Podcast: Helping Someone Who’s Struggling With Addiction

In this episode, Rocco A. Iannucci, MD, and Michael Walsh, MS, MCAP, CIP, discuss how to approach the topic of addiction, ways to navigate the uncertainty of a hard conversation, and what to do if other close family members are also struggling with their own addictions or mental health challenges.

Dr. Rocco Iannucci is the director of Fernside, a McLean Signature Addiction Recovery Program. His clinical interests include treatment of people with severe substance use disorders and those with coexisting mental health conditions.

Michael Walsh, MS, MCAP, CIP, is president and chief executive officer of Duke Behavioral Health, a consulting, intervention, and coaching company. He is a master’s level certified addiction professional (MCAP) and certified intervention professional (CIP).

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Episode Transcript

Jenn: Hey everyone, welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi folks. Thanks for joining us. I’d like to introduce myself, I’m Jenn Kearney. I’m a digital communications manager for McLean Hospital and over about the next hour, Dr. Rocco Iannucci and Michael Walsh, will be facilitating a discussion about the role of the family in interventions. And the two of them we’ll be talking about how to approach the topic of addiction, ways to navigate the uncertainty of a difficult conversation, what to do with other close family members who are also struggling with their own addictions or mental health challenges, and we’ll also address additional questions.

Just a little bit of background on the two of them before I hand the mic over, Rocco Iannucci, is the director of Fernside, which is a McLean Signature Addiction Recovery Program. Fernside provides world-class residential treatment for adults who live with addiction to substances such as alcohol, cocaine, or opiates.

And Michael Walsh is a master’s level certified addiction professional, and certified intervention professional with knowledge, experience and understanding of the treatment industry, all the way from intervention through the admission process, case management, treatment services, and the continuing of care coordination for both patients and alumni.

So, Rocco and Mike, first of all, thank you both so much for joining today. It’s going to be an incredibly valuable hour, I can already tell, I would love for you to just take the mic over and to talk about the role of families in interventions.

Michael: Great. Thanks, Jennifer. And it’s nice to meet you both. For anyone that’s on there, again, I look at intervention from a number of different perspectives. I’ve been the recipient of an intervention plan by the Massachusetts State Police. I have facilitated interventions on everything from politicians, Fortune 500 CEOs, and a mafia boss in New Jersey, children, adolescents. The scariest ones to me are matriarchs, most of the matriarchs I’ve encountered would rather chew nails than take help from the people that they would help. They have a tendency to help everyone in the family and when people turn around and try to help them, they would rather chew nails, they scare me more than the mafia boss did.

So, I know there are a number of questions that we’ve already had, I’m going to take questions. This is one subject that I typically don’t plan a talk for, I’ve done countless interventions, I’m also been the son at my father’s intervention, I’ve been the brother of my brother’s intervention, and I’ve been the best friend at my best friend’s intervention, which is much more difficult to me than being the professional at an intervention.

So maybe I would start and then I’ll turn it over to Dr. Iannucci, to give you a little perspective on what my approach to intervention is. A lot of people look at, like the TV show, and they think of an event, a lot of shouting and a lot of chaos and drama, as a professional interventionist, my goal was the opposite is that. I very rarely have chaos and drama, and typically if there is chaos and drama, it comes from the person we’re trying to approach with love and concern.

I look at my role as a professional is to get to know the intended patient, to learn more about the family system, and then to go in in a way that is least hostile, least intimidating, and really deliver a message of love and concern. That being said, I believe that two really important things to come out of an intervention, that’s love and concern, and consequences sometimes. If we don’t have to use consequences, great. If someone is in need of a little correction in their life, I don’t believe in using a heavy hand.

On the other hand, I’ve intervened on surgeons who were up snorting cocaine all night, and telling me and their family that they can’t sit and talk to us because they have to be in the operating room. In which case I have no problem going full on consequences and telling them, “Look, I’m not a doctor and I’m not your mother, but you don’t have to stay and listen to us, but I assure you you’re not going in the operating room. ‘Cause my first call is to the Medical Board, my second call is to the Chief of Surgery.”

So again, I really try to approach this, a lot of people will ask me what my style of intervention is. And I asked one of the men I respect the most in this industry, Ed Storti, who’s been a professional interventionists in California for probably 40 years now. Early on I said, “Ed, you know what, what’s my style? Is it invitational? Is it family systemic? Is it the Johnson Model?” And he said, “If you’re any good, it will become the Michael Walsh Model. And you’ll never do the same intervention with any two families or businesses.” And that’s what I’ve tried to live to today. I take every opportunity I can to train in new styles, I believe in the stages of change.

And I want to approach a family or business that approaches me by asking them questions. The first question is typically what’s your success rate or what’s the success rate of this facility that you have in mind? And my first question back is typically, what’s your idea of success? I’ve worked with families and individuals who want their son or daughter to stop getting arrested, and others whose idea of a successful intervention and treatment is abstinence and a spiritual awakening. And there’s a lot of ground between those two points. So, the first thing I’ll need to do as a professional is to figure out, what’s realistic, what their objectives and goals are, and then explain to them what the options are. And a successful intervention isn’t an event, in my mind, it’s a process, and hopefully a lifelong process. And with that I’ll pass it to Dr. Iannucci.

