How to talk about someone’s substance use

K Michelle Peavy

is a licensed clinical psychologist and research scientist at the Addictions, Drug and Alcohol Institute (ADAI) in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle. She also has a private practice specialising in treating individuals with substance use disorders, as well as supporting family members of people with SUDs. She lives in Seattle, Washington.

Edited by Matt Huston

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Need to know

Has someone in your family started drinking more heavily? Or maybe you suspect your teenager is using drugs. Or you see your friend’s occasional cocaine use escalate. You wonder: Should I say something? If so, what? Perhaps you have already had conversations with someone in your life about their substance use, and those conversations might have ended in arguments and bad feelings. No single conversation is likely to change another person’s behaviour but, if you are a family member or close friend of someone who could be struggling with a drug or alcohol problem, you might be in the best position to support that person and encourage them to pursue change.

Many people who want to talk with someone about their drinking or drug use approach the situation in one of two ways – they ‘come in swinging’ with advice, information and mandates, or they don’t say anything at all. Neither of these approaches is likely to help the other person. But both are understandable given that: people are not taught skilful ways to have these conversations; we might worry about miscalculating someone’s substance use, risking offending or pushing the person away; substance use disorders are highly stigmatised, making the topic even more sensitive; these conversations can be awkward and negative; and the stakes feel especially high for family members and loved ones.

What you can do instead, if you see evidence that substance use is hurting someone you care about, is approach with kindness and curiosity. You can start a conversation, get the person thinking. You can provide a safe space for the other person to explore change.

In this Guide, we will take some cues from a form of specialised counselling for the loved ones of people who misuse alcohol and drugs, called Community Reinforcement Approach and Family Training (CRAFT). Studies on CRAFT show that family members who undergo this training are more likely to see their loved one seek addiction treatment or reduce their substance use than are those who don’t do CRAFT. What follows are some key ideas from CRAFT, as well as other guidance drawn from research on what actually motivates people to seek treatment or change their use. First, let’s take a more detailed look at what doesn’t work:

Silence and secrecy. ‘It’s none of my business.’ ‘I didn’t want to start another fight.’ ‘I wasn’t sure if it was really a problem or not.’ People stay silent about others’ drug or alcohol use for all kinds of reasons. But if you are genuinely concerned about another’s behaviour, speaking up is a loving way to respond. Not saying anything (or repeatedly covering for a person’s substance use) will, at best, limit how impactful you could be. At worst, silence provides tacit approval for behaviour that could be unhealthy for the person you care about.
Cutting the person out of your life. Like silence, avoiding or ignoring a person who has a problem with drinking or drug use means that you’ve given away your own ability to have any influence on that person. But, perhaps more importantly, cutting the person out of your life might leave them without the support they need when they want to make difficult changes.
Nagging. Many parents have goaded their kids since toddlerdom about whether they’ve brushed their teeth, have a warm enough jacket, or packed their water bottles. Needling people about their substance use may be just an extension of relationship patterns established over many years. Instead of ‘You’ve got to do your homework! Don’t you care about your grades?’ it’s ‘You can’t keep drinking like this. Don’t you care about your kids/health/job etc?’ Seems like a logical approach to take, but it doesn’t work. That is, nagging doesn’t compel kids to want to do their homework, nor does it motivate people to want to change a complex behaviour such as substance use.
Yelling. Watching someone make repeated, illogical decisions is frustrating. Not only can you get caught in your own emotional heat, but you might also think that yelling will scare the person into changing, or at least demonstrate how much damage their behaviour is doing. We want people to reflect on their drinking or drug use. But yelling at them creates an environment that makes self-reflection near impossible.
Shaming. Trying to make someone feel ashamed of themselves can really backfire. When people feel shame, what do they want to do? Hide. How do people who have a substance problem like to hide? Substance use.
Punishment. If your focus is to increase the other person’s suffering in order to ‘teach them a lesson’ or ‘make them change’, you have adopted a punitive stance. It’s common and even understandable to reach for punishment as an option. Nevertheless, decades of research have shown that, while punishment may decrease unwanted behaviour in the short term, it usually does not get people to make long-term changes. Worse, it could backfire and have serious consequences for your relationship.
Intervention-style ambushes. The US reality TV series Intervention (2005-) popularised one approach to dealing with a loved one who has a substance use problem. The show used a variation on the Johnson Model of intervention, which involves gathering a team of concerned family members, planning a confrontation with the person whose drug use or drinking is a concern, and providing the person with a forced choice of seeking treatment for their problem. Research indicates that this method often does not result in change. It’s empathy that creates an environment in which people can explore their situation and move towards change. Research aside, we can ask ourselves what our own response to coercion is. Resentment? Hostility? Avoidance? Most of us don’t respond well to being told what to do in a confrontational way.
Simply providing information about the harms of substance use. It’s natural to want to pull back the curtain and reveal why drug use and drinking can be unhealthy or harmful. Here, the assumption is that people are making decisions without the proper information. But many people who struggle with a substance use disorder are intimately aware of the problems associated with their use. In fact, using drugs or alcohol despite negative consequences is a symptom of a substance use disorder. And it’s an experience that people feel a great deal of confusion, fear and shame around. In my clinical practice, people who misuse drugs or alcohol often express painfully: ‘I know using is bad for me, but I do it anyway.’

