The Stigma of Enabling Behaviors

Written by: Maria A. Avila, LMFT, MCAP

Many of us are all too familiar with the concept that came out in the 1980s that described how family members perpetuated the vicious cycle of addiction. “Enabling” behaviors offered examples of how families responded and coped with their loved one’s struggle with substance use disorders and how it fed the destructive path of the person struggling with dependency issues. We have come to understand reasons why families continue to engage in these behaviors, many times knowing full well how detrimental it could be to the recovery process. Nevertheless, this concept warrants further inquiry to improve our understanding of families’ resistance and the dilemmas that keep them from changing despite their better judgment. A better appreciation of this struggle may serve to elicit more cooperation in working with such families.

Doing for others what they can do for themselves is a common definition of enabling in the addiction world. Do we always know what the dependent is capable of, especially under the influence of mood- altering chemicals? The ultimate family fear is pulling out of this enabling process and having their loved one die as a result. This is a very real and valid fear. The longer the rescuing continues, the greater the chances of this happening.

If one’s irresponsibility has been facilitated for so long that the progression of addiction has taken hold over one’s neurochemistry, the person may not be able to make decisions that will result in asking for help. At what point should the family step in, and how should it? Would pulling back and letting the loved one face the consequences of their actions at certain points be appropriate? Families struggle to accept that not taking action at times would be the helpful thing to do. They see this as a form of abandoning the person they love.

Neurobiology has shown us how addiction works in the brain, how it hijacks the reward pathway and reinforces destructive behaviors. The power of addiction can be so strong that it has gotten families to take over the responsibilities of the dependent when they are unable to. Recognizing when their loved one can begin to make decisions and take control of their life is critical.

If we believe that chemical impairment takes away choice from a person with moderate to severe substance use disorder, then it is up to the family to take control and make decisions for the person who is unable to at that time. The valuable question then becomes how to take over. An intervention, if the dependent person is not ready and not able to because of impairment, could be to have legal action enforced to get the necessary help. Although radical for many, this could provide an opportunity for recovery without further risks.

The challenge for professionals in working with families is to help them recognize the types of interventions necessary and when to implement them. To tell families to stop enabling is like saying to the dependent, “Just say no to drugs.” Neither is helpful. The question should no longer be, “Do I enable or not?”, but rather, “When and how should I enable?”

There can be a fine line in knowing when to step in and when to pull back. This dance is the key to facilitating recovery. It can be further complicated when boundaries are blurred, non-existent or a family’s self-esteem has been affected by previous destructive interactions. To some family members, a sense of worthiness comes from ongoing rescuing behaviors, making it painful for them to change these behaviors.

Guidance for Professionals

Professionals have many avenues for decreasing families’ resistance to exploring this struggle. First, validate families’ feelings of the real possibility of loss. Trying to convince them that they will lose their loved one, even if they continue to enable, shuts them down from further discussion. The reality is that we do not really know what can happen if families discontinue enabling at some point with certain people. Generally, the quicker these behaviors stop, the better chance for recovery, yet families’ fears prevent them from seeing this.

Confronting them when they say that the reason they engage in such behaviors is because they love the dependent person and discounts their relationship and feelings. The more families feel heard, the more you can keep them in a dialogue that will offer clarity about the situation and themselves.

Second, help families reach the point of understanding that they have done everything possible to be of help. With this comes the recognition of limits and boundaries. This is difficult when you are facing the possibility of losing a loved one from the consequences of their behaviors.

When is enough enough? Brené Brown’s research on vulnerability and shame sheds light on this struggle. She states in her book Daring Greatly, “You have to believe you are enough, to say, enough.” Believing one is worthy and deserves a better life will help to identify one’s limits and will allow for them to be setting these within the chaos that comes from someone caught up in the cycle of active addiction. Work on families’ self-esteem, feelings of guilt and fear. This will help to facilitate a better understanding of their inherent strengths, which were robbed by the addiction and their past trauma.

