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
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
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.
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)
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.
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?
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.
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
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
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?
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
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.
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.
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.
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
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
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
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.
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.
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.
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?
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,
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!”