Relapse/Relapse Prevention: Part 2 of 3
For the (Rest of the) Family
“Expectations are resentments under construction.” -Anne Lamott
Relapse and families. Google this combination and you’ll get some 42 million hits. 42 million!! But I could find only one reference to an actual Family Plan for THEIR relapses/lapses into old behaviors and sadly it’s a list that in my opinion is too long and too loaded with traditional thinking (we’ll look at it in a bit). I don’t even like the language I’m using here: “relapse” meaning someone has used a drug again? Or perhaps something else? (we don’t speak of “relapse” in cancer or diabetes care, do we?) And I realized recently that when I use the term “family” I’m too often meaning ‘the folks that don’t have a drug problem’. But isn’t the “addict” part of the family? And more important, isn’t our usual language leaving them out of the family literally – the sense of connectedness, a being unit, that they likely already don’t feel a part of? Or is that the point? Sigh. But we’ll focus on language another time. Here I want to ask us to see relapse/lapsing in a bigger context: that family members who don’t have drug problems can fall back into their old behavior patterns too and therefore “relapse” or “lapse”. And it’s this that I want to focus on in Part 2 of our blog on Relapse Prevention: if the system I live in/am part of doesn’t change, how can I or anyone change within that system? And if we all don’t begin to understand why someone is using drugs, how would our loved ones with a drug problem begin to make changes? The short answer, I’d argue, is they can’t.
In the 1980’s, the late John Bradshaw was the darling of PBS with his specials, one titled “On The Family” . I took one of his courses when he came to the Bay Area in the early 90’s and one thing I remember (and still use) is this: the family system is like a mobile – touch one part of it and everything shifts. The other main take away for me is how he said the word disease, which Bradshaw would pronounce dis-EASE. As we’ve all learned more about trauma and traumatic events, this pronunciation has come back to me. As I write this series on relapse prevention and change, I find it a timely reminder as well. I used drugs for more than two decades not ONLY because of my dis-EASE but often because of it.
I recall the Family Program that we had at the hospital-based treatment facility I entered and, later, at which I worked. Every Thursday evening for a year, the former patient (me!) could return for a Continuing Care Group (not called “aftercare” on purpose as we believed that the treatment stay was just the beginning of treatment not the end of it), family and other significant others could attend the Family Meeting, and kids (under 12, I believe, and for an extra fee) could attend Kids Connection. So, every Thursday evening for a year, my ex and I and my son Jesse attended their respective support group meeting and afterwards, we went for dinner. It was incredibly helpful for all of us as it made clear that the whole family is involved in treatment (or needs to be); the patient wasn’t the only one needing to make change. All of this was included in the cost of my treatment stay. Additionally, significant others could attend our annual Family Intensive (for an added fee). This was a week-long program to focus on healthy communication, how to care for yourself, how to support your loved one in crisis/relapse, bringing sex back into your relationship, and much more. The program was designed and run by one of my longtime sponsors and mentors, Dr. Mickey Apter-Marsh (Mickey had a PhD in Human Sexuality as well as having trained as a therapist). She also liked to say she had a “black belt in Al-Anon.” In those days, we spoke of co-dependency and enabling – words I find lacking in nuance today – but nevertheless, these were ground-breaking concepts in the late 1980’s-early 1990’s. While I would change some of the specifics in a program in 2020, we (and most inpatient treatment providers) had an incredible and mostly free support program for family members. We recognized most patients would be returning home after treatment, to the same place that they problematically used alcohol and other drugs, and those other family members would need support to make their own changes too if treatment was to be successful. What happened?
Earlier I mentioned the one entry I found on Google on this topic. It’s from Debra Jay It Takes a Family: A Cooperative Approach to Lasting Sobriety (2014). Ms. Jay uses Terry Gorski’s “Relapse Warning Signs” and developed what she calls “Family Relapse Warning Signs.” Here are a couple of entries from her 34-item list:
- I allow my daily activities to interrupt my recovery schedule including my Al-Anon meeting, daily reading, time with my sponsor, service work, or working the Twelve Steps.
