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Contents

What Is a TIP?...vii

Consensus Panel...ix

KAP Expert Panel and Federal Government Participants ...xi

Foreword ...xiii

Executive Summary ...xv

Chapter 1—Substance Abuse Treatment and Family Therapy...1

Overview...1

Introduction...1

What Is a Family?...2

What Is Family Therapy?...4

Family Therapy in Substance Abuse Treatment...8

Goals of This TIP...18

Chapter 2—Impact of Substance Abuse on Families ...21

Overview...21

Introduction...21

Families With a Member Who Abuses Substances...23

Other Treatment Issues...28

Chapter 3—Approaches to Therapy...31

Overview...31

Differences in Theory and Practice...31

Family Therapy for Substance Abuse Counselors...49

Substance Abuse Treatment for Family Therapists...64

Chapter 4—Integrated Models for Treating Family Members...73

Overview...73

Integrated Substance Abuse Treatment and Family Therapy...73

Integrated Models for Substance Abuse Treatment...85

Matching Therapeutic Techniques to Levels of Recovery...105

Chapter 5—Specific Populations ...109

Overview...109

Introduction...109

Age...110

Women...114

Race and Ethnicity...116

Sexual Orientation...130

People With Physical or Cognitive Disabilities...131

People With Co-Occurring Substance Abuse and Mental Disorders ...136

Rural Populations...138

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Chapter 6—Policy and Program Issues ...147

Overview...147

Primary Policy Concerns...147

Program Planning Models...149

Other Program Considerations...160

Directions for Future Research...161

Appendix A: Bibliography ...165

Appendix B: Glossary...191

Appendix C: Guidelines for Assessing Violence...195

Appendix D: Resources ...199

Appendix E: Resource Panel ...203

Appendix F: Cultural Competency and Diversity Network Participants...205

Appendix G: Field Reviewers...207

Appendix H: Acknowledgments...209

Index ...211

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In This

Chapter…

Introduction

WhatIsaFamily?

WhatIsFamily

Therapy?

FamilyTherapyin

SubstanceAbuse

Treatment

GoalsofThisTIP

1 Substance Abuse

Treatment and Family

Therapy

Overview

Thischapterintroducesthechangingdefinitionof“family,”theconcept offamilyintheUnitedStates,andthefamilyasanecosystemwithinthe largercontextofsociety.Thechapterdiscussestheevolutionoffamily therapyasacomponentofsubstanceabusetreatment,outlinesprimary modelsoffamilytherapy,andexploresthisapproachfromasystems perspective.Thechapteralsopresentsthestagesofchangeandlevelsof recoveryfromsubstanceabuse.Effectivenessandcostbenefitsoffamily therapyarebrieflydiscussed.

Introduction

The family has a central role to play in the treatment of any health problem,includingsubstanceabuse.Familyworkhasbecomeastrong andcontinuingthemeofmanytreatmentapproaches(Kaufmannand Kaufman1992a;McCradyandEpstein1996),butfamilytherapyisnot usedtoitsgreatestcapacityinsubstanceabusetreatment.Aprimary challengeremainsthebroadeningofthesubstanceabusetreatmentfocus fromtheindividualtothefamily.

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Itisimportanttounderstandthecomplexrole that families can play in substance abuse treatment.Theycanbeasourceofhelptothe treatmentprocess,buttheyalsomustmanage theconsequencesoftheIP’saddictivebehavior. Individualfamilymembersareconcerned abouttheIP’ssubstanceabuse,buttheyalso havetheirowngoalsandissues.Providing services to the whole family can improve treatmenteffectiveness.

Meetingthechallengeofworkingtogetherwill callformutualunderstanding,flexibility,and adjustmentsamongthesubstanceabuse treat-mentprovider,familytherapist,andfamily. Thisshiftwillrequireastrongerfocusonthe systemic interactions of families. Many divergent practicesmustbereconcilediffamilytherapy istobeusedinsubstanceabusetreatment.For example,thesubstanceabusecounselor typi-callyfacilitatestreatmentgoalswiththeclient; thus the goals are individualized, focused mainly ontheclient.Thisreducestheopportunityto includethefamily’sperspectiveingoalsetting, whichcouldfacilitatethehealingprocessfor thefamilyasawhole.

Working out ways for the two disciplines to collaboratealsowillrequireare-examination ofassumptionscommoninthetwofields. Substanceabusecounselorsoftenfocusonthe individualneedsofpeoplewithsubstanceuse disorders,urgingthemtotakecareof them-selves.Thisviewpointneglectstohighlightthe impactthesechangeswillhaveonotherpeople inthefamilysystem.WhentheIPisurgedto takecareofhimself,heoftenisnotprepared forthereactionsofotherfamilymembersto the changes he experiences, and often is unpreparedtocopewiththesereactions.On theotherhand,manyfamilytherapistshave hopedthatbringingaboutpositivechangesin thefamilysystemconcurrentlymightimprove thesubstanceusedisorder.Thisviewtendsto minimizethepersistent,sometimesoverpowering processofaddiction.

Bothoftheseviewsareconsistentwiththeir respectivefields,andeachhasexplanatory power,butneitheriscomplete.Addictionisa

majorforceinpeoplewithsubstanceabuse problems.Yet,peoplewithsubstanceabuse problemsalsoresidewithinapowerfulcontext thatincludesthefamilysystem.Therefore,in anintegratedsubstanceabusetreatmentmodel based on family therapy, both family functioning andindividualfunctioningplayimportantroles inthechangeprocess(LiddleandHogue2001).

What Is a Family?

There is no single, immutable definition of

family.Differentculturesandbeliefsystems influencedefinitions,andbecauseculturesand beliefschangeovertime,definitionsoffamily bynomeansarestatic.Whilethedefinition offamilymaychangeaccordingtodifferent circumstances, several broad categories encompass most families:

•Traditionalfamilies,includingheterosexual couples(twoparentsandminorchildrenall livingunderthesameroof),singleparents, and families including blood relatives, adoptivefamilies,fosterrelationships, grandparentsraisinggrandchildren,and stepfamilies.

•Extended families, which include grandpar-ents,uncles,aunts,cousins,andother relatives.

•Electedfamilies,whichareself-identifiedand arejoinedbychoiceandnotbytheusualties of blood, marriage, and law. For many people, theelectedfamilyismoreimportantthanthe biologicalfamily.Exampleswouldinclude

■ Emancipatedyouthwhochoosetolive

amongpeers

■ Godparentsandothernon-biologically

relatedpeoplewhohaveanemotionaltie (i.e.,fictivekin)

■ Gayandlesbiancouplesorgroups(and

minorchildrenalllivingunderthesame roof)

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therapy,geographicallydistantfamilymembers canplayanimportantroleinsubstanceabuse treatmentandneedtobebroughtintothe ther-apeuticprocessdespitegeographicaldistance. Families must be distinguished from social supportgroupssuchas12-Stepprograms— althoughforsomeclientsthesedistinctionsmay befuzzy.Onedistinctionisthelevelof commit-mentthatpeoplehaveforeachotherandthe durationofthatcommitment.Another distinc-tionisthesourceofconnection.Familiesare connectedbyalliance,butalsobyblood(usually) andpowerfulemotionalties(almostalways). Supportgroups,bycontrast,areheldtogether by a common goal; for example, 12-Step programsare purpose-driven and context-dependent.Thesameistrueofchurch commu-nities,whichmayfunctioninsomewayslikea family;butsimilartoself-helpprograms, churcheshaveaspecificpurpose.

Forpracticalpurposes,familycanbedefined accordingtotheindividual'sclosestemotional connections.Infamilytherapy,clientsidentify whotheythinkshouldbeincludedintherapy. Thecounselorortherapistcannotdetermine whichindividualsmakeupanotherperson’s family.Whencommencingtherapy,the coun-selorortherapistneedstoasktheclient,“Who isimportanttoyou?Whatdoyouconsider yourfamilytobe?”Itiscriticaltoidentify peoplewhoareimportantintheperson’slife. Anyonewhoisinstrumentalinproviding support,maintainingthehousehold,providing financialresources,andwithwhomthereisa strongandenduringemotionalbondmaybe consideredfamilyforthepurposesoftherapy (see,forexample,Pequegnatetal.2001).No oneshouldbeautomaticallyincludedor excluded.

