How to Involve the Family in Recovery and Treatment

Foreign I'd like to welcome everybody to today's presentation on involvement and treatment of the family in recovery. I'm your host, Dr. Donnelly Snipes. In today's presentation, we're going to briefly define the family, explore recovery as a family issue. And when we talk about recovery, we're talking about substance abuse or mental health issues. We're not just talking about addiction. We're going to discuss the impacts of substance abuse or mental illness on the family system, list the goals of family involvement, identify challenges to family involvement, and finally identify strategies to help family members feel heard, valued and secure in the recovery process. Now, I think it's interesting to note that uncontrolled substance abuse or mental health issues or mental illness in a family are both identified as two of the adverse childhood experiences that when we talk about adverse childhood experiences, if those exist in a family, then you've got two aces right off the bat. And generally substance abuse and mental health issues co occur. So if you have one, there's a good chance the other one is going to be there, either in the person with the substance abuse issue or one of the other family members. So we're going to talk a lot about that. Family broadly includes relatives, partners, friends, or any supportive network that is expected to provide nurturance through consistency, attention, responsiveness, encouragement and safety. And you'll recognize that last part as my mnemonic for a secure attachment to consistency, attention, responsiveness, encouragement and safety. There are a lot of different types of families. Not everybody gets along with their blood relatives. They may not embrace or rely on their genetic family for support, but that's okay. We want to look at who does this person interact with on a regular basis and look to for support, for encouragement, for safety. Work can be considered a family. People at work, and a lot of times we project our family roles at work, so we do see a lot of interaction. You're working with people 40 or more hours a week, so it's natural that you form some sort of relationship with some of them. Now, not everybody you work with be considered part of your family. Just like not everybody that you're genetically related to are you considering part of your family. I have second and third cousins I've never met, have no idea what their name is. You know, I have no feeling one way or another. I'm not pushing them away. But if I'm thinking of my family, that's not who springs to mind. For some people, church or other spiritual organizations can be embraced as family, especially those who don't have a lot of blood relatives that they. That they rely on. Some people find comfort and solace and security at church or in their religious organization. Some people are just the opposite and they find that to be a very toxic environment. I'm not saying we one way or another. And the neighborhood can actually be considered as part of one's family in some situations. I remember when I grew up, we live in. Lived in an apartments and in those apartments people got to know each other and we would hang out. I actually managed an apartment complex for a while and every evening the residents that had dogs were. Would all get their dogs together and we'd all meet in the center of the apartment complex and let our dogs play and hang out and talk. And some people got to be better friends than others. But there was support and there was consistency there. So in some ways the neighborhood can be seen as a family. And when we look at the impacts of addiction and mental illness, we do want to recognize that those issues don't only impact the individual or the people that that individual considers part of their family. It impacts the greater system. If they are calling in sick from work a lot, if they're unable to pay their mortgage or their rent and they end up having to move. So there's more transition. There are a lot of ways that mental health and addiction can impact the. The. The larger system. We're not going to focus a lot on that today. I have other videos on talking about the sociocultural impact of addiction and mental illness. But I do want you to recognize that today we're going to really focus on the family as those people that the identified patient relies on. What's. Who's the identified patient? The identified patient is the one who's getting blamed or getting told that they've got a problem and they need to go to treatment. Most of the time, not always, but most of the time when somebody has a mental illness or an addiction, they become the identified patient and they are blamed or scapegoated sometimes for. For what's going on with them. A dysfunctional family. If people are in a dysfunctional family, it often fails to provide the secure environment that people need. So our families can be dysfunctional. And as I mentioned earlier, since substance abuse and mental illness are two of the very well known adverse childhood experiences, we know that if there is uncontrolled substance, substance abuse or mental illness in the household, then there's probably going to be some dysfunction. I keep emphasizing uncontrolled because people can go into remission, people can get a handle on it, whatever. However, you want to call it just because somebody at some point had a diagnosis of something, it doesn't mean it is continuing to be a problem in their life. So if it's controlled it a whole different story. Looking at recovery as a family issue, addiction and mental illness impact each piece of the entire family system. If you have one person and, and I'm going to give you some examples in a minute, but if you have one person who's the identified patient in the family, and we'll start with addiction because that's one of the easiest ones to conceptualize. The other people in the family are taught don't talk, don't trust, don't feel. The other people in the family are going to start developing