Someone you care about is drinking or using drugs. You can see many ways he/she is creating problems in his/her life and creating harm in yours. Whether they are your partner, child, sibling or friend you have stood by them as they have tried or refused treatment.

You may have left them, kicked him/her out (or considered it) begged, pleaded, bargained, been tough, been soft. You are still here because you love this person, fear for them, feel sorry for them or all of the above. But you feel defeated and weak. You experience profound helplessness, frustration, anger and fear. Today's optimisms induced by a new promise of never again is replaced by tomorrow’s disappointment when promises are broken. You end up with questions about loyalty, love, support and limits. How much help is too much? How many times should you cover up or lie for them? How many times do you unbolt the door to let them have a shower or a sleep or a feed? Should you give up hope of them changing, preferring family peace to fighting for change through chaos? You may have been told by experts that you need to stop enabling, to start practising tough love. You hope they'll recognise how they are hurting themselves and everyone else. The truth is people can only see what they are ready to see, and sometimes all you can do is sit back and wait.

Denial and hitting rock bottom
You may have learned that addiction is a disease and that only total abstinence with the support of the Twelve Steps is the treatment. You've come to believe that they must want to continue using or else all the trouble they've had would have convinced them to give up their substances. Their denial is so thick that only hitting rock bottom will motivate them to get sober. You've been told to stop bailing them out, cleaning up their mess, let them face consequences. Eventually they will hit rock bottom and sobriety will be possible and only with sobriety will come a better life. Having believed this you urge them into treatment. However in spite of the acceptance and popularity of abstinence-based treatment your family member has not got better. Despite the advice to abandon them you've loved them since they were born and the prospect of their death is too hard to contemplate.

Understanding how people change
So you've had it with promises and disappointments, exhausted by the fear and the suffering the substance abuse has brought, ashamed of their behaviour, feel terrible for those they've hurt. You've heard of being patient, coping and passive in the face of all this. You're tempted to take the advice, quit or get out. The problem is though, TOUGH LOVE DOESN'T WORK. It's also awful for everyone to put into practice. It is totally unrealistic to expect people to change complicated behaviours on the basis of an ultimatum. Any approach that limits you to an all-or-nothing choice ignores the reality of HOW PEOPLE CHANGE. People change in incremental steps, practising new behaviours and new ways of coping with life and feelings over time. The crucial ingredients to making lasting changes are understanding and support. When we expect immediate changes and refuse to be with the person during the process we undermine the very goal we seek to accomplish.

Separating a person from their behaviour
Understanding, however, does not mean that you do not set limits. You set limits with two-year-olds and you set limits with adults. The limits you are setting are on behaviours. Children need limits that protect them from traffic, fire, poison etc. Adults need different limits, e.g., you can't yell at me, I can't let you take all our money for drugs. It is more usual to separate a person from his or her behaviour. Spending all our money on drugs and alcohol doesn't mean we are stupid – we may be just overcome by need. Behaviours can be changed. Aspects of our personality can change. First of all we must have a basic sense of being valued to make it worthwhile to take care of ourselves. When we have children we give them unconditional love. As they grow, the older they get, the less we can expect unconditional love to exist between parent and child. Relationships become equal partnerships in which we have to earn love and respect even from our parents. This is normal and healthy. Once we grow up the only place we can get unconditional love or more accurately unconditional positive regard is from a skilled therapist. You are not your child's, partner's or friend's therapist. You don't have to provide unconditional love to an adult no matter how much they may need it.

Harm reduction approach
The harm reduction approach suggests that you undertake the same kind of balanced evaluation of different options for taking care of yourself that we have encouraged the drug user to undertake. To weigh the pros, cons and consequences of actions so that whatever actions you take reflect the complexity of the relationship with the drug user and the rest of the family. Just as the drug user needs to respect the complexity of his or her relationship with drugs before making decisions that will actually work and that can be maintained, you need to respect the complexity of your relationship with the drug user. Harm reduction does not mean you have to end a relationship to improve it. Nor is abstinence the basis for an improved life. Neither does an addict have to hit rock bottom to change. Incremental changes in drug using behaviour along with incremental improvements in emotional coping skills are realistic and achievable goals. Abstinence may come at some point but for most people with drug and alcohol problems it is almost never a first step. For families it means a new way of thinking about the issue.

A new way of thinking
We know that this new perspective is a lot to swallow. It goes against everything you've learned about what addiction is and how it should be treated. How can someone who is still drinking or using the very drugs that make everything worse get better? We're asking you to develop an entirely new set of ideas about this person you love and his or her relationship with drugs and alcohol. Your ability to be helpful to this person, and take care of yourself, will be enhanced by a change of perspective.

Abridged By Tony Trimingham 'Over the Influence' by Pat Denning, Jeannie Little and Adina Glickman - Guildford Press.