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Hayley: Hello everyone. My name is Hayley. And this is another episode of “Straight Talk with the Doc,” a podcast that takes a real look at addiction, mental health, and treatment. I’m joined today by our content director Jeff and our medical director addiction medicine specialist, Dr. Bhatt. Dr. Bhatt, how are you doing today?
Dr. Bhatt: I’m great Hayley. Thank you. How are you doing?
Hayley: I’m doing good as well.
Dr. Bhatt: Jeff we don’t want to leave you out. How you doing, Jeff? Sorry Hayley before we start. Jeff you doing okay?
Jeff: I’m fine, now. You know, now I’m fine.
Dr. Bhatt: Okay. We don’t want to leave you out.
Hayley: So, Dr. Bhatt you’ve worked with many patients over the years who are struggling with different addictions and you’ve helped create treatment plans for these individuals, but anyone who knows someone with a drug or alcohol problem knows that it’s not just the individual that is affected the close friends and the family of an addict can have their lives turned upside down when someone they love starts abusing drugs and alcohol.
So this episode is for them.
Dr. Bhatt I’d like to talk to you today about how family members can offer support without enabling their loved one. And you know, when it comes to treatment what can the family do? But first I want to start by asking you about the signs of substance abuse, to look out for? If someone is listening to this and they suspect their spouse for example or their child is abusing drugs or alcohol, what kind of changes should they pay attention to?
Dr. Bhatt: Sure. You know, I think that question is kind of unique to where somebody is in their life span. If we’re talking about a teenager, let’s start there. When we first see somebody who may be starting substances so we’re not talking about an established person who is suffering with maybe a substance use disorder. But somebody who has never used before but is starting to develop you know risky usage. So, oftentimes adolescents start to experiment, and we see them declining in school. So often school performance starts to change, it is a big sign. Often if the child or adolescent starts to isolate more, they’re becoming more secretive or staying in their rooms. Many times if they become very temperamental, irritable, or angry, you see a lot of mood changes. And, you know, being absent or not coming back on time. And, you know, just changing a pattern of being certain responsibilities towards your family. Again, we’re talking about teenagers, hopefully they’re going to school.
So if you see somebody with some drastic mood changes and changes in hygiene, appearance, maybe not keeping up with their, going to take a shower or staying in their room for hours at a time. These are all signs that something’s going on with these individuals. That can often be present when somebody starts to use.
Secondarily is when we’re talking about somebody who might have an established substance use disorder. These individuals probably have been recognized obviously by people around them and similarly, but in just a different stage in their life, if somebody starts again to behave erratically, if they start to stop keeping the responsibilities towards their family, towards their jobs. If we see money or objects, sometimes if they need it to use to buy drugs, but that are not accounted for. And again, probably periods where their mood is changing, where they look sedated, or they look like they’re on something that could be elevating them. So mood changes, behavioral changes. These are often hallmark signs that somebody has started using again,
Hayley: You mentioned some physical changes, like reduced hygiene. Can you kind of explain, why does that happen? Why would abusing drugs or alcohol, do that to somebody?
Dr. Bhatt: Yeah. I mean, that’s a good question. It might sound obvious that, when we’re using something that’s changing the way we think that’s altering our mind. When somebody goes from using to full-blown addiction, there’s an evolution that’s occurring here. Our brains’ motivational mechanism, our reward mechanism, the things that we hold in higher priority, they start to get altered. So our hierarchy of things that are important to us change. Pursuing now the drug becomes priority number one. What suffers there is the importance or the recognition of the importance of other things that we might recognize when we’re not suffering from addiction. Like keeping basic hygiene, worrying about the way we look, worrying about the way we smell, worrying about things that might belong to say, self care. But unfortunately, when you suffer for something, that’s kind of hijacked your mind and the way you think, and it’s artificially inducing the way you do anything in life, the way you look, the way you dress and the way you take importance about your self care is neglected.
So, yeah, that’s a, that’s a big thing, but you know, so many other things can happen, not just, with hygiene. A lot of times it’s more their mood, the way they react, the way they feel defensive, the way that they get angry quickly, or sustained periods of being elevated and high and energetic. There’s this physical component and then there’s this behavioral and an emotional component that need to be looked out for.
Dr. Bhatt: Sorry, just to add one last thing, then there’s some more signs that people might be using IV drugs. You might see things on their body, you might see, an injection mark and bruising. Sometimes these are not very obvious because people can cover them up. Those are other things that you need to look out for.