- Temporary issues, such as an illness, keep me away from recovery activities, but I do not return once I am well or otherwise unburdened.
- I’m not eating enough or too much.
First of all, if Al-Anon and other 12-Step support helps you, who am I to disagree? I would suggest the first entry could be read another way which concerns me: “Nothing is more important than my recovery – defined as abstinence –- and my life activities are unrelated to it.” I’m sorry but to me that just doesn’t make sense. Also, if this is an approach to ‘sobriety’ as Ms. Jay states, that would be only for the family member problematically using drugs, right? Or is she referring to ‘sobriety’ as something different than abstinence? Some do make that argument, which I’m not going to address here, but Ms. Jay doesn’t explain her terminology (please note: I have not read her book though). Finally, the way the title of this piece is worded to me also sounds like the family is doing these things ONLY to help the “addict” stay sober. We’ve talked before about recovery being more than abstinence; in fact, our government believes that to be true as well as is suggested in SAMHSA’s definition. My definition of recovery? Simply this: mindfulness+connectedness+inner growth™.
I decided to see if FSDP member and my old friend, Dr. Stanton Peele, JD, PhD, had some thoughts on this topic. Stanton shared with me some of what he and collaborator Zach Rhodes discuss with their clients participating with their online treatment for problem drug use, The Life Process Program:
We wouldn’t suggest divorcing someone if they’re still smoking even if you’re quitting but you may need to have some reasonable limits around each other’s behavior. Bottom line: your whole intimate group/family is going to have to change — like reciprocity marital counseling. The main topic of conversation becomes ‘how can we go forward without setting one another off?’
Family relapse prevention is something we don’t often discuss in this culture when talking about addiction. However, in Australia, Family Drug Support, (FDS), has been talking about family system change for many years. Let’s return to our mobile for a moment. I think we can all agree being in a relationship with someone(s) who are engaged in less healthy or potentially problematic behaviors affects us all – and maybe it affects us regardless of whether its problematic or not (that’s also another convo!). Anyway, it’s going to be necessary for us all to look at how we need to think about and adjust our own actions and words to support change in The Family System, regardless of whether our loved one problematically involved in some less than healthy behavior – the “addict” or “identified patient” to use the common term – makes a change or not. Tony Trimingham, CEO of FDS, (and someone with his own personal story of inconceivable change after his son died from a drug-related event) discusses several concepts involved in Family Relapse Planning in his helpful booklet, “A Guide to Coping: Support for Families Faces with Problematic Drug Use.” Here are a couple of suggestions from this booklet:
- Look at the outcome or goal you’re expecting from treatment. Are you defining “success” as your loved one being drug free for a year? Five years? 6 months? What if they cut down or change to a less harmful drug? What if they leave formal treatment but maintain the change they’ve made? Unfortunately, our expectations (and this applies to all family members) usually have a way of setting us up for disappointment. So, let go of those expectations (easier said than done)!
- Have access to support for yourselves. Groups (all kinds), professionals, education, books, and more can all be helpful. Just skip the TV and Dr. Phil or Dr. Drew please.
- Accept the reality of the situation. Acceptance doesn’t mean agreement! However, it does mean that we must learn to separate our feelings of hurt, disappointment, and fear from the fact that people we love – even those who use drugs problematically – are entitled to determine their own lives and decisions about it. And who knows? Maybe those decisions will include getting some help? (It did for me)
- Support isn’t rescuing. “Parental and family support have been shown to be one of the strongest factors in “successful” treatment” of alcohol and other drug problems. One of the main things I work on with families is helping them determine how they can support their loved one in a way(s) that works for everyone. That means, like good negotiating, no one is going to be completely happy with the results. There’s always a way to give support.
