Excerpt from Coming to Harm Reduction Kicking & Screaming, 2nd Edition: 

Stories of Radically Loving People Who Use Drugs.

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Harm Reduction & Families¹

 

Family means no one gets left behind or forgotten. …David Ogden Stiers

Treat people as if they are what they can be and you help them become

who they’re capable of being. …Johann von Goethe

 

Hanging out with a friend, twenty-six-year-old Danny, a white, suburban male, took a pill. One pill. One pill that contained a highly concentrated, unregulated drug used to prolong a narcotic’s effect. A few hours later he was dead. For Danny’s mother, Louise, the loss has been immeasurable. Some days she can’t shower. Others she can’t get out of bed, the absence of her son leaving her “raw.”

 

“It’s been a nightmare,” she says. “The cops said that they can’t really do anything about it. There are so many homicides in Baltimore [where this happened]. They said unless there’s an actual stabbing or gunshots … wounds to the body … [t]hey just don’t have the manpower.” Before adding, “I guess if you want to kill somebody, Baltimore City’s the place to do it.”

 

Danny, a young man who was just getting his life back together, liked to have fun, he’d still enjoy a drink or two, and this fateful night he’d thought he could keep the party going by popping a benzodiazepine. Unlike the anti-anxiety meds prescribed by a licensed physician or psychiatrist, Danny got his Xanax off the street. He split the pill with a friend, John. John lived. Danny did not.

 

This luck of the draw is called “The Chocolate Chip Effect.” The term was coined for the efficient potency of bathtub fentanyl because of the way it can pool and isolate in minuscule but powerful spots. In this analogy, fentanyl is the chocolate chip in the cookie. Maybe you have a taste and get the chocolate chip. Maybe you don’t. Maybe you live. Maybe you die.

 

Danny’s mom Louise, an emergency room RN and fervent advocate of harm reduction, acknowledges that some people are going to keep using drugs. [Harm reduction] says, “[L]et’s reduce the chance of killing yourself until you can make better choices.”

 

And she has tried to use her son’s death to help others, starting with his memorial and funeral service, where Louise handed out Narcan, an opiate overdose revival agent, as well as fentanyl test strips.

 

“There were probably two hundred kids at Danny’s funeral,” she says with bittersweet pride.

 

John, the friend who survived the night Danny did not, joined in helping hand out the Narcan and strips. By the end of the service, all but a few of each were gone. Louise acknowledges she is not the first parent to suffer such a loss, nor is she the first to hope her child’s death will be the last.

 

“I want to stop other parents from having to go through this,” she says. “He took a pill,” Louise says. “He wasn’t out robbing houses to get high.”

 

“My son mattered,” she says. “And he will always matter to me, and if I can keep this from happening to some other mother [I will]. Because nobody deserves this.”

                                                                                           

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Kendra opened the door to find her son dead from an overdose. She had long before decided that in order to keep Jon alive, she would not only buy his drugs but have him use in the family home, in the downstairs bathroom, always with the door open, so she could hear if he fell or cried out that something was wrong. This was the hardest decision she had ever made but it was the only way she could sleep at night since his return home from his 5th rehab in less than two years for his drug use. She was determined that her only child would not die in the streets so what other choice did she have now?

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As I write this new section of the second edition of Coming to Harm Reduction in the summer of 2024, we’ve seen some 110,000 deaths from drugs in the US, mainly from mixing various drugs, which has always been the deadliest way of using drugs especially illicit ones. We are in a crisis of overdoses. However, to be honest, we still have nearly 500,000 deaths a year from smoking- related illnesses. And the Alcohol-Related Disease Impact application estimates that each year there are more than 178,000 attributable to excessive alcohol use, making alcohol one of the leading preventable causes of death in the United States, behind tobacco, poor diet and physical inactivity, and illegal drugs.4,5 Yet we hear very little about tobacco and alcohol. Why? Because they are legal (or licit) drugs and so we as a culture have decided to accept these drugs even though more harm is caused by them than most illicit drug use. Drug use here in the US is as complicated as the two opening real-life stories demonstrate. And every family must find their own way to endure their loved one’s addiction, and possible recovery, however they each choose to define that.

