If someone you know is struggling with substance use, they are not alone: 46.3 million people age 12 or older — 16.5 percent of the population — met the criteria for having a substance use disorder in the past year, according to a national survey released earlier this year by the U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration. That statistic includes 29.5 million people with an alcohol use disorder and 24 million with a drug use disorder.
Seeing someone you care about struggle with substance use can produce all sorts of emotions, including anxiety, fear, frustration, concern, and helplessness. One of the most important things you can do is express compassion and support for your loved one, according to Dr. Samantha Lookatch, a psychologist at NewYork-Presbyterian and Columbia University Irving Medical Center who specializes in substance abuse and addiction treatment and has led research on how social support can aid in recovery. “Often our anxiety can come out as anger or frustration with someone, and it’ s difficult for someone to accept support if they feel defensive,” says Dr. Lookatch. “Try to avoid judgment and lean on the concern that we have for that person.”
Health Matters spoke to Dr. Lookatch to better understand substance use disorders and to learn the most effective ways you can support a loved one who is struggling with substance use.
Health Matters: What does it mean to have a substance use disorder? Dr. Lookatch: Substance use disorders are diagnosable using the Diagnostic and Statistical Manual (DSM), the mental health diagnosing system. The criteria include consuming the substance in larger amounts and for a longer amount of time than intended, a persistent desire to cut down or regulate use, cravings, impaired ability to fulfill major obligations, risky behavior, and more.
Another helpful term that is a little bit broader is problematic substance use. Even if someone doesn’t meet the DSM criteria, their use may still be concerning, for example in teenagers and young adults who use substances like cannabis, in which potency has increased in the past couple of decades. Even if someone’s casually using and doesn’t have a substance use disorder, the use could still be problematic and cause other mental and physical health issues.
It’s often a combination of environment and genetics for people.
Struggling with a substance is not a choice or character flaw. It’s important to move away from these old myths that tend to cause shame, blame and diminishment of the problem, which can subsequently reduce the level of compassion we feel toward a loved one.
What is the best way to approach or respond to someone who is struggling with substance use? Some of the most important things we can do is be empathic and validate someone’s feelings.
We don’t want to say things like, “Yeah you definitely need to stop,” or “You’ve been really out of control.” Instead, try to express compassion and support. You can say something like “I’ve noticed these things and I’m worried.”
What else can you do to be helpful in this kind of conversation? You can ask someone what would be helpful for them. Sometimes people want that help in identifying providers or programs or next steps, and sometimes people want to do that on their own. If someone shares that they don’t know what to do next, partner with them and offer to figure it out together, as opposed to telling someone what to do.
How specifically might you support someone with the holidays coming up, or social events that involve substances? We call that coping ahead. If something big is coming up that might be difficult or triggering, be it a holiday or an anniversary, you can ask how you might be able to support them. If someone is sober or abstinent, you can offer to be a sober companion with them or not use.
If you’re hosting and you know who people are coming that don’t drink, have non-alcoholic options that aren’ t just water so that they can still feel included and not othered in some way.
You can also be curious — a lot of times people know what would help them but might be anxious to ask, so inquiring can help signal to them that you are a supportive person and want to be a part of their sober support network.
It’s nice to plan an activity that has nothing to do with substances. Suggest coffee or a museum — something totally different from a bar. Sometimes people feel the burden of having to come up with different things that aren’t substance related. When they can be offered those things, that can help not only normalize that everything doesn’t have to include substances, but that other people are also interested and willing to spend time with them in settings that are substance-free.
What can you do if the person is defensive, or not ready to accept support? An important piece of trying to support someone is knowing that there are windows of opportunity that open and close, and being mindful that sometimes the window shuts before we’re able to get there and breathe some of that fresh air in with the other person. And being able to say, “OK, I understand maybe you’re not interested right now. If you change your mind, know that I’m here to help in whatever way I can.” That way that seed is planted, and they know that you remain a safe person to be able to come back to, who recognizes that there may be a problem without judging, attacking, or blaming them. And really having that open, supportive stance.
"Some of the most important things we can do is be empathic and validate someone’s feelings. You can say something like 'I’ve noticed these things and I’m worried.'"
— Dr. Samantha Lookatch
What role does social support play in recovery? Social support is crucial. With substance use and addiction, we often stop relating to other people and we attach instead to substances. Instead of having those people you lean on at the end of a difficult day, it’s the substance. If you’re feeling happy, instead of celebrating with loved ones or friends, you’re using the substance. So the substance really starts to take over all of these connections that we would have with other people. For recovery, it is imperative that those connections to people are restored.
Research shows that if you keep in your network someone who is still fully supportive of your substance use and you have regular contact with them, you’re more likely to return to use than if your network is full of people who are your champions for change. So having loved ones is necessary to be able to make effective and lasting change, whether it’s a moderation goal, harm reduction goal, or total abstinence.
What can loved ones do to help educate themselves? NewYork-Presbyterian and Columbia provide a set of therapeutic techniques called CRAFT (community reinforcement and family training) to train loved ones in developing a basic understanding about addiction, helping to see what is going on in the substance use cycle for their loved one, and their own points of intervention.
They may be engaging in behaviors that unintentionally support use. For example, if you have a loved one who you wake up in the morning to make sure they don’t sleep through their alarm and get to work on time — while that’s an act of love, at the same time it tells them that they can stay up late because they know you’re going to help them in the morning. They don’t experience some of those natural consequences. It helps us understand what natural consequences we can let our loved ones experience so that they can recognize their use is causing a problem, and choose a different path.
What can someone do to take care of themselves, while also supporting their loved one? It’s important to know when to step back and recognize you’ve done everything within your control, and the rest is up to the person with problematic substance use. There is a parallel path of healing where everyone has to recognize the things they have to accept and the things they can change.
Treatment can be crucial for loved ones too. Group therapy is effective because a lot of times we go underground with our shame when our loved one is struggling with substance use. When we feel so alone with it, it becomes too much to carry.
We run groups for CRAFT, and people often are shocked that they can relate to these other individuals so quickly, that they understand exactly what it’s like even though maybe it’s a different substance or the relationship isn’t the same. Maybe it’s a partner versus an adult child. But there’s this fast connection and sense of belonging and understanding that happens that’s also so crucial for healing and being able to move forward.
What is the No. 1 thing you’d tell someone who just learned someone in their life is struggling with substance use? That they can be helpful along the path of that person’s treatment or recovery, and the burden is not theirs. I have a visualization of walking alongside someone. If someone is struggling, picture walking beside them and holding their arm. They can lead and guide their next steps, and you can help them get there.
Samantha Lookatch, Ph.D. is a licensed clinical psychologist specializing in the treatment of substance use and other co-occurring mental health disorders. She also has training in the treatment of anxiety, depression, trauma disorders and couples therapy. Her research has broadly focused on addiction treatment outcomes with her fellowship work addressing the role of social support in the enhancement of addiction treatment for veterans.