Rocco: That’s great. Thank you. Well, so I should say just for a little context, I’m a psychiatrist and run a residential treatment program. So, I intend to be on the opposite end of the intervention, I’m on the receiving end of the intervention, as opposed to the initiation, getting people into treatment. I can speak a little bit more about how things go well, from that perspective.

To the topic at hand, we’re talking about intervention, we’re talking about also the role of families. Families really are essential, I mean, those are the key players in most interventions. And if things go well for us in treatment, in residential treatment, they’re important players, an important presence and important allies to the patient and the rest of the clinical team, whether things work the way we want to, it’s a collaborative process where they’re really team members and try and figure out how to help their loved one, but also generally to help the whole family move in a better direction.

Because as we all know that the addiction is a disease that really affects the entire family, not just the identified patient. The experience with families is most of the time, they’re looking for ways to help. When we have family meetings the most common question is, what should we be doing, and what can we do that would be helpful? How do we help? And I think in essence, that’s how interventions get started, as families are looking for a way to help. They’re not sure what to do, so they’re turning to a professional to help coordinate their efforts to give them guidance, how to be effective with their loved ones and in getting their loved ones help.

We all know that sometimes even the most well-meaning efforts can go awry, or can move things in a counterproductive direction. And that’s where having, I think, an experienced professional could really be a useful thing. Families oftentimes, it’s not for want of trying, and it’s not for a lack of desire to help their loved one, but they don’t necessarily know what to do and how best to approach it. It’s still, in terms of maybe laying out some common scenarios where things go awry, what we see on the treatment side of things, and then maybe we can take questions from there.

Sometimes we run into problems where it becomes clear that the loved one has a substance use disorder themselves. And so, the environment that the patient returns to might need some work to be a productive recovery environment. Sometimes there’s so much anger in both directions that the family interactions become emotionally charged, and it’s hard to move them in a positive direction. It can be situations where there’s kind of over control being exerted by the family member, where they’re trying to make decisions about recovery and about the best approaches, and there’s ways to sort of intervene to try to turn that around and help with that situation.

From my perspective again, on the receiving end of things, interventions go well when they address developing cohesion in the family. Though a lot of times everyone wants the same thing, but they’re going about it in different ways, one person might be engaging in behavior that actually helps sustain the addiction. They’re just trying to help, but they actually make it easier for people to continue their behavior. Or as Michael was saying, sometimes there’s a need for consequences, but they’re hard to actually implement, unless everyone in the family’s on the same page with what the consequences are going to be, and that they really are going to carry them out if needed. So, it can be really helpful to have a professional involved in that as well.

And then one of the other challenges that we run into is when the patients don’t allow open communication, because we have laws that we have to operate under, and the patient at the end of the day gets to have the final say as to who we talk to and who we don’t. I will say with a little patience and engagement and establishing some trust with the patient, generally they do involve their families and a lot of time releases. We do try to ally with them to make sure that they understand that they’re our patient, they’re our top priority.

And perhaps if there’s things that are not happy about in the situation with their families, maybe we can help with that, if they let us talk to the family. If they don’t let us talk to the family, then they’re likely going to walk right back out to the same situation that was present before they came here. They’re coming in. Yeah, our goal is to have an entire team, if we can get that, including when we can, have the intervention team involved as well in next steps, if that’s a role that they play. Oftentimes they’ve had a lot of communication and they have a good relationship with the family, which can be a helpful thing as well.

And then just have everyone working together because everyone wants the same thing at the end of the day. It may not be the same specific thing, but they want the loved one to do well. That’s what they want, to have a healthy, happy and productive life.

Jenn: Please go ahead.

Michael: No, I just wanted to follow in with everything Dr. Iannucci, I totally agree with. One of the things I would just add on to that is, I believe the family system is so important. And I say system because it’s not always what we would think of as a traditional family. There are many times that work relationships are extremely important to the long-term success. I’ve had situations where children have been orphaned young and they grew up in the system, they wind up being successful, they typically will have more of a family unit that is a non-traditional one. And trying to figure out who is going to be helpful in the long-term success and willing to participate in family programming and things like that.

And it’s one of the advantages of having a professional interventionist. A lot of times people think it’s about getting the person into the door, so Dr. Iannucci and his team, Fernside, can start to do their work. That’s part of it to us as professionals, it’s pretty easy to get someone into treatment, getting the family system to get healthy and change so that the long-term success of that person who had to treatment has an easier path, that’s really difficult.

So there are a lot of things that I think we could talk about, but I think education of the family, and then taking it to the next step and figuring out which of the family members need actually to do their own work, which is typically a lot more common than they think it is. They think if we can help their loved one get into treatment and quote unquote, fix them, then everything will be fine. My mentor used to say, “Taking someone to treatment and not treating the family system, is like petting a leper from a leper colony, treating the leprosy, sending them home and saying, ‘Don’t get leprosy.’”

So I think that it’s really important for us to encourage communication, to figure out who’s a healthy member of that family system that they’re willing to sign a release of information for, because it’s really not practical to have everyone in the family system, calling the treatment center every day to see how the person is doing. And the other really important ingredient, I think in family work is to identify from the outset who the assets are and who the liabilities are, at least from an interventionist standpoint, because although they all go in with the same idea that, “We want to get Joe or Susie helped.” Their idea of what help looks like and how much they’re going to have to participate in change for this to be a successful treatment process and recovery, is often quite different.

