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Sandra lives with bipolar disorder. I am her psychiatrist or p-doc or shrink (as in Dr. Fink, the shrink). Sandra (not her real name), and I have worked together for many years. At today’s appointment, she is moving a little slowly due to some back pain, but she tells me that her mood and energy have remained steady. That is outstanding news, because until a couple of months ago she was experiencing a terrible mood episode that rocked her lifea difficult mixed episode (mania and depression), along with substance use and memory and thinking problems. Her symptoms disrupted relationships with her family and worsened existing financial troubles. But, fortunately, her mood and energy level have not wavered to any clinically significant degree. Today she smiles and tells me about her volunteer work and playing tennis with a friend. Then she stops, and she cries softly and asks me how to help her parents understand what is wrong with her.

While the good news is that many people in Sandra’s life are starting to grasp that bipolar disorder is the problem (and that Sandra is not the problem), her own family of origin shuns and shames her, telling her that they have been advised to “stop enabling” her “bad behavior.” They will not let her come to stay with them, and she has been excluded from family events. Sandra is heartbroken.

I have heard the term “enabling” countless times in my practicein a range of settings, from spouses of adults with bipolar disorder to parents of children with anxiety and depression. Unfortunately, the term is often misused, as in the situation with Sandra’s family.

The language of “enabling” comes from the substance use recovery movement and refers to behaviors that directly or indirectly reinforce someone’s substance use. This approach encourages those who love someone with substance use disorder to allow the natural consequences of the disorder to happen, which theoretically will motivate the person with the disorder to enter into recovery.

How well this approach has been studied, or if it is effective, is unclear, but the concept has taken hold in popular culture and has expanded quickly into mental health and child development/parenting. Enabling, the theory goes, is counterproductive to the “tough love” that is needed for someone to experience and learn from the negative outcomes of their bad behaviors. Unfortunately, those who use this language often extend the definition of “enabling” to cover emotional support, warmth, and compassion toward someone who is not getting better.

I feel as though I tread in delicate territory when I try to re-consider this approachbecause it has been so soundly absorbed into common wisdom and “accepted truth,” but it is based on some profound misconceptions. So I try to help loved ones recognize the misconceptions that underlie the “stop enabling” advice by pointing out the following facts:

  • Psychiatric symptoms are not “bad behaviors” that change based on external motivators. The inactivity of depression, the irritability of anxiety, the impulsivity of mania, to name a few, aren’t choices that people can change based on the consequences of their behavior. In fact, people who are suffering with psychiatric illness despair over their inability to make change even as things are falling apart around themor when they re-gain their clear thinking they are racked with guilt over damage done.
  • Those struggling with mental illness need ongoing love and care, even when their symptoms make them seem unlovable. Withholding your love or your support causes more despair and guilt, layering onto their mood and behavioral symptoms in ways that are bound to actually make things worse.
  • Mental illness breaks many things in someone’s life. Sometimes resources for even basic life needs are erodedpersonal finances, occupation, education, nutrition, hygiene, sleep. The idea that just letting someone struggle until they “figure it out” is profoundly ineffective, not to mention mean-spirited. Things will predictably get worse. But if you are still misattributing your loved ones challenges to their own choices, you will see this as “proof” that they “just don’t want to get well.”

Of course there are complexities here. People suffering with acute mania, for example, may reject all help and care because the illness prevents them from seeing that they are ill. But getting angry and rejecting them will not make it better. You may have to stop trying to convince them of something that they cannot understand, but expressing your love and support will not “enable” their mania. You may have to set boundaries for your own health and safety, but that isn’t the same as purposely withdrawing yourself, with the idea that it will help your loved one get better. Shutting someone out is not helping. Connection and love are not “enabling.” While this is not the term’s original meaning or intent, it is often misinterpreted and used in dangerous ways, as my patient’s family had been advised to do.

Sandra and I sort through some of these ideas and try to come up with ways to help her parents and brothers begin to question some of their assumptions about enabling. Sandra feels great relief at the re-building of her life with her wife and kids, but there is a big hole where her own family has stepped out of the picture, thinking that they are “doing the right thing.” Sandra wipes her tears and heads back out into the world, where her illness remains vastly misunderstood and compassion can be hard to come by.

Check out the latest edition of my book, Bipolar Disorder For Dummies, 3rd Edition, which you can now order on Amazon.com.

Turning your back photo available from Shutterstock