Insomesituations,establishinganindividualin treatmentmayrequireametaphoricdefinition of family, such as the family of one’s workplace. Astreatmentprogresses,theideaoffamily sometimesmaybereconfigured,andthenotion maychangeagainduringcontinuingcare.In othercases,clientswillnotallowcontactwiththe family,maywantthecounselorortherapist to

see only particular

family members,or

Anyone who is

instrumental in

providing support,

maintaining the

household,

provid-ing financial

resources, and

with whom there is

a strong and

enduring

emotional

bond may be

considered family

for the purposes of

therapy.

mayexcludesome familymembers. BrooksandRice (1997,p.57)adopt Sargent’s(1983) defi-nition of family as a “group of peoplewith common ties of affec-tion and responsibility wholiveinproximity tooneanother.”They expand that definition, though,bypointing

out four characteris-ticsoffamiliescentral tofamilytherapy:

•Familiespossess

nonsummativity, whichmeansthat

thefamilyasa

wholeisgreater

than—anddifferent

from—the sum of its individual members. •Thebehaviorof

individualmembers isinterrelated throughtheprocess of circular

causali-ty,whichholdsthatifonefamilymember changeshisorherbehavior,the

otherswillalsochangeasaconsequence, whichinturncausessubsequentchangesin thememberwhochangedinitially.Thisalso demonstratesthatitisimpossibletoknow whatcomesfirst:substanceabuseorbehaviors thatarecalled“enabling.”

•Eachfamilyhasapatternof communication traits,whichcanbeverbalornonverbal, overtorsubtlemeansofexpressingemotion, conflict,affection,etc.

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The

Concept

of

Family

IntheUnitedStatestheconceptoffamilyhas changedduringthepasttwogenerations. Duringthelatterhalfofthe20thcenturyinthe United States, the proportion of married couples withchildrenshrank—suchfamiliesmadeup only24percentofallhouseholdsin2000 (FieldsandCasper2001).Theideaoffamily has come to signify many familial arrangements, includingblendedfamilies,divorcedsingle mothers or fathers with children, never-married womenwithchildren,cohabitingheterosexual partners,andgayorlesbianfamilies(Bianchi andCasper2000).

Someanalystsareconcernedaboutindications ofincreasingstressonfamilies,suchasthe increasingnumberofbirthstosinglemothers (from26.6percentin1990to33percentin 1999[U.S.CensusBureau2001c]).The increaseinsingle-motherfamilies,whichtypically havegreaterper-personexpensesandless earningpower,mayhelptoexplainwhy,inthe generalprosperityofthelasthalfofthe20th century,thepercentageofchildrenlivinginthe poorestfamiliesalmostdoubled,risingfrom15 to28percent(BianchiandCasper2000). Bengtson(2001)assertsthatrelationships involving three or more generations increasingly arebecomingimportanttoindividualsand families,thattheserelationshipsincreasingly arediverseinstructureandfunctions,andthat formanyAmericans,multigenerationalbonds areimportanttiesforwell-beingandsupport overthecourseoftheirlives.

The

Family

as

an

Ecosystem

Substanceabuseimpairsphysicalandmental health,anditstrainsandtaxestheagencies thatpromotephysicalandmentalhealth.In familieswithsubstanceabuse,familymembers oftenareconnectednotjusttoeachotherbut also to any of a number of government agencies, suchassocialservices,criminaljustice,or childprotectiveservices.Theeconomictoll includesahugedrainonindividuals’ employa-bilityandotherelementsofproductivity.The socialandeconomiccostsarefeltinmany workplacesandhomes.

Theecologicalperspectiveonsubstanceabuse viewspeopleasnestedinvarioussystems. Individualsarenestedinfamilies;familiesare nestedincommunities.Kaufman(1999)identifies membersoftheecosystemofanindividualwith asubstanceabuseproblemasfamily,peers (thoseinrecoveryaswellasthosestillusing), treatmentproviders,non-familysupport sources,theworkplace,andthelegalsystem. Theideaofanecologicalframeworkwithin whichsubstanceabuseoccursisconsistentwith familytherapy’sfocusonunderstanding humanbehaviorintermsofothersystemsin aperson’slife.Familytherapyapproaches humanbehaviorintermsofinteractionswithin andamongthesubsetsofasystem.Inthis view,familymembersinevitablyadapttothe behaviorofthepersonwithasubstanceuse disorder.Theydeveloppatternsof accommo-dationandwaysofcopingwiththesubstance use(e.g.,keepingchildrenextraordinarily quietornotbringingfriendshome).Family memberstrytorestorehomeostasisand maintainfamilybalance.Thismaybemost apparentonceabstinenceisachieved.For example,whenthepersonabusingsubstances becomesabstinent,someoneelsemaydevelop complaintsand/or“symptoms.”(Seebox,p.5, foranillustration.)

Familymembersmayhaveastrongerdesireto movetowardoverallimprovedfunctioningin thefamilysystem,thuscompellingandeven providingleveragefortheIPtoseekand/or remainintreatmentthroughperiodsof ambivalenceaboutachievingasoberlifestyle. Alternately,clarifyingboundariesbetween dysfunctionalfamilymembers—including encouragingIPstodetachfromfamilymembers whoareactivelyusing—canalleviatestresson theIPandcreateemotionalspacetofocuson thetasksofrecovery.

What

Is

Family

Therapy?

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Homeostasis

A young couple married when they were both 20 years old. One spouse developed alcoholismduringthefirst5yearsofthemarriage.Thecouple’slifeincreasingly becamechaoticandpainfulforanother5years,whenfinally,atage30,the substance-abusingspouseenteredtreatmentand,overthecourseof18months, attainedasoliddegreeofsobriety.Suddenly,lackofcommunicationand

difficultieswithintimacycametotheforeforthenon-substance-abusingspouse, whonowoftenfeelssadandhopelessaboutthemaritalrelationship.The non-substance-abusingspousefinds,after18monthsofthepartner’ssobriety,that thesoberspouseis“nolongerfun”orstilldoesnotwanttomakeplansfor anotherchild.

Almostallyoungcouplesencountercommunicationandintimacyissuesduring thefirstdecadeoftherelationship.Inanalcoholicmarriageorrelationship, suchissuesareregularlypushedintothebackgroundasguilt,blame,and controlissuesareexacerbatedbythenatureofaddictivediseaseanditseffects onboththerelationshipandthefamily.

Thepossiblecomplexitiesoftheabovesituationillustrateboththerelevanceof familytherapytosubstanceabusetreatmentandwhyfamilytherapyrequiresa complex,systemsperspective.Manysystem-relatedanswersarepossible: Perhapsthenon-substance-abusingspouseisfeelinglonely,unimportant,oran outsider.Withthefocusofrecoveryontheaddiction—andtheIP’sstrugglesin recovery—thespousewhopreviouslymighthavebeencentraltotheother’s drinkingand/ormaintainingabstinence,evenconsideredthecauseofthedrinking, isnow,18monthslater,tangentialtowhathadbeenmajor,highlyemotional upheavalsandinteractions.Thenow“outsiderspouse”maynotevenbeaware offeelinglonelyandunimportantbutinstead“actsout”thesefeelingsinterms offindingthenowsoberspouse“nofun.”Alternatively,perhapsthenowsober spouseisindeednofun,andtheproblemslieinhowharditisforthesober spousetorelaxorfeelcomfortablewithsobriety—inwhichcasetheresolution mightinvolvebothpartnerslearningtodevelopanewlifestylethatdoesnot involvesubstanceuse.