Most people don’t understand what treatment or recovery are, unless they’ve had an experience themselves, or have been lucky enough to watch someone that they love or know recover. It really is the unknown, the stories I hear from people, what they think it’s going to be like, and consequently, the difference in what this type of treatment, especially, is in actuality is quite different. So I think the family system is really important to not only getting the person into treatment, but again, getting them all into whatever is an appropriate level of care for the family system and encouraging them to continue that work after they leave the facility.

Jenn: So, what are some ways in which family members can be active and helpful participants during an intervention?

Michael: During an intervention, to me, it’s love and concern, I’m a big believer in appealing from heart to heart. If a lot of times it’s the most uncomfortable thing for families to do is to look someone in the eye and say, “I love you, I think you’re in trouble, I want you to get some help.” It’s a lot easier to go in and say, “You did this, you did that. You’re not doing this, you’re not doing that,” and a lot of shame involved. Even when the goal in their mind is that, “I want to help them,” the communication style is typically very dysfunctional, it gets that way over a lifetime.

When we got in and we look at intervention process and the treatment experience, it’s a snapshot of the family history. So, it’s really, to me about going and doing an evaluation on the family system, finding those assets, identifying the liabilities. And it’s often, it’s counterintuitive. When I walk in and I see what they’re doing, to quote unquote help, they don’t see how destructive that quote unquote help is.

So, for instance, a parent, a lot of times they’ll say, “I don’t want them to get in trouble.” So, if you’re on the phone with me, they’re in trouble. If we’re talking about sending them to McLean, they’re in trouble. So, trying to prevent them from getting in trouble, I’m trying to prevent them from dying, going to jail for a long-term, or even worse becoming paralyzed. I’ve got a brother-in-law who’s a quadriplegic from a drunk driving accident. He was 16 years old, when he got in this drunk driving accident. He wasn’t the cause of the accident, but he was drinking and driving as well. He’s 56 years old now, he’s been a quadriplegic in a chair for 40 years. A lot of times he says he thinks he would have been better off if he died in that accident.

So, again, it’s coming in with a fresh perspective. It’s helping them to learn because the education, in my mind I would start talking about this stuff, feelings and emotions, et cetera, in kindergarten. But if we can go in and get a family to drop down the defenses, forget about where all the hot buttons we’ve have installed in each other are, and have an honest conversation on love and concern, most people will start to change. It’s really an amazing experience to see it in action.

Rocco: Yeah, and I’d say from the family perspective as well, I think if they go into these interactions prepared for the fact that there might be some anger, there’s going to be potentially some resistance or defensiveness, even if they’re really approaching things from love and concern. And to try to not take that personally, try to have a plan for how to respond and just stick to that plan, because otherwise, yeah, it could devolve into more of a shouting match.

We oftentimes try to move people, and this is in the context of family work that we do as opposed to interventions, but there’s a lot, I think there’s a lot of similarities, but trying to keep people in the present and the future, as opposed to bringing up a lot about the process, there could be a role for that, I think, in intervention for people to understand where things are.

But I think, I appreciate Michael’s emphasis on honest emotional communication, as opposed to this detail and checkoff, remember that, and you missed this and missed, more about, “This is how I felt, this is how the people really care about you feel and the worries that we have.” And people are oftentimes more open to hearing about that stuff than about a laundry list of, of their misdeeds, which are pretty shameful for that. A lot of times they feel that they understand they don’t want to talk about it, they don’t want to hear about it.

Jenn: I know oftentimes when it’s that laundry list of things that need to be changed, or a lot of times people approach these kinds of conversations and interventions as accepting defeat, and not actually feeling, not necessarily feeling motivated to change, but just accepting that it’s something that they need to overcome. Are people who are fully motivated, the only folks who are going to benefit from treatment, or is there a spectrum of folks that would be benefiting from addiction treatment?

Michael: Well, I think there’s been a lot of research on that. I hear that a lot that if they don’t want to change, they can’t change. We know for instance, Physicians Recovery, Dr. Hankers who was one of the architects of that research which was back 15 years ago now, most of the doctors were intervened on, they weren’t volunteering to go to treatment, however they had an 85% success rate over five years. And the only reason I say those statistics is we drug-tested them for three to five years. In most studies, we don’t have the benefit of the drug test, so we ask people how they’re doing. They had remarkable outcomes in that group. And the court system has had pretty good success in a lot of areas. Some not as good as others, but in overall, most of the research shows that it’s very effective.

Is it beneficial for someone to go in voluntarily? Yes, I believe it is. It’s one of the reasons that one of my kind of bait and switches, I’ll tell on myself, is that the way I design my intervention process, is I almost want them to make the decision to go, even though we’re, quote unquote, forcing them, we’re using a lot of emotional leverage and things like that. If we don’t rush it and push it, we can get them through this process into the point where they’ve gone from pre-contemplation to at least contemplation, and sometimes they even get into action.

It’s amazing to watch that process happen in a short period of time, where there’s that dynamic as you started, they may be very resistant and angry when we walked through the door, as soon as we start to approach them with love and concern, their heightened anger and resentment and fear really dropped significantly. And if you can get someone to sit and listen to that love and concern, you can really move them pretty quickly through those first couple of phases of the stages of change.

And I’ve had the experience of walking into treatment with people that I’ve intervened on, unless you give me a hug before I leave. And a lot of times the nursing staff will say, “It’s really amazing.” Like a lot of people come in and they’re like, “Get that SOB away from me.” I really believe that part of my job is to take them from that place of pre-contemplation through the stages, to where I can get them to at least contemplation. Then the treatment center doesn’t have that totally resistant client.

