“Love Has No Labels: The Rise and (hopeful) Fall of Tough Love in America?” — Part 2

Welcome to the August 2018 edition of Family Matters – Families Matter, our new blog authored and curated by FSDP’s Guest Blogger–pioneering harm reduction therapist, educator, advocate and author Dee-Dee Stout. To learn more about how your family can join our growing community of enlightened friends and advocates sign up here now.tyler-nix-525388-unsplash

Last month we started our discussion of “tough love” and its origins. This month we’ll continue this look at this well-known and used concept to see if it really works and is the most effective strategy for families who love someone who misuses drugs.

We’ve discussed Synanon and its use of harsh confrontation and “tough love” in treating drug use problems. We’ve looked at Al-Anon and its concept of “letting go with love” and seen that what that often looks like is anything but love – though setting limits is important, too. Also, we’ve discussed how this concept of “tough love” isn’t just bad for helping drug users make changes but also bad for loving family members. We also talked about the difference between gaining or giving approval versus love. Finally, we looked at what more pain does for drug users: encourages them to use more, not less. So, let’s pick up the conversation here, starting with more on harsh confrontation.

You may have questions by now and I’m going to try to guess what some of them are and provide answers here. 1) Is tough love the same as harsh confrontation? The answer is yes! 2) I thought treatment is supposed to break through the denial of a person addicted to substances? The answer is no, that’s actually more likely to harm clients especially those with other underlying mental illnesses including trauma. 3) Don’t people who use drugs problematically need to be shown what a mess their lives are and how they’ve hurt others, such as their families? Again, the answer is no, they’re fully aware already and are usually extremely ashamed of their lives and behaviors even though families may not see this.

By the way, these are all reasonable questions to ask. Let me suggest, as many experts in the field do, that we look at how we treat other chronic medical conditions. Let’s take diabetes for example: when one has diabetes and is reliant on medication, do we complain that they are “addicted” to insulin? Of course not. We’re happy that there is a medication that can help them live a more full and healthy life. But with medication-assisted treatments (MAT) we hear negative comments (Narcotics Anonymous (NA) has made their views clear in their official pamphlet on MAT) such as how folks are just trading one drug for another; that they aren’t really “clean”. Here in California, our Department of Health Care Services has informed treatment providers that they expect us not to ask clients to engage in activities that we wouldn’t ask of those with other chronic health conditions such as diabetes. So, for instance, would we ask someone with diabetes to list their character defects that may have led to their illness? Of course not. Would we ask them to hold hands in prayer around a circle? No again (while any individual may find this helpful, we wouldn’t consider this professional treatment). We certainly wouldn’t put a toilet seat around their necks and tell loved ones to throw them out of the house for eating less healthy foods! But these are all deemed reasonable treatment approaches to addiction to many in our profession even today. (This calls for a lengthier discussion on addiction that I’ll do in another installment)

As I often do, I got out the dictionary to view some definitions of these 2 words as I prepared to write. Using the online version of Merriam-Webster’s (M-W) dictionary, I found “tough” means durable, strong, resilient, sturdy, rugged, solid, stout (I couldn’t resist!), long-lasting, heavy-duty, industrial-strength, well built, made to last. And what of love? “Love” is defined by M-W as “unselfish, loyal and benevolent; concern for the good of another.” Love is further defined as “an assurance of affection.” An assurance of affection. Wow. In my experience with “tough love”, there was absolutely none of that. In fact, withholding affection/love is at the crux of “tough love.”

So if these 2 words are polar opposites, how did they come to occupy the same space in our heads and in our common lexicon? As stated previously,    the phrase “tough love” was originally used by therapeutic community programs such as the former Walden House in San Francisco and DayTop Village and Phoenix House in NYC and continues to be used frequently today (just Google it to see for yourself). Using this concept of tough love, parents were encouraged to check their troubled teens into wilderness camps and behavior modification programs to deal with their kids increasingly frustrating and sometimes dangerous behaviors. And parents absolutely mean/t well; they were at a loss as to how to control their “out of control” teens. Plus they were listening to the so-called experts tell them, “you have to stop coddling your kids; you need to get tough with them – show them who’s boss.”

