Social Support, Family Dynamics, and Therapeutic Relationships in Post-Incarceration Recovery for People Who Use Opioids

Social Support, Family Dynamics, and Therapeutic Relationships in Post-Incarceration Recovery for People Who Use Opioids | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Social Support, Family Dynamics, and Therapeutic Relationships in Post-Incarceration Recovery for People Who Use Opioids Sarah Pollock, Derrick Moyo, Pretty Ndini, Urvisha Bhoora, Tonderai Mabuto, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9012567/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Social support after release from incarceration is crucial for social reintegration and rehabilitation. For people with current or previous substance use, social support systems are a key factor in their recovery. Supportive interpersonal relationships with family members and service providers can significantly impact substance use, social, and psychological outcomes. In this qualitative analysis, we explore how individuals navigate familial and service provider support systems in the context of their substance use recovery after release from incarceration. Methods This analysis drew from a longitudinal cohort study examining challenges of illicit opioid use faced by people living with HIV transitioning from correctional facilities to the community in the Tshwane District in South Africa. In-depth interviews were conducted at 30, 60, 120, and 180 days post-release. Participants (n = 18) who completed at least three of the four in-depth interviews were included. Results This analysis identified complex dynamics between family relationships, personal agency, and opioid use disorder (OUD) recovery. Three themes were identified: conditional acceptance and dependence on family resources; otherness and desires for normalcy; and supportive relationships in therapeutic spaces. Sustained family support and encouragement were vital to participants' successful recovery trajectories. Compassionate, non-judgmental treatment from social workers fostered greater engagement in care. Conclusions Strong social support in OUD recovery can significantly impact health and wellness of people with OUD. Carceral and community health programs should prioritize social reintegration, family involvement, and community-based resources alongside clinical interventions. Substance use opioids recovery social support therapeutic relationships incarceration reentry Background Upon release from incarceration, individuals face adverse reentry conditions characterized by economic precarity(1,2), unstable housing(3–9), health care interruptions(1,3–8), stigma(1,5,10,11), and disrupted social networks(1,9,10,12–16). These individuals typically have limited access to health and social services and face ongoing challenges in securing essential resources(1,2,4,6,9,10,17). Without effective discharge planning or care linkage services, most formerly incarcerated individuals struggle to access medical care(18,19), experiencing high levels of mortality, morbidity, and hospitalization(20–23). For people with active or prior substance use disorders (SUDs), lack of care continuity after release exacerbates psychiatric symptoms and suicidality(1,18,20) and heightens risk for drug relapse and overdose(2,20,24–26). Additionally, these individuals face challenges reconnecting with their families(15) and communities while navigating the complex process of rebuilding their sense of self and social bonds(9,27,28). Social support systems frequently serve as the most critical factor in the SUD recovery process.(29,30) Consistent engagement with community organizations and membership in supportive communities can transform an individual’s social network from problematic to supportive(33,34) and facilitate long-term identity change, contributing to sustained recovery(35,36). The effects of substance use disorders extend beyond the individual to impact entire families, just as family relationships and dynamics play a crucial role in both the development of addiction and recovery success(37). During the reentry period, families can be important sources of encouragement, strength, and resilience(3,5,9,27,38) and provide assistance with SUD treatment access(10,39) and medication adherence(5). The quality of interpersonal relationships, including family, partners, and peers, can determine the effectiveness of substance use disorder (SUD) treatment(40–43), significantly influencing substance use patterns, treatment utilization, and relapse risk (40–42,44–49). Supportive family systems are especially powerful in fostering substance use treatment motivation and engagement(39,50–57) and positive treatment outcomes(42,58–62), as individuals who enter treatment with strong, cohesive family relationships have reported positive social, psychological, and substance use management outcomes(41,63). Reentry(2,6) and community-based(9) programs offer support by facilitating skill development and employment opportunities, fostering confidence, and establishing connections to basic needs and treatment services. Consistent respect, trust, and praise from providers is highly valued by patients(64–66) and has been shown to promote positive SUD treatment outcomes(48,64–67) including adherence(68) and retention(64–66,69). Illicit opioid use is increasing in Africa(70–72). Opioids, referred to by locals as nyaope (73–75), are among the most common substances used in prisons in multiple regions of South Africa(76,77). Treatment programs that provide evidence-based medications such as MOUD are scarce in sub-Saharan Africa(78,79). High incarceration(80,81) and recidivism(80,82) rates in South Africa intersect significantly with opioid use disorder, creating an overlap between addiction and carceral involvement(76,77,83). Given that recovery from SUDs is a long-term and continuous process(84,85) requiring sustained support, a longitudinal approach to examining OUD and social support relationships is ideal. There is a dearth of literature centered on factors that facilitate sustained recovery from SUDs within South Africa(86). The current study is a qualitative investigation of SUD recovery and relationship dynamics among individuals with OUD in South Africa engaged in community-based treatment services, exploring how participants navigate familial and other support systems in the context of their recovery. Methods Study setting and population This analysis used data from a longitudinal study that examined self-reported illicit opioid use among people living with HIV (PLHIV) as they transitioned from correctional facilities to the community in South Africa’s Tshwane District. The study was implemented between March 2021 and June 2023 in Kgosi Mampuru II Management Area, Gauteng, South Africa. A cohort of 37 formerly incarcerated PLHIV self-reporting current or previous opioid use ( nyaope ) were recruited and offered harm reduction services and methadone maintenance treatment provided by the Community Oriented Substance Use Programme (COSUP). Post-release follow-up and COSUP linkage Within two weeks of release, a field researcher and COSUP social worker met with participants to update contact information, provide harm reduction counselling and methadone planning, connect the participant with a COSUP site and peer navigator, and encourage them to continue HIV care with a community clinic. Study participants were linked to COSUP to receive standard of care services including assessment of needs, harm reduction services, methadone, if determined to be appropriate based on routine screening, and peer support. Data collection: Qualitative methods In-depth interviews were conducted by trained interviewers in the participant’s language of choice (English, isiZulu, isiXhosa, or Setswana). Interviews were scheduled at the following intervals: 30, 60, 120, and 180 days post-release. The interview topics focused on substance use, substance use management, social support, HIV care, experiences with COSUP and other opioid use support services. Data analysis Participants (n = 18) who completed at least three of the four in-depth interviews were included in this analysis. The participants completed 62 total interviews across all time points. The average age of participants was 35 years (SD: 5.65). 17 participants identified as heterosexual and one as bisexual. Audio recordings were transcribed verbatim, translated into English as needed, and uploaded into MAXQDA software (VERBI GmbH, Berlin) for coding. Qualitative data were analysed thematically, using deductive and inductive coding. Transcripts were read by researchers for data familiarisation. Concepts were explored using a priori coding guide with codes that included living environment, relationships, social support, identity, substance use, stigmatization, COSUP services, and MOUD. Under each code, inductive subcodes were created to define common domains. Results We identified complex dynamics between family relationships, personal agency, and OUD recovery. Findings illuminated three themes that shaped participants' recovery trajectories over the six-month study period. First, participants experienced conditional autonomy and material restrictions, e.g., limited access to their homes, which served as both punishment and motivation for change. Second, the language of "normalcy" emerged as central to participants' recovery narratives, representing not merely abstinence from illicit substances but a broader restoration of social identity and moral standing within their communities. Finally, therapeutic spaces that offered non-judgmental support often served as alternatives venues and communities to strained family relationships, providing emotional safety and professional guidance that participants often could not access within their family systems. Together, these themes demonstrate how recovery unfolds within complex social contexts where family dynamics, social stigma, and institutional support intersect to either facilitate or hinder individuals' paths toward sustained recovery. In the results below, we explore these themes and use case trajectories to illustrate how dynamics changed over time following reentry. Theme 1: Acceptance and dependence on family resources (i.e., material support) Participants' acceptance by their families was often conditional upon their ability to demonstrate worthiness through behavioral compliance or economic contribution, particularly in the earlier months of reentry. Notable restrictions included family denying participants food access and entry into homes. One participant described sleeping in a tent in his sister’s yard and only having access to bathing facilities, explaining: “I can’t earn my keep right now, I really can’t. Eh I can’t contribute to lights and water bill; I can’t contribute to rent eh it’s just terrible. So, I find myself in the yard” (Participant 607-007; 30-day interview) . Participants attributed home access restrictions to family members’ concerns about actual or perceived continued substance use, rather than other behaviors that might negatively affect the household: “There is no one who does not wish to stop smoking drugs. Do you know in other houses a person who smoke drugs is not allowed to enter, even if they don’t steal or what, they are just not allowed inside the house. There are houses like that, where you cannot enter if you use drugs” (Participant 607-006; 180-day interview). Principles such as "a man should earn his keep" (Participant 607-007; 30-day interview) and “a man must help” (Participant 605 − 012; 30-day interview) were used by participants to justify their restrictions on access to basic resources. Participants internalized their limited ability to assist the household financially, expressing deference to their families and guilt over their inability to contribute financially, with statements like “I just have to be grateful for the little bread that they provide for me” (Participant 605 − 012; 30-day interview ) and “I shouldn't be a burden” (Participant 605 − 012; 60-day interview ). Only when participants reduced their drug use and demonstrated they could contribute to the household through daily chores did they describe having access to the house: “A better [name]…. the old [name] was no longer entering in the house but now he does” (Participant 607 − 012; 120-day interview). For some, material dependence compounded with the stigma of substance use resulted in feelings of infantilization and distress over loss of independence. One participant described frustration over being judged by his younger sister: “It almost feels like I am younger than her, and she's the older sibling, and it hurts me when it gets there I am older than her. I am the one who should be giving her advice, because what I have gone through, she has not experienced that. I have more experience than her, whether she works or not, whether she has more income than me, I have more life experience than her” (Participant 607 − 011; 30-day interview). Despite being the older sibling with greater lived experience, the participant felt his sister dismissed or devalued him because of his substance use and "mistakes," discounting the insights his experiences could provide. Diminished personhood and its associated psychological impacts varied across participants. Despite being accused of stealing