Substance Use Disorder Treatment and 

Family Therapy 

UPDATED 2020 

TREATMENT IMPROVEMENT PROTOCOL 

TIP 39 
TIP 39

Please share your thoughts about this publication by completing a brief online survey at: 

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The survey takes about 7 minutes to complete and is anonymous. 

Your feedback will help SAMHSA develop future products. 

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TIP 39

Contents 

Foreword vii 

Executive Summary ix 

Resource Panel xxi 

Cultural Competency and Diversity Network Participants xxii 

Publication Information xxiii 

Introduction ix 

Overall Key Messages ix 

Content Overview x 

TIP Development Participants xvii 

Consensus Panel xvii 

KAP Expert Panel and Federal Government Participants xviii 

Field Reviewers xix 

Chapter 1—Substance Use Disorder Treatment: Working With Families 1 

Scope of This TIP 2 

Family Counseling: What Is It, and Why Is It Useful? 5 

Family Counseling Objectives 10 

Understanding Families 10 

Common Characteristics of All Families 11 

History of Family-Based Interventions in SUD Treatment 15 

Diferent Pathways in Working With Families 17 

Where Do We Go From Here? 21 

Chapter 2—Infuence of Substance Misuse on Families 23 

The Role of Genetics and Family History in the Development of and 

Recovery From SUDs 24 

Common Characteristics of Families With SUDs 26 

Family Types: SUDs and Family Dynamics 30 

Where Do We Go From Here? 42 

Chapter 3—Family Counseling Approaches 43 

Overview of Family-Based SUD Treatment Methods 50 

Family Approaches To Support Ongoing Recovery 68 

Where Do We Go From Here? 74 

Chapter 4—Integrated Family Counseling To Address Substance 

Use Disorders 75 

Appropriateness of Integrated Family Counseling for SUDs 76 

Whom To Involve in Integrated Family Counseling for SUDs 79 

Screening and Assessment in Integrated Family Counseling 80 

Goals of Integrated Family Counseling for SUDs 89 

Where Do We Go From Here? 94 

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TIP 39 Substance Use Disorder Treatment and Family Therapy 

Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status 95 

Scope of This Chapter 96 

Why Focus on Diverse Family Cultures? 97 

Culturally Responsive Family Counseling 98 

SUD Treatment for Specifc Family Cultures 105 

Where Do We Go From Here? 117 

Chapter 6—Administrative and Programmatic Considerations 119 

Developing a Family-Centered Organizational Culture as an Administrator 120 

Incorporating Family Counseling and Family Programming 121 

Supporting Workforce Development 125 

Encouraging Collaboration as an Administrator 133 

Addressing Other Programmatic Considerations 136 

Where Do We Go From Here? 141 

Appendix—Bibliography 143 

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Exhibits 

Exhibit 1 1 TIP Organization 3 

Exhibit 1 2 Key Terms 4 

Exhibit 1 3 Benefts and Challenges of Family Counseling in SUD Treatment 6 

Exhibit 1 4 Treatment Issues According to Family Type 11 

Exhibit 1 5 Homeostasis 12 

Exhibit 1 6 The Matrix Intensive Outpatient Approach 17 

Exhibit 1 7 Understanding Client Reluctance Toward Family Involvement 19 

Exhibit 1 8 Multifamily Groups 20 

Exhibit 2 1 The Role of the Medical Model When Working With Families 25 

Exhibit 2 2 Family Traits That Afect SUD Initiation, Maintenance, and Recovery 26 

Exhibit 2 3 Efects of Diferent Substances on Families 27 

Exhibit 2 4 Family Roles When a Parent Has an SUD 39 

Exhibit 3 1 Overview of Family-Based Treatment Approaches Addressed in Chapter 3 44 

Exhibit 3 2 BCT Interventions 55 

Exhibit 3 3 Concepts Underlying BSFT 62 

Exhibit 4 1 A Narrative Approach to Family Assessment 82 

Exhibit 4 2 Genogram Symbols 87 

Exhibit 4 3 O’Neill Genogram 88 

Exhibit 5 1 Eight Questions To Consider When Ofering SUD Treatment for 

Families of Diverse Racial/Ethnic Backgrounds 100 

Exhibit 5 2 Family-Based SUD Services for Youth of Diverse Races/Ethnicities 105 

Exhibit 6 1 Levels of Program Integration 122 

Exhibit 6 2 Cross-Training 123 

Exhibit 6 3 Sample Policies and Procedures To Support Integrated Family 

Counseling for SUD Treatment 123 

Exhibit 6 4 Developing a Supervision Contract With a Family Counselor 131 

Exhibit 6 5 Multicultural Supervision 132 

Exhibit 6 6 Systemic–Developmental Supervision 134 

Exhibit 6 7 SCORE-15 Index of Family Functioning and Change 140 

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TIP 39

Foreword 

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the U.S. Department of 

Health and Human Services agency that leads public health efforts to reduce the impact of substance 

abuse and mental illness on America’s communities. An important component of SAMHSA’s work is 

focused on dissemination of evidence-based practices, and providing training and technical assistance to 

healthcare practitioners on implementation of these best practices. 

The Treatment Improvement Protocol (TIP) series contributes to SAMHSA’s mission by providing sciencebased, best-practice guidance to the behavioral health feld. TIPs refect careful consideration of all 

relevant clinical and health service research, demonstrated experience, and implementation requirements. 

Select nonfederal clinical researchers, service providers, program administrators, and patient advocates 

comprising each TIP’s consensus panel discuss these factors, offering input on the TIP’s specifc topics in 

their areas of expertise to reach consensus on best practices. Field reviewers then assess draft content and 

the TIP is fnalized. 

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory 

process have helped bridge the gap between the promise of research and the needs of practicing 

clinicians and administrators to serve, in the most scientifcally sound and effective ways, people in need of 

care and treatment of mental and substance use disorders. My sincere thanks to all who have contributed 

their time and expertise to the development of this TIP. It is my hope that clinicians will fnd it useful and 

informative to their work. 

Elinore F. McCance-Katz, M.D., Ph.D. 

Assistant Secretary for Mental Health and Substance Use 

U.S. Department of Health and Human Services 

Substance Abuse and Mental Health Services Administration 

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TIP 39

Executive Summary 

Introduction 

This Treatment Improvement Protocol (TIP) update provides information and guidance on the latest 

science-informed, family-based interventions and family counseling approaches for substance use 

disorders (SUDs). Intended audiences include SUD treatment providers such as drug and alcohol 

counselors, licensed clinical social workers, licensed marriage and family therapists, psychologists and 

psychiatrists specializing in addiction, psychiatric and mental health nurses (specialty practice registered 

nurses), and peer recovery support specialists. The TIP’s audience also includes SUD treatment program 

administrators, supervisors, and clinical/program directors. 

SUDs are complex, lifelong conditions that affect not just people in recovery but their families as well. 

To give a person struggling with alcohol and drug addiction the greatest chance at lasting, successful 

recovery, families often need to be included in treatment and services. This TIP is designed to help 

providers and administrators better understand how to do this by describing the unique impacts of SUDs 

on families; how family functioning and dynamics can both support and interfere with recovery; and how 

treatments, services, and programs can best be tailored to families’ needs. 

An expert panel developed the TIP’s content based on a review of the most up-to-date literature and 

on their extensive experience in the feld of alcohol and drug addiction treatment and family counseling. 

Other professionals also generously contributed their time and commitment to this publication. 

The TIP is divided into six chapters so readers can easily fnd material they need most. Below is a summary 

of the TIP’s main messages, followed by a description of each chapter’s key content areas. 

Overall Key Messages 

Families affect and are affected by SUDs. In most cases, including family members in a client’s treatment 

or services for substance misuse is benefcial and makes achieving and sustaining long-term recovery more 

likely. 

Family-based SUD interventions are supported by empirical evidence and have been shown to be 

effective in promoting long-term behavior change, including recovery. A wide variety of family-based 

treatment models and approaches are available. You can select from these based in part on the family’s 

makeup, needs, readiness for change, treatment setting, and level of care required. 

No two families are identical, and as such, the ways in which family members function and interact 

with one another will vary from family to family. As a clinician, you should be prepared to adapt SUD 

treatments and services to each family’s unique background, structure, and situation. 

Each family has its own ways of behaving and relating to one another. Those dynamics infuence substance 

misuse and recovery and should be considered when making shared treatment decisions with clients and 

their family members. You should be able to identify common family structures and dynamics and 

understand how they infuence substance misuse. This will help you develop more targeted treatments 

that directly address a given family’s dysfunctions and needs. 

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TIP 39 Substance Use Disorder Treatment and Family Therapy 

Most families are doing their best to adapt to 

the situation of a family member struggling with 

substance misuse. In general, families usually 

are just trying to maintain a steady state (or 

homeostasis). Sometimes that means engaging in 

behaviors that actually support the family member’s 

substance misuse. Avoid blaming, shaming, and 

using judgmental labels (e.g., referring to family 

members as “co-dependent” or “enablers”) 

when working with families. Instead, offer them 

education, empathy, 

and support. 

There are several ways you can integrate 

family-based treatments and services into care. 

Motivational interviewing (MI), family-focused 

interviews and assessments, genograms, and familybased treatment goals are just a few options. 

Families are diverse and may need treatments 

and services tailored to factors such as their 

racial/ethnic background, level of acculturation, 

immigration/nativity status, and history of military 

service. 

It is not enough for clinicians to learn about and 

offer family-based treatments and services for 

substance misuse. Administrators, directors, 

and clinical supervisors also play a role in 

delivering family-based SUD treatment and 

ensuring programs adopt and maintain a familycentered culture. This means comprehensively 

addressing a wide range of program development 

and workforce factors, like hiring and 

retention, training, clinician and supervisor core 

competencies, and licensing and credentialing. 

Programs that establish and foster close ties 

to the surrounding community can better help 

clients and families access resources that meet 

their needs. Administrators are vital to this process 

as well. 

Content Overview 

This TIP is divided into six chapters designed to 

thoroughly cover all relevant aspects of the ways 

in which families are touched by SUDs and how 

providers can offer treatment and services to help 

meet families’ full range of needs. 

Chapter 1: Substance Use Disorder 

Treatment: Working With Families 

This chapter lays the groundwork for 

understanding the treatment concepts and 

theories of family-based SUD treatment discussed 

in later parts of this TIP. It is for providers and 

administrators. 

Families are complex entities; no two are the 

same. To provide effective family-based services 

for SUDs, one must understand different types 

of families and the common characteristics 

families often possess (including their rules, roles, 

boundaries, and communication styles). 

Family counseling can help families facing SUDs 

in many different ways, including by teaching 

them to better understand how their interactions 

and behaviors are contributing to a family 

member’s substance misuse and learning how to 

adapt their behaviors to support a family member’s 

recovery. Family-based interventions are often 

centered on helping families learn how to change 

their behaviors toward and interactions with one 

another, how they can be a positive infuence on 

recovery, and how to prevent substance misuse in 

future generations. There are numerous familybased treatment models, approaches, settings, 

and formats for SUDs, giving providers (and their 

client families) a wide range of tools and options 

from which to choose. 

In Chapter 1, you will learn about: 

• The benefts and challenges of offering family 

counseling for SUDs, including why you should 

include families in SUD treatment and services 

and in goal setting for those treatments and 

services. 

• The history of family-based SUD treatment and 

how the incorporation of families into traditional 

treatment approaches and settings has changed 

over time. 

• The core objectives of current family-based 

treatment for SUDs, such as helping the 

family become a source of strength in their 

family member’s recovery and helping them 

understand how they infuence their family 

member’s substance-related behaviors. 

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• Common characteristics present in nearly 

all families (e.g., roles, rules, communication 

patterns, degree of loyalty, culture) and how 

those characteristics vary—and subsequently 

affect a family member’s recovery. 

• The various pathways by which family-based 

SUD treatment and services are delivered, 

such as parallel, sequential, and integrated 

approaches. Different pathways may be more 

appropriate for certain families depending on 

their particular structure, way of functioning, 

and dynamics. 

• The different degrees of family involvement 

that can occur in SUD treatment across different 

levels of care and settings (e.g., residential 

treatment, outpatient care). 

Chapter 2: Infuence of Substance Misuse 

on Families 

This chapter summarizes the ways in which 

substance misuse affects family dynamics (the ways 

in which families behave toward and relate to one 

another) and family systems and the ways in which 

those in turn infuence substance misuse. This 

chapter is for providers. 

Families operate in their own unique ways. Family 

dynamics play a large role in both sustaining and 

reducing/preventing substance misuse. Although 

all families are different, certain families affect and 

are affected by SUDs in similar ways. You should be 

aware of how the dynamics among specifc family 

types—such as families with young or adolescent 

children, families with adult children, childless 

couples, and blended families—are affected by and 

contribute to the risk of substance misuse in the 

family. This will help you better determine which 

treatment/services are best suited to the family and 

their dynamics. 

This chapter also presents the latest empirical 

evidence about common traits of families touched 

by drug and alcohol addiction. Again, although 

each family is different, this discussion will help 

you understand and identify possible targets of 

intervention, such as poor communication style, 

high levels of family confict, ineffective parenting 

approaches, and lack of family connectedness. 

In Chapter 2, you will learn the following: 

• Families with SUDs tend to share certain 

characteristics, which are often the focus 

of treatment and services. These include 

problems with communication, confict, 

parenting skills, family cohesion, and family 

attitudes about substance use. 

• Most families engage in behaviors to try 

to maintain homeostasis, or balance. Family 

members often try to keep things as “normal” 

and consistent as possible, and in doing so may 

behave in ways that actually make substance 

misuse more likely. Sometimes this is called 

enabling. Rather than criticize or shame families 

for such behaviors (which are completely normal 

and, in a way, adaptive), instead work with 

families to help them learn how to develop 

healthier behaviors and dynamics. 

• There may be gender-specifc differences in 

how family dynamics affect and are affected by 

SUDs. These gender differences may need 

to be taken into consideration when offering 

treatment and services. For instance, women 

are often socialized to be caretakers and to not 

be confrontational. A mother or daughter may 

feel that it is not her place to criticize a family 

member’s substance misuse and may instead 

engage in caretaking or “enabling” behaviors. 

These gender beliefs may need to be addressed 

in treatment if they are contributing to family 

dysfunction and preventing recovery. 

• In couples in which one partner has an SUD, 

research suggests there is a high risk of 

interpersonal violence and mistreatment. Be 

sure to screen for all forms of abuse. 

• Parents struggling with SUDs may not be able 

to properly care for their young or adolescent 

children, possibly leading to negative physical, 

emotional, economic, and social outcomes for 

offspring. Neglect and other forms of abuse also 

may be present. This raises professional and 

legal issues related to safety, and means loss 

of child custody may become a factor at some 

point during treatment/services. 

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• Children of parents with SUDs may be forced 

to take on roles inappropriate for their 

developmental stage. For instance, a teenager 

may feel that he has to become the “father” of 

the household because his father has alcohol 

use disorder and cannot reliably earn a living 

and help support the family. This can be a 

signifcant source of stress for the child. 

• It is easy to sympathize with young children 

living with parents with drug and alcohol 

addiction, but do not overlook the effects of 

SUDs on adult children. Even when grown, 

children can be negatively affected by their 

parents’ substance misuse, including being at 

risk for substance misuse themselves as well 

as other unhealthy outcomes (e.g., suicide 

attempts, higher mortality). 

• Just by nature of their structure, blended 

families often struggle with certain diffcult 

dynamics and situations (like loss of a biological 

parent or stepparents/stepchildren feeling 

like “outsiders”). When SUDs are thrown into 

the mix, this can raise the family stress level 

even higher. Be particularly sensitive to the 

diffculties facing blended families with SUDs, 

and understand how helping them strengthen 

their bonds with one another can be a powerful 

factor in supporting recovery and preventing 

substance misuse. 

• Adolescent substance misuse can negatively 

affect parents and siblings and also place 

the youth at risk for dangerous or unhealthy 

outcomes (like car accidents, dropping out of 

school, or continued substance misuse into 

adulthood). A family may need help identifying 

dynamics and functions that are supporting the 

teen’s SUD and making recovery more diffcult. 

Chapter 3: Family Counseling Approaches 

This chapter reviews research-based family 

counseling approaches specifcally developed 

for treating couples and families in which the 

primary issue facing the family system is an SUD. 

It describes the underlying concepts, goals, 

techniques, and research support for each 

approach. This chapter is for providers. 

The numerous family-based SUD treatments 

that exist differ in the strategies and techniques 

used to address substance misuse. However, 

Substance Use Disorder Treatment and Family Therapy 

these treatments share certain features, such as 

an emphasis on treating the family as a whole 

rather than focusing only on the individual with 

an SUD; using a nonblaming, collaborative 

approach to care; and adapting to the culture and 

values embraced by each family. Specifc familybased treatments that can be used effectively 

to help families improve their functioning and 

enhance recovery include psychoeducation, 

multidimensional family therapy (MDFT), behavioral 

couples and family therapy, brief strategic family 

therapy (BSFT), functional family therapy, and 

solution-focused brief therapy. This chapter 

discusses each in detail. 

In Chapter 3, you will learn the following: 

• Family-based treatment guides families in 

enhancing their thoughts about and reactions to 

substance misuse. This in turn typically leads to 

major changes within the family as a whole. 

• Regardless of approach, all family-based 

treatment shares certain core aspects. Aspects 

include improving the health and well-being 

of the whole family, not just the person with 

substance misuse; respecting the value of family 

and other social relationships as a key part of 

recovery; and meeting harm-reduction goals 

other than abstinence, which can still beneft the 

family and the individual. 

• Psychoeducation is a widely used approach to 

family-based SUD treatment, and many families 

can improve their functioning and dynamics 

simply by learning about drug and alcohol 

addiction and recovery. Do not underestimate 

the power of this seemingly simple 

intervention. 

• MDFT has good empirical support for reducing 

SUDs, especially among adolescents. It 

addresses individual behaviors and family 

processes. It has improved functioning among 

adolescents, parents, families as a whole, and 

families’ relationships within their communities. 

• Behavioral couples and family counseling 

approaches help support recovery by 

teaching clients to improve the quality of 

their relationships, engage in healthier 

communication, and build positive relationships 

with one another. 

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• BSFT uses a problem-focused, practical 

approach to reduce or eliminate youth 

substance misuse and enhance family 

functioning. 

• Functional family therapy also takes a problemsolving approach to engaging, motivating, 

and creating behavior change among clients. 

Families are also taught how to apply their 

newfound skills to future situations. 

• Solution-focused brief therapy invites families to 

build a positive vision of their future and identify 

interpersonal changes and improvements in 

target behaviors needed to make that vision a 

reality. 

• Network Therapy uses a combination of 

individual and group therapy approaches and 

involves members of the client’s network of 

supportive family members and friends in 

sessions. The main goal is for members of 

the supportive network to learn how they can 

reinforce the client’s efforts to achieve and 

maintain abstinence. 

• In addition to understanding specifc 

treatment approaches, consider offering 

other family-based skills and services that can 

support recovery across the continuum of 

care. These could include engaging the family 

in treatment, linking members to community 

and mutual-aid recovery supports, facilitating 

behavioral contracts between the person in 

recovery and his or her family members, and 

teaching relapse prevention techniques (e.g., 

family-based problem-solving). 

• Case management services can help families 

address problems within larger systems of 

care, like healthcare-, education-, legal-, and 

childcare-related issues. These commonly occur 

in individuals and families with SUDs and thus 

should be a standard part of family-based 

SUD treatment. 

• Family peer recovery support services offer 

families the valuable opportunity to learn from 

others who have walked in their shoes. This can 

be incredibly powerful and healing, as families 

touched by drug and alcohol addiction often 

feel isolated and struggle with stigma, shame, 

and confusion. 

Chapter 4: Integrated Family Counseling 

To Address Substance Use Disorders 

This chapter discusses the advantages and 

limitations of integrated treatment models and the 

degree of providers’ involvement with families. 

It offers guidelines on how to deliver family 

counseling in combination with specifc SUD 

treatment and to match counseling approaches 

to each family’s specifc level of recovery. The 

intended audience is providers. 

As a general rule, families should be incorporated 

into SUD treatment and services to give individuals 

the best chances at lasting recovery. Be sure to 

let the individual in recovery decide who in 

the family should be invited to participate in 

treatment. Barriers to participation may need to 

be problem solved, such as family members who 

live far away, have scheduling conficts, or simply 

refuse to be a part of treatment. As in individual 

counseling, screening and assessment are critical 

components to information gathering, but in this 

context, both processes should be family based. 

For instance, discuss not only the individual’s 

history of substance misuse but also how substance 

misuse has occurred historically, throughout the 

family. Rather than focusing entirely on problems 

within the family, be sure to also explore family 

members’ strengths, including supportive qualities 

(e.g., warmth, compassion), talents, and goals. This 

will help you maintain a positive tone throughout 

treatment and can help keep families motivated 

and engaged in care. 

In Chapter 4, you will learn that: 

• In some instances, certain family members 

should not be included in SUD treatment and 

services. Such situations include when intimate 

partner violence has occurred, when child abuse 

or neglect has occurred, when individuals are 

currently withdrawing from substances, when 

clients with SUDs are also are struggling with 

psychosis or are suicidal, and when clients 

have signifcant cognitive problems (like severe 

learning or memory problems). 

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TIP 39 Substance Use Disorder Treatment and Family Therapy 

• Mandated family treatment can be diffcult 

because family members are not seeking 

care willingly. In such cases, MI can help you 

build rapport with clients and enhance their 

willingness and desire to participate in 

treatment. 

• As with individual treatment, screening 

and assessments should be conducted to 

identify current and past problems in need of 

intervention. Use a family-based focus that 

explores the family history of SUDs, mental 

disorders, abuse, legal problems, work and 

school issues, and overall health. Family 

interviews can help you gather this information 

and also serve as an opportunity for you to 

build rapport with families, educate them about 

treatments and services, and get their “buy-in” 

to enter and stay engaged in treatment. 

• Family-based assessments help you determine 

the history of the family’s functioning and 

substance misuse. Do not forget to also 

explore the family’s strengths and supports. 

• A genogram can help you and your client 

families visualize their current and history of 

substance-related problems. It is also a way to 

depict their strengths and resources. 

• Family members may each have different goals 

for treatment, and that’s okay. Your job is to 

help them identify changes they would like 

to make, teach them how to make those 

changes, and guide them in becoming sources 

of support for one another. You can do this by 

educating families about SUDs and recovery, 

facilitating communication between family 

members, and linking them to community-based 

resources and support networks. 

• It is common to encounter certain challenges in 

working with families with SUDs, but these can 

be overcome by helping families build healthier 

coping skills, educating them to correct myths 

and misconceptions about SUDs and recovery, 

offering case management services to help 

coordinate schedules and service needs, and 

addressing each family member’s particular 

stage of change. 

Chapter 5: Race/Ethnicity, Sexual 

Orientation, and Military Status 

This chapter discusses family counseling for 

SUDs among families of diverse racial and ethnic 

backgrounds; lesbian, gay, bisexual, or transgender 

(LGBT) families; and military families (including 

active duty personnel and veterans). Each section 

discusses the latest empirical evidence for familybased SUD treatment with that population as well 

as suggestions for how you can tailor family-based 

interventions to improve outcomes. This chapter is 

for providers. 

Family-based counseling is supported by empirical 

evidence as a safe and effective option for 

overcoming drug and alcohol addiction. However, 

no SUD treatment is “one size fts all” for all 

families. Certain families may beneft more from 

particular treatment approaches, formats, and 

settings than from others, based in part on their 

attitudes, beliefs, and dynamics. These attitudes, 

beliefs, and dynamics often differ based on a given 

family’s culture or background. As such, it is critical 

that you as a clinician understand how diverse 

families may affect and are affected by substance 

misuse and tailor your treatments and services as 

needed. For instance, in families of certain racial 

or ethnic backgrounds, there may be language 

barriers or cultural beliefs that make treatment 

seeking less likely. In military families, there may 

be attitudes that normalize substance misuse and 

make recovery seem unnecessary. This chapter will 

guide you through some specifc types of families 

and how their dynamics, functions, attitudes, and 

values could affect treatment. 

In Chapter 5, you will learn that: 

• Diversity among families is an important factor 

to consider when trying to understand how 

substance misuse fts into a particular family and 

which treatments and services may be best for 

them. 

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• It is not enough to just be culturally sensitive 

to such issues; rather, you should provide 

family-based treatment and services that are 

culturally responsive. This includes adopting 

cultural humility, in which you seek to learn 

from your client families rather than imposing 

onto them your own beliefs, ideas, and 

knowledge about a given culture. 

• There are several factors to consider when 

working with diverse family cultures, including 

their family structure, role of extended family 

members, spiritual/religious beliefs, immigrant/ 

nativity status, family values, approach to 

communication, experience with racism or 

other discrimination, and history of extended 

separation (especially between parents and 

children). 

• When working with African American families, 

you should consider tailoring treatments and 

services by using culturally relevant storytelling 

techniques, helping parents strengthen the 

bonds between each other, and addressing 

racial socialization (that is, the ways in which 

parents, directly and indirectly, teach their 

children about race and society). 

• Outcomes of family-based SUD treatment for 

Latino families may be best when you offer 

treatments and services in their native language, 

explore the family’s history of migration 

and cultural transition, and understand how 

substance use is defned and discussed in their 

country of origin. 

• For Asian American families, you can adapt 

family-based SUD treatment by discussing the 

concept of collectivism and how that might ft 

into the family’s views, values, and customs; 

exploring the family’s level of acculturation; 

and learning about help-seeking and coping 

behaviors common in their country of origin. 

• For American Indian/Alaska Native families, 

a systemwide approach that involves the 

entire community, tribe, or clan is often 

needed. Helping families understand their 

interconnectedness, and how the behavior 

of one family member can have ripple effects 

on the rest of the family, is critical and may 

require clinicians to involve valued others who 

are outside the family (e.g., community elders, 

spiritual healers) in the treatment process. 

• LGBT families have not been the subject of as 

much research as families of diverse racial and 

ethnic backgrounds. Nevertheless, evidence 

suggests that these families may beneft from 

strategies such as alliance building among 

family members, including nontraditional family 

members, in treatment and having separate 

counseling sessions with family members 

nonaccepting of your client. 

• If working with military families, you will beneft 

from learning about military culture, as it is 

very different from civilian life. This includes 

understanding power hierarchies, values 

and expectations for behavior, and attitudes 

about substance misuse. Military families may 

beneft from treatment and services that take 

into account their history of long periods of 

separation (e.g., deployment) and relocation, 

both of which are common in military culture 

and can be signifcant sources of strain that 

might make substance misuse by parents, 

adolescents, or both more likely. 

Chapter 6: Administrative and 

Programmatic Considerations 

This chapter outlines family-related aspects of 

substance misuse that programs should account 

for when providing alcohol and drug addiction 

treatment and recovery support services. 

This chapter is for administrators and clinical 

supervisors. 

The key to developing and implementing familybased SUD treatment and services is to ensure 

treatment programs adopt a family-centered 

culture. This means administrators, directors, 

supervisors, and other leadership should work 

together to ensure existing treatment and services 

are family friendly, tailored to families’ full range of 

needs, and based on empirical evidence. A familycentered culture means an organization includes 

family members and their needs throughout 

the treatment and service provision process, 

including as part of engagement and in shaping 

the physical program environment. Integrating 

family counseling and program elements requires 

education and buy-in among staff as well as the 

families you serve. Efforts to enhance workforce 

development also must be present, such as the 

hiring and retention of clinicians competent and 

comfortable in working with families with SUDs. 

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In Chapter 6, you will learn that: 

• Program policies and procedures should be 

implemented in ways that make treatment 

and services accessible and effective for 

families. 

• Fully integrated family-based programs are 

those in which all staff understand the ways in 

which family can infuence (and are infuenced 

by) substance misuse. As a refection of this, 

administrators, program managers, and clinical 

supervisors should help create, implement, 

and document policies that are family friendly. 

Clinicians should understand how to incorporate 

these policies into practice. 

• Clinical staff, including supervisors, should 

possess family-centered counseling 

competencies. This includes recruiting and 

hiring clinicians, supervisors, and administrators 

who already have the training and knowledge to 

support a family-based culture in your program 

setting. 

• Core skills for SUD treatment and service 

providers include having knowledge of familybased interventions and treatment models; 

diverse cultural factors that affect families with 

substance misuse; the ways in which family 

dynamics, relationships, and communication 

affect recovery; and system concepts, theories, 

and techniques. 

Substance Use Disorder Treatment and Family Therapy 

• Administrators and supervisors need to ensure 

that clinicians engage family members as 

appropriate throughout all stages of care and 

that they show families respect, honor their 

strengths, and recognize their unique needs. 

• One way in which programs demonstrate their 

commitment to building and maintaining a 

family-centered culture is by making certain 

that staff have the necessary training, 

licensing, and credentialing in family 

counseling. 

• By providing ongoing opportunities for 

staff training and education, programs and 

administrators help ensure clinicians and 

supervisors possess the latest evidence-based 

knowledge and practical understanding of 

working with families with substance misuse. 

• Administrators should develop and maintain 

ongoing supportive partnerships with 

community-based organizations to help 

family members stay integrated within their 

community and access a wide range of 

services for all needs (e.g., those related to 

child welfare, social services, the legal system, 

housing, spirituality/faith, education/vocation). 

Building and maintaining strong relationships 

with the surrounding community will also help 

a program stay up to date on available and 

effective local resources for client families. 

xvi 
TIP 39

TIP Development Participants 

Note: The information given indicates participants’ 

affliations at the time of their participation in this 

TIP’s original development and may no longer 

refect their current affliations. 

Consensus Panel 

Each TIP consensus panel is a group of primarily 

nonfederal addiction-focused clinical, research, 

administrative, and recovery support experts 

with deep knowledge of the TIP’s topic. With the 

Substance Abuse and Mental Health Services 

Administration’s Knowledge Application Program 

team, members of the consensus panel develop 

each TIP via a consensus-driven, collaborative 

process that blends evidence-based, best, and 

promising practices with the panel members’ 

expertise and combined wealth of experience. 

Chair 

Edward Kaufman, M.D. 

Editor in Chief 

American Journal of Drug and Alcohol Abuse 

Dana Point, California 

Co-Chair 

Marianne R.M. Yoshioka, Ph.D., M.S.W. 

Associate Professor 

Columbia University 

School of Social Work 

New York, New York 

Workgroup Leaders 

Mary M. Gillespie, Psy.D., CASAC 

Professor 

Hudson Valley Community College 

Saratoga Springs, New York 

Gloria Grijalva-Gonzales 

Certifed Sr. Substance Abuse Case Manager/ 

Counselor 

San Joaquin County – Offce of Substance Abuse 

Allies Project 

Stockton, California 

I. Andrew Hamid, Ph.D., M.S.W., MFT, CSW 

Professor 

Columbia University 

School of Social Work 

New York, New York 

David Rosenthal, Ph.D. 

Executive Director 

Lower East Side Harm Reduction Center 

New York, New York 

Daniel Santisteban, Ph.D. 

Research Associate Professor 

University of Miami 

School of Medicine 

Miami, Florida 

Carol Shapiro, M.S.W. 

Executive Director 

Family Justice Center 

New York, New York 

Panelists 

Fred U. Andes, D.S.W., M.S.W., M.P.A., LCSW 

Assistant Professor of Sociology 

New Jersey City University 

Jersey City, New Jersey 

Paul Curtin, M.A., CAC, NCAC II 

President 

Alcohol Services, Inc. 

Syracuse, New York 

Jo-Ann Krestan, M.A., MFT, LADC 

Family Therapist/Writer 

Private Practice 

Surry, Maine 

Eric E. McCollum, Ph.D., LCSW, LMFT 

Professor and Clinical Director 

Virginia Tech Falls Church 

Marriage and Family Therapy Program 

Falls Church, Virginia 

xvii 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Margaret McMahon, M.T.S., M.S., M.S.W. 

Clinician 

Private Practice 

Washington, DC 

Greer McSpadden, M.S.W., LISW 

Director, BHS 

First Nations Community Health Source 

Albuquerque, New Mexico 

William Francis Northey, Jr., Ph.D. 

Research Specialist 

American Association for Marriage and Family 

Therapy 

Alexandria, Virginia 

Marlene F. Watson, Ph.D. 

Director 

Programs in Couple and Family Therapy 

Drexel University 

Philadelphia, Pennsylvania 

Loretta Young Silvia, Ph.D., M.Ed. 

Associate Professor of Psychiatry 

Wake Forest University School of Medicine 

Department of Psychiatry and Behavioral Medicine 

Winston-Salem, North Carolina 

KAP Expert Panel and Federal 

Government Participants 

Barry S. Brown, Ph.D. 

Adjunct Professor 

University of North Carolina at Wilmington 

Carolina Beach, North Carolina 

Jacqueline Butler, M.S.W., LISW, LPCC, CCDC III, 

CJS 

Professor of Clinical Psychiatry 

College of Medicine 

University of Cincinnati 

Cincinnati, Ohio 

Deion Cash 

Executive Director 

Community Treatment and Correction Center, Inc. 

Canton, Ohio 

Debra A. Claymore, M.Ed.Adm. 

Owner/Chief Executive Offcer 

WC Consulting, LLC 

Loveland, Colorado 

Carlo C. DiClemente, Ph.D. 

Chair 

Department of Psychology 

University of Maryland Baltimore County 

Baltimore, Maryland 

Catherine E. Dube, Ed.D. 

Independent Consultant 

Brown University 

Providence, Rhode Island 

Jerry P. Flanzer, D.S.W., LCSW, CAC 

Chief, Services 

Division of Clinical and Services Research 

National Institute on Drug Abuse 

Bethesda, Maryland 

Michael Galer, D.B.A., M.B.A., M.F.A. 

Independent Consultant 

Westminster, Massachusetts 

Renata J. Henry, M.Ed. 

Director 

Division of Alcoholism, Drug Abuse, and Mental 

Health 

Delaware Department of Health and Social Services 

New Castle, Delaware 

Joel Hochberg, M.A. 

President 

Asher & Partners 

Los Angeles, California 

Jack Hollis, Ph.D. 

Associate Director 

Center for Health Research 

Kaiser Permanente 

Portland, Oregon 

Mary Beth Johnson, M.S.W. 

Director 

Addiction Technology Transfer Center 

University of Missouri–Kansas City 

Kansas City, Missouri 

xviii 
TIP 39

Eduardo Lopez 

Executive Producer 

EVS Communications 

Washington, DC 

Holly A. Massett, Ph.D. 

Academy for Educational Development 

Washington, DC 

Diane Miller 

Chief 

Scientifc Communications Branch 

National Institute on Alcohol Abuse and Alcoholism 

Bethesda, Maryland 

Harry B. Montoya, M.A. 

President/Chief Executive Offcer 

Hands Across Cultures 

Espanola, New Mexico 

Richard K. Ries, M.D. 

Director/Professor 

Outpatient Mental Health Services 

Dual Disorder Programs 

Seattle, Washington 

Gloria M. Rodriguez, D.S.W. 

Research Scientist 

Division of Addiction Services 

NJ Department of Health and Senior Services 

Trenton, New Jersey 

Everett Rogers, Ph.D. 

Center for Communications Programs 

Johns Hopkins University 

Baltimore, Maryland 

Jean R. Slutsky, P.A., M.S.P.H. 

Senior Health Policy Analyst 

Agency for Healthcare Research and Quality 

Rockville, Maryland 

Nedra Klein Weinreich, M.S. 

President 

Weinreich Communications 

Canoga Park, California 

Clarissa Wittenberg 

Director 

Offce of Communications and Public Liaison 

National Institute of Mental Health 

Kensington, Maryland 

Consulting Members 

Paul Purnell, M.A. 

Vice President 

Social Solutions, L.L.C. 

Potomac, Maryland 

Scott Ratzan, M.D., M.P.A., M.A. 

Academy for Educational Development 

Washington, DC 

Thomas W. Valente, Ph.D. 

Director, Master of Public Health Program 

Department of Preventive Medicine 

School of Medicine 

University of Southern California 

Alhambra, California 

Patricia A. Wright, Ed.D. 

Independent Consultant 

Baltimore, Maryland 

Field Reviewers 

Field reviewers represent each TIP’s intended 

target audiences. They work in addiction, mental 

health, primary care, and adjacent felds. Their 

direct frontline experience related to the TIP’s 

topic allows them to provide valuable input on a 

TIP’s relevance, utility, accuracy, and accessibility. 

Additional advisors to this TIP include members of 

a resource panel and an editorial advisory board. 

Stephanie Abbott, M.A. 

Adjunct Professor 

Marymount University 

Arlington, Virginia 

Raymond P. Adams, M.P.S., CAP 

Drug Court Substance Abuse Counselor 

Florida 16th Judicial Circuit Court 

Marathon, Florida 

xix 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

David Bergman, J.D. 

Director of Legal and Government Affairs 

American Association for Marriage and Family 

Therapy 

Alexandria, Virginia 

James Bertone, LCSW, LADC 

Rehabilitation Specialist II 

Bureau of Alcohol and Drug Abuse 

Carson City, Nevada 

Thomas W. Blume, Ph.D., LPC, LMFT, NCC 

Associate Professor 

Doctoral Program Coordinator 

Oakland University 

Rochester, Michigan 

Lane Brigham, Ph.D. 

Thibodaux, Louisiana 

Susanne Caviness, Ph.D. (CAPT, USPHS) 

Senior Program Management Offcer 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Paula Corey 

Senior Vice President 

Palladia, Inc. 

New York, New York 

Janice M. Dyehouse, Ph.D., M.S.N., R.N. 

Professor of Nursing 

University of Cincinnati College of Nursing 

Cincinnati, Ohio 

Jo-an M. Fox 

Nashville, Tennessee 

Joel Frank 

Milwaukee, Wisconsin 

Anne M. Herron, M.S. 

Director 

New York State Offce of Alcoholism and Substance 

Abuse Services 

Albany, New York 

M. Kay Keller, M.P.A., SSW 

Senior Human Services Program Specialist 

Contract Manager Program 

Department of Children and Family Services 

Substance Abuse Program Offce 

Tallahassee, Florida 

Malcolm V. King 

Substance Abuse Program Manager 

Virginia Department of Juvenile Justice 

Richmond, Virginia 

G. Richard Kinsella 

Vice President 

Syracuse Behavioral Healthcare 

Syracuse, New York 

Michael Warren Kirby, Jr., Ph.D., M.A., CAC III 

Chief Executive Offcer 

Arapahoe House, Inc. 

Thornton, Colorado 

Janet M. Lerner, D.S.W., RCSW 

Administrator 

Narco Freedom, Inc. 

New York, New York 

Ruby J. Martinez, Ph.D., R.N., CS 

Assistant Professor 

University of Colorado 

Denver, Colorado 

Dan A. McRight 

Nashville CPE Partnership 

Nashville, Tennessee 

Jerry Moe, M.A. 

National Director 

Betty Ford Center’s Children’s Program 

Rancho Mirage, California 

Fariha Niazi, LMHC 

Brief Therapy Institute 

NOVA Southeastern University 

Fort Lauderdale, Florida 

William (Bill) Francis Northey, Jr., Ph.D. 

Research Specialist 

American Association for Marriage and Family 

Therapy 

Alexandria, Virginia 

xx 
TIP 39

Gwen M. Olitsky, M.S. 

Founder and C.E.O. 

The Self-Help Institute for Training and Therapy 

Lansdale, Pennsylvania 

Randall W. Phillips, LMFT, LPC/MHSP 

Union City Medical Center 

Counseling and Consulting Services 

Union City, Tennessee 

Gerard J. Schmidt, M.A., LPC, MAC 

Clinical Affairs Consultant 

NAADAC, The Association for Addiction 

Professionals 

Morgantown, West Virginia 

Thomas L. Sexton, Ph.D. 

Professor and Director 

Center for Adolescent and Family Studies 

Counseling Psychology Program 

Indiana University-Bloomington 

Bloomington, Indiana 

Meri Shadley, Ph.D., MFT, LADC 

Associate Professor 

Center for the Application of Substance Abuse 

Technologies 

University of Nevada, Reno 

Reno, Nevada 

Mary K. Shilton 

Executive Director 

National Treatment Accountability for Safer 

Communities 

Washington, DC 

Robert Walker, M.S.W., LCSW 

Assistant Professor 

University of Kentucky 

Center on Drug and Alcohol Research 

Lexington, Kentucky 

Sis Wenger 

Executive Director 

National Association for Children of Alcoholics 

Rockville, Maryland 

Kerry W. Wicks, LAC 

Program Director 

North Dakota Department of Human Services 

Jamestown, North Dakota 

Ann S. Yabusaki, Ph.D. 

Substance Abuse Director, Psychologist 

Coalition for a Drug-Free Hawaii 

Substance Abuse Programs and Training 

Kaneohe, Hawaii 

Resource Panel 

Shirley Beckett, NCAC II 

Certifcation Administrator 

NAADAC, The Association for Addiction 

Professionals 

Alexandria, Virginia 

Susanne Caviness, Ph.D. (CAPT, USPHS) 

Senior Program Management Offcer 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Frank Canizales, M.S.W. 

Management Analyst, Alcohol Program 

Indian Health Service 

Rockville, Maryland 

Peggy Clark, M.S.W., M.P.A. 

Center for Medicaid and State Operations 

Centers for Medicare and Medicaid Services 

Baltimore, Maryland 

Christina Currier 

Public Health Analyst 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

James Gil Hill 

Director 

Offce of Evaluation, Scientifc Analysis and 

Synthesis 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

xxi 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Hendree E. Jones, Ph.D. 

Assistant Professor 

CAP Research Director 

Johns Hopkins University Center 

Baltimore, Maryland 

William (Bill) Francis Northey, Jr., Ph.D. 

Research Specialist 

American Association for Marriage and Family 

Therapy 

Alexandria, Virginia 

Hector Sanchez, M.S.W. 

Team Leader 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Karen Urbany 

Public Health Advisor 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Steve Wing 

Senior Advisor for Drug Policy 

Offce of Policy and Program Coordination 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Cultural Competency and 

Diversity Network Participants 

Elmore T. Briggs, CCDC, NCAC II 

President/CEO 

SuMoe Partners 

Germantown, Maryland 

African American Work Group 

Frank Canizales, M.S.W. 

Management Analyst, Alcohol Program 

Indian Health Service 

Rockville, Maryland 

Native American Work Group 

Ting-Fun May Lai, M.S.W., CSW, CASAC 

Director 

Chinatown Alcoholism Center 

Hamilton-Madison House 

New York, New York 

Asian Work Group 

Hector Sanchez, M.S.W. 

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Hispanic/Latino Work Group 

Ann S. Yabusaki, Ph.D. 

Kaneohe, Hawaii 

Asian Work Group 

xxii 
TIP 39

Publication Information 

Acknowledgments 

This original version of this publication was 

prepared under contract numbers 270-99-7072, 

270-14-0445, and 283-17-4901 by the Knowledge 

Application Program (KAP) for the Center for 

Substance Abuse Treatment (CSAT), Substance 

Abuse and Mental Health Services Administration 

(SAMHSA). Karl D. White, Ed.D., and Andrea 

Kopstein, Ph.D., M.P.H., served as the Contracting 

Offcer’s Representatives (CORs) for initial TIP 

development. Christina Currier served as the 

CSAT TIPs Task Leader. Content was reviewed and 

updated in 2020. Suzanne Wise served as the COR, 

Candi Byrne as the Alternate COR, and Jennifer 

Keyser Bryan, D.H.Sc., M.P.A., M.S.W., as the 

Product Champion. 

Disclaimer 

The views, opinions, and content expressed herein 

are the views of the consensus panel members and 

do not necessarily refect the offcial position of 

SAMHSA. No offcial support of or endorsement by 

SAMHSA for these opinions or for the instruments 

or resources described is intended or should be 

inferred. The guidelines presented should not be 

considered substitutes for individualized client care 

and treatment decisions. 

Public Domain Notice 

All materials appearing in this volume except those 

taken directly from copyrighted sources are in the 

public domain and may be reproduced or copied 

without permission from SAMHSA or the authors. 

Citation of the source is appreciated. However, this 

publication may not be reproduced or distributed 

for a fee without the specifc, written authorization 

of the Offce of Communications, SAMHSA. 

Electronic Access and Copies of 

Publication 

This publication may be ordered or downloaded 

from SAMHSA’s Publications and Digital Products 

webpage at store.samhsa.gov. Or, please call 

SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) 

(English and Español). 

Recommended Citation 

Substance Abuse and Mental Health Services 

Administration. Substance Use Disorder Treatment 

and Family Therapy. Treatment Improvement 

Protocol (TIP) Series, No. 39. SAMHSA Publication 

No. PEP20-02-02-012. Rockville, MD: Substance 

Abuse and Mental Health Services Administration, 

2020. 

Originating Ofce 

Quality Improvement and Workforce Development 

Branch, Division of Services Improvement, Center 

for Substance Abuse Treatment, Substance Abuse 

and Mental Health Services Administration, 5600 

Fishers Lane, Rockville, MD 20857. 

Nondiscrimination Notice 

SAMHSA complies with applicable federal civil 

rights laws and does not discriminate on the basis 

of race, color, national origin, age, disability, or 

sex. SAMHSA cumple con las leyes federales 

de derechos civiles aplicables y no discrimina 

por motivos de raza, color, nacionalidad, edad, 

discapacidad, o sexo. 

SAMHSA Publication No. PEP20-02-02-012 

First printed 2004 

Updated 2020 

xxiii 
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Chapter 1—Substance Use Disorder 

Treatment: Working With Families 

KEY MESSAGES 

TIP 39 SUBSTANCE USE DISORDER TREATMENT AND 

FAMILY THERAPY

• Substance use disorders (SUDs) affect not just 

those with the disorders, but also their families 

and other individuals who play signifcant roles 

in their lives. 

• Integration of family-based counseling 

interventions into SUD treatment honors the 

important role families can play in the change 

process. 

• Families can greatly infuence the treatment of 

any illness, including SUDs. Family involvement 

on any level can: 

- Motivate individuals facing addiction to 

receive or continue treatment. 

- Improve overall family functioning. 

- Foster healing for family members affected 

by the consequences of addiction. 

- Reduce risk in children and adolescents of 

being exposed to violence and of developing 

SUDs/mental disorders. 

• Family counseling in SUD treatment is 

positively associated with increased treatment 

engagement and retention rates, treatment 

cost effectiveness, and improved outcomes for 

individual clients and their families. 

The integration of family counseling into SUD 

treatment has posed an ongoing challenge since 

the inception of family therapy in the 1950s. 

Family counseling has been woven into treatment 

across the continuum of care, from prevention 

approaches, to treatment interventions, to 

continuing care services. Even so, it can be diffcult 

for providers and programs to ft family services 

into existing schedules flled with the demands of 

SUD treatment and related services. SUD treatment 

programs may also face challenges related to 

funding, training, and other administrative aspects 

of integration. 

To ensure use of family counseling and family 

services to their greatest potential within SUD 

treatment, it is essential to broaden the focus 

of SUD treatment from an individual to a family 

perspective. It is common to acknowledge the 

unique individual factors (e.g., environmental, 

genetic, biological) that may infuence a person’s 

substance misuse and SUD treatment outcomes. 

Yet equally important are interpersonal factors— 

social, occupational, and familial (relationships, 

dynamics, and interactions). Both individual and 

interpersonal factors can affect one’s access to, 

initiation of, and engagement in SUD treatment. 

These same factors infuence SUD treatment 

outcomes. 

1 
TIP 39

Just as others can have an impact on an individual’s 

substance misuse, the individual’s substance misuse 

can likewise affect those around them. People 

who misuse substances are likely to affect at least 

a handful of others who have or had some form of 

relationship with them, such as friends, partners, 

coworkers, relatives, and members of their 

communities. 

The consequences of a person’s substance misuse 

can be especially powerful for his or her family 

members. Four main theoretical models inform 

the SUD treatment approaches and familybased interventions that can best address those 

consequences: 

• Family disease 

• Family systems 

• Cognitive–behavioral therapy 

• Multidimensional family therapy (MDFT) 

Scope of This TIP 

Audience 

This Treatment Improvement Protocol (TIP) is 

structured to meet the needs of professionals 

with a range of training, education, and clinical 

experience in addressing SUDs. The primary 

audience for this TIP is SUD treatment counselors— 

many, but not all, of whom possess certifcation 

in addiction counseling or related professional 

licensing. 

Substance Use Disorder Treatment and Family Therapy 

Additional providers among this TIP’s primary 

audience are peer support specialists, psychiatric 

and mental health nurses, primary care providers 

(such as family physicians, internal medicine 

specialists, and nurse practitioners), and allied 

healthcare professionals who may provide SUD 

treatment—some of whom may have credentials 

in couples and family therapy, treatment of SUDs 

or mental disorders, or criminal justice services. 

The TIP will refer to these audiences collectively as 

“providers” for brevity. 

This TIP also offers guidance for addiction 

treatment program administrators, supervisors, and 

clinical/program directors (called “administrators” 

for brevity) working in behavioral health programs 

and agencies that provide SUD treatment and 

recovery support services. 

Secondary audiences include educators, 

researchers, policymakers, and healthcare and 

social service personnel beyond those specifcally 

mentioned above. 

Organization 

This TIP consists of six chapters (Exhibit 1.1). Some 

readers may prefer to go directly to chapters most 

relevant to their areas of interest. However, the TIP 

starts with core concepts laying the groundwork 

for understanding families and how SUDs can 

affect them, before moving to more specifc 

family approaches, counseling techniques, and 

programmatic considerations. 

2 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

EXHIBIT 1.1. TIP Organization 

Chapter 1, Substance Use Disorder Treatment: Working With Families, lays the groundwork for 

understanding the treatment concepts and theories of family discussed in later chapters of this TIP. It is for 

providers and administrators. 

Chapter 2, Infuence of Substance Misuse on Families, summarizes the ways in which substance misuse 

affects family dynamics and systems and the ways in which those dynamics and systems can, in turn, 

infuence substance misuse. This chapter is for providers. 

Chapter 3, Family Counseling Approaches, reviews research-based family counseling approaches 

specifcally developed for treating couples and families in which the primary issue within the family system 

is an SUD. It describes the underlying concepts, goals, techniques, and research support for each approach. 

This chapter is for providers. 

Chapter 4, Integrated Family Counseling To Address Substance Use Disorders, discusses the advantages 

and limitations of integrated treatment models and the degree of providers’ involvement with families. It 

offers guidelines providers can use to deliver family counseling in combination with specifc SUD treatment. 

It will also help providers match their counseling approaches to specifc levels of recovery. 

Chapter 5, Race/Ethnicity, Sexual Orientation, and Military Status, discusses family counseling for SUDs 

among families of diverse racial and ethnic backgrounds; families with lesbian, gay, bisexual, or transgender 

family members; and military families (including active duty personnel and veterans). Each section 

discusses relevant empirical evidence for family-based addiction treatment with that population as well as 

suggestions for how providers can adapt family-based interventions for addiction to improve outcomes in 

specifc family populations. This chapter is for providers and administrators. 

Chapter 6, Administrative and Programmatic Considerations, outlines family-related aspects of substance 

misuse programs that administrators should note when providing addiction treatment and recovery 

support services. 

Goals 

This TIP will help SUD treatment providers and 

administrators: 

• Understand the common concepts of family 

structure and dynamics, as well as terminology 

central to these concepts (Exhibit 1.2). 

• Learn the impact of SUDs on families and how 

the presence of SUDs affects every family 

member. 

• Offer SUD treatment via culturally responsive 

approaches that involve the family as a whole. 

• Appreciate the value of family involvement in 

treatment. 

• Integrate specifc family counseling models, 

techniques, and concepts into SUD treatment 

to enhance effective family coping and healthy 

communication patterns—paving the road 

toward recovery for everyone in the family. 

• Train and motivate staff to include family 

members in treatment. 

• Support staff in exploring the role of SUDs 

in family counseling and in developing 

collaborative relationships to meet the diverse 

needs of families. 

Chapter 1 3 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

EXHIBIT 1.2. Key Terms 

• Addiction*: The most severe form of SUD, associated with compulsive or uncontrolled use of one or more 

substances. Addiction is a chronic brain disease that has the potential for both recurrence (relapse) and 

recovery. (This term is not used for diagnostic purposes in the American Psychiatric Association’s [APA’s] 

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]. This TIP uses “addiction” 

interchangeably with SUDs for brevity and refers only to addictions related to alcohol or drugs.) 

• Binge drinking*: A drinking pattern that leads to blood alcohol concentration levels of 0.08 grams per 

deciliter or greater. This usually takes place after four or more drinks for women and fve or more drinks 

for men (National Institute on Alcohol Abuse and Alcoholism, n.d.; Center for Behavioral Health Statistics 

and Quality, 2020). However, older adults are more sensitive to the effects of alcohol and treatment 

providers may need to lower these numbers when screening for alcohol misuse (Kaiser Permanente, 

2019). Additionally, other factors such as weight, decrease in enzyme activity, and body composition (e.g., 

amount of muscle tissue present in the body) can also affect alcohol absorption rates. 

• Continuing care: Care that supports a client’s progress, monitors his or her condition, and can respond to 

a return to substance use or a return of symptoms of a mental disorder. Continuing care is both a process 

of posttreatment monitoring and a form of treatment itself. It is sometimes referred to as aftercare. 

• Family-based interventions: Family-based interventions include those that provide psychoeducation 

and other assistance to family members and those that involve family therapy. This TIP uses family-based 

interventions interchangeably with family counseling. In the SUD treatment and recovery support feld, 

families are involved at different points along the continuum of care and engaged in interventions of 

varying intensity. Most SUD treatment providers who work with families are not licensed family therapists, 

but they may have training in specifc competencies to meet the varying needs of families with SUDs. 

• Family therapy: Family therapy views the whole family as the primary client and intervenes specifcally 

on a systems level with the family unit. Family therapy may occur across all behavioral health service 

settings and within behavioral health subspecialties (e.g., mental health services, addiction treatment, 

prevention). To identify as a marriage and family therapist, a provider must receive specifc training and 

licensing; requirements vary across states. In addition, many family therapists seek specialized training to 

meet the needs of their clients and the requirements for their profession to treat families. 

• Integrated interventions: Specifc treatment strategies or therapeutic techniques in which interventions 

for the SUD and mental disorder are combined in one session or in a series of interactions or multiple 

sessions. 

• Peer recovery support services: The range of SUD treatment and mental health services that help 

support individuals’ recovery and that are provided by peers. The peers who provide these services are 

called peer recovery support specialists (“peer specialists” for brevity), peer providers, or recovery 

coaches. 

• Relapse*: A return to substance use after a signifcant period of abstinence. 

• Recovery*: A process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential. Even individuals with severe and chronic SUDs can, 

with help, overcome their SUDs and regain health and social function. This is called remission. When 

those positive changes and values become part of a voluntarily adopted lifestyle, that is called being in 

recovery. Although abstinence from all substance misuse is a cardinal feature of a recovery lifestyle, it is 

not the only healthy, prosocial feature. 

• Substance misuse*: The use of any substance in a manner, situation, amount, or frequency that can 

cause harm to users or to those around them. For some substances or individuals, any use would 

constitute misuse (e.g., underage drinking, injection drug use). (In this TIP, the term describes use of a 

substance [e.g., illicit drugs, benzodiazepines, opioids] in ways that are harmful or meet SUD diagnostic 

criteria.) 

Continued on next page 

4 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

Continued 

• SUD*: A medical illness caused by repeated misuse of a substance or substances. According to DSM-5, 

SUDs are characterized by clinically signifcant impairments in health, social function, and impaired 

control over substance use and are diagnosed through assessing cognitive, behavioral, and psychological 

symptoms. SUDs range from mild to severe and from temporary to chronic. They typically develop 

gradually over time with repeated misuse, leading to changes in brain circuits governing incentive 

salience (the ability of substance-associated cues to trigger substance seeking), reward, stress, and 

executive functions like decision making and self-control. Multiple factors infuence whether and how 

rapidly a person will develop an SUD. These factors include the substance itself; the genetic vulnerability 

of the user; and the amount, frequency, and duration of the misuse. (DSM-5 no longer uses the terms 

“substance abuse” and “substance dependence.” Rather, it defnes each SUD as mild, moderate, or severe. 

The number of diagnostic criteria an individual meets determines the disorder’s level of severity. A mild 

SUD is generally equivalent to what was formerly called substance abuse, and a moderate or severe SUD 

is generally equivalent to what was formerly called substance dependence [APA, 2013].) 

*Defnitions of all terms with an asterisk are based closely on those that appear in Facing Addiction in America: The 

Surgeon General’s Report on Alcohol, Drugs, and Health (U.S. Department of Health and Human Services [HHS], 2016). 

This resource provides information on substance misuse and its impact on U.S. public health. The report is available 

online (https://addiction.surgeongeneral.gov/sites/default/fles/surgeon-generals-report.pdf). 

The TIP consensus panel developed this 

publication from its extensive experience, 

knowledge, and review of the literature. The panel 

included representatives from several disciplines 

involved in family counseling and SUD treatment, 

including alcohol and drug counselors, family 

therapists, mental health practitioners, researchers, 

and social workers. Other professionals also 

generously contributed their time and commitment 

to this project. In encouraging counselors, 

administrators, and others who work in the feld to 

acknowledge substance misuse as a critical issue 

that can negatively affect families, the consensus 

panel hopes the guidance in this TIP will help 

families move toward recovery. 

Family Counseling: What Is It, and 

Why Is It Useful? 

Family counseling is a collection of family-based 

interventions that refect family-level assessment, 

involvement, and approaches. A systems model 

underlies family counseling. The model views 

families as systems, and in any system, each part 

is related to all other parts. A change in any part 

of the system will bring about changes in all other 

parts (Becvar & Becvar, 2018). Family counseling 

uses family dynamics and strengths to bring about 

change in a range of diverse problem areas, 

including SUDs. 

A family is a complex system that attempts to keep 

equilibrium (or “homeostasis,” in family therapy 

terms). When substance misuse occurs in the 

family, members will try to manage the behavior 

of the person who is using drugs or alcohol and 

the consequences of that use for the family. A 

family may go through a range of responses to 

keep the family functioning. Some may view these 

responses as unhealthy, enabling, compensatory, 

or counterproductive, but they serve a purpose— 

to keep the system operating. This operating 

system directly infuences treatment engagement, 

treatment outcomes, use of support systems, and 

sustained recovery for each family member. 

When a person has an SUD, his or her family 

members experience signifcant effects, some 

more powerfully than others (e.g., older siblings 

with less direct exposure to parental SUDs may 

be less affected than younger siblings still living in 

the home). Families experience hardships, losses, 

Chapter 1 5 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

and trauma as a consequence of a member’s 

SUD (Black, 2018; Reiter, 2015). Some families 

tend to blame or create excuses for the person’s 

substance misuse. They generally have strong 

feelings, whether they express them or not, toward 

the family member who drinks or uses drugs. 

Family members may direct these feelings toward 

the substance rather than the person. If families 

minimize the impact of the SUD, they may blame 

another family member or stressful situation for the 

presenting problem (Reiter, 2015). 