The joint use of both recovery and family therapy techniques will improve marital communicationandbothpartners’capacityforintimacy.Theseelementsof personalgrowthareimportanttothedevelopmentofserenityinrecoveryand stabilityintherelationship.

anypartofthesystemwillbringaboutchanges inallotherparts.Therapybasedonthispoint ofviewusesthestrengthsoffamiliestobring aboutchangeinarangeofdiverseproblem areas,includingsubstanceabuse.

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chemicaldependencyonboththeIPandthe family.Frequently,intheprocess,marshaling thefamily’sstrengthsrequirestheprovisionof basicsupportforthefamily.

Infamilytherapy,theunitoftreatmentisthe family,and/ortheindividualwithinthecontext ofthefamilysystem.Thepersonabusing sub-stancesisregardedasasubsystemwithinthe familyunit—thepersonwhosesymptomshave severe repercussions throughout the family system.Thefamilialrelationshipswithinthis subsystemarethepointsoftherapeuticinterest andintervention.Thetherapistfacilitates discussionsandproblemsolvingsessions,often withtheentirefamilygrouporsubsetsthereof, butsometimeswithasingleparticipant,who may or may not be the person with the substance use disorder.

Adistinctionshouldbemadebetweenfamily therapyandfamily-involvedtherapy. Family-involvedtherapyattemptstoeducatefamilies abouttherelationshippatternsthattypically contributetotheformationandcontinuationof substanceabuse.Itdiffersfromfamilytherapy inthatthefamilyisnottheprimarytherapeutic grouping, nor is there intervention in the system offamilyrelationships.Mostsubstanceabuse treatmentcentersoffersuchafamily

educa-tionalapproach.It typicallyislimitedto psychoeducationto

Family therapy is

a collection of

therapeutic

approaches that

share a belief in

family-level

assessment and

intervention.

teachthefamily aboutsubstance abuse,related behaviors,andthe behavioral,medical, andpsychological consequencesofuse. Children also need age-appropriate psychoeducation programspriorto beinggroupedwith other family membersineither education or therapy. (Formore informa-tionseechapter6,

under“FamilyEducationandParticipation,” andseealso Children’s Program Kit:

Supportive Education for Children of Addicted Parents [SubstanceAbuseandMentalHealth ServicesAdministration(SAMHSA)2003], developedbySAMHSAandtheNational AssociationforChildrenofAlcoholics.)

Inaddition,programmaticenhancements(such asclassesthatteachEnglishasasecond lan-guage)alsoarenotfamilytherapy.Although educational family activities can be therapeutic, theywillnotcorrectdeeplyingrained,

maladaptiverelationships.

Thefollowingdiscussionspresentabrief overviewoftheevolutionoffamilytherapy models and the primary models of family therapyusedtodayasthebasisfortreatment. Chapter3providesmoredetailedinformation aboutthesemodels.

Historical

Models

of

Family

Therapy

Marriage and family therapy (MFT)hadits originsinthe1950s,addingasystemicfocusto previousunderstandingsofthefamily.Systems theoryrecognizesthat

•Awholesystemismorethanthesumofits parts.

•Partsofasystemareinterconnected. •Certainrulesdeterminethefunctioningofa

system.

•Systemsaredynamic,carefullybalancing continuityagainstchange.

•Promotingorguardingagainstsystem

entropy(i.e.,disorderorchaos)isapowerful dynamicinthefamilysystembalancing changeofthefamilyrolesandrules. The strategic school of family therapy

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bringaboutsuddenanddecisivechange” (NicholsandSchwartz2001,p.97). Basedonobservationsoftherelationship betweenfamilystructureandbehavior,along withworkwithinner-citychildrenandtheir families,Minuchin(1974)developedanother approach, structural family therapy.Minuchin andFishman(1981)believedthatfamiliesusea limitedrepertoireofself-perpetuatingrelational patternsandthatfamilymembersdivideinto subsystemswithboundariesthatregulatefamily communicationandbehavior.Theysoughtto shiftfamilyboundariessotheboundary betweenparentsandchildrenwasclearer. Interventionisaimedathavingtheparents workmorecooperativelytogetherandat reducingtheextenttowhichchildrenassume parentalresponsibilitieswithinthefamily. Onemajormodelthatemergedduringthis developmentalphasewas cognitive–behavioral family and couples therapy.Itgrewoutofthe earlyworkinbehavioralmaritaltherapyand parentingtraining,andincorporatedconcepts developedbyAaronBeck.Beckreasonedthat peoplereactaccordingtothewaystheythink andfeel,sochangingmaladaptivethoughts, attitudes,andbeliefswouldeliminate dysfunc-tionalpatternsandthetriggersthatsetthemin motion(Beck1976).Thisunionofcognitive andbehavioraltherapiesinafamilysettingwas newanduseful.Thetherapistconsidersnot onlyhowpeople’sthoughts,feelings,and emotionsinfluencetheirbehavior,butalsothe impacttheyhaveonspousesandotherfamily members.Cognitive-behavioralfamilytherapy andbehavioralcouplestherapyaretwomodels thathavestrongempiricalsupport.

Throughthe1980sand1990s,newermodels ofMFTwerearticulated.Inresponsetothe problem-focusedstrategicandstructuralfamily therapies,authorssuchasdeShazer,Berg, O’Hanlon,andSelkmanpromulgated solution-focused family therapy (e.g.,BergandMiller 1992;deShazer1988).Theyassertedthat pinpointingthecauseofpoorfunctioningis

unnecessaryandthattherapyfocusedon solutionsissufficienttohelpfamilieschange. Soonaftertheintroductionofsolution-focused therapytotheMFTlandscape,Whiteand Epston’s Narrative Means to Therapeutic Ends (1990)heraldedthe narrative movement

inMFT.Thisfamilytherapydevelopmenthas focusedonthewaypeopleconstructmeaning andhowtheconstructionofmeaningaffects psychologicalfunctioning.

Intheearlypartofthe21stcentury,MFT seemspoisedtoundergoanotherchange, focusedonempiricallydemonstratingthe effectiveness of different approaches to therapy. The few models that have been tested

empiricallyhaveshownpromisingresults.For example, functional family therapy, multisys-temic therapy, multidimensional family therapy,

and brief strategic family therapy allhave beenshowntobehighlyeffectiveinreducing acting-outbehavioramongadolescentsand/or inreducingtheriskforproblembehavior among their younger siblings. Among the couplestherapymodelsknowntohavereduced maritaldistressandpsychologicalproblemsare

emotionally focused couples therapy, cognitive– behavioral couples therapy, behavioral couples therapy, integrative couples therapy,and

systemic couples therapy.(Seechapter3for furtherinformation.)

Primary

Family

Therapy

Models

in

Use

Today

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preparethemforfamilytherapy),ormembers

ofaresidentialtreatmentsetting.

Mostfamilytherapymeetingstakeplacein clinicsorprivatepracticesettings.Home-based therapybreaksfromthetraditionalclinical setting,reasoningthatjoiningthefamilywhere itlivescanhelpovercomeshame,stigma,and resistance.Itisareturntothepracticesof socialworkerswho,intheearly20thcentury, didtheirworkinclients’homes(Beels2002). Meetingthefamilywhereitlivesalsoprovides valuableinformationabouthowthefamily reallyfunctions.

Fourpredominantfamilytherapymodelsare usedasthebasesfortreatmentandspecific interventionsforsubstanceabuse:

1. The family disease model looksatsubstance

abuseasadiseasethataffectstheentire family.Familymembersofthepeoplewho abusesubstancesmaydevelop codepen-dence,whichcausesthemtoenabletheIP’s substanceabuse.Limitedcontrolled

researchevidenceisavailabletosupportthe disease model, but it nonetheless is influential inthetreatmentcommunityaswellasinthe generalpublic(McCradyandEpstein1996). 2. The family systems model isbasedonthe

ideathatfamiliesbecomeorganizedbytheir interactionsaroundsubstanceabuse.In adapting to the substance abuse, it is possible forthefamilytomaintainbalance,or home-ostasis. For example, a man with a substance usedisordermaybeantagonisticorunable toexpressfeelingsunlessheisintoxicated. Usingthesystemsapproach,atherapist wouldlookforandattempttochangethe maladaptivepatternsofcommunicationor familyrolestructuresthatrequiresubstance abuseforstability(Steinglassetal.1987). 3. Cognitive–behavioral approaches arebased

ontheideathatmaladaptivebehaviors, includingsubstanceuseandabuse,are reinforcedthroughfamilyinteractions. Behaviorallyorientedtreatmenttriesto changeinteractionsandtargetbehaviors thattriggersubstanceabuse,toimprove

communicationandproblemsolving,and tostrengthencopingskills(O’Farrelland Fals-Stewart1999).