Third, teach families to be responsible to the dependent person and not for them. After years of living someone else’s life, it may be difficult to recognize when that other person is ready to take over. Stepping in at unnecessary times can be a difficult habit to break. It can also feel threatening—the idea of not being needed in the same way as before. Affected family members tend to feel responsible for others’ actions. As children, they may have developed the common belief that the reason either parent used substances had to do with them. Help families recognize their motivations for enabling and who they really may be enabling for. Guide family members through this maze in order for them to be more accepting of their own boundaries and to come to better terms with their decisions.

Finally, recognizing the difference between chemical and emotional impairment can help in understanding a more effective way to respond. Using a simple formula to help families distinguish between hurting and helping may enlist their cooperation in evaluating their behaviors more effectively and honestly. The formula is this: When you enable, you take something away, such as ridding one of responsibility, decision-making, problem-solving, or intense feelings that can encourage behavior change. When you help, you give something such as the ability to make decisions on one’s own or a feeling of accomplishment.

When someone is too impaired to think on their own, taking action may help them get to the place where they can regain control of their life. In this instance, the person is not taking away the loved one’s ability to think on their own because physically they are unable to do so at that moment because of substance use. If they are in a state where they can think and are feeling the consequences of addiction, allowing the person to have those feelings may encourage behavior change.

Eradicate Stigma

Just as addiction has been stigmatized, so has the term “enabling” and those who engage in these behaviors. Recognizing and appreciating a family’s struggle to know when to step in or step back provides the impetus to remaining in a dialogue that will help give family members confidence and insight. Shaming them into reacting in ways they are not ready for is not the answer.

As professionals, we need to be patient and respectful with a client’s pace and readiness to change. Enabling may not always be feeding the addiction, but rather paving the way for help to be sought.

About the Author

Maria A. Avila, LMFT, MCAP is a licensed marriage and family therapist and master’s level certified addiction specialist in private practice. She has over 30 years of experience working with individuals, couples and families. Along with her clinical experience she has taught at Barry University and the University of Miami and has conducted numerous workshops and presentations. Maria was the clinical supervisor of a renowned addiction treatment center in Miami and was previously in charge of the family program. She created a website especially for those struggling with this issue. You can visit this website at substanceabuseanswers.com or MariaAAvila.com.

Maria A. Avila, LMFT, MCAP

What is so “trusted” about the Trusted Provider Network?

Written by: Brittany Hunt, LCSW
Clinical Oversight Specialist at TPN.health

As a licensed clinical social worker, the concept of trust is an important one to me. I see trust as intimately linked with respecting the dignity and worth of a person, one of the social work core values. The majority of my work has been in the anti-sexual violence field, where I have worked with sexual assault survivors at various parts of their healing journey post-assault. The most important part of my job was trusting the client: trusting their story, trusting that they were in pain, trusting that they had the resilience to heal, and ultimately trusting that as a society we can end sexual violence. By having this trust in my clients, I hoped that they would have trust in me. Forming relationships with clients through shared trust, even the very short-lived relationships that blossom when responding directly to a crisis, has been by far the most impactful part of my social work career.

When I started working on the TPN.health clinical team, I was worried about losing the special connections I made doing direct service work. Social work is inherently relational, and how could I feel these relationships on a tech platform from behind a screen in an office? Like many people in our increasingly digital world, especially during the COVID 19 pandemic, I have had to rethink relationships and connection. Technology is an amazing tool to bring people together all around the world to share, learn, commiserate, and connect. I was ultimately attracted to working at TPN.health because of its potential to fuel relationships, and its focus on trust.

TPN.health strives for our network to be filled with the best clinicians out there, the people you would trust with your loved ones’ care. How do we do this? Whenever a new user signs up for TPN.health, our clinical team verifies their license with the relevant state board, to ensure that every professional on our site meets the criteria to treat clients in their state. Another feature that helps to make sure that our users are credible professionals is the endorsement feature. Endorsing a colleague on TPN.health signals to the greater community that this is someone you know is a caring and competent professional. These endorsements are important, especially when making referrals to professionals you may not have worked with yet.

Trusted clinicians’ voices are involved in every step of our development, including our digital beta-referral feature, which will allow clinicians to more easily find other professionals for their clients on a secure platform. In addition to our team of licensed clinicians, we want to hear from other clinicians from diverse fields and backgrounds to make sure that TPN.health remains a trusted resource. Just like how we need to trust our clients for them to trust us, we know that we will need to trust our users in order for you to trust us. Please, drop us a line on how you think TPN.health could be helpful in your work. 