My own parents tried to do this with me when I was 15 or 16 (It backfired. I filed for legal emancipation and won. However, my relationship with my parents and siblings was forever damaged, as was I). It would seem that the concept of tough love is really about control. And when did control become synonymous with loving?

“Tough love” is also often associated with criminal activity or with children. In other words, if you’re a person who uses drugs problematically – or a criminal or a child – our society says using tough love is acceptable. The thinking is that in any of these three instances the person you’re using “tough love” with is incapable of learning any other way; their behavior must be controlled for their own good. In fact, the definition according to an old book we used to use in addiction treatment and studies called “Addictionary” (by Judy and Jan Wilson, 1992; Hazelden) “tough love is a phrase that describes behavior to stop enabling addiction. When you refuse to cover up for an addict, to rescue them, or to prevent them from experiencing consequences of their addiction, that is tough love. It is loving of the person but tough on the disease.” But is this true? And is this the most effective treatment modality? Perhaps the best question is who does the concept of tough love harm? I’d argue that tough love harms everyone involved – and that often once used, it damages relationships beyond repair.

But it works sometimes, right? I guess that depends on your definition of “works.” Can you get your loved one to behave or not behave in a way that’s acceptable to you? Probably, with enough threatening and coercion. But again, that’s not love. And it usually isn’t helpful for those of us diagnosed with a mental illness or substance use disorder (or chronic pain condition). In fact, Johann Hari, in his book “Lost Connections” argues that disconnecting from loved ones (as parents and partners are often told to do) who are “misbehaving” is typically the worst thing a parent or partner can do; losing connections to love – friendships, enjoyable activities such as sports, pets, and more — is often the exact scenario that is ripe for addictive behavior and other mental illnesses to thrive in, to fill the void left by the withholding of love and affectional bonds. I know I can definitely relate to this.

Now let’s be clear here: I’m not saying that limit setting is unnecessary. Of course, it’s necessary. Limit setting is part of being a responsible parent and, sometimes, a loving partner. But the most important piece is that when you set limits with someone, you do so with unconditional love and appreciation for the other person.

You listen to their ideas, negotiate, and you have this conversation–this is crucial–when you’re not emotional. Once again, the time for limit setting is BEFORE the undesired behavior occurs, not afterwards (when limit setting is done after the behavior occurs, it’s called ‘punishment’). There are exceptions, which again each family must work out for themselves (this is the work of family or couples treatment/therapy). Bottom line, when dealing with the problematic drug-use of a loved one, yelling, screaming, throwing out their alcohol or other drugs, etc, isn’t helpful to anyone.   And it certainly isn’t loving behavior.

Now let’s be clear here: I’m not saying that limit setting is unnecessary. Of course, it’s necessary. Limit setting is part of being a responsible parent and, sometimes, a loving partner. But the most important piece is that when you set limits with someone, you do so with unconditional love and appreciation for the other person.

OK so what about the idea that “addicts” must be shown what a mess their lives are and take responsibility? Well, I can tell you that I was aware every moment that my life was a mess when I had a substance use disorder as we now term the condition. There was no need to show me how bad things were. In fact, whenever I got a glimpse of the mess that was my life, I wound up using more to cover the pain and the shame. This is a typical response we see in many problem drug users. Lastly, let’s look at how tough love confronts personal responsibility. The tough love that my family of origin gave me did two things: 1) made me more ashamed and reluctant to try to change (if it’s my fault and I’m such a fuck up, why bother trying to change?); and 2) ruined any chance of a healthy family system because my family couldn’t look at what they may have contributed to my life of addiction (no I don’t blame them). Most of the “mess” or “unmanageability” as 12-Step would describe it, are problem behaviors of illicit drug users due to the illegality of most drugs of misuse. When drugs are illegal, drug users must go to places to get drugs where they are likely to be put in danger, risking rape and other physical harms, as well as jeopardizing their freedom by being caught by police with the results often being arrest/jail/prison, especially if you happen to be black or brown. Plus, drug users tend to use more in these circumstances than they would in safer locations, and they overdose more often. More on this in future segments.