4. Mostrecently, multidimensional family therapy (MDFT)hasintegratedseveral differenttechniqueswithemphasison therelationshipsamongcognition,affect (emotionality),behavior,andenvironmental input(Liddleetal.1992).MDFTisnotthe onlyfamilytherapymodeltoadoptsuchan approach.Functionalfamilytherapy (AlexanderandParsons1982), multisys-temictherapy(Henggeleretal.1998),and briefstrategicfamilytherapy(Szapoczniket al.inpress)alladoptsimilar multidimen-sionalapproaches.

Family Therapy in

Substance Abuse

Treatment

Goals

of

Family

Therapy

Theintegrationoffamilytherapyinsubstance abusetreatmentisstillrelativelyrare.Family therapyinsubstanceabusetreatmenthelps familiesbecomeawareoftheirownneedsand providesgenuine,enduringhealingforpeople. Familytherapyworkstoshiftpowertothe parentalfiguresinafamilyandtoimprove communication. Other goals will vary according towhichmemberofthefamilyisabusing sub-stances.Familytherapycananswerquestions suchas

•Whyshouldchildrenoradolescentsbe involvedinthetreatmentofaparentwho abusessubstances?

•What impact does a parent abusing substances haveonhisorherchildren?

•Howdoesadolescentsubstanceabuseimpact adults?

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needs to change, not just the IP. Family therapy, therefore,helpsthefamilymakeinterpersonal, intrapersonal,andenvironmentalchanges affectingthepersonusingalcoholordrugs.It helpsthenonusingmemberstoworktogether moreeffectivelyandtodefinepersonalgoals fortherapybeyondavaguenotionofimproved familyfunctioning.Aschangetakesplace,family therapyhelpsallfamilymembersunderstand whatisoccurring.Thisout-in-the-open under-standing removes any suspicion that the family is “ganging up” on the person abusing substances.

Amajorgoaloffamilytherapyinsubstance abusetreatmentisprevention—especially keepingsubstanceabusefrommovingfromone generationtoanother.Studyafterstudyshows thatifonepersoninafamilyabusesalcoholor drugs,theremainingfamilymembersareat increasedriskofdevelopingsubstanceabuse problems.Thesinglemostpotentriskfactorof futuremaladaption,predispositiontosubstance use,andpsychologicaldifficultiesisaparent’s substance-abusingbehavior(JohnsonandLeff 1999).A“healthyfamilystructurecanprevent adolescentsubstanceabuseeveninthefaceof heavypeerpressuretouseandabusedrugs” (Kaufman1990a,p.51).Further,iftheperson abusingsubstancesisanadolescent,successful treatmentdiminishesthelikelihoodthat sib-lingswillabusesubstancesorcommitrelated offenses(Alexanderetal.2000).Treating adolescentdrugabusealsocandecreasethe likelihoodofharmfulconsequencesin adult-hood, such as chronic unemployment, continued drugabuse,andcriminalbehavior.

Therapeutic

Factors

Because of the variety of family therapy models, thediverseschoolsofthoughtinthefield,and thedifferentdegreestowhichfamilytherapyis implemented,multipletherapeuticfactors probablyaccountfortheeffectivenessoffamily therapy.Amongthemmightbeacceptance fromthetherapist;improvedcommunication; organizingthefamilystructure;determining accountability;andenhancingimpetusfor change,whichincreasesthefamily’smotivation

tochangeitspatternsofinteractionandfrees thefamilytomakechanges.Familytherapy alsoviewssubstanceabuseinitscontext,notas anisolatedproblem,andsharessome charac-teristicswith12-Stepprograms,whichevoke solidarity,self-confession,support,self-esteem, awareness,andsmoothre-entryintothe community.

Stillanotherreasonthatfamilytherapyis effectiveinsubstanceabusetreatmentisthat itprovides a neutral forum in which family membersmeettosolveproblems.Sucha rationalvenueforexpressionandnegotiation oftenismissingfromthefamilylivesofpeople withasubstanceproblem.Thoughtheirlives areunpredictableandchaoticthesubstance abuse—thecauseoftheupheavalandafocal organizingelementof

familylife—isnot discussed.Ifthe

subjectcomesup,the

Family therapy in

substance abuse

treatment helps

families become

aware of their own

needs and

provides genuine,

enduring healing

for people.

toneoftheexchange is likely to be accusatory and negative.

Inthesupportive environmentoffamily therapy,thisuneasy silencecanbebroken inwaysthatfeel emotionallysafe.As thetherapistbrokers, mediates,and restruc-turesconflictsamong familymembers, emotionallycharged topicsare allowed to come into the open. The therapisthelps ensurethatevery familymemberis

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empoweringandmayprovideenoughenergyto createpositivechange.Eachofthese improve-mentsinfamilylifeandcopingskillsisahighly desirableoutcome,whetherornottheIP’s drugoralcoholproblemsareimmediately resolved. It is clearly a step forwardforthe familyofapersonabusingsubstancesto becomeastable,functionalenvironmentwithin whichabstinencecanbesustained.

Toachievethisgoal,familytherapyfacilitates changesinmaladaptiveinteractionswithinthe familysystem.Thetherapistlooksfor

unhealthy relational structures (such as parent-childrolereversals)andfaultypatternsof communication(suchasalimitedcapacityfor negotiation).Incontrasttotheperipheralrole thatfamiliesusuallyplayinothertherapeutic approaches,familiesaredeeplyinvolvedin whateverchangesareeffected.Infact,the majorityofchangeswilltakeplacewithinthe

familysystem,subsequentlyproducingchange intheindividualabusingsubstances.

Familytherapyishighlyapplicableacross manyculturesandreligions,andiscompatible with their bases of connection and identification, belongingandacceptance.Mostculturesvalue familiesandviewthemasimportant.This preeminencesuggestshowimportantitisto includefamiliesintreatment.Itshouldbe acknowledged,however,thataculture’shigh regardforfamiliesdoesnotalwayspromote improvedfamilyfunctioning.Inculturesthat reverefamilies,peoplemayconcealsubstance abusewithinthefamilybecausedisclosure wouldleadtostigmaandshame.

Additionally, the definition, or lack of definition, oftheconceptof“rehabilitation”variesgreatly acrossculturallines.Culturesdifferintheir viewsofwhatpeopleneedinordertoheal.The identitiesofindividualswhohavethemoral

Selected Research Outcomes of Family

Approaches to Substance Abuse

Treatment

•Bukstein(2000,p.74)foundthat“family-focusedinterventionsareempirically well-supportedforyouthwithaconductdisorderorsubstanceusedisorder.” Henotesthat68percentofadolescentswithasubstanceusedisorderalsohad acomorbiddisruptivebehaviordisorder.Buksteinemphasizesthatfamily therapyinterventionscanfocusontheenvironmentalfactorsthatpromote bothdisorders.

•Catalano et al. (1999) sought to determine whether family-focused interventions forparentsonmethadonewouldreducetheirdruguseandpreventchildren fromstartingtousedrugs.Afterstudying144methadone-treatedparentswith 78childrenforayear,with33sessionsoffamilytraining,theauthorsfound significantimprovementsinparentingskills,lessparentaldruguse,fewer deviantpeers,andbetterfamilymanagement.

