Can An Enabling Relationship Lead to Relapse?

Loved ones can be as entrenched in the negative cycle of addiction as the substance abuser himself. Invariably, those involved in a relationship with a substance abuser – be it a parent, friend, or intimate partner – will come across the argument that they may be enabling the drug abuse in one form or another. They may even hear that they have a “codependent” relationship with the substance abuser. But what do these terms mean, and how are they different?

Enabling vs. Codependency

According to Allan Schwartz, PhD, codependent persons display enabling behaviors, though not all persons who enable a substance abuser are codependent. One of the hallmarks of codependency is that a loved one becomes so consumed with caring for, rescuing, or “fixing” the substance abuser’s life that she doesn’t live her own in a fulfilling, satisfactory way. The codependent person’s identity and feelings of self-worth get wrapped up in the illness of addiction. At this level of involvement, it can be exceptionally difficult for the codependent person to realize her negative contribution to the disease.

Enabling behaviors may include:

• Providing the substance abuser with money, groceries, or services, thus paving the way for the drug abuse to continue
• Allowing the substance abuser to reside in the same residence, although his presence is disruptive and even dangerous
• Minimizing or hiding the impact of the substance abuse on the user, oneself, and other loved ones
• Justifying the support given out of fear that the substance abuser will get worse or fatally overdose if her needs are not accommodated

A codependent’s support can be dangerous. As Schwartz discusses, he has personal experience with the risks associated with a family’s enabling behavior. He recalls an occasion when friends asked for a therapist referral for their daughter, whom they described as depressed. In addition to being depressed, the daughter was in fact a long-time opioid abuser. The daughter was under the care of a psychiatrist, but for depression and not opioid abuse. Neither the daughter nor her parents disclosed her substance abuse to the psychiatrist. The daughter tragically passed away from an overdose. The parents had the best intentions for their daughter, but their enabling behavior – protecting the daughter from having to confront the opioid abuse – contributed to the loss of her life. An unfortunate detail, as Schwartz notes, is that the parents sincerely did not realize how they were enabling their daughter’s opioid abuse when keeping it a secret from everyone, including the psychiatrist.

A Family Disease

Addiction specialists are in agreement that substance abuse is a family disease. Family dynamics often play a role in the development of substance abuse and the maintenance of that abuse, and they can even contribute to a relapse. But on the other hand, families often play a key role in getting a substance abuser into treatment and assisting with aftercare (i.e., helping the substance abuser to maintain sobriety). In this way, the role of family in substance abuse appears to be like that of a poison/antidote.

As the National Council on Alcoholism and Drug Dependence explains, family and other loved ones misconceive of substance abuse as something that can be fixed, and once fixed, everyone will automatically be healed and have a “normal” life. There is often a misconception that the substance abuser is the one with the

“problem” – but this is often not the case. It may seem as if the substance abuser is the only addict in the family but that is not likely true. Codependency is a co-addiction and one that the family may not be able to see.

Loved ones of substance abusers may be able to describe in detail the positive contributions they have made to recovery, such as getting the substance abuser into rehab, but it may be far more difficult for them to see the ways that they enabled the initial use, and even helped to trigger a relapse. Substance abuse is often a sign that a family is in distress and needs to transforms itself from the inside out. The substance abuser alone does not need to recover as much as the entire family needs to recover from long-standing wounds.

Why Relapse Occurs

According to the National Council on Drug Abuse (NIDA), the rate of relapse among substance abusers ranges from 40 to 60 percent, which is similar to other chronic diseases, such as diabetes, hypertension, and asthma. This statistical facts support that relapse (whether it occurs after days, months, years, or even decades) is not simply a matter of choice. As NIDA and many medical research studies point out, there are biological factors underpinning drug relapse, such as the way drugs impact the neurotransmitters in the brain.

Dopamine is a neurotransmitter (chemical messenger) that plays a direct role in the feeling of pleasure we experience whether we are eating, working out, engaging in sexual relations, or experiencing other stimulating activities. Most drugs trigger an intense release of dopamine in the brain, resulting in a “euphoric rush.” However, with continued drug use, the body loses its ability to properly regulate the release of dopamine, and this neurotransmitter’s receptors become weaker. This dynamic also explains, in part, why substance abusers need to consume more of a drug over time – the dopamine receptors have lost sensitivity, but the brain remembers the initial “high” and wants it back again. The substance abuser, fueled by this memory, becomes engrossed in “chasing the high.”

According to research published in the journal Neuroscience & Biobehavioral Reviews, there are scientific findings that the brain is a highly efficient recording device in terms of remembering drug use. It is well established that relapse can occur after even decades of abstinence, but why? Part of the reason is that the memory of drug abuse is not only conscious, but also unconscious. It has been observed that when a recovered person comes across familiar elements of past drug abuse – such as passing a once-favorite bar – there can be an unconscious igniting of a desire to use again. Receptivity to drug cues can occur unconsciously. This phenomenon has been described as “Pavlovian conditioning” – the learned association of one thing with another (such as a bar with drinking) can strongly motivate behavior (such as having a drink).