Integrating family counseling into SUD treatment 

leverages the important role families can play 

in helping their family members change their 

substance use. Integrated SUD treatment and 

family counseling acknowledges that SUDs affect 

others beyond those with the disorder (Lassiter, 

Czerny, & Williams, 2015). Whether an adolescent 

or adult has the SUD, the entire family system 

needs assistance. 

Family counseling helps each family member 

understand: 

• How the SUD affects him or her as an individual. 

• How the SUD affects the whole family. 

• How he or she adjusts or changes certain 

behaviors in response to the individual’s 

progressing SUD. 

• How to make changes as an individual and as a 

family to address the impact of the SUD. 

Rather than focusing solely on individuals who 

have SUDs, family counseling widens the focus by 

shifting attention to clients and their whole families. 

This shift in focus supports identifcation of goals as 

a family group and as individuals within that group. 

It also creates a transparent atmosphere that helps 

individuals with SUDs see that their families are not 

blaming them for their addiction or ganging up on 

them to seek treatment. Exhibit 1.3 describes some 

of the benefts and challenges of this approach. 

EXHIBIT 1.3. Benefts and Challenges of Family Counseling in 

SUD Treatment 

Benefts 

With new insights and coping skills, families can create an environment that supports recovery for every 

family member. Here are selected benefts of family counseling in SUD treatment: 

Treatment engagement and retention. Family involvement in SUD treatment is linked with increased 

rates of entry into treatment, reduction of SUD treatment barriers (e.g., lack of fnances, untreated trauma), 

decreased dropout rates during treatment, and better long-term outcomes (O’Farrell & Clements, 2012; 

Rowe, 2012). 

Prevention. Family counseling may play a signifcant role in prevention. Family-based treatment for 

individuals with SUDs can help prevent substance misuse in other family members by correcting 

maladaptive family dynamics (Bartle-Haring, Slesnick, & Murnan, 2018; Horigian et al., 2014). Family 

counseling that focuses on family functioning and parenting skills can improve behavioral health outcomes 

in children affected by parental SUDs (Bartle-Haring et al., 2018; Calhoun, Conner, Miller, & Messina, 2015). 

Motivation. Engaging family members from the outset gives them an opportunity to learn about SUDs, 

the biopsychosocial effects of addiction, and how SUDs affect the entire family. Depending on the severity 

and length of time of addiction, some family members may see SUD treatment as a hopeless cause. Others 

may be anxious about how treatment may change things for their families. Still others may be opposed to 

Continued on next page 

6 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

Continued 

treatment, believing that they have spent too many years focusing on the family member with the SUD and 

its consequences. Counselors can use a family member’s view of treatment to guide the initial direction of 

sessions and to generate motivation. 

Lower costs. Compared with individual therapy and mixed therapy (that is, therapy that is neither solely 

individual nor solely family based), family-based treatments aimed at reducing SUDs are associated with 

lower costs of delivery (Morgan, Crane, Moore, & Eggett, 2013). Some approaches, such as brief behavioral 

couples therapy (BCT; Rowe, 2012), also show greater cost-effectiveness compared with standard outpatient 

treatments. BCT shows a more than 5:1 beneft-to-cost ratio, resulting in at least a $5 savings to society for 

every dollar spent providing BCT (Schumm & O’Farrell, 2013a). Compared with individual and mixed therapy 

for SUDs, family counseling results in fewer treatment sessions per episode of care and signifcantly lower 

costs per session ($93.45 for family therapy versus $120.96 for individual treatment and $240.20 for mixed 

therapy; Morgan et al., 2013). Studies on cost-effectiveness do not use consistent outcome measurements 

and methods, but evidence suggests that family-based SUD treatment approaches are cost-effective 

(Morgan & Crane, 2010). 

The offset factor. Family counseling for SUDs can result in a net savings not just in direct care costs, but 

also in savings to society—such as reduced healthcare spending and juvenile justice costs. For instance, 

every dollar spent on SUD treatment in general saves $4 to $7 in reduced drug-related crime, criminal 

justice costs, and theft (National Institute on Drug Abuse, 2018). A review of family counseling for adolescent 

externalizing disorders including SUDs (Goorden et al., 2016) suggested that family-involved addiction 

treatment for adolescents (e.g., family drug court, drug court plus multisystemic therapy) could provide 

additional cost offset. These treatment approaches were associated with signifcant reductions in criminal 

activity-related costs from preintervention to 4-month follow-up (McCollister, French, Sheidow, Henggeler & 

Halliday-Boykins, 2009). 

Treatment outcomes. Evidence from studies mostly focused on adolescent substance misuse suggests that 

family counseling for SUDs is more effective than treatment as usual (Baldwin, Christian, Berkeljon, & Shadish, 

2012; Rowe, 2012; Tanner-Smith, Wilson, & Lipsey, 2013). Family-based interventions appear to (Horigian et al., 

2015; Klostermann & O’Farrell, 2013; Morgan & Crane, 2010; O’Farrell & Clements, 2012; Rowe, 2012): 

• Improve SUD prevention efforts. 

• Reduce substance misuse and positive urine samples. 

• Raise rates of abstinence. 

• Lessen substance-related problems. 

• Decrease juvenile delinquency (including recidivism and drug-related arrests). 

• Strengthen family coping abilities. 

• Improve family functioning and children’s functioning. 

• Lessen co-occurring problems (e.g., internalizing conditions, externalizing conditions, suicide attempts). 

Outcome studies extending past 1 year are limited (Rowe, 2012). Available data suggest that BCT can yield 

desirable treatment outcomes, including reduced substance use, days of heavy alcohol consumption, drugrelated arrests, legal and family problems, and hospitalizations. BCT is also linked with increased abstinence 

and treatment adherence (O’Farrell & Clements, 2012; Rowe, 2012). 

Continued on next page 

Chapter 1 7 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Continued 

Cultural responsiveness. Family- or parenting-based SUD treatment for youth (e.g., MDFT, brief strategic 

family therapy [BSFT]) had positive effects among African American, Latino, and Asian American teens, as 

did parent training (Garcia-Huidobro, Doty, Davis, Borowsky, & Allen, 2018; Steinka-Fry, Tanner-Smith, Dakof, 

& Henderson, 2017). Specifcally, BSFT, MDFT, and functional family therapy have been validated for Latino 

families (Liddle, Dakof, Henderson, & Rowe, 2011; Liddle, Rowe, Dakof, Henderson, & Greenbaum, 2009), 

and MDFT and multisystemic family therapy have demonstrated strong effects with African American 

families (Henderson, Rowe, Dakof, Hawes, & Liddle, 2009; Liddle, Dakof, Turner, Henderson, & Greenbaum, 

2008; Liddle et al., 2009). Family-based interventions that focus on parent–child dyads have been shown 

to improve outcomes in African American, Asian American, and Latino youth, such as enhancing family 

relationships, reducing substance use, decreasing risky behavior (e.g., having sex while under the infuence 

of substances), and improving substance refusal skills (Brody, Chen, Kogan, Murry, & Brown, 2010; Brody et 

al., 2012; Fang, Schinke, & Cole, 2010; Prado et al., 2012; Schinke, Fang, Cole, & Cohen-Cutler, 2011). Although 

comparatively less research has been conducted on American Indian and Alaska Native populations than 

other minority groups, evidence suggests that adapting family-based interventions for SUDs to Native 

American cultures can effectively reduce substance misuse, improve family strength and cohesion, and 

enhance other SUD treatment outcomes (Substance Abuse and Mental Health Services Administration 

[SAMHSA], 2018). 

Flexibility in treatment planning. Integrated models enable counselors to tailor treatment plans to refect 

individual and family factors. Early in treatment, families may need education about substance misuse and its 

effects. Families in later stages of treatment may need help as they address such issues as trust, forgiveness, 

acquisition of new recreational skills, role changes, reestablishment of boundaries in the family and at work, 

and changing the specifc interaction patterns that may have evolved from substance misuse in the family. 

New perspectives. Family counseling can provide a neutral space in which family members meet to 

address problems and identify needs. In this safe environment, they can express, identify, and validate 

feelings. Family members are often surprised to learn that other family members share their feelings. Family 

members gain a broader perspective and can better understand the perspectives of other family members, 

which can be empowering and may provide insight and compassion that will foster positive change. 

Family functioning. Integration of family-based interventions into SUD treatment improves the 

psychosocial functioning of the family unit (Cosden & Koch, 2015). For instance, parent–child mediation to 

reduce problematic child behaviors (including substance misuse) not only improves substance misuse and 

related intentions, but also increases family communication and cohesion and decreases family confict 

(Tucker, Edelen, & Huang, 2017). Compared with treatment as usual, BSFT for adolescents with substance 

misuse has been associated with more positive parent-reported family functioning (Robbins et al., 2011). 

Interestingly, some research suggests that improvements in substance use outcomes from family-based 

interventions are the result of enhanced family functioning (Horigian et al., 2015). 

Relapse prevention. Social/family support from those who do not use substances helps people avoid returns 

to substance use (Cavaiola, Fulmer, & Stout, 2015). The quality and scope of one’s social network strongly 

predicts future abstinence (Korcha, Polcin, & Bond, 2016; Menon & Kandasamy, 2018). Lack of family support can 

damage recovery, particularly when it results from family members avoiding or withdrawing from the person 

Continued on next page 

8 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

Continued 

with addiction (Menon & Kandasamy, 2018). Family qualities that can enhance recovery include being honest, 

being supportive of addiction treatment, providing emotional support, and being a consistent presence in the 

recoveree’s life. Conversely, family member qualities associated with greater risk of relapse and lower chances 

of abstinence include lacking knowledge about addiction, being unsupportive of recovery, having severe 

family problems, and using substances actively themselves (Brown, Tracy, Jun, Park, & Min, 2015). 

Challenges 

Integrating family counseling into SUD treatment does pose some specifc challenges: 

Complexity. Family counseling as a modality is more complex than individual or group therapies. It requires 

dealing with more than one person at a time, in contrast to individual therapy. Unlike standard group therapy, 

family counseling also requires engaging a group of people with a shared history, set rules, roles, and hierarchy, 

and well-established patterns of communication. For counselors, delivering family counseling can feel similar to 

serving as a new group therapist for group members who have been together for decades. 

Training. Integrating family counseling into SUD treatment settings takes special training and skills, yet training 

for effective family approaches is not readily available. Making such training available requires administrative 

commitment in workforce and professional development as well as resources. Integration can increase stress 

among counselors and administrative staff, given the demand on treatment space, the strain of incorporating 

family sessions into already-full program schedules, and the addition of new clinical tasks or staff members. 

Funding. Outside of adolescent treatment, it has historically been challenging to receive ample, consistent 

funding or reimbursement for integrated family counseling as a modality in SUD treatment. 

False beliefs among providers. Historically, the individual client has been the sole focus of addiction 

services. Providers of SUD treatment and related healthcare services have often overlooked the families of 

these individuals (Ventura & Bagley, 2017). Some providers incorrectly believe families to be the direct cause 

of clients’ substance misuse, even though the role of genetics and family environments differ from person 

to person. Such misperceptions can make providers less willing to involve families in treatment. False 

perceptions may also perpetuate the belief that families cannot learn appropriate skills to support relatives 

with SUDs. 

Diffculty implementing manualized family counseling. Robust evidence shows manualized family 

counseling for SUDs to be effective, yet use of such interventions in SUD treatment programs is low (Hogue 

et al., 2017). Numerous factors contribute to this lack of widespread use, including high costs of using 

licensed materials for training and maintaining certifcation; the structured, infexible design of manualized 

family approaches; and the challenge of sustaining staff/program training and certifcation over time 

(Hogue et al., 2017). 

Research limitations. Relatively little research is available concerning the effectiveness of family 

counseling and SUDs with specifc populations, particularly families from diverse racial, ethnic, and cultural 

backgrounds. More recent research has focused on families with adolescents. Thus, less evidence is being 

generated in determining effcacy of family-based interventions that involve other family types and other 

identifed individuals in the family unit who have SUDs (e.g., parents or spouses with SUDs). 

Chapter 1 9 
TIP 39

Family Counseling Objectives 

This section summarizes some of the core 

objectives of family-based interventions for SUDs. 

Core objective: Leverage the family to infuence 

change. From the outset, family-focused 

interventions encourage family members to 

motivate each other to make important lifestyle 

changes, including shifts away from alcohol and 

drug misuse. Family counseling for SUDs also 

helps families develop effective coping and 

communication skills that will promote recovery for 

each member. Family counseling takes advantage 

of the strength of family relationships to support 

all family members in their initiation of and 

engagement in treatment, continuing care services, 

mutual aid, and peer support services. 

Core objective: Use a strengths-based 

approach to involve families in treatment. 

Family involvement can have a positive infuence 

on treatment engagement—and lack of family 

involvement can derail SUD treatment. Families can 

have negative effects on SUD treatment in other 

ways, too. Certain aspects of family relationships 

and parenting practices can worsen alcohol and 

drug misuse, relapse risk, stress, and behavioral 

problems. Using a strengths-based approach, 

family counseling addresses such problematic 

family dynamics (e.g., parent–child role reversals), 

as well as inconsistent or ineffective parenting 

practices. Family counseling can encourage 

parenting practices that help prevent SUDs in 

children, improve SUD treatment outcomes in 

adolescents, and enhance the family recovery 

process. 

Core objective: Change family behaviors and 

responses that may support continued substance 

misuse. Another core objective is assessing and 

reorganizing families’ behavioral, cognitive, and 

emotional responses that may unintentionally 

support the continued misuse of alcohol and drugs, 

and that place signifcant stress and responsibility 

on family members who do not have an SUD. Most 

families experience stress, loss, and trauma as a 

direct or indirect consequence of addiction in the 

family; family counseling focuses on addressing 

these consequences to improve family functioning 

Substance Use Disorder Treatment and Family Therapy 

and to potentially prevent further stress-related 

symptoms, substance misuse of spouse or 

children, and other biopsychosocial effects. Family 

counseling in SUD services adopts a traumainformed stance. It also identifes and addresses 

safety concerns (e.g., domestic or sexual violence), 

the unique needs of the family, and the potential 

obstacles a family may face in accessing and using 

family services. 

Core objective: Prevent SUDs from occurring 

across family relationships and generations. 

Family counseling aims to keep SUDs from moving 

from one generation or relationship to another. If 

a parent misuses alcohol or drugs, the remaining 

family members are at increased risk of developing 

SUDs and mental disorders or establishing 

relationships with someone who misuses alcohol 

or drugs. If the person misusing substances is 

an adolescent, successful treatment reduces the 

likelihood that siblings will misuse substances 

or commit related offenses (Whiteman, Jensen, 

Mustillo, & Maggs, 2016). 

Understanding Families 

What Is a Family? 

Although many people view “family” as the group 

of people with whom they share close emotional 

connections or kinship, there is no single defnition 

of family. Diverse cultures and belief systems 

infuence defnitions, and because cultures and 

beliefs change over time, concepts of family are 

not static. In some cultures, the defnition of family 

is narrow and determined by birth, marriage, 

or adoption. In other cultures, more expansive 

defnitions include in the concept of family 

those individuals who share a household, values, 

emotional connections, and commitments. The 

level of commitment people have to each other 

and the duration of that commitment also vary 

across defnitions of family. 

Family Types 

Just as there is no single defnition of family, 

there is also no typical family type. Families are 

quite diverse in organizational patterns and living 

arrangements. Some families consist of single 

10 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

parents, two parents, or grandparents serving 

as parents. Many families are blended, including 

children from previous relationships. Many others 

are intergenerational within the household 

and include extended family members, such as 

grandparents, uncles, aunts, cousins, other relatives, 

and close friends. Still other types are adoptive or 

foster and other families whose members are not 

biologically related and instead come together by 

choice. Different family constellations often present 

specifc and predictable challenges. For instance, 

in newly formed blended families, conficts are 

typical between parents on how to parent and 

between a parent and stepchild on the rights of 

who can discipline, who holds authority, and so 

forth. Common challenges for single parents include 

the stress of balancing many responsibilities while 

parenting. Understanding family types can help 

counselors anticipate expected and normative family 

issues that SUDs can complicate (Exhibit 1.4). 

Common Characteristics of All 

Families 

A systems view of families assumes that some 

core characteristics infuence functioning across 

all family types. In systems theory, the family is a 

system of parts that is itself embedded in multiple 

systems—a community, a culture, a nation. Families 

strive for balance and self-regulate accordingly 

(Nichols & Davis, 2017). The next sections 

summarize key characteristics of families from a 

systems perspective. 

Subsystems 

Subsystems are groupings in the family that 

form according to roles, needs, interests, and so 

forth. Subsystems appear in most families among 

parents, siblings, and couples (Gehart, 2018). A 

subsystem can be one person or several family 

EXHIBIT 1.4. Treatment Issues According to Family Type 

Certain treatment issues are more likely to arise in some family types than others when addressing 

substance misuse in a family member: 

• Client who lives with a spouse (or partner) and minor children. Most data on the effects of parental 

substance misuse on children demonstrate that a parent’s substance misuse often has lasting, negative 

effects (Calhoun et al., 2015). The spouse of a person who misuses substances is likely to protect the 

children and assume parenting duties not fulflled by the parent misusing substances. If both parents 

misuse alcohol and drugs, the effects on children are likely to worsen. 

• Client who lives in a blended family. Blended families may face unique challenges even when no one in 

the family misuses substances. Substance misuse can intensify these challenges, making it harder for the 

family to integrate and fnd stability. 

• Older client who lives with an intergenerational family, including their own children and 

grandchildren. An older adult with an SUD can affect everyone in the household. Some family members 

may try to work around the older person, ignoring SUD-related issues or writing off substance misuse as 

part of “old age.” Many family members are committed to being caregivers, yet they are often left out of 

treatment decisions and recovery planning (National Academies of Sciences, Engineering, and Medicine, 

2016). Counselors may need to mobilize additional family resources to treat the older adult’s SUD and 

other comorbid physical conditions. 

• Adolescent client who lives with family of origin. When an adolescent misuses alcohol or drugs, 

the needs and concerns of siblings in the family may be ignored or minimized while the parents 

address continual issues and crises related to the adolescent’s substance misuse. In many families with 

adolescents who misuse substances, parental substance misuse is evident (Ali, Dean, & Hedden, 2016). 

Chapter 1 11 
TIP 39

members. Subsystems have their own roles and 

rules in the family. For example, in a healthy 

family, a parental subsystem (including one or 

more members) maintains some privacy, takes 

responsibility for providing for the family, and has 

power to make family decisions. 

EXHIBIT 1.5. Homeostasis 

Substance Use Disorder Treatment and Family Therapy 

Subsystems can signifcantly affect individuals’ 

behavior in the family. They can motivate and 

positively infuence a family member. But some 

subsystems are unhealthy, even if they serve 

a necessary function in the family—as with a 

parentifed child assuming adult roles that are not 

age-appropriate (Exhibit 1.5). 

Family members work to keep the family stable via emotional, cognitive, and behavioral responses. The idea 

of stability and balance, or “homeostasis,” in the family emerged in the early 1950s, with the development 

of Bowen’s natural systems theory (Rambo & Hibel, 2013). This theory suggests that systems try to maintain 

balance in the interest of preservation. Following is an example of homeostasis in a family affected by SUDs. 

Within this two-parent household, the father developed alcohol use disorder and stimulant use disorder. 

Prior to having three children, he indicated that his primary use was cocaine. After the birth of their frst 

child 12 years ago, he began drinking more alcohol and using stimulants more sporadically. 

As the father’s drinking progressed, the mother focused on controlling his alcohol consumption. She 

started by monitoring how much he drank and checking on him when he was out (e.g., calling him, going 

to the bar to fnd him). She also took on increasing responsibilities, like driving their children to all activities, 

working additional hours out of fear that the father would lose his job, and assuming all household and 

parenting tasks. 

The oldest daughter, age 12, often worried about her father when he went drinking but showed irritation 

toward him when he was home. She ignored his directives and stopped communicating with him. 

Meanwhile, she aligned with her mother. Preoccupied with the idea that her father treated her mother 

unfairly, she began trying to pick up his slack. In so doing, the daughter took on more parenting duties for 

her younger sister (age 9) and brother (age 6) while she herself had less supervision and more freedom in 

and outside the home. 

After the father entered treatment and accepted continuing care services, both parents felt as if they were 

having more family diffculties than before, despite working hard to communicate with each other and deal 

with the effects of addiction on their relationship. They found their oldest daughter hostile and hard to talk 

to. “She wasn’t like this before—but now, if there is a rule to break, she does,” the father stated. 

Neither parent realized the signifcant challenges their daughter had faced since her father’s treatment. 

She had held a powerful role in the family by serving as a confdant for her mother and surrogate parent 

for her siblings. That role granted her authority and certain privileges. Her parents were unable to see 

through their daughter’s anger to her pain. They did not yet realize that, in essence, their daughter had 

been demoted back to a child’s role without enough support. Thus, she was fghting to regain the more 

powerful role. 

In hindsight, the mother stated that her daughter became a “parent replacement, a little adult.” She had 

relied more and more on her daughter for emotional support as her spouse’s SUD progressed. 

12 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

Rules 

Families operate with rules. Rules provide guidance 

on acceptable behaviors and exchanges, and they 

refect family values. Most rules are unspoken, but 

some are more prescriptive, such as not allowing 

a child to date until he or she is 16 (Goldenberg, 

Stanton, & Goldenberg, 2017). The structure of 

rules creates a sense of safety—as long as those 

rules are not too rigid. 

Some families hold rules rigidly even when 

circumstances call for reevaluation. Other families 

experiencing duress or operating chaotically may 

not have enough rules. In families with SUDs, 

unspoken rules develop in response to the effects 

of drinking or drug use. For example, children may 

come to understand that they don’t ask permission 

from their mother when she is drinking. 

Shared Values, History, and Narratives 

Each family holds certain beliefs and values (e.g., 

specifc moral beliefs). Children may move away 

from these values and beliefs as adolescents or 

adults, but they are nonetheless infuenced by them. 

Families have shared histories and often develop 

defning narratives around past familial events. 

Individual family members can adopt these 

narratives even when they were not personally 

present for key events within that narrative, such as 

by hearing stories of past events about ancestors. 

Events in each family member’s life can be 

incorporated into the defning family narrative over 

time as well. 

Based on their values, histories, and signifcant life 

events, families assume certain characteristics and 

identities, such as always having been risk-takers. 

These translate across generations and infuence 

the selection of partners, hobbies, and occupations 

(e.g., intergenerational vocations as frst responders, 

military personnel, or healthcare professionals). 

Roles 

Family members assume certain roles, which often 

relate to generation (e.g., parent, grandparent), 

cultural attitudes, family beliefs, gender, and 

overall family functioning. Some roles develop in 

response to stress or the underfunctioning of a 

family member. 

Historically, the addiction feld has used role and 

birth order theory to help families explore how 

they have adjusted or reacted to SUDs in the 

family. Roles help families maintain homeostasis, 

yet certain roles affect the individuals in that role 

negatively or distract from underlying issues. For 

example, a family may see a child as the root of 

their problems, although one or both parents have 

signifcant SUDs. 

Boundaries 

Family boundaries regulate the fow of information 

in and outside the family. There are individual and 

generational boundaries within families, as well as 

boundaries between families and other systems. 

Appropriate boundaries vary from culture to culture. 

Families may present with boundaries that initially 

appear unhealthy but turn out to be a function of 

culture. Boundary types range from rigid or fxed to 

diffused. Ideally, boundaries are clear, fexible, and 

permeable, allowing movement and communication 

in and outside the family as needed. 

However, some families have very strict boundaries 

that keep people outside the family from 

engaging with or providing support to family 

members. Similarly, rigid boundaries can restrict 

communication or discussions across generations. 

For example, a father may state, “This is just the 

way it is in this house,” without allowing discussion 

of the rule or boundary in question. 

Other families’ boundaries are too loose or too 

enmeshed. They may reduce privacy and allow 

inappropriate access to information. For instance, 

a sister may have a private conversation with her 

sibling, which the sibling then shares with everyone 

in the family without the sister’s permission. 

Another example is a child privy to too much adult 

information about a sibling, parent, or other person. 

Power Structures 

Some family members have more power or 

infuence than others. Power differences are 

expected across generations (e.g., between parent 

and child) but can also occur between parents. 

There can also be differences in which parent 

makes which types of decisions for the family. 

Chapter 1 13 
TIP 39

Sometimes, families give decision-making power 

to children or to a specifc child, allowing the child 

to control relationships between the two parents, 

between parents and other siblings, and so forth. 

This occurs often when a family is under stress, or 

when a parent who had more infuence disengages 

with the family because of an illness, divorce, 

or SUD. 

Counselors can harness family power structures to 

foster change. To do so, counselors should realize 

that power is not always obvious. A family member 

who seems uninfuential may have more power 

than one assumes. For example, a family member 

who appears more subservient may have learned 

to use somatic complaints to curtail an activity or 

to communicate disregard for a course of action 

nonverbally. 

Communication Patterns 

Each family has patterns of communication. These 

can be verbal or nonverbal, overt or subtle, and 

they may refect cultural infuences. They are 

families’ unique means of expressing emotion, 

confict, and affection. Communication patterns 

may not be obvious to one outside the family but 

can signifcantly infuence how family members 

act toward each other and toward people outside 

the family. 

Communication patterns refect relationship 

dynamics, including alliances. They can indicate 

support and respect, or lack thereof, between 

family members. For example, a teenager in family 

counseling may look to a parent before answering 

a question; a husband may roll his eyes when his 

wife speaks. 

Directionality is important in family communication 

patterns. One directional pattern that frequently 

occurs is called triangulation (Bowen, 1978). 

Triangulation happens when, instead of 

communicating directly with a family member who 

has an SUD, families who are under stress or lack 

coping skills instead talk around the person or 

with a third party in the family system. An example 

would be a mother who calls her daughter to talk 

about her son’s drinking rather than talking to 

the son himself about his problem with alcohol. 

Substance Use Disorder Treatment and Family Therapy 

The daughter, in turn, does not redirect or set a 

boundary with her mother. Triangulation often 

includes a third person as a go-between, an 

object of concern, or a scapegoat. Triangulation 

can involve someone who is not considered a 

family member. 

Durability and Loyalty 

Families are durable; membership in a family never 

expires. Even family members who have moved 

far away, disengaged emotionally, or become 

estranged from the family are still a part of it. Some 

family theorists would go so far as to say, “once in 

the family, always in the family.” Even divorced or 

deceased family members remain a part of their 

families’ shared histories. 

Families also tend to be loyal. It can be diffcult 

for family members to divulge secrets or express 

differences outside the family. Family members 

can and will oppose certain family beliefs or report 

certain family incidents, but when they do so, they 

normally experience shame, fear, or feelings of 

disloyalty. Loyalty can be a strength or a limitation 

for counselors in addressing family problems. 

Developmental Stage 

All families are engaged in one or more family 

developmental stages. Families are not static 

across the life span. Marked by transitions, aging, 

births, and deaths, extended families undergo 

developmental stages that predicate the normative 

stresses, tasks, and conficts they may face. 

Understanding these normative stages will help 

counselors better perceive a family’s presenting 

problems, including SUDs. 

Counselors can tailor SUD treatment to meet 

family needs through developmental tasks. 

Following is an example of a couple who could 

beneft from treatment that aligns with their 

family development stage. 

A couple met 25 years ago through a shared 

interest in the club scene, and they married after 

2 years of dating. They have three children who 

are now in college or living independently. Before 

having their children, the couple’s relationship 

centered around their use of alcohol and drugs. 

14 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

may involve community- and faith-based activities 

or participation in mutual-help groups to alleviate 

stress and provide support. 

History of Family-Based 

Interventions in SUD Treatment 

Family Theory—Initial Research 

After War World II, research started to explore 

the role of families in the development and 

maintenance of mental disorders. In part, 

family therapy was an outgrowth of research on 

communication patterns within families who had 

a family member with schizophrenia (Bregman 

& White, 2011). Interest in the role of families, 

family dynamics, and family theoretical approaches 

appeared to emerge simultaneously in the 1950s 

among practitioners and researchers in the United 

States and other countries. 

Incorporating the Concept of Systems 

Into Family Models 

Thereafter, family models started to incorporate 

the concept of systems, which was grounded 

primarily in psychoanalytic theory (Gladding, 

2019). This systems-informed theory of the family 

evolved into several new schools of thought, 

each of which began to inform specifc treatment 

strategies and training centers. At frst, it was 

typical for practitioners to subscribe to just one 

model of family therapy. Yet, as more therapists 

began endorsing an eclectic approach that 

synthesized several family treatment models, the 

feld witnessed a burgeoning of family therapy 

applications. Treatment for SUDs, eating disorders, 

and adolescent behavioral problems increasingly 

refected aspects of family therapy. 

Family counseling is a collection of treatment 

approaches and techniques founded on the 

understanding that if change occurs with one 

person, it affects everyone else in the family 

and creates a “change” reaction. 

Their substance misuse was curtailed throughout 

the parenting years but escalated after the last 

child left the home. In recent months, the husband 

stopped drinking and began receiving treatment 

at an intensive outpatient counseling program. The 

husband’s abstinence has amplifed the couple’s 

sense of being strangers in the same house, which 

initially became apparent when their children 

moved out. They feel as if they no longer know 

what to do with each other or how to be together. 

The couple frst connected through substance use. 

Now, they must reconnect with each other through 

different interests and activities and rework their 

relationship to center on emotional connection. 

They would likely beneft from the therapeutic 

tasks suited to new relationships. Such tasks 

may include prescribed activities, such as formal 

dates, and spending time without others to get 

reacquainted. 

Context and Culture 

Many systems signifcantly infuence family 

members and the functioning of the family 

unit. These include educational, community, 

employment, legal, and government systems. 

Families operate as parts of these sociocultural 

systems, which themselves exist in diverse 

environments. A family-informed, systemsbased approach to SUD treatment will take into 

consideration questions such as: 

• What are the current community or geographic 

stressors? 

• What are the effects of acculturation? 

• What economic and supportive resources are 

available to the family? 

• Does the family have access to services? 

• How do culture, race, and ethnicity infuence 

the family (e.g., how are issues of power or 

oppression at play for the family)? 

Sociocultural interventions often stress the 

strengths of clients and families in specifc 

contexts; such interventions include job training, 

education and language services, social skills 

training, and supports to improve clients’ 

socioeconomic circumstances. Other interventions 

Chapter 1 15 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

At the same time, treatment of SUDs as a primary 

condition was taking hold. As with family therapy’s 

view of SUDs as a symptom of family issues, SUD 

treatment often viewed substance misuse as a 

symptom of underlying pathology. As the SUD 

treatment feld evolved, it started to recognize the 

infuence of biological, familial, cultural, and other 

psychosocial factors on substance use. 

Initial Integration of Families Into SUD 

Treatment 

SUD treatment services, which at frst were 

mainly residential, began to incorporate family 

activities into their programs. The goal was to rally 

individual clients’ family members in supporting 

their recovery and to address the ways in which 

family members, particularly spouses, contributed 

to clients’ substance misuse. It is no accident that 

the terms “co-alcoholic” and “codependent” were 

applied to spouses. Early SUD treatment programs 

began incorporating family psychoeducation, but 

there was an inherent attitude of “them” (family) 

versus “us” (those in recovery or treatment). 

Drug and alcohol counselors were often in recovery 

themselves, yet had no experience addressing their 

own family histories. In earlier attempts to involve 

families in SUD treatment, spouses were invited 

to sessions of groups that the family member with 

the SUD attended regularly with other individuals 

in residential treatment. This did not often foster 

a welcoming environment for spouses, who were 

generally ill-prepared and had no alliances to 

create a sense of safety in the group. The objective 

of including spouses and other family members 

in this way was to gain collateral information from 

them about patterns of substance misuse in the 

individual with the SUD—and to highlight spouse 

or family behaviors that contributed to past use 

or could trigger a relapse. The focus was on the 

individual’s, rather than the whole family’s, recovery 

from addiction and its effects. 

Specialized Family SUD Treatment 

Programs 

By the 1980s, family psychoeducation programs 

became the hallmark of family-based interventions 

in SUD treatment programs. As these specialized 

programs developed, they increasingly addressed 

the effects of parental SUDs on children and adult 

children (Wegscheider-Cruse, 1989). Virginia 

Satir’s communication family model (Satir, 1988), 

adapted by Sharon Wegscheider-Cruse, gained 

prominence in SUD treatment; programs adopted 

a systemic perspective to explore how family 

dynamics and roles shifted in response to family 

members with SUDs. Some programs included the 

individual with the SUD and his or her entire family, 

whereas others involved everyone except the 

family member with the SUD; some were couples 

oriented, and still others treated individuals 

affected by substance misuse (e.g., children and 

adult children programs). 

Many specialized family SUD programs began to 

close in the 1990s as a result of managed care, 

pressure to shorten treatment length, and limited 

funding sources (White, 2014). A persistent view 

of family services as ancillary meant little or no 

reimbursement from insurance and other funding 

sources. Programs self-funded family services or 

offered them on a cash basis, which was usually 

unsustainable. 

Recognition of family-based SUD interventions 

as effective has since increased, and funding has 

improved. In 2018, about 60 percent of SUD 

treatment programs offered marital/couples 

counseling; 81 percent provided some familybased interventions (SAMHSA, 2020). Recently, 

family counseling has thrived, as has research into 

family-based SUD treatment for adolescents and 

behavioral couples therapy (Lassiter et al., 2015). 

Family psychoeducation (Exhibit 1.6), multifamily 

groups, and limited family sessions are common 

approaches to integrating family counseling with 

SUD treatment, and objectives have expanded to 

support healing of entire families. 

16 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

Current Models for Including Families in 

SUD Treatment 

Four theories predominantly inform current familybased approaches in SUD treatment: 

• The chronic disease model views SUDs as 

similar to other chronic medical conditions 

and acknowledges the role of genetics in 

SUDs (White, 2014). Practitioners of this 

model approach SUDs as chronic illnesses that 

affect all members of a family and that cause 

negative changes in moods, behaviors, family 

relationships, and physical and emotional health. 

• Family systems theory holds that families 

organize themselves through their interactions 

around substance misuse. In adapting to 

substance misuse, the family tries to maintain 

homeostasis (Klostermann & O’Farrell, 2013). 

• Cognitive–behavioral theory assumes that 

behaviors, including substance misuse, 

are reinforced through family interactions. 

Treatment under this model works to change 

EXHIBIT 1.6. The Matrix Intensive 

Outpatient Approach 

The Matrix Intensive Outpatient Program’s 

Counselor’s Family Education Manual provides 

a psychoeducational format for working with 

families in a nonthreatening way. (There are other 

manuals in this structured treatment approach 

for clients with stimulant use disorders that are 

designed for clients and counselors.) Families have 

the opportunity to learn about methamphetamine 

misuse, other drug and alcohol misuse, treatment, 

and the recovery process. The manual offers 

guidance to counselors on how to explore with 

family members the effects of SUDs in the family 

unit. It also helps counselors teach families how 

they can support individual family members’ 

recovery. 

The manual is available online (https://store. 

samhsa.gov/product/Matrix-Intensive-OutpatientTreatment-for-People-with-Stimulant-UseDisorders-Counselor-s-Family-Education-Manualw-CD/SMA15-4153). 

interaction patterns, identify and target 

behaviors that could trigger substance misuse, 

improve communication and problem-solving 

skills, and strengthen coping skills and family 

functioning (O’Farrell & Clements, 2012). 

• MDFT integrates techniques that emphasize 

the relationships among cognition, affect 

(emotionality), behavior, and environment 

(Liddle, Rowe, Dakof, Ungaro, & Henderson, 

2004). MDFT is not the only family therapy 

model to adopt such an approach; functional 

family therapy (Alexander & Parsons, 1982), 

multisystemic therapy (Henggeler & Schaeffer, 

2016), and BSFT (Szapocznik, Muir, Duff, 

Schwartz, & Brown, 2015) refect similar 

multidimensional approaches. 

Diferent Pathways in Working 

With Families 

Parallel, Integrated, and Sequential 

Approaches 

Parallel 

Family counseling and family-based interventions 

can be an addition to SUD treatment. Parallel 

approaches deliver family counseling and SUD 

treatment independently, but at the same time. 

Some concurrent treatment approaches involve 

the person with SUD; others treat families 

separately from the family member with SUD. 

This depends on providers’ philosophy and 

program logistics. 

When family counseling and SUD treatment 

occur at the same time, communication between 

providers is vital. To prevent treatment goals 

from conficting, both providers should have 

competency in family processes and SUDs. In 

keeping with the principles of recovery-oriented 

systems of care (ROSCs), they should work 

together, in collaboration with the client and 

family, to improve family functioning, address the 

dynamics and effects of addiction in the family, 

and build a family environment that supports 

recovery for all. Case conferencing is an effcient 

way for family counselors and SUD treatment 

providers to address conficting service objectives 

and other concerns constructively in a forum 

that fosters identifcation of mutually agreeable 

priorities and coordination of treatment. 

Chapter 1 17 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

RESOURCE ALERT: SAMHSA’S ROSC RESOURCE GUIDE 

ROSCs are comprehensive, integrated systems of care that address the full continuum of medical and 

behavioral health needs. ROSCs make it easier for individuals and families to seek SUD treatment and other 

behavioral health services by supporting informed decision making and ensuring access to, and continuity 

of, care across service settings. According to SAMHSA’s (2010) Recovery-Oriented Systems of Care (ROSC) 

Resource Guide: 

The central focus of a ROSC is to create an infrastructure or “system of care” with 

the resources to effectively address the full range of substance use problems within 

communities. The specialty SUD feld provides the full continuum of care (prevention, 

early intervention, treatment, continuing care, and recovery) in partnership with other 

disciplines, such as mental health and primary care, in a ROSC. A ROSC encompasses 

a menu of individualized, person-centered, and strength-based services within a selfdefned network. By design, a ROSC provides individuals and families with more options 

with which to make informed decisions regarding their care. Services are designed to 

be accessible, welcoming, and easy to navigate. A fundamental value of a ROSC is the 

involvement of people in recovery, their families, and the community to continually 

improve access to and quality of services. (p. 2) 

The guide offers an overview of ROSCs, outlines steps for ROSC planning and implementation, and provides 

a collection of ROSC-related supporting resources. It is available online (www.samhsa.gov/sites/default/fles/ 

rosc_resource_guide_book.pdf). 

Integrated 

Integrated interventions embed family counseling 

within SUD treatment. The individual with the 

SUD participates in family approaches as part of 

the SUD treatment program. Integrated family 

counseling for SUDs can effectively address 

multiple problems by taking into account each 

family member’s issues as they relate to the 

substance misuse, as well as the effects of each 

member’s issues on the family system. The 

integrated framework assumes that, although 

SUDs occur in individuals, solutions to substance 

misuse exist within the family system that will 

support recovery among all family members. 

Exhibit 1.7 explores integrated family SUD 

counseling for individuals who may not initially 

wish to include family members in their treatment 

process. 

18 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

EXHIBIT 1.7. Understanding Client Reluctance Toward Family 

Involvement 

Most clients are willing to invite a substance-free family member or friend to support their recovery (e.g., 

when recovering from opioid misuse; Kidorf, Latkin, & Brooner, 2016). However, some people with SUDs 

do not wish to contact their families, and they may not sign a Release of Information that would allow 

their providers to initiate such contact. This limits the possibilities of family-based interventions, but family 

involvement in SUD treatment can still be a goal. Family members generally have additional information 

about clients’ behavioral patterns and the effects and consequences of their substance misuse. Even if 

solicited, this information may feel overwhelming for the person in treatment—yet it can also motivate the 

person to recover. 

As counselors build therapeutic alliances with clients, they gain insight into clients’ hesitancy toward 

inviting family members into the treatment process. Before promoting family involvement, counselors 

should understand clients’ rationale for preventing it. Their reasons may be well-founded (e.g., a history of 

abuse or estrangement). Younger clients may try to separate themselves out of a desire to fnd an identity 

outside the family. Others may fear what family members will say or feel ashamed of their behavior while 

using. 

Once counselors understand the reasons behind clients’ reluctance to include their families in treatment, 

it becomes easier to develop respectful strategies to integrate family counseling into SUD treatment. 

Counselors can make informed decisions with their clients about whether, and how, to involve the family if 

appropriate and if the client grants permission. 

Different programs endorse different strategies to promote family involvement. In programs that promote 

family services during the intake process and reinforce an ongoing expectation of family inclusion, family 

participation is typically more accepted. 

Sequential 

Sequential treatment implements family-based 

approaches after initial SUD treatment. Some 

SUD treatment programs keep family involvement 

minimal until the individual with the SUD has 

obtained and maintained recovery. Sometimes, 

such an approach results from a lack of program 

resources. Other times, this approach may refect 

the outdated idea that sobriety or recovery must 

come frst, regardless of an individual’s unique 

circumstances and family dynamics—despite 

family-based SUD treatment interventions typically 

enhancing outcomes for individuals and families. 

In some cases, circumstances and dynamics do 

warrant treating the SUD before involving the 

family—as when a family member with an SUD 

also has a co-occurring disorder not yet stabilized 

in treatment. In this scenario, it may be best to 

limit or postpone family-based interventions until 

stabilization. In other cases, sequential treatment 

is just the natural course of a family’s path to 

recovery. 

Families and couples may seek family counseling 

after SUD treatment. Many families struggle in 

early recovery, particularly the frst year or two, 

even if they felt united in hope, motivation, and 

support during SUD treatment. The reality of 

recovery sets in; couples and families realize 

that it takes time and can dramatically change 

interpersonal dynamics, roles, and relationships. 

For instance, members of a couple in recovery 

may have different expectations for emotional 

and sexual intimacy; one partner may want more 

intimacy, whereas the other may fnd intimacy 

uncomfortable without using substances. 

Chapter 1 19 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Contrasting expectations may produce stress in 

couples unaccustomed to supporting each other 

emotionally; some couples at this stage are still 

relearning how to talk productively with one 

another. Families and couples may need family 

counseling and therapy well after their initial 

recovery from SUDs. 

Settings and Formats 

Although family-based interventions vary widely 

from one treatment facility or provider to another, 

they are applicable across settings. As primary 

or ancillary approaches to address SUDs, such 

interventions can be integrated at many points 

along the continuum of care (e.g., inpatient 

or outpatient detoxifcation, outpatient SUD 

treatment services, medication-assisted treatment 

settings, short- or long-term inpatient or residential 

SUD treatment). 

EXHIBIT 1.8. Multifamily Groups 

Family-based interventions are fexible. Providers 

can tailor them to match specifc family needs and 

to suit specifc treatment settings. The intensity 

and format of the family-based intervention should 

align with the stage and duration of an individual’s 

SUD treatment, and should also address the 

presenting needs of that individual’s family. 

These interventions can be brief, emphasizing 

psychoeducation, parenting skills training, and 

supportive services. They can also be intensive, 

with case management and outpatient or inpatient 

programming that explores family dynamics and 

relational issues. 

Across settings, families may engage in individual 

family sessions and educational programs or 

counseling services involving multiple families. 

Exhibit 1.8 describes multifamily approaches to 

address SUDs. 

Multiple family therapy (MFT) is a specifc model for group family counseling. It originated from Laqueur’s 

family meetings in state hospital settings, which aimed to improve management strategies for patients 

who had schizophrenia (Laqueur, Laburt, & Morong, 1964). Today, MFT generally appears in residential and 

intensive outpatient SUD treatment settings and involves numerous families of clients in SUD treatment 

at the same time. It uses a variety of family models and approaches (see the “Current Models for Including 

Families in SUD Treatment” section). Some groups are closed; others are open, allowing family members to 

start attending group sessions at any time. Some groups have a set timeframe, such as four to six sessions, 

whereas other groups meet continually throughout the year. 

MFT groups typically include psychoeducational and experiential activities, such as role plays. The idea is 

that families are more likely to understand and accept their own dynamics if they witness similar dynamics 

in another family’s interaction in group. Well-facilitated groups can lessen shame and improve coping 

skills in families while reassuring them that they are not alone. The group process also helps families see 

that they can beneft from treatment as others have (even if the family member who uses substances 

does not maintain abstinence). MFT is especially useful for involving a family early in treatment, motivating 

individuals to continue SUD treatment, and achieving prevention (Steinglass, Sanders, & Wells, 2019). 

MFT helps normalize family experiences related to SUDs. For instance, family members in a group 

MFT session may be asked to stand in a circle with fve to six other families of various types, races, and 

socioeconomic backgrounds, each of whom has unique relational dynamics and has experienced varying 

effects and consequences of SUDs. The group counselor may ask everyone who feels as if they are different 

or fears not ftting in to take one step into the circle—and nearly everyone standing might step in. 

This is the value of MFT: It shows individuals and families that they are not alone in their experiences, feelings, 

and reactions to a family member’s substance misuse. MFT can be a starting point for family recovery. 

20 Chapter 1 
Chapter 1— Substance Use Disorder Treatment: Working With Families TIP 39

Levels of Family Involvement 

SUD treatment programs can intervene with 

families at different treatment phases and levels 

of engagement. In detoxifcation, a counselor may 

frst offer psychoeducation and general information 

about substance misuse and treatment options that 

seems applicable. Residential treatment programs 

may provide family intakes, family counseling 

sessions, and MFT groups to improve family 

functioning, address effects of SUDs in households, 

and help families identify their needs in recovery. 

Family-based interventions have different functions 

and require specifc counselor and programmatic 

competencies. For example, in continuing 

care services, parenting skills training may be 

implemented after discussing how the SUD and 

related family dynamics have affected parenting. 

In residential treatment, family sessions may 

explore the relational patterns and behavioral 

consequences of substance misuse or identify 

specifc behaviors associated with drinking or 

drug use to establish ways for interrupting those 

patterns and behaviors. In intensive outpatient 

treatment, a family component can help individual 

family members defne specifc goals to help with 

family functioning. 

Where Do We Go From Here? 

This chapter provided fundamental information on 

historical perspectives as well as current models 

and theories of the family; rationales for including 

families in SUD treatment; and an overview of 

family-based interventions. In Chapter 2, readers 

will fnd a more detailed exploration of the effects 

of SUDs on families, family roles and dynamics, 

and long-term outcomes. Chapter 2 addresses the 

effects of SUDs on diverse family groups, including 

those with adolescents who have SUDs and parents 

who have SUDs. 

Chapter 1 21 
This page intentionally left blank. 
Chapter 2—Infuence of Substance 

Misuse on Families 

KEY MESSAGES 

TIP 39 SUBSTANCE USE DISORDER TREATMENT AND 

FAMILY THERAPY

• Substance misuse and substance use disorders 

(SUDs) affect families in many ways. Use 

of alcohol and drugs can infuence family 

dynamics, communication styles, patterns of 

confict, and cohesion (degree of closeness with 

one another), among other effects. 

• When substance misuse is present in a family, 

dysfunctional patterns and relationships often 

occur as the family struggles to keep their life 

as normal as possible. Family members are 

usually doing their best to cope, but sometimes 

their ways of coping and keeping balance in 

the family can be unhealthy. 

• SUD treatment providers should approach 

families with empathy and understanding, not 

judgment and blame. 

• Almost all families in which substance misuse 

occurs share certain features. Even so, family 

types can infuence how families experience 

and attempt to cope with substance misuse. 

Families with young children, families with 

adult children, couples, blended families, 

same-sex couples, and families in which an 

adolescent is misusing substances have their 

own unique family dynamics and outcomes. 

• Parental substance misuse is especially 

damaging to both young and adult children. It 

increases children’s risk of experiencing SUDs 

and mental disorders, among other negative 

outcomes. 

Chapter 2 of this Treatment Improvement 

Protocol (TIP) summarizes how SUDs affect 

families and family functioning. It will help SUD 

treatment providers understand the types of 

relationships and patterns of behavior they are 

likely to encounter in the delivery of familybased SUD treatment and related services. 

This chapter: 

• Summarizes effects of SUDs on families, including 

family factors associated with substance misuse 

and the biopsychosocial consequences for 

spouses/partners, parents, and children of 

varying ages. 

• Introduces the roles of family history and 

genetics in substance misuse and recovery. 

• Identifes common family features and dynamics 

associated with substance misuse (e.g., high 

levels of confict, low-quality communication, 

low levels of cohesion). 

• Discusses the unique dynamics, 

interrelationships, and effects of SUDs in fve 

specifc family types: 

- Couples in which a partner has an SUD. 

- Parents with an SUD who have young 

children. 

- Parents with an SUD who have adult children. 

- Blended families in which a family member 

has an SUD. 

- Families with an adolescent who has an SUD. 

SUDs affect more than just the person who 

misuses substances; they can potentially affect 

the person’s entire family as well, infuencing 

breakdown in the ways in which family members 

get along, communicate, and bond with each 

other. A family is a system consisting of different 

23 
TIP 39

 

Substance Use Disorder Treatment and Family Therapy 

“parts” (the family members), so a change in one 

part can cause changes throughout the system. 

When a family member has an SUD, the effects on 

that person’s family can vary signifcantly, depending 

on factors such as SUD severity, access to resources, 

family type, patterns of substance misuse, and the 

presence of substance misuse or related activities in 

the family home, to name just a few. 

In reading Chapter 2, you will learn to recognize 

common family features and dynamics associated 

with substance misuse to help guide you toward 

the interventions and services that will best 

meet each family’s needs. Improving your grasp 

of these factors will help you avoid judging or 

pathologizing families dealing with SUDs and, 

instead, offer them understanding and empathy. 

The Role of Genetics and Family 

History in the Development of 

and Recovery From SUDs 

Family history of substance misuse is linked to an 

increased risk of developing SUDs (Huibregtse et 

al., 2016; Prom-Wormley, Ebejer, Dick, & Bowers, 

2017; Reilly, Noronha, Goldman, & Koob, 2017). 

Genetic research suggests that there are multiple 

genes for alcohol use disorder (AUD) and SUDs 

involving nicotine, cannabis, cocaine, and opioids 

(Prom-Wormley et al., 2017). Genetic risk of SUDs 

may vary according to parent gender (Nadel 

& Thornberry, 2017). (For more information on 

gender differences in families and risk of SUDs, see 

the section “Traditional Gender Roles, SUDs, and 

Family Dynamics.”) 

COUNSELOR NOTE: CAN FAMILIES BENEFIT FROM GENETIC COUNSELING 

FOR SUDs? 

Should you refer families facing substance misuse to genetic counseling? The answer is not clear. 

Genetic counseling for SUDs is relatively new. More research is needed to determine the extent to which 

genetic counseling is useful for families with SUDs and how they can act on the information such counseling 

delivers. 

According to a study of families’ desire for genetic counseling for AUD, Kalb, Vincent, Herzog, and Austin (2017) 

surveyed adults with AUD, a family history of AUD, or both and found that: 

• Most individuals believed that genetics and family history are important contributors to AUD. 

• Although 40 percent of people surveyed had heard of genetic counseling and 32 percent knew what 

genetic counseling was, only one person had previously undergone genetic counseling (not for AUD). 

• After receiving information on genetic counseling for AUD, 62 percent thought it would beneft them. 

• Of people surveyed, 72 percent expressed some degree of concern about their children developing AUD, 

and 43 percent had similar concerns about their siblings. 

• Only 5 percent of survey respondents reported choosing to not have children or to adopt—in part because 

of their AUD/family history of AUD. However, a little more than one-quarter (26 percent) were unsure of 

whether their family history of AUD would affect their future decision making about having children. 

Although these promising results suggest that referral to family genetic counseling may be benefcial, 

these services are still relatively new in the SUD treatment world. Not every family will be interested in these 

services, and there may not be a genetic counselor in your community to whom you can refer families. 

Further, it is important for families to understand the context of genetic infuences on substance use in terms 

of epigenetics, which suggest the presence of factors, such as environment, that can affect gene expression. 

The best approach is to talk with families about genetic counseling to explain how it may or may not 

be of use to them, and ask them their thoughts about a possible referral. 

24 Chapter 2 
Chapter 2—Infuence of Substance Misuse on Families TIP 39

Genes play a role in the development and 

progression of substance misuse and SUDs 

(Schuckit, 2014). For example, the quantity and 

frequency of alcohol, nicotine, and cannabis use 

in one study were greater among nonadopted 

adolescent siblings than adopted adolescent 

siblings, although a shared home environment (a 

nongenetic factor) that includes substance use was 

also thought to contribute to an extent (Huibregtse 

et al., 2016). However, earlier data from the 

National Epidemiologic Survey on Alcohol and 

Related Conditions (NESARC) (Yoon, Westermeyer, 

Kuskowski, & Nesheim, 2013) found lifetime rates 

of SUDs were greater among adopted adults 

than nonadopted adults, which also points to the 

importance of shared environment. 

One allele (a variant form of a gene) is associated 

with an increased risk of relapse for individuals 

with AUD (Dahlgren et al., 2011). In a comparison 

of people in recovery from alcohol dependence 

conducted in Sweden, those with the DRD2 A1 

allele had a signifcantly higher rate of relapse 

(89 percent) than did those without the allele 

(53 percent). Other studies suggest that a family 

history of substance misuse increases relapse 

risk for people in SUD remission (McLaughlin 

et al., 2010; Milne et al., 2009). Certain genes/ 

alleles related to reward mechanisms and 

neurotransmitters in the brain (e.g., dopamine, 

serotonin) also may increase cravings and, thus, 

returns to use (Blum et al., 2017; Leventhal et al., 

2014). 

Exhibit 2.1 further demonstrates how biology 

fts into a framework for understanding SUDs in 

families. 

EXHIBIT 2.1. The Role of the Medical Model When Working 

With Families 

As SUDs progress, they often change the person’s behavior, emotions, and thinking processes. Some family 

members may see these changes as evidence that the person is caustic, spiteful, or weak. They are not likely 

to attribute the changes to substance misuse, but rather to a faw in the individual’s personality or decisionmaking skills. As the SUD progresses, it is harder for some family members to separate the person from the 

substance misuse. Some counselors use an image of a blanket covering a person as a metaphor to depict 

how the SUD (the “blanket”) hides the person underneath. 

The medical model of SUDs emphasizes genetic and physiological factors like long-term changes in brain 

chemistry after substance misuse (Frank & Nagel, 2017; MacNicol, 2017). This model highlights the genetic 

predisposition to substance misuse and transgenerational familial patterns of SUDs. Some families may 

beneft from understanding this model as they come to view SUDs not as a personal weakness, but as a 

disease. 

Although the medical model is widely known and accepted, it is not the only model to explain drug and 

alcohol addiction. Other models include the public health model, the general systems theory of addiction, 

the sociocultural model, and behavioral-cognitive models (e.g., social learning theory). Do not assume that 

all providers and all programs support the medical model of addiction. Descriptions of these models are 

beyond the scope of this TIP. However, know that the program in which you work may or may not support 

the medical model of addiction. Similarly, after exploring these different theories, you may or may not come 

to support the medical model yourself. For more information about explanatory, prevention, and treatment 

models of SUDs, review Facing Addiction in American: The Surgeon General’s Report on Alcohol, Drugs, 

and Health (HHS, 2016), available online (https://addiction.surgeongeneral.gov/sites/default/fles/surgeongenerals-report.pdf). 

Chapter 2 25 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Common Characteristics of 

Families With SUDs 

No two families are exactly alike, but families 

in which substance misuse occurs often share 

common features. They typically (Bradshaw et al., 

2016; Elam, Chassin, & Pandika, 2018; Klostermann 

& O’Farrell, 2013): 

• Show a lack of fexibility, rather than an excess. 

• Have high levels of distress and dysfunction. 

• Have low levels of family expressiveness, 

cohesion, and agreement. 

• Experience what has been termed the 

“reciprocal causality” of maladjustment. This 

means the substance misuse leads to family 

dysfunction, but that family dysfunction and 

confict also affect substance misuse and 

relapse. Thus, the two are interconnected. 

See Exhibit 2.2 for more family characteristics 

linked with SUD onset, maintenance, and recovery. 

A literature review and meta-analysis (Yap, Cheong, 

Zaravinos-Tsakos, Lubman, & Jorm, 2017) identifed 

common factors in the families of adolescents who 

misuse alcohol. These factors include: 

• Parents using alcohol. 

• Parents expressing a positive attitude about 

alcohol use. 

• Parents providing children with easy access to 

alcohol. 

• Families experiencing higher levels of confict. 

• Parents and children having low levels of quality 

relationships with one another. 

EXHIBIT 2.2. Family Traits That Affect SUD Initiation, Maintenance, 

and Recovery 

• Family factors affecting SUD initiation: 

- Exposure to substance use by a family member (social learning) 

- Parental control that is either very rigid or very permissive 

- Lack of family connectedness and support (especially during times of stress and diffculty) 

- Certain socioeconomic factors, like families where both parents work and have little time to spend with 

(and thus monitor) their children 

• Family factors affecting SUD maintenance: 

- High use of substances during family events, like gatherings and celebrations (social learning) 

- Weak bonds between family members (especially between parents and children) 

- Ineffective, inconsistent, or otherwise low-quality communication between family members 

- Low-quality parenting skills, including use of severe punishment 

- Both excessive control and excessive permissiveness 

• Family factors associated with less successful recovery from SUDs: 

- Any dysfunctional pattern in the family’s dynamics, including problems with family boundaries, family 

cohesion, and family roles 

- Lack of open and consistent communication 

- Low-quality parenting skills 

- Lack of parental warmth and involvement; parental rejection 

- Divorce or death of a parent 

Source: Mathew, Regmi, & Lama (2018). 

26 Chapter 2 
Chapter 2—Infuence of Substance Misuse on Families TIP 39

 Exhibit 2.3 gives examples of ways in which certain substances commonly affect families. 

EXHIBIT 2.3. Effects of Different Substances on Families 

SUBSTANCE EFFECTS ON THE FAMILY 

Alcohol • Problems with communication 

• High levels of confict 

• High risk of chaos and disorganization (e.g., inconsistent parenting 

practices) 

• Breakdown of family rituals, rules, and boundaries 

• High potential for emotional, physical, or sexual abuse, or a combination 

thereof 

• Efforts by family members to “cover up” for the family member with alcohol 

misuse 

Opioids • High potential for illegal activities (e.g., buying illicit opioids, like heroin; 

diverting prescription opioid medications) 

• Increased risks of chaos and unpredictability 

• Greater risk of contracting an infectious disease, such as HIV/AIDS and 

hepatitis, which can affect family members’ roles and responsibilities (e.g., 

parenting children, caring for dependent others, working to earn a livable 

income, fulflling school-related duties) 

• Increased risk of engaging in sex work to support the cost of opioids, which 

can affect the family member’s health, roles, and responsibilities 

• High potential for SUDs 

Cocaine • High potential for illegal activities (e.g., buying or selling cocaine) 

• Increased risk of stealing from family, work, or others to purchase cocaine 

(which, in certain forms, can be high cost) 

• Increased chances of legal problems 

• High potential for SUDs 

Source: Mathew et al. (2018). 

Chapter 2 27 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

MINI-CASE EXAMPLE 

A stay-at-home mother drinks to the point of not being able to pick up her youngest child from school, 

manage the bills, or take care of the house. To keep the family functioning as normally as possible, her 

teenage daughter may take up these responsibilities rather than try to convince her mother to stop 

drinking. Thus, the mother continues to drink, knowing her daughter is there to “pick up the pieces.” 