•Cunningham and Henggeler’s 1999 overview of multisystemic therapy, a family-based treatment model, found high rates of substance abuse treatment completionamongyouthwithseriousclinicalproblems.

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abuse,schizophrenia,andconductdisorder.Thestudiesalldemonstratedthe superiorityofbrieffamilytreatmentoverindividualandgrouptreatmentsfor reducingdruguse.

•Friedmanetal.(1995)conductedastudyof176adolescentdrugabuseclients andtheirmothersinsixoutpatientdrug-freeprogramswithfamilytherapy sessions.Theauthorsfoundthatthemorepositivelytheclientdescribedthe family’sfunctioningandrelationshipsatpretreatment,themoreclient improvementwasreportedbyclientormotheratfollow-up.Theyconcluded thattheadolescentswithbettertreatmentoutcomesbegantreatmentwith morepositiveperceptionsoftheirfamilies.

•Inareviewofcontrolledtreatmentoutcomeresearch,LiddleandDakof (1995a)foundthatdifferenttypesoffamilyinterventioncanengageandretain peoplewhousedrugsandtheirfamiliesintreatment,significantlyreducedrug useandotherproblembehaviors,andenhancesocialfunctioning.Theyalso concluded that family therapy was more effective than therapy without families, butcautionedagainstovergeneralizingthisfindingbecauseofmethodological limitationsandtherelativelysmallnumberofstudies.

•McCrady and Epstein (1996) noted that an extensive literature supports family-basedmodelsandtheeffectivenessoftreatmentsbasedonthefamilydisease, familysystems,andbehavioralfamilymodels.Researchknowledgeislimited, however,byalackofattentiontocultural,racial,sexual,andgender orienta-tionissuesamongsubjects;thelackofcouplestreatmentresearchonpeople usingdrugs;andthelackoffamilytreatmentresearchonindividualswith alcoholabusedisorders.

•O’FarrellandFals-Stewart(2000)concludedthatbehavioralcouplestherapy ledtomoreabstinenceandbetterrelationships,decreasedtheincidenceof separationanddivorce,reduceddomesticviolence,andhadafavorable cost/benefitratiocomparedtoindividualtherapy.

•Shapiro(1999)describesLaBodegadelaFamilia,afamilytherapyapproach usedtoreducerelapse,paroleviolations,andrecidivismforindividuals releasedfromprisonandjail.Withintensivefamily-basedtherapies,the 18-monthrearrestratedroppedfrom50to35percent.

•Inastudyusingbothfamilyandnon-familytreatmentsforsubstanceabuse, StantonandShadish(1997)concludedthat(1)whenfamily-couplestherapy waspartofthetreatment,resultswereclearlysuperiortomodalitiesthatdo notincludefamilies,and(2)familytherapypromotesengagementandretention ofclients.

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authoritytohelp(forexample,anelderora minister)candifferfromculturetoculture. Therapistsneedtoengageaspectsofthe cultureorreligionthatpromotehealingandto considertherolethatdrugsandalcoholplayin theculture.(Issuesofcultureandethnicityare discussedindetailinchapter5.)

Effectiveness

of

Family

Therapy

While there are limited studies of the effec-tivenessoffamilytherapyinthetreatmentof substanceabuse,importanttrendssuggestthat family therapy approaches should be considered morefrequentlyinsubstanceabusetreatment. Muchofthefederallyfundedresearchinto

substanceabuse treatmenthas focusedoncriminal

Family therapy is

highly applicable

across many

cultures and

religions, and is

compatible with

their bases of

con-nection and

identi-fication, belonging

and acceptance.

justiceissues, co-occurringdisorders, and individual-spe-cifictreatments.One reasonisthat

researchwithfamilies is difficult and costly. Ambiguitiesin definitionsoffamily andfamilytherapy alsohavemade researchinthese areasdifficult.Asa result,familytherapy hasnotbeenthe focusofmuch substanceabuse research.However, evidencefromthe researchthathas beenconducted, includingthat describedbelow,indicatesthatsubstanceabuse treatmentthatincludesfamilytherapyworks betterthansubstanceabusetreatmentsthatdo not(Stantonetal.1982).Itincreasesengagement andretentionintreatment,reducestheIP’s drug and alcohol use, improves both familyand socialfunctioning,anddiscouragesrelapse.

Althoughtheeffectivenessoffamilytherapyis documentedinagrowingbodyofevidence, integratingfamilytherapyintosubstanceabuse treatmentdoesposesomespecificchallenges: •Familytherapyismorecomplexthan

non-familyapproachesbecausemorepeopleare involved.

•Familytherapytakesspecialtrainingand skillsbeyondthosetypicallyrequiredin manysubstanceabusetreatmentprograms. •Relativelylittleresearch-basedinformationis

availableconcerningeffectivenesswith sub-setsofthegeneralpopulation,suchas women,minoritygroups,orpeoplewith seriouspsychiatricproblems(O’Farrelland Fals-Stewart1999).

Thebalance,however,certainlytipsinfavor ofafamilytherapyintreatingsubstanceabuse. Basedoneffectivenessdataandtheconsensus panel’scollectiveexperience,theconsensus panelrecommendsthatsubstanceabuse treat-mentagenciesandprovidersconsiderhowthey mightincorporatefamilyapproaches,including age-appropriateeducationalsupportservices fortheirclients’children,intotheirprograms.

Cost

Benefits

Only a few studies have assessed the cost benefitsoffamilytherapyorhavecompared thecostoffamilytherapytootherapproaches suchasgrouptherapy,individualtherapy,or 12-Stepprograms.Asmallbutgrowingbodyof data,however,hasdemonstratedthecost bene-fitsoffamilytherapyspecificallyforsubstance abuseproblems.Familytherapyalsohas appearedtobesuperiorinsituationsthatmight insomekeyrespectbesimilartosubstance abusecontexts.

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groupcomparedto36percentinacontrol group(SextonandAlexander2002).Thecost ofthefamilytherapyrangedfrom$700to $1,000perfamilyforthe2-yearstudyperiod. Theaveragecostofdetentionforthatperiod wasatleast$6,000peryouth;thecostofa residentialtreatmentprogramwasatleast $13,500.Inthisinstance,thecostbenefitsof familytherapywereclearandcompelling (SextonandAlexander2002).

Otherstudieslookattheoffsetfactor;thatis, therelationshipbetweenfamilytherapyand theuseofmedicalcareorsocialcosts. Fals-Stewartetal.(1997)examinedsocialcosts incurredbyclients(forexample,thecostof substanceabusetreatmentorpublicassistance) andfoundthatbehavioralcouplestherapywas considerably more cost effective than individual therapyforsubstanceabuse,withareduction ofcostsof$6,628forclientsincouplestherapy, comparedtoa$1,904reductionforclientsin individualtherapy.

Similarresultswerenotedinastudybythe NationalWorkingGrouponFamily-Based InterventionsinChronicDisease,whichfound that6monthsafterafamily-focused interven-tion,reimbursementforhealthserviceswas50 percentlessforthetreatmentgroup,compared toacontrolgroup.Whilethisstudylookedat chronicdiseasessuchasheartdisease,cancer, Alzheimer’sdisease,anddiabetes,substance abusealsoisachronicdiseasethatisinmany waysanalogoustothesephysicalconditions (FisherandWeihs2000).Bothchronicdiseases andsubstanceabuse

•Arelong-standingandprogressive •Oftenresultfrombehavioralchoices •Aretreatable,butnotcurable

•Haveclientsinclinedtoresisttreatment •Havehighprobabilityofrelapse

Chronicdiseasesarecostlyandemotionally draining.Substanceabuseissimilartoa chronicdisease,withpotentialforrecovery;it even can lead to improvement in family func-tioning. Other cost benefits result from preven-tive aspects of treatment. While therapy usually

is not considered a primary prevention interven-tion, family-based treatment that is oriented towardaddressingriskfactorsmayhavea significantpreventiveeffectonotherfamily members(Alexanderetal.2000).Forexample, itmayhelppreventsubstanceabuseinother familymembersbycorrectingmaladaptive familydynamics.