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In the second edition, I knew I wanted to have a chapter devoted to families who 1) have used some non-traditional ways to help their loved ones and 2) want/wanted a way to help their loved ones without using “tough love” or worse the now too often deadly “let-them-hit-bottom” concept. Here I’ve also added several stories from families—as well as some case examples from my work with families using Harm Reduction Psychotherapy or HRT—of those who have used harm reduction or “non-traditional strategies” to help their loved ones with an addiction. These same harm reduction strategies have allowed many families to begin the healing process sooner and make healthy changes for themselves regardless of the outcome of their loved one’s attempts at changing their relationship to a substance. At the end of this section, you’ll find a few basic Harm Reduction Psychotherapy (HRT) concepts that many of the families I work with have found useful when designing their own change journeys into something often called recovery. While nothing works for everyone and certainly not for all families, my hope is to give readers and families an idea of how anyone might begin to have deeper conversations with themselves and others about what I call The 3 “L’s” of Holistic HRT for Families: love, limits, and doing what you can live with.

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Taking harm reduction principles and strategies and applying them to working with families might seem to be a new concept and, in many ways, it is a novel way to think about harm reduction and harm reduction therapy. Though looking closely at some early experiences in my own work with families in drug treatment, I think harm reduction has always been a part of my work and others’, too, though not as pronounced as it could be or is now. But we’ll get back to this a bit later. For now, let’s travel back to the start of my work with families to see how I and the field got to where we are today.

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A Very Brief History of Family Work in Addiction Treatment:

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I’ve worked with families since the early days of my career in the late 1980’s. Developing and running family programs in social model treatment programs was something I came to enjoy and did many times over the course of 15 years or so. Of course, I mistakenly thought I was teaching participants something about their role in their loved one’s addiction along with the basic concepts on addiction and recovery, when really, they were teaching me, because what I really needed to learn was how to listen to them. I’m grateful I am finally learning how.

 

In the beginning…

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It was in 1951, 16 years after the start of AA, that Lois Wilson, AA co-founder Bill Wilson’s wife, is believed to have first discussed publicly that wives (remember, no one considered couples to be anything other than heterosexual back then and men were the main “alcoholics”) also needed support while their problematically drinking husbands sought a new relationship with alcohol—abstinence—in AA.

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Family programs in addiction treatment were available in nearly all drug treatment in the late 1980’s and early 1990’s. This was also the heyday of the 12 Step, this-is-your-brain-on-drugs, abstinence-only Minnesota medical disease model of drug treatment, and when we first saw the terms co-dependency, adult children of alcoholics (ACOA), and other (mainly white) middle-class, heterosexual, nuclear family, socially constructed ideas of how an otherwise healthy family structure would become dysfunctional at the hands of a family member who was using substances, sometimes problematically. Out of this time came experts such as Melody Beattie, Sharon Wegscheider-Cruse, and Claudia Black, all teaching families and the majority culture that substances were the cause of nearly all our family’s problems and destruction, and that the only solution was to confront the “addict” about their substance use, require them to enter formal, typically residential treatment, or lose access to the family’s love and support. And so, in the midst of this volcano, the worst concept of them all, “tough love,” was born (more on that later).

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In residential treatment, the identified patient (IP) was typically not allowed access to their family members unless the family was participating in Family Group. Families were seen as problematic to the work the treatment agency and staff were doing with the patient (this also included outside therapists and doctors). Even phone calls were often limited to once weekly and were brief, on purpose. In those days, the role of treatment was to cut off the IP from all external influences that were believed to be hugely problematic to their lives and certainly to their recovery. However, once the family had completed the Family Program, connected with Al-Anon and had met with the client and therapist, they were considered “in recovery” themselves. Typically, a conjoint (a meeting of the IP, their family, and the Primary Therapist) was scheduled just prior to discharge where the therapist would facilitate a meeting to encourage family members to be clear on the severe consequences suggested if the IP returned to drug use. The IP was also to begin the process of making amends to their families for the destruction their addiction had caused. I just realized today how much we were furthering the shame we knew the patient had under the mistaken belief that this shame would keep them from returning to drug use and allow the family to heal.

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Through her lens of one attachment theory, our hospital’s Family Therapist, Ashe Maranthe, taught me the importance of relationships especially in families where someone had an addiction; how patients viewed their family members and how family members viewed their loved one using drugs. This was the early 1990’s and we had a free yearlong 1.5 hour-long Family Group as part of the continuing care (we purposefully didn’t call it aftercare like many other programs as we felt treatment was a beginning not an end) we offered for both patients and family members. For an added fee, our hospital rehab also offered a week-long Family Program Intensive run by another lifelong mentor of mine, the late Mickey Marsh, PhD, MFCC who held a doctorate in Human Sexuality. Family members would stay at a local hotel and come to a location off campus to meet with others also challenged by an addiction in the family. Here they would learn about the disease of addiction, codependency, family roles, support groups (AlAnon or NarAnon were the only ones available in those days and AlAnon was seen as superior) and learn that they were also going to need to make changes if their family member’s treatment was going to be successful.

