The Problem of Denial

“What can we do to help our daughter, who is a young adult, living at home, and who is not compliant with treatment recommendations from mental health professionals and appears to be using substances and behaving in other self destructive ways?”

We are often asked what can parents and family of young adults or seriously affected adults with mental illness and/or substance abuse do to intervene when they see that their family member seemingly spiraling downward in a pattern of self destructive behavior and failing to take care of themselves.

A general framework for thinking about what to do and when to do it that we have found useful is Prochaska and DiClemente’s Stages of Change Model. We encourage you to review this information as you think about how to talk to someone who is preoccupied with an idea or behavior that is self-destructive.

One idea that often comes up is the idea that limits should be established and if those limits are violated then the family member should be kicked out of the house. We feel that limit setting and establishing consequences is extremely important in a situation where people are being seriously self destructive. But the idea that saying either you do X or we will kick you out of the house fails more often than it succeeds, and when it fails the consequences can be serious.

There are several reasons for this. First, at a psychological level, we find that a common communication style in families dealing with these issues is that long periods of artificial calm, during which the problem is not discussed, alternate with periods of high tension when a crisis forces the family to deal with the problem. What happens is that the family “teaches” the affected member that discussion about the problem is inevitably destructive, painful and associated with punishment. So denial and avoidance is reinforced.

In our experience what is needed is sustained communication about the problem. That communication needs to be fundamentally loving and needs to be based on an understanding of the process of change.

Limits need to be established not as punishments to force change but because sustained communication is only possible if there are limits and boundaries. Usually the problem has taken years to develop. It makes sense that going from denial to active engagement in treatment takes months, even years. Steps forward are followed by occasional steps backward. The family needs to “pace itself” for a “marathon” rather than a “sprint.”

The limits are really a way of not getting overwhelmed and stressed out so that the family has to abandon the affected individual. Abandonment is generally catastrophic.

So the first question is what kind of support and involvement with the affected person can the family tolerate indefinitely. Here are some possibilities:

  • Regular conversation that avoids certain topics or during periods when the family member is not intoxicated.
  • Food and shelter (where this is not possible in the family house, families can arrange for direct payment for housing and food).
  • Support for treatment.
  • Etcetera.

Then the family needs to think about what kinds of involvement with the affected person might be contingent on that person’s behavior. When the person is doing something positive (not using alcohol or drugs, or taking medications as prescribed) then the family adds support:

  • Help with problems in living.
  • Sharing a family dinner.
  • Etcetera.

The best contingencies are ones that are not financial. The help should be access to resources and problem solving more often than money. Working out these contingencies is something that usually requires professional support.