at home and denied food, some participants withheld blame and concluded that it was their responsibility “to bring back that trust” (Participant 605 − 018; 60-day interview) and “ prove to them that I am dedicated ” (Participant 605 − 018; 120-day interview) . Other participants felt the negative effects of reduced autonomy and family social standing more acutely, with one reporting that “other people at home, they treat me as if I don't exist” (Participant 607 − 012; 60-day interview) due to his nyaope use, making him “feel bad. It hurts” (Participant 607 − 012; 60-day interview) . He elaborated on his desire for patience and emotional support from his family. Instead, he felt spoken to harshly and seen as a “useless person.” In contrast, several participants’ families took an autonomy-respecting stance, even in the context of ongoing substance use and reliance on material support. Some family members provided consistent emotional and financial support, showing patience and understanding towards the participant’s substance use challenges. Supportive relationships characterized by love and encouragement emerged as positive forces in participants' recovery journeys. One participant who did not use nyaope throughout the study period described his mother's influence: "that is the thing that gives me power, even my mother gives me support. She says, 'keep it up, stop using drugs. Because if you don't stop using drugs, you are limiting your days of living'” (Participant 605 − 010; 60-day interview). Another participant’s family took an informal harm reduction approach to his substance use, allowing him to use nyaope at home to keep him off the street and away from potential criminal activity. Spending more time at home and working for the family business allowed his family to begin "truly understanding me and what was happening with me" (Participant 607-001; 30-day interview) , bringing them closer and creating harmony within the household. Case trajectory Participant 607 − 012 lived with his mother. He resumed using nyaope two months after his release and continued to use nyaope throughout the study period. During this period his mother exerted significant control over his daily routine. At 30 days, he described how living with his mother was challenging because of her controlling and overbearing tendencies. If he did not act according to her standards he would “suffer my mother’s harsh rules, then I would eat when she feels like it” . He explained that his mother expected him to work and get chores done around the house, making him feel “like I was being used, like I was supposed to be always working, and not even get the time to relax like this, to rest." These obligations prompted him to avoid the house and to use nyaope on the streets, away from his mother’s monitoring. At 60 days post-release, the participant described having restricted access to the house, often watching TV by looking through a window. When his mother invited him inside to massage her hand, he was excited to reconnect with his home environment “…it has been a long time not entering the house, like even smell the scent of the house and sit on the sofa, things like that. That moment made me happy." At 120 days post-release, the participant continued to experience conflict with his mother who was “still yelling;” however, he reported more compliance with chores and was granted access to the house. By 180 days post-release, the relationship with his mother was still strained and she threatened to call the Criminal Investigation Department during arguments. He described the situation with his mother as "very painful...because she is someone who is close to me most of the time, so she is the person I should be able to tell how I feel...But she doesn’t want to know how I’m feeling" . Despite indicating a desire to quit nyaope , the participant struggled to stay away from " the street life ," illustrating how family dysfunction and limited autonomy can compromise the recovery process and push an individual to a place of greater acceptance but also greater risk for illicit substance use. Participants experienced varying degrees of family acceptance and reintegration. For some, addiction led to discriminatory treatment that extended beyond limited resource access to encompass damaged relationships and diminished status within family structures. These results highlight how social and emotional marginalization can profoundly impact individuals and demonstrate that dignity encompasses not just material well-being but also the quality of interpersonal interactions. Additionally, the results show the importance of non-judgmental family support in fostering a positive and sustained recovery journey. Theme 2: Otherness and desires for normalcy Participants invoked the language of "normalcy" to describe both what they had lost through substance use and what they hoped to regain through recovery. Normalcy was not framed simply as abstinence from substances, but as a broader ideal encompassing stability, self-worth, and social inclusion. After receiving methadone from COSUP and abstaining from nyaope for two weeks, a participant expressed feeling like a “normal person” (Participant 607 − 011; 180-day interview) . He went on to explain that he felt revitalized to listen to music and enter stores without fear “just like any other person” , as his sobriety allowed him to fully experience life’s simple pleasures and go about his daily routine without stigma. Continued substance use, in contrast, was described as a condition of otherness and abnormality, a state of social and moral deviance, exclusion, and diminished personhood. For most participants, achieving normalcy was synonymous with stopping nyaope . One participant openly shared that he did not consider himself a “normal person” because if “I was a normal person, I would be doing things that are done by normal people who don’t use drugs” (Participant 607 − 012; 30-day interview) . He described the stigma he experienced in everyday settings: “People who use drugs are judged, it doesn’t matter whether it’s at your home or where. As someone who use drugs entering the shop, the floor walker there will keep following you, but as a normal person they won’t follow you at all. They always think you are there to steal. Even though you didn’t go in to steal. So do you see that they are judgmental” (Participant 607 − 012; 60-day interview). The participant’s perception of exclusion and “otherness” reinforced his desire to stop using illicit substances and gain employment so he could “live a normal life, just like any other person” (Participant 607 − 012; 180-day interview) . Sobriety represented not only freedom from substances, but freedom from a perceived stigmatizing gaze that marked him as deviant. For many participants, the desire for normalcy was tied to traditional social roles, particularly that of being a father, partner, or provider. Fatherhood was both a relational role and a moral identity, reflecting a desire to break the cycle of addiction for the next generation: “I don’t want him to imitate the drug addiction part of my life. Lot of things that is passed on from one generation to the next. I don’t even want to be like that in front of the child, you don’t even see me behave that way” (607-007; 30-day interview) . The motivation to stop using illicit substances was also tied to a deep longing to restore a sense of identity and belonging within the family, specifically, to return to how they were perceived before their drug use: “again with the issue of drugs...I want to see myself going back to normal to be the same [name] they knew” (605 − 010; 30-day interview) . This yearning for recognition by others as "normal" underscores that rehabilitation is as much about social reintegration and repairing relational identity as it is about managing addiction. Case trajectory Participant 607 − 011 lived with several family members. He actively used nyaope throughout the study until reporting in the 180-day interview that he had stopped using nyaope and started methadone. Throughout the study, the participant voiced a consistent desire to stop using nyaope while balancing tensions with his sister and caregiving responsibilities. At the 30-day interview he noted reengagement with the community and positive feedback from them, “ you still smoke? if you smoke, you need to stop because you actually look like you are not smoking. Now you look like a changed person, are you working.” He described this as a form of social validation, reinforcing his shift toward a more “normal” and socially acceptable identity. At 60 days, despite struggling to reduce his nyaope use before initiating methadone, he made meaningful efforts to shift his behavior by spending more time at home and helping with chores, which he believed encouraged his sister to be more emotionally available and to communicate more with him. At 120 days, the participant described being judged in social spaces but reaffirmed his commitment to change, emphasizing his desire to secure employment and “live a normal life that one should live.” By 180 days, the participant reported no longer using nyaope and initiating methadone treatment at COSUP, making him feel “Like a person. I think that it’s now that I hear. I can feel, that feeling of every normal person, I was not normal,” underscoring how achieving abstinence restored his perceived sense of normalcy and self-worth. The concept of normalcy was central to how many participants understood their substance use and envisioned their path toward social stability and acceptance. While active addiction was marked by deviance and judgment, the desire to escape these labels and shed anticipated stigma motivated positive change, prompting participants to reclaim their identities and repair family relationships. Theme 3: Supportive relationships in therapeutic spaces Many participants relied on support from social workers to navigate their substance use recovery challenges, particularly when family relationships were strained or absent. For some, consistent support from social workers created a sense of stability and encouragement. Participants described how COSUP social workers offered both motivation and practical guidance while fostering a safe, non-judgmental space for open communication: “They build me and they give advice. Every time they talk to me, I feel okay, and I can talk to them freely. That benefits me a lot because I can share anything that bothers me. They talk although they don’t know me, they don’t judge me, they create a safe space for me" (Participant 600-003; 30-day interview ). One participant emphasized that receiving guidance from a social worker was his primary reason for engaging with COSUP services, explaining, "That is what gives me courage. Before, I had no one to confide in when I faced a problem—no one at all. But now, at least there is someone I can turn to. Life has brought me immense stress, but having someone to share my struggles with has made a difference. I've been able to open up about some of the things weighing on me” (Participant 605 − 010; 120-day interview. Participants also recognized the value of having someone to rely on beyond their family. For example, Participant 605 − 018 recounted how a COSUP social worker accompanied his mother and sister to court as they navigated a custody dispute. He reflected, "It makes me happy, that thing. I’ve got a shoulder to cry on, you get me. You mustn’t only have family support—even outside your family, you must get it” (Participant 605 − 018; 60-day interview). In the absence of other confidants, social workers were especially meaningful, providing reassurance and relief, especially in areas where participants felt unable to confide in family members. The presence of non-judgmental, supportive social workers was repeatedly described by participants as central to their emotional resilience and sense of hope during recovery. Participants also described the empowering effect of being heard and receiving practical guidance from social workers: “They give you power, you become strong” (Participant 607 − 011; 120-day interview ). The sessions were not only therapeutic but also educational, helping participants develop insight into their situations: “You may know but only to find that you didn’t have the full understanding when you spend time in those sessions with the social workers, they are professionals, and they know what they are doing” (Participant 607 − 011; 120-day interview ). The emotional investment and care shown by social workers helped foster motivation and accountability, as one person shared, “They do take care, you see it’s not simple that journey, but they make it in a way that you also feel that there are people that care and you don’t want to disappoint them because you can see they care.” (Participant 607 − 014; 30-day interview) This sense of support without judgment helped participants reframe their personal challenges and view recovery as manageable. In contrast to the shame and indignity described in the first two themes, social workers approached addiction through a lens of evidence and compassion, which participants were more receptive to. Case trajectory Participant 600-002 lived with several family members. She used nyaope earlier in the study until reporting in the 120-day interview that