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Mickey Marsh used to say she had a black belt in AlAnon. Her last husband, the late Dr. Earle Marsh, had been the Chair of the OB/GYN department at UCSF and one of the first doctors to teach other doctors and medical students about addiction. He also still has the distinction of being the only story in the Big Book of AA that includes drug use (as he tells it, he was addicted to methamphetamines as well as alcohol). Plus, his original sponsor in AA had been its co-founder, Bill Wilson. Doc Earle, as he was called, was also part of the rotating experts we had at the hospital, often speaking to patients about sex (he was hugely sex positive, mainly to raise endorphins in those recovering brains but also just for joy²) as well as nutrition, meditation/spirituality, and of course, AA. The Drs. Marsh were beloved by all and I’m confident they both would be proponents of holistic harm reduction psychotherapy today.

 

OK, so now that we’ve discussed a bit about the theories used to create family programs back in the 1980’s, let’s move to what we should be doing with families today. Sadly, the biggest change I’ve seen in rehab is the exclusion of family programs or the severe shrinking of them at least. It seems ridiculous to think that we could take one member of a system out of that system just to return them to the same system and not expect negative results for all. But this is all too often what happens. Gratefully there are folks out there who focus on working with families in addiction and especially who do this from a harm reduction perspective. Let’s discuss what I mean by that now.

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The Intersection of HR/HRT and Family/Couples Work

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If harm reduction psychotherapy (HRT) is a method of client-centered counseling or therapy that has multiple parts to it, then HRT with Families & Couples will be just as complex. It’s also very creative and flexible, offering clinicians working with families and addiction treatment to do so individually as no two families are ever alike in their resources, needs, or goals. This is what traditional family work in addiction treatment too often forgets.
 

In all harm reduction work, we value and center the voice of the individual. Therefore, in Family & Couples HRT, a large part of our job is to value and center the voice of the family. This isn’t easy as many times family members have differing goals or needs. But this strategy can lead to a conversation about negotiation as well as learning to view the family/couple as another entity. I prefer to use the term “negotiation” to “compromise” as too many people hear compromise and think, “Oh boy, what I am going to have to give up!” The word negotiation, though, says each person will get some of what they want/need. It’s also a more positive perspective and that’s what we want: less focus on problems and more focus on solutions and what’s going right.

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When I first started learning about family dynamics in addiction treatment, we used the term “co-addicts” to describe family members. The idea behind using this term was to show that the person addicted as well as the family member(s) all begin to behave in less healthy ways, a parallel process of maladaptive coping if you will. Reading about codependency again for this new section, I was struck by how the “diagnosis” of codependency (remember, there is no actual diagnosis as codependency is not found in any DSM) is based on someone else’s interpretation of your behavior. This is one of the problems I have with the term. For example, as one writer and advocate of the term states, one characteristic of codependent behavior is one person handling the finances because “they’re better at it,” rather than encouraging the other person to learn those skills themselves³. If my partner is genuinely better at finances and I’m better at fixing the car, why is that a problem versus a division of labor? And further, a problem that needs a diagnostic label? Alternatively, what if we see this division of labor as each member of a system (a couple in this case) doing what they’re good at, playing to their strengths? Of course, each partner should know some basic things about the finances (such as the institution where the finances are kept, where the checkbook and bills are kept, or what platforms are being used to receive and pay for things); ditto fixing the car. But each partnership or other type of family needs to decide for themselves what division of labor works best for them.

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Of course, this is the problem with all labels: they are stiff, very black and white, and frankly unlikely to be of much use beyond some general conversation or theoretical musings (and insurance payments!). And yet we, especially here in the States, consistently insist on using them, harm be damned. Let’s take this example from Patt Denning, PhD, coauthor of Practicing Harm Reduction Psychotherapy, now in its second edition. She states,

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Maria was a married 27-year-old woman who came to the community mental health clinic where Patt was working. Maria said she was seeking family therapy to help with some family troubles. Her husband of a decade was working very long hours and to relax he would come home and drink excessively every night. This behavior was helping him unwind but also meant he couldn’t help with their 3 children or help Maria with other chores. She was also becoming increasingly uncomfortable about calling into the office for her husband, making excuses for his tardiness or absences. To Patt, Maria’s problems mainly seemed to stem from her husband’s drinking. Since Patt’s training led her to view Maria’s behaviors as “classic codependency,” she told Maria that she needed to stop making excuses for her husband’s drinking as both were now hurting their family. Patt also gave Maria a referral to a standard alcohol and other drugs treatment facility for her husband to hopefully receive treatment and for Maria to learn more about her “codependent” behaviors. Patt states that she was pleased with her assessment of the situation and felt she had done a “good job” referring Maria since while Patt was trained in marriage and family counseling but certainly wasn’t an expert on alcohol and drug use. However, Patt says after a conversation with the treatment facility, she was a little uncomfortable as it seemed they were only focused on this perception of how Maria’s behaviors were contributing to her husband’s alcoholism and not viewing the family system as a whole, as Patt’s clinical training taught her to do. But they were the experts.