About the Author

Brittany Hunt is a licensed clinical social worker originally from Rhode Island. After graduating from Vassar College in 2012, she moved to New Orleans and began working in the anti-sexual violence and reproductive justice movements. She loves reading, throwing dinner parties, and karaoke.

Brittany Hunt, LCSW
Clinical Oversight Specialist
at TPN.health

The Case of Termination

Written by: Maria A. Avila, LMFT, MCAP

I recently resigned from an organization where I had worked for almost 16 years. In order to allow the different groups of people I worked with digest and accept the news, it was decided that I should proceed in stages. After revealing the news to the leadership group I was part of, I addressed those colleagues that I supervised. We  gathered in my office with my director present and I delivered the news. After the initial blow, the discussion was diverted into questions and concerns over other matters. The conversation was among the staff and director. The announcement of my departure quickly got me off center stage, to my relief. It was at this moment that I realized how this experience could be translated into termination issues with clients. 

The work of emotional and behavioral transformation can be quite intimate between a clinician and their client. In working with those at an intensive inpatient or intensive outpatient level, the process of termination usually comes to fruition sooner rather than later. Working with clients in an outpatient setting brings about the same  process but perhaps after a longer period of time. Regardless of the level of  treatment, clients reach a time when they feel they are ready to depart from the work they started. How this procedure is handled can be of upmost importance in the  therapeutic process. Dealing with termination of a therapeutic relationship is based on how we, as clinicians, view this issue, and especially, how comfortable we are with it. In the example of my resignation, the diversion to other issues from the end of a relationship with an organization and coworkers demonstrated my own discomfort with sadness that takes place in this process of loss. 

When insurance companies dictate the length of relationships we are to have with clients, it forces the issue must faster. We have a better idea of how much time we have and certainly have the opportunity to begin the steps needed to prepare a client  for the end. If one’s relationship is not controlled by insurance, then the time to build  this closeness may be more fluid. Whether the client is working in an individual or  group setting a certain level of trust and understanding has transpired. There are several questions that should be addressed. Do we wait for the last session before  trying to access feelings around this loss? Do we assume that the client does not have these feelings as they have not come up since the day termination was known? Do we force discussion of the process because we assume that there must be something  there that needs to come out? Do we assume if the client prematurely leaves right  before the deadline or begins to act out that they were never that invested to begin with? How may using humor deflect from the feelings? All of these questions are aimed at addressing our own possible misconceptions of the termination process. They are also intertwined with our own feelings of saying good bye and with endings in general. Let’s look at the different scenarios. 

Do we wait for the last session to address termination issues? 

If you have successfully engaged a client into the treatment process and have established a bond, it is only logical that the end of this relationship will have some effect on them. Pretending that it will be business as usual is an oversimplification of what relationships are about. Think of when a client brings up important issues at the end of a session. Do they really want to deal with them? In a time when relationships are challenged, clinicians need to try and model effective interactions that contribute to positive relationships. Encouraging discussion of difficult and negative feelings, allowing this discussion to flow as well as being able to validate these  feelings are cornerstone in our ability to model effective communication. When we wait for the last session to do this it cheats the client and others, especially if in a group, to have had the opportunity to explore and communicate the accompanying  feelings. The pressure one may feel about having to express something at that  moment does not do justice to the therapeutic process. The last session should be a  time to summarize and express any other feelings or thoughts that have been expressed previously about this issue.  

Strategies: Clinicians need to be able to recognize their own struggle in dealing with  the end of a relationship. An awareness of this can help us to be more attuned to others’ struggles and help them access issues that may arise from termination. Giving enough notice allows for this process to unfold. Depending on how much time we have, two or more weeks may be sufficient. In the case of planned vacations or  absences on the clinician’s part, the same principle can be practiced. Give them sufficient time to know you will be away. Even if the absence is temporary, we  underestimate the effects it can have on some clients. 

Do we assume that the client does not have any feelings as they have  not come up since the day the termination date was known? 

