A plea for the psychological needs to be given equal status with behavioural, cognitive and practical need for individuals who abuse substances/ alcohol.
‘Tough love’ – the need to hold both the toughness
‘Tough love’ is a well-known phrase used to describe a way of being which demands setting and holding boundaries to demonstrate that behaviours are unacceptable. We can see it working to effect in families where teenagers are pushing the boundaries. In the family the tough attitude is counteracted by the holding and love which the family unit, in normal circumstances, provides. If we transfer this model to our service user’s we must ensure that both elements are present, the toughness and the compassion and holding. Yet it is true that service users that lapse are often asked to leave abstinent based groups or services without a clear care pathway being provided. They are asked to leave one service sometimes without the provision of a follow-on service. The necessary toughness for holding the boundary in these circumstances exists but not the holding and the compassion which are both components of so called tough love.
Abstinence groups are necessary and very holding for clients. The boundary of abstinence encourages individuals to stay abstinent as it is vital in order to be accepted as a member of that group. The absence of alcohol/ other substances enables the individual to be more present and to gain more from the group and facilitation processes. We know, however, that when we come under unmanageable pressure we are all more likely to regress and revert to old strategies that have helped us to cope in the past. The same is true of our client group. The Cycle of Change [i] confirms that lapse is a natural part of how we integrate new behaviours. It is easy to relate to this in the fact that gym membership swells each New Year, spurred on by new resolutions, followed by a dwindling of membership by spring. Yet, for example, while holding all this knowledge there are still services which provide abstinent groups, and even complete services, which exclude individuals who lapse without referring them elsewhere. In essence these services are withdrawing support at the very time when the individual needs most support – when some difficulty has produced an emotion which has overwhelmed them and they have sought to self-soothe in the only way they know how. The exclusion from support supplied by the organization and their peers can be seen as punishment, if the exclusion is not balanced with a holding, compassionate response, not only for the lapsed individual but also by members of the group from which they have been ejected. An implied threat about what could happen to other members in similar circumstances is present. If the individual is excluded from the group or the service, the chance to explore and learn from the lapse is lost to the individual and the group and the exclusion can increase feelings of shame and self-loathing.
If we consider the psychological aspect of the service user and relate that to the Cycle of Change rather than just their behaviour, we can see that in an abstinent group there will be individuals at different stages on the Cycle of Change. There might be individuals whose behaviour demonstrates abstinence but who are psychologically still in pre-contemplation or contemplation. These might include individuals who are under threat if they do not become sober, for instance, by a partner or those who have serious health problems or those who are in the criminal justice system - individuals who are going along with abstinence, rather than adopting it because that is want they want for themselves. There will be other members of the group who will be at the maintenance stage on the Cycle of Change.
The alternative of exclusion from an abstinent group would be to allow the lapsed individual to return to the group once the using stops. As long as the individual is still psychologically in maintenance on the Cycle of Change, the lapse can be used to prevent a recurrence. By discussing the circumstances of the lapse in the group, usually the behaviour can be normalized, shame can be taken away, the group inevitably on hearing the circumstances find compassion for their colleague and can, if/when they find themselves in similar circumstances find their own self-compassion more easily. Naturally, if the individual that has lapsed is elsewhere on the Cycle of Change to invite them back to the abstinent group would not only leave them with too little help but it could damage the ethos of the group. Under these circumstances to provide the holding incorporated in the concept of tough love, we need to facilitate a referral to another group or organization so that the service user does not feel abandoned and ‘dropped’.
We all know that there are many ways in which service users can push boundaries, some more aggressive than others. It is part of the human makeup that when we are under threat we lose our compassion for the attacker so that we can defend ourselves [ii]. When service users push boundaries in an overtly aggressive manner, it is natural for workers to feel under threat and for their compassion to be put to the test.
The attitude of tough the toughness in tough love ultimately comes from a place of ‘I know best’, from a place of ‘I’m OK’/ ‘You’re not OK’. By its very use we bring our attention to rest on the behaviour of the person rather than the distress that underlies the behaviour. What we are doing by holding boundaries is keeping ourselves safe but if we do not at the same time hold onto our compassion for the vulnerable person behind the boundary breaking, how the other experiences it is often as punishment. If we only hold the boundary with our toughness and neglect the compassion, it implies that the underlying distress is unacceptable and that addressing the distress is not relevant to that person’s recovery.
If a punitive model by which to regulate behaviour is internalized and integrated as a way of being, it is unlikely to be successful in regulating behaviour in the long term. As we know from the work of Miller and Rollnick (2002) coercion often has the opposite effect. If the abstainer is using a critical, strict part of themselves by which to maintain their abstinent position they are likely to reach a point where the pressure becomes too much, the rebel part of themselves kicks in, the ‘sod it’ attitude emerges and they lapse, whereas if the abstainer is using a nurturing, compassionate part of themselves they are much more likely to feel supported and stay clean or sober.
This is an invitation, and hopefully the prompt to a discussion or re-thinking, on what we offer to service users who lapse while in an abstinence group, what we mean when we use the term ‘tough love’ and a plea for the ‘love’ part to be as rigorously held to as the ‘toughness’. I believe that we can only claim to be acting from a position of ‘tough love’ if we are providing both elements – toughness and love.
[i] PROCHASKA J.O. & DICLEMENTE C.C. & NORCROSS J.C. (1992) In search of how people change. Applications to addictive behaviors. In American Psychologist. 47, (9) pp1102-111
[ii] GILBERT P. (2001) Evolutionary approaches to psychopathology: the role of natural defences. In Australian and New Zealand Journal of Psychiatry. vol . 35, pp17-27.
MILLER W.R. & ROLLNICK S. (2002) Motivational Interviewing – preparing people for change. The Guildford Press London and New York