It may seem illogical for the daughter to act in a way that actually supports her mother’s AUD. But she 

is just trying to keep her family functioning as consistently as possible. This is typical of families with 

SUDs—members do their best to survive and try to prevent further disruptions in their relationships 

and functioning. “Enabling” behaviors that result from such efforts to keep the balance may seem 

counterproductive and ill advised, but they are actually adaptive. (Also see the counselor note “How Do 

‘Enabling Behaviors’ Infuence Substance Misuse in Families?”) 

Homeostasis 

In nearly all families affected by substance 

misuse, there is a tendency to try to maintain 

homeostasis. This means that family members 

will behave in ways to try and keep the family 

functioning as it always has, even if that means 

supporting the family member’s substance misuse 

to prevent change or imbalance. Unhealthy family 

relationships, roles, rituals, and functions often 

develop in part because families are attempting 

to maintain homeostasis. The following case is just 

one example of an attempt to keep the balance in 

a family dealing with an SUD. 

When one person in a family 

begins to change his or her 

behavior, the change will affect 

the entire family system. It is 

helpful to think of the family 

system as a mobile: when one 

part in a hanging mobile moves, 

this affects all parts of the 

mobile but in different ways, and 

each part adjusts to maintain a 

balance in the system.” 

(Lander, Howsare, & Byrne, 2013, 

p. 197) 

As an SUD treatment provider, you need to 

understand the role of homeostasis in family 

dynamics and help family members develop 

healthier behaviors and relationships with 

one another without blaming, lecturing, or 

judging them. 

It also is critical that you identify and understand 

a family’s efforts to maintain homeostasis. The 

family members’ readiness to change (or lack 

thereof) may affect family functioning, and family 

functioning may affect their readiness to change 

(Bradshaw et al., 2016). Both factors—family 

readiness to change and functioning—may affect 

the person with an SUD and his or her willingness 

to seek recovery. 

Traditional Gender Roles, SUDs, and 

Family Dynamics 

Traditional gender roles are an important factor in 

understanding family dynamics and SUDs. In U.S. 

culture, family functions and roles have traditionally 

differed by gender, such that men were typically 

the “breadwinners” and primary decision makers 

for the family, whereas women were caretakers and 

sources of emotional support. The relationships, 

roles, and functions in a family are affected by 

that family’s view of gender roles in general. For 

example, in a family that believes women should 

not work outside the home, a wife having to take 

a job because of family fnancial strain may become 

28 Chapter 2 
Chapter 2—Infuence of Substance Misuse on Families TIP 39

a major source of stress or shame. Further, it is 

common for family bonds to differ across gender, 

with the formation of strong mother–daughter and 

father–son dyads but, in many cases, comparatively 

weaker bonds between parents and their children 

of the opposite gender. 

Traditional gender roles relate to substance 

misuse. Strict adherence to stereotypical gender 

expectations may increase SUD risk in young 

people. For instance, adolescents with high scores 

of male-typicality (i.e., behaviors and attitudes 

typical in men) had a 70-percent higher frequency 

of intoxication and 79-percent higher frequency 

of cannabis use than adolescents with the lowest 

scores of male-typicality (Mahalik, Lombardi, Sims, 

Coley, & Lynch, 2015). Similarly, men who are more 

adherent to male-typical behaviors and norms are 

256 percent more likely to use alcohol, tobacco, 

and cannabis as adolescents and 66 percent 

more likely to use them as young adults compared 

with men who are less adherent to male-typical 

norms (Wilkinson, Fleming, Halpern, Herring, & 

Harris, 2018). 

COUNSELOR NOTE: WHAT DOES GENDER HAVE TO DO WITH SUBSTANCE 

MISUSE? 

According to McHugh, Votaw, Sugarman, and Greenfeld (2018) and Kuhn (2015): 

• Men have a higher risk of early- and late-onset substance use than women. Yet women may progress 

from initiation of substance use to SUDs faster than men, particularly for alcohol, cannabis, and opioids. 

• The prevalence of SUDs is higher for men than for women. 

• The biopsychosocial, functional, and quality of life consequences of SUDs (including problems with family 

functioning) tend to be more severe in women than in men. 

• Women often face unique barriers to SUD treatment, like childcare burdens and lack of family support. 

• Adolescents’ development of SUDs can differ across genders because of differences in initiation and 

frequency of use as well as differences in biology, behavior, and personality characteristics, all of which 

contribute to SUDs. For instance: 

- Differences in cannabis use appear as adolescents age, with boys showing more use than girls. 

- In some research, levels of alcohol use increase more rapidly with age among male adolescents than 

among female adolescents. 

- Nonmedical use of prescription opioids appears more common in female than in male adolescents. 

- By late adolescence, boys tend to exceed girls in frequency and amount of alcohol, tobacco, and 

cannabis use. 

- SUD-related biological mechanisms, behaviors, and personality traits in adolescents also can differ by 

gender. This includes factors like sensation seeking (greater in men); inhibitory or self-control abilities 

(greater in women); history of childhood abuse (greater in female adolescents); presence of depression, 

anxiety, or bipolar disorders (greater in female adolescents); presence of conduct disorder or attention 

defcit hyperactivity disorder (greater in male adolescents); and reactivity of the hypothalamic– 

pituitary–adrenal axis system in puberty (higher reactivity in pubertal female adolescents). 

For additional discussion about substance misuse and recovery services for women specifcally, see TIP 

51, Substance Abuse Treatment: Addressing the Specifc Needs of Women (Substance Abuse and Mental 

Health Services Administration [SAMHSA], 2009). 

Chapter 2 29 
TIP 39

Research suggests that there are gender-related 

differences in the dynamics and functioning of 

families in which substance misuse occurs: 

• Among parents in SUD treatment (Burstein, 

Stanger, & Dumenci, 2012): 

- Mothers were signifcantly more likely than 

fathers to identify internalizing, externalizing, 

and substance use-related behaviors in their 

adolescent children. 

- Maternal, but not paternal, scores on a measure 

of psychopathology predicted adolescents’ 

internalizing problems and substance use. 

• Family functioning and adolescent substance 

misuse may differ by gender. In their survey 

of more than 1,000 high school students, 

Ohannessian, Flannery, Simpson, and Russell 

(2016) found that: 

- Decreased family functioning (such as lowquality father–adolescent communication) 

predicted greater alcohol use among girls 

but had no bearing on boys’ alcohol use. 

- Low level of quality mother–daughter 

communication plus family dissatisfaction 

predicted alcohol use in girls, but only 

because of girls’ depressed mood. 

• In boys, lower quality adolescent–mother 

communication, family cohesion, and family 

adaptability were linked to greater alcohol and 

cannabis use (Russell, Simpson, Flannery, & 

Ohannessian, 2019): 

- The relationship between adolescents’ 

alcohol use and low levels of family cohesion 

and adaptability were accounted for by boys’ 

depression but not girls’ depression. 

- Instead, among girls in the study, there was a 

relationship between higher depression and 

lower family functioning but no relationship 

with substance misuse and family functioning. 

• Gender differences in parent–child dynamics 

also may infuence substance misuse in families 

with adult children. In one study (Reczek, 

Thomeer, Kissling, & Liu, 2017), parent–child 

relationships infuenced adult sons’ but not 

daughters’ smoking behaviors. For sons only, 

more contact with mothers was associated with 

a steeper decrease in smoking over time; less 

Substance Use Disorder Treatment and Family Therapy 

contact with mothers, with a steeper increase in 

smoking over time. Greater support from fathers 

also was associated with greater smoking in sons 

(but not daughters) at baseline but a steeper 

decline over time. 

Different family members may be at different risk 

for harmful outcomes of family-related substance 

misuse. Do not assume that mothers, fathers, sons, 

daughters, or other family members all experience 

the same effects. In providing family-based SUD 

treatment, keep in mind that: 

• A family’s expectations and beliefs about 

gender roles may infuence dynamics and 

functioning as well as substance misuse among 

family members. For instance: 

- A family’s belief that a son’s alcohol misuse is 

not as serious as a daughter’s and not worth 

treating because “boys will be boys” may 

contribute to the son’s continued substance 

misuse. 

- A wife who believes it is her job to support 

her family and “keep the peace” may feel 

the urge to “cover up” her husband’s opioid 

use disorder (OUD) rather than confront him 

about it directly. 

• You may need to address a family’s unhealthy 

dynamics and dysfunction. One approach is to 

provide education about the effects of genderrelated beliefs and expectations, especially if 

such beliefs and expectations are worsening a 

family member’s substance misuse. 

• Because of gender-based differences, female 

and male members of the family may beneft 

from different interventions and services to 

address their unique risk factors and needs. 

Family Types: SUDs and Family 

Dynamics 

Not all families develop the same patterns or 

dynamics in response to SUDs. Families are 

incredibly diverse, and their presenting problems 

and concerns are infuenced by many contextual 

factors and life events. However, there are common 

threads among families with similar family types 

and identifed SUDs. Common relational dynamics 

and issues surrounding SUDs arise when you 

work with couples without children, families with 

30 Chapter 2 
Chapter 2—Infuence of Substance Misuse on Families TIP 39

adolescents, or blended families. So, too, do 

different treatment issues emerge based on the 

age and role of the person who uses substances in 

the family, whether small children or adolescents 

are present, and the type of SUD. 

Using available research and organized according 

to family type, the following section highlights the 

effects, dynamics and patterns, and experiences of 

fve different family types: 

• Couples in which a partner has an SUD. 

• Parents who have SUDs and young or 

adolescent children. 

• Parents who have SUDs and adult children. 

• Blended families in which a family member has 

an SUD. 

• Families with adolescents who have SUDs. 

Descriptions of the fve family types in the 

following sections refect availability of relevant 

research. If you provide SUD treatment or recovery 

support services for other family types, you are 

still likely to see some patterns and effects of 

substance misuse similar to those in the types this 

TIP does address. 

Couples in Which a Partner Has an SUD 

Substance misuse can be toxic to intimate 

partnerships (i.e., married and nonmarried 

couples). Relationships often have diffculty 

sustaining when at least one person in the 

relationship has an SUD. Data from the NESARC 

(Cranford, 2014) show that rates of marriage 

dissolution among couples with lifetime AUD are 

signifcantly higher than in couples without lifetime 

AUD (48 percent versus 30 percent). A 10-year 

follow-up on the National Comorbidity Survey 

(Mojtabai et al., 2017) similarly found that alcohol 

or drug misuse signifcantly increased the risk of 

future divorce by 1.62 times. 

Be aware that one of the most well known 

factors associated with SUDs in intimate 

relationships is the occurrence of violence, 

especially when the person with the substance 

misuse is male. Pooled data from years 2008 

through 2015 of the National Survey on Drug 

Use and Health (NSDUH) (Harford, Yi, Chen, 

& Grant, 2018) found that symptoms of SUDs 

were associated with signifcantly higher rates of 

self- and other-directed violence. Results from 

the NESARC-III match these fndings and show an 

increased risk of violence among people with AUD, 

cannabis use disorder, or other drug use disorders 

(Harford, Chen, Kerridge, & Grant, 2018). 

Drug use and alcohol misuse are associated with 

increased intimate partner violence specifcally 

(Reyes, Foshee, Tharp, Ennett, & Bauer, 2015). For 

example: 

• The American Society for Addiction Medicine 

reports that substance misuse occurs in about 

40 percent to 60 percent of cases of intimate 

partner violence (Soper, 2014). 

• In women who have experienced intimate 

partner violence, rates of substance misuse 

are 2 to 6 times higher than in women without 

intimate partner violence, ranging widely from 

18 percent to 72 percent (SAMHSA, 2017). 

• Rates of lifetime intimate partner violence 

among SUD treatment-seeking women vary 

from 47 percent to 90 percent (SAMHSA, 2017). 

COUNSELOR NOTE: WHAT ARE THE 

EFFECTS OF SUBSTANCE MISUSE 

BEYOND THE NUCLEAR FAMILY? 

• Extended family members may experience feelings 

of abandonment, anxiety, fear, anger, concern, 

embarrassment, or guilt; they may wish to ignore 

or cut ties with the person misusing substances. 

• Some family members even may feel the need 

for legal protection from the person misusing 

substances. 

• Moreover, the effects on families may continue for 

generations: 

- Intergenerational effects of substance misuse 

can have a negative effect on role modeling, 

trust, and concepts of normative behavior, 

which can damage the relationships between 

generations. 

- For example, a child with a parent who misuses 

substances may grow up to be an overprotective 

and controlling parent who does not allow his or 

her children suffcient autonomy. 

Chapter 2 31 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

COUNSELOR NOTE: WHAT IS CODEPENDENCE? 

Although the term codependent originally described spouses of people with AUD, it has come to refer to 

any relative of a person with any type of behavioral or psychological problem. The term has been criticized for 

pathologizing caring functions, particularly those that have traditionally characterized women’s roles, such as 

empathy and self-sacrifce. Despite the term’s common use, Klostermann and O’Farrell (2013) note a lack of 

consensus in the feld about using it to refer to people who misuse substances and the families of those people. 

They further note that usage ranges from a shorthand label for family members affected by an individual’s SUD 

to a synonym for a personality disorder. Indeed, little scientifc inquiry has focused on codependence. It is best 

to avoid using this term both directly with clients and in discussing families with SUDs. 

Just because a person is in an intimate 

relationship with someone with an 

SUD does not mean that violence will 

occur in that relationship. However, 

intimate partner violence is common 

in such relationships and leads to 

negative, unhealthy dynamics. It also 

creates ethical and safety concerns for 

counselors and clients. 

Consequences of a partner’s substance 

misuse may go beyond issues of trauma 

and physical safety; there also can be 

fnancial effects (e.g., money spent on 

drugs rather than rent, medical costs 

related to treating SUDs or related 

physical problems) and psychological 

consequences, which may include: 

• Denial or protection of the person with 

the substance misuse. 

• Anger. 

• Stress. 

• Anxiety. 

• Hopelessness. 

• Neglected health. 

• Shame. 

• Stigma. 

• Isolation. 

When substance misuse is present in 

an intimate relationship, both partners 

need help. The treatment for either 

partner will affect both, so SUD treatment 

programs should make both partners feel 

welcome. 

COUNSELOR NOTE: HOW DO 

“ENABLING BEHAVIORS” INFLUENCE

SUBSTANCE MISUSE IN FAMILIES? 

Watching a family member struggle with substance misuse 

is diffcult, as is not knowing how best to help him or her. 

Many times, family members (and often partners/spouses) 

will engage in behaviors that help maintain the person’s 

substance misuse, not because they want the person to 

keep misusing substances but because they do not know 

what else to do or how exactly to help. For instance, the 

parents of an adult son who misuses prescription opioids 

might continue to give him money, let him live at home, 

and bail him out of jail. All of these behaviors keep the son 

from experiencing the negative effects of prescription 

opioid misuse and thus make it easier for him to continue 

misusing (and give him less of a reason to seek recovery). But 

because his parents clearly love their son and don’t want to 

see him suffer, they think they are doing the “right thing” by 

continuing to house him and support him fnancially. 

These behaviors are often called enabling behaviors. As 

a counselor, you should understand that enabling is a 

common, normal reaction among family members of 

people with SUDs. Do not shame, blame, or lecture 

family members who are enabling substance use-related 

behaviors. In general, families are just trying to do the 

best they can to help their family member in the best way 

they know how. Instead, gently offer education about why 

these behaviors, although well intended, actually work 

against recovery. Help family members come up with 

more adaptive ways to support the individual but without 

supporting the substance misuse. 

32 Chapter 2 
Chapter 2—Infuence of Substance Misuse on Families TIP 39

Even when people are in recovery and seeking to 

improve their lives, relationships can suffer. For 

instance, during early stages of recovery, partners 

may (Ast, 2018): 

• Have diffculty adjusting to and expressing 

feelings about their partner’s recovery. 

• Experience loneliness/separation (e.g., 

physically, upon the person entering residential 

treatment). 

• Struggle with changes in intimacy and 

communication with their partner. 

• Feel threatened by their partner forming new 

and emotionally intimate bonds with others in 

recovery (e.g., 12-Step sponsors and attendees) 

or spending much of their time participating 

in recovery activities that do not involve the 

partner (e.g., attending “90 meetings in 90 

days”). 

• Struggle with no longer being the person’s only 

source of support. 

• Feel that their partner has made recovery, not 

the relationship, the primary focus and top 

priority. 

• Feel left out of the recovery process (especially 

if not invited to participate in services). 

CLINICAL CASE EXAMPLE: UNDERSTANDING FAMILY CHANGES THAT 

OCCUR WITH SUBSTANCE MISUSE 

As an individual progresses from SUD initiation to maintenance and recovery, the individual’s relationships 

with family members and partners also will undergo change. It is important for counselors to understand 

this parallel process. Changes in family relationships and dynamics can affect a person’s substance misuse 

and recovery effort (either by worsening it or supporting it). It can be helpful to point out to families and 

couples that a person’s entry into treatment or recovery can lead to improvements in family relationships. 

Consider the following case example from Robin, a 32-year-old woman who is married to Ron, who has 

AUD. Robin discusses how her relationship with Ron changed over the course of their 10-year marriage and 

how these changes seemed to mirror the stages of Ron’s AUD. 

“Ron and I met at a bar. He was there with friends, and I was there for a bachelorette party. We both had a 

lot to drink that night, but neither of us minded or thought that was bad. There was no judgment there. We 

both thought drinking was fun and, frankly, enjoyed getting drunk. 

“Throughout our relationship, our activities often centered around alcohol use—going out drinking with 

friends, going on wine tours and tastings, having happy hour after work. It was almost as if drinking 

brought us closer together. It gave us a shared activity, and we truly enjoyed it. 

“After we were married for about a year, I noticed a real change in Ron’s drinking. He was drinking more, I 

think in part because of his promotion at work that resulted in him having a lot more responsibilities and 

longer working hours. He no longer seemed to drink because it was fun; he seemed to drink because it 

was the only way he could deal with stress or escape his work life. As a result, he was drinking more heavily 

and more often. This caused a rift between us. I didn’t want to drink as frequently or as much as he did, and 

often he would get completely drunk while I remained sober. This meant that I had to be the one to drive 

us home or to help him into bed or to make sure he got up and went to work the next morning. I started to 

feel more like his mother than his wife. He constantly complained that I wasn’t ‘fun’ anymore. 

“Then things really took a turn for the worse. When he drank, Ron would become argumentative and angry. 

He even shoved a guy in a bar who he thought was staring at me. If we were in the presence of friends or 

out in public, I’d get so embarrassed by his drunken tantrums and loud voice. At that point, I didn’t want 

Continued on next page 

Chapter 2 33 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Continued 

to touch the stuff myself. I started pulling away from Ron, wanting less and less to spend time with him. 

Because I pulled away, he spent more time with his drinking buddies. I realized that most of our friends and 

family also were drinkers—and some of them were quite heavy drinkers, like Ron. It was so hard for me to fnd 

someone who understood and could sympathize with the negative feelings I was having about alcohol. 

“Just as Ron’s life was falling apart and he did everything he could to hide it at work, I did everything I could 

to put on a happy face to the world and to make it appear as though we had ‘the perfect’ marriage. But really, 

it was anything but perfect. Ron lost his job because he kept failing to keep up with his duties because of 

constantly being hungover. I had to take a second job to help make up for the lost income. I also had to hide 

his fring from my parents. The constant lying to them and the rest of our family made me sick to my stomach. 

“Alcohol played a big role in our problems. Our relationship changed as his alcohol use changed and became 

more dangerous. At frst, the drinking was fun, and our relationship was flled with fun times, playfulness, and 

laughter. But as he started having problems and drinking more heavily, our relationship became strained. 

“But on the upside, once Ron decided to pursue recovery, our relationship changed again—this time, for 

the better. Once he got sober, we reconnected. He opened up to me about his drinking and apologized for 

all of the ways it hurt me and our marriage. We even started fnding things to do together—things that did 

not involve drinking, for once! Now, we go on hikes or catch a movie sometimes. I am so grateful that Ron 

fnding recovery not only helped him heal but helped our relationship heal as well.” 

A review of quality of life issues affecting partners 

of people who misuse substances (Birkeland et al., 

2018) found that substance misuse was linked to 

partner reports of low quality of life—even more so 

when substance misuse was severe. In many studies 

included in the review, the partner’s quality of life 

was worse than that of the general population— 

sometimes as low as that of the partner with 

the SUD. 

The disruption of family life and the stress of being 

a caregiver not only increase the risk of relapse 

for people with SUDs and mental disorders, they 

also contribute to SUDs and mental disorders 

among family members. On the other hand, family 

members (particularly between spouses, intimate 

partners, or parents and their adolescent or 

transition-age children) who can provide general 

support to the recovering person; goal direction; 

and monitoring of substance use, medication 

adherence, and early warning signs of relapse can 

have a positive infuence on recovery by lessening 

the risk of relapse and reducing hospitalizations, 

healthcare costs, and family stress. 

Parents Who Have SUDs and Young or 

Adolescent Children 

Substance misuse among parents with young 

or adolescent children affects family dynamics, 

often because substance misuse makes it 

hard for parents to fulfll their childrearing 

responsibilities. For example, parents with 

SUDs often have affective dysregulation that 

can make it hard for their children to develop 

healthy attachments, form trusting relationships 

with others, and learn how to regulate their own 

emotions and behaviors (Lander et al., 2013). 

Children often develop complex systems of denial 

to protect themselves against the reality of the 

parent’s SUD. But denial is harder for children to 

maintain in a single-parent household in which the 

parent misuses substances. In such circumstances, 

children are likely to behave in a manner that is not 

age-appropriate to compensate for the parental 

defciency—for example, they may act as surrogate 

spouses for the parent with the SUD. (For more 

information, see TIP 51 [SAMHSA, 2009].) 

34 Chapter 2 
Chapter 2—Infuence of Substance Misuse on Families TIP 39

COUNSELOR NOTE: IS IT 

COMMON FOR CHILDREN TO LIVE 

WITH PARENTS WHO MISUSE 

SUBSTANCES? 

Approximately 14 percent of children living with 

two parents have at least one parent with an 

SUD, and around 8 percent of children live in 

single-parent households in which the parent 

has an SUD. The annual average percentage of 

children and adolescents (from birth to 17 years 

of age) living in a household with at least one 

parent with AUD or an illicit drug use disorder is 

10.5 percent and 2.9 percent, respectively. 

The 2009 to 2014 NSDUHs suggest that nearly 9 

million children ages 17 and younger live with at 

least one parent who has an SUD. This includes: 

• Almost 13 percent of children ages 0 to 2. 

• About 12 percent of children ages 3 to 5 and 

ages 6 to 11. 

• 12.5 percent of children ages 12 to 17. 

Source: Lipari & Van Horn (2017). 

SUDs in families may increase the likelihood of 

child abuse/neglect (Kepple, 2017; Smith, Wilson, 

& Committee on Substance Use and Prevention, 

2016). Per the National Survey of Child and 

Adolescent Well-Being (Kepple, 2018), past-year 

SUDs increased occurrence of child physical abuse 

by 562 percent; emotional abuse by 329 percent; 

and neglect by 140 percent. Past-year light-tomoderate drinking, heavy drinking, or illicit drug 

use signifcantly increased chances of physical and 

emotional abuse and neglect. 

Substance misuse by parents is itself considered an 

adverse childhood event (others include domestic 

violence and child abuse/neglect). Parental 

substance misuse is associated with signifcantly 

increased risk in children of later developing an 

SUD (Finan, Schulz, Gordon, & Ohannessian, 2015; 

Smith et al., 2016) or an impairment in the ability 

to cope with stress, which can affect relapse (e.g., 

among heroin users who were abstinent, as per 

Gerra et al., 2014). 

Most data on enduring effects of parental 

substance misuse on children suggest its effects 

to be often detrimental (Calhoun, Conner, Miller, 

& Messina, 2015). Parental substance misuse can 

have cognitive, behavioral, psychosocial, and 

emotional consequences for children (Smith et al., 

2016), including: 

• Receiving inconsistent parenting. 

• Experiencing disruptions in family routines. 

• Witnessing parent confict. 

• Lacking a sense of security and stability from 

parents. 

• Being involved with Child Protective Services or 

other child welfare programs. 

• Living in an unsafe home (e.g., open fames or 

access to lighters; if crystal methamphetamine is 

being made at home, possible exposure to toxic 

chemicals). 

• Living in a dirty or cluttered home. 

• Having household needs go unmet, given lack 

of money (e.g., not enough food, unpaid utility 

bills). 

• Living with a relative or unrelated caregiver 

(e.g., foster parent), especially if child safety is 

at risk. 

• Being exposed to strangers coming and going 

in the house (e.g., to purchase, sell, or use 

drugs), which increases the risk of harm to the 

child (e.g., sex traffcking). 

• Witnessing criminal behavior. 

• Becoming separated from the parent because of 

incarceration. 

• Being exposed to harsh discipline. 

• Having an increased risk of missing school. 

• Having an increased risk of medical illness and 

hospitalization. 

• Having an increased risk of mental disorders, 

including co-occurring mental disorders. 

• Incurring permanent neurodevelopmental 

changes affecting later risk of mental/physical 

disorders. 

As with people who were maltreated and believe 

the abuse was their fault, children of parents with 

SUDs may feel guilty and responsible for their 

parents’ substance misuse as well as for fnding 

Chapter 2 35 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

COUNSELOR NOTE: GRANDPARENTS AND YOUTH SUBSTANCE MISUSE 

U.S. families are diverse and often include cohabitating grandparents. According to U.S. Census Bureau data 

(2019a), in 2018, about 6.0 million children under age 18 lived in a household in which a grandparent was the 

householder. That same year, 7.1 million grandparents reported living with grandchildren under age 18 (U.S. 

Census Bureau, 2019b). 

What does this type of family structure mean for child/adolescent risk of substance misuse? 

• Children living with grandparents because of parental substance use may have a history of abuse or 

neglect by their parents. This history increases risk of later substance misuse. In such cases, grandparents 

who offer love, support, and stable resources (e.g., housing, food, clothing, education access) may be 

protective against SUDs, other stressors, and negative outcomes (Lent & Otto, 2018). 

• However, in some research, grandparent-only households are linked to a greater risk of substance misuse. 

Among almost 80,000 youth in the Florida Department of Juvenile Justice, living in a grandparent-only 

home was associated with a 28-percent greater risk of 30-day opioid misuse than living in a single-parent 

home (Shaw, Warren, & Johnson, 2019). This risk was particularly high among youth ages 10 to 15. 

• The relationship between grandparents and grandchildren, and youth substance misuse may be linked to 

culture. 

- For instance, in American Indian/Alaska Native communities, grandparents often play a central role in 

childrearing and may be a positive source of communication with grandchildren about culture, family, 

and the dangers of substance misuse (Myhra, Wieling, & Grant, 2015). 

- Among a small sample of Native American grandparents raising grandchildren, 36 percent of 

households included a child, parent, or grandparent with an SUD (Mignon & Holmes, 2013). 

- In American Indian youth (Martinez, Ayers, Kulis, & Brown, 2015), grandparents’ negative attitudes/ 

beliefs about alcohol/ cigarette use infuenced grandchildren’s choices not to use alcohol more than 

parents’ attitudes/beliefs. 

them treatment (Smith et al., 2016). Children 

whose parents use illicit drugs must cope with 

knowing their parents’ actions are illegal, and they 

may be forced to engage in illegal activity on their 

parents’ behalf. 

Generally, children with parents who misuse 

substances are at increased risk for negative 

consequences, but positive outcomes are possible. 

In a review of the literature on children of parents 

with SUDs, Wlodarczyk, Schwarze, Rumpf, 

Metzner, and Pawils (2017) identify some positive 

developments, including resiliency and reduced risk 

of substance misuse. These were especially likely in 

children who had certain protective factors, such as: 

• Secure attachments to parents. 

• Flexible use of multiple coping strategies. 

• A high degree of parental support. 

• A high degree of family cohesion. 

• Low levels of parent-related stress. 

• High levels of social support for the child. 

Nonetheless, substance misuse can lead to 

inappropriate family subsystems and role taking. 

For instance, in a family in which a mother uses 

substances, a young child may be expected to 

take on the role of mother. When a child assumes 

adult roles and the adult misusing substances 

plays the role of a child, the boundaries 

essential to family functioning are blurred. The 

developmentally inappropriate role taken on by 

children robs them of a childhood, unless healthy, 

supportive adults intervene. 

The spouse of a person misusing substances is 

likely to protect the children and assume parenting 

duties that are not fulflled by the parent misusing 

substances. If both parents misuse alcohol or 

use illicit drugs, the effect on children worsens. 

Extended family members may have to provide 

36 Chapter 2 
Chapter 2—Infuence of Substance Misuse on Families TIP 39

care as well as fnancial and psychological support. 

Grandparents frequently assume a primary 

caregiving role. Friends and neighbors also may 

be involved in caring for the young children. In 

cultures with a community approach to family care, 

neighbors may step in to provide whatever care 

is needed. 

Because of its potential effects on recovery and 

relapse, another factor in family life you should 

assess for is the need to care for dependent 

others, such as children. Losing custody of a 

child, whether formally (i.e., removal from the 

home by child welfare or other legal authorities) 

or informally (e.g., sending the child to live with 

a relative), is associated with an increased risk of 

maternal substance misuse (Harp & Oser, 2018). 

Fear of loss of custody can be a barrier to a mother 

accessing SUD services. This has implications for 

the safety and well-being of her child and also 

affects the family unit. Loss of custody among 

women who misuse substances is more likely when 

those mothers face socioeconomic stressors (e.g., 

unstable housing, unemployment, low education 

level), have a history of childhood trauma, or have 

co-occurring mental disorders (Canfeld, Radcliffe, 

Marlow, Boreham, & Gilchrist, 2017). Other 

research has associated caregiving for a child or an 

ill family member with increased odds of remaining 

abstinent from alcohol or reducing drinking (Jessup 

et al., 2014). 

Parents Who Have SUDs and Adult 

Children 

Parental SUDs can negatively affect both young 

children and grown children. Compared with 

research on young children affected by parental 

SUDs, comparatively less research has examined 

the effects in adulthood. And much of the available 

literature concerns adult children of parents with 

AUD, so less is known about adult children of 

parents with OUD or cannabis use disorder, for 

instance. 

Adult children of people with SUDs are at risk 

for negative biopsychosocial outcomes, and 

they may: 

• Feel stigmatized, especially when parental 

substance misuse is severe (Haverfeld & Theiss, 

2016). 

• Hesitate to disclose parents’ SUDs to others for 

fear of rejection (Haverfeld & Theiss, 2016). 

• Have more negative life events (Drapkin, Eddie, 

Buffngton, & McCrady, 2015). 

• Have an increased mortality rate. One study 

looked at data from the National Health 

Interview Survey Alcohol Supplement-Linked 

Mortality File (Rogers, Lawrence, & Montez, 

2016). Compared with people who did not grow 

up in a household with problem alcohol use: 

- People who lived with a mother with problem 

drinking had a 23-percent higher risk of 

death. 

- People who lived with a father with problem 

drinking had a 14-percent higher risk of 

death. 

- People who lived with both parents with 

problem drinking had a 39-percent higher 

risk of death. 

• Have increased risk of SUDs (Eddie, Epstein, 

& Cohn, 2015), major depressive disorder 

(Klostermann et al., 2011; Marmorstein, Iacono, 

& McGue, 2012; Yoon, Westermeyer, Kuskowski, 

& Nesheim, 2013), and persistent depressive 

disorder (Thapa, Selya, & Jonk, 2017). 

• Be at increased risk for suicide attempt (Alonzo, 

Thompson, Stohl, & Hasin, 2014). 

A study of personality features and functioning 

among adult children of parents with AUD 

identifed fve personality types that commonly 

occur in this population (Hinrichs, Deffe, & Westen, 

2011): 

• Inhibited adult children, who may feel anxious, 

depressed, and guilty about their parents’ SUDs. 

They may behave passively and may be at an 

increased risk for generalized anxiety disorder. 

• High-functioning adults, who are emotionally 

healthy, responsible, and empathic. 

• Adults with externalizing features, such as 

alcohol misuse and psychopathology. 

• Emotionally dysregulated adults, who may 

have a history of childhood abuse or otherwise 

traumatic childhood environment and are 

especially at risk for depression or bipolar 

disorder. 

Chapter 2 37 
TIP 39

• Reactive/somaticizing adults may react to 

stress via physical symptoms and be anxious, 

angry, and controlling. 

Having grown up in traumatic, unstable 

environments, adult children of parents who misuse 

substances may feel angry with, resentful of, or 

otherwise negatively toward their parent with an 

SUD (Haverfeld & Theiss, 2016). Diffculties in 

establishing trusting, healthy relationships as a 

child or adolescent may carry over into adulthood. 

Similarly, problems with affective regulation that 

arose during childhood may remain later in life 

(Haverfeld & Theiss, 2016). Other emotional and 

behavioral features and patterns that may appear 

in these individuals include anxiety, dysfunctional 

intimate relationships, low self-esteem and 

insecurity, antisocial behaviors (e.g., aggression), 

problems communicating with others, and ignoring 

one’s own needs to care for others (Haverfeld & 

Theiss, 2016). 

Unhealthy family patterns that emerge when 

a parent of a young child has an SUD also 

may occur in families in which the children are 

grown. For instance, adult children may engage 

in “enabling” behaviors to try to maintain 

homeostasis. Their families often experience chaos 

and unpredictability. See Exhibit 2.4 for more 

discussion of family roles and dynamics that can 

occur among adult children of parents with SUDs 

(as well as among young children and spouses of 

people with SUDs). 

Blended Families in Which a Family 

Member Has an SUD 

The Census Bureau estimates that, in 2018, about 2.4 

million U.S. households included stepchildren under 

18 years of age (U.S. Census Bureau, 2019c). Blended 

families, in which a nonbiological parent lives in the 

household (typically because one or both spouses 

have had children from a previous relationship), 

face their own challenges apart from intact nuclear 

families. For instance (Papernow, 2018): 

• One or both of the people in the couple have a 

child from a previous relationship, so the couple 

has not had time to experience being a couple 

Substance Use Disorder Treatment and Family Therapy 

alone, without children. 

• The “architecture” of the family is often different 

from traditional nuclear families, where both 

parents are living and are residing in the same 

household. 

• Blended families come in many forms and 

can join together because of separation, 

divorce, death, or a combination thereof. The 

partners may not necessarily be married or be a 

heterosexual couple. 

You are likely to observe unique dynamics in 

blended families, which may worsen or intensify 

in the presence of substance misuse. These 

dynamics also may increase the chances of 

substance misuse by family members. Common 

blended family dynamics and struggles include 

(Papernow, 2018): 

• Stepparents and stepchildren feeling like 

“outsiders,” especially in relationship to the 

nonbiological parent/child. This can result in 

family members feeling anxious, lonely, or 

rejected. 

• Children struggling with the loss of a biological 

parent, loyalty to a biological parent, or both. 

Children may worry that bonding closely with a 

stepparent is “betraying” their biological parent. 

This worry may be stronger in adolescents and 

girls versus young children (under age 9) and 

boys. 

• Divisions between stepparents, especially 

related to parenting tasks like discipline. 

This can create confict between couples and 

confusion among children. 

• Attempts by couples to build their own family 

culture while respecting and honoring biological 

family members not living in the home. The 

desire to quickly “blend” the new family 

together may be strong, but doing so too 

quickly or forcefully can be stressful for children. 

• Struggling with the fact that biological family 

members living outside the home are also part 

of the blended family and need to be included. 

Substance misuse in blended families can lead 

to additional strain that can weaken family 

bonds and cause unhealthy patterns of behavior. 

38 Chapter 2 
Chapter 2—Infuence of Substance Misuse on Families TIP 39

EXHIBIT 2.4. Family Roles When a Parent Has an SUD 

When a parent misuses substances, it is common for children to take on certain roles within the family. 

These roles are determined in part by the child’s personality and innate features and are designed to 

help the family maintain homeostasis, or balance. Although these roles are often discussed in literature 

describing spouses and young children of parents with SUDs, they apply to adult children as well. As a 

counselor, you should be aware of whether family members (spouses and young or adult children 

especially) are falling into these roles and how that might be affecting any unhealthy family 

dynamics. 

ROLE DESCRIPTION 

The Enabler • Protects the individual from experiencing the negative effects of substance 

misuse 

• May deal with negative effects of the relative’s substance misuse to protect 

the person 

• May spend little time on his or her own needs in caring for the person with 

an SUD 

The Family Hero • Often is the role taken by the older child 

• Is focused on being responsible for and taking care of the individual with 

an SUD 

• May feel overwhelmed and as though the entire family is relying on him 

or her 

The Lost Child • Has needs/wants that are overlooked by the rest of the family (e.g., 

achievements unrecognized) 

• May exist in his or her “own world,” separate from the family 

• May feel lonely and sad and have few close relationships 

The Mascot • Takes on the role of distracting the family from the person’s SUD, often 

through humor, charm, or becoming “the life of the party” 

• Often wants to avoid confict, which, as an adult, may result in diffculties 

dealing with problems and establishing healthy relationships 

• May not be taken seriously by others in the family (e.g., low expectations) 

The Scapegoat • Draws attention away from the family member with an SUD by getting into 

trouble or engaging in other maladaptive behavior patterns 

• May be likely to engage in substance misuse or spend time with friends 

who do 

• May be at risk for future legal, educational, and vocational problems 

Sources: Vernig (2011); Wegscheider-Cruse (1989). 

Chapter 2 39 
TIP 39

Furthermore, the challenges of being a blended 

family may increase the chances of family members 

misusing substances. Indeed, children in blended 

families appear to have higher rates of substance 

use (such as tobacco and cannabis use) than 

children in traditional intact families (van EedenMoorefeld & Pasley, 2013). 

By helping blended families build strong, 

supportive relationships with one another, you 

play a critical role in addressing or preventing 

families’ substance misuse. Consider the 

following: 

• High relationship quality with the residential 

biological parent predicts a lower likelihood 

of nonmedical use of prescription drugs by 

emerging adults (Ward, Dennis, & Limb, 2018). 

The authors suggest that closeness may help 

protect against stress and strain common in 

blended families. 

• Having a close bond with a stepparent 

living in the home also can protect against 

substance misuse in children. Per Amato, King, 

and Thorsen (2016), adolescents with weak or 

moderately strong ties to their resident parents 

(the parents with whom the adolescent lives, 

regardless of biological relation) were more 

likely to report tobacco use, cannabis use, and 

binge drinking than adolescents with strong ties 

to their resident parents (but no ties to their 

nonresident parent). 

Families With Adolescents Who Have 

SUDs 

Substance misuse among adolescents continues 

to be a serious condition that affects cognitive 

and affective growth, school and work 

relationships, and all family members. In the 2019 

NSDUH (Center for Behavioral Health Statistics 

and Quality, 2020), an estimated 4.9 percent of 

adolescents ages 12 to 17 engaged in past-month 

binge use of alcohol (fve or more drinks on one 

occasion for males and four or more for females), 

and approximately 0.8 percent took part in heavy 

alcohol use (at least fve binge episodes in the 

previous month). Additionally, in the same survey, 

about 8.7 percent of adolescents ages 12 to 17 

were currently using illicit drugs. 

Substance Use Disorder Treatment and Family Therapy 

Divorce signifcantly increases the risk of 

adolescents’ binge drinking and use of 

alcohol, tobacco, and cannabis compared 

with adolescents of married couples 

(Gustavsen, Nayga, & Wu, 2016). 

Like adults, adolescents who misuse substances 

are at an increased risk for many negative 

individual and societal consequences (Gutierrez & 

Sher, 2015; Welsh et al., 2017). These include: 

• Co-occurring mental disorders (e.g., anxiety, 

depressive, conduct, and bipolar disorders). 

• Sexual activity at an early age. 

• High-risk sexual behavior. 

• Car accidents. 

• Medical visits/hospitalizations. 

• School dropout. 

• Continued substance misuse into adulthood. 

• Risk of suicide (especially when substance 

misuse co-occurs with mental disorders). 

Family functioning, including parent–child bonds 

and communication, is connected to adolescent 

substance misuse in many ways. In a systematic 

literature review (Hummel, Shelton, Heron, Moore, 

& van den Bree, 2013), family factors associated 

with adolescent substance initiation and misuse 

included: 

• Poor family functioning. 

• Low levels of mother–child warmth. 

• High levels of mother–child hostility. 

• Low parental monitoring. 

• Harsh maternal parenting practices. 

Other family factors that appear to increase risk 

of adolescent substance misuse are (Ali, Dean, & 

Hedden 2016; Barfeld-Cottledge, 2015; Cordova 

et al., 2014; Gutierrez & Sher, 2015; Kim-Spoon 

et al., 2019; Kuntsche & Kuntsche, 2016; Lee 

et al., 2018): 

• Parental substance misuse. 

• Parental mental disorder. 

40 Chapter 2 
Chapter 2—Infuence of Substance Misuse on Families TIP 39

• Parental co-occurring mental disorders and 

SUDs (especially among mothers). 

• A lack of rules, or failure to enforce rules, about 

underage substance use. 

• Lower quality parent–child communication. 

• Household chaos. 

• High family risk-taking behaviors (e.g., criminal 

behaviors, substance misuse). 

• Socioeconomic strain. 

• Low parental education level. 

• Low levels of parental support. 

• Low levels of family attachment. 

Parental substance misuse is especially 

problematic for adolescents, as it models 

unhealthy behavior and can lead to a dangerous 

combination of physical and emotional problems 

for the youth. If a responsible adult offers 

calm, consistent, rational, and frm responses 

to adolescent substance misuse, the effect on 

adolescent learning is positive. However, if a parent 

who misuses substances attempts to address an 

adolescent’s substance misuse, the hypocrisy 

will be obvious to the adolescent, and the result 

is likely to be negative. In some instances, a 

parent with an SUD may form an alliance with 

an adolescent who is misusing substances to 

keep secrets from the parent who does not 

misuse substances. Sometimes in families with 

multigenerational patterns of substance misuse, 

extended family members may feel that the 

adolescent is just conforming to the family history. 

Adolescent substance misuse can affect families in 

the following ways (Smith & Estefan, 2014): 

• Common family reactions include confusion, 

fear, shame, anger, and guilt. 

• Parent confict may arise or, if already present, 

worsen in response to feelings of blame and 

disagreements over how to handle the child’s 

substance misuse. When parents differ in their 

confict and communication styles (e.g., avoidant 

versus direct), this can further increase tension. 

• Families often feel isolated, alone, and unsure of 

what to do or where to turn for help. 

• In some families, a family member with an SUD 

is considered a family “secret” that should be 

kept well hidden from others. In these cases, 

the silence is a form of protection, and talking 

about “the secret” may be seen by other family 

members as an act of betrayal against the family 

as a whole. 

• Because mothers are typically the primary 

caregivers, it is not unusual for mothers to feel 

guilty, blame themselves, and question whether 

they did something to “cause” their child’s SUD. 

When an adolescent misuses alcohol or uses illicit 

drugs, siblings may fnd their needs and concerns 

ignored or minimized while their parents react 

to constant crises involving the adolescent who 

misuses substances. Neglected siblings and peers 

may look after themselves in ways that are not 

age appropriate. They also may feel that the 

only way to get attention is to act out. Do not 

miss opportunities to include siblings in familybased treatment, because siblings often are as 

infuential as parents. (See also the counselor note 

“How Does One’s Substance Misuse Affect One’s 

Siblings?”) 

When working with families to address an 

SUD in one family member, note that other 

family members may engage in “hidden” 

substance misuse. Take, for example, 

adolescents in SUD treatment. Their parents’ 

substance misuse may be just as problematic 

as the adolescents’ misuse, but families may 

consider the adolescents’ to be the problem. 

In a couple, one person’s misuse may be 

more pronounced than another’s, but the 

other person also may have an SUD. Use 

of substances may be a signifcant activity 

throughout some relationship histories. 

Chapter 2 41 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

COUNSELOR NOTE: HOW DOES ONE’S SUBSTANCE MISUSE AFFECT ONE’S

SIBLINGS? 

In “The Forgotten Ones: Siblings of Substance Abusers,” Smith-Genthôs, Logue, Low, and Hendrick (2017, 

p. 130) asked siblings of people who misuse substances about problematic experiences and diffculties they 

endured. Not surprisingly, many of the siblings reported being exposed to substances at earlier ages than 

people without siblings who misused substances. Siblings’ comments about their struggles included the 

following: 

• “My brother began abusing alcohol when he was 18. It completely changed who he was under the 

infuence. He became a mean and angry person and it affected my whole family drastically.” 

• “I have had a problem being close with my mom as we used to be because E— has taken up all of her 

attention because of his addiction. The reason this problem is important is because my mom was like my 

best friend; now I feel like we are not that close anymore. Having E— constantly needing her attention 

has hindered my relationship with my mom and I have yet to get it back to the way it used to be.” 

• “Because of his substance abuse and the things he did while he was on drugs, he broke my parents’ 

hearts, almost ruined their marriage, and made my family lose the majority of our savings.” 

• “Having two brothers that are both drug addicts and alcoholics makes me sad. I never had siblings like 

other people did. I never had brothers I could count on because they were more interested in getting 

high. I gave up on trying to be there for them.” 

• “One of the main problems I have experienced as a result of her abuse is anxiety. I feel anxious and often 

overwhelmed because I want to help her and know that she needs help, but don’t know how.” 

Where Do We Go From Here? 

Families are all unique in their structure, functions, 

and needs. But families in which SUDs occur 

often share common features that contribute to 

substance misuse and can make recovery diffcult. 

As a counselor, once you identify the dynamics and 

patterns in a family dealing with substance misuse, 

what should you do next? How can you help them 

improve dynamics and patterns that are unhealthy 

and enhance ones that are supportive of recovery? 

Chapter 3 answers these questions by exploring 

the latest evidence-based family counseling 

approaches for couples and families affected by 

SUDs. It includes not only a summary of recent 

research but also practical guidance to support you 

in implementing and assessing the effectiveness of 

family-based interventions and services. 

42 Chapter 2 
Chapter 3—Family Counseling Approaches 

KEY MESSAGES 

TIP 39 SUBSTANCE USE DISORDER TREATMENT AND 

FAMILY THERAPY

• You can help clients and their family members 

initiate and sustain recovery from substance 

use disorders (SUDs) by actively involving family 

members in treatment. 

• When family members change their thinking 

about substance misuse and their behavioral 

responses to substance misuse, the entire 

family system changes. 

• Family-based SUD interventions focus on 

encouraging clients with SUDs to initiate 

and sustain recovery, improving their family 

communication and relationships to support 

and sustain their recovery, and helping family 

members engage in self-care and their own 

recovery. 

All family counseling approaches for SUD treatment 

refect the principles of systems theory. Systems 

theory views the client as an embedded part of 

multiple systems—family, community, culture, and 

society. Family counseling approaches specifc to 

SUD treatment require SUD treatment providers to 

understand and manage complex family dynamics 

and communication patterns. They must also be 

familiar with the ways family systems organize 

themselves around the substance use behaviors 

of the person with an SUD. Substance misuse is 

often linked with other diffcult life problems— 

for example, co-occurring mental disorders, 

criminal justice involvement, health concerns 

including sexually transmitted diseases, cognitive 

impairment, and socioeconomic constraints (e.g., 

lack of a job or home). The addiction treatment 

feld has adapted family systems approaches to 

address the unique circumstances of families in 

which substance misuse and SUDs occur. 

It is beyond the scope of this TIP to cover all family 

therapy theories and counseling approaches. This 

chapter reviews the most relevant and researchbased family counseling approaches specifcally 

developed for treating couples and families where 

the primary issue within the family system is an 

SUD. It describes the underlying concepts, goals, 

and techniques for each approach. This chapter 

covers the following family-based treatment 

methods (Exhibit 3.1): 

43 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

EXHIBIT 3.1. Overview of Family-Based Treatment Approaches 

Addressed in Chapter 3 

APPROACH 

PHILOSOPHY AND KEY 

PRINCIPLES CORE METHODS/GOALS POPULATIONS/ 

ISSUES 

FOR SUD TREATMENT 

Multisystemic 

Family 

Therapy (MST) 

Intensive family 

counseling approach 

that seeks to alter 

environmental infuences 

associated with an 

adolescent’s serious 

clinical problems; uses 

goal-oriented and familystrengthening strategies 

Shifts primary agent of 

change from parents to 

emerging adults and their 

social networks 

Adolescents with 

SUDs and criminal 

justice involvement; 

emerging adults 

aging out of child 

welfare system; 

mothers with SUDs 

Systemic– 

Motivational 

Therapy 

Combines elements of 

systemic family therapy 

and motivational 

interviewing (MI) 

Assessing the relationship 

between substance 

misuse and family life, 

understanding family 

beliefs about substance 

misuse, and helping the 

family work as a team 

to develop family-based 

strategies for abstinence 

Suitable for all 

families dealing with 

SUDs 

Psychoeducation Including family 

members in the 

psychoeducation process 

can improve treatment 

outcomes for clients, 

reduce returns to use, 

and enhance the entire 

family’s functioning and 

well-being 

Engaging family 

members in treatment, 

providing information, 

enhancing social support 

networks, developing 

problem-solving and 

communication skills, 

and providing ongoing 

support and referrals to 

other community-based 

services 

Primary treatment 

choice for people 

with serious cooccurring SUDs and 

mental disorders; 

useful component of 

relapse prevention in 

individual, family, and 

group work 

Continued on next page 

44 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

EXHIBIT 3.1. Overview of Family-Based Treatment Approaches 

Addressed in Chapter 3 (continued) 

APPROACH 

PHILOSOPHY AND KEY 

PRINCIPLES CORE METHODS/GOALS POPULATIONS/ ISSUES 

FOR SUD TREATMENT 

MultiDimensional 

Family 

Therapy 

(MDFT) 

Behavior change occurs 

via multiple pathways, 

in different contexts, 

and through diverse 

mechanisms; change can 

be achieved by following 

10 principles: 

• Adolescent 

substance misuse is 

multidimensional 

• Family functioning 

helps create new, 

developmentally 

adaptive lifestyle 

alternatives 

• Problem situations 

provide information and 

opportunity 

• Change is multifaceted, 

multidetermined, and 

stage oriented 

• Motivation is malleable, 

but it is not assumed 

• Multiple therapeutic 

alliances are needed as a 

foundation for change 

• Individualized 

interventions foster 

developmental 

competencies 

• Treatment occurs in 

stages; continuity is 

stressed 

• Counselor responsibility 

is emphasized 

• Counselor attitude is 

fundamental to success 

Combines individual 

counseling and 

multisystem methods 

to treat adolescent 

substance misuse 

and conduct-related 

behaviors by addressing 

four treatment domains 

with specifc goals: 

adolescents, parents, 

family members and 

relevant extrafamilial 

others, community 

MDFT occurs in three 

stages: 

• Stage I: Build the 

foundation 

• Stage II: Prompt 

action/activate change 

• Stage III: Seal the 

change and exit 

Suitable for diverse 

populations (available 

in Spanish, French), 

including ethnically 

diverse adolescents; 

families in low-income 

inner-city communities; 

youth in early 

adolescence at high 

risk; older adolescents 

with multiple problems, 

juvenile justice 

involvement, and cooccurring SUDs and 

mental disorders 

Continued on next page 

Chapter 3 45 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

EXHIBIT 3.1. Overview of Family-Based Treatment Approaches 

Addressed in Chapter 3 (continued) 

APPROACH 

PHILOSOPHY AND KEY 

PRINCIPLES CORE METHODS/GOALS POPULATIONS/ 

ISSUES 

FOR SUD TREATMENT 

Behavioral 

Couples 

Therapy 

(BCT) 

Structured approach that 

focuses on an intimate 

partner’s ability to reward 

abstinence and other 

efforts to change and 

to promote continuing 

recovery for the person 

with an SUD 

Lessens relationship 

distress, improves 

partners’ patterns of 

interaction, builds more 

cohesive relationships 

to reduce risk of returns 

to use for the partner 

with an SUD, supports 

abstinence, improves 

relationship functioning 

Appropriate participants 

are generally couples in 

which: 

• Partners are married or 

living together. 

• Neither partner has a 

signifcant co-occurring 

mental disorder. 

• Only one member has 

substance misuse. 

• There is no indication of 

risk of severe intimate 

partner violence. 

Behavioral 

Family 

Therapy 

(BFT) 

Based on social learning 

and positive and negative 

reinforcements to change 

behavior; emphasizes 

the client’s substance 

use behaviors within the 

family context; counselors 

view substance misuse as 

a learned behavior that 

peers, parents, and role 

models may reinforce and 

help maintain 

Contingency 

management strategies 

to reward abstinence, 

reduce reinforcement 

of substance use, 

and increase positive 

behaviors and social 

interactions incompatible 

with substance use 

Suitable for all families 

dealing with SUDs 

Brief 

Strategic 

Family 

Therapy 

(BSFT) 

Draws on structural and 

strategic family theory 

and interventions; 

assumes that adolescent 

substance misuse and 

other risk behaviors are 

linked to dysfunctional 

family interactions 

Interventions target 

family interactions that 

are most likely to affect 

youth substance misuse 

and other risk behaviors; 

strategies include: 

joining, enactments, 

working in the present, 

reframing negativity, 

reversals, working with 

boundaries and alliances, 

addressing power 

structures that affect 

confict, and opening 

closed systems 

Adolescents and other 

relatives dealing with 

cultural factors around 

engagement; families in 

which parental alcohol 

use is present 

Continued on next page 

46 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

EXHIBIT 3.1. Overview of Family-Based Treatment Approaches 

Addressed in Chapter 3 (continued) 

APPROACH 

PHILOSOPHY AND KEY 

PRINCIPLES CORE METHODS/GOALS POPULATIONS/ 

ISSUES 

FOR SUD TREATMENT 

Functional 

Family Therapy 

Behaviorally based 

family counseling 

approach based on an 

ecological model of risk 

and protective factors 

Changes the dysfunctional 

family behavioral and 

interactional patterns 

that maintain the 

adolescent’s substance 

misuse and reinforces 

positive problem-solving 

responses to adolescent 

risk behaviors; has three 

treatment phases and 

associated counseling 

strategies: engagement 

and motivation, 

behavior change, and 

generalization 

Suitable for all families 

dealing with SUDs; 

widely disseminated in 

the United States and 

other countries 

SolutionFocused Brief 

Therapy 

Pinpointing the 

cause of problematic 

family functioning is 

unnecessary; counseling 

focused on solutions 

to specifc problems is 

enough to help families 

change 

Helps family members 

fnd solutions to their 

problems instead of 

emphasizing the problemsolving techniques of 

structural and strategic 

counseling approaches; 

counselors emphasize 

exceptions to the problem 

(e.g., substance use) when 

it does not happen and 

help identify achievable 

solutions that enhance 

motivation and hope for 

behavioral change 

Adults with SUDs 

or mental disorders; 

families with a 

member who has 

a mental disorder; 

parents with SUDs 

and trauma-related 

symptoms in the child 

welfare system 

Community 

Reinforcement 

and Family 

Training 

(CRAFT) 

Structured, familyfocused approach that 

assumes environmental 

contingencies are 

important in promoting 

treatment entry 

Teaches family members 

and CSOs strategies for 

encouraging the family 

member who is misusing 

substances to change 

his or her substance use 

behaviors through positive 

reinforcement and enter 

SUD treatment 

Suitable for all families 

dealing with SUDs 

Continued on next page 

Chapter 3 47 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

EXHIBIT 3.1. Overview of Family-Based Treatment Approaches 

Addressed in Chapter 3 (continued) 

APPROACH 

PHILOSOPHY AND KEY 

PRINCIPLES CORE METHODS/GOALS POPULATIONS/ ISSUES 

FOR SUD TREATMENT 

Network 

Therapy 

A team-based approach 

to SUD treatment that 

enlists the help of family 

and friends to work 

with the counselor in 

promoting abstinence; 

includes components 

of various approaches 

to SUD treatment (e.g., 

cognitive–behavioral 

therapy, community 

reinforcement) as well 

as individual plus group 

sessions 

Engaging family and 

friends to work with the 

counselor to help the 

client to achieve and 

maintain abstinence; 

the network also 

serves as a source of 

emotional support and 

encouragement 

Adults with SUDs 

FOR RECOVERY SUPPORT 

Family 

Treatment 

Engagement as 

a Foundation 

for Ongoing 

Recovery 

Family, social supports, 

and community 

resources are keys to 

successful long-term 

recovery for people with 

SUDs; recovery is not 

a solo endeavor, but 

rather, a social process— 

and family members 

and CSOs often need 

their own recovery 

supports, in addition to 

the person with the SUD 

needing such supports 

Forging emotional 

bonds; establishing 

social cohesion and 

support; maintaining 

goal direction; gaining 

structure; monitoring 

by family, friends, and 

other recovery supports; 

observing good role 

models; expecting 

negative consequences 

for risk behaviors; 

building self-effcacy; 

developing coping skills; 

and participating in 

rewarding, substancefree social activities 

Suitable for all families 

dealing with SUDs 

Family 

Recovery 

Support Groups 

Family members of 

people recovering from 

SUDs beneft from 

gathering together to 

help one another learn 

how to cope with living 

with a person who has 

a chronic, debilitating 

illness 

Counselors link families 

to groups and, in 

counseling sessions, 

explore family members’ 

refections on group 

participation 

Suitable for all families 

dealing with SUDs 

48 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

EXHIBIT 3.1. Overview of Family-Based Treatment Approaches 

Addressed in Chapter 3 (continued) 

APPROACH 

PHILOSOPHY AND KEY 

PRINCIPLES CORE METHODS/GOALS POPULATIONS/ ISSUES 

FOR RECOVERY SUPPORT 

Case 

Management 

Addresses the needs 

of the client with an 

SUD and family issues 

related to the client’s 

substance misuse 

via comprehensive, 

integrated management 

of services and service 

linkages 

Assesses major life 

concerns (e.g., substance 

misuse), develops an action 

plan, actively links clients 

to community-based 

resources, coordinates care, 

and monitors participation 

in services 

Families who are or 

should be involved 

intensely with larger 

systems (e.g., criminal 

justice, child welfare, 

mental health) 

Family Peer 

Recovery 

Support 

Services 

Family peer recovery 

support specialists have 

lived experience with 

having a family member 

with an SUD, mental 

disorder, or co-occurring 

disorder; they offer 

education, emotional 

support, and resources to 

family members of those 

with an SUD 

Actively links family 

members to family-based 

resources for SUDs, mental 

health, criminal justice, 

and child welfare service 

systems; introduces and 

actively links them to 

community-based recovery 

supports 

Suitable for all families 

dealing with SUDs 

Relapse 

Prevention 

Just as people with 

SUDs are at risk for a 

return to substance 

misuse after initiating 

recovery, family members 

can also experience a 

“relapse” or return to old 

behaviors and strategies 

for trying to manage the 

stress of living with a 

family member’s active 

substance use 

Family members create 

their own relapse 

prevention plans: 

• Identify triggers/cues 

of returns to problem 

behaviors. 

• Identify cognitive 

distortions that may 

precede relapse. 

• Learn or reengage coping 

skills to manage stress of 

family members’ returns 

to misuse. 

• Plan for self-care activities 

to do and supportive 

people and crisis 

numbers to call. 