Hayley: Yeah. I’m curious, are there certain substances that are easier to hide. This could be someone that you live with. You might sleep in the same bed with them every night, but are there certain ways that they can hide things? Are there other drugs, for example, that the use is more obvious?
Dr. Bhatt: I mean, it really depends on how savvy and what access somebody has to what drugs and to what degree they go to hiding it. You might be an alcoholic or somebody who has an alcohol use disorder and, you know, where are you going to put your bottles? Where are you going to put your six pack? We’re going to put it. These are not things that are easy, you can hide cause they’re, they’re larger. But if you have done it for a while, you can find ways to put these things under your bed. Where maybe your spouse or loved one might not look or your parents. You can put them inside the toilet. There’s so many different ways. I don’t want to give people creative ideas of where they are at. But at the same time, people come up with very ingenious ways. But I think pills and smaller things are easily hidden because they’re smaller.
So the smaller something is that’s used, is often easier to, you know, people put them in places in their, in their cigarette packs and anywhere. In between their mattresses, they put them underneath their car seats. There’s so many different places. People hide things, they switch labels and bottle. It really takes somebody to start to recognize pattern change to be very keen on that recognition. So, again, that’s not the easiest question to answer because it really could be anywhere that somebody finds a place to hide that they think that somebody who might be looking won’t look. And, I think that can be basically anywhere the person, finds convenient or knows that somebody won’t look or hopefully won’t look.
Jeff: I was going to ask, I mean, obviously some signs and your symptoms are going to be I guess more obvious than others. Like if someone has like track marks on their arms or legs, that’s probably pretty significant evidence of intravenous drug use. Similarly if you actually find an illegal substance that’s pretty, strong evidence as well. Are there any other major signs that would be easier for people to pick up on, that might show stronger evidence than some others?
Dr. Bhatt: Yeah. I, do believe track marks or the IV injection marks, those are big ones. if you don’t have a medical condition to be sticking a needle in you, I mean, that is… Because people tend to repeatedly use, often the veins where they’re injecting, tend to collapse. They have to use multiple other areas in their body. So when you see these things up here, on your ankles, your feet, your legs, your arms, all over the place, your neck. These are things that are pretty, I don’t want to say patho pneumonic. But usually this is pretty clear that somebody is using an illicit substance, that they’re, shooting it. Versus sometimes people who are drinking, you might not notice it right away until that person becomes pretty intoxicated and because people tend to develop a certain level of tolerance. So things that are ingested through their mouth, you might not see those signs under external body. Those things I think will be hidden, easier. But things that need to be injected, become more obvious and are often more significant cause they’re entering your bloodstream quicker. They can have a very more deliberate effect versus something that you have to ingest to your mouth, which has to take time to pass and get absorbed. So, I’m not trying to associate negative necessarily lethality to the route that you use. Because if somebody takes fentanyl orally, which is a very potent substance, they can overdose and die very quickly and that’s not being shot. But just to answer your question. Yeah. Things that are more evident on your physical body, obviously on your skin, you’ll see these changes. Yeah. That’s more pointing towards somebody who’s using these injectable drugs.
But then behavior. Again, we’re talking physical signs. that way, but looking at somebody’s behavioral change, that’s a big one. If you’re used to seeing, your son or daughter or husband, or wife, or anybody behaving a certain way, and all of a sudden you see a pretty significant pattern or change. I mean, you need to ask why what’s going on? And if these people don’t have a good explanation or seem out of the ordinary, especially if, you know, they’ve had a substance use disorder or they’re adolescents, which are big risk periods, you should be, concerned about, substance or alcohol use.
Hayley: And you mentioned earlier about the behavior changes. Somebody just suddenly being angry, with their loved one. How does addiction change the brain in that way? To cause somebody to be angry towards their family member, who is really just trying to help?
Dr. Bhatt: You know, that that’s a little bit complicated, because we don’t know what underlying resentment or issue that somebody might have towards a specific family member. But let’s just look at one example, taking alcohol. Now, alcohol is a sedative. And it, basically, suppresses, depresses, the brains function. So if we look at one part of the brain, which is the frontal lobe of our brain, which is a very highly regulatory component of the way we behave and the we think. It controls things Iike: impulse control, planning, organizing and it can control the way we inhibit ourselves from acting a certain way. When we use alcohol, for example, it can actually block that regulatory mechanism that that frontal lobe of our brain has, and then actually can do the opposite. It can disinhibit us, so it can make us, instead of the control part of our brain being intact. Now, the alcohol is basically blocked that from functioning. So we’re out of control. And these people now, the emotions and the behaviors that are normally regulated are now unregulated. So these people tend to get a lot more, they can become aggressive or they can become angry and irritable when the more likely would be able to regulate their emotions.