she had quit and started methadone at COSUP. Her experience across study timepoints revealed the positive impact of having consistent encouragement and emotional support from COSUP social workers. At 60 days post-release, the participant described significant conflict and tension within her family and the absence of support. She explained, “ I don’t have a friend or family to talk to. I keep it inside, I don’t tell anyone, there is no one I can discuss my problems with ”. Unlike her experiences with family, she felt safe when opening up to COSUP staff, which helped alleviate emotional burdens. At 120 days post-release, she continued to engage in COSUP services and initiated methadone. By 180 days, she emphasized how the non-judgmental and confidential support allowed her free expression without fear of betrayal or stigma: “Even the things that were bothering me, it was easy for me to tell them because at home, I cannot speak to friends” . She described her relationship with COSUP staff as one marked by emotional safety, helping her to feel empowered and repair family bonds during recovery. Social workers at COSUP had a profound impact on participants' lives, fundamentally shaping their recovery trajectories. The opportunity to be authentically seen and heard in a safe stigma-free space emerged as a critical factor in fostering sustained engagement in care, reinforcing the value of effective evidence-based strategies to support those with SUD. Discussion This study sought to explore the recovery trajectories of people with OUD in South Africa who returned to communities after incarceration and to identify factors that influence such recovery. Longitudinal qualitative methodology was used to investigate SUD recovery and social relationship dynamics, engagement in community-based treatment services, and experiences of familial and service provider support systems. The findings identified that participants and their families largely viewed drug use as moral failure, with participants’ inability to contribute to the household leading to diminished status. Though addiction was often linked to reduced personhood and dignity, families' responses varied considerably: while some employed shaming and exclusionary practices, others offered acceptance and love. Service providers emerged as another vital source of support to participants, providing emotional relief and comfort. This support was especially important when family support was lacking or strained. This work builds on prior literature describing most of emotional and instrumental support(87,88) coming from family members for people using illicit substances. This type of “resource provision”(89) is often apparent among families who support adult family members with SUD(90–92) and can be considered as essential to recovery(89). However, the dual nature of family relationships in recovery processes was evident in this study, with instances of family members functioning either as catalysts for change or barriers to progress, consistent with literature documenting the contradictory roles families can play in substance use recovery trajectories(89,93,94) and societal reintegration post-release(95,96). Our findings advance understanding of strained family relationships in post-release recovery by providing contemporary evidence and detailed examination of the specific ways these dynamics impact recovery efforts. Family members' controlling and judgmental behaviors impeded trust building and created additional psychological burdens on participants, often reinforcing feelings of shame and social exclusion. Such dynamics are consistent with Padgett & Drake's(93) findings regarding familial rejection and condemnation of their family members who use illicit substances. Family disengagement and indifference also emerged as salient sources of emotional distress, reinforcing Gideon’s(97) observations that post-release, conflict often arises when family members are apathetic to individuals’ treatment or recovery and do not participate in any therapeutic programming. In our study, participants described frustration with family members’ limited interest in their recovery and well-being. Notably, distress was not always precipitated by overt conflict or explicit expressions of judgment or control. Rather, for some participants, the absence of engagement manifested through indifference or lack of inquiry conveyed the sense that their families were not invested in their recovery. This perceived disengagement was described as particularly painful, highlighting the importance of consistent familial involvement as a supportive resource(90). As participant 607-007 emphasized, “…we must interact…. And only through interaction can our problems be alleviated and maybe life made a little bit easier” . Many participants' recovery narratives were organized around reconstructing their sense of self and achieving what they conceptualized as "normalcy" consistent with previous research on incarceration and substance use recovery.(98,99) This is in contrast to the incarcerated population studied by O'Sullivan et al(98) where substance use could be either be perceived as normal (Self) or a change within themselves or their lifestyle (Other) depending on the individual. The description of not feeling like a "normal person" while using substances reflects what McIntosh and McKeganey(99) identified as the reconstruction of sense of self that occurs during recovery. However, our findings suggest this reconstruction is not simply about returning to a pre-addiction identity, but rather about achieving social stability and inclusion, and being accepted in social roles. Participant 607 − 011’s experience of being controlled by and subordinate to his sister highlights the effect of substance use on loss of social status(100). This may be particularly denigrating to men whose have built an identity on being provider and leaders in a household(100). Similarly, systematic review evidence(101) confirms that expanding social roles, belonging, and meaningful engagement facilitate recovery among individuals with co-occurring disorders, underscoring recovery as a socially embedded process of identity transformation(99,102–104). Participants consistently emphasized the transformative impact of having access to COSUP social workers who provided unconditional, judgement-free emotional support. The ability to "talk freely" and share "anything that bothers me" created safe spaces—a fundamental prerequisite for meaningful therapeutic engagement(42,48,105–107). Safe therapeutic spaces were sometimes missing from other relationships. While family members often struggled with trust issues, disappointment, and judgment related to participants' substance use history, substance use program team members offered a consistent source of validation and support. As one participant noted, the program workers "don't judge me, they create a safe space for me", reinforcing the importance of therapeutic relationships in professional settings, especially when personal relationships are compromised. In a recent qualitative study(108), formerly incarcerated individuals described how positive interactions with housing navigators were effective in facilitating linkages to housing and substance use services. Clients shared how navigators reduced anxiety and stress around drug use, bolstering their [clients’] sense of self-worth and empowering them to improve recovery health habits(108). Participants described how having "a shoulder to cry on" beyond family support was essential for their emotional wellbeing and recovery motivation. In some cases, the substance use program workers went beyond traditional program roles and performed activities such as accompanying family members to court proceedings. This embodiment of genuine care reinforces the importance of empathy(109,110) and a positive attitude(106) in strengthening the therapeutic alliance(105)—a critical factor known to influence both motivation for change and treatment effectiveness(110). For some participants, such compassion was in stark contrast to harsh and insensitive treatment from family members, emphasizing the necessity of effective and accessible evidence-based interventions for SUD. This study has the following limitations. Data collection occurred at four time points, but some participants were unable to complete all interviews, resulting in missing data. Nonetheless, over half of the participants completed three or more interviews, yielding longitudinal data to trace patterns of change over time. Participants were asked about past events, so their answers were subject to recall bias. The sample was predominantly male and had limited perspectives from women. Participants shared personal stories, which limits generalizability to other populations and settings. Lastly, recovery is recognized as a gradual and ongoing process; six months is likely not enough time to fully capture individual trajectories. Conclusions We add to the literature the importance of having strong social support in SUD recovery, showing how support from both service providers and family members can significantly impact the health and livelihoods of people with OUD. Clinicians can incorporate social aspects into their therapeutic processes by including families and social support groups(48,89) in client programming and providing SUD and recovery education(89). Further, clinicians should be cognizant of the social dimensions of life(111), considering individual’s social networks as areas to strengthen support and increase social participation(112). Consistent with United Nations standards and norms in crime prevention and criminal justice(113), correctional facilities should prioritize social connection and rehabilitation both during incarceration and throughout the community reentry process. These social connections should be facilitated between incarcerated individuals and their families, as well as with outside agencies such as COSUP that can assist with social reintegration, provide support to both individuals and their families. Such processes are aligned with restorative justice(114–116) principles that aim to assist individuals in building peaceful social lives and working toward collective healing. Our findings also highlight the broader importance of cultivating meaningful social connections and activities that support identity reconstruction and social integration. Recovery-oriented interventions should extend beyond individual therapy or MOUD to include opportunities for participants to engage in valued social roles and activities that reinforce their emerging non-user identity. This might include vocational training, community service opportunities, peer support groups, and recreational activities that provide alternatives to substance-using social networks. The emphasis participants placed on achieving "normalcy" through employment, family roles, and community participation suggests that recovery interventions should prioritize social reintegration, recognizing that sustainable recovery often depends on the availability of meaningful alternatives to substance-using lifestyles. Declarations Ethics approval and consent to participate Written informed consent from each participant was obtained using study-approved informed consent forms. The use of written informed consent forms ensured that participants were provided with detailed information about the study, including its purpose, procedures, potential risks, and protection of their privacy. Additionally, unique study-generated participant identity numbers were assigned to each participant to protect their identity and confidentiality. This practice was essential in ensuring that participants' identities were not revealed in any study-related materials. For the qualitative follow-up interviews, written informed audio recording consent was obtained from each participant prior to the start of the interview. This additional step ensured that participants were fully aware of the recording process and had the opportunity to consent to being recorded. The study was approved by the Institutional Review Boards of the University of the Witwatersrand in Johannesburg and the University of Pretoria in South Africa, the Johns Hopkins School of Medicine in Baltimore, Maryland, and the South African Department of Correctional Services. Consent for publication Not applicable Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study Competing interests The authors declare that they have no competing interests Funding This research was funded through a grant from the US National Institutes of Health Fogarty International Center: Grant No.: R21TW011689. The funder was not involved in the design, interpretation, or writing of this manuscript. Authors' contributions SP coded and analyzed the qualitative data, conceived the analysis idea, and drafted the manuscript. DM and PN conducted the in-depth interviews and made substantial contributions to acquisition of the data. UB made substantial contributions to the study design, acquisition of the data, and manuscript review. TM made substantial contributions to the study design and oversight. LS made substantial contributions to data management. JH made substantial contributions to the study design and data interpretation. CH obtained funding for and designed the study and made substantial contributions to reviewing the manuscript. JO made substantial contributions to the study design and reviewed and edited the manuscript. Acknowledgements We acknowledge the financial contribution and partnership of the City of Tshwane through COSUP (Community Oriented Substance Use Programme). We wish to thank all the study participants for their engagement and trust in the research process. 