Suitable for all families 

dealing with SUDs 

Note: The Johnson Intervention, which was included in the previous version of this TIP, has been removed. After further 

scrutinizing the research on this treatment approach, several factors raise serious concern. Although there is some 

evidence of potential beneft in terms of treatment engagement and SUD outcomes (mainly negative urine tests), this 

evidence is largely from 1999 to 2004 with no recent data in support. Also, it appears this model may do more harm than 

good, with several researchers noting that many families fnd it overly confrontational, judgmental, and blaming, and 

hence most families do not go through with the session wherein they actually confront the client. More importantly, the 

Surgeon General’s recent report on addiction singles out the Johnson Intervention as being ineffective and notes that 

confrontational approaches in general may lead to negative outcomes (https://addiction.surgeongeneral.gov/executivesummary/report/prevention-programs-and-policies). 

Chapter 3 49 
TIP 39

Overview of Family-Based SUD 

Treatment Methods 

Family counseling had its origins in the 1950s, 

adding a systemic focus to previous understandings 

of the family’s infuence on an individual’s physical 

health, behavioral health, and well-being. The 

models of family counseling that have developed 

over the years are diverse. They generally focus 

on either long-term treatment emphasizing 

intergenerational family dynamics and the family’s 

growth and well-being over time or brief counseling 

emphasizing current family issues and cognitive– 

behavioral changes of family members that infuence 

the way the family system operates. 

Family-based counseling in SUD treatment refects 

the latter family systems model. For example, in 

SUD treatment, family counseling focuses on how 

the family infuences one member’s substance use 

behaviors and how the family can learn to respond 

differently to that person’s substance misuse. 

When family members change their thinking 

about and responses to substance misuse, the 

entire family system changes. These systems-level 

changes lead to positive outcomes for the family 

member who is misusing substances and improved 

health and well-being for the entire family. 

Family counseling in SUD treatment also differs 

from more general family systems approaches 

because it shifts the primary focus from being 

on the process of family interactions to planning 

the content of family sessions. The counselor 

primarily emphasizes substance use behaviors 

and their effects on family functioning. For 

example, in a couples session in which the couple 

discusses the husband’s return to drinking after a 

period of abstinence, the counselor would note 

the interactions between the husband and wife 

but zero in on the return to use. In doing so, the 

counselor can develop strategies the couple can 

use as a team to learn from the experience and 

prevent another return to use. 

Although the specifc family-based methods this 

chapter describes refect different strategies and 

techniques for addressing substance use behaviors, 

they share the same core principles of working 

with family systems. These core principles include 

(Corless, Mirza, & Steinglass, 2009): 

Substance Use Disorder Treatment and Family Therapy 

• Recognizing the therapeutic value of working 

with family members, not just the individual 

with SUD, as they deal with SUDs. 

• Incorporating a nonblaming, collaborative 

approach instead of an authoritative, 

confrontational approach in which the counselor 

is the expert. 

• Having harm reduction goals other than 

abstinence, which can bring positive physical 

and behavioral health benefts to the individual 

and entire family. 

• Expanding outcome measures of “successful” 

treatment to include the health and well-being 

of the entire family, as well as the individual with 

the SUD. 

• Acknowledging the value of relationships 

within the family and extrafamilial social 

networks as critical sources of support and 

positive reinforcement. 

• Appreciating the importance of adapting 

family counseling methods to ft family values 

and the cultural beliefs and practices of the 

family’s larger community. 

• Understanding the complexity of SUDs and 

the importance of working with families 

to manage SUDs, as with any chronic illness 

that affects family functioning, physical and 

behavioral health, and well-being. 

Some family-based interventions in the following 

sections are SUD-specifc adaptations of general 

family systems approaches. Others were developed 

specifcally to address SUDs from a family 

perspective. Each description includes an overview 

and goals of the approach, supporting research 

specifc to SUD treatment, and relevant techniques 

and counseling strategies. 

As an SUD treatment provider incorporating 

family-based interventions into your practice, 

you should take care to work within the limits of 

your training, license, and scope of practice. Also 

take note of the specifc licensure and other 

treatment-related professional requirements 

specifc to your state. 

50 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

MST 

Much research on family-based SUD treatment 

interventions is on adolescents. A meta-analysis 

found family counseling for adolescent SUDs to be 

more effective than several individual and group 

approaches or treatment as usual (Tanner-Smith, 

Wilson, & Lipsey, 2013). Advances in family-based 

treatment approaches for adolescent SUDs can 

serve as pilot models for adult treatment. 

For example, MST was specifcally developed as 

a method for treating adolescents with SUDs 

who are involved in the criminal justice system. A 

recent adaptation of MST for emerging adults who 

are aging out of the child welfare system follows 

the principles of MST but shifts the primary agent 

of change from parents to the emerging adult and 

the emerging adult’s social network, which may or 

may not include the parents. Pilot testing of this 

adapted approach shows promising outcomes 

(Sheidow, McCart, & Davis, 2016). Another pilot 

study of MST adapted for mothers with SUDs 

(MST-Building Stronger Families) found signifcant 

reductions in substance use among adults and 

signifcantly fewer symptoms of anxiety among 

children paired with their mothers (Schaeffer, 

Swenson, Tuerk, & Henggeler, 2013). 

Systemic–Motivational Therapy 

Systemic–motivational therapy is a model of SUD 

family counseling that combines elements of 

systemic family therapy and MI. It was developed 

by Steinglass (2009) to treat alcohol use disorder 

(AUD) in the family but can be applied to other 

substance misuse. Goals include assessing the 

relationship between substance misuse and 

family life, understanding family beliefs about 

substance misuse, and helping the family work 

as a team to develop family-based strategies for 

abstinence. 

You can help the family make a hypothesis about 

the causes of SUDs and create “mini-experiments” 

to address alcohol misuse in the family. You and the 

family will collaborate to develop specifc criteria to 

assess the relative success of the mini-experiments. 

Then adjust treatment strategies according to how 

successful the mini-experiments were in addressing 

misuse (Steinglass, 2009). 

Family interventions are good options in SUD 

treatment. Use them starting with the least 

intensive (e.g., counseling and Al-Anon or 

CRAFT) before moving to the most intensive. 

Psychoeducation 

Psychoeducation was the frst family-based SUD 

treatment approach providers used extensively. It 

introduced the value of engaging family systems 

in treatment and has been an auxiliary part 

of SUD treatment programming for decades. 

Psychoeducation is more than just giving families 

information about the course of addiction and the 

recovery process. Goals include engaging family 

members in treatment, providing information, 

enhancing social support networks, developing 

problem-solving and communication skills, and 

providing ongoing support and referrals to other 

community-based services (McFarlane, Dixon, 

Lukens, & Lucksted, 2003). Psychoeducation can 

take place in individual or group sessions with 

family members, single family group sessions, and 

multiple family group sessions. 

Engaging family members in more intensive 

SUD treatment is a possible outcome of 

psychoeducation, but many family members 

beneft just from learning about addiction, 

recovery, and ways to respond to a family 

member’s substance misuse. Psychoeducation 

can include providing Internet access and links to 

information and family recovery resources such 

as pamphlets, multimedia, and recovery-oriented 

books. Psychoeducational interventions can also 

inform families about and provide referral to 

community-based family supports like Al-Anon and 

Nar-Anon. 

Psychoeducation helps family members: 

• Understand the biopsychosocial effects of 

SUDs on the client and family. 

• Learn what to expect from SUD treatment and 

the ongoing recovery process of their relative. 

• Grasp the importance of their support in 

helping the client initiate and sustain SUD 

recovery. 

Chapter 3 51 
TIP 39

• Build their own support systems and learn 

coping strategies and skills from other family 

members. 

• Increase a sense of support and reduce 

feelings of isolation and shame. 

Including family members in psychoeducation 

can improve treatment outcomes for clients, 

reduce returns to use, and enhance the entire 

family’s functioning and well-being. Family 

psychoeducation has emerged as a primary 

treatment choice for people with serious cooccurring SUDs and mental disorders (McFarlane 

et al., 2003). It has demonstrated effectiveness in 

reducing returns to use in medium-term outcomes 

in this population (Zhao, Sampson, Xia, & Jayaram, 

2015) and is an empirically supported cognitive– 

behavioral therapy (CBT) approach to SUD relapse 

prevention (Sudhir, 2018). 

Psychoeducation is a useful component of relapse 

prevention in individual, family, and group work. 

Psychoeducational strategies that can help 

prevent returns to substance use include: 

• Offering brief in-session education on SUDs, 

returns to use, and strategies for relapse 

prevention. 

• Assigning homework in the session for the 

client and family members to do between 

sessions. 

• Teaching and practicing problem-solving and 

communication skills during sessions. 

• Providing educational handouts for the client 

and family members to take home and review. 

• Suggesting reading, audio, or video material 

the client and family members can review at 

home. 

• Creating a family recovery maintenance 

notebook with educational handouts, 

homework exercises, in-session exercises, and 

journal notes on new insights and awareness, 

the effectiveness of problem-solving and 

communication strategies, and topics and 

questions for further exploration. 

MDFT 

MDFT is a fexible, family-based counseling 

approach that combines individual counseling 

and multisystem methods to treating adolescent 

Substance Use Disorder Treatment and Family Therapy 

substance misuse and conduct-related behaviors 

(Horigian, Anderson, & Szapocznik, 2016). 

MDFT targets both intrapersonal processes and 

interpersonal factors that increase the risk of 

adolescent substance misuse (Horigian et al., 

2016). 

Counselors work in four MDFT treatment 

domains (Liddle et al., 2018). Each domain has 

specifc goals: 

• Adolescents: Enhance their emotional 

regulation, social, and coping skills; 

communicate more effectively with adults; 

discover alternatives to substance use; reduce 

involvement with peers who use substances, 

antisocial peers, or both; and improve school 

performance. 

• Parents: Increase their behavioral and emotional 

involvement with the adolescent, reduce 

parental confict, work as a team, discover 

positive and practical ways to infuence the 

adolescent, improve the relationship and 

communication between parent and adolescent, 

and increase knowledge about positive 

parenting practices. 

• Family members and relevant extrafamilial 

others (e.g., neighbors, teachers, coaches, 

spiritual mentors): Decrease family confict, 

increase emotional attachments, improve 

communication, and enhance problem-solving 

skills. 

• Community: Enhance family members’ 

competence in advocating for themselves in 

larger social systems such as school and criminal 

justice systems. 

The multidimensional approach suggests that 

behavior change occurs via multiple pathways, 

in different contexts, and through diverse 

mechanisms. MDFT “retracks” the adolescent’s 

development via treatment in the four domains. 

Knowledge of adolescent development and family 

dynamics guides overall counseling strategies and 

interventions. 

In MDFT, counselor focus shifts as the 

adolescent and family progress through three 

stages. The stages and related counseling 

strategies are (Horigian et al., 2016; Liddle 

et al., 2018): 

52 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

• Stage I: Build the foundation. 

- Develop therapeutic alliances with all family 

members. 

- Explain the MDFT process. 

- Assess risk and protective factors of the 

individual, parents, family, and extrafamilial 

systems. 

- Identify personally relevant treatment goals 

of family members. 

- Use crises and stress to build motivation for 

change. 

• Stage II: Prompt action/activate change. 

- Promote positive change in feelings, 

thoughts, and behaviors of all family 

members. 

- Use active listening to empathize and raise 

hope that change is possible and aligned 

with goals. 

- Encourage the adolescent to share inner 

thoughts and experiences. 

- Enhance parenting skills through 

psychoeducation and behavioral coaching. 

- Encourage parents to set limits on, monitor, 

and support the adolescent. 

- Teach parents to manage diffcult family 

interactions in the session. 

- Teach advocacy skills to improve family 

interactions with extrafamilial community 

systems. 

- Engage community-based supports to 

help family members sustain family system 

changes. 

• Stage III: Seal the change and exit. 

- Reinforce behavioral changes of all family 

members. 

- Explore strategies to maintain change and 

prevent recurrence of adolescent substance 

misuse and conduct-related behaviors. 

- End treatment when changes have stabilized. 

The MDFT treatment format includes individual 

and family sessions, sessions with various family 

members, and extrafamilial sessions. Sessions 

are held in the clinic; in the home; or with family 

members at the court, school, or other community 

location. The format of MDFT has been modifed 

to suit the clinical needs of different clinical 

populations. A full course of MDFT ranges 

between 16 and 25 sessions over 4 to 6 months, 

depending on the target population and individual 

needs of the adolescent and family. Sessions may 

occur multiple times during the week. 

Research supports the effcacy of MDFT, and 

counselor adherence to the MDFT model 

improves substance use treatment outcomes 

(Rowe et al., 2013). MDFT has been applied in 

geographically distinct settings with diverse 

populations (it is available in Spanish and French 

as well as English), including ethnically diverse 

adolescents at risk for substance misuse. Most 

families in MDFT studies have been from lowincome, inner-city communities; adolescents 

in these studies have ranged from youth in 

early adolescence who are at high risk to older 

adolescents with multiple problems, juvenile justice 

involvement, and co-occurring SUDs and mental 

disorders. 

Several randomized clinical trials have shown 

clinically signifcant effects of MDFT on reducing 

adolescents’ drug use and related behavioral 

problems in controlled and community-based 

settings (Rowe, 2012). Data also show that family 

functioning improves during MDFT, and families 

and adolescents maintain these gains at follow-up 

(Rowe, 2012). For some adolescents, MDFT may be 

an effective alternative to residential treatment 

(Liddle et al., 2018). 

Behavioral Couples and Family 

Counseling 

Behavioral couples and family counseling promote 

the recovery of the family member with an SUD 

by improving the quality of relationships, teaching 

communication skills, and promoting positive 

reinforcement within relationships. Two variations 

of this approach are BCT and BFT. 

BCT 

BCT is a structured counseling approach for 

people with SUDs and their intimate partners. It 

focuses on an intimate partner’s ability to reward 

abstinence and other efforts to change and to 

promote continuing recovery for the person 

Chapter 3 53 
TIP 39

with an SUD. BCT aims to lessen relationship 

distress, improve partners’ patterns of interaction, 

and build more cohesive relationships to reduce 

risk of returns to use for the partner with an SUD 

(Klostermann & O’Farrell, 2013). The goals of BCT 

are to support abstinence from substances and 

improve relationship functioning (O’Farrell & 

Schein, 2011). 

Typically, clients with SUDs and their partners 

attend 12 to 20 weekly sessions. Although 

there are exceptions to these criteria (McCrady 

et al., 2016), appropriate participants for BCT 

are generally couples in which (Klostermann & 

O’Farrell, 2013): 

• Partners are married or living together for at 

least 1 year. 

• Neither partner has a co-occurring mental 

disorder that would signifcantly affect 

participation. 

• Only one member of the couple has a current 

problem with substance misuse. 

• There is no indication of risk of severe intimate 

partner violence. 

The overall counseling approach has two main 

components (O’Farrell & Clements, 2012): 

• Substance-focused interventions to build 

support for abstinence. 

• Relationship-focused interventions to enhance 

caring behaviors, shared activities, and 

communication. 

[T]he goal of BCT is to create a 

‘virtuous cycle’ (i.e., enlisting the 

. . . partner’s support in the client’s 

recovery) between substance 

use recovery and relationship 

functioning by using interventions 

designed to address both sets 

of issues concurrently and 

reinforcepositive behaviors.” 

(Klostermann, Kelley, Mignone, 

Pusateri, & Wills, 2011, p. 1503) 

Substance Use Disorder Treatment and Family Therapy 

RESOURCE ALERT: MDFT ONLINE 

The MDFT website (www.mdft.org) provides 

information about the MDFT method, summaries 

of its effectiveness in SUD treatment, and training 

resources, including a no-cost, downloadable 

clinician manual and training videos. 

Counselors begin with substance-focused 

interventions to promote abstinence, then 

add relationship-focused interventions after 

abstinence is stable, with an emphasis on teaching 

communication skills and increasing positive 

relationship activities (O’Farrell & Schein, 2011). 

Relapse prevention interventions occur during the 

fnal phase of BCT (Klostermann & O’Farrell, 2013). 

Benefts of BCT in Relapse Prevention and 

Recovery Promotion 

There is a mutual relationship between substance 

use and marital confict. Unpredictable behavior 

associated with substance misuse contributes to 

high levels of relationship dissatisfaction, instability, 

confict, and stress—all linked to returns to use in 

people with SUDs. Substance use and relationship 

confict reinforce each other in a damaging cycle of 

interactions that partners have diffculty breaking. 

Couples counseling helps couples take substance 

misuse out of the equation, harness partner 

support to positively reinforce the client’s efforts 

to remain abstinent, and change relationship 

dynamics to promote a family environment that 

is more conducive to ongoing recovery. Stress 

decreases, the risk of return to use for the person 

with the SUD is lowered, and interpersonal violence 

and other relationship problems are reduced 

(Klostermann, Kelley, et al., 2011). 

BCT Interventions 

BCT sessions are very structured. Each session 

has three counselor tasks: (1) review any substance 

use, relationship concerns, and homework 

assignments; (2) introduce new material; and (3) 

assign home practice (Klostermann, Kelley, et al., 

2011). Much of the work in BCT happens during 

54 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

completion of out-of-session assignments. The 

counselor initially works with the couple to develop 

a recovery contract that lays the foundation for 

the ongoing couples work. Counseling strategies 

include a recovery contract between the couple 

and counselor, activities and homework exercises 

that increase positive feelings between partners, 

shared activities, constructive communication, and 

relapse prevention planning. Exhibit 3.2 describes 

counseling strategies and interventions for different 

stages of treatment. 

BCT is a family-based treatment with strong 

evidence of effcacy in treating SUDs. BCT is 

signifcantly more effective than individual 

treatment for both men and women with SUDs 

in reducing substance use, increasing abstinence, 

and improving relationship functioning and 

satisfaction (O’Farrell & Clements, 2012). A 

review of the research on BCT also found that it 

is a cost-effective approach to SUD treatment, 

especially when the cost of fewer returns to use 

is factored in (Fletcher, 2013). Although earlier 

research focused on men with SUDs and their 

female partners, BCT used with female clients with 

SUDs is also associated with better substance- and 

relationship-related outcomes than the use of 

individual therapy (O’Farrell, Schreiner, Schumm, 

EXHIBIT 3.2. BCT Interventions 

& Murphy, 2016; O’Farrell, Schumm, Murphy, & 

Muchowski, 2017). Some evidence shows that BCT 

is effective in treating lesbian and gay couples 

(Fletcher, 2013). 

It is generally recommended that BCT be used 

when only one partner has an SUD (Klostermann 

& O’Farrell, 2013), but BCT appears as effective in 

couples when both partners have a current SUD 

and are pursuing recovery as in couples when just 

one partner is in treatment (Schumm, O’Farrell, & 

Andreas, 2012). Research on elements of BCT that 

are related to treatment outcomes found that the 

partner’s involvement in couples treatment, less 

confrontation, and more supportive language for 

the client’s efforts to change drinking behaviors 

were associated with greater couple satisfaction 

and reduced drinking (McCrady et al., 2019). Thus, 

BCT treatment may be particularly effective when 

both partners are motivated to change and are 

willing to support each other. 

The following sections discuss adaptations of 

BCT that have been found to be effective in pilot 

studies. These adaptations open up possibilities for 

SUD treatment programs to integrate BCT in ways 

that might better ft your treatment philosophy and 

approach than standard BCT. 

FOCUS INTERVENTIONS 

Substance 

Use 

Create a daily recovery contract. The counselor creates a recovery contract with 

the couple that it will review at the beginning of each day. Elements of the contract 

include: 

• Trust discussion. The client states his or her intention not to drink or use drugs that day, 

and the partner expresses support for the client’s efforts to stay abstinent. 

• Contract review. The couple reviews contract elements (e.g., medication adherence, 

urine screens, recovery support group attendance, agreement not to discuss past 

misuse). 

• Adherence record. The couple records performance of the daily contract on a calendar. 

Counselor review. To start each session, the counselor asks the couple about 

substance use behaviors, thoughts, urges, or cravings, and then reviews the daily 

contract adherence record. 

Continued on next page 

Chapter 3 55 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

EXHIBIT 3.2. BCT Interventions (continued) 

FOCUS INTERVENTIONS 

Relationship 

Concerns 

Relapse Prevention 

Increase positive activities. 

• “Catch Your Partner Doing Something Nice.” Each partner records 

one caring behavior performed by the other partner in a daily log. The 

counselor models how to acknowledge the caring behavior, and the 

couple practices at home. 

• Shared rewarding activities. Partners make a list of activities that they 

can do together, with their children, or as a family. The counselor models 

planning an activity and instructs the couple not to discuss conficts 

during the activity. 

• “Caring day” assignment. The counselor instructs each partner to give the 

other a “caring day” during the coming week by performing special acts 

that show caring for the partner. 

Teach communication skills. 

• Listening skills. The counselor instructs the couple to summarize the 

content and feelings of the speaker’s message and then to check whether 

the message received was the message intended by the partner. The 

couple practices during the session and at home. 

• Expressing feelings directly. The counselor invites the couple to express 

both positive and negative feelings directly instead of blaming or avoiding 

and models using “I” statements. 

• Communication sessions. The counselor assigns private, face-to-face (no 

texts, emails, phone calls) sessions; partners take turns expressing their 

views without interruption. 

• Negotiating requests. The counselor shows how to make positive, specifc 

change requests and negotiate for mutual (not coerced) agreement. The 

couple practices during the session. 

• Confict resolution. The counselor teaches problem-solving and confict 

resolution skills. 

Create a continuing recovery plan. The counselor and couple create a 

continuing recovery plan before treatment ends; the plan lists behaviors 

and activities the couple would like to continue. 

Anticipate high-risk situations. The counselor and the couple identify 

situations where the partner with SUD is at risk for a return to use and 

early warning signs of a possible return to use. The couple discusses and 

rehearses coping strategies to use to prevent returns to use. 

Create a written relapse prevention plan. The counselor and the couple 

create an action plan that includes specifc steps each partner will take 

(e.g., go to a recovery support group meeting, call a sponsor, call the BCT 

counselor) and emergency contact information. The couple discusses and 

rehearses how to manage a return to substance use if it happens. 

Sources: O’Farrell & Schein (2011); Schumm & O’Farrell (2013b.) 

56 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

CLINICAL SCENARIO: COUPLES COMMUNICATION SKILLS 

The following scenario, developed by the consensus panel, shows the BCT strategies of enhancing a 

couple’s communication skills. 

Family: Delbert, a 49-year-old man with AUD, had stopped drinking during inpatient treatment, which 

he entered after an arrest for driving under the infuence (DUI). He attended Alcoholics Anonymous (AA), 

worked every day, and saw his probation offcer regularly. Delbert was progressing well in his recovery, but 

he and his wife, Renee, continued to have daily arguments that upset their children and left both Delbert 

and Renee thinking that divorce might be their only option. Delbert had even begun to wonder whether 

his efforts toward abstinence were worthwhile. 

Treatment: Delbert and Renee fnally sought help from the continuing care program at an SUD treatment 

center where Delbert was a client. Their counselor, using a BCT approach, met with them to assess their 

diffculty. 

What became obvious was that their prerecovery communication style was still in place, even though 

Delbert was no longer drinking. Their communication style had developed over the many years of Delbert’s 

drinking—and years of Renee’s threatening and criticizing to get his attention. Whenever Renee tried to 

raise any concern of hers, Delbert reacted frst by getting angry with her for “nagging all the time” and then 

by withdrawing. The counselor, realizing the couple lacked the skills to communicate differently, began to 

teach new communication skills. Each partner learned to listen and summarize what the partner had said 

to make sure the point was understood before responding. 

To eliminate overuse of blaming, the couple learned to report how their partner’s actions affected them. For 

example, Renee learned to say, “I feel anxious when you don’t come home on time,” rather than to attack 

Delbert’s character or motivation with judgments like, “You’re as irresponsible as ever, so I can’t trust you.” 

In addition, because Delbert and Renee were focused on the negative aspects of their interactions, the 

counselor suggested they try a technique from BCT known as “Catch Your Partner Doing Something Nice.” 

Each day, Delbert and Renee were asked to notice one pleasing thing that their partner did. As they did 

so, their views of each other slowly changed. After 15 sessions of couples counseling, their arguing had 

decreased, and both saw enough positive aspects of their relationship to merit trying to save it. 

Parenting Skills Training in BCT 

BCT not only positively affects the couple, but 

also has a secondary effect on children in the 

family (e.g., enhancing children’s psychosocial 

adjustment) even when the children do not 

participate in treatment (Fletcher, 2013). Adding 

specifc content to BCT on parenting skills 

enhances the positive effects of this approach, 

not only on the couple but on the entire family. A 

randomized controlled study of BCT plus parenting 

skills training (PSBCT) found signifcant differences 

in child adjustment measures between PSBCT and 

individual treatment of the parent with an SUD 

and clinically meaningful effects between PSBCT 

and standard BCT (Lam, Fals-Stewart, & Kelley, 

2008). Adding six sessions of parent training, which 

reinforced the skills training sessions in BCT (e.g., 

adding a “Catch Your Child Doing Something 

Nice” exercise after the couple practiced the 

“Catch Your Partner Doing Something Nice” 

activity), did not compromise the effectiveness 

of traditional BCT for the couple and enhanced 

parenting skills to a greater degree than BCT alone 

(Lam, Fals-Stewart, & Kelley, 2009). 

Chapter 3 57 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

BCT for Family Counseling 

Many clients live with a family member other 

than an intimate partner. Behavioral family 

counseling is an adaptation of BCT (O’Farrell, 

Murphy, Alter, & Fals-Stewart, 2010) in which 

a client and a family member (usually a parent 

of an adult child) attend 12 adapted behavioral 

family counseling sessions. The sessions focus on 

helping the client and family member establish 

a “daily trust discussion.” The family member 

reinforces the client’s intention to remain abstinent 

from substances, reduce confict, improve 

communication, and increase positive alternative 

activities for the client. 

Behavioral family counseling emphasizes daily 

support for abstinence as in BCT, but focuses less 

on sharing rewarding activities and practicing 

communication skills at home. These adaptations 

provide a better ft with the developmental 

needs (e.g., increased autonomy, separation) of 

an emerging adult living with a parent. Research 

supports the effcacy of this adaptation over 

individual treatment on treatment retention, 

increased abstinence, and reduced substance 

misuse (O’Farrell & Clements, 2012). 

BFT 

BFT treatment approaches are based on social 

learning and operant conditioning (i.e., using 

positive and negative reinforcements to change 

behavior) theories. BFT emphasizes clients’ 

substance use behaviors in a family context (Lam, 

O’Farrell, & Birchler, 2012). Counselors view 

substance misuse as a learned behavior that 

peers, parents, and role models may reinforce 

(Lam et al., 2012). 

To counteract these infuences, treatment 

emphasizes contingency management strategies 

that reward abstinence, reduce reinforcement 

of alcohol and drug use, and increase positive 

behaviors and social interactions incompatible 

with substance use (Lam et al., 2012). The 

counselor coaches family members to engage in 

new behaviors that increase positive interactions 

and improve communication and problem-solving 

skills (Lam et al., 2012). BFT is not manual based, 

but it applies evidence-based practices in SUD 

treatment (e.g., contingency management, 

communication skills training, CBT) to family 

counseling. 

To facilitate behavioral change in a family to 

support abstinence, use BFT techniques, 

including: 

• Contingency contracting: These agreements 

stipulate what each member will do in exchange 

for rewarding behavior from other family 

members. For example, an adolescent might 

agree to call home regularly while attending a 

concert in exchange for her parents’ permission 

to attend it. 

• Skills training: The counselor may start with 

general education on communication or confict 

resolution skills, practice skills in sessions, and 

get the family to agree to use the skills at home. 

• Cognitive restructuring: The counselor helps 

family members voice unrealistic or self-limiting 

beliefs that contribute to substance misuse or 

other related family problems. An example of a 

self-defeating personal belief might be: “To ft 

in (or to cope), I have to use drugs.” Distorted 

messages from the family might include: “He 

uses drugs because he doesn’t care about us.” 

or “He’s irresponsible; he’ll never change.” 

The counselor helps the family replace these 

self-defeating beliefs with those that facilitate 

recovery and individual and family strengths. 

Family Behavior Loop Mapping 

The family behavior loop map is a step-bystep behavioral chain analysis of the family’s 

interactions and the sequence of events that lead 

to substance use behaviors and episodes when 

the client with an SUD refrains from substance use 

(Liepman, Flachier, & Tareen, 2008). The entire 

family is involved in the mapping process. Older 

children and adolescents contribute verbally to 

mapping, and younger children offer information 

about family interactions via their behavior 

(Liepman et al., 2008). This visual representation 

helps family members see their contributions to 

this systemic, interactive process. It emphasizes 

that no one person is the cause or victim of 

the negative effects of substance use behaviors 

58 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

CLINICAL SCENARIO: INDIVIDUAL COUNSELING WITH A FAMILY FOCUS 

If you work with adult clients in individual counseling, you can still work with them following a family systems 

perspective. This clinical scenario, developed by the consensus panel, describes how the counselor brings 

the family of origin into counseling metaphorically by using a family genogram to help the client make 

the connection between his substance misuse and family-of-origin issues. The counselor also initiates brief 

couples work to help the client stabilize an intimate relationship as a way to support his recovery. 

Darius, a 21-year-old man, was referred to a clinic for court-mandated SUD counseling after his third DUI 

violation; he had been on probation since age 13 for charges including burglary and domestic violence. He 

had a long history of substance misuse, had been on his own for 8 years, and had no family involved in his life. 

Darius had participated in several residential treatment programs, but he could not maintain abstinence on 

his own. 

When Darius entered outpatient treatment, he was furious with “the system” and refused initially to 

cooperate with the counselor or participate in his treatment plan. The counselor was pleased that he did show 

up for his weekly sessions. The following interventions seemed to help Darius: 

• The counselor suggested that one treatment goal might be for Darius to get off probation. At the time, he 

had 18 months of probation remaining. 

• The counselor helped Darius see how his substance misuse was linked to his criminal justice involvement. 

• The counselor made a genogram of three generations of Darius’ family of origin. It showed family 

disintegration linked to poverty, substance misuse, and intergenerational trauma (e.g., Darius’ experience 

of childhood neglect; his parents’ and grandparents’ experiences of racism and culturally infuenced 

childhood trauma). 

• The counselor initiated couples counseling to help Darius stabilize a signifcant relationship. After conferring 

with the probation offcer, the counselor decided Darius would beneft from a 6-month trial of naltrexone. 

• The probation offcer required that Darius fnd regular employment. 

During the course of treatment, Darius was able to stop drinking and reevaluate his belief system against the 

backdrop of his family and the larger judicial system in which he had been so chronically involved. He came 

to be able to express anger more appropriately and to recognize and process his many losses from family 

dysfunction. Although many of his family members continued to misuse alcohol, Darius reconnected with an 

uncle who was in recovery and who had taken a strong interest in Darius’ future. Eventually, Darius formed 

a plan to complete his GED and to begin a course of study at the local community college. The counselor 

helped Darius examine how his behaviors and the family responsibilities he took on shaped his substance use. 

(Liepman et al., 2008). The map identifes 

alternative behaviors, thoughts, and feelings that 

lead to “not using” and presents possibilities for 

discussing ways to break the chain of events. 

This strategy is rather involved. Providers who 

wish to use it in their work with families in SUD 

treatment should seek training by a family 

counselor experienced in its application. 

Family Check-Up 

A lack of parental involvement in the activities 

of their children predicts later substance use, 

according to research. Conversely, research 

consistently shows that parental monitoring and 

parent–child communication about substance use 

reduces the risk of early initiation of substance 

use and lowers rates of adolescent substance use 

(Hernandez, Rodriguez, & Spirito, 2015). 

Chapter 3 59 
TIP 39

 

Substance Use Disorder Treatment and Family Therapy 

Family Check-Up (FCU) is a brief assessment and 

feedback intervention that targets family risk 

factors linked to substance use, including lack of 

parental monitoring and low-quality parent–child 

relationships (Hernandez et al., 2015). FCU 

integrates principles and techniques of MI and 

individualized feedback to motivate families to 

change current family practices to prevent future 

substance use in children and address current 

substance use in adolescents (Hernandez et al., 

2015). 

FCU for adolescents consists of two family 

sessions (Hernandez et al., 2015): 

1. An initial intake interview to identify family 

strengths and challenges, engage the family, 

and videotape a structured assessment 

protocol of parent–adolescent interactions. 

2. A feedback session using MI to support 

parents to maintain positive parenting 

practices and change parenting practices 

associated with adolescent substance misuse. 

The feedback session has four components 

(Hernandez et al., 2015): 

• Self-assessment: Parents are asked what they 

learned about their family from participating in 

the family interactional assessment. 

• Support and clarifcation: The counselor 

provides support and clarifes family 

issues and practices that reduce the risk of 

adolescent substance use. 

CLINICAL SCENARIO: COGNITIVE RESTRUCTURING AND 

PROBLEM-SOLVING 

The following clinical scenario, developed by the consensus panel, demonstrates the BFT strategies of 

promoting cognitive restructuring and enhancing problem-solving. 

Family: Peter, a 17-year-old White adolescent, was referred for SUD treatment. He acknowledged that he 

drank alcohol and smoked marijuana but minimized his substance use. Peter’s parents reported he had 

come home a week earlier with a strong smell of alcohol on his breath. The next morning, they confronted 

him about drinking and drug use. He denied currently using marijuana, saying, “It’s not a big deal. I just tried 

marijuana once.” 

Despite Peter’s denial, his parents found three marijuana cigarettes in his bedroom. For at least a year, they 

had suspected Peter was using drugs. Their concern was based on Peter’s falling grades, his increasingly 

disheveled appearance, and his new tendency to borrow money from relatives and friends, usually without 

repaying it. 

Peter, his older sister Nancy (age 18), and his parents attended the frst two family sessions. During the 

sessions, Peter revealed that he resented his father’s overt favoritism toward Nancy, who was an honor 

student and popular athlete in her school, and his parents’ conficts with each other about unequal treatment 

of Peter and Nancy. The father was often sarcastic and sometimes hostile toward Peter, criticizing his attitude 

and problems. Peter viewed himself as a failure and experienced depression, frustration, anger, and low selfesteem. Peter wanted to retaliate against his father by causing problems in the family. In this respect, Peter 

was succeeding. His substance misuse and falling grades had created a stressful environment at home. 

Treatment: The counselor used CBT to address Peter’s irrational thoughts (e.g., seeing himself as a total 

failure) and teach him and other family members communication and problem-solving skills. The counselor 

also used BFT to strengthen the marital relationship between Peter’s parents and to resolve conficts among 

family members. The family ended treatment prematurely after eight sessions, but some positive treatment 

outcomes were realized—an improved relationship between Peter and his father, improved academic 

performance, and an apparent cessation of drug use based on negative urine test results. 

60 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

• Feedback: The counselor provides 

personalized feedback on family expectations 

about substance use, parental supervision 

and monitoring, and parent–adolescent 

communication. 

• Parenting plan: The counselor facilitates a 

discussion of the adolescent’s strengths and 

the importance of parents praising positive 

behavior. The counselor works with the parent 

to develop a brief written plan to improve family 

communication and monitor the adolescent’s 

behavior. 

Research shows lower levels of adolescent 

substance use and risk for SUD diagnosis when 

parents complete the FCU intervention (Hernandez 

et al., 2015). A systematic review and metaanalysis found that FCU as part of a larger schoolbased approach reduced marijuana use among 

adolescents (Stormshak et al., 2011; VermeulenSmit, Verdurmen, & Engels, 2015). 

BSFT 

BSFT aims to reduce or eliminate youth drug 

misuse and change family interactions that 

support drug misuse through its problemfocused, directive, and practical approach 

(Gehart, 2018; Horigian et al., 2016). Drawing 

on structural and strategic family theory and 

interventions, Szapocznik, Hervis, and Schwartz 

(2003) frst developed BSFT to address drug 

misuse among Cuban youth in Miami. The 

central assumption of BSFT is that adolescent 

substance misuse and other risk behaviors are 

linked to dysfunctional family interactions (e.g., 

inappropriate alliances, boundaries that are 

too rigid or loose, parents’ tendency to blame 

adolescents for family problems) (Horigian et 

al., 2016). Exhibit 3.3 summarizes the underlying 

concepts that shape BSFT interventions. 

BSFT interventions target family interactions 

that are most likely to affect youth substance 

misuse and other risk behaviors. Structural family 

counseling strategies in BSFT include (Gehart, 

2018): 

• Joining: The counselor establishes a working 

alliance with each family member and connects 

with the family system. The counselor identifes 

and adjusts to family members’ ways of relating 

to one another, conveys understanding and 

respect, and listens as each family member 

expresses feelings. 

• Enactments: The counselor invites the family 

to recreate dysfunctional interactional patterns 

that support substance misuse to assess and 

then restructure them through coaching, 

modeling alternative ways of interacting, or 

both. These patterns are typically rigid, so the 

counselor must take a directive role and have 

family members develop and practice different 

interaction patterns. 

• Working in the present: The counselor 

emphasizes current interactions and focuses 

less on the past. The family is more likely to 

get stuck in negative interactional patterns if 

the conversation focuses on past events. The 

discussions emphasize events happening in the 

present. 

• Reframing negativity: The counselor reframes 

negative interpretations of thoughts, feelings, 

and actions to promote caring and concern 

in the family. For example, a counselor may 

reframe a parent’s insistence on a 9:00 p.m. 

curfew as an act of caring, not a way of 

controlling the adolescent. 

• Reversals: The counselor may coach one or 

more family members to do or say the opposite 

of what they typically do or say to shake 

up typical interactional patterns. Doing so 

encourages other family members to change 

their position in the interaction as well. The 

counselor then explores the effect on the 

family’s typical interactional pattern. 

• Working with boundaries and alliances: Roles, 

boundaries, and power establish the order 

of a family and determine whether the family 

system works. Standard structural techniques 

are used to loosen or strengthen boundaries to 

better meet the developmental needs of family 

members. The counselor helps family members 

mark individual boundaries while respecting 

the individuality of others. To strengthen 

boundaries, the counselor supports parents’ 

efforts to reestablish authority as a parental 

unit and makes the family aware when a family 

member: 

Chapter 3 61 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

- Speaks about, rather than to, another person 

who is present. 

- Speaks for others, instead of letting them 

speak for themselves. 

- Sends nonverbal cues to infuence what 

another person says or to stop that person 

from speaking. 

• Detriangulation: In families dealing with SUDs, 

a child or less powerful person in a confict is 

often involved in interactions that can defect 

or diffuse tension between two family members 

who are in confict. This involvement is called 

“triangulation.” One strategy is to literally or 

metaphorically remove the third, less powerful 

person from a confict between two other 

family members so they can resolve the confict 

directly. 

• Opening closed systems: Families dealing with 

SUDs tend to be “closed” systems that disallow 

open confict. Counselors should “open” the 

system to let each family member express 

feelings and coach the family on constructive 

ways to resolve differences instead of avoiding 

or diffusing confict. 

Research over more than three decades shows 

the effectiveness of BSFT in engaging and 

retaining adolescents and family members in 

treatment, addressing cultural factors related 

to engagement, reducing adolescent drug use, 

reducing parental alcohol use, and improving 

EXHIBIT 3.3. Concepts Underlying BSFT 

Systems The family is a whole system, and every action a family member takes 

affects the entire family. Negative behavior affects the family negatively, and 

positive behavior change in the youth or parents brings positive change 

to the whole family structure. Repetitive ways in which family members 

interact create structures that can promote substance misuse or other 

adolescent risk behaviors. The counselor uses traditional structural family 

therapy concepts (e.g., subsystems, hierarchy, leadership, alliances) to assess 

the structure, organization, and communication patterns in the family. The 

counselor helps the family adapt its structure to support the developmental 

life stage of each member. 

Strategy Per the counselor’s assessment, interventions are strategically selected to 

change family structure. The focus is on problem-solving and staying close 

to the family’s theory of the presenting problem. 

Process Focus The process of the family’s interactions is more important than the content 

of what is said in helping the counselor assess the situation and formulate 

interventions. The counselor emphasizes the quality of listening, sharing, 

and interacting of family members to identify repetitive patterns. 

Context Individuals are affected by all the systems within which they live, including 

the immediate family, extended family, peers, neighborhoods, culture, 

schools, criminal justice systems, and the larger society. Family counseling is 

also a context that can support positive change. 

Sources: Gehart (2018); Horigian et al. (2016). 

62 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

family functioning (Horigian, Feaster, Robbins, 

et al., 2015; Rowe, 2012). BSFT is effective in 

long-term reductions in adolescent arrests, 

incarcerations, and externalizing behaviors like 

aggression and rule-breaking (Horigian, Feaster, 

Brincks, et al., 2015). 

BSFT is a somewhat complex, manual-based 

treatment approach. Fidelity in community-based 

settings tends to be low (Lebensohn-Chialvo, 

Rohrbaugh, & Hasler, 2019). Implementation 

requires extensive training and ongoing 

supervision. 

Functional Family Therapy 

Functional family therapy is another behaviorally 

based family counseling approach. Its goals are 

to change the dysfunctional family’s behavioral 

and interactional patterns that maintain the 

adolescent’s substance misuse and reinforce 

positive problem-solving responses to adolescent 

risk behaviors (Rowe, 2012). It is based on an 

ecological model of risk and protective factors. 

This approach has three treatment phases and 

associated counseling strategies: engagement and 

motivation, behavior change, and generalization 

(Hartnett, Carr, Hamilton, & O’Reilly, 2017; 

Horigian et al., 2016): 

• Phase 1: Engagement and motivation 

- Engage all members of the family to enhance 

motivation. 

- Frame the counselor–family therapeutic 

relationship as a cooperative effort between 

experts. 

- Reduce negativity and blaming interactions 

through reframing. 

• Phase 2: Behavior change 

- Assess risk factors and evaluate relational 

patterns. 

- Help families develop behavioral 

competencies for parenting, communication, 

and supervision. 

- Encourage active listening and clear 

communication. 

- Help parents develop/implement rules and 

consequences for substance use and risk 

behaviors. 

• Phase 3: Generalization 

- Teach families how to generalize the skills 

they developed in Phase 2 to new situations 

and contexts other than the initial target 

behavior. 

- Anticipate and plan for the possibility of 

future problems. 

- Reframe continuing challenges as normal, 

not as failures of the family or the counseling 

process. 

- Actively link family members to communitybased supports. 

Functional family therapy has been widely 

disseminated in the United States and other 

countries. A meta-analysis of comparison and 

COUNSELOR NOTE: CULTURAL 

CONSIDERATIONS 

Culture: Become familiar with roles, boundaries, 

and power structures in families from cultures 

that differ from your own. These elements 

infuence the techniques and strategies that will 

be most effective in family counseling. 

Age and gender: Cultural attitudes toward age 

and gender can affect how you assume the 

directive role that you take in structural and 

strategic family-based counseling approaches. 

Hierarchies: Certain cultures are very attuned 

to relative positions in the family hierarchy. 

Sometimes, children may not ask questions 

of the parent. Other children will remove 

themselves from the situation until the parent 

notices they are not there. You should attend to 

who is who in the family. Who is revered? Who 

are friends? What is its history? Where is its place 

of origin? These are clues to understanding a 

family’s hierarchy. 

For more information on cultural considerations 

in family counseling for SUDs, see Chapter 5 

of this TIP. See also Treatment Improvement 

Protocol (TIP) 59, Improving Cultural Competence 

(https://store.samhsa.gov/product/TIP-59-

Improving-Cultural-Competence/SMA15-4849). 

Chapter 3 63 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

CLINICAL SCENARIO: JOINING AND ESTABLISHING BOUNDARIES 

The following clinical scenario, developed by the consensus panel, describes strategies for joining and 

establishing boundaries in the family. 

Family: The client is a 22-year-old White woman who misuses prescribed medication and has depression 

and schizophrenia. She is the younger of two children whose parents divorced when she was 3. She stayed 

with her mother, while her brother (age 7 at the time) went with their father. Both parents remarried 

within a few years. Initially, the families lived near each other, and both parents were actively involved 

with both children, despite ill feelings between the parents. When the client was 7, her stepfather was 

transferred to a location 4 hours away, and the client’s interactions with her father and stepmother were 

curtailed. Animosity between the parents escalated. When the client was 8, she chose to live with her 

father, brother, and stepmother, and the mother agreed. The arrangement almost completely severed 

ties between the parents. At the time the client entered a psychiatric unit for detoxifcation, the parents 

had no communication at all. The initial family contact was with the father and stepmother. As the story 

unfolded, it became clear that the client had constructed different stories for the two-family subsystem of 

parents. She had artfully played one against the other. This was possible because the birth parents did not 

communicate. 

Treatment: The frst task was to persuade the father to ask the mother to attend a family meeting. He 

and the stepmother agreed, although it took great courage to make the request. The father believed his 

daughter’s negative stories about her relationship with her mother. The older brother (the intermediary 

for the past 4 years) and his wife also attended the next session. The relationship between the counselor 

and the paternal subsystem was well established, so it was critical to also join with the maternal subsystem 

before starting family system work. The counselor helped the mother and stepfather build equal parental 

status in the group, which gave the mother free rein to tell the story as she saw it and express her beliefs 

about what was happening. 

A second task was to establish appropriate boundaries in the family system. Specifcally, the counselor 

sought to join the separate parental subsystems into a single system of adult parents and to remove the 

client’s brother and sister-in-law as a part of that subsystem. This exclusion was accomplished by leaving 

them and the client out of the frst part of the meeting. This procedural action realigned the family 

boundaries, placing the client and her brother in a subsystem different from that of the parents. 

This activity proved to be positive and productive. After the frst hour of a 3-hour session, the parents were 

comparing information; reframing incorrect assumptions about each other’s beliefs and behaviors; and 

forming a healthy, reliable, and cooperative support system for their daughter. This outcome would have 

been impossible had the counselor not joined with the mother and father in a way that allowed them 

to feel equal as parents. Removing the brother from the parental subsystem required the client to deal 

directly with the parents, who were committed to communicating with each other and to speaking to their 

daughter in a single voice. 

64 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

randomized controlled studies found signifcant 

support for the effectiveness of functional 

family therapy compared with other treatment 

approaches, including CBT, psychodynamic, 

individual, and group counseling for adolescents, 

parenting education groups, and probation and 

mental health services (Hartnett et al., 2017). 

Solution-Focused Brief Therapy 

In the 1980s and 1990s, Berg and Miller (1992) and 

de Shazer (1988) developed a family counseling 

approach to help family members fnd solutions 

to their problems instead of using the problemsolving approach of structural and strategic 

counseling. The main assumptions of solutionfocused therapy are that pinpointing the cause 

of problematic family functioning is unnecessary 

and that counseling focused on solutions to 

specifc problems is enough to help families 

change. 

In solution-focused brief therapy, families 

generate treatment goals. The role of the 

counselor is to emphasize times when the problem 

(e.g., substance use behavior) does not occur and 

help the family identify achievable solutions that 

enhance motivation and optimism for behavioral 

change (Klostermann & O’Farrell, 2013). 

In solution-focused brief therapy, the counselor 

helps the family develop a detailed, carefully 

articulated vision of what the world would be like if 

the presenting problem were solved. The counselor 

then helps the family take the necessary steps to 

realize that vision. Because of its narrow focus on a 

specifc target problem, this therapeutic approach 

works well with many SUD treatment strategies. 

Many family counseling strategies and techniques 

in solution-focused therapy are basic to any 

family counseling approach—joining with the 

family, managing the emotional intensity of 

family sessions, negotiating treatment goals 

with the family, and attending to family patterns 

of interaction (McCollum & Trepper, 2013). The 

following techniques characterize solutionfocused therapy, specifcally. 

Developing a vision of the future: The counselor 

invites family members to envision what life would 

be like without the problem, such as substance 

misuse. This process engages family members in 

using their imagination to open up new possibilities 

for generating solutions to the problem, enhances 

the family’s hope that things can and will change, 

and highlights the benefts of change. 

Asking the miracle question: This is perhaps 

the most representative of the solution-focused 

therapy techniques. It elicits each family member’s 

vision of life without substance misuse. The miracle 

question traditionally takes this form (De Jong & 

Berg, 1998): 

I want to ask you a strange question. 

Suppose that while you’re sleeping 

tonight and the house is quiet, a 

miracle happens. The miracle solves 

the problem that brought you here. But 

you’re asleep, so you don’t know that 

the miracle has happened. When you 

awake tomorrow morning, what will 

be different to show you that a miracle 

happened and that the problem that 

brought you here has been solved? 

Envisioning interpersonal change: Counselors 

help family members set goals that respect the 

views and needs of other family members. Ask the 

person with the SUD questions like (McCollum & 

Trepper, 2013): 

• What will other family members notice about 

you as you move closer to your goal to stop 

drinking? 

• If we video recorded your family at Sunday 

dinner after you quit drinking, what would it 

look like? 

• How would family members be interacting 

differently? 

Identifying exceptions to the problem: 

Sometimes the substance use behavior that 

brings the family to counseling is absent or less 

severe. It is important to help the family identify 

these exceptions and build solutions from there. 

For example, you might ask each family member 

about a time when the substance use behavior did 

not happen. You might ask a spouse, “Can you 

tell me about a time when you and your spouse 

were arguing, but he did not grab a beer from the 

refrigerator?” 

Chapter 3 65 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Identifying problem sequences: The counselor 

helps the family identify a specifc target behavior, 

like the adolescent leaves the house and smokes 

marijuana to reduce stress during a parental 

argument. You then ask a series of questions to 

identify the sequence of behaviors of all family 

members that contributed to the problems. 

These questions might include (McCollum & 

Trepper, 2013): 

• When does Tony typically leave the house to get 

high with his friends? 

• Who is there during this event? 

• What happens frst? 

• What did each of you do frst? 

• What happened next? 

• How did this situation end? 

Identifying solution sequences: The next step 

is to identify the solution sequence of family 

member behaviors during an exception to the 

problem sequence. This helps the family shift the 

focus from the problem to the solution. Families 

often get stuck in the problem sequence and 

begin to believe that there is only one outcome 

to the problem. Questions you can ask to identify 

the solution sequence during an exception might 

include (McCollum & Trepper, 2013): 

• Can you tell me about a time when the 

sequence started, but Tony didn’t go get high 

with his friends? 

• How was this different? 

• What did each of you do differently to shortcircuit the problem sequence and help with a 

solution? 

• What did each of you do frst? 

• What happened next? 

• What can each of you do differently to make the 

solution sequence happen again? 

Solution-focused brief therapy replaces the 

traditional expert-directed approach aimed 

at correcting pathology with a collaborative, 

solution-seeking relationship between the 

counselor and the family. It encourages the family 

to focus on what life will be like when the problem 

is solved. The emphasis is on the development of a 

solution in the future, rather than on understanding 

the development of the problem in the past or its 

maintenance in the present. 

COUNSELOR NOTE: ASKING THE MIRACLE QUESTION 

If the answer to the miracle question is “I don’t know,” as it often is, encourage the client to take time before 

answering. Prompt the client, if necessary, with questions like: “Lying in bed, what would you notice that 

would tell you a miracle had occurred? What would you notice at breakfast? What would you notice at 

work?” Then: 

• Expand on each change noticed. For example, the counselor might ask, “How would that make a 

difference in your life?” If the client answered that he would not wake up thinking about drinking, ask, 

“What would you think about? How would that make a difference?” 

• Accept the client’s answer and do not request alternative responses. Some clients say their miracle would 

be to win the lottery. The counselor should not dismiss the response by saying, “Think of a different 

miracle.” Instead expand the response by asking questions such as: “What would be different in your life if 

you won the lottery?” “What would be different if you paid all your bills on time?” 

• Make the vision interpersonal. Ask, “If your miracle comes true, what would others notice about you?” 

• Help the client see that elements of the miracle are already part of life. Even if those elements are small, 

ask, “How can you expand the infuence of those small parts of the miracle?” 

66 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

Research supports the effectiveness of solutionfocused brief therapy. A review of controlled 

outcome studies found that it provided signifcant 

positive benefts to adults with mental disorders 

and showed promise for improving family 

functioning, particularly for families under stress 

of having a family member with a mental disorder 

(Gingerich & Peterson, 2013). A study of parents 

with SUD and trauma-related symptoms who 

were involved in the child welfare system found 

that solution-focused brief therapy was effective 

in reducing substance use and trauma-related 

symptoms (Kim, Brook, & Akin, 2018). 

CRAFT 

Another much-studied family-based intervention 

that focuses on CSOs is CRAFT. CRAFT 

is a structured, family-focused, positive 

reinforcement approach, usually four to six 

sessions in length, that teaches family members 

and CSOs strategies for encouraging the 

family member who is misusing substances to 

change his or her substance use behaviors and 

enter SUD treatment. For example, a positive 

reinforcer may tell the family member how much 

the CSO enjoys spending time with him when he 

is not smoking marijuana or going to a movie with 

him after a day without drinking. The underlying 

assumption of CRAFT is that environmental 

contingencies are important in promoting treatment 

entry (Bischof, Iwen, Freyer-Adam, & Rumpf, 2016). 

The counselor’s role in CRAFT is to work with family 

members to change the way they interact with the 

person who has an SUD and that, in turn, will have 

an impact on his or her substance use behaviors. 

The focus of this intervention is the family. 

Community Reinforcement 

CRAFT is a prime example of an SUD treatment 

approach that uses community reinforcement, 

which promotes SUD recovery by engaging family 

members and other natural supports in treatment. 

The goal of community reinforcement is to work 

together to provide positive incentives for 

people with SUDs to stop using substances; get 

progressively involved in alternative, meaningful, 

positive social activities not associated with 

substance use; and enter or stay in treatment. 

Community reinforcement helps family, friends, 

and social supports positively reinforce behavior 

change instead of confronting continued substance 

use or other risk behaviors. People pressed into 

SUD treatment by confrontation are more likely 

to return to use than those encouraged to enter 

through positive reinforcement. CRAFT is effective 

for clients with SUDs, people with co-occurring 

SUDs and mental disorders, and people in urban 

and rural communities. 

A Less Structured Approach 

CRAFT is highly structured, which works well 

in some scenarios. It can also be adapted 

to provide a less structured family-focused 

approach. This involves providing families and 

CSOs with psychoeducation on the effects of 

substance misuse on the family and coaching on 

communication skills, which include: 

• Refraining from blaming and shaming the family 

member. 

• Expressing concern about the family member’s 

substance use behavior and its effects on the 

family. 

• Expressing hope that the family member will 

get help. 

• Offering affrmations and positive reinforcement 

for any positive change in substance use 

behaviors. 

Family members and CSOs may need 

encouragement to attend community-based 

recovery support groups like Al-Anon and 

Nar-Anon. Research has associated Al-Anon with 

positive psychosocial and physical outcomes for 

family members and CSOs (Roozen, de Waart, & 

van der Kroft, 2010). 

Network Therapy 

Network Therapy combines aspects of individual, 

group, and family-based counseling by enlisting 

the help of a client’s family and friends (ideally, 

three or four people) to work with the counselor 

to help the client achieve and maintain 

abstinence (Galanter, 2014; Galanter, 2015). It uses 

three key elements to help people with substance 

misuse attain lasting recovery: cognitive–behavioral 

relapse prevention techniques, the client’s existing 

Chapter 3 67 
TIP 39

supportive social “networks,” and communitybased resources that support abstinence (e.g., 

mutual-aid support programs). 

Goals and objectives of Network Therapy designed 

to help clients stabilize and abstain from substance 

use include (Galanter, 2014; Galanter, 2015): 

• Having the client participate in individual 

sessions with the counselor as well as group 

sessions with the counselor and the network of 

family and friends. 

• Making abstinence the immediate and 

primary treatment goal from the outset. This 

is achieved by using an ecological approach 

(that is, focusing on engaging family and social 

resources) or a problem-solving family therapy 

approach (that is, focusing on the substance 

misuse problem itself rather than the inner 

workings and relationships within the family). 

• Helping clients achieve long-term stability 

using a variety of SUD treatment tools. For 

example, avoiding relationships with others 

who are actively misusing substances, initiating 

medication-based treatment, attending 

mutual-aid support programs, and developing 

contingency contracts are all potential options. 

• Ensuring sessions have a “teamwork” feel and 

not a confrontational feel to them. Unlike some 

family-based therapy approaches, the goal is 

not to work out unhealthy dynamics, personality 

conficts, or relationship problems between 

the client and the network. Network Therapy 

is also not intended to be an “intervention” in 

the sense that there is no confrontation of the 

client or threats to withdraw support if the client 

does not seek abstinence. The goal is simply for 

the network to remain supportive and engage 

in behaviors that help the client become and 

remain abstinent. 

• Emphasizing to the network the importance 

of solidarity and remaining committed as a 

group to supporting the client. For instance, 

counselors should emphasize the importance 

of all network members regularly attending 

sessions and engaging in supportive activities 

designed to help the client abstain from 

substances. 

Substance Use Disorder Treatment and Family Therapy 

Research has found Network Therapy is associated 

with decreased substance use as refected by 

opioid-free and cocaine-free urine tests over 

time (Galanter, Dermatis, Glickman, et al., 2004; 

Galanter, Dermatis, Keller, & Trujillo, 2002). 

Some research on Network Therapy suggests 

these outcomes result from improvements to the 

therapeutic alliance (Glazer, Galanter, Megwinoff, 

et al., 2003). Researchers have adapted Network 

Therapy by combining it with behavioral therapy 

and naltrexone (Rothenberg, Sullivan, Church, 

et al., 2002) as well as by combining it with 

community reinforcement approaches (known as 

Social Behavior and Network Therapy [Orford, 

Hodgson, Copello, et al., 2009; Williamson, Smith, 

Orford, et al., 2007]). 

Family Approaches To Support 

Ongoing Recovery 

You can integrate family-based interventions into 

SUD treatment to greater or lesser degrees along 

a continuum. Counseling approaches to involve 

family in treatment and continuing care may 

include: 

• Engaging family members and CSOs in helping 

the individual with an SUD get into treatment. 

• Engaging family members and CSOs while those 

with an SUD are in treatment. 

• Linking actively to family/CSO recovery supports 

and comprehensive case management services. 

• Facilitating behavioral contracting between 

family members and clients around such issues 

as abstinence and medication adherence. 

• Improving communication to help clients and 

partners address relationship conficts and 

stressors. 

• Enhancing family members’ problem-solving skills 

and supportive behaviors to avoid returns to use. 

Engagement of Families in Treatment 

It is well documented that family, social supports, 

and community resources are keys to successful 

long-term recovery for people with SUDs 

and co-occurring disorders. Recovery is not a 

solo endeavor; it is a social process. Recovery 

68 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

supports can include spouses, intimate partners, 

CSOs, parents, extended family members, friends, 

community members, spiritual mentors, teachers, 

clergy, recovering peers, employers and coworkers, 

case managers, and primary care and behavioral 

health service providers. 

Moos (2011) noted that social factors protect 

people from developing SUDs and may also 

help them initiate and maintain recovery. These 

include forging emotional bonds; establishing 

social cohesion and support; maintaining goal 

direction; gaining structure through school, 

work, or faith-based organizations; monitoring 

by family, friends, and other recovery supports; 

observing and imitating positive role models; 

expecting negative consequences for engaging in 

risk behaviors; building self-effcacy; developing 

effective coping skills; and participating in 

rewarding, substance-free social activities. These 

processes “are refected in the active ingredients 

that underlie how community contexts, especially 

family members, friends, and self-help groups, 

promote recovery” (Moos, 2011, p. 45). 