imbalances in their autonomic nervous system. The sympathetic response, the stress response is going to become a lot stronger and the relaxation response is going to become a lot weaker, which eventually leads to emotional dysregulation. We're going to see a lot more hyper vigilance because the people in the family are walking on eggshells. They' looking for clues, they're looking for non verbals. They're looking for hints about what's going to happen and what they need to do. We start seeing as a result of the nervous system imbalance and the stress and the hypervigilance, a lack of sleep or a lack of quality sleep, the gut, your gut health automatically changes when you're under stress. Your immunity goes down. So you're getting sicker when you're under stress. And guess what, your cells actually age faster. We see a greater buildup of reactive oxygen species which are otherwise known as free radicals and it puts a stress on the body. So we see increased cellular aging. This also all the stress in all these areas leads to systemic inflammation in the body. We know that systemic inflammation is associated with blood sugar regulation problems, dementia, depression, autoimmune issues. So we can see that the health of a stressed out family is going to deteriorate interpersonally. The people in the family may start struggling with self esteem. They may have shame issues. They don't want to bring anybody home. They don't want anybody to know about their secret. They may have attachment issues because it's not a consistent, secure, responsive, safe environment. They may have difficulty trusting themselves. They don't know when their thoughts are right or wrong because remember they're told, don't talk, don't trust, don't feel. So they have difficulty trusting themselves, let alone anybody else. The person who is the identified patient and maybe the Enabler may not be trustworthy. And what I mean by that, I don't mean that they're doing it maliciously. I mean that they may be inconsistent. They may be unable to be trusted to provide for basic needs of children. They may be unable to be trusted to be honest with one another. And a lot of that has to do with behaviors that develop as a result of the problem, the addiction, the mental illness, whatever. And communication usually goes into the toilet in these families. There tends to be a lot of conflict. Conflict. There tends to be a lot of, remember, don't talk, don't trust, don't feel so don't talk says we're not communicating. We're not going to talk about how you feel or what your thoughts are because they don't matter right now. What matters is trying to help the identified patient stay sober, stay happy, calm down, whatever the goal is for them emotionally. With all this stress and with this lack of secure attachment and support in a safe environment, people tend to become a little bit more irritable and resentful at not only the identified patient, but at others. They become angry with the other people in the family, particularly the enabler, because they're not getting their own needs met. They may become resentful of other people who have these apparently perfect lives. If you go on to Facebook or Instagram and they feel again, they start feeling shame, they start feeling inadequate, incompetent, there may be a lot of guilt because they feel like, like in some way they're responsible for the health and well being of the identified patient. They may be jealous of other people again who have what appears to be a happier life, who don't have to deal with this crap. There may be anxiety about, you know, what's today going to be like? Is today going to be the day that there's another crisis? They may have anxiety that other people are going to find out. They, there's a lot of things they can have anxiety about. They are going to have grief because in these environments, part of being an adverse childhood experience or an adverse experience for any people of any age is that in these dysfunctional families, people are not getting their needs met. And they may resent that, but they've got to grieve that loss. They've got to grieve the loss of the, the vision of this perfect marriage, the vision of this perfect family. They've got to grieve what they believe they were entitled to that they didn't get. Well, you didn't get it. So you need to grieve the fact that you didn't get it and start to figure out what's going to help you move forward. And then there's just flat depression, that sense of hopelessness and helplessness. No matter what I do, it feels like it's wrong. No matter what I do, there's no relief. No matter what I do. I'm always scared that this person is going to relapse or decompensate cognitively. Well, lack of sleep, lots of stress, systemic inflammation, lack of support, and distressful emotions all combine to contribute to brain fog. It is hard to think when your stress response is activated, when, which is almost always the case in a dysfunctional family because people don't feel safe. It unhooks, if you will, from your wise mind. So concentration, attention, problem solving, organizing, memory, learning, all of those things become impaired. And if you don't realize where it's coming from, especially. Well, not especially in children, but sometimes when people have brain fog as a result of all this other stuff that's going on, other people don't realize that there's all this other stuff going on. So they're like, why aren't you focusing? Why aren't you concentrating? Why are you so disorganized? And the person feels ashamed. The first person feels guilty, the person feels helpless because they're like, I don't know why I can't concentrate. Well, let me give you a hint. Let's look at back at the past slide. We do want to, in some ways normalize brain fog and help people realize it's not your. It's not an inadequacy. It is a biological and neurological result of chronic stress. And yes, it will clear as the stress is reduced and as the nervous system heals, it alters people's self, other and world schema. Remember, schema