'I don't know what we should have done differently': A qualitative study on the dilemmas of 'tough love' and toxic drugs in British Columbia, Canada

BackgroundIn British Columbia, Canada, a public health emergency of unregulated drug deaths presents a fraught backdrop for concerned significant others (CSOs).MethodCommunity-based Participatory Action Research design. We conducted 22 semi-structured qualitative interviews with CSOs about their perceptions and experiences during the toxic drug crisis. We examined how 'tough love' constructs informed their relationships with and responses to their loved ones.ResultsUnderstandings of tough love were widely varied and intertwined with decisions around supporting loved ones at risk of overdose. These decisions involved three main mediating factors: (1) perceived potential outcomes around the loci of various harms; (2) beliefs, attitudes and values around love and compassion, the nature of drug use, and personal agency; (3) available personal assets or social capital. Participants often displayed significant levels of uncertainty and regret that was mitigated by the psychosocial concept of 'boundaries' in contrast to codependency-derived dichotomies of tough love and enabling.ConclusionDecisions around levels of support or engagement involve complex negotiations within a highly pressurized context of a toxic supply of illicit drugs. Inconsistently understood normative language influences confounding relational negotiations for CSOs, who require theoretical frameworks that help them negotiate decisions within their own limits and values, both moral or pragmatic.