- No one knows what’s best for your family except your family. And by “family” I mean including the person problematically using drugs. With limited exceptions, if you can continue communicating with your loved one including family conversations about their drug use, your efforts will pay off greatly. This may not be easy, but it can be one of the most important things you do. Please remember, no professional – including me – can tell you what’s best for your family. A good professional is there to help you have these critical, complicated conversations and help you sort what each member of the family desires, needs, expects, is willing to do, etc. But we do NOT have your answers; we can only help you uncover yours.
- Make a plan. Here in California, we encourage all residents to have an earthquake or other disaster plan. I’ve been calling relapse prevention plans “earthquake plans” for years as I see them in the same sphere: we hope we won’t have an earthquake but let’s be prepared for it, as best we can. For families, I want you to know what your “bottom lines” are; what you’d like to see your loved one do if they return to using a drug problematically; what your loved one wants to happen if there’s a lapse; how you’ll show your loved one that you need to make changes too. I’d also like you all to know how each of you – including the one problematically using drugs – can say something to you about your own lapse. In my family, we used a code word. We all agreed that when someone said the code word (say, “penguin”), it meant we stopped the conversation, agreed to return to the conversation later, and let it go for then.
Having a relapse prevention plan for families and other concerned loved ones also says to our loved one problematically using drugs that we understand this is a system, a family, and we’re in it together; we’re willing to do our own work to help make some positive changes in our family while they make their own, or not. Dr. Gabor Mate has a story about this that always brings me to tears, which he related to Chris Grasso in his book Dead Set on Living: Making the Difficult but Beautiful Journey from F#*king Up to Waking Up. Here’s an excerpt:
…you’re the one whose behavior shows us how much pain there is in our family. Thank you for showing that to us…because we realize that’s we’re as much a part of it as you are. We’re going to take on the task of healing ourselves…
In the work I do with families, one consistency is that there is no consistency. As Mickey’s husband, Dr. Earle Marsh, MD*, used to say to me often, “Baby, life’s a crap shoot. You just do your best and let it roll! ” Each family I work with has their own ideas as to what’s important to them, what their own values and goals are. Those are the ingredients that I need to gently guide them towards what’s best for them. I may certainly, with their permission, suggest they view or consider something in a slightly or radically different way but ultimately, they are the arbiters of their own family actions.
So, are there some things in general that families or other loved ones of someone with a behavior problem can do for themselves? Yes. In fact, the very first one is to see that you need to make changes too, regardless of whether your loved one (with the problematic behavior) ever changes. This doesn’t mean to leave your loved one behind. Instead of focusing on what you’re NOT willing to do, I suggest families focus on what they CAN do for their loved ones using drugs problematically. We want to reward the behavior we’d like to see more of instead of punishing the behavior we want to see less of. This lets our loved ones know that we’re not closing the door on them and (no “buts!”) we have limits regarding some behaviors.
A relapse prevention plan should be a helpful road map for everyone on this journey we typically call “recovery”. After all we’re all affected by each other’s behavior, so we all need to make our own road map. A good relapse prevention plan should also allow for spontaneity in life and not be written as if it’s a legal contract but rather as a general guide to where we all want to be. It should be fluid and flexible, responsive to new events and circumstances. We take more time to talk about the colors we put on our walls than we do on what we want to happen when life throws us a curve ball. So, by yourselves or with professional assistance, be sure to write your own relapse plan – or wellness plan – now so you know where you’re headed. And whatever you do, don’t leave home without yours!
*Dr. Marsh was the Ob/Gyn deptartment chair at UCSF for many years. He taught the first course on addiction for medical students there as well. Doc Earle, as he was known, was also a longtime active member of Bay Area 12-Step, whose first sponsor was the co-founder of AA, Bill Wilson. Doc and Mickey were my lifelong friends, co-sponsors, and even part of my Master’s committee. You can read Earle’s story in the AA Big Book (Physician Heal Thyself: 35 Years of Adventures in Sobriety by an Aa ‘Old Timer’). They are both gone now and long ago broke their own anonymity.