So here we are at the end of this discussion on “tough love”. And I hope I’ve shown that tough love doesn’t look much like love at all. Instead the concept appears to be all “tough” with “control” at its core. Think of it this way: with positive reinforcement (think B.F. Skinner and others), I reward you for positive behavior (coming home on time) by giving you something you want (perhaps an extended curfew on one night) and set limits regarding less positive behaviors (think staying out after curfew) but I do this BEFORE you are late. And I do this when I’m not emotionally raw. If I wait and give you “consequences” for your undesired behavior, then I’ve punished you. That does not lead to positive behavior change. It leads to controlling with fear. Also, too often we fail to couple “consequences” with any kind of reward for the positive behavior. And when that consequence is withholding love and affection, well, can you see where this could lead to increased drug use? Not what anyone wants. But now we’re “woke” and can see while it isn’t what I wanted, it is expected. This denial of love and affection leads more people to have a (another?) traumatic experience and we know trauma and addiction – and other mental illnesses – tend to feed off each other. I am sure that this is not the outcome that any parent – or partner or loved one – wants for their child/partner/loved one.

So what have I learned – and what do I hope I’ve shared with you all here on this topic of “tough love?” Here are my Top Four “Take Aways” from this discussion:

1) Perhaps the most important take away is this: I hope I’ve made the case that we as a culture need to stop treating the concept of “tough love” as something positive and healthy. I’m optimistic that I’ve shown how inaccurate and horribly damaging to individuals and families tough love actually is, too;

2) That the concept of tough love really means that this concept is tough on all of us: drug users and loved ones/families alike. Like my own unrepaired family of origin, I have seen so many that will never recover from this so called “treatment intervention/sign of love.” Nothing could be further from the truth;

3) That what we really need instead is a concept let’s call “love AND limits,” meaning there is no limit on our love – ever – and (not “but”) we human beings have limits, too: on our time, our resources, our finances, and more. That’s called life and should always be negotiable and honest.

4) We can no longer afford to use a tired, inaccurate, corrosive concept such as “tough love” to (hang in here with me ok?) “excuse” us from the task having difficult conversations about hard topics with people that we love, what I’m calling “Compassionate Conversations.” What do I mean by this? I mean we must begin the work of having conversations that are about deep, profound, empathetic listening to one another, conversations that seek to really understand.

Today it seems that the conversations we typically have with loved ones – especially with drug users – are ones with agendas to get them to stop using. So, what’s the worst that could happen if we could truly let go of our old agendas and just listened? And just for the record, I’m not suggesting that we should agree with how our loved ones view something or how they behave right now, but rather I’m suggesting that our conversational goals change from getting-them-to-do-something-I/we-want to one of astonishing appreciation: of their views, their perspectives, their reasons for using/behaving in less than healthy ways. Let us decide that gaining compassion will be our attending agendas in these conversations.

Our world today is filled with rhetoric (with few real conversations) that is siloed and dishonest, cut off from reality, and full of prejudgments and predetermined agendas. Sadly, when we act from these values, we do so from fear–fear of losing power, fear of not being accepted, fear of losing our place in the world, fear of losing our loved ones to drug use and more. But when we push forward incorporating these fears rather than fighting them and force ourselves to see what is and become “woke” as the modern vernacular states, we have opportunities galore to change our relationships to ourselves, to our loved ones, and to the world. We learn how to say things like, “I love you more than anything AND I’m uncomfortable/unhappy/it’s difficult being around you when you’re loaded/high/under the influence. But when you’ve come down/sobered up/are able to moderate, let’s have lunch/dinner/go to that movie we’ve talked about.” Or how about, “I really love spending time with you when you’re emotionally available to me/us/the family/yourself.” I realize these “compassionate conversations” aren’t dramatic so they won’t make for good “reality” television, however they do make for good, healthy, strong relationships in real life. Plus research shows us these types of conversations are also more likely to help encourage positive changes toward healthier behaviors for everyone.