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Bringing fear into focus: The intersections of HIV and masculine gender norms in Côte d’Ivoire. PLOS ONE. 2019 Oct 23;14(10):e0223414. doi:10.1371/journal.pone.0223414 De Ruysscher C, Vandevelde S, Vanderplasschen W, De Maeyer J, Vanheule S. The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review of Qualitative Research From a First-Person Perspective. Journal of Dual Diagnosis. 2017 Oct 2;13(4):264–79. doi:10.1080/15504263.2017.1349977 PubMed PMID: 28699834. Best D, Beckwith M, Haslam C, Alexander Haslam S, Jetten J, Mawson E, et al. Overcoming alcohol and other drug addiction as a process of social identity transition: the social identity model of recovery (SIMOR). Addiction Research & Theory. 2016 Mar 3;24(2):111–23. doi:10.3109/16066359.2015.1075980 Chen G. Identity Construction in Recovery from Substance Use Disorders. Journal of Psychoactive Drugs. 2024 Jan 1;56(1):109–16. doi:10.1080/02791072.2022.2159592 PubMed PMID: 36538493. Koski-Jannes A. Social and Personal Identity Projects in the Recovery from Addictive Behaviours. Addiction Research & Theory. 2002 Jan 1;10(2):183–202. doi:10.1080/16066350290017266 Brunelle N, Bertrand K, Landry M, Flores-Aranda J, Patenaude C, Brochu S. Recovery from substance use: Drug-dependent people’s experiences with sources that motivate them to change. Drugs: Education, Prevention and Policy. 2015 May 4;22(3):301–7. doi:10.3109/09687637.2015.1021665 Kolind T. Form or content: The application of user perspectives in treatment research. Drugs: Education, Prevention and Policy. 2007 Jan 1;14(3):261–75. doi:10.1080/09687630601073807 Erickson M, Deering K, Ranville F, Bingham B, Young P, Korchinski M, et al. “They Give you a bus Ticket and They Kick you Loose”: A Qualitative Analysis of Post-Release Experiences among Recently Incarcerated Women Living with HIV in Metro Vancouver, Canada. Violence Against Women. 2023 May 17;10778012231172693. doi:10.1177/10778012231172693 Dewey JM, Hibbard P, Watson DP, Konchak JN, Hinami K. A qualitative investigation into the effectiveness of a housing navigator program linking justice-involved clients with recovery housing. Health & Justice. 2024 Sep 14;12(1):37. doi:10.1186/s40352-024-00293-6 Miller WR, Rollnick S. Meeting in the middle: motivational interviewing and self-determination theory. International Journal of Behavioral Nutrition and Physical Activity. 2012 Mar 2;9(1):25. doi:10.1186/1479-5868-9-25 Mee-Lee D, McLellan AT, Miller SD. What works in substance abuse and dependence treatment. In: The heart and soul of change: Delivering what works in therapy, 2nd ed. Washington, DC, US: American Psychological Association; 2010. p. 393–417. doi:10.1037/12075-013 Kiepek N, Ausman C, Beagan B, Patten S. Substance use and meaning: transforming occupational participation and experience. Cad Bras Ter Ocup. 2022;30:e3037. doi:https://doi.org/10.1590/2526-8910.ctoAO23023037 Lopes RE, Malfitano APS. Social Occupational Therapy [Internet]. 1st ed. 2020 [cited 2025 Aug 27]. Available from: https://shop.elsevier.com/books/social-occupational-therapy/lopes/978-0-323-69549-7 Compendium of United Nations standards and norms in crime prevention and criminal justice [Internet]. New York: United Nations Office on Drugs and Crime; 2006. Report No. Available from: https://www.unodc.org/pdf/criminal_justice/Compendium_UN_Standards_and_Norms_CP_and_CJ_English.pdf Restorative Principles [Section 2 – RJC Principles of Restorative Practice] [Internet]. Restorative Justice Council. Available from: https://restorativejustice.org.uk/what-restorative-justice Johnstone G, Ness DV. Handbook of Restorative Justice. Routledge; 2013. 673 p. Ness DWV, Strong KH, Derby J, Parker LL. Restoring Justice: An Introduction to Restorative Justice. 6th ed. New York: Routledge; 2022. 240 p. doi:10.4324/9781003159773 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 12 May, 2026 Reviewers agreed at journal 21 Apr, 2026 Reviewers invited by journal 09 Mar, 2026 Editor assigned by journal 09 Mar, 2026 Submission checks completed at journal 04 Mar, 2026 First submitted to journal 02 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9012567","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603987664,"identity":"4dd15c39-1254-434e-bc9b-f9f17f413ded","order_by":0,"name":"Sarah Pollock","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYHACxgMPGBjk+BnOgDjMxOk5kMDAYCzZQKqWRIMDPERqkZ/dfOBAQoVdgvHBs8ckGCqsExsIaTG4cyzhQMKZ5DyzA+fSJBjOpBOhRSLH4EBi24FiswNnzCQY2w4T1iI/A6IlcXMDSMs/IrQw3IBq2cAA0tJAhBaYX4wlDpwxtkg4lm5M2GGzmw8++FBhJ8c/44zhjQ811rKEHSYBZxxgYEggqBxFCz9h40fBKBgFo2CEAgCdH0cP9O6nBQAAAABJRU5ErkJggg==","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Pollock","suffix":""},{"id":603987666,"identity":"8ccccf60-bb5b-4c3c-8ba5-9282984f710a","order_by":1,"name":"Derrick Moyo","email":"","orcid":"","institution":"Aurum Institute","correspondingAuthor":false,"prefix":"","firstName":"Derrick","middleName":"","lastName":"Moyo","suffix":""},{"id":603987669,"identity":"c56a3ee2-8f01-468e-b9ca-29f5d87ce242","order_by":2,"name":"Pretty Ndini","email":"","orcid":"","institution":"Aurum Institute","correspondingAuthor":false,"prefix":"","firstName":"Pretty","middleName":"","lastName":"Ndini","suffix":""},{"id":603987672,"identity":"370495d1-544c-48f8-802e-cdf53cd3c935","order_by":3,"name":"Urvisha Bhoora","email":"","orcid":"","institution":"University of Pretoria","correspondingAuthor":false,"prefix":"","firstName":"Urvisha","middleName":"","lastName":"Bhoora","suffix":""},{"id":603987676,"identity":"893c790f-4328-4ad4-890b-c086b23f8e21","order_by":4,"name":"Tonderai Mabuto","email":"","orcid":"","institution":"Aurum Institute","correspondingAuthor":false,"prefix":"","firstName":"Tonderai","middleName":"","lastName":"Mabuto","suffix":""},{"id":603987678,"identity":"9e3dc330-483b-4952-b3f3-0c47da31487c","order_by":5,"name":"Laura Steiner","email":"","orcid":"","institution":"Johns Hopkins University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Steiner","suffix":""},{"id":603987679,"identity":"bc76b4a4-5a85-44b1-9316-cbe83ff4c1e5","order_by":6,"name":"Jannie Hugo","email":"","orcid":"","institution":"University of Pretoria","correspondingAuthor":false,"prefix":"","firstName":"Jannie","middleName":"","lastName":"Hugo","suffix":""},{"id":603987680,"identity":"cca22ff9-5ac7-4ab6-a359-f89bb9a1e568","order_by":7,"name":"Christopher J. Hoffmann","email":"","orcid":"","institution":"Johns Hopkins University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"J.","lastName":"Hoffmann","suffix":""},{"id":603987681,"identity":"1829f591-1168-41ec-8eea-363f6103c6e5","order_by":8,"name":"Jill Owczarzak","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Jill","middleName":"","lastName":"Owczarzak","suffix":""}],"badges":[],"createdAt":"2026-03-02 17:09:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9012567/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9012567/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104576418,"identity":"d3b8dd20-8f3e-4ad7-92ff-45667e83350b","added_by":"auto","created_at":"2026-03-13 13:56:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":626308,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9012567/v1/7c46e8a6-0feb-483c-857a-9885d240e39a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Social Support, Family Dynamics, and Therapeutic Relationships in Post-Incarceration Recovery for People Who Use Opioids","fulltext":[{"header":"Background","content":"\u003cp\u003eUpon release from incarceration, individuals face adverse reentry conditions characterized by economic precarity(1,2), unstable housing(3\u0026ndash;9), health care interruptions(1,3\u0026ndash;8), stigma(1,5,10,11), and disrupted social networks(1,9,10,12\u0026ndash;16). These individuals typically have limited access to health and social services and face ongoing challenges in securing essential resources(1,2,4,6,9,10,17). Without effective discharge planning or care linkage services, most formerly incarcerated individuals struggle to access medical care(18,19), experiencing high levels of mortality, morbidity, and hospitalization(20\u0026ndash;23). For people with active or prior substance use disorders (SUDs), lack of care continuity after release exacerbates psychiatric symptoms and suicidality(1,18,20) and heightens risk for drug relapse and overdose(2,20,24\u0026ndash;26). Additionally, these individuals face challenges reconnecting with their families(15) and communities while navigating the complex process of rebuilding their sense of self and social bonds(9,27,28).\u003c/p\u003e \u003cp\u003eSocial support systems frequently serve as the most critical factor in the SUD recovery process.(29,30) Consistent engagement with community organizations and membership in supportive communities can transform an individual\u0026rsquo;s social network from problematic to supportive(33,34) and facilitate long-term identity change, contributing to sustained recovery(35,36). The effects of substance use disorders extend beyond the individual to impact entire families, just as family relationships and dynamics play a crucial role in both the development of addiction and recovery success(37). During the reentry period, families can be important sources of encouragement, strength, and resilience(3,5,9,27,38) and provide assistance with SUD treatment access(10,39) and medication adherence(5).\u003c/p\u003e \u003cp\u003eThe quality of interpersonal relationships, including family, partners, and peers, can determine the effectiveness of substance use disorder (SUD) treatment(40\u0026ndash;43), significantly influencing substance use patterns, treatment utilization, and relapse risk (40\u0026ndash;42,44\u0026ndash;49). Supportive family systems are especially powerful in fostering substance use treatment motivation and engagement(39,50\u0026ndash;57) and positive treatment outcomes(42,58\u0026ndash;62), as individuals who enter treatment with strong, cohesive family relationships have reported positive social, psychological, and substance use management outcomes(41,63). Reentry(2,6) and community-based(9) programs offer support by facilitating skill development and employment opportunities, fostering confidence, and establishing connections to basic needs and treatment services. Consistent respect, trust, and praise from providers is highly valued by patients(64\u0026ndash;66) and has been shown to promote positive SUD treatment outcomes(48,64\u0026ndash;67) including adherence(68) and retention(64\u0026ndash;66,69).\u003c/p\u003e \u003cp\u003eIllicit opioid use is increasing in Africa(70\u0026ndash;72). Opioids, referred to by locals as \u003cem\u003enyaope\u003c/em\u003e(73\u0026ndash;75), are among the most common substances used in prisons in multiple regions of South Africa(76,77). Treatment programs that provide evidence-based medications such as MOUD are scarce in sub-Saharan Africa(78,79). High incarceration(80,81) and recidivism(80,82) rates in South Africa intersect significantly with opioid use disorder, creating an overlap between addiction and carceral involvement(76,77,83). Given that recovery from SUDs is a long-term and continuous process(84,85) requiring sustained support, a longitudinal approach to examining OUD and social support relationships is ideal. There is a dearth of literature centered on factors that facilitate sustained recovery from SUDs within South Africa(86). The current study is a qualitative investigation of SUD recovery and relationship dynamics among individuals with OUD in South Africa engaged in community-based treatment services, exploring how participants navigate familial and other support systems in the context of their recovery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting and population\u003c/h2\u003e \u003cp\u003eThis analysis used data from a longitudinal study that examined self-reported illicit opioid use among people living with HIV (PLHIV) as they transitioned from correctional facilities to the community in South Africa\u0026rsquo;s Tshwane District. The study was implemented between March 2021 and June 2023 in Kgosi Mampuru II Management Area, Gauteng, South Africa. A cohort of 37 formerly incarcerated PLHIV self-reporting current or previous opioid use (\u003cem\u003enyaope\u003c/em\u003e) were recruited and offered harm reduction services and methadone maintenance treatment provided by the Community Oriented Substance Use Programme (COSUP).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePost-release follow-up and COSUP linkage\u003c/h3\u003e\n\u003cp\u003e Within two weeks of release, a field researcher and COSUP social worker met with participants to update contact information, provide harm reduction counselling and methadone planning, connect the participant with a COSUP site and peer navigator, and encourage them to continue HIV care with a community clinic. Study participants were linked to COSUP to receive standard of care services including assessment of needs, harm reduction services, methadone, if determined to be appropriate based on routine screening, and peer support.