Other

Considerations

Familytherapyforsubstanceabusetreatment demandsthemanagementofcomplicated treat-mentsituations.Obviously,treatingafamilyis morecomplexthantreatinganindividual, especiallywhenanunwillingIPhasbeen man-datedtotreatment.Specializedstrategiesmay benecessarytoengagetheIPintotreatment. Inaddition,thesubstanceabusealmostalways isassociatedwithotherdifficultlifeproblems, whichcanincludementalhealthissues,cognitive impairment,andsocioeconomicconstraints, such as lack of a job or home. It can be difficult, too,toworkacrossdiverseculturalcontextsor discernindividualfamilymembers’readiness forchangeandtreatmentneeds.

Thesecircumstancesmakemeaningfulfamily therapy for substance abuse problems a complex andchallengingtaskforbothfamilytherapists andsubstanceabusetreatmentproviders. Modificationsinthetreatmentapproachmay benecessary,andthesuccessoftreatmentwill depend,toalargedegree,onthecreativity, judgment,andcooperationinandbetween pro-gramsineachfield.

Complexity

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childrenneedtoparticipateinagroupoftheir

own.Inafamilytherapyprogram,thechild’s andtheparent’ssubstanceabuseproblems wouldbeaddressedconcomitantly.

Anotherfactorthatcancomplicateanytherapy processisexternalcoercion,suchas court-mandatedtreatmentormandatesarisingoutof childprotectiveservicesrequirements.These situationscanaffectfamiliesinvariedways; treatment providers should approach mandated familytherapywithheightenedvigilanceabout theroleofcoercioninfamilyprocess.Oftenin substanceabusetreatment,alegalmandateor someotherformofcoercionmakestherapya requirement. The nature of mandated treatment islikelytohaveaneffectonthedynamicsof familytherapy.Itcanplaceconstraintsonthe therapistandraisedistractingissuesthathave anegativeeffectontreatment,requiringmore care,coordinationofservices,andcase man-agement.Thelegalandethicalthicketisdense inthesecircumstances.Anexceptioniswhen theclientisaminor,thecourtscanmandate treatmentandfamilytherapy.Practitioners shouldavailthemselvesofallrelevant resources(e.g.,professionalassociations, supervision,ethicalguidelines,localandState legalandconsumerorganizations)before venturingtotreatfamiliesundercourtorderor similarsituations.Therapistsmustforma workingalliancewitheachfamilymemberand establishtrustwiththefamilysothatsensitive informationcanbedisclosed.Thisrequiresthe therapisttodemonstratethatsheisonthe fam-ily’ssidetherapeutically,butshealsoneedsto disclosetothefamilyanyotherobligationsshe hasasaresultofherposition.Forexample,by agreeing to treat the family under the particular circumstancesathand,thetherapistmightbe obligated to make progress reports to probation orparoleagencies.

Co-occurring problems

Eventhoughanindividualwithasubstanceuse disordergenerallybringsafamilyinto treat-ment,itispossiblethatmorethanoneperson inthefamilyhassubstanceabuseproblems, mentalillness,problemswithdomestic

violence,orsomeothermajordifficulty. Substanceabuse,infact,maybeasecondary reasonforreferralfortherapy.Changingthe family’smaladaptivepatternsofinteraction mayhelptocorrectpsychosocialproblems amongallfamilymembers.Formore informa-tionaboutco-occurringmentalandsubstance usedisordersseetheforthcomingTIP

Substance Abuse Treatment for Persons With Co-Occurring Disorders (CenterforSubstance AbuseTreatment[CSAT]indevelopment k).

Biological aspects of

addiction

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aspectsoffamilysystemsorcognitive–behavioral traitsifafamilyisbeingevicted,isnoteating properly,iswithoutfinancialresourcesand employment,orisexperiencingsomeother threattodailylife.Second,thereimbursement systemsthatcanbeaccessedprobablywill determinehowlongtreatmentwillcontinue, irrespectiveofclientneeds.Therefore,family therapytreatmentsforsubstanceabusemust bedesignedtoberelativelybriefandtotarget aspectsofthefamily’senvironmentthatmaybe maintainingthedrugabusesymptomatology (e.g.,Robbinsetal.inpress).Inaddition, familymembersshouldbereferredtoAl-Anon, Alateen,andNAR-Anontoenhancetheir potentialforlong-termrecovery.

Cultural competence

Culturalcompetenceisanimportantfeaturein familytherapybecausetherapistsmustwork with the structures of families from many cultures.Knowledgeofandsensitivityto culturesisinvolvedindetermining

•Towhatextentisthefamily’sdivergencefrom mainstreamnormsafunctionofpathologyor adifferentculturalbackground?

•Howisthefamilyarranged—hierarchically? Democratically?Withinthisstructure,what arethecommunicationpatterns?

•Howwellisthisfamilyfunctioning?Thatis, towhatextentcanthefamilymeetitsown goalswithoutgettinginitsownway? •Whattherapeuticgoalsareappropriate? •Whataretheculture’sprescribedrolesfor

eachfamilymember?

•Whoaretheappropriatelydefined“power figures”inthefamily?

Theneedforculturalcompetencedoesnot implythatatherapistmustbelongtothesame culturalgroupastheclientfamily.Itispossible todevelopculturalcompetenceandworkwith groups other than one’s own. A sensitive therapistpaysattention,sensescultural nuances,andlearnsfromclients.Evenwhen thetherapistisfromthesamecultureasthe familyintreatment,trustcannotbeassumed. Itmustbebuilt. The expectationsregardingthe

therapist’sroleasan

agentofchangemust

Substance abuse

almost always is

associated with

other difficult life

problems, which

can

include

mental

health

issues,

cog-nitive

impairment,

and socioeconomic

constraints.

be clearly discussed in relation to the devel-oping trust with the family and individual members.

Issuesrelatedto culturalsensitivity andappropriateness areconsideredin greater detail in chapter5andinthe forthcomingTIP

Improving Cultural Competence in Substance Abuse Treatment (CSATin development b).

Stages of

change and

levels of

recovery

Theprocessofrecoveryiscomplexand multifac-eted.Oneusefulframeworkforunderstanding thisprocessinvolvesstagesofchange

(Prochaskaetal.1992),whichcanbeapplied toanindividualortothewholefamilyand usedasaframeworkfortreatment.Thefive stagesofchangeare

1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance

Individualstypicallyprogressandregressin theirmovementsthroughthesestages

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tionalinformation

onthestagesof change,referto chapter3ofthisTIP

Treatment must be

customized to the

needs of each

family and the

person abusing

substances.

andseealsoTIP35,

Enhancing Motivation for Change in Substance Abuse Treatment

(CSAT1999b).

WhileProchaskaet al.(1992) conceptu-alizedreadinessfor change,other researchershave modeledthestagesof recoveryafter treat-menthasbegun.One suchmodelofthe paththrough treat-mentisKaufman’s(1990b)progressivelevelsof recovery:

• Dry abstinence isatimewhenclientsmust copewithproblemsrevolvingaroundthe ces-sationofsubstanceuse(suchaswithdrawal, suddenrealizationoftheactualdamage intoxicationhascaused,andtheshamethat follows).

Sobriety,or early recovery,concentrateson maintainingfreedomfromsubstances.Bitby bit,theclientishelpedtosubstitute health-sustainingbehaviorsforrelationshipsand circumstancesthatprecipitatesubstanceuse. •Advanced recovery shiftsfromsupportto

examinationofunderlyingpersonalissues thatpredisposetheclienttosubstanceuse. Trustandintimacyarere-established,and theclientmovesthroughtheterminationof therapy.

ThisTIPapproachesstagesofchangefor familiesbycombiningBepkoandKrestan’s stagesoftreatmentforfamilies(1985)and HeathandStanton’sstagesoffamilytherapy forsubstanceabusetreatment(1998). Together,thephasesoffamilychangeare

Attainment of sobriety. Thefamilysystemis unbalancedbuthealthychangeispossible. •Adjustment to sobriety. Thefamilyworkson

developingandstabilizinganewsystem. •Long-term maintenance of sobriety. The familymustrebalanceandstabilizeanew andhealthierlifestyle.

