You probably don’t need convincing that treatment for your loved one would be helpful. Your loved one may be less clear. So, how do you get her to go? Happily, our answer—this chapter—is relatively short, because so much of what you’ve already done lays the groundwork for her to consider entering treatment. Remember: people are more likely to engage in treatment when they have a choice among treatment options, a rationale they agree with, and an intensity of treatment that matches their needs; when their obstacles are addressed and they participate in the decision.
Maybe you can’t imagine your loved one ever being willing to talk about treatment, let alone go. Maybe you’ve talked about it but he has refused every time. Maybe he’s gone to treatment and it didn’t seem to work. This chapter will help you optimize the process of suggesting treatment. With your understanding of motivation and the skills you now have at your disposal for taking care of yourself, communicating, and influencing your loved one, you’ll have a better chance of success than ever. This chapter will show you how to capitalize on the work you’ve already done to collaborate with your loved one.
Based on this collaborative foundation, there are proven strategies for eliciting your loved one’s interest in getting help. Specifically, we’ll elaborate on two major components of CRAFT you have learned: first, seeing things from her perspective—what motivates her, what barriers she perceives to treatment, what options make sense to her—and second, using positive communication—timing the conversation(s), planning what you will say, and, as always, rehearsing before you go live.
If you doubt that there’s any approach to suggesting treatment that could work in your case, it should reassure you to remember that the studies evaluating the effectiveness of CRAFT only included people who were initially unwilling to enter treatment. In those studies, the treatment-refusing substance users decided to seek help after their family members had completed only five (on average) out of twelve CRAFT sessions. So, if your loved one is expressly unwilling, then he is precisely the person these strategies were designed to help.
Remember Motivation?
To prepare to invite your loved one into treatment, first brush up on the motivational principles in chapter 2. Motivation is enhanced by:
• Having a choice among options
• Having reasons that make sense for a particular choice
• Having a sense of competence about what you are doing
• Getting information without pressure
• Feeling acknowledged, understood, and accepted as you are
• Getting positive feedback for positive change
You’ll recognize these factors in the following guidelines for suggesting treatment.
Helpful Guidelines for Suggesting Treatment
See it from your loved one’s point of view. Her point of view may be the same as or very different from yours, but either way, the appeal of your invitation to treatment ultimately depends on why it might be important to her. What issues matter to her and how can you link these to her desire to change? If continuing a theater project she’s involved in at school is important, the treatment options you suggest should reflect that. Perhaps he hasn’t liked group therapy in the past, especially ones with “women talking about their feelings,” but he would go for individual sessions with a male therapist. When you put your suggestion in terms that are meaningful to your loved one, he will more likely consider it.
Use your positive communication skills. If you haven’t already started to put positive communication (see chapter 9) into practice, do! As strange as it may sound, you must (re)learn to talk, and suggesting treatment probably isn’t the easiest place to practice with at first. Ideally, you’ll have some fluency in positive communication (being positive, brief, specific, keeping a behavioral focus, labeling your feelings, offering understanding, taking partial responsibility, and offering to help) going into this particular discussion or series of discussions about treatment. Positive communication does not aim for everyone to be in agreement or like what they hear, but to increase receptivity and understanding, both of which are crucial when suggesting treatment to your loved one. The point is to lower defensiveness in conversation, so that everyone involved can hear each other, consider, and collaborate.
Consider past attempts. If you’ve already tried in one way or another to suggest treatment and he declined, take heart. Failed attempts are not reasons to believe it will never work, but clues to what could work better next time. The Communication Analysis exercise in chapter 9 (page 172) will help you examine what could go differently. You also know now that change takes time and practice. You can try to engage your loved one in the idea of treatment and if he declines, learn from the experience and try again.
Address barriers to treatment. Treatment location, cost, approach, schedule, how simpatico other people in the program are (if group treatment), and other such logistics not only contribute to people’s initial willingness to say yes to treatment; when these issues are not adequately addressed, they are also common reasons people give for dropping out of treatment. You can’t anticipate or ultimately remove every obstacle, but it is certainly worth brainstorming what might get in the way for your loved one and what could at least reduce the barriers. Is the AA meeting you found attended by young twentysomethings like your son or mostly retired sixtysomethings? Are the program’s groups available at a convenient time for your mother-in-law to babysit or only at times when child care coverage will be problematic? If your loved one is afraid, what could you do to make it less scary? Validating obstacles to treatment as your loved one sees them will also help you address them as problems to be solved together rather than positions she has to defend.