Because unless we’ve got like the medical board has some heavy leverage like that, a lot of times the family members will come in and they think, if it’s a family business, for instance, that they just sending me here because my brother wants to take over and I’m supposed to take. It’s all kinds of family dynamics that can come into play, if we can’t get them from that resistance and pre-contemplation into, again, at least contemplation, but sometimes we’ll get them all the way to action. They walk in the door of the treatment center, having not knowing they were being intervened on, to a place of, tell me what to do.

Rocco: Yeah, I’ve seen that. I think it’s a myth, I agree with Michael, it’s a myth that people have to have the right reasons to get into recovery. They have to be internal reasons, it’s got to be some sort of an awakening. Really, there’s not a wrong reason for folks if their life is not going in the right direction, to change it into a better direction. And there is, yeah, there’s good research on external incentives, whether they’re family interventions, the physician, some of the sports programs where there are drug courts, those things can be helpful to people and they can get folks moving in the right direction.

We also see in a residential apartment, you receive people coming from an intervention. You see the intervention kind of cook a little bit over the first week that people are there, where things are still settling in. And they do, even if it doesn’t hit immediately, if they’re willing to come in and think about it a little bit more, re-engage with their family, start to talk a little more about things you could see the benefits for folks.

So, no, I would say the people who are very high motivation, maybe you don’t need to see Michael, they may not need to see me either. They may be able to go kind of find their own way with the right help, but find their own way in recovery. A lot of what our programs have to offer in our interventions are for folks that are lower on the motivation level, and that is a part of the illness.

If you can get people even away from the substance for a period of time, that in and of itself can help, because they’re not having as much of the strong physiological urges to use the substance. And their thinking starts to get a little more, they get a little more able to actually rationally weigh pros and cons and kind of look at consequences and see them more clearly. So some of it is just doing what you can on the outside to support getting them away from the substance, even for a period of time, so the brain can heal, and then they’ll have more of an opportunity to make some choices that they’ll probably be happier with in the long run.

Michael: Yeah.

Jenn: I did want to ask a little bit, I wanted you guys to elaborate a little bit more on that motivation, not from the patient standpoint, but from the family standpoint. Do either of you have advice about managing cases or interventions where the family or family system doesn’t want to participate as much as actually is necessary for change to occur?

Michael: You know, it’s amazing to me how distorted the family system can get when you’re in the middle of the disease. I actually had a young lady call me about 10 years ago from Jacksonville, Florida, and she was a heroin addict. She came from a very affluent family, and she had been asking her family to help. And they told us she wasn’t that bad. And she wanted me to intervene on her family to get them to agree to send her to treatment, which was mind boggling to me. And I guess I did intervene. I asked her for her mother’s phone number, and I called her and had a conversation, first with her mother, and then with her mother and father and brother, and was able to convince them to send her to treatment.

But it was shocking to me that this young lady was on the phone, came from a family that was totally able to help, and it wasn’t like she had been to treatment 50 times and just wanted them to pay. She’s sincerely trying to change her life and in desperate need of help, and they were oblivious to it. So, families are so different. The other part of that is to get them to understand, again, I’d go to the education piece because you don’t learn this until you’re in the middle of it.

Most people, even in the field, I don’t think wake up one day and say, “I think I’m going to go into an alcohol and drug treatment because I have nothing else to do.” I hear a lot of times clients will say, “I woke up one day and decided to go to treatment.” I’m a big fan of, what was it? It’s usually a liver, a lover, or a lawyer involved with getting someone to seek help. But again, understanding what that is. And I usually will sit the family down and start with a conversation that revolves something around, you see them on the highway and they think they need to change lanes. I see them on a different highway going in the wrong direction.

So if we were talking about changing lane, I wouldn’t be here, you wouldn’t be going to Dr. Iannucci, you would be setting up an appointment with a therapist, maybe a psychiatrist to have the medication check and moving on with your lives. When we get to the part of what we’re talking about, intervention, and we’re talking about residential treatment, typically the intended patient and the family system really doesn’t understand what we’re actually talking about and how far off the rails this thing has gotten.

Rocco: Yeah, we typically see, I love the story, it turns intervention really on its head, where you ask the person what their addictions are, and they say, “Can you convince them I need help?” Well, yeah, you hear all kinds of things, don’t you? Yeah, we typically see families that want to be very involved, where we get a hiccup most commonly is the family doesn’t want to change their own relationship with alcohol most commonly, sometimes drugs, but they’re, “Eh, eh, there’s one patient here. We’re not talking about my, what I do, we’re talking about what they do.”

And the person we’re working with, the patient, oftentimes doesn’t want us to dig at that too aggressively. It’s not necessarily appropriate for us to, we’re in treatment relationship with one person. So, but a lot of times we can have conversations and just listen, and just listen to a loved one and let them make their own conclusion, help the patient to communicate. If they have considered that love and concern themselves, they can communicate that as well.

At the end of the day, our bottom line is that we just recommend to them a home environment that’s free of drugs and alcohol. Whatever it is they need to, it’s not about we’re diagnosing them from afar or trying to figure out when we’re not working with them. But the home environment that the person returns to, if they want that person to have the best chance of success with stated goal that having a home environment that’s free of drugs and alcohol, is really the most helpful thing. That’s something people can accept, not defensively.