As a clinical psychologist, I’ve worked with family members who desperately want to change their loved one’s alcohol or drug use and, upon learning what doesn’t work, I often get the question: ‘What else can I do?’ The answer is: a lot! Sometimes our habits of negative communication and non-communication get so ingrained that we fail to see all the ways that we can engage and be there for someone with a substance problem.

Before we get to that, it’s important to consider expectations. What do you hope to get out of a conversation? What’s even possible? If you expect that one conversation will get the person to ‘realise’ that they have a problem and stop using, you’ll probably be disappointed. It is certainly possible for people to develop awareness about their substance use and to approach change, but it could take many conversations and possibly other actions on your part. For the initial conversations, it’s reasonable to think that you might better understand the person’s desires and motivations related to their drinking or drug use, and to plant the seed of change. To begin this process, consider the following strategies.

What to do

Express your concern and be curious

If you have avoided talking with someone about their drug or alcohol use, try opening the door. Timing is important to consider: conversations about a person’s substance use are best done when things are relatively peaceful, and neither person has been drinking or using drugs. Use your best judgment, based on what you know about the person, in deciding when, where and how to start the conversation. Is the person more comfortable at their house or in a public space? Does it make sense to set aside a time, or would that seem too formal and stilted? Might the conversation start with a text or note, to be followed up later?

People who receive communication training or go to couples therapy are often told to use ‘I’ statements. The idea is to talk to the other person from your own perspective in order to avoid blaming and evoking defensiveness. The same applies here. Your initial statement on the topic could be as simple as something like: ‘I’m worried about your drinking/drug use.’

Alternatively, or additionally, you could engage in a more in-depth conversation about the person’s substance use in a curious way, with the intention of understanding their experience. Questions like: ‘What do you like about drinking/using the drug? What do you get out of it?’ get at what underlies a person’s substance use. Understanding their motivations can help you summon compassion, which ultimately helps create a safer space for the exploration of possible behavioural changes. (See the Learn More section below for a way of considering the functions of someone’s substance use in detail.)

Perhaps you’ve already tried starting the conversation and the person left the room, made jokes, refused to talk, got impatient or angry, or used other signals that said Nope, don’t want to talk about this. Try not to be discouraged. Most of us want to avoid topics that feel annoying or uncomfortable to talk about. These are good moments to summon empathy and to decide what’s next. You might make an understanding comment like: ‘These things are hard to talk about.’ Or: ‘I know this makes you uncomfortable, but I brought this up because I care about you.’ A bit of humour or playfulness might fit here, and a ‘thanks for hearing me out on this’ never hurts. You might choose to drop the conversation right then and there with the intention of picking it up again later. Pat yourself on the back for trying, consider what went well, and think about how you might approach the next time. Just like any skill, these conversations get better with practice.