Unfortunately, many geographical locations lack treatment options, and the only treatment option available may require sacrifices from your loved one and perhaps your whole family. For this reason, think carefully about what you can manage. Think creatively, but be realistic.
Use motivational hooks. You know what pushes your loved one’s buttons and what catches his interest. Use this knowledge to plan what you will say and how you will say it. Make it easy for him to say yes. “I’m seeing someone who is helping me think about our marriage in a positive way. Maybe you’d like to come with me for a session?” This presentation probably would get a better reception, knowing as you do that he is worried about your marriage, as opposed to “You need to see someone about your drug problem.”
Other hooks could include proposing a consultation (versus “starting treatment”); describing how he can choose what to address in therapy, including non-substance-related problems (perhaps he is motivated to get help for his depression but not his marijuana use), and viewing therapy as a path to obtaining something else that he values (if he gets help quitting marijuana, he could apply for that job he knows has a drug test up front).
Look for hooks in your Behavior Analysis from chapter 2 (pages 67–68) as well. When you considered negative consequences of your loved one’s use, which ones did you asterisk because you thought he would agree? In the example we gave, Janie knew that both she and her husband, Oscar, worried about their finances. She also knew that Oscar was a “numbers guy” who would feel more comfortable talking about numbers than feelings. Janie did a little math in order to present treatment options to Oscar in terms of how much less they would cost than the money they currently spent on substances. (She included her own wine consumption as a gesture of taking partial responsibility.) She showed Oscar that weekly outpatient treatment could save them enough in a year to take a trip to Yosemite, where he had long wanted to go, and the option of less intensive, less expensive treatment was a revelation to him. He hadn’t considered it because he hadn’t known it existed.
Have treatment options (plural) ready. Because motivation fluctuates, it’s helpful to do research and make contact with viable treatment facilities beforehand, in preparation to seize a good moment. This is why we preceded this chapter with the one on “Treatment Options.”
When the moment comes, having more than one option will lessen pushback and increase the chances of forward movement. This changes the conversation from yes/no (where a single no can shut down the discussion) to a range of possibilities to consider. Of course, a person can still answer “none of the above,” but a menu of options is harder to dismiss, invites participation, and promotes collaboration.
Timing matters. As with any positive communication, there will be better and worse opportunities to suggest treatment; if you figure these out now you can be ready for them when they occur (and resist the impulse to have the discussion when you’d better not). Some general pointers for timing the conversation:
• Don’t suggest treatment when she is high or hungover. There’s a greater chance at those times for irritability, guilt, reactivity, and instability.
• Look for windows of opportunity. These include times when your loved one is feeling particularly remorseful in the wake of a substance-related crisis or when someone has said something to him about his use that has given him pause. Windows can happen at positive moments too, like when he expresses interest in your therapy or curiosity about changes he has seen in you—for example, if you started exercising or he noticed you seem calmer. At these times he may be more receptive to the idea of joining you, because he can see the upsides of making changes.
• Consider when and where your loved one tends to be the most approachable in general. If she gets irritable when she’s hungry, talk to her after a meal. If she needs time to decompress after work, don’t pounce on her when she walks in the door. If she is less guarded when you’re in the car or walking the dog, plan your communication for then.
• Consider what else is going on in his life, so you can pick, say, a night of the week that isn’t the night before he has a performance review with his boss. The more you can see it from his point of view, the better you’ll anticipate timing that could work for or against your purpose.
• Don’t displace something else she likes. No matter how strongly you feel that this subject is more important than something she wants to watch on TV, finding a time that doesn’t conflict with something else she wants to do will avoid unnecessary antagonism and improve your chances of success.
• Don’t forget your own windows. It matters when you are feeling calm, optimistic, warm, and balanced. When are you least likely to be interrupted? When are you most relaxed? When will there be time for both of you to speak and listen without feeling distracted or rushed? Have you gotten enough sleep?