\u003c/p\u003e\n\u003ch3\u003eData collection: Qualitative methods\u003c/h3\u003e\n\u003cp\u003eIn-depth interviews were conducted by trained interviewers in the participant\u0026rsquo;s language of choice (English, isiZulu, isiXhosa, or Setswana). Interviews were scheduled at the following intervals: 30, 60, 120, and 180 days post-release. The interview topics focused on substance use, substance use management, social support, HIV care, experiences with COSUP and other opioid use support services.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;18) who completed at least three of the four in-depth interviews were included in this analysis. The participants completed 62 total interviews across all time points. The average age of participants was 35 years (SD: 5.65). 17 participants identified as heterosexual and one as bisexual. Audio recordings were transcribed verbatim, translated into English as needed, and uploaded into MAXQDA software (VERBI GmbH, Berlin) for coding. Qualitative data were analysed thematically, using deductive and inductive coding. Transcripts were read by researchers for data familiarisation. Concepts were explored using a priori coding guide with codes that included living environment, relationships, social support, identity, substance use, stigmatization, COSUP services, and MOUD. Under each code, inductive subcodes were created to define common domains.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified complex dynamics between family relationships, personal agency, and OUD recovery. Findings illuminated three themes that shaped participants' recovery trajectories over the six-month study period. First, participants experienced conditional autonomy and material restrictions, e.g., limited access to their homes, which served as both punishment and motivation for change. Second, the language of \"normalcy\" emerged as central to participants' recovery narratives, representing not merely abstinence from illicit substances but a broader restoration of social identity and moral standing within their communities. Finally, therapeutic spaces that offered non-judgmental support often served as alternatives venues and communities to strained family relationships, providing emotional safety and professional guidance that participants often could not access within their family systems. Together, these themes demonstrate how recovery unfolds within complex social contexts where family dynamics, social stigma, and institutional support intersect to either facilitate or hinder individuals' paths toward sustained recovery. In the results below, we explore these themes and use case trajectories to illustrate how dynamics changed over time following reentry.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1: Acceptance and dependence on family resources (i.e., material support)\u003c/h2\u003e \u003cp\u003eParticipants' acceptance by their families was often conditional upon their ability to demonstrate worthiness through behavioral compliance or economic contribution, particularly in the earlier months of reentry. Notable restrictions included family denying participants food access and entry into homes. One participant described sleeping in a tent in his sister\u0026rsquo;s yard and only having access to bathing facilities, explaining: \u003cem\u003e\u0026ldquo;I can\u0026rsquo;t earn my keep right now, I really can\u0026rsquo;t. Eh I can\u0026rsquo;t contribute to lights and water bill; I can\u0026rsquo;t contribute to rent eh it\u0026rsquo;s just terrible. So, I find myself in the yard\u0026rdquo; (Participant 607-007; 30-day interview)\u003c/em\u003e. Participants attributed home access restrictions to family members\u0026rsquo; concerns about actual or perceived continued substance use, rather than other behaviors that might negatively affect the household:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There is no one who does not wish to stop smoking drugs. Do you know in other houses a person who smoke drugs is not allowed to enter, even if they don\u0026rsquo;t steal or what, they are just not allowed inside the house. There are houses like that, where you cannot enter if you use drugs\u0026rdquo; (Participant 607-006; 180-day interview).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePrinciples such as \u003cem\u003e\"a man should earn his keep\" (Participant 607-007; 30-day interview)\u003c/em\u003e and \u003cem\u003e\u0026ldquo;a man must help\u0026rdquo; (Participant 605\u0026thinsp;\u0026minus;\u0026thinsp;012; 30-day interview)\u003c/em\u003e were used by participants to justify their restrictions on access to basic resources. Participants internalized their limited ability to assist the household financially, expressing deference to their families and guilt over their inability to contribute financially, with statements like \u003cem\u003e\u0026ldquo;I just have to be grateful for the little bread that they provide for me\u0026rdquo; (Participant 605\u0026thinsp;\u0026minus;\u0026thinsp;012; 30-day interview\u003c/em\u003e) and \u003cem\u003e\u0026ldquo;I shouldn't be a burden\u0026rdquo; (Participant 605\u0026thinsp;\u0026minus;\u0026thinsp;012; 60-day interview\u003c/em\u003e). Only when participants reduced their drug use and demonstrated they could contribute to the household through daily chores did they describe having access to the house: \u003cem\u003e\u0026ldquo;A better [name]\u0026hellip;. the old [name] was no longer entering in the house but now he does\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;012; 120-day interview).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFor some, material dependence compounded with the stigma of substance use resulted in feelings of infantilization and distress over loss of independence. One participant described frustration over being judged by his younger sister:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It almost feels like I am younger than her, and she's the older sibling, and it hurts me when it gets there I am older than her. I am the one who should be giving her advice, because what I have gone through, she has not experienced that. I have more experience than her, whether she works or not, whether she has more income than me, I have more life experience than her\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;011; 30-day interview).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite being the older sibling with greater lived experience, the participant felt his sister dismissed or devalued him because of his substance use and \"mistakes,\" discounting the insights his experiences could provide.\u003c/p\u003e \u003cp\u003eDiminished personhood and its associated psychological impacts varied across participants. Despite being accused of stealing at home and denied food, some participants withheld blame and concluded that it was their responsibility \u003cem\u003e\u0026ldquo;to bring back that trust\u0026rdquo; (Participant 605\u0026thinsp;\u0026minus;\u0026thinsp;018; 60-day interview)\u003c/em\u003e and \u0026ldquo;\u003cem\u003eprove to them that I am dedicated\u003c/em\u003e\u0026rdquo; \u003cem\u003e(Participant 605\u0026thinsp;\u0026minus;\u0026thinsp;018; 120-day interview)\u003c/em\u003e. Other participants felt the negative effects of reduced autonomy and family social standing more acutely, with one reporting that \u003cem\u003e\u0026ldquo;other people at home, they treat me as if I don't exist\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;012; 60-day interview)\u003c/em\u003e due to his \u003cem\u003enyaope\u003c/em\u003e use, making him \u003cem\u003e\u0026ldquo;feel bad. It hurts\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;012; 60-day interview)\u003c/em\u003e. He elaborated on his desire for patience and emotional support from his family. Instead, he felt spoken to harshly and seen as a \u0026ldquo;useless person.\u0026rdquo;\u003c/p\u003e \u003cp\u003eIn contrast, several participants\u0026rsquo; families took an autonomy-respecting stance, even in the context of ongoing substance use and reliance on material support. Some family members provided consistent emotional and financial support, showing patience and understanding towards the participant\u0026rsquo;s substance use challenges. Supportive relationships characterized by love and encouragement emerged as positive forces in participants' recovery journeys. One participant who did not use \u003cem\u003enyaope\u003c/em\u003e throughout the study period described his mother's influence: \u003cem\u003e\"that is the thing that gives me power, even my mother gives me support. She says, 'keep it up, stop using drugs. Because if you don't stop using drugs, you are limiting your days of living'\u0026rdquo; (Participant 605\u0026thinsp;\u0026minus;\u0026thinsp;010; 60-day interview).\u003c/em\u003e Another participant\u0026rsquo;s family took an informal harm reduction approach to his substance use, allowing him to use \u003cem\u003enyaope\u003c/em\u003e at home to keep him off the street and away from potential criminal activity. Spending more time at home and working for the family business allowed his family to begin \u003cem\u003e\"truly understanding me and what was happening with me\" (Participant 607-001; 30-day interview)\u003c/em\u003e, bringing them closer and creating harmony within the household.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCase trajectory\u003c/h3\u003e\n\u003cp\u003eParticipant 607\u0026thinsp;\u0026minus;\u0026thinsp;012 lived with his mother. He resumed using \u003cem\u003enyaope\u003c/em\u003e two months after his release and continued to use \u003cem\u003enyaope\u003c/em\u003e throughout the study period. During this period his mother exerted significant control over his daily routine. At 30 days, he described how living with his mother was challenging because of her controlling and overbearing tendencies. If he did not act according to her standards he would \u003cem\u003e\u0026ldquo;suffer my mother\u0026rsquo;s harsh rules, then I would eat when she feels like it\u0026rdquo;\u003c/em\u003e. He explained that his mother expected him to work and get chores done around the house, making him feel \u003cem\u003e\u0026ldquo;like I was being used, like I was supposed to be always working, and not even get the time to relax like this, to rest.\"\u003c/em\u003e These obligations prompted him to avoid the house and to use \u003cem\u003enyaope\u003c/em\u003e on the streets, away from his mother\u0026rsquo;s monitoring. At 60 days post-release, the participant described having restricted access to the house, often watching TV by looking through a window. When his mother invited him inside to massage her hand, he was excited to reconnect with his home environment \u003cem\u003e\u0026ldquo;\u0026hellip;it has been a long time not entering the house, like even smell the scent of the house and sit on the sofa, things like that. That moment made me happy.\"\u003c/em\u003e At 120 days post-release, the participant continued to experience conflict with his mother who was \u0026ldquo;still yelling;\u0026rdquo; however, he reported more compliance with chores and was granted access to the house. By 180 days post-release, the relationship with his mother was still strained and she threatened to call the Criminal Investigation Department during arguments. He described the situation with his mother as \u003cem\u003e\"very painful...because she is someone who is close to me most of the time, so she is the person I should be able to tell how I feel...But she doesn\u0026rsquo;t want to know how I\u0026rsquo;m feeling\"\u003c/em\u003e. Despite indicating a desire to quit \u003cem\u003enyaope\u003c/em\u003e, the participant struggled to stay away from \"\u003cem\u003ethe street life\u003c/em\u003e,\" illustrating how family dysfunction and limited autonomy can compromise the recovery process and push an individual to a place of greater acceptance but also greater risk for illicit substance use.\u003c/p\u003e \u003cp\u003eParticipants experienced varying degrees of family acceptance and reintegration. For some, addiction led to discriminatory treatment that extended beyond limited resource access to encompass damaged relationships and diminished status within family structures. These results highlight how social and emotional marginalization can profoundly impact individuals and demonstrate that dignity encompasses not just material well-being but also the quality of interpersonal interactions. Additionally, the results show the importance of non-judgmental family support in fostering a positive and sustained recovery journey.\u003c/p\u003e\n\u003ch3\u003eTheme 2: Otherness and desires for normalcy\u003c/h3\u003e\n\u003cp\u003e Participants invoked the language of \"normalcy\" to describe both what they had lost through substance use and what they hoped to regain through recovery. Normalcy was not framed simply as abstinence from substances, but as a broader ideal encompassing stability, self-worth, and social inclusion. After receiving methadone from COSUP and abstaining from \u003cem\u003enyaope\u003c/em\u003e for two weeks, a participant expressed feeling like a \u003cem\u003e\u0026ldquo;normal person\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;011; 180-day interview)\u003c/em\u003e. He went on to explain that he felt revitalized to listen to music and enter stores without fear \u003cem\u003e\u0026ldquo;just like any other person\u0026rdquo;\u003c/em\u003e, as his sobriety allowed him to fully experience life\u0026rsquo;s simple pleasures and go about his daily routine without stigma.