Often the actively using person does not initiate treatment.  This is consistent with the processes of denial whereby the addict is busy answering the question “How do I know I don’t have a problem?”  The people surrounding the addict are often experiencing more distress than the person with the addiction.  The addict has denial and the “comfort” of the substance while everyone else is feeling the pain.

Actively using addicts are constantly causing pain of one kind or another.  This is not because they are attempting to harm anyone.  It occurs as a function of the distorting effects their addiction has on their lives and relationships.  In extreme cases you have the pain of accidents caused by drunk drivers, but there are far more ubiquitous pains suffered by people involved with the addict.  The pain of alcoholic rage, ruined birthdays, and lost income are a few common examples.  For the most part, it’s the non-addicted other who experiences the pain.

As a general rule, anything that causes the actively using person to experience the distress while relieving the people involved with the addict is movement in the right direction.  You could think of it as a social system where there is a certain amount of pain and suffering which needs to be experienced.  The more the system can organize itself so that the addict experiences the pain and suffering, the more likely the addict is to realize they have a problem.  This is part of the wisdom of the “tough love” phenomenon.

The problem is that most social systems organize themselves so that the people involved with the addict experience the distress.

To some extent, caring about someone involves accommodating their needs, desires and idiosyncrasies.  As long as one conceives of drinking and drug taking along these lines, behaviors to accommodate appear no different than making sure the kids have their favorite snack food for the Sunday afternoon trip to Grandma’s house.

It has been my experience that someone other than the actively using person is more likely to seek help than the addict.

Many years ago a woman, let’s call her Betty, came in to see me and revealed that her husband was an alcoholic.  She had gotten my name from one of my colleagues.  She had tried to persuade her husband to get help in a variety of ways and had gone to Al-Anon for some time.  He accused her of nagging.  She was becoming progressively more desperate because their kids were entering adolescence and there were signs of alienation and acting out in her eldest son.  By the time she got to me she was becoming disaffected with the Al-Anon program because she felt there must be something she could do to get him to accept his alcoholism.

One of the common misconceptions that people take away from Al-Anon’s three C’s (You didn’t Cause it; You can’t Control it, You can’t Cure it) is that there is nothing a person can do to influence the behavior of the addicted loved one.

What happens over time in the families and intimate social systems of addicts is that the behavior of the non-addicted members shapes itself around the constraints of the addiction.  In this way, the life of the addict and the shape of their intimate social networks are distorted by the addiction.  Stories of flushing alcohol down the toilet, promises extracted and broken or children being counseled to avoid Mom or Dad during certain times of day are prevalent in the family life of addicts.  The accommodations intimates make in trying to maintain relationships with actively using addicts are generally referred to as “enabling behaviors” and generally have the effect of colluding with the addiction.  These behaviors are often seamlessly interwoven into the fabric of family life so that the members are unable to see their relationship to the addiction.

In my conversations with Betty, the specifics of her story and life with her husband, Bob, began to unfold.  They were high school sweethearts and he was drafted and sent to Vietnam shortly after graduation.  He was a gentle Ben sort of man whose father and grandfather were both alcoholics.  When he returned from the war, they got married and started their family.  There did not appear to be any adverse consequences of his military experience, though he had a lot of trouble keeping jobs because of conflicts with one boss after another.

This did not present a major problem for the family since Betty had a steady job with good benefits.  Eventually, they decided Bob should go into his own business as a plumber, which was made possible by Betty’s steady income.  Over the years Bob had moderate success but never enough that Betty did not have to work.  It was Bob’s dream for her that she not have to work.  By the time I met her they were 15 years into the marriage and Betty was making the bulk of the family income.  Over time she had taken on more and more of the financial responsibility as Bob limped along in his business.  She did not mind because she felt the stress of his business was causing him to drink, so therefore, whatever would reduce the stress might make it easier for him to stop.  The fact that his drinking increased as his income decreased was lost on her.  The fact that the more responsibility she shouldered, the less functional he became was obscured by her belief that stress was causing the drinking.