Choose the right person to have the discussion. It may not be you. Typically, as the one reading this book, you will be the one to suggest getting help. Possibly, though, there is someone else your loved one tends to listen to, someone with whom he is less defensive. Consider family members, friends, and mentors, your family doctor, rabbi, or another trusted adviser. Does your son’s uncle have a better relationship with him these days than you or your husband? Does your wife’s best friend have her ear right now more than you? Use your imagination and try to leave your ego out of it.
However, consider how your loved one will react to someone else knowing he has a problem. If the person already has his or her own reasons to be concerned, all the better. If not, be careful how much you disclose about your loved one’s problems. Sometimes people can be helpful without knowing all the details. If someone else agrees to do it and you feel comfortable asking, suggest that he read this chapter and chapter 9, “Positive Communication.”
Be positive. Be careful not to present treatment as punishment. This is difficult when you’re frustrated, fed up, and impatient for change, but treatment is not a bad consequence of behaving badly. It’s an opportunity for change! Also take care not to convey reasons for treatment as criticism. Again, make sure your loved one agrees with the reasons you see for making changes; at the very least, note that while you think they are good reasons, you understand that they might not seem so to him. Positive communication will help you avoid these pitfalls.
Start small. As previously noted, the requirements for people with substance problems to declare readiness to quit forever and go to rehab and/or attend 12-step meetings have prevented many people from seeking help or even considering change. Similarly, anxious and upset family members often want to insist on a “program,” though an individual therapist or medical doctor is a legitimate—and for some people more approachable—option. It’s tempting to lock on to the hope that a certain type of treatment is “it,” but it’s more helpful to start where your loved one is willing to start.
You can make the idea of treatment easier to chew on by breaking it into bite-size pieces. A single consultation, no strings attached, for example. A “sobriety sampling” experiment rather than a vow to never use substances again. Help may well be more palatable as something to try for a period of time rather than an admission of overwhelming need. Small is a fine and often more feasible place to start.
Rehearse. Rehearse the words you want to use, the tone you know is most effective, and the validation you know you should remember to make about his fears. When people are nervous, they often speak faster, have an “edge” in their tone of voice, say too much, and forget things. When people are nervous but they have practiced, they radically improve the match between what they want to say and what they do say. You’ll be nervous. Practice. You’d take the time to practice giving a speech or a toast, so why not for a discussion where you ask your loved one to change?
Have an exit plan. No matter how perfectly you deliver your lines, your loved one might still object. Planning how you will react if this happens can save the invitation from turning into an argument. If you have a plan for walking away before heavy conflict ensues, you will be in a better position to perhaps adjust your presentation and try again when another window of opportunity opens. Know your own “buttons” that could be pushed and cause an angry response on your part. The world won’t stop turning if you get angry, but it won’t help your loved one agree to treatment either. Try to foresee what she might say or do that could set you off and plan how you will walk away, calm yourself down, take a break, or otherwise reorient yourself to the path you want to be on.
You get more than one shot if you need it! You will feel more comfortable having an exit plan knowing you will be able to try again. You can step away when the wrong button gets pushed, or you’re just not getting anywhere, and circle back. Take some time to analyze what happened, what didn’t work well, what did work well, and how you might modify your discussion (timing, tone, what you forgot to mention, and so on). Be patient, and try again.
Here are some examples of what it might look like when you put it all together:
Since those layoffs at your job, you seem to be drinking more on the weekends. I totally understand why you would want to forget about work, but you’re forgetting about other things too. (Brief, specific understanding statement.) It upsets me when we go out for dinner with friends and you don’t remember the conversation later. (Brief, specific feeling statement.) Do you think there might be other ways to deal with the stress at work? Your sister was saying she likes her new therapist. Maybe her therapist could recommend someone? (Offer to help.)
Have you noticed we haven’t been fighting as much lately? I’ve been doing some things to help me be in a better mood, and it’s gotten me thinking about ways to make things better between us. (Brief, specific, partial responsibility.) Can I show you this website I found that talks about science-based approaches to change? (Brief, specific offer to help.) It doesn’t sound anything like that guy you talked to last year who told you that you have an incurable disease. (Understanding in the form of acknowledging what the loved one experienced as unhelpful in the past.)