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About 6 months later, Patt met with Maria again after she called asking for therapy. Maria said she was grateful for Patt’s help and that the treatment center had “saved my life.” However, the family was in trouble in other ways now. Patt’s own words continue here:

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With the encouragement of her alcohol counselor and the group members, she had stopped protecting her husband. When she stopped calling his employer to make excuses for his absences, he was fired. Despite advice and confrontations from the counselor and the group about how she should divorce her husband, she found that she just could not leave him. After he lost his job, the family of 5 was now dependent on welfare. The husband’s “recovery” (abstinence from alcohol) was intermittent, and Maria was overwhelmed. Evaluation showed Maria to be anxious and dysphoric, with insomnia, hopelessness, difficulty concentrating, and irritability with the children. She expressed both fear and resignation regarding her husband’s alcoholism and her continued ability to help him and her children. I was alarmed and distressed. What had I done? What help did I give her? (emphasis mine; p4 – 5)

 

Denning goes on to say that she learned a lot that day—and that she would never again mistake

someone’s coping behaviors for codependency even when they may be problematic. As Jane

Peller would say, “don’t confuse preferences with problems.”

If we’re not going to use the old ways of viewing all family systems impacted by addiction as problematic, how should we view them? One way to improve our view of these systems immediately is to give compassion and validation to all family for doing their best in typically awful circumstances. And yes, that includes the family member using problematically!

 

When we begin to see that addiction is often a response to a traumatic event or extreme

situation, we can begin to comprehend how anyone, even one of you, might be tempted to turn

to substances to cope. Remember: it’s not the substance but rather what it does for someone

that leads to the addiction. Drugs are merely doing what we designed them to do: relieve some

distressed state or help us to feel more elated, relaxed—better than we feel right now.

 

Are there some “bits and pieces” of HRT I might use with families that are also in keeping with some of the traditional Family Therapy concepts I learned so long ago? Absolutely.

1. I often start by asking about the values of each member of the family, including the member using substances. One thing I like to do with many of the families I work with is to ask each member to separately complete the Personal Value Cards Sort⁴. However, rather than follow the instructions provided, I ask them to come up with their Top 10 most important values from the list of some 120 values (or they may make up their own of course) and bring them in some form to the next family session. In conversation with the entire family, if possible, we then go one value at a time to discuss how they know this is of value to them. Sometimes I ask them if I were watching their behavior, what would tell me that this value is important to them? For example, the value of humor is important to me. You would know that by listening to me talk as I nearly always manage to get some laughter into whatever I’m doing, even a session!

2. Another thing I’d like to know more about is what the family knows about addiction or why people use drugs—so I ask! I often include some education about the Stages of Changes and the theory called “Drug, Set, Setting,” if they allow. I might also discuss the many ways people change (and yes there are many. I have a shelf full of books telling me this) and usually something about how all harm reduction includes abstinence (it just doesn’t demand it). By the way, this last part always surprises everyone.

3. Lastly, I’d like to know something about the state of communication in their family, especially with their family member using drugs. Often there’s no direct communication between the family and their loved one using substances. Sometimes there’s one person in the family that the member using drugs will speak to or perhaps a trusted family friend, but they aren’t speaking to their direct family members. Typically, by the time families get to me, they’ve a) already been told about the traditional ways to get their family member “clean and sober,” b) they’ve spent a financial fortune (one family I worked with had spent $250k by the time they got to me), and lastly c) they’re exhausted and frightened and angry and overwhelmed and don’t really want to hear what I want them to do; they only want to hear how to get their loved one off drugs. And I understand.

 

I also want to let them get to know me as I get to know them so some personal disclosure on my part often helps build trust—which I rightly need to earn, not expect, from any client. Finally I need to answer every question, honestly and directly. That means I’m often saying, “I don’t know,” which can be frustrating. But my job isn’t to tell families and couples what to do or give direct advice (with great exception)—after all this is their family not mine—but rather my job is to listen deeply to them: their dreams, their desires, their fears, what they’ve tried already, what has & hasn’t worked and where they each are now in this process. Mainly, I need to know how much they can honestly invest in this work right now. Everyone I know who works in harm reduction with families tries their best to be aware of resources of all kinds and accommodate as best we can. At the very least we can be honest about that, and sometimes we’re the first professionals who have been.