Combiningthesetwomodelsprovidesasimple, straightforwardcategorizationforafamily’s progressinrecoveryregardingattainmentof, adjustmentto,andlong-termmaintenanceof sobriety.Foradditionalinformationonthese phasesoffamilychange,seechapter4.

Unanswered research

questions

Atpresent,researchcannotguidetreatment providersaboutthebestspecificmatches betweenfamilytherapyandparticularfamily systemsorsubstancesofabuse.Researchto datesuggeststhatcertainfamilytherapy approachescanbeeffective,butnoone approachhasbeenshowntobemoreeffective thanothers.Inaddition,eventhoughtheright modelisanimportantdeterminantof appro-priatetreatment,theexacttypesoffamily therapymodelsthatworkbestwithspecific addictionshavenotbeendetermined.However, agrowingbodyofevidenceoverthepast25 yearssuggeststhatchildrenbenefitfrom par-ticipatinginage-appropriatesupportgroups. Thesecanbeofferedbytreatmentprograms, school-basedstudentassistanceprograms,or faith-basedcommunities.

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therapy—whichcanbeusedinadditionto

fam-ilytherapy(LiddleandHogue2001).

Safety

and

Appropriateness

of

Family

Therapy

Onlyinraresituationsisfamilytherapy inad-visable.Occasionally,itwillbeinappropriate orcounterproductivebecauseofreasonssuch thoseasmentionedabove.Sometimes,though, familytherapyisruledoutduetosafetyissues orlegalconstraints.Familyorcouplestherapy shouldnottakeplaceunlessallparticipants haveavoiceandeveryonecanraisepertinent issues,evenifadomineeringfamilymember doesnotwantthemdiscussed.Familytherapy canbeusedwhenthereisnoevidenceofserious domesticorintimatepartnerviolence.

Engaginginfamilytherapywithoutfirst assess-ingcarefullyforviolencecanleadnotonlyto poortreatment,butalsotoariskforincreased abuse.

Asystemsapproachpresumesthatallfamily membershaveroughlyequalcontributionsto theprocessandhaveequityintermsofpower andcontrol.Thisbeliefisnotsubstantiatedin theresearchonfamilyviolence.Hence,family therapyonlyshouldbeusedwhenonefamily memberisnotbeingterrorizedbyanother. Resistancefromadomineeringfamilymember canbeaddressedandrestructuredbyfirst allyingwiththisfamilymemberandthen grad-uallyandgentlyquestioningthisperson(and thewholefamily)abouttheappropriatenessof thedomineeringbehavior(Szapoczniketal. 1988).(SeealsoappendixC,Guidelinesfor AssessingViolence.)

Itisthetreatmentprovider’sresponsibilityto provideasafe,supportiveenvironmentforall participantsinfamilytherapy.Childrenbenefit byattendingsupportgroupsspecificallyfor them;itisimportanttocreateasafe environ-mentinwhichtheycandiscussfamilyviolence, abuse,andneglect.Usually,awaycanbe

foundtoincludeeventhefamilymemberwho hasturnedtoviolenceasawayofdealingwith problems.Thatpersonisavitalpartofthe familyandwillbepivotalinunderstandingthe natureofthefamilyviolence.Forexample, Johnson(1995)distinguishesbetweencommon coupleviolenceandpatriarchalterrorism.The formerischaracterizedbyoccasionalviolent outburstsbyeitherspouseandisnotlikelyto escalate.Itisusuallyanintermittentresponse toconflict,andintherapycanbeexamined andchanneledintomorepositiveexpression. Patriarchalterrorism,however,issystematic maleviolencewiththegoalofcontrol.Itmay notbepossibleoradvisabletoincludea chron-icallyviolentpartnerinthefamilytherapy process.

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Domesticviolenceisaseriousissueamongpeople withsubstanceusedisorders,anditmustbe factoredintotherapeuticconsiderations.If,for example,arestrainingorderprohibitsspouses fromseeingeachother,thetreatmentprovider mustworkwithinthislimitation,using thera-peuticconfigurationsthatmakesurethata clientwhoisabusiveisnotinasessionwiththe personheorshehasbeenbarredfromseeing. Often when there is concomitant family violence, theoffenderismandatedtocompletea

Batterer’sInterventionProgrambefore partici-patinginanycouple’swork.Atthesametime, thevictim/spouseisengagedinsafetyplanning andsometimestreatmentforhisorherown issues.

Onlythemostextremeangercontraindicates familytherapy.KaufmanandPattison(1981) developedtheconceptoftheneedforaperiod ofabstinencebeforesufficienttrustcanbe builttocounteracttheanger.Includingall fam-ilymembersintreatmentandprovidingthema forumforreleasingtheirangermayhelpto worktowardthatthreshold.Redefiningthe problemasresidingwithinthefamilyasa wholecanhelptransformtheangerinto moti-vationforchange.Inturn,thismotivationcan beusedtorestructurethefamily’sinteractions sothatthesubstanceabuseisnolonger supported.Thetherapist’sabilitytoreframe proposedobstructionsbyfamilymembersis oftenthekeytocreatingapositivetherapeutic direction.

Itisuptocounselorsandtherapiststoassess thepotentialforangerandviolenceandto con-structtherapysoitcanbeconductedwithout endangeringanyfamilymembers.Becauseof thelife-and-deathnatureofthisresponsibility, theconsensuspanelincludesguidelinesforthe screeningandtreatmentofpeoplecaughtupin thecycleoffamilyviolence.These recommen-dations,adaptedfromTIP25, Substance Abuse Treatment and Domestic Violence (CSAT 1997b),arepresentedinappendixC.However, these guidelines are not a substitute for training; counselorsandtherapistsshouldhavetraining andsupervisioninhandlingfamilyviolence cases.

If,duringthescreeninginterview,itbecomes clearthatabattererisendangeringaclientor achild,thetreatmentprovidershouldrespond tothissituationbeforeanyotherissueand,if necessary,suspendtherestofthescreening interviewuntilthesafetyoftheclientcanbe ensured.Theprovidershouldrefertheclient orchildtoadomesticviolenceprogramand possiblytoashelterandlegalservices,and shouldtakenecessarystepstoensurethesafety ofaffectedchildren.Anyoutcryofanticipated dangerneedstoberegardedwiththeutmost seriousnessandimmediateprecautionstaken.

Goals of This TIP

General

Goals

Connections

The integration of family therapy into substance abusetreatmentisanimportantdevelopment inthetreatmentofaddictions.Historically, barriershaveseparatedthefields,amongthem differencesincredentialing,treatmentmodels, andcostforhigher-trainedfamilytherapists. ThisTIPisintendedtoprovideanopportunity forprovidersfrombothdisciplinestolearn fromoneanother.Itprovideslanguagethatwill helpbothfieldstalkaboutfamilytherapyand addictionandfacilitateanewandmore collab-orativewayofthinkingaboutsubstanceabuse treatment.

InmanyStatesandjurisdictions,credentialing requirementsareraisingstandardsfor sub-stanceabusecounselorsandfamilytherapists. Thesechanges,whichwillrequirefurther edu-cation,provideopportunitiesforpractitioners toexpandtheirhorizonsastheyupgradetheir professionalskills.Thisprocesscanfurther cross-fertilizethefieldsbymakingthe practi-tionersofbothfieldsmorefamiliarwitheach other’swork.

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practitionerswillbeabletousethisTIPto

helpeducateinsurersandbehavioralmanaged careorganizationsabouttheimportanceof coveringfamilytherapyservicesforclientswith substanceusedisorders.