Although family members can be a source of 

support for the person with the SUD, they 

also need their own recovery support. Family 

structure, roles, relationships, rules, and rituals are 

altered by addictive and risk behaviors associated 

with SUDs. These changes are “deeply imbedded 

within family members and habitual patterns of 

family interaction and will not spontaneously remit 

with recovery initiation” (White & Sanders, 2006, 

p. 63). Family members can experience stress 

related to the behaviors of the person with an SUD, 

increased dependence on them, and diffculties 

dealing with the complexities and limitations of SUD 

treatment services. In addition, fnancial stressors 

for families can include high healthcare costs; lost 

jobs; and large losses of family income, savings, and 

assets. These stressors take a tremendous toll on 

families. 

You can help clients and family members initiate 

and sustain recovery by actively involving family 

members in treatment. The following are some 

guidelines for engaging family members in SUD 

treatment: 

• Talk with your client in the early stages of 

treatment about the importance of having 

family members, CSOs, and recovery support 

people involved in his or her treatment. 

• Discuss issues around safety and cultural 

appropriateness of inclusion of family members 

and recovery supports, including boundaries 

around confdentiality. 

• Have your client sign releases to have family 

members and recovery supports involved. 

• Work collaboratively with your client to 

develop a plan for identifying supportive family 

members and recovery supports; inviting them 

to an initial counseling, family group session, or 

psychoeducational session; and deciding what 

issues will be addressed. 

• During initial recovery support sessions, offer 

culturally appropriate information regarding 

the nature of your client’s substance use or 

mental disorders; early warning signs of returns 

to use; the impact of these chronic conditions 

on family members and recovery supports; and 

the importance of family and recovery support 

involvement in treatment. 

• Facilitate behavioral contracting between 

family members and the client around such 

issues as abstinence and medication adherence. 

• Improve communication skills to help the client 

and his or her spouse or intimate partner address 

conficts and stressors in their relationship. 

• Ask recovery supports to share positive, nonsubstance-using experiences with the client. 

• Get input from family and recovery supports 

on the client’s early warning signs of returns 

to use. 

• Discuss the importance of self-care with 

recovery supports. 

• Share information on community resources 

and mutual-help groups for family members 

and CSOs. 

• Discuss the purpose and location of resources, 

and what to expect at support group meetings. 

• Facilitate contact between your client’s 

recovery supports and a peer recovery 

support specialist, if available, to link them 

actively with and expedite participation in 

community-based programs. 

Chapter 3 69 
TIP 39

• Plan for follow-up meetings to address 

ongoing recovery and relapse prevention 

concerns. 

• When appropriate, refer for assessment 

or individual counseling family members or 

recovery supports who have their own substance 

use or mental health concerns—or refer them to 

family therapy to address family issues beyond 

your scope of practice. 

• Involve supportive family members and 

other recovery supports in developing and 

implementing the continuing care plan; ask 

for their help to address barriers to continued 

treatment engagement. 

• Work collaboratively with your client and 

recovery supports to develop a relapse 

prevention and emergency plan (in the event 

of a lapse) that includes appropriate roles for 

recovery supports (take care not to burden 

them with responsibilities that your client should 

handle). 

Family Recovery Support Groups 

Strategies for incorporating family recovery support 

group participation in family counseling include: 

• Exploring family member’s understanding of and 

prior participation in mutual-aid (referred to as 

recovery support or mutual-help) groups. 

• Discussing and dispelling misconceptions about 

family recovery support groups. 

• Exploring the challenges and benefts of 

participation in family recovery support groups. 

• Actively linking family members to communitybased recovery support groups that are in 

alignment with the recovery support the client is 

participating in. 

• Offering space in family counseling sessions to 

explore family members’ refections on recovery 

support group participation (e.g., likes and 

dislikes, education on SUDs and their effects 

on families, coping strategies, differences 

between recovery support and family counseling 

approaches). 

There are a number of family-focused, 

community-based mutual-aid groups with which 

you should be familiar. The mostly widely available 

U.S. groups are 12-Step groups like Al-Anon. 

Substance Use Disorder Treatment and Family Therapy 

However, other family-focused mutual-aid groups 

are available in some areas and online, including 

Families Anonymous and SMART Recovery Family 

and Friends. You should be familiar with both local 

and online family recovery support groups and 

maintain up-to-date contact information so that 

you can easily link family members to appropriate 

recovery supports. 

12-Step Groups 

The oldest mutual-help group for family members 

is Al-Anon Family Groups. It was started in 1951 

(Al-Anon Family Group Headquarters, Inc., 

2016) in recognition of the need among family 

members of people recovering from AUD to 

gather together and help one another learn 

how to cope with the stress of living with a 

person who has a chronic, debilitating illness. 

Al-Anon is based on the 12 Steps of AA (Al-Anon 

Family Group Headquarters, Inc., n.d.) and helps 

family members learn self-care and stress coping 

strategies, such as letting go of responsibility for 

a relative’s substance use and allowing him or her 

to experience its natural consequences. Family 

members learn to focus on their own mental, 

physical, emotional, social, and spiritual needs 

while still supporting their relative’s recovery. 

Other 12-Step recovery groups for family members 

are based on the Al-Anon model. Nar-Anon is for 

family members of people with SUDs other than 

AUD; Co-Anon, for family members of people with 

cocaine use disorder. Adult Children of Alcoholics 

is for adults with a parent who has AUD, and 

Alateen is for adolescents with a parent who has 

AUD. 

Mutual-Help Groups for Family Members of 

Individuals With Co-Occurring Disorders 

The National Alliance on Mental Illness (NAMI) 

offers peer-led psychoeducation courses for 

families, partners, and friends of people with 

mental illness to help them understand the 

illness and increase their coping skills. These 

activities, which vary in length and in frequency 

of meeting, empower participants to become 

advocates for their family members. These groups 

can help family members (NAMI, 2019): 

70 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

COUNSELOR NOTE: SEE FOR YOURSELF! ATTEND OPEN RECOVERY 

SUPPORT GROUP MEETINGS 

If you have never attended a recovery support group meeting for yourself or as a family member of 

someone with an SUD, you would beneft from attending a few open meetings to understand the concepts 

and to observe the principles that might be helpful to clients and family members. Anyone can attend a 

recovery support meeting that is open to the public. In meeting directories of 12-Step groups like Al-Anon, 

there is designation of “open” in the description to let you know that the public is welcome to attend. A 

beneft of attending meetings is that you can enhance your ability to prepare family members for attending 

recovery support groups and give an overview of what to expect at a meeting. For example, attendees can 

say “pass” if they are not interested in speaking. You can also answer questions about issues that come up 

in recovery support groups that might seem to confict with family counseling. For example, in Al-Anon 

groups, family members may be encouraged to “detach with love” from the family member with the SUD. 

This idea might be confusing and in confict with some family counseling approaches that guide family 

members to get involved in close monitoring of the behavior of the person with the SUD, including drug 

testing. You can help family members reframe this slogan from detaching emotionally to a suggestion—for 

example, not to take responsibility for the family member’s substance misuse, while continuing to support 

and love them. 

• Improve coping skills. 

• Find strength in sharing their experiences. 

• Avoid judging another’s pain. 

• Reject guilt and fnd greater self-acceptance. 

• Embrace humor as healthy. 

• Accept that they cannot solve every problem. 

• Understand that mental disorders are chronic 

illnesses. 

Case Management 

Case management is a psychosocial intervention 

that assesses major life concerns (e.g., substance 

misuse), develops an action plan, actively 

links clients to community-based resources, 

coordinates care, and monitors participation in 

services (Rapp, Van Den Noortgate, Broekaert, & 

Vanderplasschen, 2014). A meta-analysis of studies 

on clients with SUDs found that case management 

interventions were associated with better 

outcomes than standard treatment in active linkage 

to and retention in ancillary and SUD treatment 

services (Rapp et al., 2014). 

Family case management addresses not only the 

needs of the client with an SUD, but also family 

issues related to the client’s substance misuse. 

For example, criminal behavior, unemployment, 

fnancial and food insecurity, domestic violence, 

and child maltreatment are often present in families 

where one or more family members are misusing 

substances. Family case management is for families 

who are or should be involved intensely with larger 

systems, which include the workplace, schools, 

healthcare clinics, the criminal justice system, foster 

care and child welfare agencies, mental health 

facilities, and faith-based organizations. People 

with SUDs can receive family case management 

services in a variety of settings, including specialty 

SUD treatment programs, mental health service 

programs, adult drug courts, family courts, and 

child welfare agencies. 

If your clients need intensive case management, 

your role as an SUD treatment provider is to link 

them and their families to specialized services. 

These services can range from less intensive (e.g., 

general case management support services) 

Chapter 3 71 
TIP 39

to more intensive (e.g., wraparound services, 

assertive community treatment programs) (Rapp 

et al., 2014). If clients and their families need less 

intensive case management services, act as a 

community liaison by initiating contact with other 

agencies that can provide services to them. You can 

inform clients about resources in the community, 

collaborate with other service providers, and 

advocate for clients and their families when 

needed. 

Family Peer Recovery Support Services 

Peer recovery support services for people with 

SUDs have demonstrated effcacy in helping 

people initiate and sustain recovery (Bassuk, 

Hanson, Greene, Richard, & Laudet, 2016). Peer 

recovery support services for family members are 

also available. A family-focused peer recovery 

support specialist is a nonclinical provider who is 

trained and supervised in providing education, 

support, and resources to family members who 

have a family member with an SUD. Family 

peer recovery support specialists have lived 

experience of having a family member with an 

SUD, mental disorder, or co-occurring disorder. 

Family peer recovery support specialists 

understand the perspective of family members 

living with the effects of substance use behaviors 

and the challenges and successes of recovery. 

They provide education and emotional support 

to family members and actively link them to 

Substance Use Disorder Treatment and Family Therapy 

Meeting complex family needs 

requires coordination across 

systems. Most families with 

substance use disorders are 

involved in multiple service 

delivery systems (e.g., child 

welfare, health, criminal justice, 

education). Coordination and 

collaboration prevents conficting 

objectives and provides optimal 

support for family members.” 

(Werner, Young, Dennis, & 

Amatetti, 2007, p. 13) 

family-based resources in the addiction 

treatment, mental health, criminal justice, and 

child welfare service systems. Family peer 

recovery specialists also introduce and actively 

link family members to community-based 

recovery support services like Al-Anon. 

You should become familiar with family peer 

recovery support services in your community 

so that you can actively link family members 

to a peer recovery support specialist who can 

help family members follow through on their 

own recovery goals in concert with the family’s 

treatment plan. 

RESOURCE ALERT: FAMILY-FOCUSED RECOVERY SUPPORT GROUP 

ONLINE RESOURCES 

Faces & Voices of Recovery Family- and FriendFocused Mutual Aid Groups 

https://facesandvoicesofrecovery.org/resources/ 

mutual-aid-resources/ 

Friends of Recovery Family Resources 

https://for-ny.org/family-resources 

SMART Recovery Family & Friends 

www.smartrecovery.org/family 

72 Chapter 3 
Chapter 3—Family Counseling Approaches TIP 39

CLINICAL SCENARIO: DEBBIE’S CASE MANAGEMENT 

The following scenario, developed by the consensus panel, describes strategies for providing case 

management. 

Debbie, a 24-year-old single mother of a 4-year-old, received general public assistance, which kept her 

involved with the child welfare system. Her Child Protective Services (CPS) social worker noted that Debbie’s 

fnancial and parenting diffculties were related to her alcohol misuse. After multiple attempts to achieve 

stable recovery in outpatient treatment, Debbie was faced with losing custody of her child. Debbie’s 

daughter was placed in foster care. It was at this time that Debbie entered an inpatient program for women 

with SUDs. 

After Debbie’s completion of the inpatient program, she transitioned to a continuing care program. There, 

the counselor initiated family-centered treatment. Debbie asked a female friend from church to attend 

these sessions as a CSO. The counselor contacted the CPS case manager and collaborated with her to start 

supervised visits between Debbie and her daughter. Debbie’s friend agreed to be present and supervise 

the visits. 

As Debbie made progress in SUD treatment, the frequency and length of the visits increased. After a year 

in recovery, the counselor and CPS case manager recommended family reunifcation for Debbie and her 

daughter. Unfortunately, the court hearing was scheduled for 3 weeks after the start of the kindergarten 

program Debbie had enrolled her daughter in. The counselor recognized that delaying the daughter’s entry 

into the class might create more adjustment stress for the child, potentially resulting in school problems. 

Debbie told her counselor she was already worried about the stress of readjustment for herself and her 

daughter when the daughter returned home. The counselor and case manager collaborated to seek 

an earlier court date, giving Debbie and her daughter time to adjust to living together again before the 

daughter entered the school program. 

The counselor encouraged CPS and the larger criminal justice system to consider the needs of the family 

system in adjudicating Debbie’s case. This family-focused SUD intervention incorporated some family case 

management activities, including service linkages, collaboration and coordination with other agencies, and 

client advocacy. 

Relapse Prevention for Families 

Just as people with SUDs are at risk for a return 

to substance misuse after initiating recovery, 

family members can also experience a “relapse” 

or return to old behaviors and strategies for 

trying to manage the stress of living with a 

relative’s active substance use. Family members 

are often acutely aware of the signs that a relative 

is using again. Seeing such signs may activate 

family members’ anxiety, anger, and feelings of 

helplessness; it can trigger old behaviors like 

blaming, shaming, ineffective communication, 

neglecting self-care, and becoming overly 

responsible for family functioning. Family members 

may reengage in risk behaviors like smoking, 

drinking, and overeating to manage their stress. 

A seemingly small cue that the relative has 

returned to substance use can set off a family 

member. These cues can be linked to previous 

traumatic events. For example, Bev’s husband 

(Harry) is a police offcer. When Harry is not 

drinking, he leaves the car in the driveway. When 

he is drinking, he puts the car in the garage so that 

neighbors will not notice that he is drunk. When 

Bev sees the car in the garage, she remembers the 

many times that Harry came home drunk. Bev goes 

Chapter 3 73 
TIP 39

into a panic and starts screaming at him when she 

sees the car in the garage, even though Harry has 

not been drinking. 

The same principles of relapse prevention 

counseling apply to both family members and 

the individual with the SUD. Family members can 

create their own relapse prevention plans if you 

help them: 

• Identify their own triggers or cues that signal a 

return to old behaviors. 

• Identify cognitive distortions (e.g., all-or-nothing 

thinking) that may precede a behavioral relapse. 

• Learn or reengage effective coping skills to 

manage the stress of the individual’s return to 

misuse. 

• Create a written plan for family members, 

including specifc self-care activities they can 

do, support people they can contact, and crisis 

numbers to call if the situation warrants. 

See the updated TIP 35, Enhancing Motivation 

for Change in Substance Use Disorder Treatment 

(Substance Abuse and Mental Health Services 

Substance Use Disorder Treatment and Family Therapy 

Administration, 2019a; https://store.samhsa.gov/ 

product/TIP-35-Enhancing-Motivation-for-Changein-Substance-Use-Disorder-Treatment/PEP19-

02-01-003), for more information about relapse 

prevention plans. 

Where Do We Go From Here? 

Family counseling approaches in SUD treatment 

refect the principles of systems theory. Such 

approaches view the client as an integral part of 

the larger family system. In SUD treatment, family 

counseling focuses on how the family infuences 

one member’s substance use behaviors and how 

the family can learn to respond differently to 

substance misuse. When family members change 

their behavioral responses to substance misuse, 

the entire family system changes, leading to 

improved health and well-being for everyone. 

Chapter 4 advances the systems theory approach 

and provides counseling strategies to apply 

during intakes, initial sessions, and other stages of 

treatment. 

74 Chapter 3 
Chapter 4—Integrated Family Counseling To 

Address Substance Use Disorders 

 KEY MESSAGES 

TIP 39 SUBSTANCE USE DISORDER TREATMENT AND 

FAMILY THERAPY

• Consider the family from the client’s point of 

view—that is, whom the client would describe 

as a family member or a signifcant other. 

• Many families or family members may be 

hesitant to participate in treatment at frst. 

However, some family members are willing to 

attend at least an initial session. 

• Integrating family-based counseling 

techniques into substance use disorder (SUD) 

treatment is possible along a continuum of 

care, from assessment through the various 

stages of family counseling. 

Chapter 4 discusses common issues you may face 

as an SUD treatment provider using an integrated 

family counseling approach. It also presents 

family-centered counseling strategies you can 

use to overcome these challenges. This chapter 

will help you determine when to use family-based 

interventions across the continuum of care, whom 

to involve in those interventions, and what to 

consider when providing screening and assessment 

in a family context. It also summarizes the goals 

of family involvement in a client’s SUD treatment 

and identifes your role in providing integrated 

family counseling, along with the stages of family 

counseling. 

Family involvement can positively affect SUD 

treatment engagement and retention. Whether 

you provide individual or group treatment, family 

member psychoeducation, or counseling for 

couples or families as part of your organization’s 

treatment program, it is important to keep a familycentered focus. Because most SUD treatment 

services and reimbursement are geared toward 

individuals who initially present for treatment, the 

frst step in providing integrated family counseling 

for SUD treatment is to ask the individual client 

whom he or she considers to be family. Who are 

the signifcant people in the client’s life who can 

support the client’s recovery and also beneft from 

family-based interventions? 

The size, norms, and values of a person’s social 

network and the quality of social and family 

support affect the recovery of the individual with 

an SUD. Positive social/family support (especially 

support for recovery) is related to long-term 

abstinence and recovery, and negative social/ 

family support (e.g., interpersonal confict, social 

pressure to use) is related to increased risk for 

returning to substance misuse (Brown, Tracy, Jun, 

Park, & Min, 2015; Cavaiola, Fulmer, & Stout, 2015; 

Moos & Moos, 2007; Worley et al., 2014). These 

associations occur in diverse populations with 

people who use various substances. Social support, 

bonding with family members, goal direction, and 

monitoring by families help clients’ recovery efforts 

(Moos, 2011; Moos & Moos, 2007). 

Engaging family members in treatment is the key 

to decreasing interpersonal confict among family 

members and increasing family bonding and other 

elements of recovery support for the client. 

75 
TIP 39

Appropriateness of Integrated 

Family Counseling for SUDs 

It is your responsibility to provide a safe, 

supportive environment for all participants 

in family counseling. Generally, you can use 

integrated family counseling to treat SUDs when 

there are no health or legal constraints and no 

current risk of intimate partner violence in the 

family or couple with whom you are working. 

However, engaging clients and their families in 

family-based interventions without frst carefully 

assessing for such constraints, and particularly for 

violence in the family, can result in less effective 

treatment and increased risk of physical or other 

forms of abuse. 

Only in rare situations are family-based 

interventions and counseling inadvisable, 

inappropriate, or counterproductive. Integrated 

family counseling is often an excellent way to 

approach the treatment of SUDs, but you may 

sometimes need to rule it out because of safety, 

health, or legal constraints. Several factors, 

including the presence of violence in the family, 

can infuence your decisions about involving family 

members in treatment. The following sections 

discuss these factors. 

History of Family Violence 

Intimate Partner Violence 

Domestic violence is a serious issue among 

people with SUDs. Before considering couples 

or family counseling, evaluate the client’s history 

of violence, particularly in family contexts. 

Ask about current violence and criminal justice 

involvement and adjust your counseling approach 

accordingly. For example, if a restraining or 

protection from abuse order prohibits spouses 

from seeing each other, make sure that the spouse 

who has been violent does not have direct contact 

in your treatment program with the protected 

partner. To the extent possible, arrange for 

separate treatment for the client who is violent, 

such as in a Batterer’s Intervention Program, and 

individual counseling focused on safety planning 

for the partner who has been a victim of violence. 

Experts in the feld of domestic violence 

generally do not recommend joint counseling 

Substance Use Disorder Treatment and Family Therapy 

for couples in which intimate partner violence 

has occurred (National Domestic Violence Hotline, 

2014) because: 

• It is not effective. 

• It is unsound practice if based on the 

assumption that both people are responsible for 

the violence. 

• It is unsound practice if sessions focus on 

improving communication instead of the abusive 

behavior. 

• It can be dangerous; the nonabusing partner 

may be punished after being honest during 

sessions. 

Violence is often a behavioral expression 

of anger, but anger does not always result 

in violence. Family members can learn how 

to express anger appropriately and safely via 

structured family counseling. Extreme anger or 

threats of violence, however, rule out family 

counseling. 

When screening and treating families in which 

violence occurs, do not practice outside the scope 

of your training. Consult your clinical supervisor 

to determine the appropriate course of action if 

you believe that any family member is in danger 

of domestic violence. 

Child Abuse 

Child abuse and neglect are serious 

considerations in the delivery of SUD treatment. 

Children in violent households have more physical, 

mental, and emotional problems than do those 

in nonviolent homes. Substance misuse and child 

maltreatment must be addressed at the same time 

to ensure children’s safety—but do not include 

children in family sessions if there is current risk of 

child abuse by family members. 

Once you have addressed safety issues, you 

may still be able to engage parents in couples 

counseling that focuses on parenting issues. Refer 

all family members for appropriate counseling, 

including children. If you suspect a parental fgure 

in the family is abusing a child, consult your 

supervisor immediately and follow agency policy 

and mandated reporting laws in your state to 

report the abuse. 

76 Chapter 4 
Chapter 4—Integrated Family Counseling To Address Substance Use Disorders TIP 39

COUNSELOR NOTE: INTERVENING WITH A DOMINEERING FAMILY 

MEMBER 

A systems approach to SUD treatment assumes that all family members contribute roughly equally to the 

process and have similar degrees of power and control. A domineering member disrupts this balance. If 

there is a dominant family member, but no violence, integrated family counseling for SUDs is likely still 

appropriate. 

When a family member dominates the conversation and blocks exploration of sensitive topics, 

reframe the domineering behavior. For example, acknowledge that this family member has considerable 

responsibility for protecting the family and that his or her intention is to take care of the family. This will help 

you work together with the dominant family member (Szapocznik, Hervis, & Schwartz, 2003). You then can 

begin to question the family about how the behavior is working or not working for the family. 

All participants in couples and family counseling should have a voice and a safe place to raise important 

issues, even if a domineering family member does not want to discuss those issues. Another strategy is 

to block interruptions by the domineering family member and create pauses in the conversation to 

encourage other family members to speak (Gehart, 2018). Doing so begins to shift the power dynamics in 

the family system. 

Severity of Health Issues 

Substance Withdrawal 

Given the intensity of physical and emotional 

instability people in withdrawal experience, it 

is not practical to attempt integrated family 

counseling during this process. Until the person 

stabilizes after withdrawal, provide the family with 

psychoeducation about SUDs and the effects of 

substance misuse on the family system. Continue 

to assess the physical and emotional stability of 

the client with the SUD over time; protracted 

withdrawal symptoms can affect the ability to 

participate in family counseling. 

In addition, a parent in withdrawal may experience 

intense feelings, which can increase the risk of child 

maltreatment. During this time, provide additional 

support to the family and make sure that children 

know how to fnd safe adults to help and protect 

them when needed. 

Serious Mental Illness 

Clients with SUDs often have co-occurring 

mental disorders. Family counseling is generally 

appropriate for clients with SUDs and mental 

disorders—and in fact, some family-based 

interventions are particularly effective for 

specifc co-occurring mental disorders, including 

severe adult anxiety disorders (Gehart, 2018). 

A review of the evidence found that any kind 

of brief psychoeducation, including familybased interventions, reduces relapse, increases 

medication adherence, and improves social 

functioning of people with serious mental illness 

(SMI; Zhao, Sampson, Xia, & Jayaram, 2015). 

SMI is a diagnosable mental, 

behavioral, or emotional disorder 

that an adult has experienced 

in the past year that causes . . . 

serious functional impairment 

that substantially interferes 

with or limits at least one major 

life activity. Examples include 

schizophrenia, bipolar disorder, 

and major depression.” (www. 

samhsa.gov/dbhis-collections/smi) 

Chapter 4 77 
TIP 39

Family counseling may not be helpful for clients 

who are actively suicidal or psychotic. Families 

of clients in these states may have other goals 

they would like to address in family counseling. 

However, your primary goal in cases of active 

suicidality or psychosis is to provide treatment 

to stabilize clients. Family-based interventions 

with clients who have co-occurring disorders 

should focus on education about the mental 

disorder, the effects of SUDs and co-occurring 

mental disorders on families, and development 

of coping skills to manage those effects. For 

example, address medication nonadherence as a 

risk behavior, like substance misuse, and help the 

family engage in positive reinforcement strategies. 

(See Chapter 3 for more information about positive 

reinforcement strategies). 

Signifcant Cognitive Impairment 

Cognitive impairment can include short- and 

long-term memory problems as well as diffculties 

in learning, concentration, and decision making 

(U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, 2011). 

It may be linked to extensive substance misuse or 

head trauma and may cause disruptive behavior. 

Family counseling is not as effective with clients 

who have signifcant cognitive impairment. 

However, you can still consider integrated family 

counseling and family-based SUD interventions for 

clients with such impairments. Family counseling 

can be helpful if the client is not overly disruptive, 

is also involved in individual counseling or other 

rehabilitation treatment, and is stabilized on 

appropriate medications as needed. Your goals 

in this situation are to help all family members 

understand how to cope with behavioral 

disruptions and support the client to remain 

abstinent from alcohol and drugs. 

Mandated Family Counseling 

Another factor that can complicate any 

counseling process is external coercion. One or 

more family members, particularly those with SUDs, 

can be mandated to treatment by the criminal 

justice system, Child Protective Services, or an 

Substance Use Disorder Treatment and Family Therapy 

employer. In these circumstances, the person who 

has been mandated is likely to be angry and to try 

to get you, as well as family members, to focus on 

how unfair the situation is. 

Your frst priority should be to form an alliance 

with the mandated client without “taking sides” 

with the client regarding the need for treatment. 

Motivational interviewing (MI) strategies can help 

you build a therapeutic alliance and help the client 

and family members resolve their ambivalence 

about participating in family counseling (LloydHazlett, Honderich, & Heyward, 2016). 

MI is an evidence-based counseling approach 

that has demonstrated effectiveness with clients 

who are mandated to treatment and has been 

used as an intervention to help enhance client 

motivation to participate in formal treatment 

(Miller & Rollnick, 2013). Although MI is used 

primarily in individual and group counseling, you 

can adapt MI principles and counseling strategies 

in family sessions with a focus on changing 

substance use that negatively affects family 

functioning (Lloyd-Hazlett et al., 2016). See TIP 35, 

Enhancing Motivation for Change in Substance 

Use Disorder Treatment (Substance Abuse and 

Mental Health Services Administration [SAMHSA], 

2019a; https://store.samhsa.gov/product/TIP-35-

Enhancing-Motivation-for-Change-in-SubstanceUse-Disorder-Treatment/PEP19-02-01-003) for 

more information about MI. 

Address the issue of communicating with the 

referring organization. Clarify that your primary 

concern is the family’s well-being, and share with 

them any requirements you must follow regarding 

release of information or progress to the referring 

organization. Inform all family members about 

agency policies, their rights and responsibilities as 

clients, and your legal/ethical responsibilities as a 

counselor. Have family members sign all pertinent 

releases as part of this informed consent process. 

78 Chapter 4 
Chapter 4—Integrated Family Counseling To Address Substance Use Disorders TIP 39

COUNSELOR NOTE: THINK OUTSIDE THE BOX 

If you are an SUD treatment provider who is not familiar with family work, it can be helpful for you to think 

“outside the box” when working with clients in groups. Remember to think about clients not as separate 

isolated individuals, but as part of a family system that can be a potentially important source of recovery 

support for the client. Confict in a family system is not necessarily a threat to the client’s recovery. Familybased interventions can help families resolve conficts and fnd ways to positively reinforce the client’s 

treatment and recovery goals. Encouraging clients to participate in family-based interventions can improve 

family relations and support the client’s recovery. Encourage clients to invite family members to familycentered treatment activities at your agency. If your agency does not provide family counseling, refer 

clients, when appropriate, to family counselors who are knowledgeable about the impact of SUDs on the 

family system. Communicate and collaborate with family counselors in your community and coordinate 

with them to ensure that the client and family are receiving the best possible care. 

Whom To Involve in Integrated 

Family Counseling for SUDs 

From individual to multiple family counseling 

formats, family-based interventions can include 

a combination of family members (e.g., couples 

or siblings), the entire family, an individual family 

member, or several family groups at one time. In 

family counseling, the units of treatment are the 

family and the individual within the context of the 

family system. 

It is up to clients to identify whom they would 

like to include in family counseling. Make your 

best efforts to include anyone the client thinks 

is signifcant—anyone who provides emotional or 

fnancial support, maintains the household, or has 

a strong, enduring social or emotional bond with 

the client. The term “family” can mean people 

living in the client’s household, immediate family 

members (e.g., a parent, spouse, intimate partner, 

siblings, children), and extended family members 

(e.g., grandparents). Some clients want no family 

involved in treatment or may include or exclude 

some family members. 

Explore the client’s ambivalence and reasons for 

excluding family members. You can offer your 

ideas about why you think it might be important 

or helpful to include specifc family members, but 

honor the client’s autonomy and right to give or 

not give permission to include family members 

in treatment. 

Once the client gives permission, there are several 

factors you should consider in determining 

whether and how to involve family members in 

family sessions. These considerations include: 

• Geographic constraints: Some clients have 

no signifcant family members close enough 

to attend family sessions in person. Using 

secure teleconferencing and videoconferencing 

technology is one strategy for including family 

members in important conversations with 

the client. Another strategy might be to hold 

longer family sessions (e.g., 2 hours) or multiple 

sessions over consecutive days with family 

members who are able to travel and attend 

family counseling. 

• Work and scheduling conficts: Work or other 

scheduling conficts of family members can be 

obstacles to their attendance at family sessions. 

Sometimes these are legitimate concerns and 

sometimes they are expressions of ambivalence 

about participating in family counseling. 

Strategies for overcoming these obstacles 

include providing multiple session times outside 

of normal work hours and exploring family 

members’ reluctance to participate in family 

counseling via an individual session or phone 

consultation. 

• Disruptive behavior: You may need to exclude 

from family sessions a family member who 

is continually angry, blaming, or disruptive. 

Address this issue with the family and the 

individual separately, explore options for 

Chapter 4 79 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

addressing that family member’s needs (e.g., 

individual counseling, referral to other support 

services), and then reinvolve the individual in 

family sessions when his or her needs have been 

addressed. 

• Family subsystems: One helpful strategy for 

managing the family counseling process is to 

do individual or subsystem work with different 

constellations of family members, when needed. 

For example, if parents have overly rigid 

or loose boundaries, help them reestablish 

appropriate boundaries and authority in the 

parental subsystem before including children in 

family sessions. Do not include children in family 

sessions if the focus of the work is solely the 

couple’s relationship. 

• Refusal to attend counseling: Strategies to 

include relatives who refuse to attend sessions 

include: 

- Arranging an empty chair in the room to 

represent that family member and addressing 

the absent family member metaphorically. 

- Calling the family member who is not present 

during the family session to enlist his or her 

help in answering a question that has come 

up in the session. 

Decisions about which and how family members 

participate in family counseling depend on the 

client’s wishes, family members’ willingness, and 

your judgment of what is most helpful for the 

entire family. 

Screening and Assessment in 

Integrated Family Counseling 

Individual Assessment With a Family 

Focus 

Assessment is one of the most important 

components of any SUD treatment program. 

Individual assessment should be family focused. 

Gathering information about the client’s family: 

• Yields a more thorough, and perhaps more 

accurate, family history. 

• Presents an opportunity to confrm and clarify 

information on the client. 

• Provides insight into the context where 

substance misuse most often occurs and where 

it may have started or accelerated. 

• Sets the tone for a continuing focus on the 

family. 

• Identifes family resources to help plan 

long-term care. 

• Documents specifc information that can 

determine treatment goals. 

Conduct a comprehensive psychosocial assessment 

with the individual who is identifed as the primary 

client with the SUD as part of your standard 

assessment procedures. Assessments in SUD 

treatment programs focus on the individual’s 

current and history of substance use. Other 

information gathered during an individual 

assessment that is helpful to understanding current 

family functioning includes the client’s: 

• History of mental disorders. 

• History of family-of-origin SUDs or mental 

disorders. 

• History of domestic violence. 

• History of trauma. 

• History of physical, emotional, verbal, or sexual 

abuse. 

• History of criminal justice involvement, including 

arrests for driving under the infuence and 

periods of incarceration. 

• Occupational and work history, including 

periods of unemployment or underemployment. 

• Sexual and reproductive health history, including 

HIV status, safe sex practices, sexual or gender 

identity, and sexual practices. 

During individual assessment, emphasize the 

importance of including family members in 

treatment, encourage discussion about who 

might be involved in family treatment, and explore 

the current family situation from the client’s 

perspective. Including family members at the 

start of SUD treatment gives you an opportunity 

to provide education about the biological and 

psychosocial aspects of SUDs. It also helps uncover 

client and family strengths and begins the process 

of preparing family members for changes to the 

family system that will happen as the client initiates 

recovery (van Wormer & Davis, 2018). 

80 Chapter 4 
Chapter 4—Integrated Family Counseling To Address Substance Use Disorders TIP 39

Here are some questions that can start the 

conversation: 

• Who can support you while you are in 

treatment? 

• Who in the past has been the most helpful to 

you? 

• Who is taking care of your children while you are 

in treatment? 

• Does anyone in your family use substances? 

• Is anyone in your family recovering from a 

substance use disorder? 

• How would your family react to your recovery 

from the substance use disorder? 

• What does your family think about your being 

here? Did you tell them? Why or why not? 

• How is substance use an important part of your 

family life? 

• Who in your family or support system would you 

like to be involved in your treatment? 

• Is it okay if we talk about the ways that your 

family can be involved in treatment? 

This conversation sets the stage for the initial 

family interview. If the client agrees to family 

involvement in treatment, get signed privacy/ 

confdentiality releases and then schedule an initial 

family interview. 

Family Interview 

Before determining whether to use family-based 

interventions, you should conduct a family 

interview. The family interview is part of the 

assessment process. Although family members 

may feel ambivalent about getting involved in 

treatment, they are often willing to attend at 

least an initial interview. 

The primary focus is to engage the family and 

begin to develop an alliance with each family 

member. You can also use the initial interview 

to determine how the family functions, identify 

major family problems, and identify the family’s 

perception of how the SUD has affected their 

family and each member (Schumm & O’Farrell, 

2013b). You should also make a preliminary 

determination of any current or history of family 

violence and physical or sexual abuse because 

safety is paramount. 

Other tasks for the family interview include: 

• Determining the need for further screenings and 

assessments of SUDs and mental disorders for 

individual family members. 

• Determining whether an immediate intervention 

or referral is needed or whether the family can 

return for a more thorough assessment later. 

• Telling the family what will be involved in a more 

extensive assessment. 

• Evaluating the appropriateness of including 

children in family sessions and when it would be 

most effective to include them. 

• Providing information about the treatment 

process including schedules, treatment 

activities, staff involvement, and program 

expectations. 

• Suggesting an out-of-session assignment for 

each relative present (if he or she agrees to 

further counseling) as a way for them to take a 

small step toward change (van Wormer & Davis, 

2018). 

• Scheduling an initial family counseling session 

for a more comprehensive family-based 

assessment. 

Family-Based Assessment 

A family-based assessment differs from an 

individual assessment. The focus of a family 

assessment is not the history of substance misuse 

of the identifed client, but an evaluation of 

current family functioning, the history of substance 

misuse over time and across generations, and the 

role of substance misuse in the development of 

family problems (Schumm & O’Farrell, 2013b). 

You can also explore the history of the individual’s 

SUD over time, but always link this history to 

the development of family system dynamics and 

functioning over time (Schumm & O’Farrell, 2013b). 

Family counseling assessments focus on family 

interactions and family strengths. 

The primary assessment task is to observe 

family interactions during sessions to determine 

alliances, conficts, interpersonal boundaries, 

and communication and meaning. In a family 

systems approach to assessment, the counselor 

identifes the interactional behavior sequences that 

contribute to the problem (i.e., substance misuse), 

Chapter 4 81 
TIP 39

 

Substance Use Disorder Treatment and Family Therapy 

including the actions and reactions of everyone in 

the system and the associated meanings (Gehart, 

2018; see the “Family Behavior Loop Mapping”

section of Chapter 3). 

Ask each family member to describe his or her 

theory about the client’s substance use behavior. 

Their input will help you understand how the family 

system is organized around and reacts to the 

behavior (Gehart, 2018). The next task is to explore 

the family’s strengths and positive ways they have 

managed the disruptions to family life caused by 

substance misuse. Exhibit 4.1 offers an alternative 

approach. 

EXHIBIT 4.1. A Narrative Approach to Family Assessment 

One family assessment strategy that might be particularly useful in SUD treatment comes from narrative 

therapy, a nonpathologizing approach to family and community practice originally developed by Michael 

White and David Epston (1990). It involves a two-step process, which includes (1) mapping the infuence 

of the identifed problem on family life and (2) mapping the infuence of family members on the problem 

(Gehart, 2018). When you engage in this process, use externalizing language (e.g., say “the drinking” 

instead of “Dad’s drinking”). This puts the problem instead of the person with the problem in the center 

of the conversation, where family members can work as a team to lessen the problem’s effects on family 

functioning. 

Some issues you can ask family members about during this mapping process (Gehart, 2018) include: 

• Mapping the effects of substance misuse on the family by asking questions like: 

- How does substance misuse affect your mood, eating, sleeping, feelings of panic, worry or obsessive 

thinking, thoughts about hurting yourself or others, or hurtful behavior toward yourself or others? 

- How does substance misuse affect your relationships at home, work, or school, or with your extended 

family or social network? 

- How does substance misuse affect your social and recreational activities? 

- How does substance misuse affect your daily functioning and ability to meet your responsibilities at 

home, work, or school? 

- How does substance misuse affect your spiritual life, beliefs, or sense of purpose in life? 

• Mapping the effects of family members on substance misuse by asking questions like: 

- What are some ways that you have used to lessen the negative impact of substance misuse on yourself 

or other family members? 

- Are there times when you can keep substance misuse from negatively affecting your thoughts, feelings, 

eating, sleeping, or other daily activities? 

- What are some ways that you were able to do this? 

- Are there times when you can protect your relationships from the negative effects of substance 

misuse? 

- What are some ways that you were able to do this? 

- Are there ways that you can maintain a sense of meaning and purpose, despite the negative infuence 

of substance misuse? 

Use a white board, easel with newsprint, or paper to list the infuence of the problem and the infuence 

of family members on the problem. Doing so creates a map of how the family system organizes around 

substance misuse, and also how the family’s strengths and expertise defy, stand up to, or take power away 

from substance misuse. 

82 Chapter 4 
Chapter 4—Integrated Family Counseling To Address Substance Use Disorders TIP 39

Strengths Assessment 

Conduct a strengths assessment with the client 

and all family members involved in treatment. The 

goal of this assessment is to identify their current 

coping skills and abilities; family, social, and recovery 

supports; motivation and commitments to change; 

self-effcacy; and other sources of recovery capital. 

This will give you a baseline of family coping 

skills and client-centered knowledge, values, and 

resources to build on in helping the family develop a 

treatment and recovery plan. Recognizing different 

strengths available to clients is an important element 

of conducting an effective strengths assessment. 

The term “recovery capital” refers to the internal 

and external resources that a person draws on 

to begin and sustain recovery. Internal resources 

include client values, knowledge, skills, self-effcacy, 

and hope. External resources include employment; 

safe housing; fnancial resources; access to health 

care; as well as social, family, spiritual, cultural, and 

community supports (White & Cloud, 2008). 

A strengths-based assessment is more than simply 

asking clients to name their strengths at initial 

intake (White & Cloud, 2008). Some clients will 

have diffculty identifying their strengths or say that 

they don’t have any. As part of the family history, 

conduct a careful and thorough exploration of 

family members’ internal and external resources, 

how they have overcome adversity in the past, and 

how they have previously managed problems like 

SUDs, physical illness, or mental illness. 

Uncovering exceptions or unique outcomes when 

SUDs and mental disorders have overwhelmed 

family functioning is key to helping the family 

expand awareness of their values, strengths, 

competencies, and abilities. View strengths broadly 

to include family members’ values, interpersonal 

skills, talents, and knowledge gained from previous 

efforts to overcome SUDs or adversity (including 

trauma). Also consider the family members’: 

• Spirituality and faith. 

• Personal hopes, dreams, and goals. 

• Family, friend, and community connections. 

• Cultural and family narratives of resilience. 

• Ability to heal. 

• General skills in daily living. 

There are four broad categories of strengths to 

explore in this assessment (Rapp & Goscha, 2012): 

• Personal attributes are personal qualities 

associated with identity, such as honesty, 

assertiveness, warmth, compassion, and caring. 

• Talents and skills are abilities and competencies 

a person has developed, such as being good 

at managing money, fxing cars, or using a 

computer. 

• Environmental strengths are external resources 

that can help a person achieve his or her 

recovery goals. External resources can include 

a safe living environment, supportive family 

and friends, affliation with a spiritual or faithbased community, and participation in recovery 

support groups. 

• Interests and aspirations are activities that 

enrich a person’s life (e.g., hiking, dancing, 

traveling), along with goals and dreams that 

motivate forward movement in life (e.g., wanting 

to get a high school equivalency degree, learn 

to play the guitar, or get a job helping others). 

In addition to doing an initial strengths assessment, 

maintain a strengths-focused lens throughout 

counseling to set a positive tone for family sessions 

and enhance family members’ motivation to 

address challenging problems (Tuerk, McCart, & 

Henggeler, 2012). 

Genograms 

Initially conceptualized by Murray Bowen (1978) 

as part of an intergenerational family model, a 

genogram is a comprehensive pictorial map of 

a family’s health, communication, relationship, 

vocational, and other psychosocial patterns within 

and across three or more generations of the family. 

It provides information about marriages, divorces, 

births, geographical locations, deaths, and illness 

over the generations. It also depicts family patterns, 

events, and relationships, including emotional 

closeness, enmeshment, confict, and emotional 

cutoffs (Platt & Skowron, 2013). Genograms are 

useful to discuss in psychoeducational sessions, 

family interviews, and assessments (Platt & Skowron, 

2013). The genogram is both an assessment 

instrument and a counseling intervention (Gehart, 

2018). As an assessment tool, it can help identify 

intergenerational dynamics. As an intervention, it 

Chapter 4 83 
TIP 39

can help family members see how they are living 

out dysfunctional family patterns, roles, and rules 

(Gehart, 2018). 

A genogram can also help family members see 

their current problems from a wider perspective 

and identify strengths and resources. You can also 

use a genogram as a project the family works on 

together to enhance communication and bonding. 

A genogram can help you identify intergenerational 

relationship patterns and generate hypotheses 

about counseling interventions (Shellenberger, 

2007). 

The genogram is fexible. Tailor it to the needs and 

current challenges of the family. Some of the themes 

you can highlight in a genogram include: 

• Substance misuse across generations. 

• Mental illness and trauma across generations. 

• Individual and family strengths across 

generations. 

• The roles of culture and spirituality across 

generations. 

• The impact of substance misuse, mental illness, 

trauma, and family strengths on relationship 

patterns (e.g., enmeshment, confict, emotional 

cutoffs, or emotional support and closeness). 

Strategies for creating a genogram with a family 

include the following: 

• Beginning the process at the initial family 

interview. Ask family members about their 

understanding of SUDs and how their family 

member’s substance misuse has affected 

family relationships. Then trace the history 

of the problem and family dynamics to prior 

generations. Also ask about important events like 

births, graduations, marriages, and deaths and 

how those events may be linked to the current 

substance misuse (Shellenberger, 2007). 

• Asking about family members with SUDs who are 

or were in recovery and any information family 

members have about their recovery efforts. 

• Filling in as much genogram information as 

possible about current and extended family 

members. Start with the identifed client and his 

or her current spouse or intimate partner. Work 

up to include parents, stepparents, and siblings. 

Then work down to the children. 

Substance Use Disorder Treatment and Family Therapy 

• Spending time gathering information about the 

child’s relationships with parents and siblings— 

if the identifed client is one of the children 

(e.g., a teenage son)—before moving on to 

extended family. 

• Giving family members between-session 

assignments to gather more family history to 

bring back to the next family session. This can 

help family members gain further insight into how 

intergenerational family dynamics affect current 

family functioning. 

• Asking young children to draw themselves and 

other relatives, including extended family (e.g., 

aunt, uncle, grandparent) during the session or 

at home and to bring the drawing to a family 

meeting. 

• Continually adding to the genogram for a 

fuller, richer understanding of family history, 

relationship dynamics, and the role of substance 

misuse and recovery efforts in family life across 

generations. 

Genograms are not intended for an initial 

assessment only. Work on the genogram at 

different points in the treatment process to 

see how counseling may have affected family 

relationships. For example, a couple’s relationship 

might be represented as conficted initially, but 

after some couples work, the genogram might 

include the symbol for a closer, less conficted 

relationship. Genogram are a tool to assess family 

progress throughout treatment. Exhibit 4.2 shows 

common symbols used in genograms. 

The genogram in Exhibit 4.3 shows fve generations 

in American playwright Eugene O’Neill’s family, 

depicted by Monica McGoldrick (1995). The key 

to symbols depicts a slightly different version 

of how to identify family members with SUDs, 

mental disorders, physical illnesses, emotional 

closeness, confict, and cutoffs than shown in 

the key in Exhibit 4.2. It is a good example of 

how a genogram can uncover a family history of 

substance misuse. The Counselor Note on how to 

have meaningful conversations about genograms 

also gives important guidance on what clients 

and their families need to know about this helpful 

tool, including how it relates to SUD treatment 

and recovery. For more information about the 

heritability of addictions and the role of genetics 

and family history in SUD treatment and recovery, 

also see Chapter 2 (pp. 24-25). 

84 Chapter 4 
Chapter 4—Integrated Family Counseling To Address Substance Use Disorders TIP 39

COUNSELOR NOTE: TALKING TO CLIENTS ABOUT GENOGRAMS IN A 

MEANINGFUL WAY 

Most clients and families will not have heard of a genogram before, and genograms can be confusing 

without an explanation of their appearance and purpose. To get the best use of the genogram, you need to 

have a meaningful, productive discussion with clients and their families about its role and value as well as 

the process of developing a genogram. 

When talking about genograms with clients and families, be sure to discuss with them: 

• What a genogram is. For instance, you can say something like: 

- “A genogram is a way of recording and interpreting your family’s history so you can better understand 

the genetic, medical, social, and cultural aspects of your family.” 

- “A genogram is a lot like a family tree in that it is a picture that uses shapes and fgures to represent the 

people, relationships, and events in your family.” 

• How the genogram process works. Tell them things like: 

- “To develop your genogram, I’ll ask you a series of questions going back to your great grandparents. If 

you do not know some of the answers now, perhaps you can look into them between our sessions, and 

we can discuss how this family history is important to your current efforts in recovery.” 

- “Here is an example of what we will create.” (Show the example genogram in Exhibit 4.3). “We will use 

standard symbols representing individual family members and their physical and mental health history 

and specifcs on their history of substance use.” 

- “You will see me using various symbols and shapes on this genogram. Each symbol or shape has a 

specifc meaning. For instance, males are represented by a square, and females are represented by a 

circle. A pregnancy is represented by a triangle. A divorce is depicted by two lines crossing through this 

line connecting the two spouses.” (Be sure to point to the symbols and shapes on the genogram as you 

are explaining them.) 

• What types of questions you will ask. For instance, let them know you will ask things like: 

- “To whom was your grandfather married?” 

- “How many siblings does your mother have?” 

- “Tell me about any history of alcoholism in your family.” 

- “Has anyone in your family attempted or completed suicide?” 

- “Who in your family is widowed, divorced, or unmarried?” 

- “Who in your family has experienced mental health issues? What about anyone who received 

treatment for a psychiatric disorder?” 

- “What was your aunt and uncle’s marriage like?” 

- “Has anyone in your family ever been arrested or incarcerated?” 

• Why you are creating the genogram and how it can help them. You can say something like: 

- “A genogram can give you insight into the many different things that have happened in your family, 

such as negative family dynamics and family struggles, like divorce, death, and broken relationships. It 

also can help you understand why these things might have happened.” 

- “Many people are not fully aware of their family history. By recording it in a genogram, you might learn 

new information about your past and your loved ones.” 

- “A genogram is a good way to see repetitive patterns of behavior that have occurred in your family— 

especially patterns of behavior you want to stop, like abuse, confict, legal problems, or addiction.” 

Continued on next page 

Chapter 4 85 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

COUNSELOR NOTE: TALKING TO CLIENTS ABOUT GENOGRAMS IN A 

MEANINGFUL WAY (continued) 

• How the genogram can help specifcally with substance misuse. You can mention things like: 

- “Many people do not realize the extent to which their family has experienced substance-related 

problems. A genogram can help you uncover such information and show you that you are not alone in 

your struggles.” 

- “Seeing how your family has been affected by substance misuse can be a powerful reminder of the 

importance of treatment and recovery.” 

- “It is not unusual for people with substance misuse to blame themselves. But addiction has nothing to 

do with weak character or personality faws. A genogram can show you the biological roots, or ‘genetic 

loading,’ of substance misuse and why some individuals are more vulnerable to the effects of drinking 

and/or drug use than others.” 

- “The family environment—like your culture—plays a critical role in development and is an important 

infuence on how we learn to relate with others, communicate, and respond to both positive and 

negative experiences. Understanding your immediate and closest family members’ experiences with 

using substances can help reduce self-blame and shame and instead motivate you to break these 

generational cycles.” 

- “This genogram can show you how your immediate family can have both positive and negative effects 

on your current efforts toward recovery.” 

- “Understanding the infuence of your family relationships is a helpful tool for clients and their involved 

family members seeking a path toward recovery.” 

• Any feelings of discomfort that may develop as they work through the genogram. For instance: 

- “It is not uncommon for people to feel overwhelmed when looking at their completed genogram, 

especially if you see a lot of mental health or addiction issues in your family. Remember that we can talk 

through any of those feelings as needed.” 

- “Many clients fnd this to be a useful way of gaining knowledge and insight into the ways their family 

history has shaped their lives and behavior. But some people fnd the creation of their genogram to be 

emotionally diffcult. We will take things slow, and if at any time you need to stop and talk about how 

you are feeling or if you just need a break, let me know. Does that sound okay?” 

86 Chapter 4 
Chapter 4—Integrated Family Counseling To Address Substance Use Disorders TIP 39

EXHIBIT 4.2. Genogram Symbols 

Source: From Gehart. eBook: Mastering Competencies in Family Therapy: A Practical Approach to Theory 

and Clinical Case Documentation, 3E. © 2018 South-Western, a part of Cengage, Inc. Reproduced by 

permission. www.cengage.com/permissions. 

Chapter 4 87 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

EXHIBIT 4.3. O’Neill Genogram 

Source: McGoldrick (1995). Reprinted with permission of the author. 

88 Chapter 4 
Chapter 4—Integrated Family Counseling To Address Substance Use Disorders TIP 39

Goals of Integrated Family 

Counseling for SUDs 

In person-centered SUD treatment, the clients’ 

desire, ability, reasons, and need to change drive 

counseling goals. The same is true for integrated 

family counseling to address SUDs. Yet each family 

member may have different ideas about what 

he or she can gain from participating in family 

counseling. For example, parents may want their 

son to stop drinking with friends. The son may 

participate in family sessions to get his parents to 

stop fghting. The goal of each family member may 

differ, but the overarching goal is to engage the 

family in changing communication patterns that 

support the son’s substance use. 

Your overall focus in family counseling is on the 

roles, relationships, and communication patterns 

of the family system (van Wormer & Davis, 2018). 

Be aware of the core objectives of family-based 

interventions as you work with family systems to 

identify their specifc treatment goals. 

There are several core objectives of family-based 

interventions in SUD treatment: 

• Leverage the family to infuence change— 

Encourage family members to support 

and enhance each other’s desire, abilities, 

reasons, and need to make important lifestyle 

changes, including shifts away from substance 

misuse. Your goal is to help families develop 

effective coping and communication skills 

that promote recovery and prevent returns to 

substance use. 

• Involve families in SUD treatment—Get family 

members involved in treatment in some 

way. This might include family members 

attending a family psychoeducational activity 

or participating in a structured family-based 

counseling intervention, as described in Chapter 

3. Your goal is to help families recognize their 

strengths, address family dynamics, and build 

effective relationship skills. 

• Change family behaviors that support substance 

misuse—Help the family recognize behavioral, 

cognitive, and emotional responses that 

unintentionally support the client’s continued 

substance misuse. Address negative effects of 

substance misuse on family systems to improve 

functioning. 

• Prevent SUDs across generations—Help families 

recognize the intergenerational transmission of 

family patterns that promote substance misuse. 

Your goal is to help families prevent SUDs in 

current and future generations by encouraging 

parenting practices that help prevent SUDs in 

children, improve SUD treatment outcomes in 

adolescents, and enhance the family recovery 

process. 

The following sections describe ways to meet these 

objectives by focusing on certain goals in your 

provision of integrated family counseling for SUDs. 

Understand Your Role as an SUD 

Treatment Provider 

Your role in family-based interventions depends, to 

some extent, on your level of training, education, 

licensing, and scope of practice. For example, if 

you are leading a family psychoeducation group, 

your primary role is as a guide or educator. In 

couples counseling, your role is to facilitate the 

couple’s interactions. Whatever family-based 

intervention you provide, your role also includes: 

• Approaching the family on their own terms. 

• Working together with the family. 

• Facilitating communication among all family 

members. 

• Facilitating family member interactions (avoid 

being an arbiter of right and wrong). 

• Educating family members about how families 

work. 

• Educating family members about the effects of 

substance misuse on the family. 

• Educating family members about the recovery 

process. 

• Facilitating the development of a relapse 

prevention plan. 

• Actively linking family members to communitybased recovery support and other services. 

Chapter 4 89 
TIP 39

The key to successful family work is to maintain a 

focus on engagement and collaboration with the 

family throughout treatment. 

Optimize Initial Sessions 

After the family interview and assessment process, 

initial family counseling sessions should focus on 

building a relationship with the entire family. The 

identifed client should always be part of family 

sessions. The only times to exclude someone are 

if he or she is intoxicated or under the infuence of 

drugs (“high”), has severe psychiatric symptoms 

(e.g., hallucinations, delusions, severe mania), has 

threatened violence, or a combination of these. 

To engage family members’ support for a client 

with SUD as he or she initiates and sustains 

recovery, you can: 

• Welcome and thank family members for coming. 

• Use refective listening to understand family 

members’ frustrations and concerns. 

• Use externalizing language (e.g., “the drinking,” 

not “her drinking”) to help the client and 

family members disengage substance use from 

negative identity conclusions. Making the SUD 

an external focus of attention allows everyone to 

work as a team to defeat it. 

• Explore how family members have been helpful 

in the past. 

• Explain ways that family members can support 

the client’s recovery. 

• Ask the client whether he or she is willing to 

have family members help in this way. 

• Ask whether family members have any 

questions. 

• Ask whether the client has any questions about 

family members’ participation. 

• Summarize the important points of the session 

and recovery commitments anyone has made. 

• Actively link family members to communitybased family recovery supports (e.g., Al-Anon) 

and additional behavioral health or social 

services, when appropriate. 

• Assess the willingness of family members to 

participate in ongoing family counseling if 

appropriate. 

Substance Use Disorder Treatment and Family Therapy 

Initial sessions should focus on: 

• Working together with the family. 

• Orienting them to the family counseling process. 

• Continuing the assessment of how substance 

misuse has affected each family member. 

• Reframing substance misuse from a character 

faw to a biochemical and behavioral problem 

they can work together to remove from their 

lives. 

• Continuing the assessment of family strengths 

and strategies they have already used to lessen 

the impact of substance misuse on the family. 

• Exploring family hopes for the future and each 

family member’s ideas on how counseling can 

help. 

Key opening strategies include building 

relationships and giving each family member 

time to share his or her frustrations and hopes for 

the future. Avoid jumping too quickly into goal 

consensus. 

Acknowledge Stages of Change 

The process of recovery from SUDs is complex 

and multifaceted. A useful framework for 

understanding this process involves the stages of 

change (SOC) model, a transtheoretical approach 

to behavior change, originally developed by 

Prochaska and DiClemente (1984). The SOC 

model was developed for use with individuals, but 

it can be a helpful approach to assessing family 

members’ readiness to discuss a problem that they 

often view as something so shameful they can’t talk 

about it. The SOC approach can help you guide 

families through the process of change. 

The fve stages of change and the counseling 

focus for each stage adapted for family work 

(DiClemente, 2018; van Wormer & Davis, 2018) are: 

1. Precontemplation: Client or family doesn’t 

perceive a problem or need for behavior 

change. Counseling focus: Engage the family. 

Establish a working alliance with each family 

member. Help family members identify their 

core values, hopes, and dreams and how 

substance misuse or other disruptive behaviors 

are blocking them from achieving their goals. 

90 Chapter 4 
Chapter 4—Integrated Family Counseling To Address Substance Use Disorders TIP 39

Remember, each family member might be in 

a different stage of change around specifc 

behavioral change goals. 

2. Contemplation: Client or family is ambivalent 

about behavior change and begins to identify 

reasons for change. Counseling focus: Elicit from 

each family member his or her own reasons for 

wanting or needing to change certain behaviors, 

including substance misuse, to help the family 

reach their goals. Reinforce family members’ 

strengths and their capacity to take action 

toward desired solutions to family problems. 

3. Preparation: Client or family is motivated to 

change behavior and starts taking steps toward 

change. Counseling focus: Help family members 

clarify their own goals and strategies for change, 

offer some options and advice, if asked for, 

and encourage them to engage in recovery 

and social support resources outside of family 

counseling. 

4. Action: Client or family is actively engaged in 

behavior change. Counseling focus: Help the 

family develop a change plan that includes 

tasks for each family member. Invite one family 

member to write out the plan. Then make a 

copy for each family member. At the next family 

session, review the plan and how each family 

member did with achieving change goals. Tweak 

the plan if needed and continue to evaluate the 

plan’s effectiveness. 

5. Maintenance: Client or family has changed 

behavior and is actively engaged in sustaining 

change. Counseling focus: Help the family 

anticipate potential stressors that could 

destabilize family functioning again. As 

behavioral changes are made, substance misuse 

decreases or the client becomes abstinent, and 

family function shifts to supporting the family to 

maintain those behavioral changes outside of 

treatment. 

Apply the SOC approach to a behavior each 

family member can change to support recovery 

and enhance family functioning. For example, 

when one partner’s drinking is interfering with a 

couple’s relationship, the drinking partner needs 

to change the drinking behavior. At the same time, 

the nondrinking partner may need to change his 

or her negative communication pattern of blaming 

and judging the drinking partner and shift to a 

positive communication pattern that reinforces 

nondrinking behavior. Please note that each family 

member may be at a different stage of change or 

level of motivation regarding the behavior change 

that he or she needs to make to improve family 

functioning. 

