest treatment with a reasonably good chance that your loved one will be receptive to the idea.
Kathy and Jim: Opening Windows
Good things were happening once Kathy got into the habit of mapping Jim's drinking and planning in advance how she would handle different situations. Although he was still drinking a lot, which was still causing problems, there were more evenings that Jim would come straight home from work and spend the evening sober with Kathy. He also had started taking Ted out for pizza and video games on Saturday afternoons as well as spending a little more quality time with the two younger children. On top of that, Kathy had set up a regular date with her sister every Thursday evening, and Jim knew he was expected to be home to watch the kids. He didn't always show up on time (and Kathy would drop the kids off at her mother's or a neighbor's), but he did accept responsibility for the evening.
Life had definitely improved since the days when Kathy felt it was not worth living. However, Jim was still drinking, and even though he enjoyed his afternoons with Ted and accepted responsibility for Thursday evenings with the children, he would still frequently come home drunk or pop open a beer before his scheduled outing with Ted. When that happened, Kathy would not let him drive with the child, and Jim would get angry and storm out of the house to drink. Nonetheless, Kathy felt like she finally had a little control over her life, and Jim had rediscovered some pleasure in his family, which made it easier for her to tempt him to remain sober.
Kathy made a list of the times she thought Jim would be most receptive to entering treatment. Whenever he got drunk instead of taking Ted out on Saturday, Jim would wake up Sunday morning racked with guilt. He would apologize profusely and typically try to abstain all day to atone. Kathy decided this would be a good time to bring up treatment, as would the Friday mornings after the Thursday nights when he'd come home late and drunk to find his kids gone to his mother-in-law's house and a note from Kathy telling him how disappointed the children were.
Having identified these windows of opportunity, Kathy waited for them and prepared. She found a good therapist not far from the house who was willing to juggle her calendar and fit Jim in as soon as he said okay. This woman was a cognitive-behavioral clinical psychologist who focused on helping alcoholics develop the skills needed to turn away from liquor and rebuild their lives. She also insisted that Kathy be prepared to be an active member of the therapy team with Jim. Kathy was thrilled and made a couple of appointments just for herself in the meantime—partly to get to know the therapist and partly to help keep her own spirits up.
When the moment arrived and Jim was apologizing for another ruined Saturday, Kathy said, “Jim, I know you want things to be good for the kids and us. I do too. In fact, I've been seeing this wonderful therapist who has really helped me to manage my feelings. She would love to meet you, and you might find her helpful. I've got an appointment with her tomorrow. You can really make a difference for our family if you come with me and talk to her.” Prepared to back off at the slightest sign of anger, Kathy was delighted when Jim asked her if this was a “shrink for crazies” and if she was going to try to mess with his head. Happy to satisfy Jim's curiosity about the psychologist, Kathy explained how they just talk about stuff. “The therapist,” she said, “helps me figure out how to get along better with you as well as control my own feelings so I don't fly off the handle and mess things up.” Kathy knew this was the very thing Jim had spent the morning apologizing for. Jim agreed to meet the therapist, and Kathy quickly called the answering service to leave a message that they would be in to see her at the pre-agreed time Monday morning.
Kathy was so thrilled and Jim so determined to not act like “a crazy” that the rest of the day was wonderful. He did not drink, and Kathy went out of her way to let Jim know how much she loved him and enjoyed his sober company.
* * *
*For a detailed description of CRA, please see: Meyers, R. J., and J. E. Smith. 1995. Clinical guide to alcohol treatment: The community reinforcement approach. New York: Guilford Press.
chapter 12
Relapse Prevention
Carlene and Peter
Peter had really cut back his drinking quite a bit over the few months Carlene had been applying her newly learned behavior-change skills and PIUS communica
tion. He had even been attending AA meetings fairly regularly and seemed to be sincere about wanting to kick his drinking habit. Nonetheless, every three or four weeks he would have a particularly bad day at work, or he and Carlene would argue over money, and he would go on a binge. Carlene struggled between wanting to reward his nondrinking behavior and feeling betrayed by the times he did drink. In spite of the fact that things were better, she still worried a lot.
Here we are at the final step. This must be the happily-ever-after part, right? Not quite. Snow White and Prince Charming lived happily-ever-after. The rest of us live in the real world. That means we enjoy good times, work through tough times, and generally keep moving forward one step at a time.
Real life is full of ups and downs, as you well know, and the difference between people who get stuck in the downs and those who do not is in how they interpret them. For instance, consider someone whose partner abuses alcohol and whose life is consumed with surviving in this difficult relationship. This individual can look at the situation and see it as awful and hopeless and give up hope of ever having a better life. Or the person can look at the situation and see problems that need solving and put energy into figuring out how to do that. (The second person should sound very familiar at this point.) In fact, the real winners at life even go so far as to see problems as opportunities. Anytime something goes wrong or someone messes up, you have the opportunity to learn a little more about what makes things or people tick by taking them apart (the behaviors, not the people) and figuring out what caused the problem.
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