\u003c/p\u003e \u003cp\u003eContinued substance use, in contrast, was described as a condition of otherness and abnormality, a state of social and moral deviance, exclusion, and diminished personhood. For most participants, achieving normalcy was synonymous with stopping \u003cem\u003enyaope\u003c/em\u003e. One participant openly shared that he did not consider himself a \u003cem\u003e\u0026ldquo;normal person\u0026rdquo;\u003c/em\u003e because if \u003cem\u003e\u0026ldquo;I was a normal person, I would be doing things that are done by normal people who don\u0026rsquo;t use drugs\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;012; 30-day interview)\u003c/em\u003e. He described the stigma he experienced in everyday settings:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;People who use drugs are judged, it doesn\u0026rsquo;t matter whether it\u0026rsquo;s at your home or where. As someone who use drugs entering the shop, the floor walker there will keep following you, but as a normal person they won\u0026rsquo;t follow you at all. They always think you are there to steal. Even though you didn\u0026rsquo;t go in to steal. So do you see that they are judgmental\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;012; 60-day interview).\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participant\u0026rsquo;s perception of exclusion and \u0026ldquo;otherness\u0026rdquo; reinforced his desire to stop using illicit substances and gain employment so he could \u003cem\u003e\u0026ldquo;live a normal life, just like any other person\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;012; 180-day interview)\u003c/em\u003e. Sobriety represented not only freedom from substances, but freedom from a perceived stigmatizing gaze that marked him as deviant.\u003c/p\u003e \u003cp\u003eFor many participants, the desire for normalcy was tied to traditional social roles, particularly that of being a father, partner, or provider. Fatherhood was both a relational role and a moral identity, reflecting a desire to break the cycle of addiction for the next generation: \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t want him to imitate the drug addiction part of my life. Lot of things that is passed on from one generation to the next. I don\u0026rsquo;t even want to be like that in front of the child, you don\u0026rsquo;t even see me behave that way\u0026rdquo; (607-007; 30-day interview)\u003c/em\u003e. The motivation to stop using illicit substances was also tied to a deep longing to restore a sense of identity and belonging within the family, specifically, to return to how they were perceived before their drug use: \u003cem\u003e\u0026ldquo;again with the issue of drugs...I want to see myself going back to normal to be the same [name] they knew\u0026rdquo; (605\u0026thinsp;\u0026minus;\u0026thinsp;010; 30-day interview)\u003c/em\u003e. This yearning for recognition by others as \"normal\" underscores that rehabilitation is as much about social reintegration and repairing relational identity as it is about managing addiction.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCase trajectory\u003c/h2\u003e \u003cp\u003eParticipant 607\u0026thinsp;\u0026minus;\u0026thinsp;011 lived with several family members. He actively used \u003cem\u003enyaope\u003c/em\u003e throughout the study until reporting in the 180-day interview that he had stopped using \u003cem\u003enyaope\u003c/em\u003e and started methadone. Throughout the study, the participant voiced a consistent desire to stop using \u003cem\u003enyaope\u003c/em\u003e while balancing tensions with his sister and caregiving responsibilities. At the 30-day interview he noted reengagement with the community and positive feedback from them, \u0026ldquo;\u003cem\u003eyou still smoke? if you smoke, you need to stop because you actually look like you are not smoking. Now you look like a changed person, are you working.\u0026rdquo;\u003c/em\u003e He described this as a form of social validation, reinforcing his shift toward a more \u0026ldquo;normal\u0026rdquo; and socially acceptable identity. At 60 days, despite struggling to reduce his \u003cem\u003enyaope\u003c/em\u003e use before initiating methadone, he made meaningful efforts to shift his behavior by spending more time at home and helping with chores, which he believed encouraged his sister to be more emotionally available and to communicate more with him. At 120 days, the participant described being judged in social spaces but reaffirmed his commitment to change, emphasizing his desire to secure employment and \u003cem\u003e\u0026ldquo;live a normal life that one should live.\u0026rdquo;\u003c/em\u003e By 180 days, the participant reported no longer using \u003cem\u003enyaope\u003c/em\u003e and initiating methadone treatment at COSUP, making him feel \u003cem\u003e\u0026ldquo;Like a person. I think that it\u0026rsquo;s now that I hear. I can feel, that feeling of every normal person, I was not normal,\u0026rdquo;\u003c/em\u003e underscoring how achieving abstinence restored his perceived sense of normalcy and self-worth.\u003c/p\u003e \u003cp\u003eThe concept of normalcy was central to how many participants understood their substance use and envisioned their path toward social stability and acceptance. While active addiction was marked by deviance and judgment, the desire to escape these labels and shed anticipated stigma motivated positive change, prompting participants to reclaim their identities and repair family relationships.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Supportive relationships in therapeutic spaces\u003c/h2\u003e \u003cp\u003e Many participants relied on support from social workers to navigate their substance use recovery challenges, particularly when family relationships were strained or absent. For some, consistent support from social workers created a sense of stability and encouragement. Participants described how COSUP social workers offered both motivation and practical guidance while fostering a safe, non-judgmental space for open communication:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They build me and they give advice. Every time they talk to me, I feel okay, and I can talk to them freely. That benefits me a lot because I can share anything that bothers me. They talk although they don\u0026rsquo;t know me, they don\u0026rsquo;t judge me, they create a safe space for me\" (Participant 600-003; 30-day interview\u003c/em\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant emphasized that receiving guidance from a social worker was his primary reason for engaging with COSUP services, explaining,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\"That is what gives me courage. Before, I had no one to confide in when I faced a problem\u0026mdash;no one at all. But now, at least there is someone I can turn to. Life has brought me immense stress, but having someone to share my struggles with has made a difference. I've been able to open up about some of the things weighing on me\u0026rdquo; (Participant 605\u0026thinsp;\u0026minus;\u0026thinsp;010; 120-day interview.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also recognized the value of having someone to rely on beyond their family. For example, Participant 605\u0026thinsp;\u0026minus;\u0026thinsp;018 recounted how a COSUP social worker accompanied his mother and sister to court as they navigated a custody dispute. He reflected,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"It makes me happy, that thing. I\u0026rsquo;ve got a shoulder to cry on, you get me. You mustn\u0026rsquo;t only have family support\u0026mdash;even outside your family, you must get it\u0026rdquo; (Participant 605\u0026thinsp;\u0026minus;\u0026thinsp;018; 60-day interview).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e In the absence of other confidants, social workers were especially meaningful, providing reassurance and relief, especially in areas where participants felt unable to confide in family members. The presence of non-judgmental, supportive social workers was repeatedly described by participants as central to their emotional resilience and sense of hope during recovery.\u003c/p\u003e \u003cp\u003eParticipants also described the empowering effect of being heard and receiving practical guidance from social workers: \u003cem\u003e\u0026ldquo;They give you power, you become strong\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;011; 120-day interview\u003c/em\u003e). The sessions were not only therapeutic but also educational, helping participants develop insight into their situations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You may know but only to find that you didn\u0026rsquo;t have the full understanding when you spend time in those sessions with the social workers, they are professionals, and they know what they are doing\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;011; 120-day interview\u003c/em\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe emotional investment and care shown by social workers helped foster motivation and accountability, as one person shared,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They do take care, you see it\u0026rsquo;s not simple that journey, but they make it in a way that you also feel that there are people that care and you don\u0026rsquo;t want to disappoint them because you can see they care.\u0026rdquo; (Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;014; 30-day interview)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis sense of support without judgment helped participants reframe their personal challenges and view recovery as manageable. In contrast to the shame and indignity described in the first two themes, social workers approached addiction through a lens of evidence and compassion, which participants were more receptive to.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCase trajectory\u003c/h2\u003e \u003cp\u003eParticipant 600-002 lived with several family members. She used \u003cem\u003enyaope\u003c/em\u003e earlier in the study until reporting in the 120-day interview that she had quit and started methadone at COSUP. Her experience across study timepoints revealed the positive impact of having consistent encouragement and emotional support from COSUP social workers. At 60 days post-release, the participant described significant conflict and tension within her family and the absence of support. She explained, \u0026ldquo;\u003cem\u003eI don\u0026rsquo;t have a friend or family to talk to. I keep it inside, I don\u0026rsquo;t tell anyone, there is no one I can discuss my problems with\u003c/em\u003e\u0026rdquo;. Unlike her experiences with family, she felt safe when opening up to COSUP staff, which helped alleviate emotional burdens. At 120 days post-release, she continued to engage in COSUP services and initiated methadone. By 180 days, she emphasized how the non-judgmental and confidential support allowed her free expression without fear of betrayal or stigma: \u003cem\u003e\u0026ldquo;Even the things that were bothering me, it was easy for me to tell them because at home, I cannot speak to friends\u0026rdquo;\u003c/em\u003e. She described her relationship with COSUP staff as one marked by emotional safety, helping her to feel empowered and repair family bonds during recovery.\u003c/p\u003e \u003cp\u003eSocial workers at COSUP had a profound impact on participants' lives, fundamentally shaping their recovery trajectories. The opportunity to be authentically seen and heard in a safe stigma-free space emerged as a critical factor in fostering sustained engagement in care, reinforcing the value of effective evidence-based strategies to support those with SUD.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study sought to explore the recovery trajectories of people with OUD in South Africa who returned to communities after incarceration and to identify factors that influence such recovery. Longitudinal qualitative methodology was used to investigate SUD recovery and social relationship dynamics, engagement in community-based treatment services, and experiences of familial and service provider support systems. The findings identified that participants and their families largely viewed drug use as moral failure, with participants\u0026rsquo; inability to contribute to the household leading to diminished status. Though addiction was often linked to reduced personhood and dignity, families' responses varied considerably: while some employed shaming and exclusionary practices, others offered acceptance and love. Service providers emerged as another vital source of support to participants, providing emotional relief and comfort. This support was especially important when family support was lacking or strained.