They may or may not agree to it, usually they agree to it, but even if they don’t agree to it, you don’t drive them because they’re afraid. Occasionally we get people that are afraid to step foot in Fernside because they think there will be an intervention waiting for them, waiting for the family member when they show up. So, we try to keep it pretty, well, pretty welcoming and nonjudgmental the atmosphere whenever we have to talk about what you need to, yeah.

Michael: And not an unprompted fear, I have done the second intervention during family more than once.

Rocco: So, their fear is well founded then.

Michael: And I do agree with not having the alcohol in the house, a lot of times, if I have a family system that doesn’t have a problem with alcohol, but they drink, they’ll ask, “Should we have wine on the table at Thanksgiving?” And if you could wait a year, give them some runway to get to a place where then they can make a decision. Do they want, are they ready to be around it or not, some people a year, are okay with that.

I’ve met people that were in recovery at 40 years sober, who still don’t like to be around people who are drinking. That’s a whole another, it’s a whole other podcast in my mind about what recovery really is. But if someone’s getting out of treatment in October and they’re going home for Thanksgiving, I wouldn’t have any alcohol in the house or on the table. Certainly not at Thanksgiving or Christmas, let’s look at maybe next year.

Rocco: Yeah. Yeah. We try to take that away from the patient having to ask for it in the early stages. Yeah, I generally say the same thing because the rest of our lives, and usually the patient doesn’t want that either. And they don’t know how they’re going to feel in a year, but a year, yeah, it gives them plenty of time to get their feet planted on the ground and see what is and is not helpful.

And yeah, we make that general recommendation so that the patient doesn’t feel like, “Oh, I have to go ask people for this. I don’t want them to change their lives for me.” So great, if they can change their lives a little bit for us, then we’ll ask for that instead.

Jenn: I know you two have both touched upon having the home environment be a place for continuing recovery, where it’s more of a safe space, there aren’t specific triggers that might refuel somebody’s habits. What happens when a family members are in the home environment that are more of liabilities versus assets, which Michael, I think you had alluded to before, how do you approach the conversation with an individual that might be more of a liability to somebody’s recovery process?

Michael: Yeah, there’s no one answer to that, but I’ve done everything from asking to talk to that person outside one-on-one and saying, “Look, I’m not judging, I’m just saying I think that you might want to get an evaluation. Have you ever considered not drinking? When was the last time you went without drinking for a period of time?” Because like most of us, we don’t see when we cross that line, others see it long before we do.

So again, I think it can be a very powerful conversation it happens often at interventions. I know a lot of interventionists that say, if someone in the family drinks, whether or not they drink too much, but certainly if they drink too much or use drugs, they don’t want them at the intervention. I always ask everyone to come to the rehearsal, because I want to interview the entire family and see as many people that can make an emotional impact on this person as possible. And then kind of figure out who needs to be at the intervention.

And it’s often been very effective to have people they drink with, who they see themselves as the same as, come and say, “No, you used to drink like me, but you’re way worse now, you need to go.” That’s can often be much more powerful than me or Dr. Iannucci or their mother or anybody else saying it. When your drinking buddy is sitting in there in your intervention saying, “Yeah, no, you’re not, you don’t drink like me anymore, you’re way worse.” That can make a serious impact on them.

Consequently, what do we do with that person when they get out of treatment? Starting to talk to the friends and family about how do we limit the contact with them again, at least at the beginning? How do we maybe talk to their family to maybe get them some help? So again, a lot of different things can come out of the intervention process, if you look at it as a process and not an event.

Rocco: Yeah, I would say that it’s a whole, probably another hour or a couple of hours, because there’s different ways in which, well, different people have different relationships. There’s folks that are going to be in their lives. I think you would say people in the home, those folks who are a fact of their lives in most cases. So, you’re working with that person to try to make an environment as supportive as possible. If it’s a problem behavior that they have, then either helping them look at changing it or not doing it around the patient, or the patient may have to try to withdraw. If it’s a matter of something that’s important, that the patient needs, that they’re not getting from there, could they get it from there? Can they get it from somewhere else?

So, we tend to spend a lot of time talking to the folks we work with on figuring that out. What do you need from this relationship? What do you need generally? Can you get that elsewhere? Can you get it from this relationship? How can we help you with that? And so, we have family meetings pretty extensively. While folks are at, in our program to try to work on that, particularly with the most kind of key significant others, the primary people in their lives, people that they might live with.

Then you also have, there’s a whole separate issue of young people and their friends, and their friends are not in the household, and yet they’re so important to them. So, it made to us look like a casual question, you can stop hanging out with that person? But to them is, “wow, we’ve known each other like six months, we’re like this.” It’s looks a little different, the nature of the relationships, I think dictates how you approach and how they feel about the relationship.

Michael: And I think, I do think that the trickiest ones are the spouses, significant others, the then drinking buddies. And then one of them is off in treatment and the other one’s kind of happy. But then when we start to look at, what kind of changes are you willing to make? Sometimes they don’t want to change at all.

And that can really be a tricky thing, because again, you’re losing your drinking buddy. You not just husband and wife or cohabitating as partners. It’s my significant other and my drinking buddy. And now this one’s not drinking and doesn’t want me drinking. I didn’t have the problem, you have the problem, that’s really a lot more difficult to untangle.