Ask what kind of support will promote change, and offer it

Here’s something you can do: offer support. But what does ‘support’ even mean? People often think they know what others need in terms of their substance problem: treatment, ‘hitting bottom’, cutting off contact with the ‘bad kids’, and even ‘realisation’ (ie, ‘They just need to realise what they’re doing to themselves!’). When we offer the kind of support that we assume others need, we might have good intentions. So good that we are paving our way to hell with them, as the saying goes.

The truth is, the best kind of support is the kind that the other person will accept. You might have some really great ideas about what they need, but only they know what they’re willing to do and what kind of support they want from you. And the way to know what that support looks like is to ask directly: ‘You’re in the best position to know what might help you make changes, but I’m here to help. What do you think would be helpful right now?’ Or, simply: ‘How can I support you?’ Examples of support you can provide might include researching professional help options (eg, therapists, prescribers, formal substance use disorder treatment), checking insurance benefits to understand what kind of services are covered, or providing accountability for the person as they try to cut down or quit. If someone is not ready for these steps, you can be a listening ear, help them clarify their substance use goals, or engage in activities with them that do not involve drinking or drug use.

In addition to offering support, consider that you yourself might benefit from support of some kind. In other words, it’s important to take care of yourself. If you’ve lost touch with hobbies or friendships or avoided events, perhaps because of a loved one’s substance problem, reconnecting with these things will help you feel better – and possibly enable you to better support your loved one.

Stay connected and set limits: you can do both

Staying connected to someone with a drinking or drug problem is strategically important – it allows you to keep the conversation going and provide needed support. For some people, staying connected might mean sending sporadic text messages, maybe making an occasional phone call. For others, staying connected means providing stable housing or other resources to someone with a substance problem. There’s a universe of options, and the ones you choose will depend on your own comfort and limits.

Maintaining the connection does not mean you’re ‘enabling’ substance use. You can both stay connected and set loving and firm boundaries consistent with your expectations of people you care about. You don’t want to delete someone you love from your life, but you need to maintain the relationship without compromising your own wellbeing.

What limits do you want to set in your relationship? You might notice if you’re doing things that you feel resentful about later, like cleaning up messes (literal and figurative) that resulted from a person’s substance use. Your limits are highly personal, and worth thoughtful consideration. For one person, setting a limit is refusing to be the ‘alarm clock’ for a roommate who otherwise would show up late to work after a late night of partying. A parent might leave the wreckage of last night’s drinking adventures for their teenager to clean up. Another parent might stop letting their adult son borrow money because it’s clear that the money is used to buy drugs. The sibling of a person who struggles with alcohol might insist on hosting family gatherings in order to ensure that no alcohol is present. In a different family, a sibling might refuse to host family gatherings, to ensure an easy escape from a sibling’s ‘drug talk’.

It can be tricky to consistently apply limits. But it’s unfair to the other person if you set a limit, don’t hold to it, and then blame the person for blowing through a limit that you did not uphold. Once you decide on a limit, it’s important to communicate it and stand by it consistently.

Affirm the positive

Our brains have a natural bias towards the negative, which simply means that we tend to notice and focus on the things that go poorly more than the things that go smoothly. For example, you might notice when clothes lay strewn across the bathroom floor, but not when they’ve been folded neatly and put in drawers. In a similar way, you might notice and feel anxious about a person’s drug use or drinking, but fail to notice the signs that they are attempting to make changes.

You can tune your antennae differently and start noticing the behaviours that you want to see more of, such as help-seeking of any kind, attempts to limit drinking or drug use, or any statement indicating a desire to change. You can notice and then affirm the positive you see in the other person: ‘I know you started taking medication for your substance use. That’s a great step toward change.’ You can also notice when they do things that might ‘compete’ with substance use. For example: ‘Thanks for coming to Claire’s gymnastics practice today. We love it when you’re here with us.’

Positive statements like these not only reinforce these behaviours, they decrease the likelihood that the conversation goes sideways. Consider how a loved one might react to the statement: ‘You always choose your partying friends over us!’ Regardless of how true it feels, this statement could shut down or fire up the other person – either one leading the conversation into unproductive territory. Negative statements can elicit defensiveness, avoidance and snide retorts. Positive statements can elicit surprise, curiosity and an open conversation.