But also, in anger, there’s a defense mechanism going on, right? Many people are so sensitive about their substance use that they basically will project it out on somebody else, try to blame the other person. Trying to distract them from their own use or give them a reason that is substantiated enough that says, “Hey, you know what? I have a reason to use. And they put that blame, project that anger out onto somebody else and say, “It’s your fault and that’s why I have to use.” So a lot of it has to do with, the drug, having certain effects on your brain that can make you, act physiologically, a different way. But then there’s also that psychological component that the mind has to have to often rationalize and justify why we have to use. And that often incorporates a lot of defensibility towards the substance use.
Hayley: Okay. That makes sense. So I want to talk about a term that I think most people have heard, which is being an enabler. But what does that really mean? What does it mean to enable somebody?
Dr. Bhatt: You know, we use that term all the time. I don’t think I’ve really like defined it like that,. But an enabler, basically is somebody or a behavior and action, a dialogue that negatively reinforces somebody’s substance use or addictive behaviors. So it’s, it’s like an inadvertent action that unfortunately, maybe intended to reduce someone’s substance use, but unfortunately enhances their usage.
An example could be, if I am the parent of a teenager who I know is using alcohol. And I know every time this teenagers going out, he might get into fights, might get into trouble, might try and take the car. We’re afraid he might get into an accident or get some legal consequences. So I kind of offer that teenager, “look, let me buy you a six pack, but stay home and drink. So, you know, you can use at home.” So you’re basically trying to take away the negative consequence of getting into a fight or the legal action, but you’re actually giving that person what you’re actually trying to have them not do in the first place, which is use alcohol. And that is enabling them to consume, but in your house. So you’re trying to avoid one consequence, but unfortunately, reinforcing the behavior that you’re trying to stop in the first place that’s causing those consequences. Those are enabling type behaviors.
Hayley: Okay. And I think a big issue too, is also people, giving money to somebody. Say somebody is spending all of the money that they get in and they’re spending that on drugs. And now they tell their family, I don’t have money for food and their family is giving them more money. How can that be detrimental? Because the family member might hear that and be like, “Well, I need to help them. You know, I need to support them.”
Dr. Bhatt: Yeah. I mean, when you love somebody, you succumb to guilt and responsibility that you may have towards them. This is a very big dynamic that’s involved. And you just mentioned it. You’re giving somebody money to, hopefully they can care for themselves. But when somebody is addicted, they’re not necessarily looking at the best priority or the best ways to take care of oneself. Their mind is focused on using a drug or alcohol. And so unfortunately, even though the intention is there to hopefully maybe pay for their rent or pay for their food, when somebody, unfortunately suffering with substance use disorders, they’re not thinking straight. They’re going to use that money in the wrong way. They’re going to go and pursue more drugs or alcohol. And so detrimentally, when you’re using in those negative ways, those negative ways and the consequences will continue. It’s a difficult thing to do because we feel the need to help, but having it without certain checks and balances can unfortunately lead to just further perpetuating the substance use disorder.
Jeff: I was going to add, a lot of, a lot of, other behaviors that seem well intentioned, like defending someone who’s using or constantly helping them avoid consequences for their actions can often have the opposite of the intended effect. It can also enable drug use and alcohol use a lot as well.
Dr. Bhatt: Yeah, you’ll see that a lot. We kind of explain it in a way that we can talk bad about our family, but we can’t have anybody else do it. And that is unfortunately, because we’ve become in a way codependent to these negative behaviors. And when I use that term, I’m talking about us having this unfortunate dynamic where we are also somehow psychologically behaviorally involved with the substance use and the individual who’s abusing the substance. But we are trying to correct that course. But when somebody from externally tries to point that out, we will often defend that in an attempt to deny that the problem actually exists. So we also as family members and loved ones, have defense mechanisms. That denial is almost a protection that we, we want to minimize the occurrence. But unfortunately if that’s done in front of that other person, yes, again, it’s another negative reinforcement. If that person who we’re trying to have stop use is hearing this message it’s definitely a mixed one for that.
Hayley: So in what ways can somebody offer support, but without enabling them?