In addition to biology, a host of environmental factors can play a contributing role in relapse. Lisa Espich understands the environmental dimension of relapse well. Espich is the author of the book Soaring Above Co-Addiction, which provides an account of her marriage to a substance abuser, and how she was able to transform herself into a higher-functioning individual and help her husband recover at the same time. According to Espich, the following common environmental factors present risks of relapse:

• Stress.Drug abuse is often a coping strategy. In the absence of healthy strategies, a relapse can occur in response to a known or a new life stressor.
• Celebrations:The idea of “treating” oneself during special times of the year can be devastating when the treat is an unhealthy one, such as drugs. Using after a period of abstinence presents a formidable risk of overdose, which can be fatal.
• Encountering cues: Relapse can occur when a recovering individual comes across people, places, things, and even scents that are associated with prior drug abuse.
• Discontinuing aftercare: Post-recovery, it is never recommended for a recovering individual to stop therapy, fail to attend group meetings, or decline structured support from addiction specialists.
• Poor motivation: Personal transformation and family involvement are critical to abstinence maintenance, but ultimately the substance abuser must find the internal motivation to want to change and take the necessary steps to do so. Family members are advised to maintain hope, continue to work on themselves, and encourage the substance abuser to recover.

Substance abuse is a complex disease that requires a multidisciplinary treatment approach. Rehab services are not intended to provide à-la-carte services. Relapse is preventable, but efforts to maintain abstinence should not be carried out in a spotty fashion. Holes in the recovery process, either during primary treatment or aftercare, open up dangerous pitfalls. It often requires personal commitment, positive family involvement, and engagement in an effective aftercare program to sidestep the deep pitfall of relapse.

What You Can Do When Relapse Happens

At the outset, it is important for family members and other loved ones to understand that a relapse is not a failure. Relapse often signals that a new treatment intervention is necessary. As discussed, there are several reasons why relapse occurs. In some cases, the treatment facility may not have been the best match (such as a dual-diagnosis client entering a rehab program that is not sufficiently set up to treat co-occurring disorders). However, even the most successful rehab programs cannot benefit a substance abuser who does not sincerely and adequately commit to the recovery process.

While there are many outpatient programs with successful recovery rates, some substance abusers may require the even greater round-the-clock care of an inpatient rehab service. One of the greatest ways a family can assist a relapsed substance abuser is to identify an appropriate rehab center, and ensure that it offers a comprehensive, thorough intake process, and well-structured treatment plan.

Family members may need to offer encouragement if the relapsed substance abuser is not ready to seek formal treatment. To that end, Everyday Health offers the following tips:

• Follow the aftercare treatment plan. Family members are encouraged to maintain awareness of their role – they are not addiction professionals. In the face of a relapse, refer the substance abuser back to the treatment plan and encourage her to get support from her therapists, counselors, and recovery group members.
• Avoid guilt trips. Understandably, loved ones can feel frustrated when a relapse occurs, but it is advisable to maintain a supportive, non-blaming attitude as guilt-tripping the substance abuser can fuel drug abuse.
• Accountability. It is important to hold the substance abuser accountable for the relapse, while at the same time offering support. A relapse is not a loved one’s fault, and any attempt the substance abuser makes to shift blame for the relapse onto a loved one may be a manipulation technique. The substance abuser may want to make the loved one feel guilty about the relapse to shut down any criticism about the drug use and allow him to keep using.
• Avoid the “fixing” behaviors. Loved ones are best advised to see themselves more as guide posts to recovery than chaperones – excessive handholding in the process is an enabling behavior that keeps the substance abuser from assuming adequate personal responsibility for recovery.

As discussed, substance abuse is a family disease, and it is most advisable that family members help treat addiction by working on themselves therapeutically. For those family members who have a loved one in rehab, the treatment center may offer a host of options, including family therapy group meetings, individual counseling, and educational programs. Outside of the rehab center, or if the substance abuser is not in rehab, family may seek individual psychotherapy sessions (which most health insurance plans cover) and attend Nar-Anon or other group recovery meetings.

Nar-Anon is a national network of group recovery meetings aimed at helping family members and loved ones affected by substance abuse. Nar-Anon groups replicate the traditional 12 steps of its parent organization Narcotics Anonymous. Family members are usually welcome to attend Narcotics Anonymous meetings with the substance abuser, but the focus of this group is on the user’s perspective, and the family members may not receive adequate support. Nar-Anon developed to address the specific needs of family members and loved ones.

Nar-Anon is founded on principles of spirituality and faith. Hallmarks of the program include recognizing the impact of the loved one’s addiction, engaging in honest and nonjudgmental communications between members, and providing one another with mutual support. Those who are interested in group recovery meetings but not drawn to the spiritual foundations of Nar-Anon are best advised to get a recommendation from an addiction specialist, psychotherapist, or research local opportunities online.

Recovery may start with the substance abuser, but it doesn’t end with him. Family members who recognize how their behaviors can unintentionally contribute to a loved one’s initial substance abuse or a relapse will also realize how actively taking steps to help themselves can help everyone.

At Orlando Recovery Center, help is available not only for those struggling with substance abuse, but for their loved ones as well. It’s our goal to provide family members with much needed information on how they can support the individual in recovery, as well as how to take proper care of themselves.