So, let’s tip “tough love” into the collective trashcan and from our collective vocabulary. Instead let’s work towards an agenda/belief of “love and limits” through “compassionate conversations.” Frankly, after all the pain caused to us all from using “tough love”, just how much harder can this new way of being really be?

#stopthestigma #recoverywithoutabstinence

In honor of September being Recovery Month, don’t miss next month’s edition: Reinventing Recovery

 

“Love Has No Labels: The Rise and (hopeful) Fall of Tough Love in America?” — Part 1

 

Welcome to the second installment of Family Matters – Families Matter, our new blog authored and curated by FSDP’s Guest Blogger–pioneering harm reduction therapist, educator, advocate and author Dee-Dee Stout. To learn more about how your family can join our growing community of enlightened friends and advocates sign up here now

tyler-nix-525388-unsplash
(photo by Tyler Nix @unsplash)

Hello again!

Before we get into the meat of this topic, I need to say a couple of things: First, I apologize for not finding a way to present this in my usual more light-hearted way. This just seemed too serious of a topic for that. I just finished reading Maia Szalavitz’ 2006 book Help at Any Cost which deeply disturbed me. Although I was certainly aware in a general way about a lot of the material about teen “treatment” programs, I was both obsessive to finish the book (reading until 2AM) and distressed that these programs are still around. Here in the Bay Area, our local newspaper, The San Francisco Chronicle just did an expose on teen “leadership” schools. As a result of the excellent journalistic work, many supporters and contributors to these programs have now removed their support, both financial and verbal. But there are some who insist these programs are meaningful.

This is also true in Ms. Szalavitz’ book. I’ve seen this in my classrooms over the years of teaching folks to become certified alcohol and other drug counselors. Many of my former students came from Synanon-influenced programs (often ones they attended as clients and then became workers, which I did, too) such as the former Walden House and Delancey Street (which is the only true therapeutic community (TC) left as they do not employ any professionals, the definition of a TC) and some have insisted that they were helped by such “tough love.”

I had the opportunity to ask the world-renowned researcher, Emeritus Professor William R. Miller (author/developer of Motivational Interviewing (MI) about this once. “is it possible that these folks were actually helped by these abusive tactics?” He responded, “I believe that these are people that are so motivated to make a change in their lives that you could have put them anywhere and they would’ve found a way to get better. So, their lives improved not because of the treatment they received but in spite of it.” That response has stuck in my mind and did so while writing this blog installment.

Finally, I was allowed to view the new film Fix My Kid, a documentary on the organization Straight, Inc, a popular behavior modification program for teens from the 1970’s (it was closed in the 1990’s but really just redesigned and opened under new names).  I can’t begin to tell you how upset I became watching this.  Some of this is certainly due to my own experiences with “tough love” but as a human being, I don’t see how anyone could view this without teetering between anger, outrage, and incredible sadness.  I highly recommend a viewing when it becomes available – but be prepared.

And two more blog housekeeping things:  1) As this topic is both so important and large, I’m doing two installments this time.  Today we present Part 1, covering some of the basics of “tough love” and approximately one month later you can expect to see Part 2, which will go into more detail especially as to how the culture came to embrace this concept.  Please let me know at info@fsdp.org what you think about this two-part format.  2) Since September is National Recovery Month, I’ll be doing an installment on the word “recovery” then which I promise will not be your typical take on the word!

And so…here we go again!

“Love means never having to say you’re sorry.” If you remember that phrase, you were around in 1970 when the film, Love Story, came out (starring Ali MacGraw and Ryan O’Neal) and this phrase about love was the tagline in the studio’s advertising that, using today’s language, went viral. Even then I wasn’t very fond of the phrase. To me, love was quite the opposite: it meant I could make mistakes and saying you’re sorry was part of the healing process – and love would always still be there; it was a given; it had no limits – even if I do. We’ll return to setting limits later.