The termination process can reignite feelings similar to those clients that are grieving losses or have been abandoned or rejected. The defenses these client may have used  to deal with the trauma could manifest in detachment, disengagement and other  behaviors that appear indifferent. One can mistake these for an absence of feeling versus a survival technique. The clinician may think that lack of expression of feelings may be due to the client’s level of disinterest or distance in the relationship. If clinicians are not aware of their own discomfort with endings, they can easily align with the client’s distance, justifying that it was a superficial relationship to begin  with. 

Strategies: Bring up the topic in subsequent groups to introduce the idea that this is  an important issue to be addressed. It allows others to think about what they are  feeling in regards to this at different times. Confront the indifference and ask directly  what they think of leaving the relationship.  

Do we force discussion of the process because we assume that there must be something there that needs to come out? 

The best moments in therapy are usually unplanned. Clinicians need to respect the pace of clients. Feelings cannot be rushed, no matter how much insurance companies try to rush the process along. Expecting that a client is ready to discuss feelings about termination at a specific time may be unrealistic. The clinician’s job should be to prompt the discussion, not force it.

Strategies: Create an environment that allows for clients to feel safe about what they contribute. Respecting their silence or resistance in addressing an ending creates this safety. If the client does not have anything to say in this regard, let it go. 

Do we assume that if the client leaves right before their last day or begins to act out, they were never that invested to begin with? 

A common pattern seen in clients towards the end of their treatment is that they may appear to deteriorate toward the end. Much to our disappointment, we may infer that they had not really learned much to begin with. We may react with annoyance, frustration and anger not seeing it as a sign of sadness due to the upcoming separation. Viewing it as such can allow the clinician to engage in a discussion of loss and sadness which could redirect the patient’s energy and coping. 

Strategies: Family therapists may say that prescribing the symptom is indicated here. This can also be described as reverse psychology. It means that the clinician makes a suggestion which is the opposite of what is expected from the person. The clinician may say to the client that the occurrence of these behaviors is natural in this process of termination and predict that they will begin to engage in them. This techniques usually stops the acting out behavior from occurring.

How may humor be used to deflect? 

All too often the defense of making a joke or light of intense feelings is seen in therapy as a defense against pain. Many times the client may lack insight on what they are doing and distract from the therapeutic process by making others laugh. In a group setting this may become contagious, encouraging others in this deflection.  

Strategies: Increase awareness of this behavior as a way to deflect. Help the client understand their feelings more honestly and help them allow themselves to feel these feelings. 

The delayed process involved in dealing with my resignation certainly helped me deal with feeling the upcoming loss and be able to talk about it with others. It allowed them the same time to be either silent or react as time went on. At the end, I can only be thankful for the opportunity that aided me in this termination. Going forward I will be more sensitive to recognizing a client’s vulnerability in this process.

About the Author

Maria A. Avila, LMFT, MCAP is a licensed marriage and family therapist and master’s level certified addiction specialist in private practice. She has over 30 years of experience working with individuals, couples and families. Along with her clinical experience she has taught at Barry University and the University of Miami and has conducted numerous workshops and presentations. Maria was the clinical supervisor of a renowned addiction treatment center in Miami and was previously in charge of the family program. She created a website especially for those struggling with this issue. You can visit this website at substanceabuseanswers.com or MariaAAvila.com.

Maria A. Avila, LMFT, MCAP

My Social Work Friend… Whose Needs Are You Meeting?

Written by: Cindi J. Jeffrey, LMHP, LISW

Idealism in Social Work

I found a paper I had written for my undergraduate social work degree. In it, I alluded to the fact that I wanted to change the world. My idealism was prolific throughout the paper; however, my vision of how I fit into the world may have been a tad skewed.

Interestingly, I am not the same professional in social work when I began this journey many decades ago. Furthermore, I am not the same person. Personal experiences, professional encounters, and traumatic cases have provided me with a new outlook on how I view our profession. Looking back at the time that paper was written is almost embarrassing. I wonder if I truly helped my clients or rendered them dependent upon me.

Social Work Goals

As a social worker, I have always made it a point to be more personable and open. I worked hard to break the stereotypical vision that most people appeared to have of the white-gloved woman going through your house and looking for things you have done wrong. I focused on what was going right, and after I earned some trust, we could go into what was not working so well.