Dr. Bhatt: I think sometimes family members go to these extremes and it’s hard. There’s no rule books here. I think a lot of people tend to say “we try to, you know, put a script together of this is how you can or cannot behave.” You know, although yes, addiction is a, a brain disease. There’s such a huge, psychological and behavioral component to it that it takes also psychological behavioral reactions and actions to assist those individuals who suffer. So, first of all, I think recognizing addiction as it is, not necessarily a behavioral disorder or a problem with weakness and, not just thinking you can talk one, talk them out of it and understanding that it is a brain disease. So one is a family member should try and intervene and interact when you think that they’re in their clean clearest state. That’s not often easy if somebody is using all the time, but maybe while they’re fully intoxicated, might not be the time to try and rationalize with them. And I think that often is something that, doesn’t work and going from fully enabling them to just mitigate, the buzzing in the ear, because of all the arguing and the fighting and the complaints and the blame, sometimes people will give in and just give in to shut that person up. But at the same time, giving and giving and then turning in, “I’m not giving you anything.” So there’s an extreme of fully enabling or fully shutting somebody out. And I don’t think those two polar behaviors work. I think it’s hard because, people end up trying to be so good that they feel like, I gotta do this tough love.
To answer your question, you got to kind of catch them at the right time and the right place in a graded way, that can help. And it could be as, as simple as starting to not enable as much. Opposed to totally abandoning that human being. It also could be, supporting that person and empathizing with them and understanding what they’re going through instead of like maybe shaming them and guilting them, but understanding that they’re going through a difficult process. I think one of the things that anybody wants to know is that the other person is trying to be understanding and open-minded, and is trying to put themselves in their shoes. So you want to develop that, opposed to that animosity and those negative feelings. Also, if we are going to the extreme, there are many States that have, involuntary commitments.
So having the law assist them. Cause if somebody is using to the point where it’s such a significant detriment, and I’m not going to spell this out specifically because each state has its own laws regarding involuntary placement for people with substance use. But these are things that somebody can do to intervene when people are using to the extreme. Where, you know, it’s going to kill them or hurt somebody else. And then along the way in the middle, you can get somebody like an interventionist to help. These are professionals, these are often people in long-term recovery themselves who have trained to come and speak with the individual to help. So there’s a spectrum. I guess what I’m advising is not to go from one end to the other, but try and meet the patient where they’re at.
Jeff: I wanted to add a little point for that. You mentioned like different States have involuntary commitments for drug and alcohol use. I know that is often kind of controversial for a number of reasons and a lot of people don’t like to take that step. But there are very few people who want to go to rehab. The vast majority of people who do go to rehab, for example, do so because they were given an ultimatum by their job or their family, or the law, that they had to go. The reason inherently why you go for treatment does obviously matter, but at the end of the day, if someone’s substance abuse is putting their own life or other people’s lives at risk, that is a step that a lot of families do have to seriously consider.
Dr. Bhatt: Yeah. And so let me kind of clarify on Hayley’s previous question. When I was talking about interventions or when we’re talking about steps about enabling. I was kind of giving that scope. But absolutely, if the person through whatever means is able to get into treatment, which we ultimately, hopefully will want, just like for any medical conditions we want to get them professional help. They have to be willing to go. That was the part, if they are not and if those options exist. But if somebody can get in, for whatever reason, if it’s mandated, if there’s something being held over their head, if they’re in terms of, you know, a job loss or family will not speak with them, that is unfortunately the motivating factor for people to get into treatment.
It’s ironic, but at least those things give that person opportunity to get some clarity and break that cycle. It’s over many people that are resistant to getting that help. Yeah. You know, we talk about people having to hit rock bottom, where they have nowhere to go, or nobody’s support them, no means to eat or buy drugs. They often will seek out treatment. But even those which might be seemingly negative, those are positives because the minute you into treatment, your brain is starting to heal, the minute drugs or alcohol are removed. I don’t think it’s ever too late. If somebody’s got a terminal condition due to their substances or it has unfortunately damaged your body so much. But you know our bodies and our minds are very resilient.
And I’m not giving this as hope for people to continue using to the extreme. “Hey, you know, Dr. Bhatt said, you know, our bodies are resilient.” Cause people who are unfortunately addicted will use anything to continue to use. But the point is yes, getting into treatment for whatever reason is going to help these individuals with that moment of clarity. But that should be the earliest goal. Hopefully, in a voluntary manner without having to take long or get a legal mandate to have them go.
Hayley: For kind of my last question. Say someone does go and they complete treatment, and they’re early in their recovery. How, as a family member or a close friend, how do you offer support?
