Monday, August 22, 2016

Enabling? Forget it!

The views in this blog are my own and not necessarily the views of my employer or any educational organization I may be affiliated with. But they probably should be.

"Enabler" is one of those words with people use when they want to sound like the know something about addiction, but both in and out of the field it is applied to so many different behaviors and situation that it is practically meaningless. In my experience the concept of "enabling" is usually introduced into the conversation about a difficult case just as the team is preparing itself to discharge the client or to use the threat of discharge to coerce the client into a higher level of care. In public it's most often attached to the parent or loved one of someone struggling with addiction but they never say exactly what they mean and I suspect they don't really know. I have NEVER seen anyone helped by this concept being introduced. I've never seen a case turned around by addressing "enabling." The reason may be that it is only introduced after the team has given up and is looking for a way to get rid of the living reminder of that failure.

So what is an enabler? Tell us Internet!


  1. a person or thing that makes something possible.
    "the people who run these workshops are crime enablers"

    • a person who encourages or enables negative or self-destructive behavior in another.
      "he criticized her role as an enabler in her husband's pathological womanizing"

So in the business of recovery an enabler is something, a person, policy, or institution, that makes it possible for a person to use drugs. This sounds like a terrible thing. This begs many questions but the first that comes to mind is this. How are we making it possible for them to do drugs? Do we really have that power? In the case of the treatment centers who floated this concept as a reason why it might be in the client's best interest to be kicked out of the program, didn't the client use before they came to us? Then how did we suddenly take on this responsibility? We are not making it possible for the client to use drugs and I offer as evidence that most and possibly all of the clients discharge in in order to stop enabling in my experience continued using as much or more than they did before coming to us. It seems we aren't so powerful after all. 

But it is rare for treatment centers to be called enablers, the term is usually reserved for the parents and loved ones of people struggling with addiction and it is to them that it does the most harm. It is hard to watch someone you love struggle with addiction. Those who have to will at best find themselves awake with worry night after night and at worst will suffer profound trauma. The will watch the person they love go through ups and downs. They may experience numerous heart rending disappointments as promising starts turn to relapse again and again. They may have to bury their child. It is unbelievably cruel to tell them at any point along the way that it is their fault, that they could have stopped it from happening if only the hadn't been so kind.

Parents and loved ones have, like treatment centers, do not have the power to make it possible to use. They are not encouraging the behavior unless they are literally telling their children to use. But so I'm not at risk of being as vague as those who promote the concept I want to give some specific actions/behaviors that ate definitely NOT enabling. 

-Providing your loved one with food IS NOT enabling 
-Allowing your loved one to live in a safe place after a relapse IS NOT enabling 
-Giving your loved one a little money even when you suspect they are using IS NOT enabling 
-Telling your loved one "I love you no matter what. I love you if you relapse and I love you if you never use again" IS NOT enabling 

As for examples of things that definitely are enabling 

-I don't know. I'm not sure I've ever seen any

My recommendation for people with loved ones struggling with substance use is to forget they ever heard the word "enabler" and my advice to my peers in the field is to stop using it completely. Loved ones worry more about how healthy your behaviors are for you, but don't pretend you have the power to stop your child's addiction. If punishment were an effective treatment for addiction the U. S. Prison system would be the greatest treatment center in the world. It's not.

Monday, August 8, 2016

Rethinking Relapse

While standing in line at the pharmacy I was approached by a client I worked with at my former position at a small methadone clinic. There is always some discomfort when seeing a client in public because one must balance politeness with protecting the clients confidentiality, this is doubly important with methadone patients. That being said I love it when clients come up to me in public. He asked me about my new job, if I regretted leaving, might I ever work at a methadone clinic again.  He listened to my answers the told me the best news I'd heard in a long time. "I'm doing great" he said, "I've got take homes." I was barely able to pause long enough to ask permission before hugging him. 

He had struggled with heroin addiction for years, had gone to then dropped out of treatment many times over the last few decades.  He had been with my clinic long before I was hired and the year he worked with me had been filled with sincere promises to stop using followed by drug screens reactive for heroin month after month after month, until the last month. I wish I could take credit for it but it was a therapeutic relationship with a nurse on the team that got him to do what I'd been trying to do for a year. He overcame his shame about being on methadone, started to look at it as medicine instead of an extension of his addiction, and adjusted his dose to a level that let him quite heroin use completely.  All I did was keep the powers that be from kicking him out and I refused to threaten to kick him out. In spite of the reactive screening month after month he was making progress. He rarely missed a day, he was addressing health issues that had gone unmanaged for years, and he was learning and applying self care techniques. I knew if he kept on going as he was eventually the heroin would stop too. I was excited to see the nonreactive screen before I left for my new job, I was thrilled to hear that in the following month he continued to improve, but I was not surprised.

I don't like the word relapse. In my opinion true relapse is rare and almost nonexistent with a client who is engaged in treatment and when it does occur it is usually caused by the reaction of the treatment team rather than the continued use.  AA unofficialy recognizes that not every use is a relapse, the term "slip" is often used to differentiate a one time use from a full blown relapse. SMART Recovery distinguishes between a "lapse" which is a short return to substance use usually a single night to a few days and a "relapse" which can last from several weeks to several years. In the clinical setting we are often behind the support groups and treat every use as a relapse. Relapse is loosely defined as a return of all or some of the symptoms of addiction, one of which is problematic substance abuse and when I say it almost never happens I'm not saying people in treatment don't abuse substances, they do.  What I'm saying is, that when they do, it's not relapse. It's not even a "slip" or a "lapse." What I'm proposing is that the substance abuse in most of what we call relapse isn't the return of a symptom, it's a symptom that, like in the example above, just hasn't gone away yet.

The above client wasn't relapsing for most of the year I worked for him. He simply continued to use, regularly, possibly daily. There were many reasons for this, he had inadequate coping skills to deal with anxiety, he had easy access to large amounts of cash, and I near unlimited supply. But the main reason he kept using was he was so ashamed of using methadone to treat his addiction that he wouldn't let the doctors raise his dose to a therapeutic level. When he didn't supplement his methadone dose with street opiates he went into withdrawal and while he could make it a few days he couldn't achieve the sustained  abstinence from heroin that was his goal, so most days he didn't try. While this continued use may have slowed the clients progress and was a blow to his self esteem he did continue to recover. 

It might be argued that his continued use may not fit the strictest definition of relapse, but his continued use certainly put him at risk for it. I agree it is possible, maybe even likely that the client's use would have spiraled out of control and put all his progress at risk. Haven't all of us even those of us who have worked in the field a short time seen it happen over and over again? A client abuses a substance, maybe they tell us, maybe they just get caught. One use leads to another and after a time you see the clients asking for change on the street, read about them in the arrest section of the paper or worse the obituaries. There is one event that has always occurred between that first use and the sad ending, the clients is either kicked or driven out of a treatment program.

In short, if you are working with a client who walks into your office and reports they got drunk over the weekend I would argue they didn't relapse. They just haven't reached their goal of complete abstinence yet. As long as they continue to work towards that goal they almost can't relapse.

 If this happens


Help them take an inventory of their progress, ask questions like "how are you reacting to this use now? How is that different from a year ago?"

Review coping and grounding skills 

Review needs and supports


Discharge or threaten to discharge the client

Pressure or scare the client into a higher level of care 

Call it a relapse.