I’ve been reading a lot of things about love/tough love/etc, preparing for this blog. In a piece from the HuffPost from 2012, writer Sheryl Paul states that if there are conditions on love, then it’s not love but approval – either trying to get it or give it. I hadn’t thought of it in quite that way but she’s absolutely right. And love is NOT the same as approval. In fact, the challenge of love is to love. Full stop. Anything else is based on approval and doesn’t feel like love to the person on the receiving end – because it’s not. Real love isn’t conditional.

A popular phrase in 12-Step/AlaAnon is “you have to let them hit bottom.” We are told as family members that this is “letting go with love.”  However, what if “their bottom” is death? Or jail/prison? Or something else traumatic? How is letting someone “hit their bottom” showing love and not simply trying to control or give approval for “doing the right thing” and not “enabling”? And what evidence do we really have that hitting bottom works? None, save some individual stories of such (side note: I just googled the phrase “hitting bottom” and found a disturbing number of articles and treatment centers advocating this approach). Back to Dr. William Miller: MI has shown us, as has CRAFT (Community Reinforcement Approach and Family Training; developed by Dr. Robert Meyers), that standing by and letting a problem drug user get to the absolute worst place they can does little to actually help them seek treatment/change. In fact, it typically makes things worse (the late Dr. G. Alan Marlatt showed this in several studies and discusses this in his seminal books, Harm Reduction and Relapse Prevention).

Anecdotally, when I was in more pain (of all kinds) and things got even worse, that made drug use even more attractive, no matter the negative consequences. And this is typical. This doesn’t mean family shouldn’t allow for some natural consequences. What those are and how one decides when enough is enough must be decided by each individual family and needs to be discussed with the problem drug user beforehand so there are no surprises

So, where did we get this idea of “tough love” especially if it’s harmful? And why is it still such a popular approach? Although tough love is a concept used on adults as well as teens, according to Szalavitz’ book, Help at Any Cost, the phrase “tough love” was first coined by Bill Milliken in his book of the same name in 1968 that discussed parenting approaches. There is also another book of nearly the same name, ToughLove by Phyllis and David York from 1985. Either way, the phrase started out as a term for parents to describe interventions to be used as their teenagers began to act out – perhaps using/misusing alcohol and other drugs – and engage in other less-healthy/desirable behaviors. Unfortunately, typical adolescent separation/developmental behaviors became pathologized (still often are….more on that perhaps at another time). Before the phrase “tough love” caught on in parenting circles, the concept was used here in California by a group long gone but whose long reach can still be felt in drug treatment facilities here and across the country: Synanon.

Synanon was a California institution. It was founded in 1958 in the then sleepy beach town of Santa Monica, by Charles (Chuck) Dederich. According to journalist Matt Novack, Synanon “was one of most dangerous and violent cults America had ever seen…” I have seen the outcomes of Synanon up close and personal through my work in treatment facilities, many founded by former Synanon members. Several ideas of these persuasive and talented people were sensible. Sadly, though I believe all meant well, many of their ideas were still too infused with the highly confrontational concepts of Synanon. Having worked and been trained in some of these treatment centers, I am saddened to know that while I helped many people in the dozen or so years I worked in this confrontational style, I am aware that I harmed many others. But Synanon was more than highly confrontational. It was far worse and caused far greater harm.

Synanon was the developer of something they called “The Game.”

“They played the “game” in which anyone was allowed to say anything, true or not, to someone to cause an effect. Only the threat of violence was prohibited. It was a game because one being gamed could turn the game on another.

