Families of Persons With Substance Use and Mental Disorders: A Literature Review and Conceptual Framework*

Abstract: There are significant knowledge gaps concerning the experiences of families of persons with co-occurring substance and mental disorders and the impact of families on treatment of individuals with these disorders. This paper presents a conceptual framework for examining family involvement of adults in treatment for co-occurring substance and mental disorders. An overview of the characteristics, problems, and needs of these individuals and their family members is presented. The extant literature pertaining to our conceptual framework is reviewed with focus on predictors of family involvement with clients, predictors of family member involvement in clients' treatment, and consequences of family involvement for client treatment outcomes. Gaps in the research literature and implications for future research and practice are discussed. Key Words: drug and alcohol use/abuse and families, families and mental illness, mental illness, substance use. Although there are extensive, but largely separate, research literatures on the experiences of families of persons with either substance use or mental disorder, little is known about the families of persons with cooccurring substance use and mental disorders and the effect of families on the treatment of such clients (Clark, 2001; Merikangas & Stevens, 1998; Mueser & Fox, 2002; Silver, 1999). Co-occurring disorders, defined as the presence of two or more simultaneous existing conditions, in this case substance abuse and mental illness, can lead to greater negative consequences for both clients and family members than a single disorder alone (e.g., Albanese & Khantzian, 2001; Clark, 1996). Subsequently, the treatment of persons with co-occurring disorders can be more complex than treatment of individuals with substance or mental disorders alone (Mueser, Drake, & Miles, 1997). Thus, it is particularly important to understand the implications of family relationships for client recovery and wellness. For example, families play significant roles in helping their substance abusing family members seek and stay engaged in treatment (Fals-Stewart, O'Farrell, & Birchler, 2003). In order to improve treatment outcomes for clients with co-occurring substance and mental disorders, theory-based research is sorely needed that focuses on understanding the predictors of family involvement with clients and in the clients' treatment, as well as an understanding of the relationship between family involvement and client outcomes. The purpose of this article is to advance a conceptual framework, which emphasizes (a) predictors of family involvement and (b) consequences of family involvement with individuals for co-occurring substance and mental disorders who are in treatment. This conceptual framework proposes that family involvement, hypothesized to be a function of the family member's stress and well-being, will have a significant influence on client outcomes. This expectation stems from theories that have emphasized connections between individual well-being and the larger family context (Biegel & Schulz, 1999; Boss, Doherty, LaRossa, Schumm, & Steinmetz, 1993), prior research on family caregiving in the context of physical and mental illness (e.g., Biegel, Johnsen, & Shafran, 1997; Biegel, Song, & Milligan, 1995; Townsend & Franks, 1995), and existing research on families of adults with substance or mental disorders. The model distinguishes between two facets of family involvement-family involvement with the client (apart from treatment) and family involvement specific to the client's treatment-because they may have different antecedents and consequences and because families may be involved in one way, but not the other. For example, a family member may provide financial assistance to the client but not be involved in the client's treatment. Both types of involvement are operationalized in terms of the quantity, nature, and perceived quality of the involvement. …