There is a fine line between enabling and empowering our clients, and that line is often drawn in the sand. Additionally, that line appears to be constantly moving and redrawn. As a young social worker, my goal was to “fix” everyone and every situation I encountered. I did not want anyone to suffer, nor did I feel accomplished unless a problem was solved. Only once the issue was taken care of was I comfortable leaving the people involved.

Enabling or Empowering?

As the years progressed, I gained more experience, and I learned how damaging enabling a client could be. While those identified problems may have been taken care of in the short term, the client learned no skills during that process. Once I was removed from the case, the same issues were likely to return, leaving the client in the same situation as when I entered.

Listen, I get it. It feels good to help. It feels good to be needed. However, when we solve every problem for our client, we meet our needs, not theirs. The client may be grateful and express themselves as such, but who did we actually help? Whose needs did we fulfill?

In social work, our jobs can be diverse. Many of us went into the field due to our personal experiences and are very good at what we do. At some point in our career, there must be a defining moment to see the clarity of our responsibilities. If we continuously enable our clients, we are not working for them; we are working to meet our own needs.

Check Yourself as a Social Worker

It is our responsibility to draw that line in the sand. We are social work professionals. We need to meet the needs of a client, not meet our own needs. It is our job to continuously monitor ourselves so we can meet the needs of our clients. It is our job to empower our clients in order not to need us anymore. Moreover, do not forget to take care of yourself, my friend.

About the Author

With over 25 years of Child Welfare experience, Cindi brings a well rounded approach to individual and couples therapy. Understanding how the family influences one’s perspectives can enhance a person’s ability to see themselves and others through their unique lenses. Recently, Cindi has been providing therapeutic interventions for seniors in nursing facilities, focusing more on adjustment disorders, end of life, and chronic illness issues. In her spare time, Cindi enjoys biking, walking and reading.

Cindi J. Jeffrey, LMHP, LISW

Humanity’s “Last Responders”

Written by: Peter Lazar, LCSW

August 14 of 2004 was just another sweltering summer day in New York City and we were approaching the third anniversary of 9/11. It was around 90 degrees; the kind of day that just a few minutes walk from the subway to work would render anyone a heap of sweat. On a day like that, ice and air conditioning are not taken for granted.  

At the time, I was working for an Employee Assistance Program firm that provided amongst other services, psychological counseling and resources for client company employees. For anyone seeking those services, they would call the hotline, and were greeted on the other end by a licensed clinician.  

I had finished a long shift working the hotline when at precisely 4:10 PM, the power cut out. At first, my colleagues and I were a bit confused about what was happening. Thinking that the power was out just on our floor, we quickly learned that the building was dark and we needed to leave. We made our way down 21 flights of stairs to reach the street and it was then we discovered the entire city was dark. At that moment, we certainly didn’t know that this would hold true for most of the Northeastern United States and parts of Canada. 

In 2004, there was barely any internet and certainly no smartphones. There was no way for us to know the cause until one could get their hands on a battery-operated radio. Walking up Second Avenue, I could see a sense of panic in other’s eyes. As we were literally and figuratively in the dark, the city was eerily silent as we awaited, well, anything really. Was this a routine summer power outage or were we under attack again? We later found out that the cause was a software bug in the alarm system of an energy company’s control room in Eastlake, Ohio.  

The blackout lasted just a week, but little did we know that the impact would reach further than our collective experience of that day. Within just a few weeks, the hotline filled with calls from New Yorkers complaining of anxiety, restlessness, irritability, and medicating behaviors such as increased alcohol consumption.  

It wasn’t a stretch to see that these people were experiencing symptoms of Post Traumatic Stress Disorder (PTSD) and needed professional help. At our clinical team meetings where we reviewed these cases, a pattern began to emerge. We realized they all had something in common: they were in or near New York City during the attack of 9/11, and these people did little to nothing to deal with the emotional aftermath.

This is not an uncommon phenomenon. People who lived through the Great Depression developed money-related disorders, such as hoarding behaviors. Another example would be Holocaust survivors, many of whom subsequently exhibited severe anxiety and hyper-vigilance. Given what we now know about the epigenetic aspects of trauma, we also saw many of these behaviors in their descendants. There is no doubt that when the veil lifts on the COVID-19 pandemic, we will experience an emotional reckoning, and those in the mental health field need to be prepared.  