are beliefs we have that help us anticipate and what's going to happen and interpret what's going on right now. So based on my prior experiences, I'm interpreting this situation as I perceive it to be, not necessarily as it is. And based on my priority experiences, I have certain expectations for how you will respond for what is going to happen. Doesn't mean I'm right. It means that I am anticipating and based on prior experiences, but not necessarily facts. In this context, at this time, those self, other world schema become very skewed toward helplessness, toward negativity, toward feelings of rejection and failure and criticism. And those schema tend to be held. So in the future, what's the lens that the person Perceives the world through. It's one of persecution and helplessness. What is the world or what is the. The lens that the person expects the world to react or others to react from? That lens of expectation is shaded by their prior experiences. Environmentally, there's tension, there's unsafeness. And it could be, if we're talking substances, it could be because substance or substances are around. It could be because the substance user is bringing dealers or. Or whomever into the home. Who knows? It could be unsafeness because the substance user becomes very angry when they are using, or because they frequently overdose or because they're spending so much time and money on the addiction that they can't pay the rent. So homelessness and environmental instability become the norm instead of. Well, they become the norm. So there's a lot of ways that the environment can feel unsafe and unstable for not only the family members, but also for the identified patient. We need to recognize that, you know, the identified patient sees that on some level, at some points, they see the chaos or the dysfunction in the family. They recognize on some level their impact on the family. And they may fear rejection, they may fear criticism, they may fear inability to recover. And so they start to feel unsafe. And. And we start to have this situation where everybody just avoids the elephant in the room. Thinking about it, John is addicted to alcohol and tends to become very angry and irresponsible when he drinks. How does it impact his spouse? Thinking about it physically, how is his spouse impacted when he drinks? You know, his spouse knows that when John comes home, he's been out drinking. I know that he's probably going to be in rare form. So physically, tension's going to increase. Physically, the person. If John doesn't come home before they go to bed, they are probably not going to sleep well physically. This chronic stress of wondering, when is John going to drink? When is John. What is John going to be like when he comes home? Is John going to even come home, or is he going to get into a car wreck? All of that is extremely stressful. Interpersonally, the spouse may be an a. Be an enabler who tries to protect John from the natural consequences of his actions, which is exhausting in and of itself. They may have difficulty finding support because family members and friends have pulled away. They've been like, this is a train wreck, and you need to take steps to protect yourself and stay safe. And the spouse says, no, I'm sticking around. So the person. The. The spouse starts losing support. Or maybe they can't tell other people. This is a secret they're trying to keep and to hide so they can't. There's nobody they can talk to about John's angry outbursts or his drinking. Emotionally, you can imagine how the spouse feels. Cognitively, there's that brain fog and that sense of feeling overwhelmed and that negative anticipation. Whatever happens if John's late coming home, cognitively I'm going to jump to the conclusion that John's been out drinking and he's going to come home and he's going to be in rare form and it's just all hell's going to break loose. So cognitively, that expectation, that schema is going to tend to probably be more stressful. And environmentally, even if the bills are getting paid, when there's tension between people in a home, in a household, it's uncomfortable and it may even feel unsafe because the, the spouse's walking on, walking around on eggshells, trying not to tick off John, trying not to do something that is going to trigger John to drink. Thinking about John's kids, well, mom is completely overwhelmed trying to manage John and try to keep him, you know, doing the next right thing and going forward. So mom and John are often disengaged from the children or inconsistently engaged with the children. And this is where you start seeing those family roles. The enabler, the scapegoat, the mascot, the hero and the lost child. The kids also feel this stress. This stress is palpable in the family. And a lot of times in these chaotic households, basic needs don't get met. Meals are not always prepared, shopping's not always done, laundry is not always done. And so the children start feeling unsafe and unprotected. In terms of John's friends and his support system, they're not around him as much. So they may not be quite as physically impacted. They may not be quite as stressed out about what he's doing. But a lot of times when there is mental illness or addiction or both, it negatively impacts relationships. People who are healthier tend to be able to see unhealthy and self destructive behavior and they tend to, they want to help, but when their desires to help are rebuffed, they may eventually start withdrawing. They're like, yeah, you know, John's fun and all, but when he starts drinking, yeah, I don't, I don't think I want to be a part of that mess. So we start to see John losing social support from his healthier friends and developing social support with friends who will, in recovery circles, we say cosign on his cognitively. His friends may Recognize that this is a bad thing. And emotionally, they may feel guilty for backing away, but they recognize it's what they need to do. And in terms of John's employer, you know, how good do you think