The very last thing I say to most families is that while I can’t ever guarantee the outcome of our work on their family member’s drug use, I can almost guarantee that they, the other family members, will feel better about what they are doing, or not doing. When families are a bit less stressed out, more ideas of what they can do and won’t do, and an actual roadmap to wherever they choose to go, is also more imaginable. At the conclusion of our work, I would like each family and each family member to know how to communicate better with each other, to have some basic knowledge about how change happens, understand why we all use drugs, and develop a more realistic, balanced view of what they can control and what they can’t. Most of all I want them to have hope. And I am a proud enabler of it!

I also want families to know that their family structure is unique and therefore their roadmap to recovery or changes will also be unique. Our first goal in Family HRT is to keep the lines of communication open with their family member using substances, or to repair that communication if at all possible. If that’s not possible, we can work on the communication between the rest of the family members, which is often strained too. Parents often can’t agree on how to handle their child’s drug use while they are still living at home; couples argue about the amount their partner should drink at a party, and more. And lastly, while exiting your family member is always an option, I always ask families to please make it the last option not the first. Most importantly, if you make a threat to exit your family member or something else, you’d better be prepared to follow through or else future limits will not be taken seriously.

 

I want to end this chapter with an excerpt from the interview by a new pal, author Chris Grosso, with Dr. Gabor Mate, in Chris’ book Dead Set on Living. I often use this excerpt in the classroom when teaching the next generation of therapists and counselors as a great example of “out of the box thinking” especially in their work with families and couples in addiction treatment. It is by far the best example I know of a new way for families and others with loved ones problematically using substances to conceive addiction. And it always leaves me breathless and in tears. Perhaps it will touch you as deeply too.

 

Chris met with the eminent physician and addiction expert, Dr. Gabor Mate. They were speaking about families and Chris said he felt his family had done everything they could to help him, but Dr. Mate disagreed with that assessment. Instead, Mate said that of course Chris’ family had done everything they knew to do and that nothing worked; he wasn’t arguing with Chris about that. However, he said that didn’t mean there was literally nothing else they could have tried. Perhaps they could have said something like this:

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We recognize that your addiction is not your primary problem … you’re in a lot of pain. And that pain is not yours alone. [It] has been carried in our family for generations… You’re just the one who’s soothing it with that behavior… Thank you for showing [how much pain there is in our family] to us… We’re going to … [heal] ourselves. We invite you to be there if you feel like it. And if you’re not ready … then just do what you need to do right now.⁵

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Chris goes on to say that Dr. Mate was certainly not saying that his parents were to blame for Chris’ addiction. He just wanted to show Chris—and all of us—that there are indeed other options, other ways of viewing addiction. However, each family is also free and should have limits or rules around whether they can maintain some contact with their loved one in addiction. The other part of this conversation that is crucial is that if you’re going to have your loved one who’s using substances in your life, then you must accept them right where they are and stop trying to change them. What we can’t do is to remain a part of their lives and nag or threaten to try to change them. If we do that, we’re only saying to our loved ones that they are not enough the way they are, that in order for us to truly love them, they must change and be who we want them to be.

 

To me, one of the most important things Dr. Mate states in this excerpt is to recommend that families not try to change the family member using substances. So, what can we do instead? We can focus on improving communication or find reasons through conversation that our family member might want to make a change in their drug use or offer to assist them however they want when they are ready to make any positive change. In the meantime, I hope families will hear that there’s much they can do for themselves which just might have a positive effect on all their family members, those using drugs and those not. What isn’t OK is to focus solely on the family member using substances because the change the family may want might never happen. I believe it would be awful if this kept you from having any relationship with that “problem” family member because it will hurt you as well as the rest of the family…and it may mean that you won’t be around when your family member decides to examine and possibly change their relationship to substances. This is why HHRT/HRT Family and Couples work in addiction is so very important. After all, we can hardly ask our loved ones using substances to work on themselves if we’re not willing to do the same ourselves.

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[1] The term family here will be used for ease of reading and includes all groups of concerned people: couples, friends, traditional/non-traditional families and more.

[2] Dr. Earle Marsh had studied with Alfred Kinsey, participating in some of his early research on human sexuality.

[3] “Demystifying Codependency” by S.M. Stray in Medium, 8.12.2019 (accessed 8.14.2024).

[4] These are available for free at https://www.motivationalinterviewing.org/sites/default/files/valuescardsort_0.pdf. There are also a variety of ones available for sale at Amazon and other retailers.

[5] Dead Set on Living, by Chris Grosso (2018) Gallery Books, NY/NY. p25-6.