Educating families about the SOC framework can 

help them identify where they each are in the 

stages and support each other to move toward 

positive change. The SOC approach provides an 

overarching model for behavior change from an 

SUD treatment perspective. See TIP 35, Enhancing 

Motivation for Change in Substance Use Disorder 

Treatment (SAMHSA, 2019a; https://store.samhsa. 

gov/product/TIP-35-Enhancing-Motivation-forChange-in-Substance-Use-Disorder-Treatment/ 

PEP19-02-01-003), for more information about the 

SOC model. 

Chapter 4 91 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

COUNSELOR NOTE: THE ROLE OF FAMILY IN RELAPSE PREVENTION 

Factors that protect against relapse for people with SUDs (SAMHSA, 2015a) include: 

• Family support for recovery. 

• Involvement in peer recovery support groups and recovery-oriented social experiences. 

• Positive coping skills. 

• High motivation to change risk behaviors. 

• Self-effcacy. 

• High levels of confdence in managing high-risk situations. 

• Active engagement in spiritual or religious practices or community events. 

• Beliefs that enhance hope and resilience. 

Because family members often can identify early warning signs that the client may not be aware of, involve 

them in identifying early signs of a potential return to use. Family members can also provide positive 

emotional and instrumental support (e.g., transportation to Alcoholics Anonymous meetings or help with 

monitoring medications) for the client’s recovery. This support can help prevent a return to substance 

misuse. 

If the client relapses (i.e., returns to previous levels of substance use), the family also is likely to return to old 

patterns of behavior. A key strategy to help the client and family get back on track right away is to create an 

emergency plan so the family knows what to do if the client returns to substance misuse. Work with family 

members and the client to create the plan. Write it out and give each family member a copy. 

The plan should: 

• Explain that a return to drinking or drug use is not inevitable but also is not unusual. The longer a person 

can abstain, the greater the likelihood that he or she will not return to use. 

• Make it clear that the client is responsible for his or her own behavior. 

• Identify the steps family members are willing to take to support the client’s reengagement in his or her 

recovery (e.g., call the treatment agency’s crisis number and talk to the on-call counselor if the client is 

intoxicated, transport the client to a recovery support meeting). 

• Explore the family’s options for dealing with the client’s return to substance misuse, including self-care 

(e.g., get help from an Al-Anon, Alateen, or other family recovery support; talk to a friend). 

• Give a responsible family member your number and available hours to contact you for support and help 

with next steps for the family and the client. 

Another useful framework for understanding the 

stages of change that the family system undergoes 

in family counseling comes from Virginia Satir 

(Satir, Banmen, Gerber, & Gomori, 1991). These six 

stages (Gehart, 2018) are: 

1. Status quo: This is a state of family homeostasis 

in which at least one family member has 

symptoms of a mental disorder or SUD; the 

family organizes interactions and functioning 

around the symptom. 

2. Foreign element: A foreign element moves 

the system off balance. The foreign element 

could be a life crisis like substance misuse or a 

counseling intervention like offering the family 

a new perspective on or information about 

substance misuse. 

3. Chaos: The counseling intervention throws the 

family system into a temporary state of chaos. 

The family most often experiences discomfort 

and tries to get back to the stage 1 status quo. 

92 Chapter 4 
Chapter 4—Integrated Family Counseling To Address Substance Use Disorders TIP 39

4. Integration: Eventually, the family system 

interprets the new information in a meaningful 

way, which opens up new possibilities for 

change. 

5. Practice: The family system develops new 

ways to interact/communicate based on new 

information. 

6. New status quo: This is a new state of 

homeostasis that supports all family members 

to grow and contribute to enhanced family 

functioning. 

Families often undergo the stages several times 

until the system gets used to change (Gehart, 

2018). This framework is based on the idea that 

the family system is resilient and will fnd its way 

to a new and healthier level of functioning. Your 

task is to be respectful of how the family uses 

and responds to your introduction of a “foreign 

element” and honor the family system’s autonomy 

(Gehart, 2018). 

Address Common Challenges 

You will encounter challenges, myths, and 

obstacles that hinder engagement and treatment 

of families dealing with SUDs. Some challenges 

are related to attitudes and myths about offering 

family counseling in SUD treatment settings. 

Others may be related to integrating family work 

into SUD treatment settings. Still others are related 

to family issues such as low motivation to change 

and power dynamics within the family. The next 

sections describe some challenges and strategies 

to overcome them. 

Family Counseling Is Secondary 

SUD treatment has historically been viewed 

through the lens of an individual approach. 

Integrated family-based interventions should be as 

much of a priority in your treatment program as any 

other treatment activity. When family counseling 

is viewed as an adjunct to individual or group 

counseling, it sends the message to clients and 

family members that family counseling is simply 

not that important. Evaluate your attitudes about 

family involvement in treatment and be a champion 

for integrating family-based interventions as an 

important and primary part of SUD treatment. 

Family Counseling Is Too Painful 

The SUD treatment feld has promoted the myth 

that family counseling that includes the client 

with SUD may bring up painful feelings for the 

client that will somehow lead to a return to use or 

jeopardize the client’s recovery. Although family 

counseling may temporarily shake up the family 

system and activate intense feelings, these feelings 

are a normal part of any counseling experience. 

Your task is to help the client and family members 

discover new ways of coping with intense emotions 

instead of reverting to old behaviors like substance 

misuse or blaming and shaming the family member 

with the SUD. 

Coordination of Family Services 

It is challenging to provide family-oriented case 

management or referral and coordination of 

services while doing family counseling. You are 

working with a family system made up potentially 

of many family members, who may each require 

other treatment or social services. This requires an 

appreciation for each family member’s needs and 

a concerted effort to coordinate other agencies’ 

services to satisfy multiple needs. Actively link 

individual family members to case management 

services or peer providers who can work 

collaboratively with you to coordinate the multiple 

service needs of the family. 

Keeping Family Secrets 

Secretiveness is often a hallmark of family behavior 

where there is an SUD. When family members 

become involved in counseling, they may want to 

tell you secrets outside a family session. Different 

family counseling models approach this differently. 

However, in the context of SUD treatment, it is 

important to avoid being the holder of family 

secrets. Holding a secret puts you in an ethically 

untenable position and will interfere with the family 

counseling process. Let everyone know during 

the initial family interview that you will bring up 

information a family member brings to you outside 

of family sessions, and you will do so during the 

next family session. The only exception to this 

boundary is if a family member tells you privately 

of violence or abusive behavior that needs to be 

addressed separately. 

Chapter 4 93 
TIP 39

SUD Client or Family Member Is in 

Precontemplation 

Historically, the term “denial” has described clients 

or family members who do not see substance 

misuse as a problem. This label is judgmental, so 

avoid using it and let family members know that 

using labels to confront each other leads to confict 

or an emotional cutoff. As with name calling, using 

labels like “denial” is often an attempt to establish 

power in a relationship, which is damaging to 

that relationship. Set boundaries in early family 

sessions by establishing some rules for interactions, 

including no “labels” or name calling. You can also 

reframe “denial” as precontemplation, one of the 

stages of the SOC model and simply an indication 

that the family member is ambivalent and not quite 

ready to change. 

Family’s Adjustment to Abstinence 

Just as the family system organizes itself around 

the client’s substance misuse to maintain a level of 

homeostasis, you can expect family members to 

act differently (and not always positively) when the 

client with the SUD enters recovery. For example, 

family members may express resentment and anger 

more directly to the recovering person because 

of the disruption of the family’s homeostasis. 

Children and adolescents may engage in more 

externalizing behaviors like aggression, violence, 

lying, or stealing. An adolescent or intimate partner 

who has taken on major responsibilities for family 

functioning given up by the adult client with the 

SUD may resent and unintendedly sabotage the 

client’s efforts to resume a position of responsibility 

and authority in the family system. Or the family 

may experience a period of relative harmony that 

is disrupted if other family issues begin to surface. 

Your task is to help family members adjust to 

these changes in lifestyle, fnd ways to support the 

client’s recovery, learn new relationship and coping 

skills, and fnd healthier levels of functioning and 

family homeostasis. 

The Client on Medication 

Clients with co-occurring mental disorders or those 

who are prescribed medications for alcohol use 

disorder or opioid use disorder often are uncertain 

about adhering to medication routines. Some of 

the reasons clients stop taking medications include 

Substance Use Disorder Treatment and Family Therapy 

cost, negative side effects, the belief that they are 

not in recovery because they are substituting one 

drug for another, or systemic barriers (e.g., having 

to go to a clinic every day to receive a methadone 

dose). When clients stop taking medications, 

symptoms of mental disorders or old substance 

use behaviors reemerge, and families return to 

previous patterns of dysfunction. The issue of 

medication adherence is a common theme in the 

families you serve. Your task is to raise this issue, 

when applicable, in family sessions. 

Before jumping to educating family members 

about medications and how important medication 

adherence is for individual and family stability, 

explore both the client’s and the family’s 

perspective about medication and its role in family 

functioning. As you explore multiple perspectives, 

use some motivational counseling tools like 

elicit-provide-elicit; that is, eliciting what family 

members already know about medication, asking 

permission to offer information, providing brief 

chunks of information, and then eliciting the family 

members’ reactions to the information (Miller & 

Rollnick, 2013). Once the topic is raised and all 

family members have accurate information about 

the medication and the importance of medication 

adherence in family stability, the conversation can 

shift to the family working as a team to support 

the client to adhere to medication as prescribed 

or safely taper off medication under medical 

supervision if and when it is no longer needed for 

the client to maintain stable recovery. 

Where Do We Go From Here? 

Integrating family-based counseling techniques 

into SUD treatment is possible along a continuum 

of care, from initial assessment through the 

various stages of family counseling. This chapter 

examined some of the common issues you may 

face and family-centered strategies you can use 

along that continuum of care, including when to 

use family counseling, who can be involved, the 

goals of family-based interventions, and your role 

as a counselor. Chapter 5 examines your role in 

delivering culturally responsive family-based SUD 

treatment. It also explores the diversity of family 

cultures you will encounter in your work. 

94 Chapter 4 
Chapter 5—Race/Ethnicity, Sexual 

Orientation, and Military Status 

KEY MESSAGES 

TIP 39 SUBSTANCE USE DISORDER TREATMENT AND 

FAMILY THERAPY

• Family cultures often have specifc practices, 

structures, values, and belief systems that can 

affect substance use and substance-related 

outcomes (e.g., achieving recovery). 

• Understanding the ways in which diverse 

family cultures function is critical to identifying 

and addressing family-related factors—like 

communication patterns, parenting practices, 

and level of acculturation—that increase the 

risk for substance misuse. 

• Family separation (e.g., because of 

immigration or military deployment) and lack 

of communication about substance misuse 

may be present across many family cultures. 

Similarly, racial discrimination, stigma, shame, 

and prejudice may exert infuence across 

multiple generations, infuencing families’ 

substance use and help-seeking behaviors. 

Family characteristics and feelings related to 

these factors should be addressed as a part of 

family counseling for substance use disorders 

(SUDs). 

• Much of the empirical literature is silent on 

how best to adapt family-based counseling 

interventions for SUDs to the specifc needs 

of the diverse family cultures discussed here. 

However, to the extent possible, you should still 

try to use family-based treatment/services that 

meet families where they are—that is, services 

matched to the family’s level of motivation to 

change and responsive to their unique change 

goals. 

Chapter 5 of this Treatment Improvement 

Protocol (TIP) will guide providers in delivering 

family-based SUD treatment that is culturally 

responsive and evidence based. It addresses: 

• General information about diverse family 

cultures and why you, as a provider, need to be 

aware of their specifc treatment/service needs 

and challenges. 

• Culturally responsive family counseling. 

• Background issues and aspects of family 

structure and functioning in specifc 

populations, which will help guide your approach 

to meeting the needs of families from a cultural 

perspective. 

• Specifc family cultures (e.g., families of diverse 

racial and ethnic backgrounds; families with 

lesbian, gay, bisexual, or transgender [LGBT] 

members; military families), with summaries of 

recent scientifc evidence on the use of familybased interventions for SUDs with each population 

as well as suggestions for how to culturally tailor 

interventions to get the best outcomes. 

This chapter is not a comprehensive summary of all 

family cultures. The literature on the effectiveness of 

family counseling for SUDs in specifc cultures is often 

limited but is discussed when available. Populations 

this chapter discusses are among those commonly 

seen in SUD treatment settings, and they often have 

specifc cultural practices. 

Family-based interventions for SUDs are 

evidence-based, effective approaches to 

achieving and sustaining long-term recovery, 

particularly for adolescents (Hartnett, Carr, 

Hamilton, & O’Reilly, 2017; Horigian, Anderson, & 

Szapocznik, 2016; Ventura & Bagley, 2017). But the 

diverse makeup and culture of a family can affect 

the degree to which individuals and families facing 

substance misuse can successfully access, engage 

95 
TIP 39

in, and beneft from SUD treatment. That partly 

may be because of culture-related barriers that can 

make achieving recovery diffcult for some families 

(e.g., language barriers, stigma, or negative 

attitudes about help seeking). 

To successfully use family-based interventions, 

you must be aware of and pay attention to the 

unique features of certain family cultures. These 

features include, for example, the family’s structure, 

communication style, immigration history, 

experience of individual and historical trauma, and 

interrelationships with one another. 

Scope of This Chapter 

The topic of culture and cultural competency in 

SUD treatment (and in behavioral health services 

in general) is beyond the scope of this chapter. 

The focus of this chapter is on families and the 

ways in which family-based interventions can be 

adapted to, and thus more effective for, specifc 

family cultures discussed here (i.e., those of diverse 

racial/ethnic backgrounds, LGBT families, military 

families). 

COUNSELOR NOTE: AFFILIATION 

WITH MULTIPLE CULTURES AND 

CULTURES WITHIN A CULTURE 

People often affliate with multiple cultures to 

varying degrees—cultures centered on race/ 

ethnicity, gender, profession, age, economic class, 

geographic location, education level, and so on. For 

example, a married heterosexual African American 

couple from a rural parish in Louisiana might view 

their cultural identity very differently than a single 

gay African American father living in Manhattan. 

All may identify with aspects of African American 

culture; this facet of their cultural identities may 

fgure more or less prominently than being part of 

married versus single culture, rural versus urban 

culture, straight versus gay culture, and so forth. 

Additionally, there are often cultures within a 

culture—one may, for example, be part of Korean 

culture, and within that culture, affliate strongly 

with the subculture of Korean Catholicism. 

Substance Use Disorder Treatment and Family Therapy 

To learn more about culture and diversity issues 

in behavioral health services, SUD treatment, 

and ongoing recovery support, review these 

publications from the Substance Abuse and 

Mental Health Services Administration (SAMHSA): 

• Advancing Best Practices in Behavioral 

Health for Asian American, Native Hawaiian, 

and Pacifc Islander Boys and Men: This 

report offers tools and best practice guidance 

for working with Asian American, Native 

Hawaiian, and Pacifc Islander boys and young 

men (https://store.samhsa.gov/product/ 

advancing-best-practices-behavioral-healthasian-american-native-hawaiian-pacifc-islander/ 

SMA17-5032). 

• A Provider’s Introduction to Substance Abuse 

Treatment for LGBT Individuals: This manual 

informs clinicians and administrators about 

SUD treatment approaches that are culturally 

responsive to LGBT individuals. It covers 

cultural, clinical, health, administrative, and legal 

issues as well as alliance building (https://store. 

samhsa.gov/product/A-Provider-s-Introductionto-Substance-Abuse-Treatment-for-LesbianGay-Bisexual-and-Transgender-Individuals/ 

SMA12-4104). 

• Continuity of Offender Treatment for Substance 

Use Disorders from Institution to Community— 

Quick Guide for Clinicians Based on TIP 30: This 

publication guides SUD treatment providers in 

helping offenders transition from the criminal justice 

system to life after release, including adaptation 

to community and work cultures and the culture 

of recovery. It discusses assessment, transition 

plans, special populations, family involvement in 

treatment and transition where appropriate, and 

confdentiality (https://store.samhsa.gov/product/ 

Continuity-of-Offender-Treatment-for-SubstanceUse-Disorder-from-Institution-to-Community/ 

sma15-3594). 

• TIP 51, Substance Abuse Treatment: Addressing 

the Specifc Needs of Women: This guide 

assists providers in offering treatment to women 

living with SUDs. It reviews gender-specifc 

research and best practices, such as common 

patterns of initial use and specifc treatment 

issues and strategies (https://store.samhsa.gov/ 

product/TIP-51-Substance-Abuse-TreatmentAddressing-the-Specifc-Needs-of-Women/ 

SMA15-4426). 

96 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

• TIP 55, Behavioral Health Services for People 

Who Are Homeless: This manual emphasizes 

that SUD treatment and mental health service 

providers can improve their service delivery by 

understanding the cultural context of clients 

and having the skills to adapt to a variety of 

cultures of people who are homeless. It also 

describes intervention methods to address 

SUDs during a variety of stages of homelessness 

rehabilitation and discusses methods providers 

can use to support recovery from mental 

illness and substance misuse among people 

and families who are homeless (https://store. 

samhsa.gov/product/TIP-55-Behavioral-HealthServices-for-People-Who-Are-Homeless/ 

SMA15-4734). 

• TIP 56, Addressing the Specifc Behavioral 

Health Needs of Men: This guide addresses 

specifc treatment needs of adult men living 

with SUDs. It reviews gender-specifc research 

and best practices, such as common patterns 

of substance use among men and specifc 

treatment issues and strategies (https://store. 

samhsa.gov/product/TIP-56-Addressing-theSpecifc-Behavioral-Health-Needs-of-Men/ 

SMA14-4736). 

• TIP 57, Trauma-Informed Care in Behavioral 

Health Services: Trauma can affect individuals, 

families, groups, communities, specifc 

cultures, and generations. This manual helps 

behavioral health professionals understand the 

impact of trauma on those who experience 

it. The manual discusses trauma-informed, 

culturally responsive assessment and treatment 

planning strategies, and it highlights the 

importance of context and culture in people’s 

response to trauma and SUD recovery (https:// 

store.samhsa.gov/product/TIP-57-TraumaInformed-Care-in-Behavioral-Health-Services/ 

SMA14-4816). 

• TIP 59, Improving Cultural Competence: 

This manual provides more information 

on working with people from various 

cultures and providing culturally competent 

treatment (https://store.samhsa.gov/product/ 

TIP-59-Improving-Cultural-Competence/ 

SMA15-4849). 

• TIP 61, Behavioral Health Services for 

American Indians and Alaska Natives: This 

publication offers practical guidance for 

addressing the social challenges and behavioral 

health needs of Native American populations 

in culturally responsive ways (https://store. 

samhsa.gov/product/tip-61-behavioral-healthservices-for-american-indians-and-alaska-natives/ 

sma18-5070). 

Terminology is important. The term specifc 

populations refers to the features of families based 

on specifc, common groupings that infuence the 

process of therapy. The term culture often brings 

to mind concepts related to race and ethnicity 

but is used more broadly here. In this chapter, 

culture refers to the thoughts, interactions, beliefs, 

and values of a family that shape the way that 

family feels, thinks, and talks about and reacts to 

substance use issues. Indeed, the family cultures 

described here are known to have their own 

attitudes, ideas, customs and, in some cases, 

language that shapes the family and the ways in 

which its members relate to one another. 

Why Focus on Diverse Family 

Cultures? 

Why should SUD counselors learn about diversity 

among families? Family-based interventions 

for substance use are not “one-size-fts-all” 

approaches. Different families will have different 

needs, and in many cases, those needs are affected 

by the culture of that family. You cannot offer truly 

comprehensive, evidence-based SUD treatment 

if you ignore the culture of the family with whom 

you are working. Think about the following when 

working with diverse family cultures: 

• A supportive family is a key protective factor 

in relapse prevention and recovery promotion, 

and family support can be heavily infuenced 

by culture. Cultural differences exist in the way 

families understand, feel about, and respond to 

mental illness or SUDs (particularly, perceived 

shame about these conditions). Cultural shame 

about SUDs and mental disorders can be 

a relapse risk factor or barrier to treatment 

engagement. Thus, family ties may affect 

treatment engagement, adherence, and 

completion. Psychoeducation about the nature 

of SUDs and mental disorders as medical issues 

that can be treated, like many other chronic 

conditions, may help reduce shame and increase 

family support and acceptance. 

Chapter 5 97 
TIP 39

• Diversity may be a factor in family-based 

SUD treatment outcomes. For instance, in 

some research, ethnicity has been shown 

to be an infuential factor in outcomes from 

multidimensional family therapy (MDFT) for 

SUDs. One study that looked at fndings from 

fve MDFT clinical trials for adolescent substance 

use found that MDFT was effective only for men, 

African Americans, and European Americans, 

whereas women and Latino individuals did not 

beneft signifcantly (Greenbaum et al., 2015). 

• Cultural background can shape attitudes 

about factors like “proper” family behavior, 

family hierarchy, acceptable levels of 

substance use, and methods of dealing with 

shame and guilt. Forcing families or individuals 

to follow the customs of the dominant culture 

can create mistrust and lower the effectiveness 

of counseling. A competent treatment provider, 

however, can work with a culture’s customs and 

beliefs to improve treatment rather than cause 

resistance to treatment. 

• Some families may prefer alternative 

interventions in place of or along with family 

counseling. In cultures that place a high value 

on indigenous healing practices and spirituality, 

such as in some Latino, Asian American, African 

American, and American Indian/Alaska Native 

(AI/AN) communities, you can actively support 

clients with SUDs or mental disorders in using 

traditional healing approaches, faith-based 

community resources, and spirituality as 

supports in their efforts to lower the likelihood 

of relapse. The key is for you to keep your 

clients in the center of the conversation 

about what will be the most effective relapse 

prevention and recovery strategies for them 

based on cultural considerations and to adapt 

approaches to ft the needs of each individual 

and family. 

• Behavioral health disparities are real and, 

if unaddressed, can keep people from 

achieving and maintaining recovery. Some 

racial and ethnic groups have higher rates 

of poverty (which can be intergenerational), 

domestic violence, childhood and historical 

trauma, and involvement in the criminal justice 

system than the general population. These 

Substance Use Disorder Treatment and Family Therapy 

risk factors can increase the chances of relapse 

or recurrence of SUDs and mental disorders. 

Levels of education and of health literacy can 

also infuence awareness of and access to 

treatment and recovery supports. These and 

other gaps in treatment access and retention 

exist for a number of populations, including 

the groups described in this chapter. Your 

organization can help reduce disparities in SUD 

treatment and recovery support by improving 

outreach and sharing of information, promoting 

active linkages to culturally diverse community 

resources, and implementing relapse prevention 

treatment and recovery promotion initiatives 

that specifcally serve these populations. 

Culturally Responsive Family 

Counseling 

Cultural competence is an important feature in 

family counseling because family counselors must 

work with families from many cultures. Integrated 

family counseling for SUD treatment works for 

people from many races, ethnicities, faiths, and 

educational backgrounds. In many cultures, it 

is important to include families in treatment. 

However, a culture’s high regard for families does 

not always equate to healthy family functioning. 

People may hide substance misuse in the family 

because revealing it would lead to prejudice 

and shame. 

RESOURCE ALERT: SOCIAL 

DETERMINANTS OF HEALTH 

The Offce of Disease Prevention and Health 

Promotion maintains a website with summaries 

of many social determinants of health, as well 

as data and other evidence-based information 

regarding these determinants (www. 

healthypeople.gov/2020/topics-objectives/topic/ 

social-determinants-of-health). The site also 

provides many links to additional educational 

resources on this topic. 

98 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

Furthermore, using culturally competent, familybased services may help clients reach better 

SUD outcomes. A meta-analysis of seven studies 

looking at culturally responsive SUD interventions 

for racial and ethnic minority youth (including 

studies that used family-based approaches like 

MDFT, brief strategic family therapy [BSFT], and 

the Culturally Informed and Flexible Family-Based 

Treatment for Adolescents [CIFFTA] Program) 

showed, on average, that these treatments 

resulted in greater reductions in substance use 

than nonculturally adapted treatments (Steinka-Fry, 

Tanner-Smith, Dakof, & Henderson, 2017). 

COUNSELOR NOTE: CULTURAL HUMILITY AND WILLINGNESS TO BE THE 

STUDENT—NOT THE TEACHER 

More and more, the concept of cultural humility is being embraced in primary care and behavioral health 

services (Allwright, Goldie, Almost, & Wilson, 2019; Watkins et al., 2019). Cultural humility can help you 

not just work better with diverse family cultures but also become a better clinician in general. It can 

help you become more open and willing to learn from your clients rather than always playing the role 

of “the expert.” 

What is cultural humility, and how does it differ from cultural sensitivity, cultural awareness, and cultural 

competency? According to research (Allwright et al., 2019; Barksy, 2018; Danso, 2018): 

• Cultural competency is “the process by which individuals and systems respond respectfully and 

effectively to people of all cultures, languages, classes, races, ethnic backgrounds, religions, spiritual 

traditions, immigration status, and other diversity factors in a manner that recognizes, affrms, and values 

the worth of individuals, families, and communities and protects and preserves the dignity of each” 

(National Association of Social Workers, 2015, p. 13). In other words, cultural competency is about your 

clinical practices and making sure you have the knowledge, skills, and training to work appropriately with 

different cultures. 

• Cultural awareness and cultural sensitivity are about consciousness and self-refection. How conscious 

are you of other cultures and their unique needs? How mindful are you of your own cultural beliefs and 

how those affect the way you care for clients from other cultures? 

• Cultural humility goes a step further and asks you to release your own beliefs, ideas, and doubts about a 

given culture and treat clients as “the experts.” Cultural humility means: 

- Being willing to admit to understanding less about clients’ cultural experiences than they do. 

- Having an open heart and listening to your clients share their stories—especially when they tell you 

things that do not match what you thought you already knew about their culture. 

- Being humble and learning from your clients rather than just using what you read in textbooks or were 

taught in training sessions. 

- Questioning culture-related differences in power that can be present in working relationships, 

organizations, and systems. 

- Engaging in a lifelong process of self-refection and self-critique, especially to identify any prejudices. 

Chapter 5 99 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

To add culture into your SUD treatment 

approaches: 

• Engage aspects of the family’s culture or 

religion that promote healing. 

• Consider the role that drugs and alcohol play 

in the culture. 

• Be fexible and meet families where they are. 

• Be continuously aware of and sensitive to 

the differences between yourself and the 

members of the group you are counseling. 

Is the family a homogeneous group or one 

that represents different backgrounds? What 

is the signifcance that family members assign 

to their own identities and to the identity of 

the counselor? Does the family live in one 

community or several different communities? 

Are those communities the same as or 

different from the one in which you live? These 

considerations and responsiveness to the 

specifc cultural norms of the family in treatment 

must be respected from the start of counseling. 

Differences within the family also should be 

explored. If these factors are not apparent or 

explicit, ask. 

• Be aware of and sensitive to your own family 

culture. Counselors bring their own cultural 

issues to treatment. Your age, gender, ethnicity, 

local community, and levels of health literacy 

and education, as well as other traits, may affect 

therapeutic processes. 

You can be culturally competent even if you 

don’t belong to the same cultural groups as the 

families you serve. You can develop the cultural 

competence to work with families who affliate 

with cultures other than your own. Cultural 

competence means you pay attention to cultural 

nuances, learning from diverse clients. Even if 

you identify with the same culture as a family 

you treat, don’t assume you understand all their 

cultural views and beliefs. The ways and extent to 

which culture infuences them may differ from 

your experience. 

General Considerations When Working 

With Diverse Family Cultures 

Families and family cultures will differ in their 

structures, values, and beliefs; they also will differ 

in their SUD treatment needs. However, certain 

common family features may be present across 

many family cultures, such as their immigration 

status and history, level of acculturation (that is, the 

degree to which individuals or groups adopt the 

practices of the dominant culture), communication 

style, and hierarchical structure. Be aware of these 

general features, but also remember that each 

family is different and will operate in its own 

unique way (Exhibit 5.1). 

EXHIBIT 5.1. Eight Questions To 

Consider When Offering SUD 

Treatment for Families of Diverse 

Racial/Ethnic Backgrounds 

To help lay the groundwork for better 

understanding a particular family’s response to 

and treatment/service needs for substance use, 

here are eight questions to ask yourself: 

1. How is this family structured? 

2. What is the role of the extended family? 

3. What is the role of religion or spirituality 

within this family? 

4. What is the family’s immigration/nativity 

status? How does this affect family members’ 

level of acculturation? 

5. Are there culture-specifc family values to be 

aware of? 

6. How does the family’s culture affect their 

communication style? 

7. How does this family experience racism and 

discrimination? How do those experiences, 

along with historical trauma, affect the family? 

8. Has the family experienced any periods of 

separation (particularly between parent 

and child)? 

100 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

For more specifc information on common 

characteristics of families, see Chapter 1 of 

this TIP. 

1. How Is This Family Structured? 

The ways families are organized can affect the 

relationships family members have with each 

other. These, in turn, can directly affect their 

communication style, expectations for behavior, 

and more. 

• For instance, White, Latino, Hmong, and Somali 

students living with nuclear families (i.e., families 

made up of only the parents and their children) 

have a signifcantly lower rate of exposure to 

substance-related risk behaviors and substance 

use than students living in single-parent or 

cohabitating households (Areba, Eisenberg, & 

McMorris, 2018). 

• Hierarchical family structures (i.e., the order/ 

rank of power and authority within the family, 

such as patriarchal versus matriarchal) are 

prevalent in some cultures, including Latino 

populations (Santisteban, Mena, & Abalo, 2013) 

and Asian populations (Chuang, Glozman, 

Green, & Rasmi, 2018). For example, military 

families often adopt the same core values and 

principles that defne military culture in general, 

like respect for authority and adherence to 

chains of command. The focus on hierarchies 

and parents as authority fgures can affect 

parent–child confict and resolution, especially 

as children age into adolescence and potentially 

begin to challenge parental authority. 

• A related aspect of a family’s hierarchy and 

power structure is the way in which the family 

views and uses child discipline. For instance, 

many African American households value child 

discipline as a critical part of childrearing that 

can effectively shape children’s behavior and 

help them make good life choices (AdkisonJohnson, 2015). Understanding the intent and 

use of specifc disciplinary strategies, as well 

as whether discipline is carried out primarily 

by male or female adult relatives, can help you 

better work with families to improve parenting 

practices and reduce negative child behavior 

(like substance use) in a way that matches their 

cultural values. 

2. What Is the Role of the Extended 

Family? 

Extended family members within the household 

are typical in many cultures, especially those 

of diverse racial and ethnic backgrounds. For 

example, some families consist of grandparents 

raising their grandchildren; other families have 

multiple family groups dwelling together (e.g., 

two sisters and their spouses and children share 

a single-family home). Still others may include 

multiple generations—perhaps a single parent, 

grandparent, and adult sibling—all sharing the 

responsibility of raising a child. But how does 

extended family relate to substance misuse? 

• In a nationally representative survey (Cross, 

2018), 35 percent of children reported ever 

living in an extended family unit. Responses 

differed signifcantly by race and ethnicity, with 

only 20 percent of White children reporting 

having lived with an extended family versus 57 

percent of African American children, 35 percent 

of Latino children, and 34 percent of “other 

race” children (“other race” was not defned by 

the study authors). 

• When it comes to substance misuse, extended 

families can be both positive and negative. 

- Findings from the Los Angeles Family and 

Neighborhood Study and the decennial 

census (Kang, 2019) suggest that children 

living with extended family members are at 

an 18-percent increased risk of internalizing 

disorders and a 22-percent increased risk 

of externalizing disorders compared with 

children living in nuclear families. Extended 

families may exacerbate child misbehavior 

by increasing strain on family resources (e.g., 

leaving less time and money for the child), 

interfamily conficts, and ineffective collective 

monitoring of children by multiple family 

members (Kang, 2019). In some research, 

extended family members introduced youth 

to substance use (Gilliard-Matthews, Stevens, 

Nilsen, & Dunaev, 2015). 

- Other studies suggest extended families 

can be protective against child/adolescent 

misbehavior and maladjustment (Bai, 

Leon, Garbarino, & Fuller, 2016), including 

Chapter 5 101 
TIP 39

substance use (Areba et al., 2018) and can 

be an effective part of family counseling for 

SUDs (Zweben et al., 2015). For example, in 

a qualitative study of Mexican youth (Strunin 

et al., 2015), extended family members acted 

as mentors who provided guidance about 

safe and acceptable alcohol consumption and 

modeled negative effects of alcohol misuse, 

positively shaping youth behavior. 

3. What Is the Role of Religion or 

Spirituality Within This Family? 

Many diverse family cultures fnd strength and 

support from their spiritual or religious beliefs and 

activities, including prayer and attending services 

at faith-based institutions. 

• Religious or spiritual beliefs or activities 

may infuence the family’s engagement and 

participation in counseling. For instance, 

African American individuals may seek help 

for SUDs from spiritual or religious leaders 

(Wong, Derose, Litt, & Miles, 2018) or may 

view mental illness through a spiritual or 

religious lens. In Latino communities, church 

leaders, such as priests, may be sources of help 

seeking or referrals for formal SUD treatment 

(Cuadrado, 2018). SUD treatment providers 

should understand that cultural beliefs and 

practices may infuence help-seeking behaviors. 

Thus, some families may be reluctant to accept 

services or may decline them altogether. 

• Family encouragement of faith-based activities 

can help people seeking recovery. In the 

National Longitudinal Study of Adolescent 

Health, Latino emerging adults engaged in 

public religious activities (e.g., attending church 

services, participating in church-related social 

activities) were less likely to binge drink or use 

cannabis than youth who were not “publicly 

religious” (Escobar & Vaughan, 2014). 

4. What Is the Family’s Immigration/ 

Nativity Status? How Does This 

Affect Family Members’ Level of 

Acculturation? 

To understand family cultures and their 

subgroups, you must learn about their 

immigration history, because this may be 

Substance Use Disorder Treatment and Family Therapy 

connected to their substance misuse (Marsiglia, 

Nagoshi, Parsai, & Castro, 2014). Familybased SUD interventions, including prevention 

programming, also may have different effects 

depending on nativity (Cordova, Huang, Pantin, & 

Prado, 2012). 

• Some people leave their home country 

voluntarily to pursue opportunities or escape 

poverty. Refugees, on the other hand, may 

fee persecution, fear for their safety, and 

have much more pain and anger associated 

with their migration. Those who come from 

war-torn countries may show symptoms of 

posttraumatic stress disorder (PTSD) and other 

associated trauma; symptoms might include 

substance misuse. 

• Immigration status can affect parent–child 

relationships when one or both parents 

immigrate before the child. Parent–child 

separation can cause major stress and 

dysfunction in family relationships (e.g., poor 

attachments, feelings of abandonment). When 

people immigrate to the United States, it is not 

uncommon for them to feel family-, work-, and 

money-related stressors, which can increase the 

chances of substance misuse. 

• Degree of acculturation is linked to substance 

use behaviors and SUD treatment outcomes. 

- Among Latinos and Asians, greater 

acculturation may increase the risk of alcohol 

use, whereas lower acculturation and more 

recent immigration status may lower the 

risk of substance misuse because of the 

presence of protective factors like stronger 

family cohesion (Vaeth, Wang-Schweig, & 

Caetano, 2017). Differences in acculturation 

may be particularly relevant in cases where 

a person is using substances to cope with 

stress related to parent–child differences in 

acculturation. 

- A study of SUD treatment outcomes 

from motivational enhancement provided 

to Latino individuals found differences 

among subgroups (e.g., Cuban Americans, 

Mexican Americans, Puerto Ricans, and 

other Latino Americans) and among levels 

of acculturation, including differences in 

treatment retention and percentage of days 

abstinent (Chartier et al., 2015). 

102 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

- In the National Latino and Asian American 

Study (Savage & Mezuk, 2014), higher 

acculturation increased the risk of lifetime 

alcohol use disorder (AUD) and drug use 

disorder by 1.67 to 1.8 times. 

5. Are There Culture-Specifc Family 

Values To Be Aware Of? 

Strong and stable cultural values may be 

protective against substance misuse in racially 

and ethnically diverse families, such as Latino 

families (Cruz, King, Cauce, Conger, & Robins, 

2017): 

• Familism or familismo may be present in Latino 

families (Santisteban et al., 2013). These terms 

refer to the primary values, structures, and 

expectations of the family, which shape each 

family member’s behavior. Familism may lead 

family members to make decisions that are best 

for the family as a whole as opposed to the 

individual. It has three components: 

(1) perceived duties related to helping family 

members; (2) dependence on family members’ 

support; and (3) use of family members as 

behavioral and attitudinal referents. Familism 

emphasizes enmeshment within the family, 

high family loyalty, and pride in the family as a 

cohesive unit. 

• High familism may be benefcial in shaping 

healthy behaviors (like not misusing substances) 

if that is what is valued by the family. Yet if 

substance misuse happens within the family, 

especially across generations, familism 

may reinforce these negative behaviors by 

normalizing them. In one study of Latino 

adolescents, 3-month substance misuse was 

signifcantly correlated with lower levels of 

familism (Ma et al., 2017). 

6. How Does the Family’s Culture Affect 

Their Communication Style? 

Understanding the culture-specifc ways in which 

family members talk with one another will help 

you better understand the context for how the 

family functions, the dynamics between family 

members, and what contributes to the family’s 

dysfunction. This in turn can inform the person’s 

chances of achieving and sustaining recovery from 

substance misuse. 

• For instance, in a study of Asian and Pacifc 

Islander individuals, family openness about 

communicating about substance use was a 

positive factor in SUD treatment seeking, 

whereas family noncommunication about 

substance use was seen as discriminating and a 

barrier to treatment success (Chang et al., 2017). 

• Communication style also can shape the way 

families resolve conficts. 

- The concept of respeto refers to Latino 

values of respect in the family, which can 

infuence communication and dealing with 

confict between parents and children. 

Openly disagreeing with parents or voicing 

one’s opinion goes against the concept 

of respeto and is considered negative 

behavior (Santisteban et al., 2013). Thus, 

counseling techniques that fail to account 

for respeto and that urge adolescents to 

“speak out” against their parents may be 

counterproductive. 

- Simpatía, a focus on interpersonal 

relationship harmony, is another aspect of 

traditional communication styles in many 

Latino families. Greater respeto and simpatía 

have been linked to lower levels of Latino 

youth drug and alcohol use over 3 months 

and to abstinence from substances (Ma et 

al., 2017). 

7. How Does This Family Experience 

Racism and Discrimination? How 

Do Those Experiences, Along With 

Historical Trauma, Affect the Family? 

Feelings of racism and discrimination can 

increase the risk for substance misuse among 

people of diverse races and ethnicities. 

• In the National Latino and Asian American 

Study (Savage & Mezuk, 2014), discrimination 

increased the risk of lifetime AUD and drug use 

disorder by 1.4 to 1.54 times. 

• Structural racism has led to multiple systemic 

effects on African American families in many 

forms, such as socioeconomic disparities, voter 

suppression, educational disadvantages, and 

racial discrimination (Kelly, Maynigo, Wesley, & 

Chapter 5 103 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Durham, 2013). These challenges are signifcant 

stressors and may increase the changes seen 

in individuals misusing substances as a coping 

mechanism. 

Also be sure to acknowledge the signifcance 

of historical trauma, and consider whether it 

is playing a role in the family’s substance use 

problems. Certain cultures, like African American 

and AI/AN populations, have suffered for decades 

from social injustices, extreme physical and 

emotional trauma, and ongoing discrimination 

and prejudice. These experiences have had lasting 

effects on individuals and families. For instance, 

there is a widely held belief in AI/AN cultures 

that loss of culture because of historical trauma 

and ongoing mistreatment is a primary cause of 

mental disorders and SUDs in this population today 

(SAMHSA, 2018). It may be important to address 

such issues with families before families with 

substance misuse can fully recover. 

8. Has the Family Experienced Any 

Periods of Separation (Particularly 

Between Parent and Child)? 

In certain family cultures, parent–child separations 

may happen, sometimes repeatedly. Notable 

examples include families in which parents and 

children have immigrated separately and military 

families in which a parent has been deployed. In 

some of these cases, one parent may take over 

parenting responsibilities alone, grandparents may 

take over the duties of raising children, or children 

may stay with other members of their extended 

family or with family friends. 

• Parental separation from children is a strong 

independent risk factor for early substance 

use in children. In a sample of more than 3,000 

adolescent and adult children (about 26 percent 

of whom were African American and 8 percent 

of whom were of unspecifed race or ethnicity), 

parental separation happening between ages 

12 and 17 was as strong a predictor of initiating 

alcohol use before age 13 and of initiating 

cigarette and cannabis use before age 16 as 

living in a household with two parents with AUD 

(McCutcheon et al., 2018). 

• Youth in military families are at an increased 

risk of substance misuse compared with 

adolescents from civilian families. In one study, 

military family youth were 50 percent more likely 

than civilian youth to report both current and 

lifetime substance use (Sullivan et al., 2015). 

Long deployments are particularly stressful to 

children and parents and increase the odds of 

psychological maladjustment (Nicosia, Wong, 

Shier, Massachi, & Datar, 2017). 

COUNSELOR NOTE: ARE PARENTING INTERVENTIONS FOR SUDs AMONG 

RACIALLY/ETHNICALLY DIVERSE ADOLESCENTS EFFECTIVE? 

SUD prevention programs that target parent training appear to be effective, but comparatively less 

research has looked at racially and ethnically diverse families versus White families. What does the available 

research say? A review from Garcia-Huidobro, Doty, Davis, Borowsky, and Allen (2018) found the following: 

• Of 38 studies examined, 9 (23.7 percent) included a majority of White/European families, 5 (13.2 percent) 

included Black/African American families, 4 (10.5 percent) included Latino families, and 1 (2.6 percent) 

included Asian families, whereas 19 (50 percent) included diverse populations. 

• Among adolescents from multiple races or ethnicities, parent training was associated with improved 

scores on all substance use outcomes except for polysubstance use. 

• Among the fve studies investigating Black/African American families, parent training was linked to 

lowered tobacco, alcohol, and polysubstance use but not illicit substance use. 

• Three interventions among Latino families were effcacious across all substance use outcomes. 

• The one study focusing on Asian families found parent training to be effcacious for alcohol and illicit 

substance use but not tobacco use. 

104 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

SUD Treatment for Specifc Family 

Cultures 

This section presents brief summaries of the 

empirical evidence (Exhibit 5.2) on family-based 

SUD interventions for family cultures likely to be 

seen in your service setting, including families 

of diverse racial and ethnic backgrounds, LGBT 

families, and military families. This information is 

not meant to cover everything you need to know 

about offering SUD treatment to these family 

cultures; instead, it is designed to give you a broad 

overview of what evidence-based treatments exist 

and how you can tailor existing treatments and 

services to a family’s unique needs. 

SUD Treatment for African American 

Families 

Family-based interventions for SUDs that have 

support for use with African American families 

include MST, MDFT, and BSFT (Huey & Polo, 2017; 

Pina, Polo, & Huey, 2019; Rowe, 2012). BSFT has 

been accepted by SAMHSA as a model program 

for reducing or eliminating adolescent substance 

use behaviors and is effective for minority youth 

(particularly African American and Latino youth) 

(U.S. Department of Health and Human Services, 

Offce of Minority Health, 2018). 

In a sample of runaway youth in which 66 percent 

of participants were African American, ecologically 

based family therapy led to a decrease in 

percentage of days with substance use. Non-White 

adolescents showed signifcantly greater reductions 

than White youth (Slesnick, Erdem, Bartle-Haring, 

& Brigham, 2013). Treatment nonattendance was 

lower in the family therapy condition (12 percent) 

than in a motivational interviewing treatment 

group (34 percent) and a community reinforcement 

approach intervention group (26 percent); however, 

proportionally, there were no differences in the 

number of sessions attended across the three 

groups. 

Over the past decade, increasing evidence 

has emerged in support of a family-based 

intervention designed for rural African American 

families—the Strong African American Families 

(SAAF) Program. Developed at the University of 

Georgia, SAAF focuses on the primary prevention 

or elimination of conduct problems and negative 

health behaviors (including substance use) in rural 

African American early adolescents. SAAF has 

been shown to be effective in improving targeted 

parenting practices, adolescent self-regulation, 

and youth vulnerability to problem behaviors 

(Kogan et al., 2016). Brody, Chen, Kogan, Yu, and 

colleagues (2012) examined SAAF for reduction of 

EXHIBIT 5.2. Family-Based SUD Services for Youth of Diverse 

Races/Ethnicities 

Pina and colleagues (2019) recently reviewed the empirical evidence in support of psychosocial 

interventions for adolescents from diverse ethnic and racial backgrounds. Many of the studies included 

samples of multiple racial and ethnic groups. How did family-focused services fare in these studies of 

diverse groups of children? Among their fndings were the following: 

• In a sample of African American, Asian American, European American, and AI teens, multisystemic 

therapy (MST) led to lower alcohol, cannabis, and other drug use versus usual care. 

• In a sample of Latino, African American, Haitian or Jamaican, and European American youth, MDFT was 

associated with lower alcohol and cannabis use than peer group therapy. 

• In a sample of African American, Latino, European American, and AI adolescents, ecologically based 

family therapy and functional family therapy led to lower alcohol and drug use versus usual care. 

• In a sample of African American, Latino, and European American youth, BSFT was associated with greater 

decreases in days of self-reported drug use versus usual care. 

• In a sample of Latino teens, CIFFTA was associated with less cannabis and cocaine use than traditional 

family therapy. 

Chapter 5 105 
TIP 39

substance use, conduct problems, and depressive 

symptoms. Techniques included teen and caregiver 

skill building, prevention programming, health 

promotion education and skills, and adaptive 

racial socialization (i.e., helping youth develop 

racial pride and teaching them how to deal with 

racism and discrimination). Over 22 months, the 

intervention was associated with a 32-percent 

decrease in substance use and a 47-percent 

decrease in related problems. 

An offshoot of the original SAAF Program, called 

Protecting Strong African American Families 

(PSAAF), is similarly focused on reducing problem 

behaviors and health risks in rural African American 

adolescents but is specifcally for two-parent 

African American households (Barton et al., 

2018; Beach et al., 2016). Components of the 

intervention include (Beach et al., 2016): 

• Delivery of services in the home to foster 

greater participation by fathers. 

• A heavy focus on effective coparenting, 

including monitoring children’s behavior, 

enforcing family rules, and instilling in children 

a sense of racial pride (racial socialization). 

• Techniques to improve communication and 

problem-solving between couples. 

• An emphasis on addressing specifc domains 

of stress for African American families, including 

work, racism, fnances, and extended family 

issues. 

Compared with control families, families in 

PSAAF showed better improvements in parental 

monitoring; racial socialization (improved but 

nonsignifcant versus controls); and adolescent 

conduct problems, self-concept, and substance 

use initiation at follow-up (Beach et al., 2016). 

Adapting Family-Based SUD Interventions for 

African American Families 

When working with African American families, 

it may be helpful to tailor treatments and 

services by: 

• Including racial socialization promotion 

strategies. Helping African American 

adolescents develop a sense of pride about 

Substance Use Disorder Treatment and Family Therapy 

their race and ethnicity and effectively manage 

discrimination are considered protective 

practices that can improve self-regulation and 

promote healthy behaviors, like choosing not 

to misuse substances (Beach et al., 2016). SUD 

counselors should incorporate techniques that 

address racial pride and discrimination into 

family-based SUD interventions. 

• Helping parents strengthen their bonds with 

one another. In African American families 

with two parents, interventions focused on 

coparenting and reducing couple strain may be 

critical to preventing and improving children’s 

health-risk behavior, including substance use 

(Beach et al., 2016). Family counseling that 

includes techniques specifcally for parents may 

help enhance family communication and instill in 

children strength and resiliency. 

• Using culturally relevant storytelling. 

Cunningham, Foster, and Warner (2010) note 

how counselor use of personal narratives 

during MST for adolescent substance use was 

particularly effective for African American 

parents by helping support and reinforce 

decision making. Other counselor behaviors and 

core skills they report as benefcial for engaging 

African American families in MST for substance 

use and other externalizing disorders include: 

- Offering instrumental support (i.e., support 

for practical, everyday needs such as 

transportation and fnances). 

- Being willing to accept gifts from families 

and invitations to attend special family 

events. 

- Using a strengths-based approach and 

positive reinforcement. 

- Validating and empathizing with the family 

member’s point of view. 

- Helping families build skills by directly 

educating them (versus using indirect 

instruction). 

- Being open and honest in admitting to 

families when you make a mistake or do 

not have information or knowledge about a 

particular topic, question, or problem. 

106 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

COUNSELOR NOTE: BOOSTING AFRICAN AMERICANS’ ATTENDANCE AT 

FAMILY COUNSELING 

A small qualitative study (Awosan, Sandberg, & Hall, 2011, p. 159) asked African American clients who 

previously attended family counseling about perceived obstacles to engaging in services. Common 

concerns included: 

• The mismatch between the ethnicity of the clients and the counselor, which some respondents felt 

created a sense of mistrust. 

• The high cost of therapy. 

• The lack of support for counseling within the African American community at large (e.g., the belief that 

you shouldn’t be talking about your problems with a counselor, feeling that counseling will be unhelpful). 

When asked about what advice they would give clinicians to improve African American engagement and 

participation in family counseling, responses included: 

• “Create a program/campaign to attract people of all cultures to become therapists.” 

• “I would encourage those who can to try to place themselves where they can experience the disparity... 

take up residence in a Black neighborhood.... To remove obstacles, educate yourselves as much as you can 

about race and cultural issues in America.” 

• “Connect with others [in the] Black community. [Be] open to Afro-centric approaches in therapy and the 

need to understand Black culture.” 

SUD Treatment for Latino Families 

Substantial research documents underuse of 

services by Latino families, but family counseling 

can effectively reduce substance misuse in Latino 

individuals, especially adolescents (Henderson, 

Hogue, & Dauber, 2019; Hogue et al., 2015; Pina et 

al., 2019). For example: 

• A meta-analysis examined the effectiveness 

of seven culturally responsive SUD studies 

for diverse racial and ethnic adolescents—six 

of which targeted Latino populations in part 

or entirely (Steinka-Fry et al., 2017). Across 

all studies, there were signifcant reductions 

in youth substance use via interventions like 

Conjoint Family Therapy, BSFT, MDFT, and the 

CIFFTA Program. 

• Another meta-analysis focused solely on 

culturally responsive interventions for Latino 

youth with SUDs (Hernandez Robles, Maynard, 

Salas-Wright, & Todic, 2018) reported small 

but positive effects of culturally responsive 

interventions on improving substance use 

outcomes. 

- Of the 10 studies examined, 2 used BSFT 

or structured family therapy, and 4 included 

parents as part of the intervention. 

- The authors note than 90 percent of the 

studies integrated cultural values into 

services, with familism and respeto being 

among the most common. (See “General 

Considerations When Working With Diverse 

Family Cultures” for a brief explanation of 

these concepts.) 

• An analysis of the Bridges to High School 

Program—a culturally adapted, family-based 

intervention to prevent future SUDs and mental 

disorders in middle-school youth—found the 

program was associated with lowered substance 

use at 5-year follow-up (Jensen et al., 2014). 

Analyses indicate the intervention’s effects on 

reducing substance use stemmed in part from 

improvements in mother–adolescent confict. 

Additionally, higher levels of acculturation were 

associated with greater number of substances 

used. 

Chapter 5 107 
TIP 39

• Culturally adapted cognitive–behavioral 

therapy (CBT) for Latino adolescents and their 

parents (Burrow-Sánchez, Minami, & Hops, 

2015) is associated with improvements in the 

number of days of youth substance use, with 

ethnic identity and parental levels of familism 

moderating this effect. Specifcally: 

- Adolescents receiving adapted CBT who 

displayed greater exploration of and 

commitment to their ethnic identity showed a 

lower mean number of days of substance use 

at posttreatment and 3-month follow-up than 

did adolescents in the adapted-CBT group 

with low exploration of and commitment to 

ethnic identity. 

- Higher parent familism in the adapted-CBT 

group was associated with lower mean 

number of days of substance use at 3-month 

follow-up than lower familism in the adaptedCBT group. 

• Two prospective studies of family-based 

interventions for SUDs among Latino 

individuals (Sparks, Tisch, & Gardner, 

2013) reported signifcant improvements 

in substance use after the intervention 

compared with baseline measurements. 

Enhancements in Latino families were often 

on par with, and in some cases better than, 

improvements among non-Latino families, 

including improvements in: 

- Parenting skills. 

- Drug and alcohol use. 

- Family strengths/resilience. 

- Parent observations of children’s activities. 

- Parents’ social/cognitive skills. 

• In a randomized clinical trial of MDFT in 

juvenile drug court, Dakof et al. (2015) found 

treatment resulted in signifcant reductions 

in substance use, although reductions were 

no different from those in a control condition 

of adolescent group therapy. The study 

sample was 59 percent Latino and 35 percent 

African American. 

• Collaborating with community faith 

leaders may help behavioral health service 

providers target Latino families in need of 

mental disorder and substance use-related 

treatment (Villatoro, Morales, & Mays, 2014). 

Substance Use Disorder Treatment and Family Therapy 

Adapting Family-Based SUD Interventions for 

Latino Families 

In Steinka-Fry et al.’s (2017) meta-analysis of 

culturally responsive SUD interventions for 

adolescents, culturally responsive treatment 

components among Latino families included: 

• The provision of racially and ethnically diverse 

clinicians (though not necessarily matched to 

the race or ethnicity of clients/families). 

• Use of written materials for parents that were 

delivered in their native language. 

• Spanish-speaking counselors. 

• Easily accessible treatment locations. 

• Convenient scheduling. 

• Culture-informed assessments and treatment 

planning. 

• Treatment planning and delivery tailored 

to families who have trouble engaging 

in services. 

COUNSELOR NOTE: FAITH, LATINO 

FAMILY CULTURE, AND SEEKING 

HELP FOR MENTAL ILLNESS AND 

SUBSTANCE MISUSE 

Findings from the National Latino and Asian American 

Study (Villatoro et al., 2014) suggest that family culture 

plays a role in whether Latino families seek mental 

health services or SUD treatment. Specifcally, families 

with high levels of behavioral familismo (defned as 

level of perceived family support) were signifcantly 

more likely to seek informal or religious services (e.g., 

folk healers, mutual-help groups, online support 

groups, religious leaders) for mental and substance 

use-related needs than to seek mental health services. 

The authors suggest that these types of services may 

be more culturally aligned with Latino families or 

may be deemed more “acceptable” because of the 

prejudice associated with attending formal mental 

health services. 

Why does this fnding matter? Because Latino 

populations are known to underuse mental health 

services. 

108 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

Other suggested approaches when working with 

Latino families include the following: 

• Have a working knowledge of how substance 

use is defned in the family’s country of origin. 

Many countries of origin, such as Mexico, have a 

culture that is more permissive toward substance 

use. Immigration and acculturation into the 

United States may alter family members’ 

attitudes toward substance use. Such changes 

must be addressed, given their immediate effect 

on family relations. 

• Be aware of regional and national differences 

(e.g., North, Central, and South American 

cultural diversity in the Hispanic diaspora; 

Spanish as spoken in Mexico versus as spoken in 

Argentina or Spain or the Dominican Republic). 

• Explore family members’ experiences of 

migration, cultural transition, and ethnicminority status. Hold an open discussion 

about these experiences, which will help you 

analyze family stories and lead directly to issues 

affecting substance misuse. For instance, a 

discussion concerning how family members 

reconcile their culture of origin and American 

culture will reveal differing acculturation levels 

within the family. Also explore the issue through 

the simple exercise of having family members 

rate how close they feel to their culture of 

origin on a scale from 1 to 10. Counselors must 

make arrangements so that language does not 

impede a family member’s participation. 

• If you plan to work with Latino families with 

origins in Mexico, be familiar with spiritual 

healers, the curandero or curandera (i.e., 

folk healer). These healers can help resolve 

intrapsychic and interpersonal problems. 

Curanderismo, or the art of folk healing, is a 

particular treatment modality used primarily 

in Latino/Southwestern rural communities, 

although it is also prevalent in metropolitan 

areas with a large Latino population. Curanderos 

earn their trust from the community; the 

community validates their “practice.” This 

modality contains a mix of psychological, 

spiritual, and personal belief factors. Because 

the curanderos are considered to be holy, they 

invoke God’s and the saints’ blessings on people 

seeking their help. 

• Rather than using a businesslike approach to 

treatment, which will not appeal to many Latino 

families, take a personable tack, which will yield 

much more effective results. 

• Be attentive to family confict, which could 

affect substance use. One study of SUD 

treatment among Latino adults found that 

people who had a decrease in family confict 

from pretreatment to posttreatment showed 

less alcohol and drug use at posttreatment than 

individuals who had an increase in family confict 

from pretreatment to posttreatment (Fish, Maier, 

& Priest, 2015). 

For more guidance about family counseling with 

Latino families, see “Resource Alert: Recovery and 

Mental Health Services for Latino Families.” 

RESOURCE ALERT: RECOVERY 

AND MENTAL HEALTH SERVICES 

FOR LATINO FAMILIES 

The National Resource Center for Healthy 

Marriage and Families offers a toolkit for 

stakeholders serving the mental health needs 

of Latino individuals, couples, and families. The 

guide includes: 

• A brief summary of cultures and values 

common in Latino families. 

• A discussion of immigration and acculturation 

and how these factors infuence families. 

• Ways to improve engagement and retention of 

Latino families in services. 

• Resources for integrating marriage and 

relationship education into services. 

Access the toolkit at www.healthymarriageand 

families.org/library-resource/working-latinoindividuals-couples-and-families-toolkitstakeholders. 

Chapter 5 109 
TIP 39

SUD Treatment for Asian American 

Families 

Family-based drug and alcohol use interventions 

for Asian American families have not been 

rigorously studied, but the small amount of 

evidence seems positive. Culturally appropriate 

treatment models include CBT, strategic and 

structural family therapy, and solution-focused brief 

therapy (Cheung, 2014). Specifc study fndings 

include the following: 

• Family counseling for Asian individuals with 

SUDs has been linked to decreased substance 

use as well as improved family relationships 

(Fang & Schinke, 2014). 

• In a meta-analysis of parenting interventions 

for adolescent substance use, one study was 

focused on Asian American youth; it found the 

parenting intervention was associated with 

signifcant reductions in teen alcohol and illicit 

substance use (Garcia-Huidobro et al., 2018). 

• In a small investigation of Asian American 

mother–daughter dyads (Fang & Schinke, 2013), 

a family-based, Internet-delivered intervention 

for SUDs that focused on mother–daughter 

relationships, confict resolution, substance use 

risk, body image, mood and stress management, 

problem-solving, social relationships, and selfeffcacy resulted in many positive outcomes 

versus a control condition. These included: 

- Higher levels of mother–daughter closeness. 

- Improved mother–daughter communication. 

- Increased maternal monitoring. 

- Enhanced parental rules against substance 

use. 

- Higher self-effcacy. 

- Greater youth substance refusal skills. 

- Less intention to use substances in the future. 

- Reduced 30-day alcohol, cannabis, and 

nonmedical prescription drug use by 

daughters. 