John's work is if he was out drinking half the night before? How consistent do you think his attendance is if he's out drinking a lot? And how do you think his interaction is with other employees when he is hungover the next day? Most people when they're hungover tend to be a little bit irritable. Their head hurts, you know, they're dehydrated, their stress responses, you know, way on. So it can create problems. Even if he is showing up for work, his, the quality, quality of his work and his interactions with his colleagues and may be impaired. Tom, next scenario. Tom has major depressive disorder with anxiety. When triggered, he often goes days without getting out of bed. He has two prior suicide attempts. All right, so how does this impact Tom's spouse? Well, physically, Tom's spouse, just like John's spouse, is stressed a lot of the time. She is hyper vigilant to signs that Tom may be becoming depressed. Because with people with major depression, it tends to come in episodes and they'll have an episode and then they'll. It'll remit for a while, then there will be another episode. So his spouse tends to be more hypervigilant to signs that there's an impending episode which is stressful. His spouse tends to be more hypervigilant to any indication that Tom is feeling hopeless, helpless, powerless. Interpersonally, his spouse may feel frustrated, but again, not have a lot of social support. There's not such a thing in most places as like al anon for people with mental illness. So where does his spouse go to talk to other people who are in relationships with. With someone who has major depression? Not a lot of those places around. And it's so important to recognize the impact of Tom's depression on the family. Now, I'm not blaming Tom for what's going on. It is what it is. And for whatever reason that Tom's depression developed, it's there, but we need to address it. Emotionally, his spouse is probably somewhat anxious and, and some days, especially if Tom is in. In remission, somewhat relieved. But there's always this lingering anxiety about when is the next episode going to hit. Cognitively, his spouse is going to interpret everything he does through the lens of prior experience. So when Tom has done this in the past, if it is meant that he was getting ready to have a depressive episode or a suicide attempt, his spouse is going to assume that's what's going on now. And the spouse is going to start becoming more stressed. Tom's kids again. Mom is focused a lot on Tom now. Mom may also be focused on the kids too. But when we have a parent, a caregiver in the family that has. Obviously, caregivers are in the family that has a substance use or a mental illness issue. The kids may feel unsafe. They may feel anxious that their caregiver is going to go away. They may be worried that they're going to be abandoned by the caregiver, either through choice or through death. The kids may not understand who, why the caregiver, the identified patient, or the care other caregiver are acting the way they are. And kids think egocentrically, dichotomously and personally. What does that mean? That means that children tend to believe that their perception of what's going on, the way they see the world, is the right way and the way everybody else sees it. So if they think it's their fault and then they think everybody else in the world thinks it's their fault, if they think the sky is green, then they think everybody else in the world thinks the sky is green. That's just the way little kids think. Personally, kids think they have a lot more power than they really do. So if Tom starts becoming depressed, the child may believe it's their fault. What did I do that made Daddy sad? What did I do that made Daddy, in the case of John, what did I do that made Daddy drink or that made Daddy angry? And they tend to think in all or nothing terms, he loves me, he doesn't love me, he's safe, he's not safe. So children really have a difficult time understanding what's going on and why their caregivers aren't being Ward and June Cleaver. Children expect caregivers to be consistent, attentive, responsive, encouraging and safe. And when they're not that way, children take it personally. And they think, oh, they must may not love me, oh, I must be bad. So they're not, I'm not worthy of their attention. Oh, I must have done something and they don't want to spend time with me. Children will take it personally even if it has nothing to do with them. And that's one of the things I used to work on a lot when I would do family therapy in substance use treatment, is working with the children and the adult children to internalize this message that it wasn't anything you did, this was Something that was going on with this other person, with your caregiver. And they didn't drink because you were bad. They didn't abandon the family because they didn't love you. They had a lot of stuff going on. And for really young children, sometimes that message doesn't get through right away. But it's important that the other caregivers continue to echo that message. Common dysfunctional themes of power and control. Look what you made me do. And this is common in the person with addiction or with mental illness. I remember my grandfather had wicked anxiety and agoraphobia when he got older, and especially as his Parkinson's started getting really bad. And he would get very angry when my grandmother would be literally even two minutes late getting home from bingo. He knew exactly how long it took her to get home from bingo. And when she wouldn't get home on time, he would read her the riot act. And it was her fault that she got that he got angry. Look what you made me do. You made me get angry. You made me drink. You made me relapse. You made me feel helpless. You made me try to harm myself. The and this isn't true of all people with addiction or mental illness. Don't get me wrong. Some people own it and they would rather punish themselves. But there are a fair proportion of them that want to blame, because if they accept responsibility