Introduction: One of the difficulties confronted in early recovery is expressed by the notion that “trust takes years to develop but can be destroyed in a moment.” People in early recovery are often confronted by this dynamic—and many other challenges—in their relationships with their families. It is extremely useful to be aware of the common traps that people in early recovery can become entangled in with their families. New ways of coping with difficult scenarios can be learned in therapy, and new relational patterns can be implemented. This article by psychiatrist Michael Ascher and psychologist Barry Lessin should be required reading for clinicians, people in early recovery and their families. – Richard Juman, PsyD
For people in the early stages of recovery, engaging with loved ones can be quite challenging, resulting in the confluence of a variety of different emotions. Joy, relief, and the hopefulness of a fresh beginning often intermingle with shame and worries about an uncertain future. The excitement of forming new and positive social connections is often countered by the sadness, hurt, and anger that arises from family members continuing to focus on the problematic past.
Family relationships often consume a great deal of session time in our work with patients the first weeks and months of treatment. And we’ve learned that when our patients gain a better understanding of the potential issues, they wind up with a much better chance of avoiding some of the most predictable problems in early recovery.
People in early recovery want to feel understood and appreciated by their families as the unique and multifaceted persons that they are, but often family members are inclined to keep their focus on the substance use problems that have been center stage. In addition, interactional patterns within the family are likely to be deeply entrenched and resistant to immediate change, despite the great efforts that people in early recovery may be making to inspire changes in family dynamics.
In the early stages of recovery, managing both internal and external family expectations can be difficult. An example of an internal expectation that we often hear is “I really want to show my wife that I can manage my temper better now, but I’m worried about what will happen when I return to work.” External expectations are reflected by the parents of young adults who complain, “She has more time to get her schoolwork done now that she’s not getting high; why is she spending so much time in her room?”
Matters are complicated further when families have a poor or incomplete understanding of the nature of substance use disorders, with some family members often incorrectly assuming that you are “fixed” or “cured” once you’re in recovery. This is often voiced in this way: “He’s on Vivitrol now for his opiate problem, so there is no need for him to go to meetings or see a therapist.”
Also, family members are often struggling with their own internal conflicts and traumas so they may not be equipped with the proper skills, or the mindset, to engage with loved ones in early recovery in the most helpful way. Beyond that, family members may have substance use problems of their own, or underlying medical or mental health conditions, that can be a barrier to effective communication.
The impact of family interaction on people with mental health issues was first conceptualized by George Brown in the 1950s with the notion of Expressed Emotion (EE).EE refers to negative patterns of family interaction consisting of hostility, over-involvement, and criticism. High EE in families dealing with substance use issues is associated with poor outcomes for the whole family and specifically for the person in recovery. With the help of therapy, awareness, and support, people in early recovery can work with their loved ones to decrease the amount of EE in their family. A wonderful evidence-based program that helps families use a positive approach to communication is the Community Reinforcement and Family Training (CRAFT).
CRAFT helps family members learn how to improve their communication skills in order to more effectively express their needs and also to reestablish good self-care. It also teaches families how to impact their loved ones in recovery, while avoiding both detachment and confrontation.
Old patterns of unhealthy family interaction can feel familiar and reassuring despite being unhelpful. At the same time, implementing new and healthier ways of relating to each other can be met with anxiety and frustration. Here are 10 essential tips that people in early recovery can use to promote continued recovery while also minimizing discord with their loved ones.
1. The practice of mindfulness can help people in early recovery to settle down and be more present with others. Mindfulness training can have a profound influence on the regulation of your internal emotions. While there is no universally agreed-upon definition of mindfulness, it is helpful to understand the concept as embracing humanness and accepting one’s body, thoughts, feelings and emotions without any judgment. Practicing mindfulness can lead to greater awareness, attention, openness, and insight, and can provide the catalyst for more meaningful engagement with your loved ones.