Rocco: It’s complicated. Interestingly, even when the partner is not necessarily drinking, you would think everything might be roses if the patient stops drinking, but it can stress the situation to move from a drinking partner to non-drinking partner. It’s not something they’re used to, sometimes things that were glossed over get noticed that more. So, we try to prepare people for that as well, as things are going to be different, and there’s going to need to be some adjustment and it may be harder than you expect. Good thing, but it takes adjusting.

Michael: I’ve heard spouses say, went to the partner who’s gone off to treatment and comes home and isn’t drinking anymore. They say, you’re not going to be fun anymore.

Rocco: Right. Right.

Michael: So, they don’t want them falling down drunk, but they don’t really like the new sober person, yet either. And again, what I try to explain to them is this is a process of coming out of it. The person you are when you walk out of treatment, isn’t hopefully the person you going to be six months or a year from now.

Rocco: Right. Right. Good point. Yeah.

Michael: Yeah. Yeah.

Jenn: So, I know that both of you have talked about family meetings and that sort of encouragement through treatment, how can family members beyond those meetings and just keeping regularly in touch, how can you be supportive of a person who is getting treatment?

Rocco: So, I guess one thing I think Michael had already alluded to, is to be open to getting counseling yourself, treatment, family guidance, yourself, because these are really family problems. If they want to start out with a family problem, they become a family problem. And so, then you need a family solution as much as there’s sometimes people who want it to be the one person’s responsibility to solve the problem, that often times doesn’t work. But that can be a helpful thing.

Beyond that, we do speak a lot to the individual patient. When we have these meetings, that’s the most common question that gets asked. We do generally say, in the early stages of things, an environment free of drugs and alcohol, and then we say, what would be helpful, what do you think? Here’s an opportunity to ask for some things. And we also do turn that question around and ask the family members, what will be helpful for you to see? This is your process, are there asks that you have of the patient in this process?

So, a lot of times people know a lot about what they need and what will be helpful to them. And we’ve unpacked that a lot individually and in treatment. So, we tend to prepare for those family meetings pretty well with folks so they know what they’re looking for and how to approach it. Returning to having some professional guidance going through the process, we have some education sessions that are open to all the family members at Fernside and at McLean Hospital, generally, as to what to expect in the process of recovery, understanding a little bit more that it is a process.

Even with that though, even if folks go through kind of a course of education, it can be really helpful to have somebody in real time that can advise them through these processes, because unexpected things happen or in the moment they just might need support. “Well, I know I should do this, but it’s so hard to do that.” It’s nice to have somebody kind of cheering you on and maybe helping you hold the line if you need to.

Michael: Yeah. Yeah. And having those conversations with the family about what after treatment looks like, and the continuum care piece is usually lined up for the client leaving treatment, but the family aftercare piece can be as much or even more important. I’ll give you a couple of scenarios. You’ve got someone who’s been sent off to treatment ‘cause they’re doing whatever, and they’re not participating in the family or the family business. All of a sudden they come out of treatment, they want to re-engage in the family system. And there are other people that are used to taking control and don’t want that all of a sudden, this person’s coming in and they want to do this and they want to do that, I’m the one that always makes the decision. There’s a lot of different kinds of things that can come up in these situations.

Family businesses, where one’s been off gallivanting and the person running the business, brother, sister, cousin, spouse, whatever is resentful that they’re not there helping. All of a sudden, they come out of treatment, they want to get involved in helping, and this person is like, “Well, I’m the one in charge here.” So that extended care, that continuing care, the Al-Anon piece, all of that ongoing for the family, is oftentimes for me, harder to sell them on than the person getting out of treatment. We all know you getting out of treatment, you’re going to need to follow these continuing care recommendations. And a lot of times there’s some resentment with the family.

Unfortunately, I see a lot of times families that have the means to do things like couples counseling and workshops and things like that, don’t want to avail themselves of the help that’s out there for that. And I’ve had situations where families that don’t have the financial resources to take advantage of some of those things, desperately want to. And that’s one of the things for me that’s really frustrating is when I have a family that has the financial ability to do all of the wonderful things that we can recommend after treatment, and they won’t participate in those because they’re too busy or whatever. And then you’ve got a family that desperately we’ll do whatever we recommend, and they just don’t have the financial resources to do it, it’s really frustrating.

Rocco: Yeah. Well, Michael, can I actually ask you a question? Can you describe a little bit how you see the role of interventionist’s post intervention? ‘Cause that’s something I think people don’t, the TV show intervention, TV show ends with the intervention. People don’t understand that part of things. So maybe you can describe that a little.

Michael: Yeah, and it’s evolved, It’s actually a huge part of a lot of businesses now, in crisis case management, Mike Capella, Mike Berber, started the company together, and they actually do a lot more case management than intervention at this point. It’s one of the things that they wanted me to talk about today. And again, a lot of times that’s for the families of means that can afford it, but it’s fantastic to have that continuing care be managed after the fact. Because this isn’t sending someone off to treatment, flipping a light switch, and then we all live happily ever after. I mean, the family recovery process can be unbelievably successful if people are willing to continue to do things.