for it, that means they need to accept responsibility for change. If they blame, then the other people have to change. It's not them. This same message. Look what you made me do. Can be internalized not only by children, but by everybody else. Look what I made you do. I lost my job. And it stressed you out, which made you go drink, and then you came home. It's my fault. Look what I made you do. And this is a really common phrase that we hear from survivors of domestic violence. I believed it was my fault, and I made them get angry. I made them drink. We need to really look at those boundaries. If you would have listened to me, you wouldn't have had this problem. This is a common refrain of an enabler, which can be internalized by the person with the mental illness or the addiction. You don't love me for who I am. I'm doing the best that I can, and you don't love me. Or you're saying that I'm not capable of making my own decisions and you need to micromanage me. Another common refrain is, if it needs to be done, I'll have to do it myself. A lot of times this is the Sometimes it's the enabler, but a lot of times this is the children in the family who recognize that they can't count on the caregivers to have the energy or the focus or whatever it is to do what they need to do, to make the meals, to go shopping, to help their siblings with their homework, which in is internalized as I can't trust you and or I'm not worthy of your time, effort or attention. So ground rules in family recovery identify strategies to help the family member feel heard, valued and secure in the recovery process. If people feel like they are going to be ignored, discounted and abandoned or criticized, they ain't gonna participate. It's just, it's common sense. So we need to ask each person, what do others do that make you feel unheard or not valued? And in your family, we need to be able to have this conversation and using specific examples of what's going on. So the person would say, when I talk about my feelings about something, my caregiver tells me that I'm overreacting and I need to suck it up. Okay, well, that's a very concrete example of what somebody does that makes them feel unheard or not valued. What things do you do that keep you from feeling heard and valued? And I know this almost seems like blaming, but it's not because I want people to look inside and recognize, you know what? Sometimes I don't speak up. And then I get resentful that people aren't meeting my needs. I'm expecting them to read my mind. I'm expecting them to know what I need. And then when they don't, I don't feel valued or noticed or heard. Well, guess what? We need to stand up and say, hey, this is what I need. This is not the time for subtleties. The next question what might others do that caused you to feel insecure or fearful in this process? They get angry, they walk away. They what is it that they may do? What are you afraid of if they get angry? What are you afraid is going to happen? Are you afraid they're going to hurt you? Are you afraid they're going to abandon you? Are you afraid they're going to reject you? What is it that you're afraid of? And then let's look at how we can help you feel safe even when. Because they'll probably get angry even when they get angry. How can we help you feel safe? What evidence do you have that when you do something, it's going to have a negative experience? When, when you speak your mind, when you assert yourself that you are going to get backlash from your significant or your, your, from your caregivers or your significant other. What evidence do you have? Give an example of a time that happened. Okay, you know, that's realistic to have that fear. You've had that experience. So big question now. How do you need the people in your family to act and react? Now notice I said act and react. Acting would be communicating, being mindful. Reacting would be when I say something or do something. If you get angry, that's okay. You have a right to your feeling. But, but this is what I need. When you react, instead of screaming and throwing things, this is what I need you to do. So we want everybody to be able to articulate what they need to feel safe enough to start these new behaviors. Goals of family involvement Examine the current homeostatic environment. I couldn't think of any other word besides homeostatic, so sorry, had to use it. Homeostasis is the desire to maintain the current balance and situation in a dysfunctional family. It may not be healthy, but you know what to expect. There is predictability, there's it, it's balanced. And so we want to look at what's going on in your current environment. What are the different roles and responsibilities of each person? Do you have 8 year olds tucking mom and dad into bed because they passed out drunk on the sofa? Do you have 15 year olds taking the kids to. Taking the kids to school because mom and dad are still sleeping? Or maybe not there. Do you have caregivers, you know, the. The spouse of the identified patient not only doing stuff that they're responsible for, but then doing stuff that the identified patient is responsible for to make sure that that person doesn't experience negative consequences. So what are the roles and responsibilities? And we'll talk about what they should be in a minute. What are the distress triggers and the family responses? There are certain triggers that trigger people with substance use issues to use that trigger people with mental illness to have exasperate exacerbations of symptoms. So let's look at what these distress triggers are. People, places, things, times of day, times of year, lots of triggers. But we need to recognize in general what they are. Here's a hint. Most of the time the triggers date back to trauma or a sense of feeling powerless and unsafe. And when they're reminded of those times, they want to numb. Behavior chains is another thing we want to look at because this helps us examine what's maintaining this, the rhythm of this family. A behavior chain tells us when this happens. Then