2. Self-care is essential in order to be able to respond effectively to all of the various stressors that are common for people in early recovery. Making sure that you’re getting enough sleep, eating a balanced diet and getting plenty of exercise can minimize the frequency of setbacks in your recovery and make you more equipped to deal with any ruptures in your relationships with family members. The importance of establishing appropriate boundaries and setting limits with loved ones is an ongoing process that must be regularly explored and negotiated with the ones you care about.
3. Understanding protracted withdrawal from a substance is important. Just because you’ve made it out of the acute period of withdrawal doesn’t mean that your brain isn’t still undergoing change. This healing period can make you more vulnerable to the anxiety and depression that are symptoms of a syndrome called protracted withdrawal. It may fall on you to discuss the concept of protracted withdrawal with loved ones so that they understand how it might impact your recovery and your overall functioning during the early stages.
4. Delay the seeking of redemption. Resist the urge to immediately apologize, make amends, or seek overwhelming affirmations from loved ones for previous hurts or wrongdoings. Many of the patients that we see are eager to make promises like, “I’ll never hurt you again.” Instead, respect and try to empathize with your family’s experience and don’t make promises that you can’t keep.
5. Earning back trust. Trust falls along a spectrum. Just because you’re now in recovery doesn’t mean that you have regained the full trust of your family. This is usually one of the hardest things for our patients to accept. They are working so hard to change their behavior and goals, but their families continue to harbor resentments and engage with them as if they were still using. We hear this common refrain: “Sometimes, I wonder why I should continue working on my recovery when my family doesn’t see the progress I’m making.” It takes time to rebuild trust.
6. Embracing empathy. Anticipate the various possible sources of discord between you and loved ones, and make a plan for how you will respond in the most effective way. Work out a plan ahead of time for how you will respond if family dynamics become overwhelmingly negative. And after an argument it’s important that you remain non-defensive and own your part in the conflict. Being empathic means imagining what it must be like for your loved ones: explicitly communicating that understanding to them will promote mutual empathy and bonding.
7. Defend the use of relapse prevention medications. There is an incredible amount of misinformation on the therapeutic use of medications in recovery- medications like methadone, Suboxone and naltrexone. So, if you and your doctor decide that they’re helpful in your personal recovery, be prepared for criticism. Dealing with misinformation and stigma within your own family can be one of the hardest challenges to overcome. The best thing to do is reiterate that you have a medical condition and you and your doctors are treating the condition in many ways, including the judicious use of medication.
8. Appreciating the potentially harmful consequences of helping others in recovery. Be mindful of the potential consequences associated with being a mentor to a family member who is also struggling with substance use disorder. You may become too invested in their outcome and this can serve as a potential setback in your own recovery. In early recovery, keep the focus on yourself.
9. Resisting the urge to use with family members. Develop a series of responses to those family members who might feel threatened or disapprove of your attempts to abstain from all substances as part of the steps you are taking in your recovery. These individuals might encourage you to go back to using or misusing substances. Be prepared by knowing specifically how you will respond and what you will say if you are confronted by this scenario.
10. Understand The Family Emotional Bank Account: The concept of an emotional bank account was created by Stephen R. Covey in his book The 7 Habits of Highly Effective People. Each time you say or do something caring or generally positive, you make a deposit; each time you say something critical, or generally negative, you make a withdrawal. Unlike a real bank account, emotional deposits and withdrawals are not equal. Covey states that one critical statement usually negates five praises or other positive statements. Remember that you may have made more negative “deposits” than positive ones when you were actively using and that it will take some time for the positive “deposits” of early recovery to accumulate. Be patient until your emotional bank account starts to move into the black.
Michael Ascher, MD is a board-certified psychiatrist who serves as a Clinical Associate in Psychiatry at the University of Pennsylvania and is in private practice. He is co-editor of“The Behavioral Addictions” (Washington: American Psychiatric Publishing, 2015).
Barry Lessin is a Licensed Psychologist in private practice in Philadelphia; he has been active for almost 40 years as a clinician, administrator, educator, researcher and now co-founder of Families for Sensible Drug Policy.