University of CA, Irvine professor of psychology, Roxanne Cohen Silver, Ph.D., believes that various factors will determine an individual’s response to the pandemic. 

“Decades of psychological science on collective traumas indicate that individuals’ responses are likely to be based on several factors. These include their pre-pandemic circumstances and resources—prior exposures to adversity, physical and mental health vulnerabilities, and economic and social supports.” She goes on to say, “One must also consider exposures encountered during the pandemic: Did a family member get sick or worse? Did the person lose a job or health insurance? Was the individual an essential worker whose actions ensured others’ well-being?” (1)

All this to say, for any mental health professional, now is the time to at least familiarize oneself, if not receive proper training in the assessment of trauma & PTSD. For we have been and will continue to be humanity’s “Last Responders.” We are the place for people, when after the body may have healed, the spirit still has a ways to go. Fortunately, there are plenty of continuing education and training opportunities from which one can choose. Equally, if not more fortunately, humanity has proven time and again our resiliency through its myriad of challenges and calamities. 

  1. https://www.researchgate.net/profile/Roxane_Silver/publication/34265310_Surviving_the_trauma_of_COVID19/links/5f54339d299bf13a31a4dd84/Surviving-the-trauma-of-COVID-19.pdf

About the Author

Peter Lazar, LCSW

For over 20 years I have made it my mission to help people who struggle with the things that hold them back from living happy, valuable, and productive lives. In addition to my longstanding commitment to the treatment of addiction & co-occurring mood disorders, I have expanded my practice in the New York Metropolitan area to include the particular challenges of the divorced single parent, as well as addressing individual dilemmas in the workplace. Cognitive Behavioral Therapy, & various other informed treatment approaches are the cornerstones of my work. I am recognized nationally for my understanding of treatment options & I gladly serve as a resource.

I have presented at the Cape Cod Symposium on Addictive Disorders, and I have been a guest lecturer at Boston College, Adelphi University, and the Institute For Addiction Studies at National Counsel on Alcohol and Drug Dependency (NCADD) Westchester County, NY.

Peter Lazar, LCSW, serves as an advisor to the leadership team of TPN.Health.

A Lesson In Listening

Written by: Mark Wilson, MSW

With the pervasive influence of social media in our culture, we are robbed of the need to be present. We slip into a pattern of virtually shouting information instead of engaging humanity, fumbling for an independent voice amongst a sea of hollow opinions, and seeking a sense of community in a faceless space, all the while slowly losing our ability to listen.

My pursuit of a master’s in social work made it quite clear the power of being a listener. It wasn’t until I had the privilege of being supervised that I realized components were missing. A therapeutic relationship is not sustainable without the capacity to listen. Clients want to be heard but more so understood. Active listening* is taught consistently throughout a clinician’s education, but it lacks comprehension ability. Active listening is the chassis of the listener’s “vehicle,” but it’s missing a vital component, an engine.

Comprehension takes active listening a step farther. It understands the message and also the intended message. It allows a client to feel connected, express their emotions, and be reciprocated by the clinician in advocacy, not judgment. It’s important to note that speaking has its place but needs to be followed by a level of comprehension. The behavioral health space needs listeners, people that bring humanity back into the fold of a dialogue. Allowing voices to be heard and opinions to be shared will aid in the need for more human conversations in our loud, noise-filled world.

A challenge: Pick three conversations you have in a day to be consciously proactive in listening. Whether it is a business meeting, a scheduled check-in with a friend, or an encounter with a grocery store cashier, yield to sharing personal experiences, instead seek clarification, comprehension, and seeking the “why” of a person’s words. The hope is that you learn your listening tendencies and continue on a path of becoming a well-rounded listener. 

*The process of listening attentively while someone else speaks and withholding judgment and advice.

About the Author

Mark Wilson, MSW

Mark Wilson, CSW serves as the Clinical Liaison for the Trusted Provider Network. He pursued his Masters in Social Work from Louisiana State University to better understand the behavioral health world. He hopes to continue TPN.Health’s goal of incorporating new and innovative technology to allow the mental health field to thrive in a digital world where access can be unlimited.