Sharise was a client of ours who felt so empowered by her first session with a CRAFT therapist that she went straight home and announced to her husband that she was taking care of herself, finally, and insisted he get treatment. She told him he was “arrogant” for not thinking a therapist could help. This turned into a four-day argument. While she had initially felt relieved to “get it off her chest,” the fight made him more opposed to treatment than before.
Sharise worked with her therapist on how to reapproach her husband and suggest treatment in a way that he would be more likely to accept. She rehearsed how she could react in case he got defensive again, so as not to make it worse. She would be ready to hear no without getting angry and defensive. She knew he was under a lot of stress, but she thought his drinking was making it worse. She also knew that he assumed all therapists would sit silently and analyze him, which he thought was a waste of time. Given these hooks, she decided that the next time he launched into how stressed-out he was, she would say, I know you’re skeptical about therapy and also very busy (validating). But the therapist I spoke with sounded smart and funny (not silent), and she said some things about skills to manage stress and how that might help with your drinking (stress management being his goal). Would you agree to try just having a conversation with her?
While the evidence suggests that interventions do not successfully engage as many people in treatment as CRAFT, they can be useful in certain cases when your access and/or leverage are compromised, and your loved one is in real, imminent danger.
Johnson Institute Interventions
“JI” interventions are the typical TV intervention, in which family, friends, and colleagues are coached by a designated interventionist to approach someone they have determined to have a substance problem. With this method, the meeting is a surprise to the person using substances. Usually each participant shares a prepared statement about why he or she believes the person needs help, citing incidents or problems they’ve witnessed. This is typically paired with appreciation for who that person could be or has been in the past. An ultimatum about starting treatment (usually immediately) is then issued, and the treatment is usually rehab.
There is no licensing body to determine what occurs in an intervention. Some states have a certification process for interventionists, but some interventionists are dramatic and confrontational, which we know undermines motivation (in both the short and long term). You need to be an informed consumer if you choose this route, and at least speak to references for or families who have worked with the interventionist. Try to find an experienced, kind, and nondramatic interventionist who will listen to the information you have about your loved one. You know your loved one best and you have information the interventionist should care to know. The interventionist should indicate that he understands it as a collaborative process.
ARISE Model Intervention
A more collaborative (and motivationally sensible) kind of intervention, called ARISE, invites the substance user to participate in the process from the start, and if he or she declines, it is with the understanding that the family will meet anyway. There’s no secret. The ARISE approach treats the person with respect and invites his perspective. Its collaborative orientation lines up with evidence-based approaches. It also allows for a more traditional intervention as a last resort if nothing else succeeds, though in the research trials of ARISE interventions, a traditional intervention was almost never needed. While there is not enough good research to pronounce ARISE unequivocally an “evidence-based” approach, outcomes have been good with this method. Unfortunately, it is unclear whether the approach will catch on in the treatment community. What we can say is that it does integrate elements of the evidence-based motivational approaches we have described throughout this book.
We hear stories about interventions that were life-saving; we also hear people say they were left feeling traumatized and alienated by interventions. Both accounts are true. We appreciate the need for intervention at times, and we want to correct the misperception that it is the only way to get your loved one to change.
We applaud your patience, caring, and desire to help. We know that your heart is in your throat sometimes, and breaking at others. Yet here you are, trying to figure out how to talk to your loved one about entering treatment. We hope that he takes up your suggestion, connects with a professional, and pursues help further. We also hope that you won’t despair if he doesn’t. Success has many faces. Your conversation may not lead directly to treatment, but it may start your loved one thinking more seriously about treatment than he has before. Even if regular sessions do not follow an initial consultation, he might have taken something important from the meeting that sooner rather than later lands him on a path of change.
And if the conversation itself implodes, you know what to do: analyze what happened and plan how and when you will try again. You may need some time to feel sad, disappointed, or angry. Use your acceptance skills and take care of yourself. Change is often slower than anyone would like. As treatment providers, we’re convinced of the potential for treatment to help in many cases, but at the same time we know the research shows that many, many people change eventually, without treatment. In any case, we—you, your loved one’s friends and family and we treatment providers—can make a difference in how we invite people to change.