Adapting Family-Based SUD Interventions for 

Asian American Families 

To help address cultural barriers and ensure 

treatment/service delivery meets the unique needs 

of this population, consider the following guidance: 

Substance Use Disorder Treatment and Family Therapy 

• To ensure you are offering appropriate and 

effective family-based interventions for Asian 

families, consider taking the following steps 

(Cheung, 2014): 

- Strive toward multicultural competency. 

- Acknowledge and respect Asian collectivist 

worldviews, values, and customs, and 

understand how collectivism affects family 

functioning. 

- Learn the family’s immigration history 

and any resulting disruptions in the family 

structure. 

- Understand that Asian American families 

are often complex in structure and can 

differ in how traditional versus modern they 

are, their biculturalism, and their degree of 

“Americanization.” 

- Use strategies that Asian American families 

are comfortable with, like hypothesizing, 

perspective taking, gift giving, and balancing 

“problem talk” with “solution talk.” 

- Share personal anecdotes or personal 

information with families, as appropriate. 

- Conceptualize your role from multiple 

views rather than just seeing yourself as the 

family’s counselor—for instance, view yourself 

as a teacher and community liaison for the 

family. 

- Avoid thinking of all Asian American 

families as belonging to one single ethnic 

group. Rather, clinical programming, 

approaches, and treatment/service materials 

should be congruent with and adapted to the 

unique languages, values, family structure, 

and life circumstances (e.g., immigration 

status, history of discrimination) of the many 

heterogenous subgroups that Asian American 

families comprise (Chang et al., 2017; 

Cheung, 2014), such as Chinese, Korean, 

Japanese, Vietnamese, and Thai populations. 

This is particularly important because 

adolescent substance use and risk factors 

for misuse can vary across Asian subgroups, 

which are discussed further below (Shih et al., 

2015). 

• Include family members in treatment, with 

an emphasis on educating them about 

the recovery process and why recovery 

110 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

is important. Research on Asian American 

and Pacifc Islander individuals suggests 

these groups have problems with or have 

been reluctant to enter SUD treatment in 

part because of certain family factors. Family 

misunderstandings or misperceptions about 

SUDs and the need for treatment can cause 

recoverees shame and embarrassment about 

seeking help. 

• Explore families’ level of acculturation and 

acculturation stress (Cheung, 2014), which have 

been linked to substance use and misuse across 

subgroups of Asians immigrating to the United 

States (Park, Anastas, Shibusawa, & Nguyen, 

2014). (Subgroups—or cultures within a culture, 

as discussed previously—are secondary cultures 

within the Asian culture at large, such as Chinese 

people, Japanese people, Korean people, 

Vietnamese people, and so forth. Subgroups 

often have separate languages, customs, beliefs, 

and value systems.) 

- Asian subgroups are deeply heterogenous 

in the social, cultural, historical, and 

contextual factors surrounding their 

immigration and acculturation experiences. 

Take time to educate yourself about a family’s 

specifc background. 

- Also be mindful that acculturation and 

immigration among Asian immigrants can 

vary by generation. The life experiences 

of newly immigrated individuals and those 

not yet profcient in English can affect risk of 

alcohol use differently than immigrants with 

a longer residency and greater acculturation 

into U.S. society (Park et al., 2014). 

• When possible, match counselors of similar 

race, ethnicity, or cultural background, similar 

language, or both to Asian American families 

(Chang et al., 2017). 

• Know and incorporate into treatment the 

unique help-seeking and coping behaviors 

often present in Asian Americans, including use 

of religion, meditation, and family support (Lei & 

Pellitteri, 2017). 

SUD Treatment for AI/AN Families 

Although family-based SUD programs for AI/AN 

populations are understudied, they appear to be 

effective, particularly for youth (Pina et al., 2019). 

Liddell and Burnette’s (2017) review of culturally 

informed SUD interventions for indigenous youth 

found that all included studies reported some 

degree of improvement in alcohol or drug use 

and that community or family involvement was a 

key component in many studies. There were also 

improvements in family support and relationships, 

and the inclusion of family or community into 

service/interventions was well accepted. 

In another review, Rowan et al. (2014) examined 

interventions offered to indigenous clients (and 

often their families), which included some aspect 

of Western-based SUD services (e.g., assessment, 

education, counseling, treatment, continuing care 

services) as well as traditional cultural services. 

The following positive outcomes were reported 

among the studies that included families in their 

interventions: 

• Abstinence was maintained for 1 year in 

one-third to one-half of participants. 

• Perceived level of family support was high 

among intervention recipients (94 percent). 

• Percentage of days abstinent across 12 months 

ranged from 80 percent to 100 percent (but was 

not statistically different from a treatment-asusual group). 

• 30-day alcohol or drug use declined from 24 

percent to 5 percent. 

• Past-month substance-related stress/emotions/ 

activities decreased from 47 percent to 23 

percent. 

• Part- or full-time employment increased from 11 

percent to 20 percent. 

• Enrollment in school or occupational training 

programs increased from 7 percent to 17 

percent. 

• Arrests and acts of criminal behavior decreased 

from 31 percent to 5 percent. 

• Signifcant improvements were seen in 

self-reported depression, anxiety, problems 

concentrating, hallucinations, problems 

controlling violent behavior, and suicide 

attempt. 

Other family-based substance use reduction or 

prevention programs have been adapted to the 

Chapter 5 111 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

needs of AI/AN families (Belone et al., 2017; 

Ivanich, Mousseau, Walls, Whitbeck, & Whitesell, 

2020), but fndings on substance use outcomes 

specifcally are either currently unavailable (e.g., 

programs still being pilot tested) or have yet to 

show signifcant improvement. Further research 

will be needed to identify any potential substancerelated benefts of such family-based programs. 

SUD treatment for AI/AN families has been 

successfully provided via home visiting programs 

(Barlow et al., 2015). For instance, tribal home 

visiting programs funded through the federal 

Tribal Maternal, Infant, and Early Childhood Home 

Visiting Program have shown success in identifying 

and providing referrals for treatment of familybased substance use problems in AI/AN families 

(Novins, Ferron, Abramson, & Barlow, 2018). 

Programs offered include the: 

• Parents as Teachers Program (https:// 

parentsasteachers.org). 

• Family Spirit Home Visiting Program (http://caih. 

jhu.edu/programs/family-spirit). 

• Nurse-Family Partnership Program (www. 

nursefamilypartnership.org). 

• Parent-Child Assistance Program (http://depts. 

washington.edu/pcapuw). 

• SafeCare Program (http://safecare.publichealth. 

gsu.edu). 

Of nine programs surveyed (Novins et al., 2018), 

all implemented SUD screening and monitoring 

at intake and during in-home visits. All screened 

pregnant women and mothers; fve also screened 

fathers. Eight offered referral for community-based 

SUD treatment, and six offered home-based 

SUD services. Eight made referrals to treatment 

programs with cultural elements or access to 

traditional providers. 

Adapting Family-Based SUD Interventions for 

AI/AN Families 

Family counseling techniques for AI/AN 

populations should take a systems approach 

that incorporates not just the family but the 

community, tribe, or clan. The following strategies 

can help you maintain such an approach and 

maximize positive substance-related outcomes for 

AI/AN families (SAMHSA, 2018): 

• Understand and acknowledge the 

interconnectedness of AI/AN families. Family 

counseling with this population requires an 

approach wherein each member of the family 

is understood to be interconnected with 

one another as well as with the surrounding 

community, tribe, or clan. Thus, when change 

happens in an individual, it has ripple effects 

on the group or population at large. Nothing 

happens in isolation. 

• Help families build strong relationships 

between parents and children. A review of 

protective factors against negative health 

outcomes in AI/AN youth found positive family 

bonds, including those between parent and 

child, were correlated with low substance use 

(Henson, Sabo, Trujillo, & Teufel-Shone, 2017). 

• Learn how the family defnes itself: Who is 

considered “family,” and what is each person’s 

role? 

• Discuss with family members their thoughts 

and feelings about participating in family 

counseling. 

• Discuss with family members their thoughts 

and feelings about substance use. Parent 

and grandparent norms have been shown 

to infuence AI youth substance use. The 

presence of family members who discourage 

substance use is linked to lower intent to use 

(particularly alcohol, nicotine, and cannabis) in 

this population (Martinez, Ayers, Kulis, & Brown, 

2015). Thus, open expression of antisubstance 

use messaging from parents and grandparents 

may be useful during family counseling in 

shaping adolescent behavior. 

• Where appropriate, include valued others (e.g., 

community elders, spiritual healers) into service/ 

treatments. 

• Use family genograms to understand the 

family’s history, structure, values, and strengths. 

• Consider including family sculpting—a family 

counseling technique that involves role-playing 

and acting out dramatic representations of past 

family events. 

• Seek out information about and be willing to 

include traditional healing practices. 

112 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

• Build relationships and connections with 

spiritual advisors, traditional healers, elders, 

and others in the AI/AN community. 

Using Trauma-Informed Family Counseling in 

SUD Treatment for AI/AN Families 

Another key aspect of culturally informed SUD 

treatment and services for AI/AN families is using 

trauma-informed care (Lucero & Bussey, 2015). 

This requires acknowledging and addressing 

trauma in three areas: 

1. The historical trauma inficted on AI/AN 

cultures as a whole (e.g., discrimination, forced 

relocation). 

2. Intergenerational trauma passed down among 

family members (e.g., impact of suicides, 

adverse childhood experiences, and violence 

within the family and community). 

3. Trauma felt by the individual misusing 

substances. 

A trauma-informed approach means using (Lucero 

& Bussey, 2015): 

• Trauma-informed screening and assessment 

tools. 

• Treatment/service delivery that fosters feelings 

of safety. 

• Staff training in recognizing and responding to 

trauma symptoms. 

• Referrals to trauma-informed behavioral health 

services with providers who have worked with 

AI/AN clients. 

• An interaction style that establishes trust and 

fosters mutually respectful relationships with 

families. 

Myhra, Wieling, and Grant (2015) describe specifc 

family dynamics of AI/AN families affected by 

SUDs. These dynamics may serve as important 

targets of clinical intervention or otherwise help 

inform effective service delivery. They include: 

• The presence of grandparents as a source of 

stability, safety, and security for grandchildren, 

particularly when parents with SUDs are unable 

to care for their children. 

• The need for open communication about 

substance misuse among family members, 

especially among parents/grandparents and 

children. 

• The importance of forgiveness as a part 

of recovery and of healing broken family 

relationships. 

• The use of cultural and spiritual practices 

in promoting recovery (e.g., sweat lodge 

practices, cultural ceremonies, passing down 

cultural and ancestral knowledge to children/ 

grandchildren). 

RESOURCE ALERT: TIP 61, 

BEHAVIORAL HEALTH SERVICES FOR 

AMERICAN INDIANS AND ALASKA 

NATIVES 

SAMHSA recently developed an indepth guide 

for mental health service and SUD treatment 

provision for AI/AN clients. Download TIP 61, 

Behavioral Health Services for American Indians 

and Alaska Natives, from https://store.samhsa. 

gov/product/tip-61-behavioral-health-services-foramerican-indians-and-alaska-natives/sma18-5070. 

SUD Treatment for LGBT Families 

Research is insuffcient to suggest the effcacy of 

any one type of family counseling over another for 

use with LGBT families. In fact, little or no empirical 

research has been published investigating the use 

of family counseling in SUD treatment for these 

families. However, a review of SUD treatments 

for LGBT youth (Aromin, 2016) notes that family 

therapy is often an effective and critical addition 

to individual treatment. Specifc benefts cited in 

the review include: 

• Addressing substance use from a systems 

approach rather than solely as an individual 

problem. 

• Identifying and repairing dysfunctional family 

dynamics, especially those infuencing substance 

use. 

• Teaching assertiveness training. 

• Improving overall family functioning. 

Chapter 5 113 
TIP 39

Notably, for youth who are nondisclosed and feel 

that discussions about their sexual orientation 

cannot be separated from discussions about their 

substance use, you should weigh the pros and 

cons of including family in treatment/services 

(Aromin, 2016). If family members are included, 

issues about confdentiality and treatment alliance 

may need to be addressed. 

Strong, positive family relationships may 

buffer against substance misuse among LGBT 

individuals, as is the case among heterosexual 

individuals. 

• For instance, fndings from Waves I and III of 

the National Longitudinal Study of Adolescent 

to Adult Health (Magette, Durtschi, & Love, 

2018) showed that emerging adults who 

reported close relationships with their mothers 

in adolescence were less likely to use cannabis, 

and a strong relationship with fathers during 

adolescence predicted signifcantly lower 

past-year illicit drug use. 

• In a national survey of 12- to 17-year-olds 

(Padilla, Crisp, & Rew, 2010), parental 

acceptance of sexual orientation among LGBT 

youth (and particularly acceptance by mothers) 

was protective against future substance use. 

Specifcally, parents’ acceptance lowered the 

risk of substance use by 35 percent to 39 

percent compared with adolescents who were 

not out to their parents or whose parents were 

nonaccepting of their sexual orientation. 

These fndings underscore the infuence of parent– 

child relationships as possible risk factors for 

substance use later in life. They also suggest the 

critical role of family counseling in supporting 

and strengthening bonds among LGBT families, 

particularly during adolescence. 

Adapting Family-Based SUD Interventions for 

LGBT Families 

There is a signifcant lack of empirically validated 

research about family-based SUD counseling for 

LGBT families. Thus, identifying effective changes 

for this population is diffcult. However, it can be 

useful to consider research on family and couples 

therapy with LGBT populations in general to learn 

Substance Use Disorder Treatment and Family Therapy 

which adaptations may be useful when applied in 

the context of SUD treatment. 

For instance, guidance on how to adapt 

attachment-based family therapy to gay and 

lesbian adults with nonaccepting family members 

includes the following (Diamond & Shpigel, 2014): 

• Focus on alliance building, including getting 

to know clients and their perceptions of 

the problem. Many LGBT individuals have 

had problems with developing and sustaining 

healthy attachments with their family. Thus, 

rapport building is an important goal of 

counseling and helps build trust, empathy, and 

confdence. 

• Help clients prepare to invite family into 

treatment. Work with them on the possibility 

that family will reject their invitation. Use 

individual sessions to discuss and role-play 

conversations with family members, or have 

clients express their thoughts and feelings to 

family by writing a letter. 

• As needed, have a separate session with 

nonaccepting family members, such as parents, 

alone. If family members are not accepting of 

your client’s sexual orientation, they may feel 

avoidant or resentful of engaging in family 

counseling. You may need to gently challenge 

their false beliefs about their family member’s 

sexuality while remaining compassionate and 

empathetic. 

Other general guiding principles include: 

• Address your own potential biases about 

LGBT couples and families. Most communities 

have some sort of visible LGBT organizations, 

and countless Internet resources are readily 

available. 

• Family can be a very sensitive issue for LGBT 

clients. Use the client’s defnition of family 

rather than relying on a heterosexual-based 

model. For example, an LGBT client may defne 

family as same-sex parents and their children, 

rather than a mother and father with children. 

• Likewise, be accepting of whatever 

identifcation an individual chooses for himself 

or herself and be responsive to the need to be 

inclusive and nonjudgmental in word choice. 

114 Chapter 5 
TIP 39

 

Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status 

For example, gender-neutral words and phrases 

may be preferred, such as partner rather than 

husband or wife. Such an approach will ensure a 

greater likelihood that people will continue with 

therapy. 

• Do not overpathologize issues of boundaries 

and fusion. Many LGBT couples appear to have 

more permeable boundaries than are commonly 

seen among heterosexual couples. For example, 

a lesbian may seek support from an expartner 

to help with troubles with a current partner 

more often than would typically be seen in a 

heterosexual woman. When violence between 

partners is a treatment issue, safety must be the 

counselor’s main concern. 

• Many LGBT clients may be reluctant to include 

other members of their families of origin in 

therapy because they fear rejection and further 

distancing. Be open to including nontraditional 

family members or using nontraditional family 

models, such as one-person family counseling, 

which incorporates a family focus without 

treating the whole family of origin. Be alert to 

possible substance misuse or mental illness 

among LGBT clients’ nontraditional family 

members as well. 

• LGBT individuals should not be urged to come 

out when they are not ready. 

SUD Treatment for Military Families 

Active duty and veteran military personnel 

are at an increased risk for substance misuse, 

including AUD, drug use disorders, past-month 

heavy episodic drinking, daily cigarette use, and 

prescription drug misuse (Hoggatt, Lehavot, 

Krenek, Schweizer, & Simpson, 2017; Teeters, 

Lancaster, Brown, & Back, 2017). Additionally, 

spouses and children of military members are 

vulnerable to substance misuse (Sullivan et al., 

2015; Trone et al., 2018). Thus, family-based 

approaches in SUD treatment for military personnel 

can be key. 

Nearly all of the empirical research on SUD 

treatment in military populations has been focused 

on individual treatment effects rather than the 

effects of family-based interventions. Furthermore, 

an abundance of family-based research in military 

populations concerns topics like deployment, 

suicide/violence, or PTSD, not SUDs. Thus, it is 

diffcult to know the degree to which family 

counseling for substance misuse has been 

successfully used with military families. Examples 

of available evidence-based fndings include the 

following: 

• In a very small study of male military veterans 

and female spouses, behavioral couples therapy 

for AUD combined with cognitive–behavioral 

conjoint therapy was associated with a reduction 

in percentage of days of heavy alcohol use and 

PTSD symptoms (Schumm, Monson, O’Farrell, 

Gustin, & Chard, 2015). 

• A web-based adaptation of Community 

Reinforcement and Family Training was 

effcacious in improving social support, 

relationship quality, family confict, and spouse 

perceptions of partner drinking rates (Osilla et 

al., 2018). 

The Department of Defense has made concerted 

efforts to better address family-wide problems felt 

by military personnel, including marital issues, child 

behavioral problems, and adjustment problems, 

through programs such as Military and Family Life 

Counseling (MFLC) and Military OneSource. These 

programs provide services like couples counseling, 

psychotherapy, suicide prevention, screening, 

pharmacotherapy, telehealth, inpatient psychiatric 

care, residential treatment, and SUD treatment (Trail 

et al., 2017). Unfortunately, little peer-reviewed 

research has been conducted to assess the effcacy 

and cost-effectiveness of these programs (Trail et 

al., 2017), especially regarding SUD services and 

outcomes. However, recent analyses from the 

RAND Corporation suggest these programs can 

be effective at (Trail et al., 2017): 

• Reducing short- and long-term problem 

severity. 

• Reducing interference with work and daily 

functioning. 

• Providing needed referrals for outside services 

(including mental health services). 

• Improving stress (work-related and life stress) 

and anxiety. 

• Meeting clients’ treatment expectations. 

Specifcally, over 90 percent of participants 

reported feeling satisfed with the speed with 

Chapter 5 115 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

which care was accessed, the confdentiality of 

the care, and continuity of services. 

• Responding to military-specifc needs. 

Specifcally, 25 percent of MFLC participants 

agreed, and 69 percent strongly agreed, that 

the counselor understood military culture. For 

Military OneSource participants, 34 percent 

agreed and 44 percent strongly agreed that the 

counselor understood military culture. 

Adapting Family-Based SUD Interventions for 

Military Families 

Because of the lack of empirical data on familybased SUD treatment for military populations, our 

understanding of how to adapt traditional familybased SUD interventions for the needs of military 

families is limited. However, you can draw guidance 

from research on family counseling for military 

families in general. Consider the following when 

working with these families: 

• For adolescents with or at risk for SUDs, 

ensure parent involvement in services/ 

treatment. 

- A study of data from the 2004 to 2013 

National Surveys on Drug Use and Health 

revealed that adolescent children of veteran 

fathers were more likely than children of 

nonveteran fathers to report lifetime, pastyear, and past-month use of tobacco and 

nonmedical use of psychotropic medication 

as well as lifetime cannabis use (Lipari et al., 

2017). Lower father involvement predicted 

greater chances of youth substance use in 

this study. 

- The authors suggest that parent involvement 

and communication with children about 

substance use can be valuable, especially 

for prevention efforts. They note that 

“formal support from programs serving 

veterans’ families may be necessary to 

address prevention or intervention for 

adolescents’ substance use. In addition, 

effectively supporting families requires 

the active participation of a network of 

stakeholders, including extended family 

members, schools, health and mental health 

care providers, community leaders and 

groups, private associations, and faith-based 

and civic organizations” (p. 705). 

• Educate yourself about military culture, 

including what life is like for military families. 

The RAND assessment of MFLC and Military 

OneSource (Trail et al., 2017) indicates that, 

although most participants felt counselors 

understood military culture, many did not, and 

that was considered a barrier to successful 

treatment. 

• Consider stressors related to military life 

that may exacerbate or increase the risk 

for substance misuse. Military family life 

can be very diffcult for families, and children 

especially, in large part because of parent/ 

spouse deployment and repeated household 

relocations. These events can be a strain on 

children (Lester et al., 2016) because of: 

- Having to take over household 

responsibilities while a parent is deployed. 

- Fears about parent safety while deployed. 

- Reunifcation and readjusting to life with the 

returning parent back in the home. 

- Helping care for a parent who returns with 

combat-related injuries or trauma. 

- Adjustment problems with ftting into new 

schools and communities. 

- Having to form new bonds with teachers. 

- Having to build new friendships and integrate 

into new peer groups. 

When working with military families on substance 

use-related issues, it may be helpful to consider 

the overall context of military family life and 

related burdens placed on service members, 

spouses, and children because of deployment, 

relocation, or other military-related events and 

factors. It is possible that recovery will not be 

successfully achieved and maintained without also 

addressing such stressors if present, as they could 

make return to substance use more likely. 

• Accept that being in the military is extremely 

demanding and all encompassing; it is not 

“just a job.” Military life is “24/7.” Working 

effectively with military families means 

understanding that the person serving in the 

military (and his or her family) has made an 

extraordinary sacrifce and commitment. In 

a way, the military as an institution almost 

operates as a third person in the marriage, 

116 Chapter 5 
Chapter 5—Race/Ethnicity, Sexual Orientation, and Military Status TIP 39

RESOURCE ALERT: PROVIDING SUD SERVICES FOR MILITARY FAMILIES 

• The National Child Traumatic Stress Network supports interventions to help lower substance use and 

other unhealthy behaviors in military-family youth. They offer multiple resources specifcally for active 

duty and veteran families to help them cope with the stress (and trauma) of military family life. 

- A listing of resources can be found here: www.nctsn.org/what-is-child-trauma/populations-at-risk/ 

military-and-veteran-families/nctsn-resources. 

- Online courses about evidence-based military-informed care for families can be found here: https:// 

learn.nctsn.org/course/index.php?categoryid=28. 

• SAMHSA’s Service Members, Veterans, and their Families Technical Assistance Center provides training, 

technical assistance, and consultation to address the behavioral health needs of service members, 

veterans, and their families. Visit the center’s website for more information (www.samhsa.gov/smvf-tacenter). 

creating a relational triangle (as refected in the Where Do We Go From Here? 

common remark from spouses, “My husband is 

married to the military”) that may need to be 

addressed (Moon, 2016, p. 130). 

• Because military service is often 

transgenerational, explore whether substance 

use patterns in military personnel were 

present in other generations of the family who 

served (Moon, 2016). For instance, a father in 

the Army who drinks heavily may have grown up 

with a father who, like him, served in the Army 

and drank heavily, perhaps to cope with stress 

or trauma. This normalizes the substance misuse 

and, if unaddressed, can become a barrier to 

recovery. 

• Explore your own thoughts, beliefs, and 

biases about the military and military culture. 

Do this preparation before interacting with 

military families. The goal is to avoid any 

reactions you might have that could negatively 

infuence your work with these families (Moon, 

2016). 

You will encounter many diverse types of families 

in your clinical setting, but no two families are 

the same. Understanding why you may need to 

make adaptations to treatment for certain family 

cultures and how to make those adaptations will 

increase your chances of success in helping them 

achieve good outcomes. But it is not enough 

for just counselors to develop this knowledge. 

Service delivery that is responsive to families 

and their cultural needs requires the integration 

of appropriate staff training, competency, and 

supervision throughout the entire program. In the 

next chapter, readers will learn how administrators 

and supervisors can collaborate with providers 

to accomplish comprehensive, integrated family 

counseling for SUD treatment. The goal is to 

develop SUD programs that successfully provide 

high-quality, evidence-based care, including 

referrals, outreach, community linkage, SUD 

services, and SUD treatments for all families with 

substance misuse. 

Chapter 5 117 
This page intentionally left blank. 
Chapter 6—Administrative and 

Programmatic Considerations 

KEY MESSAGES 

TIP 39 SUBSTANCE USE DISORDER TREATMENT AND 

FAMILY THERAPY

• The key to integrating family-based 

interventions into substance use disorder (SUD) 

treatment programs is to create a familycentered culture throughout the organization. 

• Cross-training and ongoing supervision 

are essential for SUD treatment providers 

to achieve competency in family-based 

interventions. 

• Clinical supervisors overseeing integration 

efforts should have experience and training in 

family counseling as well as SUD treatment. 

• Provider collaboration supports greater service 

access and a “no wrong door” approach to 

treatment by facilitating successful referrals, 

effective engagement, and meaningful 

partnerships with community resources. 

Helping individuals and families initiate and 

sustain long-term recovery contributes to the 

overall health of communities and lowers societal 

healthcare costs. Many programs already involve 

families in the SUD treatment process in some way, 

such as through family psychoeducation groups. 

Even so, integrating family counseling into SUD 

treatment may require administrators to make 

signifcant investments of time and resources—but 

the benefts to clients, families, and communities 

make such investments worthwhile. 

As a program administrator, director, or clinical 

supervisor, you can lead your SUD treatment 

program in making changes to incorporate 

family-based interventions into existing services. 

Doing so will help: 

• Improve long-term recovery outcomes for your 

program’s clients and their families. 

• Harness the support of family members as a 

source of recovery capital for clients with SUDs. 

• Improve clients’ family functioning. 

• Protect against substance misuse among family 

members who are children or adolescents. 

Including family-based interventions in SUD 

treatment settings at any level of intensity 

requires a systematic, continual administrative 

effort. This chapter provides guidance that will 

help you initiate and maintain integration efforts by 

exploring how to: 

• Develop a family-centered culture in your 

organization. 

• Incorporate and improve the quality of family 

counseling and family-based interventions. 

• Facilitate workforce development that will 

support integrated family counseling for SUDs 

(e.g., providing ongoing staff education about 

family counseling; hiring new staff members with 

family and marriage counseling credentials to 

provide more intensive family counseling). 

• Establish or expand collaboration with 

community-based family therapists and other 

family-centered social service providers and 

programs. 

• Address programmatic issues related to the 

integration of family counseling and SUD 

treatment, such as reimbursement, regulations, 

and outcomes monitoring. 

119 
TIP 39

Developing a Family-Centered 

Organizational Culture as an 

Administrator 

A family-centered organizational culture 

fosters SUD treatment practices that 

promote dignity and respect, refect 

cultural responsiveness, and focus on 

family strengths and resources. It creates 

a welcoming atmosphere and invites 

family members of all ages into treatment 

and recovery activities. A family-centered 

organizational culture also encourages 

development of program activities that 

leverage the power of family systems 

and acknowledge the potential of family 

members—including those with SUDs—to 

be positive infuences and resources for each 

other and for other families. 

The key to integrating family-based 

interventions into SUD treatment programs is 

to create a family-centered culture throughout 

the organization. 

With your clients’ permission, try to involve 

family members in all aspects of SUD treatment 

programming. Ideally, clients’ families will have a 

voice in developing and running activities. Even 

program evaluations and outcomes research 

should refect families’ perspectives. By prioritizing 

the inclusion of families in SUD treatment, you 

can identify counseling interventions and familycentered program activities that best address the 

needs of the clients and families you serve. 

Engagement 

Ensure that all staff members understand how 

your agency will engage families throughout 

SUD treatment and family counseling processes 

and activities. Well-integrated family counseling 

for SUD treatment refects a family-centered 

organizational culture across a range of 

programming, such as: 

• Screening and assessment for substance misuse 

and family issues. 

Substance Use Disorder Treatment and Family Therapy 

• SUD treatment. 

• Family counseling and family-based 

interventions (e.g., to address intergenerational 

substance misuse issues). 

• Education and engagement (e.g., parent 

education; web-based psychoeducation about 

SUDs). 

• Community partnerships. 

• Home-based counseling and family case 

management services. 

• Process and outcome evaluations. 

Promote respectful, nonjudgmental interactions 

between clients and agency staff at all levels to 

enhance and maintain engagement. Engagement 

begins at frst contact with clients or family 

members, so it is essential that your staff members 

refect a family-centered program culture from the 

outset. 

At an administrative level, you can foster familybased SUD engagement by: 

• Informing clients of your services and familyoriented SUD treatment philosophy via brief, 

easy-to-read materials (e.g., plain jargon-free 

language; text big enough for older clients and 

those with vision diffculties to read). Consider 

having a client/family “bill of rights” in these 

materials. 

• Using family-oriented language in client and 

family interactions and in all written materials. 

• Adapting all client-related materials into 

diverse languages refecting the cultural/ethnic 

groups in your community. (See also TIP 60, 

Using Technology-Based Therapeutic Tools in 

Behavioral Health Services [Substance Abuse 

and Mental Health Services Administration 

(SAMHSA), 2015].) 

• Providing free self-assessment tools, such as 

the Alcohol Use Disorders Identifcation Test. 

• Informing clients at intake or frst contact 

about the benefts of family involvement in 

treatment and addressing their ambivalence or 

anxiety about including family members. 

• Linking clients and their families with 

community services that address critical needs, 

such as housing, employment, or health care. 

120 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

• Reaching out to families of people with SUDs 

or mental disorders by offering information 

about your services in nontraditional settings. 

• Providing transportation to your facility for 

clients and their family members through 

recovery volunteers, peer recovery support 

specialists, or case managers. 

• Conducting brief interventions over the phone 

when potential clients or family members call, 

such as with a motivational interviewing (MI) 

script that trained support staff can administer 

(Loveland, 2014). 

• Promoting reengagement with clients who 

have returned to substance use or have had 

recovery setbacks by welcoming them and their 

families back into treatment with respect and 

optimism. 

• Keeping demands on family schedules in mind 

when arranging interviews. 

To improve access and engagement, consider 

an open-access model for initial engagement 

with clients and family members. In this model, 

programs set a certain number of hours a day 

during which clients can walk into one or more 

access points (e.g., outpatient counseling program 

or primary care offce) without an appointment 

for an initial intake and admission to available 

treatment services. 

Environment 

To foster family-based SUD treatment 

engagement, create a warm, inviting treatment 

environment that feels safe and accessible for 

family members of all ages. Such an environment 

may have: 

• Large counseling rooms or spaces that can 

accommodate a family or multiple families. 

• Child-sized furniture and colorfully painted 

walls in designated family treatment spaces. 

• Free or low-cost child care at the facility, active 

linkage to childcare providers near the facility, 

or linkages to fnancial resources to pay for 

child care. 

• Adaptations to make navigating the facility 

easier for clients with mobility issues (e.g., older 

clients). 

• Age-appropriate materials (e.g., coloring 

books to occupy younger children; large-print 

handouts to provide information for older family 

members who may have impaired vision). 

• Educational programming for family members 

of all ages, complete with age-appropriate 

information and educational activities to help 

them understand the effects of substance 

misuse on their families. 

Incorporating Family Counseling 

and Family Programming 

Integration helps avoid duplication of services, 

lessen the artifcial split between counseling 

for family problems versus SUDs, and increase 

treatment effciency and effectiveness for clients 

and families. Most SUD treatment agencies 

serve diverse clients with a range of substance 

misuse profles. The array of client needs, multiple 

family infuences, and differences in providers’ 

training and priorities can compound the 

challenges of addressing substance misuse. To 

offset these challenges, professionals—including 

administrators—in family counseling and SUD 

treatment should work together. The resources, 

insights, and strategies each feld can bring to 

programming will enhance treatment. 

Understand the various degrees to which 

family counseling can be incorporated into 

SUD treatment. There are many ways to provide 

family-based interventions along the continuum 

of SUD treatment and recovery support services. 

You may opt for full integration in your program, 

offering both family counseling and SUD treatment 

in the same facility (whether the same or different 

counselors provide each service). Alternatively, 

you can build partnerships with other agencies to 

create a comprehensive referral network for SUD 

treatment and family counseling services. Exhibit 

6.1 provides a framework for levels of integration 

of family-based interventions in SUD treatment 

programs. 

Chapter 6 121 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

EXHIBIT 6.1. Levels of Program Integration 

The consensus panel of this TIP developed a framework for administrators to determine the extent to which 

their programs integrate family-based interventions with SUD treatment. The framework has four levels: 

1. Staff awareness and education. At this level, resources are almost completely informational in 

nature. Staff members generally understand that clients require support systems to maintain recovery 

and avoid relapse. Staff members develop awareness of and participate in training to enhance their 

understanding of the family as a strength and a potentially positive resource in SUD treatment and 

ongoing recovery support. 

2. Family education. At this level, the organization offers high-quality referral lists and active linkage 

to family services to interested parties for follow-up. However, the program generally lacks the 

fnancial and human resources to provide direct services to family members. The focus is on providing 

information to clients and families about the role of the family in SUD treatment and making informal 

referrals for the general public. Although the program may offer some educational seminars, they are 

not mandatory for clients and families as part of the formal SUD treatment program. 

3. Family collaboration. At this level, the program actively involves clients’ families and understands their 

importance as a potential resource in SUD treatment. The program refers clients for family counseling 

services through coordinated SUD treatment efforts that maintain collaborative ties. 

4. Family counseling integration. At this level, all components of the program and its policies support 

full integration of family counseling into SUD treatment. Systemwide, strengths-based, family-friendly 

approaches are operational and culturally responsive, providing “one-stop assistance” for clients and 

families. A family-centered culture is apparent in all levels of the program and is supported by program 

infrastructure: specifcally, human and fnancial resources. 

Encourage open communication about family 

counseling and family-based interventions, as 

well as mutual respect between SUD treatment 

providers and family counselors. Whatever your 

program’s current level of integration, it is essential 

for you to encourage an organizational culture 

that values both types of services. SUD treatment 

providers and family counselors should know when 

to refer clients and when to consult with counselors 

or clinical supervisors in the other feld. To deliver 

effective services, providers in each feld should 

coordinate and tailor their approaches so that clients 

and families who receive family counseling get the 

most beneft from family-based SUD treatment. 

Facilitate cross-training and clear procedures 

for referral and follow-up. As an administrator, 

you can foster ongoing communication by creating 

specifc procedures for referral and follow-up with 

providers from other organizations. You can also 

invite providers from other agencies to participate 

in cross-training (Exhibit 6.2) on family-based 

interventions and SUD treatment. 

Understand what makes a fully integrated 

SUD treatment and family counseling program 

work. Full integration means that services at all 

levels refect fully functional operations, policies, 

procedures, and philosophical approaches to 

providing family-based SUD interventions. The 

following paragraphs describe some characteristics 

of fully integrated programs: 

• All staff—from support staff to the executive 

director—understand the important role of the 

family as a potentially positive infuence on clients 

in the treatment and recovery process. They 

have resolved any ambivalence they may have 

had about making clinical, administrative, and 

structural changes to integrate family services 

into the program. They are ready to take action. 

• Administrators, program managers, and clinical 

supervisors reinforce written policies and 

procedures for including families in program 

activities. A manual describing how to manage 

issues specifc to family counseling is in place 

and available to all clinical and nonclinical staff 

(Exhibit 6.3). 

122 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

EXHIBIT 6.2. Cross-Training 

Cross-training helps SUD treatment providers and family counselors work together effectively by 

learning about each other’s profession. There is a shortage of SUD treatment providers who are well 

trained in family issues. Likewise, there is a shortage of family counselors with practical knowledge of SUD 

treatment techniques. Administrators can help address these shortages through cross-training. 

All providers should receive cross-training in family-based counseling approaches and SUD treatment 

strategies. SUD treatment providers should be trained in family counseling and family-based SUD 

interventions. Family counselors should be trained in SUD treatment approaches, including screening, 

assessment, MI, cognitive–behavioral therapy, and relapse prevention. 

The consensus panel also recommends ongoing training in other topics, such as domestic violence, 

child abuse and neglect, elder abuse and neglect, posttraumatic stress disorder, and cardiopulmonary 

resuscitation. 

EXHIBIT 6.3. Sample Policies and Procedures To Support Integrated 

Family Counseling for SUD Treatment 

Consult state and federal laws to ensure your policies and procedures comply with relevant regulations and 

licensing requirements. The following administrative processes should be considered when developing 

policies and procedures to support full integration of family counseling into your SUD treatment program: 

• Intake calls and scheduling. Who is responsible for frst contact with clients? Who handles the 

scheduling of appointments? Are there specifc policies for scheduling initial appointments with 

individuals who have SUDs versus scheduling initial appointments with the individual’s family members? 

• Fees and procedures for handling money. Are there specifc program fees related to family-based SUD 

treatment? What are the procedures for collecting co-pays or fees? Who is responsible for collection? 

• Intake process. Who gathers initial intake information? 

• Case assignments. Who is responsible for family case assignments? How are family cases assigned? 

• Referral sources. What procedures are in place to ensure that clients and family members have an 

opportunity to sign releases allowing providers to communicate with referral sources? 

• Initial interview. Do procedures to conduct an initial family counseling interview include a consent 

process? 

• Case management. Do policies and procedures address the following topics? 

- Professional and legal duty to warn/duty to maintain confdentiality 

- Consent for treatment 

- Special releases for video or audio recording of counseling sessions 

- Case progress notes 

- Referral and other professional interaction 

- Paperwork responsibilities 

- Case recordkeeping 

- Case transfers 

Continued on next page 

Chapter 6 123 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

EXHIBIT 6.3. Sample Policies and Procedures To Support Integrated 

Family Counseling for SUD Treatment (continued) 

• Assignment of family treatment rooms. How do clinical staff members reserve rooms specifcally used 

for family psychoeducation or family counseling? 

• Video recording sessions. Which policies and procedures guide video or audio recordings of family 

sessions? Do guidelines recommend that all family members sign a release form that details the purpose 

of the recordings? Who will have access to the recordings, and when and how will the recordings be 

destroyed? 

• Observation of sessions. Do policies about other counselors, supervisors, or clinical staff observing family 

sessions (either behind a one-way mirror or in the session) include informing clients and family members 

about the purpose of live observation and the role of observers in a session? 

• Confdentiality issues. Do reporting and testimony policies and procedures address the following topics? 

- Child abuse 

- Elder abuse 

- Danger to self and others: Duty to warn 

- Court- and subpoena-related situations 

• Alternative communication with family members. Are there policies to guide communication between 

clinical staff and family members through the following ways? 

- Home phone 

- Cell phone 

- Email 

- Text message 

• Managing crisis situations. Do policies and procedures for managing high-risk situations address the 

following topics? 

- Suicide or other risk of injury 

- Imminent hospitalization 

- In-house emergency 

- Domestic violence 

- Notifcation of supervisor 

These examples are adapted with permission from The Ohio State University’s Policies and Procedures 

Manual for the Ph.D. Specialization in Couple and Family Therapy (Bartle-Haring, Pratt, & Knerr, 2019). The 

full manual is available online (https://ehe.osu.edu/sites/ehe.osu.edu/fles/fles/couple-and-family-therapypolicies-and-procedures.pdf). 

124 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

• All clinical staff receive cross-training in 

and are comfortable with and competent 

in providing family-based interventions, 

SUD treatment approaches, and family case 

management within their licensing and scope 

of practice. They are knowledgeable about 

community social services and recovery 

resources. 

• Culturally and linguistically responsive, 

age-appropriate practices are implemented 

throughout the organization and inform all 

policies and procedures. Staff members: 

- Have cultural competence training. 

- Use treatment strategies that promote 

dignity and respect for clients. 

- Can discuss issues without inhibition or fear 

of termination. 

- Where possible, refect the cultures and 

native language of the clients and families the 

program serves. 

• Financing and human resources are adequate 

to implement and sustain family counseling 

and family-based interventions and recovery 

activities. 

• Social, individual, and family supports are 

in place to improve family relationships and 

involve family members in relapse prevention 

and recovery maintenance efforts. Established 

linkages exist with social service agencies to 

provide assistance with transportation, housing, 

medical care, food, and childcare services. 

• Program infrastructure is robust (e.g., physical 

space is suffcient and accessible; there 

are supports for Internet, video, and other 

multimedia; multilingual program materials are 

available). 

Additional considerations may include policies 

for nonclients on the treatment premises, security 

of the building, liability insurance, and service 

reimbursement. 

Supporting Workforce 

Development 

Workforce development plays a key role in 

delivering quality SUD treatment services to 

individuals and families affected by substance 

misuse. Per a family-centered SUD treatment 

philosophy and mission, workforce development 

efforts should orient all staff to the importance of 

engaging family members in the treatment process 

and providing family-centered services. 

Differing philosophies, education, training, and 

licensing requirements among SUD treatment 

providers and family counselors can complicate 

administrative issues in family-centered SUD 

treatment programs. For example, SUD counselor 

training focuses mostly on individuals with SUDs, 

yet family-based SUD interventions require 

SUD counselors to have training in family-based 

psychoeducational and counseling approaches. 

Licensed family and marriage therapists, clinical 

social workers, mental health counselors, 

psychiatric nurses, and clinical psychologists may 

have more education in family systems theory but 

less in SUD treatment approaches. These providers 

will not be able to make appropriate referrals for 

screening, assessment, diagnosis, and treatment 

of SUDs—unless they also receive the necessary 

training to conduct these aspects of service 

themselves. 

All clinical staff need training in how substance 

misuse affects family systems, family dynamics, 

and initiation and maintenance of family 

recovery. SUD counselors who provide familybased interventions need family-centered 

counseling competencies, which often require 

intensive training to develop. Their clinical 

supervisors should be trained in family counseling 

or licensed as marriage and family therapists. 

Hiring and Retention 

Recruit counselors who are interested in and 

comfortable with working with families; prioritize 

candidates with specifc education, training, lived 

experience, or professional history in working 

with families. SUD treatment counselors have 

specialized knowledge of addiction and recovery 

but may be unfamiliar with the theories and 

techniques of family systems interventions. They 

may realize the infuence a family exerts on one’s 

use of substances, but some may see family issues 

as a threat to their clients’ recovery, particularly 

when clients feel overwhelmed and unable to cope 

with their families’ reactions to treatment and the 

intense emotions that can be evoked in treatment. 

Chapter 6 125 
TIP 39

Nevertheless, addiction counselors who are 

enthusiastic about working with families can be 

as effective as family counselors who are well 

acquainted with the operation of family systems 

but may not fully understand the needs and 

stresses of people with SUDs. Peer recovery 

support specialists and recovery coaches, including 

those who have lived experience as a family 

member of someone with an SUD, can also be 

valuable members of the clinical team. 

Match staff members’ family-centered duties 

and responsibilities with their educational 

background, certifcation or license, training, 

and scope of practice. Staff members interested 

in working with families need ongoing training, 

in-house mentoring, and suffcient resources. 

For example, addiction counselors may be 

qualifed to provide family intake, family 

psychoeducation, family recovery support groups, 

or family consultations, but providing ongoing 

family counseling may be outside their current 

scope of licensure and practice. However, with 

administrative support that facilitates proper 

training and ongoing supervision, bachelor’s- and 

master’s-level addiction counselors can provide 

evidence-based family interventions like behavioral 

couples therapy (Rowe, 2012) or manualized 

approaches like the family education component in 

the Counselor’s Treatment Manual: Matrix Intensive 

Outpatient Treatment for People With Stimulant 

Use Disorders (Center for Substance Abuse 

Treatment [CSAT], 2006b, 2006c). 

Provide incentives for staff members to further 

their understanding of and training in familybased counseling for SUDs. SUD treatment 

providers may need motivation to acquire more 

intensive training and coaching in family-centered, 

evidence-based practices that ensure fdelity 

and quality service. They are more likely to fnd 

this motivation in programs that reward ongoing 

professional development with opportunities to 

move up the career ladder with commensurate job 

title changes and salary increases. 

Core Competencies 

Counselors need specifc knowledge, attitudes, 

and skills to shift from an individual to a family 

systems focus in their approach. Level of family 

Substance Use Disorder Treatment and Family Therapy 

involvement in treatment falls on a continuum. 

It may be as simple as providing collateral 

information to counseling staff during assessment 

and treatment, or it may be as intensive as 

attending psychoeducational sessions and 

participating in family counseling. 

Core competencies for working with families 

differ among professions, but all providers and 

administrators across the continuum of care 

should be able to understand the complexity 

of the clients’ family networks and interactions 

with their families (Gehart, 2018). How counselors 

apply that knowledge varies by level of family 

involvement and complexity of the family-based 

intervention. 

Acknowledge core competencies for family 

counseling as a framework for training, 

supervision, performance evaluation, and 

professional development. Across the continuum 

of care, SUD treatment providers who offer familybased interventions should understand (CSAT, 

2006a; Gerhart, 2018): 

• How counselors’ own family histories and issues 

affect their interactions with and perceptions of 

the dynamics of families in SUD treatment. 

• Systems concepts, theories, and techniques 

foundational to family-based interventions. 

• The diverse cultural factors that infuence the 

characteristics and dynamics of families and 

couples. 

• Risks and benefts of couples- and family-based 

interventions. 

• How, when, and why to involve clients’ families 

and signifcant others in treatment and recovery. 

• The effects of substance misuse on family 

communication, roles, and dynamics. 

• The characteristics of families, couples, and 

signifcant others affected by substance use. 

SUD treatment providers who offer family-based 

interventions should also demonstrate the ability 

to: 

• Show genuine care and concern for clients’ 

family members and signifcant others. 

• Respect the contributions of signifcant others to 

the treatment and recovery process. 

126 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

• Engage family members and signifcant others 

throughout the treatment and recovery process. 

• Identify systemic interactions likely to affect 

recovery (e.g., by recognizing the roles of 

signifcant others in clients’ social systems; 

by knowing the potential signs of domestic 

violence). 

• Determine who should attend family counseling 

and in what confguration (e.g., individual family 

members, couples, entire family, extrafamilial 

recovery supports). 

• Identify treatment goals based on both 

individual and systemic concerns. 

• Communicate with families and signifcant 

others about confdentiality rules, regulations, 

and boundaries. 

• Obtain consent to treatment from all individuals 

involved in family-based interventions. 

• Apply assessment tools for use with couples, 

families, and signifcant others. 

• Identify couples’ and families’ strengths, 

resilience, and resources. 

• Recognize issues beyond their own license 

and scope of practice that require referral 

for specialized evaluation, assessment, or 

treatment. 

• Apply appropriate models of assessment and 

intervention for families, couples, and signifcant 

others, regardless of their extended, kinship, or 

tribal family structures. 

• Provide culturally appropriate intervention 

strategies for couples and families. 

• Help couples, families, and signifcant others 

adopt strategies and behaviors that sustain 

recovery and maintain healthy relationships. 

• Manage session interactions with couples, 

families, and groups. 

• Follow the procedures, processes, and 

counseling methods of manualized or structured 

family-based interventions with fdelity and 

within their scope of practice and license. 

• Use family-centered supervision and 

consultation effectively. 

Certifcation and Licensure 

Programs with diverse professional staff have 

greater depth and richness in clinical teams. Even 

so, administrators can fnd it challenging to provide 

the training, supervision, performance evaluation, 

and professional development required by different 

state and national certifcation and licensing 

authorities. 

Know the certifcation and licensing requirements 

of all clinical staff who currently provide or will 

provide family-based interventions or family 

counseling in your program. Check with your state 

licensing board for rules and regulations related 

to these requirements. Having this knowledge 

will better enable you to hire clinical staff from 

diverse educational backgrounds, such as licensed 

drug and alcohol counselors, marriage and family 

therapists, clinical social workers, mental health 

counselors, psychiatric nurses, and other behavioral 

health service professionals who have training and 

experience working with families. 

Develop training programs that help counselors 

meet initial or recertifcation requirements to 

maintain their licenses. Two examples of licensing 

and certifcation authorities you should be familiar 

with are the American Association for Marriage 

and Family Therapy (AAMFT) and the International 

Certifcation and Reciprocity Consortium (IC&RC). 

AAMFT 

Fifty states and the District of Columbia 

require licenses for people practicing as family 

therapists (AAMFT, n.d.-b). Although the specifc 

educational requirements vary from state to state, 

all require at least a master’s degree. AAMFT’s 

Commission on Accreditation for Marriage and 

Family Therapy Education requires an educational 

component on the assessment, diagnosis, and 

treatment of addiction in their accreditation 

standards. More information on state licensing and 

certifcation requirements is available online (www. 

aamft.org/Directories/MFT_Licensing_Boards. 

aspx?hkey=c0f838ad-2672-4b4e-8b51-

b9578fe5c28a). 

Chapter 6 127 
TIP 39

AAMFT also offers a designation as an approved 

marriage and family therapy supervisor. This 

designation requires completion of additional 

training and an examination offered by AAMFT. 

(See www.aamft.org/AAMFT/Membership/ 

Approved_Supervisors/Supervision/Supervision. 

aspx?hkey=79f01af6-6412-4eb5-9d75-

9909aca18b1a for more information.) 

IC&RC 

IC&RC provides credentials in SUD prevention 

and counseling in 46 states and the District 

of Columbia, three branches of the military, 

some foreign countries, and the Indian Health 

Service. Each member board determines its own 

standards for certifcation or licensing based on 

IC&RC standards, which include knowledge of 

substance misuse, counseling, and ethics, as well as 

assessment, treatment planning, clinical evaluation, 

and family services. More information is available 

online (www.internationalcredentialing.org; https:// 

internationalcredentialing.org/memberboards). 

IC&RC and many member boards also offer 

a clinical supervisor certifcation (see https:// 

internationalcredentialing.org/creds/cs). 

Professional Development 

Involving families in SUD treatment heightens 

counselors’ responsibilities. For example, 

counselors need to understand the varied effects 

of substance misuse on family systems well enough 

to describe them to clients and family members. 

They must also incorporate new family-based 

interventions and activities into their general 

counseling style and treatment approach. Proper 

training and consistent clinical supervision are 

essential to support counselors in handling these 

additional responsibilities. 

Staf Training 

Family-based interventions and family counseling 

require special training and skills uncommon 

among staff in many SUD treatment programs. 

Workshops and self-study may increase counselor 

knowledge, but the key to integrating evidencebased, family-centered counseling approaches 

into SUD treatment programs is provision of 

specialized training and ongoing supervision 

(Olmstead, Abraham, Martino, & Roman, 2012). 

Substance Use Disorder Treatment and Family Therapy 

Extensive training and supervision in family-based 

interventions will help counselors develop skills 

in and maintain fdelity to these counseling 

approaches. Ideally, training and supervision 

prepares SUD counselors to work with families 

by tapping into their existing knowledge of how 

substance misuse affects families. 

Educate staff about family counseling and family 

issues to increase staff (and therefore client) 

awareness of the role families can play in SUD 

treatment, recovery, and relapse. Effective staff 

education should increase provider knowledge 

of the family as a unit and the infuence of the 

ecological setting in which substance misuse 

occurs. Administrative and supervisory staff are the 

starting point for supporting providers in becoming 

knowledgeable about family counseling issues and 

for initiating program changes that integrate or 

enhance the delivery of such services to clients and 

their families. 

Commit the necessary resources to provide 

ongoing family-centered training for counselors. 

Some strategies to train your program’s providers 

in the delivery of family-based interventions 

include: 

• Gathering input from current counseling staff 

about training opportunities available from 

their professional organizations. For example, 

state branches of the National Association of 

Social Workers (NASW) often offer low-cost 

training for members and nonmembers. 

• Partnering with local college or university 

programs that offer courses on family counseling 

topics. 

• Providing internship or feld placement 

opportunities for students in family counseling 

programs. In some such arrangements, your 

agency feld instructor or supervisor receives 

free training from the students’ social work, 

mental health counseling, or marriage and 

family counseling program. 

• Contacting professional organizations 

like AAMFT, NAADAC (The Association 

for Addiction Professionals), the American 

Psychiatric Association, or local branches of 

NASW for information on members qualifed 

to offer training on family counseling at your 

organization. 

128 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

• Vetting all trainers’ educational backgrounds 

and training experience and making sure their 

approach is consistent with your program’s 

philosophy and training needs. 

• Sending clinical supervisors and experienced 

counselors to family counseling workshops 

that offer group discounts; partnering with 

other agencies to increase group size for better 

discounts. 

• Devoting time, attention, and resources to 

help staff integrate their family counseling 

training and get comfortable with how the 

training may change some of their counseling 

practices. Ongoing family-centered clinical 

supervision is crucial to this integration process. 

• Creating small learning communities 

dedicated to advancing competence and 

professional development in family-based SUD 

interventions and family counseling among 

counselors, supervisors, and peer providers in 

your organization. Provide space for meetings 

and paid time away from regular clinical duties 

to participate in these communities and in 

training opportunities. Invite clinical staff from 

other programs to participate as well. 

• Investigating online training and ongoing 

consultation resources to reduce program costs 

for travel and overnight accommodations. (See 

“Resource Alert: Online Learning Opportunities 

and Resources.”) 

Clinical Supervision 

Clinical supervision is a primary resource for 

counselors for gaining the practical skills and 

knowledge that will help them become ethical and 

effective service providers (Boyle & McDowellBurns, 2016). Training in family-based theory and 

interventions is a good focus for supervision, which 

should be ongoing. 

Ensure that clinical supervisors have experience 

and training in family counseling or licensure 

as marriage and family therapists. These 

qualifcations are essential to help SUD treatment 

providers gain suffcient competency to provide 

family counseling. Supervisors should also have a 

range of knowledge on other issues such as child 

care, confdentiality and liability concerns related 

to providing services to children and adolescents, 

and the documentation and billing related to family 

counseling sessions. 

Direct session observation by supervisors helps 

counselors develop and maintain competency 

in common evidence-based SUD interventions 

(e.g., supervisor in session, behind a one-way 

mirror, or video recording review; Olmstead et al., 

2012). This is especially important for professional 

development of family counselors, given the higher 

level of complexity in delivering family-based SUD 

interventions. Yet one study found that only 2 

percent of SUD treatment programs that offered 

brief strategic family therapy provided supervisor 

review of audio- or video-recorded family sessions 

(Olmstead et al., 2012). 

RESOURCE ALERT: ONLINE LEARNING OPPORTUNITIES AND RESOURCES 

AAMFT (www.aamft.org) offers low-cost online learning opportunities on family counseling topics for 

members and nonmembers. 

The Addiction Technology Transfer Center (ATTC) Network (https://attcnetwork.org) offers free and lowcost webinars, videoconferencing consultation groups, and other online learning opportunities. To stay 

informed of upcoming opportunities, subscribe to the ATTC Messenger (https://attcnetwork.org/subscribemessenger), a monthly electronic newsletter that provides information about best practices, professional 

development events, funding, research literature, and other resources related to SUD treatment. 

NAADAC (www.naadac.org) offers free and low-cost webinars, publications, and other online learning 

opportunities. To stay informed of upcoming opportunities, subscribe to NAADAC’s weekly e-newsletter 

(www.naadac.org/professional-eupdate), which provides news from NAADAC and partner organizations, as 

well as information about educational events, trainings, and resources. 

Chapter 6 129 
TIP 39

Collaborate with other administrators, program 

managers, and clinical supervisors to integrate 

live supervision approaches into the training, 

supervision, and professional development of 

family counselors. (See “Resource Alert: Clinical 

Supervision and Professional Development of SUD 

Treatment Providers” for guidance on conducting 

live observation supervision.) 

Supervisor Competencies 

Regardless of the education or professional 

licensure of the providers clinical supervisors 

oversee, their supervisory responsibilities in 

integrated family counseling for SUDs include 

(Rigazio-DiGilio, 2016): 

• Facilitating counselors’ development of selfawareness, cultural and social responsiveness, 

and theoretical, technical, and cultural 

competence. 

• Monitoring the quality of counselor service 

provision. 

• Assessing counselors’ current areas of 

competence and those that need development. 

• Serving as gatekeepers for a variety of counselor 

specialties. This requires familiarity with various 

professional codes of ethics, state licensing 

requirements, scope of practice boundaries, 

and state agency licensing requirements (e.g., 

fulflling the hours of clinical supervision required 

by state mental health and SUD treatment 

departments). 

RESOURCE ALERT: CLINICAL 

SUPERVISION AND 

PROFESSIONAL DEVELOPMENT 

OF SUD TREATMENT PROVIDERS 

SAMHSA’s TIP 52, Clinical Supervision and 

Professional Development of the Substance 

Abuse Counselor (https://store.samhsa.gov/ 

product/TIP-52-Clinical-Supervision-andProfessional-Development-of-the-SubstanceAbuse-Counselor/SMA14-4435.html), details 

supervision models, offers guidelines for direct 

observation and parallel process supervision, and 

addresses transference/countertransference in 

supervision. 

Substance Use Disorder Treatment and Family Therapy 

For family counseling supervisors to carry 

out these responsibilities, they must have the 

knowledge and skills necessary to (RigazioDiGilio, 2016): 

• Apply different supervision models, methods, 

and interventions. 

• Attend to ethical, legal, and professional 

concerns of clinical staff in different areas of 

practice. 

• Manage supervisory relationships. 

• Conduct counselor assessments and 

performance reviews. 

• Address cultural diversity and responsiveness 

issues in counseling and supervisory relationships. 

• Maintain a self-refective stance in supervision. 

The Association for Counselor Education and 

Supervision (ACES) provides specifc competency 

standards for clinical supervisors that apply 

across a range of educational and professional 

backgrounds, including family counseling and 

SUD treatment. Standards include (ACES, 2011): 

• Setting goals (e.g., developing specifc goals for 

supervision, in collaboration with the counselor). 

• Giving feedback (e.g., balancing feedback that is 

challenging and supportive). 

• Conducting supervision (e.g., providing a safe, 

supportive, structured supervision context). 

• Engaging in the supervisory relationship (e.g., 

building trust and developing a solid working 

alliance). 

• Using various supervisor models and formats to 

address counselor needs. 

• Attending to cultural diversity and advocacy 

considerations (e.g., integrating multicultural 

awareness and responsiveness into your 

supervision). 

• Attending to ethical considerations in the 

supervisory relationship (e.g., providing counselor 

with a professional disclosure statement, including 

information about your professional background, 

clinical experience, and supervision approach). 

• Documenting supervision (e.g., to support 

counselor development and protect client 

welfare). 

130 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

• Evaluating counselor profciency and 

performance (e.g., communicating about 

supervisory evaluation tools and processes). 

• Fulflling educational and work experience 

requirements for providing competent 

supervision. 

• Engaging in supervision training and supervision 

of one’s own supervision as part of supervisor 

professional development. 

• Initiating supervision, such as by establishing a 

contract with the counselor (Exhibit 6.4). 