So, I’ve done it for years. We actually, when I was trained, I would talk to people for, I’ve got people I still talk to that I worked with 18, 20 years ago that I don’t charge. They’ll call me and ask for advice on this or that, and these days that’s really a business for a lot of people, it’s become a very successful and important business, because we know, I use the example of, I was about five years sober and I had high cholesterol. It wasn’t out of the range, but it was up at the high end of the range. And what’s my family history, et cetera, my doctor recommended I get it way down. And I got blood work done every six months. And he, after two years went to write a prescription for a statin, and I asked them to give me more time. He said, “I gave you two years.” I said, “Give me six months, I’ll get it down.” And six months later it was 112 points lower. And he said, “Oh my God, what did you do?” And I said, “I did what you told me to do three years ago.” So, I followed those continuing care recommendations.

And again, for the loved one that’s sent off to treatment, especially after an intervention, we typically have leverage, your team’s going to come up with this continuing care plan for when they leave. And to have someone like one of the case managers at TCM, even if it’s virtually just following up to make sure, and we look at it like the Medical Board, when you leave treatment as a physician, you got to be monitored for, anywhere from two to five years afterwards, that really helps.

So, with this case management system, the crisis case management has in place, it gives the family the ability to participate in whatever comes up, because we don’t always see all the needs at the front end. As the recovery process evolves, there are more things that come out, strains in the personal relationships, strains in the business relationships, whatever the case may be. If you’ve got that case manager that can continue to work with that family as loosely or intensely as, one, they’re willing to do, and two, that they can afford, it’s just kind of like keeping training wheels on it for awhile.

Rocco: Yeah, thank you.

Jenn: So, I did want to ask about beyond the rehearsal, I feel like this question is more directed toward Michael, but beyond the rehearsal of an intervention, how can family better navigate those uncertain and difficult conversations? I know one of the challenges is there’s that fine line of, you don’t want to come off as being too polished and disingenuine as a result, but also you want to make sure that it’s a productive and effective conversation. So, do you have any advice for navigating that?

Michael: My rule of thumb is always love and concern, Dr. Iannucci mentioned earlier that sometimes they’re resistant, angry, fearful, they’ll lash out. And it’s really hard not to react to that as a family member. I told you I was the best friend at my best friend’s intervention, and Mike did the intervention. And, I remember we walked in and I said, he either going to start crying or sweating. And we walked in, he started sweating. And all my training went out the window and I wanted to grab him by the throat and hold him down.

And what I would have hoped I would have done, what I asked families to do is don’t react to them. They may explode and yell and call us names, and if we just sit there calmly and stay in that love and concern, that’s going to be really effective because typically those interventions don’t translate to an admission right away. The person gets really angry, they leave, they go drink, and then they keep playing over and over how loving and caring the family was, and how totally out of control they were. And it actually continues the intervention. And the more you drank and try not to think about that, the more you think about that an ruminate on it. And it eventually wears them down to where they’ll come back and reengage in the conversation.

So one of the important things I tell families, whether you’re doing it alone or with a professional, and the reason it’s helpful to have a professional is, almost anybody can do that initial approach out of love and concern, staying in that love and concern, when we have installed the hot buttons on each other and we know where they are and we push them instinctively, it’s really hard to remain in that love and concern when you’re all of a sudden you’re the one getting attacked.

Jenn: So out of curiosity, what is the age range for an intervention? Is it possible to do interventions for teenagers who are just on the cusp of developing addictive behaviors? Are they different if they’re younger folks?

Michael: Well, the biggest difference is they don’t have to want to go if possible, they have to go. There are actually states where not only adolescents, but adults can be taken to court. Florida’s got a law called the Marchman Act where you can any one family member or three responsible adults can go to civil court and ask to have someone either evaluated or sent to treatment.

Rocco: And Massachusetts has those laws too.

Michael: Yeah, and when I approach families with adolescents, I look at a couple of things, is what are they using and how long have they been using? What are the behaviors? What are the dangers of doing it in the home, as opposed to shutting them out? There’s a lot of evidence that suggests that the younger adolescence, if they’re shipped off to a wilderness or whatever, and the family piece isn’t done right, it’s just band-aid on a hemorrhage. They’re going to go off for a period of time, they’ve still got to go home.

So there is a lot of benefit to, I think, with younger adolescents, treating the whole family system together on an outpatient basis, to try to prevent that child being sent off, expected to be fixed and sent back to a home that hasn’t changed. If I look at a 15, 16 year-old that overdosed and wound up in the emergency room, they’re almost all being sent to treatment immediately now because of the opiate epidemic. I don’t know that that’s always the right idea, because again, if it’s a kid who started at 12 and overdosed at 16, a lot of good reasons to send them to long-term treatment at that point. If they tried it once and overdosed, I know the fear level wants us to send them away to treatment, but is that really the right course of action? I’m not so sure.

Rocco: Yeah, I think a lot of the things that we talked about in terms of family, hold for the young people, only more so. It is really important, even more important to engage the family, families of the young folks. Those external incentives can be helpful. And even if they postpone problems, even if they minimize some of the exposure to the drugs during those periods where people’s brains are developing, that can be helpful in and of itself. It can be worthwhile to do.

Whether it’s to send them off to a residential program or not, yeah, I agree with Michael, that’s a case-by-case kind of a thing. but to get them to some kind of treatment and to help the parents get, usually it’s the parents that have the most leverage or whoever is functioning as the parents, to get into some sort of a cohesive situation, whether they’re divorced, separated or not, so that they can set some limits and get the behavior to stop.

I think sometimes people throw their hands up because, “Well, they’re going to be independent anyway, and they’ll be doing their own thing.” It’s true, but we have some good evidence that even if we can postpone that exposure to substances, that folks are less likely to develop a severe substance use disorder. So, it’s a worthy goal in and of itself.

