I’m Afraid My Boundaries Could Cause Him to Harm Himself

"Setting boundaries for an 18 year old with SUD and severe depression, with chronic suicidal thoughts. He is at rehab right now. He just turned 18 and was told if he continues to use substance and not actively engage in sobriety then he cannot reside at our home. There is the fear that he will feel hopeless if he is asked to leave and hurt himself in return.

I was thinking of providing him with a list of family members, shelters, etc if the day comes and he’s asked to leave."

Your Loved One (we weren't sure if he's your son?) is currently in a rehab facility. Hooray! Let's take a minute to feel gratitude for this important step. Your Loved One has accepted to begin looking at their substance use patterns, and is clearly not completely closed off to the idea of recovery. And meanwhile, you have the time to regroup.

Recovery is anything but linear

If you've been on this site for a while, reading up and watching our eLearning modules, you are aware that recovery is usually not a linear process. Most people experience numerous setbacks, treatment episodes, lapses, and periods of recovery, before moving into long-term recovery.

This graphic demonstrates the anything-but-linear process of recovery:

Your Loved One is 18, and struggles with multiple diagnoses. We often tell families of teen Loved Ones that having an expectation of 100% abstinence may not be realistic.  Successful treatments for substance use disorder in teens shows that use goes down while they’re in treatment but increases quickly back up over a short time. http://pop.williamwhitepapers.com/pr/2002CYTStudyImplicationsforSAP.pdf

Sobriety at this age is a monumental hurdle, and as hard as it feels, we encourage parents to give their teen children who are using substances, some additional space to make their own mistakes and learn from them.

And given the serious mental health issues your Loved One is dealing with, the substances can be considered self-medicating or self-soothing, and perhaps not the core challenge for your Loved One. I hope the rehab is doing a good evaluation of all his needs, not just addressing addiction. At that age, “addiction” must sound like an 'old person's problem,' not something that would actually apply to him, now.   

We recommend that families implement the "daybed and locker" solution, which you can read about here and here. The basic idea is: as long as they are continuing to use, and/or be inconsistent with recovery, you remove their bedroom (often a hiding/using place) and grant them a place to sleep and keep some belongings that's more out in the open. It's also much easier to remove (as a reward) than a bedroom.

Asking a loved one to leave when you're concerned about self-harm

You describe your (son) as having chronic suicidal ideations, and you're worried that putting down strict boundaries and/or asking them to leave could push them closer to harming themselves or feeling desperate.

This is a real concern, and given the young age of your Loved One, as well as his history of severe depression and suicidal ideation, we would not encourage you to pursue the boundary of "no substance use/must be fully engaged in recovery, or else, he's out."

The situation you describe is extremely difficult — it's a balancing act. Your Loved One is 18 years old, a young, tender age. Not yet an adult.

We would encourage you to keep aiming for treatment/programs that are designed specifically for people his age. The approach is not the same as with adults who have been out in the world and have more agency and experience of themselves.

Your Loved One will most likely need a high level of treatment. Dual diagnosis programs, which take into account the mental illness, would be an excellent option.

Look into the 7 Challenges, which could be an option for him directly upon leaving the treatment where he currently is.

CRAFT can help you with harm reduction

CRAFT can be seen as a harm reduction tool in your situation. Through our eLearning modules you will learn how to recognize and reward moments of non-use. You will think through what could be seen as "rewarding" to your Loved One, and also create incentives to positively reinforce any non-using behaviors.

Module 5, My Loved One Isn't Using Right Now, Now What?  guides you through the process of rewarding any and all moments of non-use. Any attempts at all on his part can be encouraged/rewarded.

We show you how to break down the idea of "sobriety" or "recovery" into a series of moments. Some of the behaviors you see will be positive, some will not, but it's important that families move away from a black and white vision of recovery, especially at such a young age. You'll learn how to respond in the moment vs. with a global stance. The former allows you to be flexible, and spontaneous. The latter forces you into stiff postures that don't make sense in the long term and make it impossible to reward the good behaviors.

You will also practice disengaging and letting natural consequences occur when he is using.

Should he go somewhere else?

Asking him to go somewhere else may one day make sense. You mentioned perhaps having him stay with certain family members. We would recommend that any family members you may ask to intervene with him, get the basics of CRAFT under their belt, and be informed about what he's dealing with.

As I write this, membership to our site is currently free-of-charge thanks to the COVID crisis, so feel free to spread the word.

Concrete things you can do now

While your Loved One is in rehab, we'd also suggest you read through the literature on suicide prevention. The person closest to the Loved One with suicide ideation has an important role to play. See the "suicide prevention" section on our Crisis Numbers page.

Try not to be too concerned that applying CRAFT might have harmful effects on your Loved One.

As you move forward and start applying some of these suggestions, keep us posted. Thanks again for writing in.