Goals

for

Specific

Groups

Substance abuse treatment

counselors

ThisTIPwillhelpsubstanceabusetreatment counselors

•Understandtheimpactofsubstanceabuseon familiestakenasawhole

•Recognizethatfamilymembersneed treat-mentinthecontextofthefamilyasawhole •Appreciatethevalueoffamilytherapyin

treatmentandintegratetheirinterventions withthegreatergoodofthefamily

Family therapists and other

clinicians

ThisTIPwillhelpfamilytherapistsbecome moreawareofthepresenceandsignificanceof chemicaldependencyandworkwiththe sub-stanceabusetreatmentcommunitysofamily environments no longer contribute to or main-tain substance abuse. It also is hoped that family therapistswillcometoappreciatemodelsof substanceabusetreatmentandthecontextin whichtheyaredelivered.

Clinical supervisors

Clinical supervisors in substance abuse treatmentprogramsandinfamilytreatment programscanusethisinformationtobecome aware of and knowledgeable about the potential connectionsbetweensubstanceabusetreatment andfamilytherapy.Thesesupervisorswillthen bebetterequippedtoincorporateappropriate familyapproachesintotheirprogramsand evaluatetheperformanceofpersonneland programsinbothdisciplines.

Treatment program

administrators

Realizinghowbeneficialfamilytherapycanbe asanadjuncttoorintegratedpartofsubstance abusetreatment,programadministratorscan usetheTIPtotrainandmotivatesubstance abusetreatmentclinicianstoincludefamily membersintreatment.Likewise,program administratorsinfamilytreatmentprograms canusetheTIPtomotivateandtrainfamily therapiststoincludetheexplorationof sub-stanceusedisordersinfamilytreatment. Sinceitisdifficulttofindcounselorswhoare expertinbothfields,itishopedthatsubstance abusetreatmentadministratorswilldevelop collaborativerelationshipswithfamilytherapy programsandmanagenecessarylogistical issues.Forexample,findingadequatespaceis oftenanissue.Workinghours,too,mayhave tobeshifted,becausestaffwillneedtowork someeveningstomeetwithfamilymembers.

Families

Theconsensuspanelhopesthatfamilytherapists willbegintoraisetheissueofsubstanceuseas acriticalissuethatcannegativelyimpact familiesandthatsubstanceabusetreatment counselorswilluseinformationinthisTIPto informfamiliesaboutwhattheycanexpect fromtreatment.Thegrowingconsumerhealth movementcanbepartoftheeducationthat emboldensfamiliestoaskforadequate treat-ment.TheIPandfamilymembersshouldbe encouragedtoidentify

•Whyistreatmentbeingpursuednow?

•Whatarethecostsandbenefitsofengagingin therapynow?

•Howis“change”definedinthestructureof “progress”intherapy?

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In This

Chapter…

Introduction

Families With a

Member Who

Abuses Substances

Other Treatment

Issues

2 Impact of Substance

Abuse on Families

Overview

FamilystructuresinAmericahavebecomemorecomplex—growingfrom the traditional nuclear family to single-parent families, stepfamilies, foster families,andmultigenerationalfamilies.Therefore,whenafamilymember abuses substances, the effect on the family may differ according to family structure.Thischapterdiscussestreatmentissueslikelytoarisein differentfamilystructuresthatincludeapersonabusingsubstances.For example,thenon–substance-abusingparentmayactasa“superhero”or maybecomeverybondedwiththechildrenandtoofocusedonensuring theircomfort.Treatmentissuessuchastheeconomicconsequencesof substanceabusewillbeexaminedaswilldistinctpsychological conse-quencesthatspouses,parents,andchildrenexperience.Thischapter concludeswithadescriptionofsocialissuesthatcoexistwithsubstance abuse in families and recommends ways to address these issues in therapy.

Introduction

Agrowingbodyofliteraturesuggeststhatsubstanceabusehasdistinct effectsondifferentfamilystructures.Forexample,theparentofsmall childrenmayattempttocompensatefordeficienciesthathisorher sub-stance-abusingspousehasdevelopedasaconsequenceofthatsubstance abuse (Brown and Lewis 1999). Frequently, children may act as surrogate spousesfortheparentwhoabusessubstances.Forexample,children maydevelopelaboratesystemsofdenialtoprotectthemselvesagainst therealityoftheparent'saddiction.Becausethatoptiondoesnotexistin asingle-parenthouseholdwithaparentwhoabusessubstances,children arelikelytobehaveinamannerthatisnotage-appropriateto compen-satefortheparentaldeficiency(formoreinformation,see Substance Abuse Treatment: Addressing the Specific Needs of Women [Centerfor SubstanceAbuseTreatment(CSAT)indevelopment e]andTIP32,

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offspring,missingthenecessary“launching

phase”intheirrelationship,sovitaltothe maturationalprocessesofallfamilymembers involved.

Theeffectsof substanceabuse frequentlyextend

People who abuse

substances are

likely to find

themselves

increasingly

isolated from

their families.

beyondthenuclear family.Extended familymembersmay experiencefeelings ofabandonment, anxiety,fear,anger, concern, embarrass-ment,orguilt;they maywishtoignore orcuttieswiththe personabusing sub-stances.Somefamily membersevenmay feeltheneedfor legalprotection fromtheperson abusingsubstances. Moreover,theeffects onfamiliesmaycontinueforgenerations. Intergenerationaleffectsofsubstanceabuse canhaveanegativeimpactonrolemodeling, trust,andconceptsofnormativebehavior, whichcandamagetherelationshipsbetween generations.Forexample,achildwithaparent whoabusessubstancesmaygrowuptobean overprotectiveandcontrollingparentwhodoes notallowhisorherchildrensufficientautonomy. Neighbors,friends,andcoworkersalso

experiencetheeffectsofsubstanceabuse becauseapersonwhoabusessubstancesoften isunreliable.Friendsmaybeaskedtohelp financiallyorinotherways.Coworkersmaybe forced to compensate for decreased productivity orcarryadisproportionateshareofthe work-load.Asaconsequence,theymayresentthe personabusingsubstances.

Peoplewhoabusesubstancesarelikelytofind themselvesincreasinglyisolatedfromtheir fam-ilies.Oftentheypreferassociatingwithothers whoabusesubstancesorparticipateinsome

other form of antisocial activity. These associates supportandreinforceeachother’sbehavior. Differenttreatmentissuesemergebasedonthe ageandroleofthepersonwhousessubstances inthefamilyandonwhethersmallchildrenor adolescentsarepresent.Insomecases,afamily mightpresentahealthyfacetothecommunity whilesubstanceabuseissuesliejustbelowthe surface.

Reilly(1992)describesseveralcharacteristic patternsofinteraction,oneormoreofwhich arelikelytobepresentinafamilythatincludes parentsorchildrenabusingalcoholorillicit drugs:

1. Negativism.Anycommunicationthatoccurs amongfamilymembersisnegative,taking theformofcomplaints,criticism,andother expressionsofdispleasure.Theoverall moodofthehouseholdisdecidedly down-beat,andpositivebehaviorisignored.In suchfamilies,theonlywaytogetattention orenliventhesituationistocreateacrisis. Thisnegativitymayservetoreinforcethe substanceabuse.

2. Parental inconsistency.Rulesettingis erratic,enforcementisinconsistent,and familystructureisinadequate.Childrenare confusedbecausetheycannotfigureoutthe boundariesofrightandwrong.Asaresult, they may behave badly in the hope of getting their parents to set clearly defined bound-aries. Without known limits, children cannot predictparentalresponsesandadjusttheir behavioraccordingly.Theseinconsistencies tendtobepresentregardlessofwhetherthe personabusingsubstancesisaparentor childandtheycreateasenseofconfusion— akeyfactor—inthechildren.

3. Parental denial.Despiteobviouswarning signs,theparentalstanceis:(1)“What drug/alcoholproblem?Wedon’tseeany drugproblem!”or(2)afterauthorities intervene:“Youarewrong!Mychilddoes nothaveadrugproblem!”

Figure

Figure 3-2 Basic Symbols Used in a Genogram
Figure 3-3
Figure 3-4 Individual, Family, and Environmental Systems

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