\u003c/p\u003e \u003cp\u003eThis work builds on prior literature describing most of emotional and instrumental support(87,88) coming from family members for people using illicit substances. This type of \u0026ldquo;resource provision\u0026rdquo;(89) is often apparent among families who support adult family members with SUD(90\u0026ndash;92) and can be considered as essential to recovery(89). However, the dual nature of family relationships in recovery processes was evident in this study, with instances of family members functioning either as catalysts for change or barriers to progress, consistent with literature documenting the contradictory roles families can play in substance use recovery trajectories(89,93,94) and societal reintegration post-release(95,96). Our findings advance understanding of strained family relationships in post-release recovery by providing contemporary evidence and detailed examination of the specific ways these dynamics impact recovery efforts.\u003c/p\u003e \u003cp\u003eFamily members' controlling and judgmental behaviors impeded trust building and created additional psychological burdens on participants, often reinforcing feelings of shame and social exclusion. Such dynamics are consistent with Padgett \u0026amp; Drake's(93) findings regarding familial rejection and condemnation of their family members who use illicit substances. Family disengagement and indifference also emerged as salient sources of emotional distress, reinforcing Gideon\u0026rsquo;s(97) observations that post-release, conflict often arises when family members are apathetic to individuals\u0026rsquo; treatment or recovery and do not participate in any therapeutic programming. In our study, participants described frustration with family members\u0026rsquo; limited interest in their recovery and well-being. Notably, distress was not always precipitated by overt conflict or explicit expressions of judgment or control. Rather, for some participants, the absence of engagement manifested through indifference or lack of inquiry conveyed the sense that their families were not invested in their recovery. This perceived disengagement was described as particularly painful, highlighting the importance of consistent familial involvement as a supportive resource(90). As participant 607-007 emphasized, \u003cem\u003e\u0026ldquo;\u0026hellip;we must interact\u0026hellip;. And only through interaction can our problems be alleviated and maybe life made a little bit easier\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eMany participants' recovery narratives were organized around reconstructing their sense of self and achieving what they conceptualized as \"normalcy\" consistent with previous research on incarceration and substance use recovery.(98,99) This is in contrast to the incarcerated population studied by O'Sullivan et al(98) where substance use could be either be perceived as normal (Self) or a change within themselves or their lifestyle (Other) depending on the individual. The description of not feeling like a \"normal person\" while using substances reflects what McIntosh and McKeganey(99) identified as the reconstruction of sense of self that occurs during recovery. However, our findings suggest this reconstruction is not simply about returning to a pre-addiction identity, but rather about achieving social stability and inclusion, and being accepted in social roles. Participant 607\u0026thinsp;\u0026minus;\u0026thinsp;011\u0026rsquo;s experience of being controlled by and subordinate to his sister highlights the effect of substance use on loss of social status(100). This may be particularly denigrating to men whose have built an identity on being provider and leaders in a household(100). Similarly, systematic review evidence(101) confirms that expanding social roles, belonging, and meaningful engagement facilitate recovery among individuals with co-occurring disorders, underscoring recovery as a socially embedded process of identity transformation(99,102\u0026ndash;104).\u003c/p\u003e \u003cp\u003eParticipants consistently emphasized the transformative impact of having access to COSUP social workers who provided unconditional, judgement-free emotional support. The ability to \"talk freely\" and share \"anything that bothers me\" created safe spaces\u0026mdash;a fundamental prerequisite for meaningful therapeutic engagement(42,48,105\u0026ndash;107). Safe therapeutic spaces were sometimes missing from other relationships. While family members often struggled with trust issues, disappointment, and judgment related to participants' substance use history, substance use program team members offered a consistent source of validation and support. As one participant noted, the program workers \"don't judge me, they create a safe space for me\", reinforcing the importance of therapeutic relationships in professional settings, especially when personal relationships are compromised. In a recent qualitative study(108), formerly incarcerated individuals described how positive interactions with housing navigators were effective in facilitating linkages to housing and substance use services. Clients shared how navigators reduced anxiety and stress around drug use, bolstering their [clients\u0026rsquo;] sense of self-worth and empowering them to improve recovery health habits(108).\u003c/p\u003e \u003cp\u003e Participants described how having \"a shoulder to cry on\" beyond family support was essential for their emotional wellbeing and recovery motivation. In some cases, the substance use program workers went beyond traditional program roles and performed activities such as accompanying family members to court proceedings. This embodiment of genuine care reinforces the importance of empathy(109,110) and a positive attitude(106) in strengthening the therapeutic alliance(105)\u0026mdash;a critical factor known to influence both motivation for change and treatment effectiveness(110). For some participants, such compassion was in stark contrast to harsh and insensitive treatment from family members, emphasizing the necessity of effective and accessible evidence-based interventions for SUD.\u003c/p\u003e \u003cp\u003eThis study has the following limitations. Data collection occurred at four time points, but some participants were unable to complete all interviews, resulting in missing data. Nonetheless, over half of the participants completed three or more interviews, yielding longitudinal data to trace patterns of change over time. Participants were asked about past events, so their answers were subject to recall bias. The sample was predominantly male and had limited perspectives from women. Participants shared personal stories, which limits generalizability to other populations and settings. Lastly, recovery is recognized as a gradual and ongoing process; six months is likely not enough time to fully capture individual trajectories.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe add to the literature the importance of having strong social support in SUD recovery, showing how support from both service providers and family members can significantly impact the health and livelihoods of people with OUD. Clinicians can incorporate social aspects into their therapeutic processes by including families and social support groups(48,89) in client programming and providing SUD and recovery education(89). Further, clinicians should be cognizant of the social dimensions of life(111), considering individual\u0026rsquo;s social networks as areas to strengthen support and increase social participation(112). Consistent with United Nations standards and norms in crime prevention and criminal justice(113), correctional facilities should prioritize social connection and rehabilitation both during incarceration and throughout the community reentry process. These social connections should be facilitated between incarcerated individuals and their families, as well as with outside agencies such as COSUP that can assist with social reintegration, provide support to both individuals and their families. Such processes are aligned with restorative justice(114\u0026ndash;116) principles that aim to assist individuals in building peaceful social lives and working toward collective healing.\u003c/p\u003e \u003cp\u003eOur findings also highlight the broader importance of cultivating meaningful social connections and activities that support identity reconstruction and social integration. Recovery-oriented interventions should extend beyond individual therapy or MOUD to include opportunities for participants to engage in valued social roles and activities that reinforce their emerging non-user identity. This might include vocational training, community service opportunities, peer support groups, and recreational activities that provide alternatives to substance-using social networks. The emphasis participants placed on achieving \"normalcy\" through employment, family roles, and community participation suggests that recovery interventions should prioritize social reintegration, recognizing that sustainable recovery often depends on the availability of meaningful alternatives to substance-using lifestyles.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent from each participant was obtained using study-approved informed consent forms. The use of written informed consent forms ensured that participants were provided with detailed information about the study, including its purpose, procedures, potential risks, and protection of their privacy. Additionally, unique study-generated participant identity numbers were assigned to each participant to protect their identity and confidentiality. This practice was essential in ensuring that participants\u0026apos; identities were not revealed in any study-related materials. For the qualitative follow-up interviews, written informed audio recording consent was obtained from each participant prior to the start of the interview. This additional step ensured that participants were fully aware of the recording process and had the opportunity to consent to being recorded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Boards of the University of the Witwatersrand in Johannesburg and the University of Pretoria in South Africa, the Johns Hopkins School of Medicine in Baltimore, Maryland, and the South African Department of Correctional Services.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current study\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded through a grant from the US National Institutes of Health Fogarty International Center: Grant No.: R21TW011689. The funder was not involved in the design, interpretation, or writing of this manuscript.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eSP coded and analyzed the qualitative data, conceived the analysis idea, and drafted the manuscript. DM and PN conducted the in-depth interviews and made substantial contributions to acquisition of the data. UB made substantial contributions to the study design, acquisition of the data, and manuscript review. TM made\u0026nbsp;substantial contributions to the study design and oversight. LS made substantial contributions to data management. JH made substantial contributions to the study design and data interpretation. CH obtained funding for and designed the study and made substantial contributions to reviewing the manuscript.\u0026nbsp;JO made substantial contributions to the study design and reviewed and edited the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe acknowledge the financial contribution and partnership of the City of Tshwane through COSUP (Community Oriented Substance Use Programme). We wish to thank all the study participants for their engagement and trust in the research process. We also wish to thank the many research staff and correctional service members who helped with the successful completion of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJoudrey PJ, Khan MR, Wang EA, Scheidell JD, Edelman EJ, McInnes DK, et al. A conceptual model for understanding post-release opioid-related overdose risk. 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Report No. Available from: https://www.gov.za/sites/default/files/gcis_document/202210/2022-09-22-dcs-ar-202122.pdf\u003c/li\u003e\n\u003cli\u003eMaluleke R. Mid-year population Estimates, 2022 [Internet]. South AfricPretoria, South Africa: Statistics South Africa; 2022. Report No. Available from: https://www.statssa.gov.za/publications/P0302/MidYear2022.pdf\u003c/li\u003e\n\u003cli\u003eMurhula P, Singh S. A Critical Analysis on Offenders Rehabilitation Approach in South Africa: A Review of the Literature. African Journal of Criminology and Justice Studies [Internet]. 2019 Feb 1;12(1). Available from: https://digitalscholarship.tsu.edu/ajcjs/vol12/iss1/12\u003c/li\u003e\n\u003cli\u003eModupi MB, Mosotho NL, le Roux HE. The prevalence of mental disorders among offenders admitted at health facilities in Bizzah Makhate Correctional Service Centre, Kroonstand, South Africa. Psychiatr Psychol Law. 27(6):963\u0026ndash;72. doi:10.1080/13218719.2020.1751742 PubMed PMID: 34104067; PubMed Central PMCID: PMC8158267.\u003c/li\u003e\n\u003cli\u003eDavidson L, White W. The Concept of Recovery as an Organizing Principle for Integrating Mental Health and Addiction Services. J Behav Health Serv Res. 2007 Apr 1;34(2):109\u0026ndash;20. doi:10.1007/s11414-007-9053-7\u003c/li\u003e\n\u003cli\u003eGueta K, Chen G, Ronel N. Maintenance of long-term recovery from substance use: a mixed methods study of self- and treatment-changers. Drugs: Education, Prevention and Policy. 