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Addressing tolerance in patients and families

December 3, 2013
by Maria A. Avila
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Maria A. Avila

The word “tolerance” is an all-too-familiar concept in the addiction field. Persons with substance abuse problems are said to have a high tolerance to substances. They can consume large amounts of a substance and not appear impaired. Their families, on the other hand, also have a high tolerance for the chaos and destruction resulting from their loved one’s actions. They are perfect complements to one another, as one cannot exist without the other.

The solution: to reverse this dynamic. Some would call this “reverse tolerance.” This involves increasing the addict’s tolerance for life and all of the complexities that come with it, while decreasing the family’s willingness to “pick up the pieces.” This is the desired goal in treatment.


Addressing self-esteem

The challenge in addressing both patients and their families lies in the same realm: poor self-esteem. The more you work on this, dynamics change, enhancing the relationship. A common formula seen in human behavior is people’s tendency to repeat what is familiar until they learn to do it differently. This means that no matter how destructive certain dynamics may seem, those who have grown up in similar circumstances are attracted to them until they learn to choose differently.

An example is seen in a woman who attends a codependency group. She describes the improvements her alcoholic husband has made since he has been in treatment. She claims that he is more responsible in helping her around the house and taking care of the children, and even communicates more often with her. In the next breath she blurts out, “I almost wish he would drink again.” Group members’ jaws drops in unison. They don't understand. She had always been complaining about him and how his drinking made him irresponsible, thus putting more pressure on her. How could she want it reversed?

But the comment makes perfect sense. This woman is uncomfortable with the change in intimacy and being able to receive help, because these dynamics are not familiar to her. Therefore, a desire to return to what is known becomes the natural response.

Another example is that of an addict who struggles with issues of loyalty. If others in the addict’s immediate family are struggling with substances as well and are not motivated to seek treatment, feelings of guilt may arise for the client. One can almost equate this with survivor’s guilt. These feelings can sway one away from change.

Questions such as “Am I deserving of these good feelings and circumstances if my family is still struggling?” may ensue. There is a stronger pull in this regard than most realize. Ties of loyalty run deep, influencing the move toward the familiar. If everyone in the family has been caretaking or has always been surrounded by chaos, change for the better may not be welcomed. Family members will challenge this change in order to maintain the status quo. Spouses/partners may become threatened by a calmer environment with less to do.

Helping people work toward what does not come naturally is one of the most challenging tasks in therapy. Retraining them to accept feelings and circumstances that they are not used to, yet are empowering and rewarding, is the key.

It comes back to working on their self-esteem. Once people begin to feel better, they question more and see circumstances differently—in essence, they become less tolerant. No longer does the familiar feel comfortable. But being able to get to this point takes time.

Author and popular singer Portia Nelson described this dynamic well in her poem “Autobiography in Five Short Chapters”:


Chapter I

I walk down the street.

There is a deep hole in the sidewalk.

I fall in.

I am lost ... I am hopeless.

It isn’t my fault

It takes forever to find a way out.

Chapter II

I walk down the same street.

There is a deep hole in the sidewalk.

I pretend I don’t see it. I fall in again.

I can’t believe I am in this same place.

But it isn’t my fault.

It still takes a long time to get out.

Chapter III

I walk down the same street.

There is a deep hole in the sidewalk.

I see it is there.

I still fall in ... it’s a habit ... But,

My eyes are open.

I know where I am.

It is my fault.

I get out immediately.

Chapter IV

I walk down the same street.

There is a deep hole in the sidewalk.

I walk around it.

Chapter V

I walk down another street.


Here we see the tendency to return to the same set of circumstances, the difficulty in changing, and how relearning something different takes us to a different route.


Guidance for clinicians

Now that we have a better understanding of the system of tolerance, let’s look at what therapists can do to be helpful in reversing the tolerance described. The following steps will help addicts and alcoholics increase tolerance to life while reducing it in a positive way for their family members.

1. Promote tolerance of feelings to decrease reactivity.