this happens, then this happens, then this happens, then the person relapses or, you know, there's a problem. So we want to look at that behavior chain and figure out what is going on in the family that leads up to family. Family drama, we'll call it. That leads up to Junior getting suspended from school. Okay, where did that come from? Doesn't even have to do with the identified patient, does it? Well, maybe it does. Maybe Junior was so stressed out and so sleep deprived that they were acting more impulsively at school and that led them to get into more conflicts at school which led to them getting suspended. So we do want to look back at the entirety and examine what is going on that is motivating or supporting these behaviors to emerge at various times. We want to recognize certain patterns as intergenerational and or illness centric. These patterns of interacting, whether it is yelling when you don't get your own way, or drinking or withdrawing or self harm or binging or shopping, whatever it is, becoming resentful or gossiping. There are a lot of different behaviors that people develop to try to survive dysfunctional environments. So we want to figure out where or how did you learn them? Did you learn them in your family of origin? You know, dad, when he was stressed out, he'd had a bad day at work, always came home, polished off a six pack. Well, my coping skill, when I've had a bad day at work, I come home, I polish off a six pack. It's intergenerational learning. Don't talk, don't trust, don't feel. If you were raised in a family where the children especially weren't allowed to have a voice, then you may be repeating that pattern. Now we want to look back. Was there addiction, was there mental illness, was there dysfunction in your family of origin? And what patterns did you learn from that that you are repeating now? Not blaming, just identifying. Because people don't know a better option if that's what they've always done. And we want to look at what was the function of the behavior in your family of origin. If things got tense and you just went to your room and didn't come out and until you had to go to school the next day, what function, how did that function to help you survive? It removed you from the tension, it removed you from the stress. It helped you feel safer. It allowed the identified patient to de escalate some. But we do want to look at some of these dysfunctional patterns that cause people in the family to feel anxious, stressed out, unable to live Authentically to communicate and maintain their boundaries. What patterns exist there and where did they come from? Sometimes the person may have come from a perfectly healthy family, which I said is why I said it's not always intergenerational. But they get into this relationship and the behaviors develop illness centric. And as the person, the identified patient, begins to really struggle with their problem, the significant others or the rest of the family want to help, and they start modifying their behavior to try to support or fix the person with the identified problem. So these behaviors of enabling and scapegoating and everything else start to become. Start to get developed as a way to maintain some sort of balance and control in a very dysfunctional situation. We also want to move on. Once we've looked at what we've got, where are we going? In a healthy family system of yours, you know, you have five people in, in your family system. All right, so who is going to be responsible for what? This is what they're supposed to do. What is each person's role in the family? Some families tend to be much more hierarchical. Other families tend to be less. But what is each person's role in the family? How do we create safety and acceptance between and among family members? No gossiping, for example, if you've got a problem with somebody down regulating before you have a discussion with them, instead of biting their head off over dinner or something, you know, there are a lot of observable behaviors that people can develop in order to better handle distress and create an environment of safety and acceptance. And then in your healthy family system, how does the family respond to distress? Because stuff's going to happen. Life's going to happen. You know, somebody you know, grandma may get cancer or the. A child may get suspended from school. Who knows, but things are going to happen. That's just life. So when life hands you lemons and how does the family respond? How do we want to see each one of these people interact in order to create a consistent, attentive, responsive, encouraging and safe environment? The only people that can define that are the people in that family. And this needs to be done with all the family members. Sometimes some therapists prefer to do it one on one with each person and then have a family meeting. Other people prefer to do it with the whole family all at once. Part of it depends on how conflictual the family is and whether people are going to feel safe initially actually being authentic. Goals of family involvement are to reduce blame. Yes, everybody probably contributed, contributed a little bit of something in some way blaming. You did this, you did that isn't going to fix anything. How do you feel when I'm pointing at you going, you did this? A lot of people, as soon as that happens, they're like, oh, back off. So blame leads to defensiveness. Yes, there's probably blame to go around for different things, but that's not going to change anything. Whatever it was, was already happened. So let's look at what's going on right now and let's look at increasing personal responsibility, taking responsibility for your part in what's going on. Yes, I got suspended from school and yes, that made dad angry. I am responsible for triggering that feeling in dad and for making my bad choices. Dad is responsible for what he does with that anger and whether he uses it as an excuse to go drink or to become aggressive. So I am not responsible for what dad does with his feelings. I am