2021 Sep 3;28(5):511\u0026ndash;22. doi:10.1080/09687637.2020.1800592\u003c/li\u003e\n\u003cli\u003eStokes M, Schultz P, Alpaslan A. Narrating the journey of sustained recovery from substance use disorder. Subst Abuse Treat Prev Policy. 2018 Sep 27;13(1):35. doi:10.1186/s13011-018-0167-0\u003c/li\u003e\n\u003cli\u003eBerkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium☆☆This paper is adapted from Berkman, L.F., \u0026amp; Glass, T. Social integration, social networks, social support and health. In L. F. Berkman \u0026amp; I. Kawachi, Social Epidemiology. New York: Oxford University Press; and Brissette, I., Cohen S., Seeman, T. Measuring social integration and social networks. In S. Cohen, L. Underwood \u0026amp; B. Gottlieb, Social Support Measurements and Intervention. New York: Oxford University Press. Social Science \u0026amp; Medicine. 2000 Sep 15;51(6):843\u0026ndash;57. doi:10.1016/S0277-9536(00)00065-4\u003c/li\u003e\n\u003cli\u003eHouse JS. Work Stress and Social Support. Addison-Wesley Publishing Company; 1981. 192 p.\u003c/li\u003e\n\u003cli\u003eEnglandKennedy ES, Horton S. \u0026ldquo;Everything that I thought that they would be, they weren\u0026rsquo;t:\u0026rdquo; Family systems as support and impediment to recovery. Social Science \u0026amp; Medicine. 2011 Oct 1;73(8):1222\u0026ndash;9. doi:10.1016/j.socscimed.2011.07.006\u003c/li\u003e\n\u003cli\u003eVentura AS, Bagley SM. To Improve Substance Use Disorder Prevention, Treatment and Recovery: Engage the Family. Journal of Addiction Medicine. 2017 Oct;11(5):339. doi:10.1097/ADM.0000000000000331\u003c/li\u003e\n\u003cli\u003eRowe CL. Family Therapy for Drug Abuse: Review and Updates 2003\u0026ndash;2010. Journal of Marital and Family Therapy. 2012;38(1):59\u0026ndash;81. doi:10.1111/j.1752-0606.2011.00280.x\u003c/li\u003e\n\u003cli\u003eBagley SM, Peterson J, Cheng DM, Jose C, Quinn E, O\u0026rsquo;Connor PG, et al. Overdose Education and Naloxone Rescue Kits for Family Members of Opioid Users: Characteristics, Motivations and Naloxone Use. Subst Abus. 2015;36(2):149\u0026ndash;54. doi:10.1080/08897077.2014.989352 PubMed PMID: 25564892; PubMed Central PMCID: PMC4809347.\u003c/li\u003e\n\u003cli\u003ePadgett DK, Henwood B, Abrams C, Drake RE. Social Relationships Among Persons Who Have Experienced Serious Mental Illness, Substance Abuse, and Homelessness: Implications for Recovery. Am J Orthopsychiatry. 2008;78(3):333\u0026ndash;9. doi:10.1037/a0014155\u003c/li\u003e\n\u003cli\u003eTran Smith B, Padgett DK, Choy-Brown M, Henwood BF. Rebuilding lives and identities: The role of place in recovery among persons with complex needs. Health \u0026amp; Place. 2015 May 1;33:109\u0026ndash;17. doi:10.1016/j.healthplace.2015.03.002\u003c/li\u003e\n\u003cli\u003eDavis C, Bahr SJ, Ward C. The process of offender reintegration: Perceptions of what helps prisoners reenter society. Criminology \u0026amp; Criminal Justice. 2013 Sep 1;13(4):446\u0026ndash;69. doi:10.1177/1748895812454748\u003c/li\u003e\n\u003cli\u003eHarding DJ, Morenoff JD, Dobson CC, Lane EB, Opatovsky K, Williams EDG, et al. Families, Prisoner Reentry, and Reintegration. In: M. Burton L, Burton D, M. McHale S, King V, Van Hook J, editors. Boys and Men in African American Families [Internet]. Cham: Springer International Publishing; 2016 [cited 2026 Feb 3]. p. 105\u0026ndash;60. Available from: https://doi.org/10.1007/978-3-319-43847-4_8 doi:10.1007/978-3-319-43847-4_8\u003c/li\u003e\n\u003cli\u003eGideon L. Family Role in the Reintegration Process of Recovering Drug Addicts: A Qualitative Review of Israeli Offenders. Int J Offender Ther Comp Criminol. 2007 Apr 1;51(2):212\u0026ndash;26. doi:10.1177/0306624X06287104\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo; Sullivan M, Boulter S, Black G. Lived experiences of recalled mentally disordered offenders with dual diagnosis: a qualitative phenomenological study. The Journal of Forensic Psychiatry \u0026amp; Psychology. 2013 Jun 1;24(3):403\u0026ndash;20. doi:10.1080/14789949.2013.795238\u003c/li\u003e\n\u003cli\u003eMcIntosh J, McKeganey N. Addicts\u0026rsquo; narratives of recovery from drug use: constructing a non-addict identity. Social Science \u0026amp; Medicine. 2000 May 16;50(10):1501\u0026ndash;10. doi:10.1016/S0277-9536(99)00409-8\u003c/li\u003e\n\u003cli\u003eNaugle DA, Tibbels NJ, Hendrickson ZM, Dosso A, Lith LV, Mallalieu EC, et al. Bringing fear into focus: The intersections of HIV and masculine gender norms in C\u0026ocirc;te d\u0026rsquo;Ivoire. PLOS ONE. 2019 Oct 23;14(10):e0223414. doi:10.1371/journal.pone.0223414\u003c/li\u003e\n\u003cli\u003eDe Ruysscher C, Vandevelde S, Vanderplasschen W, De Maeyer J, Vanheule S. The Concept of Recovery as Experienced by Persons with Dual Diagnosis: A Systematic Review of Qualitative Research From a First-Person Perspective. Journal of Dual Diagnosis. 2017 Oct 2;13(4):264\u0026ndash;79. doi:10.1080/15504263.2017.1349977 PubMed PMID: 28699834.\u003c/li\u003e\n\u003cli\u003eBest D, Beckwith M, Haslam C, Alexander Haslam S, Jetten J, Mawson E, et al. Overcoming alcohol and other drug addiction as a process of social identity transition: the social identity model of recovery (SIMOR). Addiction Research \u0026amp; Theory. 2016 Mar 3;24(2):111\u0026ndash;23. doi:10.3109/16066359.2015.1075980\u003c/li\u003e\n\u003cli\u003eChen G. Identity Construction in Recovery from Substance Use Disorders. Journal of Psychoactive Drugs. 2024 Jan 1;56(1):109\u0026ndash;16. doi:10.1080/02791072.2022.2159592 PubMed PMID: 36538493.\u003c/li\u003e\n\u003cli\u003eKoski-Jannes A. Social and Personal Identity Projects in the Recovery from Addictive Behaviours. Addiction Research \u0026amp; Theory. 2002 Jan 1;10(2):183\u0026ndash;202. doi:10.1080/16066350290017266\u003c/li\u003e\n\u003cli\u003eBrunelle N, Bertrand K, Landry M, Flores-Aranda J, Patenaude C, Brochu S. Recovery from substance use: Drug-dependent people\u0026rsquo;s experiences with sources that motivate them to change. Drugs: Education, Prevention and Policy. 2015 May 4;22(3):301\u0026ndash;7. doi:10.3109/09687637.2015.1021665\u003c/li\u003e\n\u003cli\u003eKolind T. Form or content: The application of user perspectives in treatment research. Drugs: Education, Prevention and Policy. 2007 Jan 1;14(3):261\u0026ndash;75. doi:10.1080/09687630601073807\u003c/li\u003e\n\u003cli\u003eErickson M, Deering K, Ranville F, Bingham B, Young P, Korchinski M, et al. \u0026ldquo;They Give you a bus Ticket and They Kick you Loose\u0026rdquo;: A Qualitative Analysis of Post-Release Experiences among Recently Incarcerated Women Living with HIV in Metro Vancouver, Canada. Violence Against Women. 2023 May 17;10778012231172693. doi:10.1177/10778012231172693\u003c/li\u003e\n\u003cli\u003eDewey JM, Hibbard P, Watson DP, Konchak JN, Hinami K. A qualitative investigation into the effectiveness of a housing navigator program linking justice-involved clients with recovery housing. Health \u0026amp; Justice. 2024 Sep 14;12(1):37. doi:10.1186/s40352-024-00293-6\u003c/li\u003e\n\u003cli\u003eMiller WR, Rollnick S. Meeting in the middle: motivational interviewing and self-determination theory. International Journal of Behavioral Nutrition and Physical Activity. 2012 Mar 2;9(1):25. doi:10.1186/1479-5868-9-25\u003c/li\u003e\n\u003cli\u003eMee-Lee D, McLellan AT, Miller SD. What works in substance abuse and dependence treatment. In: The heart and soul of change: Delivering what works in therapy, 2nd ed. Washington, DC, US: American Psychological Association; 2010. p. 393\u0026ndash;417. doi:10.1037/12075-013\u003c/li\u003e\n\u003cli\u003eKiepek N, Ausman C, Beagan B, Patten S. Substance use and meaning: transforming occupational participation and experience. Cad Bras Ter Ocup. 2022;30:e3037. doi:https://doi.org/10.1590/2526-8910.ctoAO23023037\u003c/li\u003e\n\u003cli\u003eLopes RE, Malfitano APS. Social Occupational Therapy [Internet]. 1st ed. 2020 [cited 2025 Aug 27]. Available from: https://shop.elsevier.com/books/social-occupational-therapy/lopes/978-0-323-69549-7\u003c/li\u003e\n\u003cli\u003eCompendium of United Nations standards and norms in crime prevention and criminal justice [Internet]. New York: United Nations Office on Drugs and Crime; 2006. Report No. Available from: https://www.unodc.org/pdf/criminal_justice/Compendium_UN_Standards_and_Norms_CP_and_CJ_English.pdf\u003c/li\u003e\n\u003cli\u003eRestorative Principles [Section 2 \u0026ndash; RJC Principles of Restorative Practice] [Internet]. Restorative Justice Council. Available from: https://restorativejustice.org.uk/what-restorative-justice\u003c/li\u003e\n\u003cli\u003eJohnstone G, Ness DV. Handbook of Restorative Justice. Routledge; 2013. 673 p.\u003c/li\u003e\n\u003cli\u003eNess DWV, Strong KH, Derby J, Parker LL. Restoring Justice: An Introduction to Restorative Justice. 6th ed. New York: Routledge; 2022. 240 p. doi:10.4324/9781003159773\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"addiction-science-and-clinical-practice","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ascp","sideBox":"Learn more about [Addiction Science \u0026 Clinical Practice](https://ascpjournal.biomedcentral.com/)","snPcode":"13722","submissionUrl":"https://submission.nature.com/new-submission/13722/3","title":"Addiction Science \u0026 Clinical Practice","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Substance use, opioids, recovery, social support, therapeutic relationships, incarceration, reentry","lastPublishedDoi":"10.21203/rs.3.rs-9012567/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9012567/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSocial support after release from incarceration is crucial for social reintegration and rehabilitation. For people with current or previous substance use, social support systems are a key factor in their recovery. Supportive interpersonal relationships with family members and service providers can significantly impact substance use, social, and psychological outcomes. In this qualitative analysis, we explore how individuals navigate familial and service provider support systems in the context of their substance use recovery after release from incarceration.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis analysis drew from a longitudinal cohort study examining challenges of illicit opioid use faced by people living with HIV transitioning from correctional facilities to the community in the Tshwane District in South Africa. In-depth interviews were conducted at 30, 60, 120, and 180 days post-release. Participants (n\u0026thinsp;=\u0026thinsp;18) who completed at least three of the four in-depth interviews were included.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThis analysis identified complex dynamics between family relationships, personal agency, and opioid use disorder (OUD) recovery. Three themes were identified: conditional acceptance and dependence on family resources; otherness and desires for normalcy; and supportive relationships in therapeutic spaces. Sustained family support and encouragement were vital to participants' successful recovery trajectories. Compassionate, non-judgmental treatment from social workers fostered greater engagement in care.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eStrong social support in OUD recovery can significantly impact health and wellness of people with OUD. Carceral and community health programs should prioritize social reintegration, family involvement, and community-based resources alongside clinical interventions.\u003c/p\u003e","manuscriptTitle":"Social Support, Family Dynamics, and Therapeutic Relationships in Post-Incarceration Recovery for People Who Use Opioids","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-13 13:56:37","doi":"10.21203/rs.3.rs-9012567/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"146566146714902756290228022903519433538","date":"2026-05-12T23:21:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141056169197514951137296897624257512256","date":"2026-04-21T16:57:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-10T02:24:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-09T15:34:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-04T09:06:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"Addiction Science \u0026 Clinical Practice","date":"2026-03-02T17:02:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"addiction-science-and-clinical-practice","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ascp","sideBox":"Learn more about [Addiction Science \u0026 Clinical Practice](https://ascpjournal.biomedcentral.com/)","snPcode":"13722","submissionUrl":"https://submission.nature.com/new-submission/13722/3","title":"Addiction Science \u0026 Clinical Practice","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"397a4037-284c-4f38-89f9-8aa16ebd9ca0","owner":[],"postedDate":"March 13th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"146566146714902756290228022903519433538","date":"2026-05-12T23:21:18+00:00","index":30,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-13T13:56:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-13 13:56:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9012567","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9012567","identity":"rs-9012567","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}