Adopt a hopeful stance

I believe that people have a natural inclination to move in the direction of growth and positive change. Sometimes that inclination is shrouded in the chaos of drug or alcohol use, but I continue to believe it’s there. When we hang on to such hopefulness, we feel more agency and optimism. This is helpful in our own lives, and it could be helpful for someone who might feel hopeless in the face of a substance use disorder. You can make statements that acknowledge the challenge of change, but that also communicate hope: ‘It’s hard to go down the pathway of making healthier decisions, but people change. You can too.’

Talking to people about their substance use can be awkward and tense, and may evoke many negative emotions on both sides. Sometimes you have to keep trying. You might have one conversation that goes off the rails. No problem! Consider a less-than-ideal conversation an opportunity to practise for next time. You don’t get just one chance. This is the beauty of not doing a confrontational ‘intervention’ where everyone hangs their hat on a single encounter. Keep talking, keep trying.

Key points – How to talk about someone’s substance use

Common responses to someone’s drinking or drug use are often unproductive. Silence and avoidance are not likely to help a relative or friend change their behaviour, nor are shaming, punishment or dramatic confrontations.
With kindness and patience, you can encourage change. Helping someone address their drug or alcohol use can involve many conversations. But you can start by seeking to understand the person’s behaviour and planting the seed of change.
Express your concern and be curious. A statement such as ‘I’m worried about your drinking/drug use’ can open up your conversation, which might also include asking about why the other person uses the substance.
Ask what kind of support will promote change, and offer it. It might be help with finding professional care, providing a listening ear, or other forms of support – see what the person thinks would help them make changes.
Stay connected and set limits: you can do both. Keeping in contact with someone who has a drug or alcohol problem can be invaluable, but it’s still important to decide what you will not do, and stand by it.
Affirm the positive. Offer reinforcement by noticing and acknowledging behaviours that you hope to see more of, rather than just the behaviours that cause you worry or disappointment.
Adopt a hopeful stance. Communicate hope about the possibility of change, treat awkward or challenging conversations as practice for the next one, and keep talking.

Learn more

Understanding the function of substance use

It’s easy to focus on the destruction that drinking and drug use can cause: the relationships ruined, responsibilities not attended to, money lost. But most people with a drinking or drug problem don’t go around purposefully making decisions to hurt people or slough off responsibility. In fact, many people with substance use disorders have immeasurable shame and guilt about how their use has affected their relationships, their health and their work.

People use drugs or alcohol because these substances serve a function in their lives. And we can’t really understand a person’s substance use until we understand its function. In certain types of behavioural therapies, therapists use a tool called a ‘functional analysis’ with their clients to help them understand their own behaviour. In CRAFT, a functional analysis can help people understand their loved one’s substance use. To do a functional analysis, we look objectively at: 1) the behaviour (substance use); 2) the triggers for the behaviour; and 3) the consequences of that behaviour. We put on our scientific or detective hats, and ask a number of questions to uncover the whole picture.

As an example, let’s say you’re trying to better understand the alcohol use of Anne, who was always a fairly heavy social drinker, but whose alcohol use seemed to increase dramatically early in the COVID-19 pandemic. It’s not just the increase in alcohol use that’s troubling. Anne took an extended leave of absence from work, then never returned. She’s been calling on the phone, seemingly alcohol-affected, at odd times, including in the morning. These phone calls are difficult, as Anne unloads her problems and is highly emotional.

Let’s go through the steps of a functional analysis of Anne’s drinking behaviour. This involves asking a series of questions. As with any writing exercise, it helps to actually engage in the writing process instead of just doing the exercise in our heads. We can use a structure like the one below, adapted from the book Motivating Substance Abusers to Enter Treatment (2004). Actively writing out answers to questions like the ones posed in the functional analysis gets us to put ourselves in the other person’s shoes. We contemplate what it might be like to inhabit their experience, enhancing our empathy.

People who use substances tend to have substance use patterns; such patterns become clear to those closest to them. In fact, family and friends can have an enormous amount of knowledge about the person’s behavioural pathways. This knowledge and experience often makes answering the questions of a functional analysis fairly easy. We can usually answer many of the items, but perhaps you want to show your desire to really understand the other person. You can do that by curiously asking questions in a non-judgmental way, for example: ‘In your own words, why do you smoke pot?’ Or: ‘What’s usually going on when you make the decision to drink?’