Michael: Yeah, and the research is clear on that, that the longer we can delay the use, the better their chances are. The younger they are when they start, the more the chance to become addicted. The other part I’d like to just throw out there, ‘cause it’s appropriate, I think is, there’s a lot of this idea and some people disagree with me, I don’t care, I’m a big believer in not snatching kids and duct-taping them at 2:00 o’clock or 3:00 o’clock in the morning. I think that causes a lot of trauma. Again, they have to go, if the parents want them to go, they may want to run.

But when done properly, we give them the opportunity to sit and have that conversation about why this is going to happen, just like if there were an adult, and I’ve got this one guy in Atlanta, Georgia, who was a former DVA agent, I’ve done a lot of work with him, I’ve never seen him have to restrain a kid. He’ll sit them down and say, “Look, this sucks. You’re 16, so you got to go.” I think it’d be better for you, if you sit down and have a conversation, let your parents tell you why, and have a conversation about it. And we can do this easy way, or we can do it the hard way.

But again, I’m not a believer in running in at 3:00 o’clock in the morning while they’re asleep and snatching and grabbing them. I just don’t think there’s a need for it. And maybe someone can make a case for it, in a certain outlier situation, but in general, I don’t think there’s any need for it.

Rocco: Yeah, and I agree with that. I think, the risks of traumatizing the kid, in most cases are going to outweigh any potential benefits. And it also undermines the parent’s authority and sort of says, “I couldn’t do this. I’m going to have somebody else jump in here and do it.” Which isn’t really the best message for a young person.

Jenn: So, one last question, so say an attendee is on here. They hear everything you’re saying, it really resonates with them and they go, “Gosh, I really think somebody in my family could benefit from this. I need to start this intervention conversation with my family.” How do they go about it? What’s their first step into getting this started.

Michael: Two things I’ll say quickly, approaching the family, unless you’re well versed in this, have some experience in it, you might want to have a conversation with a professional like me before you approach your family.

Jenn: Have intervention for the intervention.

Michael: Yeah, and some people don’t do it. I take calls from families all the time. And if I can talk them in over the phone, and again, a lot of times they’ve never had a conversation with the person they want to intervene on. And I always ask that, “Have you asked this person if they want help?” And a lot of times they’ll say, “No, can I?” Sure, absolutely. Don’t argue with them, ask an open-ended question. If they sound interested talk to them, or get them on the phone with me, I’ll talk to them about...

They say, “Well, what are you talking about? You’re talking about inpatient. You’re talking about...” Put them on the phone with a professional, let them gather some information. Doesn’t mean you can’t go to an intervention, a professional intervention down the road if things don’t get better, but I love that it takes out the situation of once before I started doing this, is the guy said, “I can’t believe you all have done this and no one ever asked me if I wanted help.”

And I thought, man, he’s got a good point, like no one’s asked them. And they’ll probably say, no, they’ll probably minimize or deflect or try to change the subject, just move on and then call me back and we’ll go to the next step. But ask them an open-ended question, ask them if they’ve thought about how family is concerned about them. If they are engaged, great, if they’re not engaged, change the subject, call me back.

Rocco: And you could see what they are willing to do. A lot of times people are willing to come to Fernside, say, but they’re willing to talk to the primary care doctor, or they’re willing to sit down and talk to somebody that they trust a bit about it. And that’s an important first step, as much as we love to have people come to us to try to help them, not everyone wants to, not everyone needs to come to Fernside. A lot of folks can get benefit from seeing a professional on an outpatient basis. And that can be a really good and perhaps less intimidating starting point for a lot of folks.

Michael: Yeah, and if someone does need, if they meet the criteria, could benefit from inpatient, once COVID is over, I always tell people, go check out a good treatment center. There are great treatment centers from free programs to in-network residential programs, to the Fernsides of the world, everything in between, and there are bad ones.

I think that you to either engage a professional who’s ethical, who’s seen these programs. And unfortunately these days, there’re so many professionals, therapists, doctors, et cetera, that don’t get to go out like I do, and vet these programs. So if you’re looking at a program, I’ll go see it once COVID opens this up again, if you... looking at a program in Massachusetts, like Fernside, and you live in Georgia, if you’ve got relatives or friends up there, ask them to go check it out, they’ve got to be pleasantly surprised.

Rocco: We can do virtual tours and people see that it’s not an institutional looking place. I think that that goes a long way, nobody wants to be in a cell for 30 days.

Michael: And again, a lot of times the first thought is One Flew Over the Cuckoo’s Nest, and I don’t need to go there. And we’re not talking about punishment, we’re talking about a life-saving opportunity. When you’re talking about good treatment, you’re talking about a life-saving, life-changing opportunity.

Rocco: Yeah, that’s a great way to put it.

Jenn: And I think that’s a really good way to wrap up this session. So, Rocco and Michael, thank you both so much for all of your expertise, and sharing an hour of your day with us.

And to all the folks joining us, thank you for joining. This actually ends the session. And until next time, be well, be safe, and have meaningful conversations with your loved ones. Michael and Rocco, thank you again, and have a great day, everyone.

Rocco: Thanks.

Michael: Thank you both. Take care, bye-bye.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to educate about, encourage compassion around, and reduce the stigma related to mental health and wellness. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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