responsible for what I did and acknowledging how it impacts people. And that's a very meta concept issue. Yes, I can do something that triggers feelings of anger or depression or even happiness in somebody else. But feelings are fleeting bits of information. What people do with them is their choice. Whether they nurture them and they use them as fuel for a fire or, or whether they recognize them and then figure out the best way to use their energy to address the situation, to move toward their rich and meaningful life. In order for people to take personal responsibility, we have to create a safe environment. We have to create an environment where people feel secure, that even if I screw up, even if I make a bad choice, that I am still going to be loved. I am not going to be abandoned, I'm not going to be abused, I'm not going to be rejected. That is so important. And again, we need to talk about, what does that look like for you if you tell your, your parents that you just failed the semester? Yeah, that's a big deal. What do you want that to look like? Yes, you screwed up. It doesn't mean you are a screw up. It means you made a or some bad choices. Which takes us to unhooking self from behaviors. We need to help not only the individual, but everybody in the family unhook what somebody does from who they are. Somebody can be a very good person and make a mistake. Increase interpersonal support of everybody in the family, both within the family and outside the family. Sometimes we just need an objective ear. So we want to encourage people within the family to find support systems both within the family and outside. We want to improve perspective taking. So if I come home and I say, you know, Mom, Dad, I really screwed up. I failed this whole semester. My perspective I'm going to take my parents perspective and realize they're going to be pretty ticked off because I just wasted 5, 10, $15,000 depending on what school you're going to, I'm going to realize they're going to be ticked off about what I did. I am. If I'm taking an accurate perspective. Hopefully I'm also recognizing they still love me, but they really dislike what I just did. And so taking perspectives and the caregivers, mom and dad are going to try to step into my shoes and say, wow, they must feel really disappointed in themselves and that must have been really scary for them to have to come and tell me. So probably me lecturing them and yelling at them and getting in their face probably isn't going to help matters any because they're already beating themselves up for it. So perspective taking can be helpful, especially before entering into a distressful conversation. Creating win wins. You know, recovery ain't all roses and bunny rabbits. A lot of times people family members may feel frustrated because some things have to change in order to support family recovery and in order to support the identified patient. But that's okay. Creating win wins. Yes, we can't do this anymore, but we can do this over here. One of the common complaints I hear in substance recovery is my significant other goes to meetings every single night. They're never home in the evening. And but creating a win win. What is it that this person can do to help you feel less abandoned? Help you feel less ignored when you go to these meetings? And maybe that means you going to your own al Anon meeting. Who knows? Creating a consistent, attentive, responsive, encouraging and safe environment and encouraging people in therapy to talk about what happened over the past week that helped you feel safe and empowered and nurtured in your in your environment. Encourage them to develop healthy boundaries and promote effective communication. That means respecting emotional boundaries, cognitive boundaries. Everybody has the right to their own feelings and thoughts as well as physical boundaries. Eliminate cognitive distortions by using fitcat facts in this context at this time or feels facts. What's going on right now based on the facts, not on my feelings. So the facts explanations. What are some alternate explanations for why this might have happened? The next E stands for exceptions. If I think this is always or never happening, are there exceptions to when this happens? And L stands for likelihood. What is the likelihood that that my worst fear is actually going to come true? We could apply either one of these to the cognitive distortions of jumping to Conclusions and mind reading. Remember, we our schema encourage us to anticipate the future based on the past doesn't mean that what's going on right now, even though it's similar to the past, doesn't mean that it means the same thing. So we need to evaluate the facts. Personalization. Are there other explanations for why this might be happening besides me and emotional reasoning? Expecting the worst or seeing life through a trauma lens? I am anxious right now. John's late getting home. I'm anxious. That must mean that he's out drinking. So we're jumping to conclusions and we're emotional reasoning again. Remember, children are learning through an egocentric, personalized and all or nothing lens. So they're going to be more likely to have these cognitive distortions that we need to help them sort through challenges in recovery. A lack of awareness of their part in maintaining the problem. So the family, and I don't mean the identified patient. A lot of times they recognize that they've created a problem, but sometimes they're taking all the blame when in reality the entire family has played into this symphony of dysfunction. Resistant to changes based on fear of failure or abandonment. If I change and it doesn't work, or if I change and you don't like it, then I'll be abandoned, overwhelmed. I just got too much going on. I'm too exhausted from dealing with this for 10 years. I just don't know where to start. Okay, let's break it down into smaller goals. A belief in the process is lacking. If the family doesn't believe that anything they do is going to make a difference, they're not going to be motivated