Addicts’ behaviors and past lives were attacked viciously in games, members were told their lives depended on staying, contacts with family were prohibited, and a system of rewards and punishments was applied. Publicly one was berated ({given a] “haircut”) for misdeeds…Dederich and Yablonsky acknowledged that the system was brainwashing…”

And brainwashing was what Synanon leaders believed drug users needed. According to Paul Morantz (an attorney Dederich attempted to murder for suing Synanon) is credited with coining the phrase “Today is the First Day of the Rest of Your Life.” He also “preached “Act as If” which meant do not try to reason as to what Synanon asks they do; as thinking got them there, just trust what they were told and act as if it is right.” Alcoholic Anonymous (AA) uses similar slogans today. In fact, Dederich was a longtime AA member and popular speaker before his transformation to cult leader (Dederich later became mentally unraveled, extremely paranoid, and preached of a new religion he called Synanon III.

Synanon was heralded as a drug addict-saving program and even had the blessings of Governor Edmund “Pat” Brown, who exempted them from health licensing laws. They also started seeing monetary gains as Hollywood superstars such as Robert Wagner, Leonard Nimoy, and Ben Gazzara came to play “the game.” Life magazine did a 14 page in-depth article in which they quoted a Congressman calling Synanon the “Miracle on the Beach.” Columbia Pictures even made a film on it. By the mid-1960’s, Synanon was known as a alternative community which attracted its members through a focus on living a “self-examined life” using “the Game” to uncover hidden truths in group sessions. Even non-drug using professionals were invited to join as long as they “gifted” their assets. Like other cults, Synanon worked by controlling its members. In Synanon the main source of control was by use of “the ‘Synanon Game.’ The “Game” could be considered a therapeutic tool, likened to group therapy; or a social control, in which members humiliated one another and encouraged the exposure of one’s innermost weaknesses, or both.” This was truly tough love at its “finest.”

Today we may not see toilet seats around clients’ necks (I heard reputable reports that this was done in some drug treatment facilities up to the late 1990’s, to demonstrate that a client had behaved like a ‘piece of shit’) but we certainly continue to have the ethos of stigma, shaming, and harsh confrontation we inherited from Synanon. The threads of Synanon are woven throughout drug treatment programs everywhere in the US (and further in a few cases) today.

PART 2 “Love Has No Labels: The Rise and (hopeful) Fall of Tough Love in America?” coming August 2018

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IMG_6574Dee-Dee has worked in the addictions/mental health worlds for more than 30 years and continues to maintain a busy clinical practice where she works with a variety of clients whose behavioral goals include abstinence, moderation, and “anything they want and in any way they want” to achieve their goals. Her book, Coming to Harm Reduction Kicking and Screaming: Looking for Harm Reduction in a 12-Step World is widely available and has received positive reviews.

 

 

Reflections on Stigma’s Insidiousness in the Addiction Treatment Community

A therapist colleague of mine who doesn’t work within a harm reduction framework has a nephew who is struggling with problematic substance use and she shared with me last week that she finds herself being more sympathetic to her clients than her nephew about their drug use.

fsdp-our-missionI had the same reaction as her when I was involved as a family member in my own family’s therapy experience when my nephew was working on his substance misuse issues. It was before I was a harm reduction therapist and my incongruent reaction to this opened my eyes to my own perceptions of my substance using clients and I realized just how pervasive the judgments about people using substances are in our culture.

fsdp-donateThe judgments were so ingrained for me, it took me several years to shed these stereotypes, but as family members we don’t have the luxury of time and such an opportunity for this awareness. These judgments are damaging to individuals and families in treatment–damage that makes healing that much more difficult. It reinforces, and sometimes adds to, the trauma that many people enter treatment wanting to address.I’ll be exploring the effects of stigma on our families in future posts and would love to include your reactions on how it has affected you and your relationhip with your loved one, and what have you done, or do, to adjust…

I’m curious about people’s reactions to this from the perspective of a family member, a person using substances, or a treatment provider?

Any suggestions for reducing the treatment-inducing stigma that can can be such a barrier to good care? Email me at barry@fsdp.org with your experiences and I’ll share them in future blog posts.