Bob was drinking more and more because he suffered from alcoholism and had yet to experience the profound personal failure that hitting bottom entails.  He was not experiencing this failure because in the face of his alcoholism Bob and Betty had co-constructed a situation in which the consequences of his alcoholism were muted by Betty’s compensatory behavior.  Betty, in trying to support and love her husband, was helping him to not experience the failure he needed to experience.

Further discussions with Betty revealed a particular pattern to Bob’s drinking.  Every night Bob would come home from work and take a hot bath.  Plumbing can be a grimy business.  Betty would be getting dinner ready and Bob would ask her if she needed anything from the store since he was going out to get cigarettes.  More often than not Bob would not return until well after dinner.  On these occasions he would invariably be drunk.  In the morning she would find him passed out on the couch.

The entire family had organized itself around this ritual.  Among the elements of this dynamic was the fact that she would not challenge him when he spoke of going out for cigarettes (she did not want to provoke a fight or nag him).  Also, their kids would be especially quiet getting ready for school because they did not want to wake up Dad, who was “sleeping” in the family room.

An incomplete list of the enabling behaviors in this family would include:

1)      Betty taking on the bulk of the financial responsibility.

2)      Betty doing what she could to lower the stress on Bob.

3)      Betty not challenging Bob’s assertion of going out to buy cigarettes.

4)      The children avoiding disturbing their father while he was passed out on the couch.

All these behaviors have the effect of insulating the alcoholic from the consequences of their addiction.  Theoretically, any adjustment in these patterns would increase the likelihood of information entering Bob’s awareness that there was a problem.

Over a period of time I worked with Betty to make adjustments.  This was not easy for her because the shape her enabling behaviors took was guided by her own map of how to be a good human being.

As a rule, the specific forms of enabling behavior are a function of the unique predispositions of the non-addicted spouse as they attempt to come to terms with the intractable nature of addiction.  To change these behaviors often requires challenging deeply held assumptions about what it means to be a good person and provoking anxiety in the non-addicted significant other.

Betty and I discussed various ways of altering the situation.  One thing she was willing to do was to rouse him from the couch and make sure he got into bed.  This was consistent with her view of being a good wife.  I also persuaded her that it was emasculating to a man to not be required to have more input into the finances.  Instead of shielding him, she became willing to inform him of their situation.

In the course of these discussions I inquired about the specifics of the drinking pattern.

Dr. Mallouk: When Bob would leave to “go out for cigarettes”, what would you

do about dinner?

Betty: Well I used to wait for him to come home but that got ridiculous.  The kids were hungry and the food would get overcooked. So now we just eat.

Dr. Mallouk: Do you set a place for him?

Betty: Yes, because sometimes he does just go to the store and back but more and more he just stays out.

Dr. Mallouk: When he stays out what do you do with his place setting?

Betty: Well we clear the table and just put his dish back in the closet.

Dr. Mallouk: Would you be willing to leave a place set for him at the table after the rest of you are done with the meal?

Betty: We could do that but what would be the point?

Dr. Mallouk: I’m not sure there is a point but here is my thinking.  I get the sense that Bob feels that it does not make any difference what he does.  It doesn’t make any difference whether he makes any money or not.  It makes no difference whether he falls asleep on the couch or not.  It makes no difference whether he comes home from the store or stays out drinking or not.  He acts as if he has no role in the family, no place.  He does not realize he is ill.  I am thinking that by leaving his place set at the dinner table, it communicates that you do not lose your standing in the family because you are ill.  He’ll have to walk through the kitchen and see that place setting and see that his absence was noted and there is still a place for him.

Betty: I think I understand.  I can certainly do that.

I would like to be able to report that two weeks later, Bob stopped drinking and began the process of recovery.  As it turns out there was no apparent change as a result of these adjustments.  At the time I was getting ready to make a presentation for the staff of a statewide mental health treatment organization.  It was about 2 months after my last contact with Betty and I planned to use this case to illustrate the point that all therapy can do is increase the likelihood that the addict will hit bottom and minimize the damage done in the process.  I was thinking of this case as a treatment failure when I contacted the family for permission to use one of the videotapes I had made for teaching purposes.

Betty answered the phone and informed me that Bob had stopped drinking and had gone to his first AA meeting.  She told me he had just asked for my phone number and wanted to come in to see me.