Sometimes it’s easiest to start with the behaviour, which in this example is alcohol use, and then consider what comes before (triggers) and after (consequences).

Triggers

Internal: what thoughts and feelings is Anne experiencing before she starts drinking?

Thoughts: ‘I’ve already messed up my career. I may as well drink.’
Feelings: loneliness; shame; regret; anxiety

External: what are the cues for drinking?

Any work-related communication
Knowing that she will be home alone without interruption

Behaviour

How can I tell that Anne has been drinking? What time of day? Where is she and who is she with?

Anne usually calls when she’s been drinking, and typically she’s tearful or expressive of other emotions.
She usually calls late morning, between 10am and 1pm.
Anne drinks by herself, but wants to stay on the phone for long periods of time.

Consequences

Short-term: what does Anne get out of drinking? What is she looking for? What kinds of experiences does she get to have? What memories are associated with drinking?

Anne escapes isolation and achieves connection through alcohol use: she feels emboldened to make phone calls, during which she talks about her thoughts and feelings freely.
Through alcohol use, Anne has access to her emotions and can share them more easily, without the shame and anxiety she usually experiences.
Anne can avoid thinking about her job situation. She gains relief from her shame.
For Anne, drinking is associated with memories of feeling connected to other people while drinking.

Long-term: what are the negative outcomes of Anne’s use? What impact does alcohol have on her life?

Anne has more or less lost her job because of alcohol use.
Several of Anne’s relationships have been negatively affected because of the way she reaches out after drinking.
Anne has worsening symptoms of depression and anxiety due to her drinking.

Here, we see that Anne’s drinking seems to follow a particular pattern, is prompted by specific circumstances, and has reliable ‘positive’ outcomes (eg, connecting socially; escaping painful feelings), and devastating long-term consequences. Interestingly, some of the long-term consequences appear to feed back into her drinking cycles: alcohol use has resulted in alienation in her relationships (long-term consequence), and the resulting loneliness (internal trigger) prompts a desire to drink.

Understanding a pattern of substance use better can help you have compassion for a person whose behaviour seems illogical. Furthermore, looking at the ‘map’ of another’s drug or alcohol use reveals potential ways to intervene. With Anne, it’s clear that alcohol bolsters her confidence to reach out and open up to a degree that she usually wouldn’t while sober. Engaging with Anne on the phone when she has been drinking reinforces the drinking behaviour, and strengthens the link between alcohol use and positive social interaction. How could you undermine the alcohol use while still supporting Anne in getting her needs (for connection) met in other ways? You might choose to not answer the phone the next time Anne calls, undercutting the short-term effect of her alcohol use. As an alternative, you could let Anne know that connecting with her is important, and offer to schedule a time to do so when she hasn’t been drinking.

A functional analysis of someone’s drinking or drug use lets us see the behaviour more clearly, put it in its context, and understand the patterns better. With this knowledge in mind, we can proceed in an empathic and effective way.

Links & books

The Recovery Research Institute in Boston, Massachusetts presents information about addiction and recovery in an easy-to-understand, visually appealing manner. Their Guide for Family Members includes facts and recommendations for family and friends affected by addiction.

The Center for Motivation and Change (CMC) in the United States provides a number of resources for loved ones of people who use drugs and alcohol, including a 20-minute guide to their Invitation to Change programme. There’s one guide for parents and a separate one for partners.

Beyond Addiction: How Science and Kindness Help People Change (2014) is a book by CMC’s co-founders that provides guidance and hope to friends, families and loved ones looking to help a person change their substance use.

Helping Families Help is a CRAFT-based website offering resources for families struggling with a loved one’s substance use. Other CRAFT-based education and support websites offer membership of Allies in Recovery (for online videos and training) and the course We the Village (for online training, individualised coaching, and facilitated groups with other family members and loved ones).

The website Learn About Treatment, from my own Addictions, Drug and Alcohol Institute at the University of Washington in Seattle, has a strong focus on opioid and stimulant use disorders; the section for family and friends includes FAQs and further resources.