Addiction, Depression May Underlie Nephew's Mood, Lack of Motivation

Q.My 19-year-old nephew, who graduated from high school last spring, isn't motivated at all.

His parents want him to go to the community college or get a job, but he won't enroll anywhere or look for work, and he won't take anti-depressants, either, even though he has had depression diagnosed.

He might be using drugs, however, as he has done in the past. He sleeps most of the day and usually goes out at night, but his parents don't know where he goes or what he does. He refuses to talk to them and is often belligerent and sometimes physically aggressive. He has also stolen money and a credit card from them, which forced them to lock up everything, and he took their car keys, too, even though he doesn't have a license.

The parents have tried so hard to motivate their son but nothing has worked, and they feel stymied and powerless. Now they're tempted to kick him out of the house if he doesn't get a job, but they're afraid he'll end up homeless.

How can we encourage -- or force -- this young man to get on a productive track?

A.You say your nephew isn't motivated, but that's not true. He is motivated to sleep late, to go out at night and maybe to take drugs as well, since stealing, aggression and apathy are some of the many signs of addiction.

If your nephew is on drugs, he needs all the help he can get from his parents and from you, for substance abuse is a mental health issue, not a behavioral problem.

Although he won't quit using drugs until he's ready to quit, he may get ready a little sooner if his parents call the police the next time he gets violent or steals from them and if they set stiff limits for him and stick to them, even when they long to give up.

They shouldn't start talking about depression or drugs, however, until they have given him small jobs to do so he will begin to feel more responsible.

The parents should also have him sign a contract, promising to do the laundry for the family, cook dinner once a week and get a paying job or a volunteer job within a month in exchange for his room and board. If he breaks one of these promises, however, he'll have to go to a psychiatrist for an assessment.

He'll object, but his parents need to know if their son really is on drugs or if he is depressed -- or both. If the psychiatrist says that depression is causing him to behave badly, he'll have to start taking his meds, but if he says that he has a drug habit, he'll have to get into some kind of treatment.

It could be the free daily meetings at Narcotics Anonymous, which has helped so many people, or the meetings offered by Smart Recovery, a similar program but without any reference to a higher power. If his parents can afford it, he should also see a therapist every week, but tell them to look for one who has a large teenage practice, is wise enough to give patients regular drug tests and is trained to use one of the new interventions that have been so successful in clinics.

The therapist might use a cognitive behavioral intervention, which would teach your nephew to cope with tempting situations and cravings; a contingency management intervention, which would use incentives to help him quit; or perhaps the new motivational interviewing technique, in which the therapist would ask him about the positive rewards of drug use, and then the negative ones. When the patient can weigh his own pluses and minuses, it often becomes more tempting to quit than to use. Or your nephew's parents might go to http://www.clinicaltrials.gov to see if their son fits into one of the free clinical studies that the government sponsors.

Your nephew would also profit from some family therapy -- and so would his parents, for the family of a drug user needs almost as much help as the user. Even if their son won't go with them, they could learn techniques to deal with him better, as well as with each other. The parents should also go to meetings of Al-Anon, in person or online, to find out what others have learned.

You could help, too, by giving your nephew a copy of the report "Overcoming Addiction" (Harvard Health, $18), which you can order at http://www.health.harvard.edu/ADD. The more supportive you are, the sooner he'll want to quit.

Questions? Send them to advice@margueritekelly.com or to Box 15310, Washington, D.C. 20003.