to do it and skills inadequate. If they. If the family doesn't have adequate communication skills or boundary setting skills or awareness of what's going on, then they're not going to be able to implement the plan effectively. We need to help people overcome fear of vulnerability such as I could get hurt, you could abandon me or I could make you relapse. So we want to address each one of those fears and figure out a plan for dealing with them. The last one partly being recognizing that you can't make another person do anything. You can trigger a feeling in them, but what they do with that feeling is their responsibility in terms of interventions for each person. And I know we're running short on time, so I'm going to speed it up here. Heal thyself. Everybody has been negatively impacted by the dysfunction and it's important to heal your own nervous system and start getting better sleep so you can better activate that wise mind. Your problem solving, your memory, your learning and your adaptability. Walk the walk, don't just talk the talk. If you're telling everybody else in the family that they should be doing this or that, are you doing it? Are you embracing the roles and maintaining the boundaries of the roles for your new healthy family? Recognize how your health, interactions, emotions, perceptions and behavior impact the family and vice versa. Be aware of how others are impacting you and how you're impacting others. It starts creating a much more mindful and safe environment. Physically reduce sympathetic overdrive and strengthen the parasympathetic nervous system. Reduce stress and strengthen relaxation. Do this by developing distress tolerance and downregulation skills. Engage in activities to improve vagal tone like biofeedback or positive behavioral activation. Increase oxytocin. Oxytocin is a powerful anti inflammatory and nervous system regulator. Who knew you can do this by creating gratitude? There are a lot of ways to increase oxytocin, but it is a powerful tool in your toolbox. Regulate circadian rhythms so your cortisol is peaking at the right times and your melatonin is going to help peak at the right time to help you get good sleep. Improve sleep quality and hygiene. Improve nutrition, hydration and gut health. Sleep, circadian rhythms and nutrition, hydration and gut health. When they are out of whack, it triggers your stress response even if nothing else is going on. So if you want to heal that stress response, we need to heal the body too. Interpersonally. Enhance self esteem and efficacy how you feel about yourself and your ability to live your rich and meaningful life. Improve secure attachment with yourself. Create a secure, consistent, attentive, responsive, encouraging and safe environment in in your own head and recognize that you can protect yourself. Recognize the power that you do have. Grieve prior attachment, traumas and losses. Communicate your needs to others. Prioritize time to authentically communicate with others. And that's important. Setting aside time to speak to your family about how you're feeling, what's going on. It is important at healing those relationships and developing a sense of safety and trust. Focus your energy on controlling your own thoughts, feelings and behaviors. Recognize that it's okay to be angry, terrified or hopeless. These are emotions. These are feelings that are triggered. It's what you do with them that can be helpful or harmful. Work with a therapist to explore traumas and related triggers that are maintaining your distress and recognize this is a big one. Recognize irritability and anxiety as a response to change. Even if you're changing in the right direction. It's stressful and it's scary, and it will trigger irritability and anxiety. Cognitively define your vision of a rich and meaningful life and how your healthy family, this new system that you're creating, fits into that vision. Embrace the dialectics, recognizing that your significant other may have to go to support groups every night, but if they're going to those support groups, it also means they're likely coming home and it's going to be a good night when they get home instead of maybe they don't come home or maybe they come home and it's conflictual. I must accept that I cannot control them and I can make decisions as needed to stay safe. Accepting, embracing the dialectics that I'm going to do what I can and I can take steps necessary to stay safe and leave the situation if needed. The other one, they, the identified patient. They're not where I wanted them to be, but they're doing the best that they can. I wanted them to have achieved all these things by now, but they haven't. Okay, well, that's my stuff. I recognize and embrace the fact that they are doing the best that they can. Know who's talking in your own head. Is it a scared child, so trauma from your past, a scared adult, trauma from this relationship, or is it your facts in this context at this time, your fit cat. Environmentally remove or mitigate distress triggers for your own distress as well as that of the formally identified patient. Alcohol, if that was a problem. A computer, if that was a trigger. Certain outfits. Maybe they wore a certain outfit when they would go out drinking, or they were wearing a certain outfit when they tried to commit suicide. You may want to get rid of that outfit. Certain people or places may be triggering because you see them and you're like, ah, this person's never good for you. Okay, consider eliminating those or figuring out how to manage those so they cause less distress. Addiction and mental illness both negatively impact the family unit. Messages and patterns learned while surviving a dysfunctional family are often continued in other relationships and intergenerationally. When the family fails to recover, the identified patient often relapses. Because dysfunctional patterns are maintained, they get sucked back in. So we need to encourage them to use the family environment to create a safe area, a safe space for them to live, learn, and grow.