Dr. Bhatt: Hopefully if they’ve been in treatment, the treatment center or the program that they’re going to… and when I’m saying treatment a lot of times it could be outpatient treatment or inpatient treatment. Hopefully, the treatment component has involved the family in the first place and educated them on specific things. Such as supporting that person in terms of not having drugs or alcohol themselves in front of them. Which is often a difficult time, a difficult thing for loved ones to do. And I’ve been to so many family meetings where the patient suffers from an alcohol drug use and yet the family’s still smoking or using marijuana. They might think it’s benign or drinking in front of them and they need to understand that they need to try and create a recovery environment for that level.
So one of the things to point out is please don’t put these negative triggers in front of them. And that’s often hard. Number two is not shaming and guilting these people. If they do end up lapsing a little bit, or maybe start to, don’t make it look like as a tremendous step back. Hopefully we’re seeing that this disease does have periods where people will relapse. But that doesn’t mean that the family should look at it as a loss or a weakness in any way. And the patient should also recognize that doesn’t mean I need to have a full-blown run because things happen in anything.
Just like if somebody who suffers from diabetes has to watch their diet. Sometimes they’re not going to eat, what’s instructed by the physician. So things can happen with addiction similarly. But I think we look at it in such a negative way. “Oh my God, he relapsed.” Well, yeah, it happens, but let’s get them back on track.
Another thing is getting them in support groups. I’m not advocating for one specific philosophy, but support groups and getting them around sober people who are living a good recovery. Living life in recovery and are not using really helps people feel connected. People who suffer from any disease like addiction or anything else, they want to feel like people understand them and who better than understanding that people who are progressing in life with an illness, in a successful way. So encouraging people to attend support groups.
Also if there’s any medication or other medical treatment that’s been prescribed ensuring these people are taking them and encouraging them to do so. Cause oftentimes if people are using for treating their own medical conditions or psychiatric conditions. By not be taking those meds or maintaining them you’re just increasing your chance to use drugs and alcohol maybe to self-medicate. These are important factors.
I use an acronym called TEAM. T for the family and the patient needs to ensure that after they’re discharged or after they complete treatment, they’re getting the right therapies that were advised. Either individual, family, or behavioral therapies. E for encouraging the proper environment drug-free, pro-recovery, and proper support groups. That leads to A like alcoholics anonymous or narcotics anonymous, those, peer support groups. And M, the last letter in team, medications. If you think of that global holistic concept and working at it together without shaming or guilting and individual, you are at least on the path for, enhanced success.
Hayley: Absolutely. I think that that’s a lot of advice that people can really take hold of and practice. Especially during the holiday season, when families are gathered. There’s often holiday parties going on, people are drinking. You know just be aware of what your loved one is going through right now.
Dr. Bhatt: You mentioned that. It’s a very important point right now. The holidays are a huge time where families are setting themselves up for certain expectations. We expect a lot from those who are suffering with addiction and those who aren’t. Its an idealized time where society reflects upon it as it has to be somewhat perfect. There’s a lot of stress involved. There’s a lot of people who haven’t seen each other for a while. There could be a lot of resentments that may be held and, you mix that with drugs or alcohol ,often that’s a recipe for disaster. Yes, this is the most important time that, people should be looking out for. Because yes, it’s a time to rejoice and celebrate, but at the same time, people suffer with substance use disorders. It’s a very vulnerable time for them, because of all those factors. Just celebrating people often say, “Hey, I’ll have a drink today. I’ll have a toast at family dinner. How often do we get together?” And, that just opens up, a really difficult situation. It’s bad enough with all those tensions that are there. Even though it’s a period where we should be rejoicing and having a good time and celebrating. But when you mix substances that, disinhibit you or release you or create artificial emotions that just unfortunately complicates the whole situation. So yes, it’s a very sensitive time and everybody needs to look out.
Hayley: Absolutely. There are a lot of great information and resources online, if you’re not sure how to interact with a family member who is in recovery and you can look that up and get some advice before you head into the season. You’ve got a lot of resources for families on Addictioncenter.com. So you can check those out. There under the information tab. We also have our other podcast episodes up on the site. So make sure to check those out. To Jeff and Dr. Bhatt, thank you again for joining me today, and thank you to those who are listening to another episode of Straight Talk with the Doc.
Dr. Ashish Bhatt
Throughout his career, Dr. Bhatt has been a leader in substance abuse treatment programs, including administrative and medical directorship positions for inpatient and outpatient programs, detox units, and inpatient residential dual-diagnosis facilities. He is a Board Certified Diplomate of the American Board of Psychiatry and Neurology in both Adult and Child and Adolescent Psychiatry, a Certified Medical Review Officer, and is Board Certified in Addiction Medicine. He has served as the Chief Medical Officer for regional and national behavioral health companies and worked to develop public and private substance abuse and dual diagnosis facilities.
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