EXHIBIT 6.4. Developing a Supervision Contract With a 

Family Counselor 

Supervision contracts describe how you, as a supervisor, will provide supervision to a family counselor. Here 

are key topics that you and the counselor should discuss and document in a supervision contract: 

• The logistics of supervision (e.g., length, frequency, and location of supervision sessions) 

• Your educational background, credentials, and preferred counseling method 

• Your preferred supervision philosophy and approach 

• Your roles and responsibilities as a family counseling supervisor—including an explanation of how your 

role differs from an administrative supervisor 

• The conditions under which you and another supervisor may discuss the counselor’s professional 

development progress and performance 

• The counselor’s own supervision goals (e.g., what the counselor wants to learn or accomplish; how 

supervision hours count toward certifcation or licensure) 

• Your expectations and logistics of how to review client and family sessions (e.g., live supervision sitting in 

on a session, one-way mirror, audio or video recording review, counselor formulation or process notes) 

• Exploration of the counselor’s experience with, comfort or discomfort with, and ideas about ways to 

adapt different supervision methods (e.g., reviewing audio/video recordings so the counselor can identify 

portions of the session that were or were not successful) 

• Schedule and documentation processes, as well as criteria, for formal counselor evaluations 

• Issues, rules, and regulations specifc to your organization and state licensing board regarding how 

supervision is conducted (e.g., rules about video recording or removing client notes from the premises) 

• Reporting requirements and emergency procedures for high-risk clients (e.g., clients who are intoxicated 

or engaging in violence, suicidal, or suspected of child maltreatment) 

• Information about how your supervisee can reach you in cases of emergency 

• Professional ethics and confdentiality guidelines: 

- Review codes of ethics for counselors and your professional association; clarify/resolve discrepancies. 

- Negotiate an agreement about adherence to ethical guidelines. 

- Clarify confdentially and the limits to confdentially in the supervisor–counselor relationship. 

- Clarify how supervision session notes and logs will be kept and who has access to that information. 

- Discuss how the counselor should notify clients and family members about your supervision, including 

the potential for live supervision. 

- Review how disagreements between you and the counselor will be discussed and resolved. 

- Clarify the conditions under which the supervisory relationship will end. 

• How the contract will be periodically reviewed and renewed (e.g., every 6 months or year or when the 

counselor has achieved professional development goals and needs to discuss new goals) 

Source: AAMFT (2019). 

Chapter 6 131 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

As a supervisor, your focus with counselors is 

on client issues and concerns. Yet the quality of 

your relationship with the counselor is a primary 

factor that will determine each counselor’s sense 

of achievement and professional satisfaction, 

similar to the quality of the counselor’s therapeutic 

relationship infuencing the effectiveness of work 

with clients and family members (Rigazio-DiGilio, 

2016). To develop a strong working alliance with 

family counselors, engage in self-refection and 

multilayered self-evaluation (Rigazio-DiGilio, 2016) 

about: 

• Your own cultural, family, and contextual 

histories and experiences. 

• The main theories and models that shaped your 

education and training in family counseling. 

• Ways in which your participation in family, 

professional, and cultural experiences shape the 

worldview you bring to every supervision session 

(see Exhibit 6.5). 

Family counseling supervision differs from 

individual counseling supervision. Instead of 

only reviewing individual client–counselor 

interactions in supervision, the supervisor 

also gives guidance to the counselor on the 

couple’s or family members’ interactions with 

each other and the counselor’s interactions with 

the couple, a single family system, or multiple 

family systems. For example, in evaluating a 

counselor’s refective listening skills, a supervisor 

might assess the counselor’s skill in paraphrasing 

multiple perspectives and feelings of relatives and 

summarizing interaction patterns in the couple or 

family (Lambie, Mullen, Swank, & Blount, 2018). 

The focus on systems, not individuals, adds 

complexity to supervision. 

Systemic–Developmental Supervision 

This model of supervision is widely used in SUD 

treatment settings. It holds that counselors 

undergo stages of professional development; it 

is the clinical supervisor’s role to match his or her 

relational stance and supervision strategies to 

counselors’ developmental stages. For example, 

a new counselor might require more structure and 

encouragement in supervision than an experienced 

counselor. 

Similarly, in the developmental model for 

supervising family counselors (Carlson & Lambie, 

2012), supervisors of beginning family counselors 

use live observation, model family counseling 

techniques, and engage in role-plays to facilitate 

the counselor’s development. As the counselor 

becomes more confdent, the supervisor can 

invite the counselor to develop a family genogram 

(see Chapter 4) and use it in supervision to 

help counselors identify transference feelings 

of family members toward the counselor and 

countertransference feelings of the counselor 

linked to the counselor’s family of origin. 

EXHIBIT 6.5. Multicultural 

Supervision 

Supervisors are inherently in a more powerful 

position in relationship to supervisees. This power 

differential may be compounded by differences in 

race, ethnicity, gender, sexual orientation, gender 

identity, socioeconomic status, and disability. 

Multicultural supervision involves bringing the 

awareness of individual, family, and societal 

cultural differences and considerations into the 

supervisory relationship (Gutierrez, 2018). Your 

responsibilities as a supervisor include recognizing 

different cultural values and perspectives on 

family and substance misuse; exploring your own 

worldview, privileges, and biases; and maintaining 

an open and safe space in which supervisees 

can raise issues about their own cultural 

identities (Gutierrez, 2018). If you understand 

and acknowledge your own biases and raise the 

issue of cultural identity differences that might 

exist between you and the supervisee, you can 

help supervisees enhance their own cultural 

knowledge and be a role model for how to have 

these conversations with clients and families. 

132 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

A genogram depicts a person’s family tree through use of symbols. Symbols of different colors or 

shapes represent individuals in the person’s family across several generations. Initially conceptualized by 

Murray Bowen (Goldenberg, Stanton, & Goldenberg, 2017) as a part of his intergenerational family model, 

a genogram is more than just a family tree: it is an important counseling tool. Using the information 

that family members provide, a genogram can visibly demonstrate family patterns, events, and 

relationships. Across health felds, the genogram offers a map of a family’s known health, communication, 

relationship (e.g., marriage, divorce), vocational, and other psychosocial patterns in each generation. It can 

aid clinical interviews, psychoeducational sessions, or assessments (e.g., the Family Genogram Interview by 

Platt & Skowron [2013]). 

The genogram is fexible and can be tailored to the needs and current challenges of a family. For 

example, a counselor may create a genogram and have family members identify those relatives with 

a history of substance misuse and related health issues. Family members can also use the genogram 

exercise to identify specifc individual strengths and inherent strengths across generations. By illustrating 

substance use, cultural characteristics, and family dynamics, the genogram can reveal certain 

infuential patterns. 

In the context of SUD treatment supervision, a genogram can help supervisors link SUD 

counselors’ family patterns back to their counseling practice and raise counselor self-awareness of 

countertransference issues that may result, in part, from these family patterns (Carlson & Lambie, 2012). 

See also Chapter 4 of this TIP. 

The supervisor may also introduce and explore 

parallel process—that is, how the supervisory 

relationship mirrors the counseling relationship— 

and focus on relationship dynamics in the couple’s 

or family’s sessions. Supervision of experienced 

family counselors is more reciprocal, so the 

supervisor becomes more of a consultant than 

a teacher. As counselors move through stages, 

they develop higher levels of self-awareness and 

differentiation from the supervisor (Carlson & 

Lambie, 2012). 

Exhibit 6.6 lists the stages and samples of 

supervision strategies in systemic–developmental 

supervision. 

A counselor may be in one stage of professional 

growth as an addiction counselor and another 

stage in developing competencies for providing 

family-based interventions. The systemic– 

developmental model of clinical supervision 

offers a framework for matching supervision 

strategies to counselor competency levels in 

delivering family-based SUD interventions. 

Encouraging Collaboration as an 

Administrator 

One of your most important roles as 

an administrator is to develop ongoing 

connections between your program and others 

that provide a range of services to families. 

Such relationships should encourage family 

participation in both SUD and family-based 

services. Yet collaborating with other behavioral 

health and community-based services involves 

more than maintaining a list of other agencies 

where staff can refer clients and family members. 

If your program does not offer in-house, 

integrated family counseling services, develop 

and maintain partnerships with other programs 

that provide family counseling and familycentered services. 

Provider collaboration ensures high-quality 

referrals, effective outreach, and meaningful 

partnerships with community resources. 

Chapter 6 133 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

EXHIBIT 6.6. Systemic–Developmental Supervision 

COUNSELOR 

LEVEL BEGINNING INTERMEDIATE EXPERIENCED 

Counselor 

Description 

High anxiety 

Low self-confdence 

Low autonomy 

Some anxiety 

Some self-confdence 

Desires autonomy 

Minimal anxiety 

Self-confdent 

Autonomous 

Supervision 

Environment 

Encouraging 

Structured 

Prescriptive 

Encouraging 

Refective 

Insight oriented 

Reciprocal or mutual 

Supervisor as consultant 

Supervisor 

Strategies 

Psychoeducation 

Direct observation 

Modeling 

Role-plays 

Create counselor 

genogram to explore 

family-of-origin issues 

related to professional 

growth 

Explore counselor recall 

of sessions to foster 

counselor refection & 

awareness 

Explore transference/ 

countertransference 

Parallel process 

Active listening 

Supervisor 

Considerations 

Introduce supervision 

style 

Assess level of counselor 

anxiety 

Maintain processoriented approach 

Focus supervision on 

counselor 

Consider using selfdisclosure 

Use supportive and 

validating statements 

Level of self-awareness/differentiation from supervisor 

Low High 

Source: Carlson & Lambie (2012). Republished with permission of Sage Publications Inc. Permission conveyed 

through Copyright Clearance Center, Inc. 

134 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

Clinical and nonclinical staff should be familiar 

with community services and resources for 

families. Counselors should match the resources of 

various local programs with a family’s needs. They 

should then provide the family with information, 

including the pros and cons, of particular programs 

to facilitate the family’s selection of those with 

resources that will work best for them. 

Supporting an informed, family-centered referral 

process requires a strong community perspective 

and resource commitment at the administrative 

level. Such support will allow staff members across 

the family services spectrum to expand their 

knowledge of community-based SUD education 

resources and family services. Staff should know 

about family-based treatment models and provide 

information using collateral resources to build 

trust with family members. Supervisors can help 

staff adjust to the changes and new information 

generated by collaboration with other providers. 

Partnerships 

Partnerships with community-based 

organizations require intensive collaboration. 

You will need to identify stakeholders in the 

community, bring them together, and work toward 

common goals (Partnership for Drug-Free Kids, 

2015). Collaborations with other agencies from 

which families seek services can help reduce 

fragmentation, duplication, and isolation of 

services. 

SUD treatment program administrators can 

be a catalyst for SUD treatment–community 

partnership with the combined goals of reducing 

substance misuse and helping families initiate 

and sustain recovery, achieve improved health 

and wellness, and become integral members of 

the community. 

Community stakeholders whose goals include 

prevention and treatment of SUDs with a focus 

on family-based interventions and recovery may 

include: 

• Other SUD treatment professionals. 

• Family counseling professionals. 

• School administrators and school personnel. 

• Youth and family organizations. 

• Family and drug court providers. 

• Probation and parole services providers. 

• Churches and other faith-based organizations. 

• Family and child welfare agencies. 

• Eldercare agencies and service providers who 

work with older adults. 

• Primary care providers. 

• Family members (including parents, youth, and 

extended family members). 

Family members are clearly key stakeholders in 

the partnership-building process. Including their 

perspectives can heighten their commitment as 

stakeholders, invest them in their own care, and 

reduce misconceptions about substance misuse 

and ambivalence about involvement in SUD 

treatment. 

Include consumer voices in the development of 

family-centered services to anchor your program 

in the community. Provide a mechanism to gather 

input from SUD providers, including those who 

work with families, and other key stakeholders. 

Doing so can support consumer-led movements 

that will encourage policy shifts related to 

community-based SUD treatment and family 

involvement. 

Adequate Resources 

Provide adequate resources to monitor and 

ensure that high-quality referrals, outreach, and 

partnership components are in place. Examples 

of such resources include: 

• A comprehensive referral system that can 

facilitate the participation of families and clients 

in family counseling activities not provided by 

your program. 

• Expanded privacy/disclosure, consent, and 

referral procedures, which may include multiple 

release of information forms, active linkage 

to other services, and follow-up from your 

counseling staff. 

• Client and family education on benefts and 

challenges of participating in other programs/ 

services. 

Chapter 6 135 
TIP 39

• Client and family information on your 

relationship to other service providers, potential 

conficts of interest, and limits of your program’s 

responsibility for the family’s treatment at 

another program. 

• Allocation of staff resources for a variety of 

tasks, including: 

- Documenting referrals. 

- Monitoring ongoing relationships with other 

agencies. 

- Coordinating information exchange about 

clients and families in accordance with Health 

Insurance Portability and Accountability Act 

(HIPAA) requirements and state law (for more 

information on HIPAA, see www.hhs.gov/hipaa). 

Develop memorandums of understanding 

(MOUs) with other agencies to clarify and 

guide the referral process and interagency 

coordination of services. Coordination efforts can 

include active involvement of SUD counseling staff 

in the therapeutic process and continual contact 

with the family counselor at the other agency. 

MOUs can provide a detailed understanding 

of the other agency’s process and procedures, 

which helps both organizations improve quality 

and avoid redundancies. For example, if each 

program screens for mental disorders, coordinated 

screening processes lessen duplication and 

client confusion, especially if different screening 

approaches provide different results. MOUs can 

also establish each program’s responsibilities for 

on-call services and procedures for responding to 

family crises. 

Monitor and improve referral services by 

involving families in evaluating the partnership 

component of your program. A follow-up survey 

to family members you have referred to another 

agency may ask: 

• Which members of your family are participating 

in the services of the agency we referred you to? 

• On a scale of 1 to 5 (1 being easy and 5 being 

diffcult), how easy was the referral process for 

you? 

• Can you provide examples of what was easy and 

what was hard about the referral process? 

Substance Use Disorder Treatment and Family Therapy 

• What can we do to improve the referral process 

going forward? 

Addressing Other Programmatic 

Considerations 

There are other issues you should address in your 

administrative efforts to integrate family counseling 

and family-based interventions into your program. 

These issues include cultural competence, federal 

and state regulations, consent related to privacy 

and disclosure, confdentiality, funding, counselor 

caseloads, treatment outcome evaluations, 

provider collaboration, and adequate resources for 

staff. 

Organizational Cultural Competence 

An organizational culture that is infused with the 

values of cultural competence and diversity on 

every level will highlight and implement such values 

concretely in staffng patterns, language, and 

cultural issues related to families and substance 

misuse. Hire staff and build an organizational 

culture that refects the diversity of the 

client populations your organization serves. 

Programmatic cultural responsiveness assessments 

explore institutional assumptions regarding services 

for specifc racial and ethnic communities. Use this 

information to reduce bias based on institutional 

misperceptions. (See “Resource Alert: Developing 

Organizational Cultural Competence” for a link to 

more information.) 

RESOURCE ALERT: DEVELOPING 

ORGANIZATIONAL CULTURAL 

COMPETENCE 

SAMHSA’s TIP 59, Improving Cultural 

Competence (https://store.samhsa.gov/product/ 

TIP-59-Improving-Cultural-Competence/SMA15-

4849), provides information, strategies, and tools 

for administrators and clinical supervisors to 

promote and improve cultural competence for 

the entire organization. 

136 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

Regulations 

Different regulations created by government 

agencies and third-party payers affect the 

SUD treatment and family counseling felds. 

Regulations infuence confdentiality, training, 

and licensing requirements. For example, federal 

regulations specifcally guarantee confdentiality for 

people who seek SUD assessment and treatment. 

Your program needs policies and procedures in 

place that allow clients to give or revoke consent 

to disclose information to other providers. 

These policies should be consistent with federal 

laws and regulations, such as HIPAA 42 CFR Part 

2 (SAMHSA, 2019b), and any state laws that 

apply (www.samhsa.gov/about-us/who-we-are/ 

laws-regulations/confdentiality-regulations-faqs). 

A consumer has the right to self-disclose 

anything he or she wants to disclose about 

his or her substance use history in group 

counseling sessions. If family-based group 

SUD counseling occurs in a HIPAA CFR Part 

2 program, as defned by 42 CFR §2.11 and 

§2.12, then program staff are bound by Part 2 

regulations in sharing any information a client 

self-discloses during such a group. 

As an administrator, you should be familiar with 

laws and regulations in your state that affect 

confdentiality, training and licensing requirements 

for counselors, delivery of family counseling services, 

duty to warn, and mandated reporting requirements 

for child and elder abuse and neglect. 

Privacy and Disclosure 

Consent issues require careful consideration 

by program administrators. All family members 

receiving services in your program should receive 

and have the opportunity to sign consent forms 

acknowledging the organization’s policies 

around confdentiality and the potential risks and 

benefts of family program activities. Parents or 

legal guardians can usually sign for children and 

adolescents (unless the adolescent has reached 

the age of majority defned by state law or if 

state law permits minors to consent to SUD 

treatment or mental health services). Forms asking 

clients’ permission to share or disclose personal 

information (e.g., so a provider can discuss a 

treatment course with family members) should 

describe in detail, for example, the program or 

staff responsibilities regarding the reporting of 

information that is required by law (such as elder 

abuse, child abuse or neglect, infectious disease, or 

duty to warn). 

Local, state, and federal laws sometimes confict. 

Consult with your in-house or local legal services 

agency to help you reconcile those conficts. 

Inform clients about the limits of confdentiality 

in family group activities so that all participants 

understand the benefts and potential risks 

of family group participation. For example, 

providers are bound by confdentiality laws, but 

family therapy group members and others in similar 

settings may not be. Each family member should 

receive clear, accurate information about what 

will happen when they engage in SUD treatment, 

family counseling, and family program activities. 

Consent for information-sharing protects clients 

before, during, and after treatment. Although many 

laws may not apply to group members, program 

staff may wish to stress to family group participants 

the importance of respecting one another’s privacy 

and what is shared in group settings as a facilitator 

of candid discussion. 

Confdentiality 

Confdentiality policies should extend 

to everyone in treatment. Maintaining 

confdentiality in family and couples counseling 

is complicated, because many individuals may 

be involved. Programs need written policies about 

when family counselors can refrain from disclosing 

information to family members not present at the 

time of a client’s disclosure and when they are 

justifed in disclosing that information (Mignone, 

Klostermann, Mahadeo, Papagni, & Jankie, 2017). 

For example, policies should guide when or if it is 

okay for a counselor seeing a couple or family to 

“keep a secret” for a family member who is also in 

individual counseling from other family members 

and when that information should be disclosed 

(e.g., when a family member is suicidal or has 

relapsed). Duty to warn may apply in some cases, 

Chapter 6 137 
TIP 39

too (www.ncsl.org/research/health/mental-healthprofessionals-duty-to-warn.aspx)—for instance, 

if clear and explicit threats are made to other 

participants, providers, or third parties. At intake, 

inform all family members involved in treatment, 

at whatever level, about disclosure policies 

during the privacy, disclosure, and consent 

process. 

Confdentially issues for family counselors 

working with adolescents and their families can 

be complex. Family counseling practices often 

refect the idea of restoring parental authority in 

the family, but adolescents’ developmental stage 

prompts movement toward independence from 

parents. You should have clear policies regarding 

adolescents’ right to and limits of confdentiality 

based on state and federal laws and professional 

ethics codes regarding treating adolescents. 

In general, all staff (clinical and nonclinical) 

should adhere to confdentiality laws and 

organizational policies. Nonclinical staff members 

may not be bound by confdentiality laws that apply 

to counselors, but they should be familiar with 

HIPAA and other applicable privacy laws and 

the importance of keeping client identifying 

information (and even clients’ presence in 

treatment) confdential. For example, family 

members and clients participating in group activities 

should not be required to sign a login sheet that 

other clients can see. One strategy is to create an 

agency procedure and physical space at reception 

where clients can discreetly sign in or inform staff 

of their arrival for a family group activity. These 

issues become especially complicated when a client 

identifes as “family” people who are not related 

by blood or law and wishes to include friends or 

coworkers in family treatment activities. 

The consensus panel recommends that 

all clients and family members involved in 

treatment sign consent forms conforming to 

42 CFR Part 2 and that program staff discuss 

confdentiality and its limits with everyone as 

part of the process by which clients can choose 

to consent to the sharing or disclosing of certain 

private/personal information. 

Substance Use Disorder Treatment and Family Therapy 

RESOURCE ALERT: SAMHSA Q&A 

ABOUT 42 CFR PART 2 

SAMHSA’s Substance Abuse Confdentiality 

Regulations webpage (www.samhsa.gov/aboutus/who-we-are/laws-regulations/confdentialityregulations-faqs) answers questions about 42 

CFR Part 2 in plain language and provides helpful 

fact sheets for determining whether Part 2 

applies to an organization and how to exchange 

information with other providers. 

The federal regulations at 42 CFR Part 2 

(SAMHSA, 2019b) are stricter than many state 

requirements regarding the privacy of individuals 

in SUD treatment. Participant patient-identifying 

information must not be disclosed either to other 

participants (including family members) or to other 

service providers without a specifc release form 

that complies with regulations or unless other Part 

2 exceptions apply. Program staff may disclose 

confdential information to other staff members in 

the same program to provide treatment. 

Funding and Reimbursement for FamilyBased Interventions 

There is considerable evidence to support 

the clinical effectiveness as well as the costeffectiveness of family-based interventions in 

SUD treatment (Akram & Copello, 2013; Morgan 

& Crane, 2010; Wells, Kristman-Valente, Peavy, & 

Jackson, 2013). However, like the SUD treatment 

system, both private and federally funded health 

insurance still emphasize individual treatment. 

For example, the average state Medicaid 

reimbursement of SUD treatment providers 

for couples or family counseling is less than for 

individual counseling (Beck, Buche, Page, Rittman, 

& Gaiser, 2018). 

Insurance providers are moving toward reimbursing 

providers with a wider range of licenses for 

couples and family counseling services. A survey 

of all states and the District of Columbia found 

that Medicaid reimbursed addiction counselors 

for couples and family counseling at a higher rate 

when they worked in an SUD treatment program 

138 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

versus private practice (Beck et al., 2018). About 

40 state Medicaid programs now have some 

reimbursement or recognition of licensed marriage 

and family therapists (AAMFT, n.d.-a). Check your 

state’s Medicaid provider manual for information 

about recognized licenses and reimbursement 

codes for family counseling. 

Some strategies for expanding the types of 

behavioral health service providers who can be 

reimbursed for family counseling services and 

increasing reimbursement rates include: 

• Identifying ways to partner with professional 

associations to encourage reimbursement 

for family counseling and family-based 

interventions. 

• Developing relationships with key staff at your 

Single State Agency for substance use disorder 

treatment services. (See SAMHSA’s Directory 

of Single State Agencies for Substance Abuse 

Services at www.samhsa.gov/sites/default/fles/ 

ssa-directory-01212020.pdf). 

• Partnering with other agencies to seek increased 

Medicaid reimbursement for family counseling. 

• Sharing the evidence that family-based SUD 

interventions are effective and reduce healthcare 

costs by improving treatment outcomes and 

long-term recovery. 

Counselor Caseloads 

Working with families increases the amount 

of clinical time and nonclinical work that 

counselors perform. Family counselors must 

not only manage more clinical complexity than 

those doing individual work, but also meet more 

documentation requirements, collaborate with 

more referral sources and multiple providers 

involved with the family, and satisfy greater training 

and clinical supervision needs. At an administrative 

level, you will need to adjust counselors’ 

caseloads to account for these additional work 

requirements (Association for Family Therapy and 

Systemic Practice, n.d.). 

Incorporate burnout prevention strategies 

in staff training and supervision activities. 

Depending on the level of family involvement in 

your treatment program and the complexity of 

the family’s needs, counselors may experience 

higher levels of stress. Ensure that counselors 

are not doing family work beyond their level of 

professional development—even when no other 

staff is available. (See the “Clinical Supervision” 

section of this chapter.) When counselors attempt 

to function at a level that is beyond their training, 

their interventions are typically ineffective, and 

they can begin to feel demoralized. This is likely to 

affect the family negatively and be a contributing 

factor to counselor burnout. 

Clinical supervisors should monitor the 

development of counselors doing family work 

and slowly introduce new family counseling 

cases into counselors’ caseload when they are 

ready. Balancing cases involving families with cases 

involving only individual clients or couples can help 

lessen counselor stress. 

Outcomes 

Evaluating client outcomes can improve 

counselor delivery of family-based services and 

provide evidence you can share with potential 

funders on the effectiveness of your program’s 

family-based SUD treatment approach (Boswell, 

Kraus, Miller, & Lambert, 2013; Moran, 2017). 

Strong evidence suggests that using a routine 

outcome monitoring (ROM) system in behavioral 

health service settings improves clinically signifcant 

client outcomes and enhances counselors’ abilities 

to predict and prevent client deterioration 

(Boswell et al., 2013). However, ROM measures 

are not universally applied in treatment programs. 

Counselors may view ROM requirements as 

intrusions into their client relationships, feel 

anxious about use of ROM information to assess 

their performance, and worry about client privacy; 

some administrators see ROM as time-consuming 

and costly (Boswell et al., 2013; Moran, 2017). 

Strategies to address concerns related to 

ROM system implementation include (Boswell 

et al., 2013): 

• Inviting counselor input about which outcome 

measures to use and what feedback would be 

most helpful to them to enhance their work with 

clients and families. 

Chapter 6 139 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

• Being transparent about benefts and 

potential time burdens that counselors may 

encounter and how ROM data will be used to 

evaluate counselor performance. 

• Making ROM measures as simple as possible 

so they are less disruptive to counselors, clients, 

and family members. For example, use selfreport measures that take less than 10 minutes 

to complete. 

• Using electronic or online outcomes 

assessment, tracking, and feedback systems 

that are simple for clients and counselors to 

use and are HIPAA compliant in addressing 

confdentiality concerns. 

• Automating reminders for counselors and 

support staff to initiate periodic follow-up 

outcome assessments with clients and family 

members. 

• Incentivizing ROM engagement (e.g., allow 

time outside regular duties for training on 

ROM processes and assessment instruments or 

reimburse fee-for-service counselors for ROM 

training). 

• Identifying one or two “local champions” 

who are well respected in your organization; 

have had positive experiences with ROM; 

are enthusiastic about ROM; and who take 

responsibility for helping you adopt, integrate, 

and sustain the ROM system in your program. 

Measuring outcomes of family counseling is 

complex—more so than, for example, measuring 

whether an individual client has stopped or 

reduced substance misuse or is attending recovery 

support groups. Before instituting a ROM process 

for family-based interventions, consider which 

family outcomes to assess and which family 

members to engage in the process. Some 

questions to ask yourself include: 

• Are you interested in knowing how your familybased interventions are affecting the functioning 

of the entire family or how the family-based 

interventions are affecting the client’s substance 

use? 

• If you treat younger children in your program, 

will they or one of their parents fll out ROM 

surveys? 

• If children or adolescents fll out outcome 

assessment instruments as part of ROM, are 

there different versions of a single instrument? 

Are instruments designed to be age 

appropriate? 

• Are the ROM instruments you are using 

culturally responsive and available in multiple 

languages? 

There is no single instrument to address all of 

these concerns, but the SCORE-15 Index of Family 

Functioning and Change (Exhibit 6.7) is specifcally 

designed to measure outcomes of family 

counseling. Consider adding it to other measures 

of substance misuse outcomes you may already use 

as part of ROM. 

EXHIBIT 6.7. SCORE-15 Index of Family Functioning and Change 

SCORE-15 is a brief, validated self-report outcome measure designed to be sensitive to systemic family 

changes that can take place in couples and family counseling (Carr & Stratton, 2017). SCORE-15 measures 

overall family functioning and has subscale scores to measure a family’s strengths and adaptability, sense 

of being overwhelmed by diffculties, and experience of disrupted communication. 

Administer the instrument at the outset of family counseling and at intervals throughout treatment to 

measure changes in family functioning. An adaptation of the SCORE-15 can be used by children as young 

as 8 (Jewell, Carr, Stratton, Lask, & Eisler, 2013). SCORE-15 has been translated into many different languages, 

including Spanish, and is free for download and use (with administration and scoring instructions) from the 

Association for Family Therapy and Systemic Practice website (www.aft.org.uk/view/score.html?tzcheck=1). 

140 Chapter 6 
Chapter 6—Administrative and Programmatic Considerations TIP 39

Engage clinical staff in a process that dispels 

misgivings about the ROM process and 

encourages buy-in. Doing so will enhance staff 

members’ motivation to improve the quality of the 

family-based interventions they provide. Involve 

them in the planning and implementation process 

right up front. This will increase their motivation 

and demonstrate your administrative commitment 

to transparency. 

Where Do We Go From Here? 

Administrators must balance the potential for 

better client and family treatment outcomes with 

the challenge and costs of program development, 

the additional training and professional 

development of counselors from different 

backgrounds, and nonreimbursable activities like 

developing partnerships with other organizations. 

In your decision-making process, remember that 

you cannot measure the value of adding familybased interventions to your treatment program 

only in terms of better substance misuse outcomes 

for specifc clients or enhanced functioning of 

specifc families. 

Families, however defned, are the cornerstone 

of our cultural life and the backbone of society’s 

structure. When you shift SUD treatment programs 

from a solely individual focus to a family-centered 

focus, you not only improve individual treatment 

outcomes but also contribute to SUD prevention 

efforts and enhance protective factors that 

can improve the health and wellness of future 

generations. Remember your agency’s mission 

statement and let that guide you to 

next steps. 

Chapter 6 141 
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TIP 39 SUBSTANCE USE DISORDER TREATMENT AND 

FAMILY THERAPY

Appendix—Bibliography 

Adkison-Johnson, C. (2015). Child discipline and 

African American parents with adolescent children: A 

psychoeducational approach to clinical mental health 

counseling. Journal of Mental Health Counseling, 37(3), 

221–233. doi:10.17744/mehc.37.3.03 

Akram, Y., & Copello, A. (2013). Family-based interventions 

for substance misuse: A systematic review of reviews. The 

Lancet, 382, S24. doi:10.1016/S0140-6736(13)62449-6 

Al-Anon Family Group Headquarters, Inc. (n.d.). The 

Legacies. Retrieved August 13, 2019, from https:// 

al-anon.org/for-members/the-legacies/ 

Al-Anon Family Group Headquarters, Inc. (2016). Al-Anon: 

Then and now: A brief history [Brochure]. 

Alexander, J., & Parsons, B. V. (1982). Functional family 

therapy. Monterey, CA: Brooks/Cole Publishing Company. 

Ali, M. M., Dean, D., Jr., & Hedden, S. L. (2016). The 

relationship between parental mental illness and/ 

or substance use disorder on adolescent substance 

use disorder: Results from a nationally representative 

survey. Addictive Behaviors, 59, 35–41. doi:10.1016/j. 

addbeh.2016.03.019 

Allwright, K., Goldie, C., Almost, J., & Wilson, R. (2019). 

Fostering positive spaces in public health using a cultural 

humility approach. Public Health Nursing, 64(4), 551–556. 

doi:10.1111/phn.12613 

Alonzo, D., Thompson, R. G., Stohl, M., & Hasin, D. (2014). 

The infuence of parental divorce and alcohol abuse on 

adult offspring risk of lifetime suicide attempt in the 

United States. American Journal of Orthopsychiatry, 

84(3), 316–320. doi:10.1037/h0099804 

Amato, P. R., King, V., & Thorsen, M. L. (2016). Parentchild relationships in stepfather families and adolescent 

adjustment: A latent class analysis. Journal of Marriage 

and Family, 78(2), 482–497. doi:10.1111/jomf.12267 

American Association for Marriage and Family Therapy. 

(n.d.-a). Medicaid. Retrieved April 6, 2020, from www. 

aamft.org/Advocacy/Medicaid.aspx 

Association for Marriage and Family Therapy. (n.a.-b). 

MFT Licensing Boards. Retrieved August 13, 2019, from 

www.aamft.org/Directories/MFT_Licensing_Boards. 

aspx?WebsiteKey=8e8c9bd6-0b71-4cd1-a5ab013b5f855b01 

American Association for Marriage and Family Therapy. 

(2019). Approved supervision designation: Standards 

handbook. Version 5. Retrieved March 30, 2020, from 

www.aamft.org/documents/Supervision/2020_AS_ 

Documents/ASHandbook02-2020edits.pdf 

American Psychiatric Association. (2013). Diagnostic and 

statistical manual of mental disorders (5th ed.). Arlington, 

VA: Author. 

Areba, E. M., Eisenberg, M. E., & McMorris, B. J. (2018). 

Relationships between family structure, adolescent health 

status and substance use: Does ethnicity matter? Journal 

of Community Psychology, 46(1), 44–57. doi:10.1002/ 

jcop.21915 

Aromin, R. A., Jr. (2016). Substance abuse prevention, 

assessment, and treatment for lesbian, gay, bisexual, and 

transgender youth. Pediatric Clinics of North America, 

63(6), 1057–1077. doi:10.1016/j.pcl.2016.07.007 

Association for Counselor Education and Supervision. 

(2011, January 18). Best practices in clinical supervision: 

ACES task force report. Retrieved April 7, 2020, from 

www.apsu.edu/mscounseling/pdfs/ACES_Best_Practices_ 

Supervision.pdf 

Association for Family Therapy and Systemic Practice. 

(n.d.). Guidance on caseload and clinical activity for 

family and systemic psychotherapists in the NHS. 

Retrieved March 30, 2020, from www.aft.org.uk/ 

SpringboardWebApp/userfles/aft/fle/Members/ 

GuidanceonCaseloadandClinicalActivityforFamily 

SystemicPsychotherapists.pdf 

Ast, L. (2018). Developing alternative stories with partners 

of illicit substance users. Journal of Family Psychotherapy, 

29(3), 201–222. doi:10.1080/08975353.2017.1410768 

Awosan, C. I., Sandberg, J. G., & Hall, C. A. (2011). 

Understanding the experience of Black clients in marriage 

and family therapy. Journal of Marital and Family Therapy, 

37(2), 153–168. doi:10.1111/j.1752-0606.2009.00166.x 

Bai, G. J., Leon, S. C., Garbarino, J., & Fuller, A. K. (2016). 

The protective effect of kinship involvement on the 

adjustment of youth in foster care. Child Maltreatment, 

21(4), 288–297. doi:10.1177/1077559516669043 

Baldwin, S. A., Christian, S., Berkeljon, A., & Shadish, W. 

R. (2012). The effects of family therapies for adolescent 

delinquency and substance abuse: A meta-analysis. 

Journal of Marital and Family Therapy, 38(1), 281–304. 

doi:10.1111/j.1752-0606.2011.00248.x 

Barfeld-Cottledge, T. (2015). The triangulation effects 

of family structure and attachment on adolescent 

substance use. Crime and Delinquency, 61(2), 297–320. 

doi:10.1177/0011128711420110 

143 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Barlow, A., Mullany, B., Neault, N., Goklish, N., Billy, T., 

Hastings, R., . . . Walkup, J. T. (2015). Paraprofessionaldelivered home-visiting intervention for American 

Indian teen mothers and children: 3-year outcomes 

from a randomized controlled trial. American Journal 

of Psychiatry, 172(2), 154–162. doi:10.1176/appi. 

ajp.2014.14030332 

Barsky, A. (2018). Cultural competence, awareness, 

sensitivity, humility, and responsiveness: What’s the 

difference? New Social Worker, 25(4), 4–5. 

Bartle-Haring, S., Pratt, K., & Knerr, M. C. (2019). Policies 

and procedures manual for the Ph.D. specialization in 

couple and family therapy. Retrieved August 9, 2019, 

from https://ehe.osu.edu/sites/ehe.osu.edu/fles/fles/ 

couple-and-family-therapy-policies-and-procedures.pdf 

Bartle-Haring, S., Slesnick, N., & Murnan, A. (2018). Benefts 

to children who participate in family therapy with their 

substance-using mother. Journal of Marital and Family 

Therapy, 44(4), 671–686. doi:10.1111/jmft.12280 

Barton, A. W., Beach, S. R. H., Wells, A. C., Ingels, J. B., 

Corso, P. S., Sperr, M. C., . . . Brody, G. H. (2018). The 

Protecting Strong African American Families Program: A 

randomized controlled trial with rural African American 

couples. Prevention Science, 19(7), 904–913. doi:10.1007/ 

s11121-018-0895-4 

Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., & 

Laudet, A. (2016). Peer-delivered recovery support 

services for addictions in the United States: A systematic 

review. Journal of Substance Abuse Treatment, 63, 1–9. 

doi:10.1016/j.jsat.2016.01.003 

Beach, S. R., Barton, A. W., Lei, M. K., Mandara, J., Wells, 

A. C., Kogan, S. M., & Brody, G. H. (2016). Decreasing 

substance use risk among African American youth: 

Parent-based mechanisms of change. Prevention Science, 

17(5), 572–583. doi:10.1007/s11121-016-0651-6 

Beck, A., Buche, J., Page, C., Rittman, D. & Gaiser, M. 

(2018). Scopes of practice and reimbursement patterns 

of addiction counselors, community health workers, 

and peer recovery specialists in the behavioral health 

workforce. Ann Arbor: University of Michigan School of 

Public Health, Behavioral Workforce Research Center. 

Becvar, R. J., & Becvar, D. S. (2018). Systems theory and 

family therapy: A primer (3rd ed.). Lanham, MD: Hamilton 

Books. 

Belone, L., Orosco, A., Damon, E., Smith-McNeal, W., Rae, 

R., Sherpa, M. L., . . . Wallerstein, N. (2017). The piloting 

of a culturally centered American Indian family prevention 

program: A CBPR partnership between Mescalero 

Apache and the University of New Mexico. Public Health 

Reviews, 38, 30. doi:10.1186/s40985-017-0076-1 

Berg, I. K., & Miller, S. D. (1992). Working with the problem 

drinker: A solution-focused approach. New York, NY: 

Norton & Co. 

Birkeland, B., Foster, K., Selbekk, A. S., Høie, M. M., 

Ruud, T., & Weimand, B. (2018). The quality of life 

when a partner has substance use problems: A scoping 

review. Health and Quality of Life Outcomes, 16(1), 219. 

doi:10.1186/s12955-018-1042-4 

Bischof, G., Iwen, J., Freyer-Adam, J., & Rumpf, H. 

J. (2016). Effcacy of the community reinforcement 

and family training for concerned signifcant others 

of treatment-refusing individuals with alcohol 

dependence: A randomized controlled trial. Drug and 

Alcohol Dependence, 163, 179–185. doi:10.1016/j. 

drugalcdep.2016.04.015 

Black, C. (2018). Unspoken legacy: Addressing the impact 

of trauma and addiction within the family. Las Vegas, NV: 

Central Recovery Press. 

Blum, K., Febo, M., Badgaiyan, R. D., Demetrovics, Z., 

Simpatico, T., Fahlke, C., . . . Gold, M. S. (2017). Common 

neurogenetic diagnosis and meso-limbic manipulation 

of hypodopaminergic function in reward defciency 

syndrome (RDS): Changing the recovery landscape. 

Current Neuropharmacology, 15(1), 184–194. doi:10.2174 

/1570159X13666160512150918 

Boswell, J. F., Kraus, D. R., Miller, S. D., & Lambert, M. 

J. (2013). Implementing routine outcome monitoring 

in clinical practice: Benefts, challenges, and solutions. 

Psychotherapy Research, 25(1), 6–19. doi:10.1080/105033 

07.2013.817696 

Bowen, M. (1978). Family therapy in clinical practice. New 

York, NY: Jason Aronson, Inc. 

Boyle, R., & McDowell-Burns, M. (2016). Modalities of 

marriage and family therapy supervision. In J. Karin (Ed.) 

Couple, marriage, and family therapy supervision 

(pp. 51–69). New York, NY: Springer Publishing Co. 

Bradshaw, S. D., Shumway, S. T., Wang, E. W., Harris, K. 

S., Smith, D. B., & Austin-Robillard, H. (2016). Family 

functioning and readiness in family recovery from 

addiction. Journal of Groups in Addiction and Recovery, 

11(1), 21–41. doi:10.1080/1556035X.2015.1104644 

Braitman, A. L., & Kelley, M. L. (2016). Initiation and 

retention in couples outpatient treatment for parents with 

drug and alcohol use disorders. Experimental and Clinical 

Psychopharmacology, 24(3), 174–184. doi:10.1037/ 

pha0000072 

Bregman, O. C., & White, C. M. (2011). Bringing systems 

thinking to life: Expanding the horizons for Bowen family 

systems theory. New York, NY: Brunner-Routledge. 

Brody, G. H., Chen, Y. F., Kogan, S. M., Murry, V. M., & 

Brown, A. C. (2010). Long-term effects of the Strong 

African American Families Program on youths’ alcohol 

use. Journal of Consulting and Clinical Psychology, 78(2), 

281–285. doi:10.1037/a0018552 

144 Appendix—Bibliography 
Appendix—Bibliography TIP 39

Brody, G. H., Chen, Y. F., Kogan, S. M., Yu, T., Molgaard, 

V. K., DiClemente, R. J., & Wingood, G. M. (2012). 

Family-centered program deters substance use, conduct 

problems, and depressive symptoms in Black adolescents. 

Pediatrics, 129(1), 108–115. doi:10.1542/peds.2011-0623 

Brown, S., Tracy, E. M., Jun, M., Park, H., & Min, M. 

O. (2015). Personal network recovery enablers and 

relapse risks for women with substance dependence. 

Qualitative Health Research, 25(3), 371–385. 

doi:10.1177/1049732314551055 

Burrow-Sánchez, J. J., Minami, T., & Hops, H. (2015). 

Cultural accommodation of group substance abuse 

treatment for Latino adolescents: Results of an RCT. 

Cultural Diversity and Ethnic Minority Psychology, 21(4), 

571–583. doi:10.1037/cdp0000023 

Burstein, M., Stanger, C., & Dumenci, L. (2012). Relations 

between parent psychopathology, family functioning, 

and adolescent problems in substance-abusing families: 

Disaggregating the effects of parent gender. Child 

Psychiatry and Human Development, 43(4), 631–647. 

doi:10.1007/s10578-012-0288-z 

Calhoun, S., Conner, E., Miller, M., & Messina, N. (2015). 

Improving the outcomes of children affected by parental 

substance abuse: A review of randomized controlled 

trials. Substance Abuse and Rehabilitation, 6, 15–24. 

doi:10.2147/sar.s46439 

Canfeld, M., Radcliffe, P., Marlow, S., Boreham, M., & 

Gilchrist, G. (2017). Maternal substance use and child 

protection: A rapid evidence assessment of factors 

associated with loss of child care. Child Abuse and 

Neglect, 70, 11–27. doi:10.1016/j.chiabu.2017.05.005 

Carlson, R. G., & Lambie, G. W. (2012). Systemic– 

developmental supervision: Clinical supervisory approach 

for family counseling student interns. Family Journal, 

20(1), 29–36. doi:10.1177/1066480711419809 

Carr, A., & Stratton, P. (2017). The SCORE family assessment 

questionnaire: A decade of progress. Family Process, 

56(2), 285–301. doi:10.1111/famp.12280 

Cavaiola, A. A., Fulmer, B. A., & Stout, D. (2015). The 

impact of social support and attachment style on quality 

of life and readiness to change in a sample of individuals 

receiving medication-assisted treatment for opioid 

dependence. Substance Abuse, 36(2), 183–191. doi:10.10 

80/08897077.2015.1019662 

Center for Behavioral Health Statistics and Quality. (2020). 

Results from the 2019 National Survey on Drug Use and 

Health: Detailed tables. Rockville, MD: Substance Abuse 

and Mental Health Services Administration. Retrieved 

September 14, 2020, from https://www.samhsa.gov/data/ 

Center for Substance Abuse Treatment. (2006a). Addiction 

counseling competencies: The knowledge, skills, and 

attitudes of professional practice. Technical Assistance 

Publication (TAP) Series 21. HHS Publication No. (SMA) 

06-4171. Rockville, MD: Substance Abuse and Mental 

Health Services Administration. 

Center for Substance Abuse Treatment. (2006b). 

Counselor’s family education manual: Matrix Intensive 

Outpatient Treatment for People With Stimulant Use 

Disorders. HHS Publication No. (SMA) 13-4153. Rockville, 

MD: Substance Abuse and Mental Health Services 

Administration. 

Center for Substance Abuse Treatment. (2006c). Counselor’s 

treatment manual: Matrix Intensive Outpatient Treatment 

for People With Stimulant Use Disorders. HHS Publication 

No. (SMA) 13-4152. Rockville, MD: Substance Abuse and 

Mental Health Services Administration. 

Chang, J. S., Sorensen, J. L., Masson, C. L., Shopshire, 

M. S., Hoffman, K., McCarty, D., & Iguchi, M. (2017). 

Structural factors affecting Asians and Pacifc Islanders in 

community-based substance use treatment: Treatment 

provider perspectives. Journal of Ethnicity in Substance 

Abuse, 16(4), 479–494. 

Chartier, K. G., Carmody, T., Akhtar, M., Stebbins, M. B., 

Walters, S. T., & Warden, D. (2015). Hispanic subgroups, 

acculturation, and substance abuse treatment outcomes. 

Journal of Substance Abuse Treatment, 59, 74–82. 

doi:10.1016/j.jsat.2015.07.008 

Cheung, S. (2014, October). Family therapy with Asian 

Americans: Principles and practice. Paper presented at 

the 20th Annual Asian American Mental Health Training 

Conference, Alhambra, CA. 

Chuang, S. S., Glozman, J., Green, D. S., & Rasmi, S. (2018). 

Parenting and family relationships in Chinese families: A 

critical ecological approach. Journal of Family Theory and 

Review, 10(2), 367–383. doi:10.1111/jftr.12257 

Commission on Accreditation for Marriage and Family 

Therapy Education. (2014, July 15). Accreditation 

standards: Graduate & post-graduate marriage and family 

therapy training programs (Version 12.0). Retrieved April 

7, 2020, from www.coamfte.org/documents/COAMFTE/ 

Accreditation%20Resources/2018%20COAMFTE%20 

Accreditation%20Standards%20Version%2012%20May. 

pdf 

Cordova, D., Heinze, J., Mistry, R., Hsieh, H. F., Stoddard, 

S., Salas-Wright, C. P., & Zimmerman, M. A. (2014). Family 

functioning and parent support trajectories and substance 

use and misuse among minority urban adolescents: A 

latent class growth analysis. Substance Use and Misuse, 

49(14), 1908–1919. doi:10.3109/10826084.2014.935792 

Cordova, D., Huang, S., Pantin, H., & Prado, G. (2012). 

Do the effects of a family intervention on alcohol and 

drug use vary by nativity status? Psychology of Addictive 

Behaviors, 26(3), 655–660. doi:10.1037/a0026438 

Corless, J., Mirza, K. A. H., & Steinglass, P. (2009). 

Family therapy for substance misuse: The maturation 

of a feld. Journal of Family Therapy, 31(2), 109–114. 

doi:10.1111/j.1467-6427.2009.00457.x 

Cosden, M., & Koch, L. M. (2015). Changes in adult, child, 

and family functioning among participants in a family 

treatment drug court. Child Welfare, 94(5), 89–106. 

Appendix—Bibliography 145 
TIP 39

Cranford, J. A. (2014). DSM-IV alcohol dependence 

and marital dissolution: Evidence from the National 

Epidemiologic Survey on Alcohol and Related Conditions. 

Journal of Studies on Alcohol and Drugs, 75(3), 520–529. 

doi:10.15288/jsad.2014.75.520 

Cross, C. J. (2018). Extended family households among 

children in the United States: Differences by race/ 

ethnicity and socio-economic status. Population Studies, 

72(2), 235–251. doi:10.1080/00324728.2018.1468476 

Cruz, R. A., King, K. M., Cauce, A. M., Conger, R. D., & 

Robins, R. W. (2017). Cultural orientation trajectories 

and substance use: Findings from a longitudinal study 

of Mexican-origin youth. Child Development, 88(2), 

555–572. doi:10.1111/cdev.12586 

Cuadrado, M. (2018). Roman Catholic priests as referral 

sources and treatment aides for Hispanics with substance 

misuse/abuse problems. Journal of Religion and Health, 

57(2), 609–621. doi:10.1007/s10943-017-0464-3 

Cunningham, P. B., Foster, S. L., & Warner, S. E. (2010). 

Culturally relevant family-based treatment for adolescent 

delinquency and substance abuse: Understanding withinsession processes. Journal of Clinical Psychology, 66(8), 

830–846. doi:10.1002/jclp.20709 

Dahlgren, A., Wargelius, H. L., Berglund, K. J., Fahlke, C., 

Blennow, K., Zetterberg, H., . . . Balldin, J. (2011). Do 

alcohol-dependent individuals with DRD2 A1 allele have 

an increased risk of relapse? A pilot study. Alcohol and 

Alcoholism, 46(5), 509–513. doi:10.1093/alcalc/agr045 

Dakof, G. A., Henderson, C. E., Rowe, C. L., Boustani, M., 

Greenbaum, P. E., Wang, W., . . . Liddle, H. A. (2015). 

A randomized clinical trial of family therapy in juvenile 

drug court. Journal of Family Psychology, 29(2), 232–241. 

doi:10.1037/fam0000053 

Danso, R. (2018). Cultural competence and cultural 

humility: A critical refection on key cultural diversity 

concepts. Journal of Social Work, 18(4), 410–430. 

doi:10.1177/1468017316654341 

De Jong, P., & Berg, I. K. (1998). Interviewing for solutions. 

Pacifc Grove, CA: Brooks/Cole Publishing Company. 

de Shazer, S. (1988). Clues: Investigating solutions in brief 

therapy. New York, NY: Norton & Co. 

Diamond, G. M., & Shpigel, M. S. (2014). Attachment-based 

family therapy for lesbian and gay young adults and 

their persistently nonaccepting parents. Professional 

Psychology: Research and Practice, 45(4), 258–268. 

doi:10.1037/a0035394 

DiClemente, C. C. (2018). Addiction and change: How 

addictions develop and addicted people recover (2nd 

ed.). New York, NY: Guilford Press. 

Drapkin, M. L., Eddie, D., Buffngton, A. J., & McCrady, B. 

S. (2015). Alcohol-specifc coping styles of adult children 

of individuals with alcohol use disorders and associations 

with psychosocial functioning. Alcohol and Alcoholism, 

50(4), 463–469. doi:10.1093/alcalc/agv023 

Substance Use Disorder Treatment and Family Therapy 

Eddie, D., Epstein, E. E., & Cohn, A. M. (2015). Pathways to 

vulnerability for alcohol problem severity in a treatmentseeking sample. Addictive Disorders and Their Treatment, 

14(2), 82–94. doi:10.1097/adt.0000000000000045 

Elam, K. K., Chassin, L., & Pandika, D. (2018). Polygenic 

risk, family cohesion, and adolescent aggression in 

Mexican American and European American families: 

Developmental pathways to alcohol use. Development 

and Psychopathology, 30(5), 1715–1728. doi:10.1017/ 

s0954579418000901 

Escobar, O. S., & Vaughan, E. L. (2014). Public religiosity, 

religious importance, and substance use among Latino 

emerging adults. Substance Use and Misuse, 49(10), 

1317–1325. doi:10.3109/10826084.2014.901384 

Fang, L., & Schinke, S. P. (2013). Two-year outcomes of 

a randomized, family-based substance use prevention 

trial for Asian American adolescent girls. Psychology 

of Addictive Behaviors, 27(3), 788–798. doi:10.1037/ 

a0030925 

Fang, L., & Schinke, S. P. (2014). Mediation effects of a 

culturally generic substance use prevention program for 

Asian American adolescents. Asian American Journal of 

Psychology, 5(2), 116–125. doi:10.1037/a0035928 

Fang, L., Schinke, S. P., & Cole, K. C. (2010). Preventing 

substance use among early Asian-American adolescent 

girls: Initial evaluation of a web-based, mother-daughter 

program. Journal of Adolescent Health, 47(5), 529–532. 

doi:10.1016/j.jadohealth.2010.03.011 

Finan, L. J., Schulz, J., Gordon, M. S., & Ohannessian, C. 

M. (2015). Parental problem drinking and adolescent 

externalizing behaviors: The mediating role of family 

functioning. Journal of Adolescence, 43, 100–110. 

doi:10.1016/j.adolescence.2015.05.001 

Fish, J. N., Maier, C. A., & Priest, J. B. (2015). Substance 

abuse treatment response in a Latino sample: The 

infuence of family confict. Journal of Substance Abuse 

Treatment, 49, 27–34. doi:10.1016/j.jsat.2014.07.011 

Fletcher, K. (2013). Couple therapy treatments for substance 

use disorders: A systematic review. Journal of Social Work 

Practice in the Addictions, 13(4), 327–352. doi:10.1080/1 

533256X.2013.840213 

Frank, L. E., & Nagel, S. K. (2017). Addiction and 

moralization: The role of the underlying model of 

addiction. Neuroethics, 10(1), 129–139. doi:10.1007/ 

s12152-017-9307-x 

Galanter, M. (2014). Network therapy for substance use 

disorders. In G. O. Gabbard (Ed.). Gabbard’s treatments 

of psychiatric disorders (5th ed., pp. 919–922). Arlington, 

VA: American Psychiatric Publishing, Inc. 

Galanter, M. (2015). Network therapy. In M. Galanter, H. 

D. Kleber, & K. T. Brady (Eds.) The American Psychiatric 

Publishing textbook of substance abuse treatment (5th 

ed., pp. 441–461). Arlington, VA: American Psychiatric 

Publishing, Inc. 

146 Appendix—Bibliography 
Appendix—Bibliography TIP 39

Galanter, M., Dermatis, H., Glickman, L., Maslansky, R., 

Sellers, M. B., Neumann, E., & Rahman-Dujarric, C. 

(2004). Network therapy: Decreased secondary opioid 

use during buprenorphine maintenance. Journal of 

Substance Abuse Treatment, 26(4), 313–318. 

Galanter, M., Dermatis, H., Keller, D., & Trujillo, M. (2002). 

Network therapy for cocaine abuse: Use of family and 

peer supports. American Journal on Addictions, 11(2), 

161–166. 

Garcia-Huidobro, D., Doty, J. L., Davis, L., Borowsky, I. W., & 

Allen, M. L. (2018). For whom do parenting interventions 

to prevent adolescent substance use work? Prevention 

Science, 19(4), 570–578. doi:10.1007/s11121-017-0853-6 

Gehart, D. R. (2018). Mastering competencies in family 

therapy: A practical approach to theories and clinical case 

documentation (3rd ed.). Boston, MA: Cengage Learning. 

Gerra, G., Somaini, L., Manfredini, M., Raggi, M. 

A., Saracino, M. A., Amore, M., . . . Donnini, C. 

(2014). Dysregulated responses to emotions among 

abstinent heroin users: Correlation with childhood 

neglect and addiction severity. Progress in NeuroPsychopharmacology and Biological Psychiatry, 48, 

220–228. doi:10.1016/j.pnpbp.2013.10.011 

Gilliard-Matthews, S., Stevens, R., Nilsen, M., & Dunaev, 

J. (2015). “You see it everywhere. It’s just natural.”: 

Contextualizing the role of peers, family, and 

neighborhood in initial substance use. Deviant Behavior, 

36(6), 492–509. doi:10.1080/01639625.2014.944068 

Gingerich, W. J., & Peterson, L. T. (2013). Effectiveness 

of solution-focused brief therapy: A systematic 

qualitative review of controlled outcome studies. 

Research on Social Work Practice, 23(3), 266–283. 

doi:10.1177/1049731512470859 

Gladding, S. T. (2019). Family therapy: History, theory, and 

practice (7th ed.). Boston, MA: Pearson. 

Glazer, S. S., Galanter, M., Megwinoff, O., Dermatis, H., 

& Keller, D. S. (2003). The role of therapeutic alliance 

in network therapy: A family and peer support-based 

treatment for cocaine abuse. Substance Abuse, 24(2), 

93–100. 

Goldenberg, I., Stanton, M., & Goldenberg, H. (2017). 

Family therapy: An overview (9th ed.). Boston, MA: 

Cengage Learning. 

Goorden, M., Schawo, S. J., Bouwmans-Frijters, C. A., 

van der Schee, E., Hendriks, V. M., & Hakkaart-van 

Roijen, L. (2016). The cost-effectiveness of family/ 

family-based therapy for treatment of externalizing 

disorders, substance use disorders and delinquency: A 

systematic review. BMC Psychiatry, 16, 237. doi:10.1186/ 

s12888-016-0949-8 

Greenbaum, P. E., Wang, W., Henderson, C. E., Kan, L., 

Hall, K., Dakof, G. A., & Liddle, H. A. (2015). Gender 

and ethnicity as moderators: Integrative data analysis 

of multidimensional family therapy randomized clinical 

trials. Journal of Family Psychology, 29(6), 919–930. 

doi:10.1037/fam0000127 

Gustavsen, G. W., Nayga, R. M., Jr., & Wu, X. (2016). 

Effects of parental divorce on teenage children’s risk 

behaviors: Incidence and persistence. Journal of Family 

and Economic Issues, 37(3), 474–487. doi:10.1007/ 

s10834-015-9460-5 

Gutierrez, A., & Sher, L. (2015). Alcohol and drug 

use among adolescents: An educational overview. 

International Journal of Adolescent Medicine and Health, 

27(2), 207–212. doi:10.1515/ijamh-2015-5013 

Gutierrez, D. (2018). The role of intersectionality in marriage 

and family therapy multicultural supervision. American 

Journal of Family Therapy, 46(1), 14–26. doi:10.1080/019 

26187.2018.1437573 

Harford, T. C., Chen, C. M., Kerridge, B. T., & Grant, B. 

F. (2018). Self- and other-directed forms of violence 

and their relationship with lifetime DSM-5 psychiatric 

disorders: Results from the National Epidemiologic 

Survey on Alcohol Related Conditions-III (NESARC-III). 

Psychiatry Research, 262, 384–392. doi:10.1016/j. 

psychres.2017.09.012 

Harford, T. C., Yi, H. Y., Chen, C. M., & Grant, B. F. (2018). 

Substance use disorders and self- and other-directed 

violence among adults: Results from the National Survey 

on Drug Use And Health. Journal of Affective Disorders, 

225, 365–373. doi:10.1016/j.jad.2017.08.021 

Harp, K. L. H., & Oser, C. B. (2018). A longitudinal analysis 

of the impact of child custody loss on drug use and 

crime among a sample of African American mothers. 

Child Abuse and Neglect, 77, 1–12. doi:10.1016/j. 

chiabu.2017.12.017 

Hartnett, D., Carr, A., Hamilton, E., & O’Reilly, G. (2017). 

The effectiveness of functional family therapy for 

adolescent behavioral and substance misuse problems: 

A meta-analysis. Family Process, 56(3), 607–619. 

doi:10.1111/famp.12256 

Haverfeld, M. C., & Theiss, J. A. (2016). Parent’s alcoholism 

severity and family topic avoidance about alcohol as 

predictors of perceived stigma among adult children of 

alcoholics: Implications for emotional and psychological 

resilience. Health Communication, 31(5), 606–616. doi:10. 

1080/10410236.2014.981665 

Henderson, C. E., Hogue, A., & Dauber, S. (2019). Family 

therapy techniques and one-year clinical outcomes 

among adolescents in usual care for behavior problems. 

Journal of Consulting and Clinical Psychology, 87(3), 

308–312. doi:10.1037/ccp0000376 

Henderson, C. E., Rowe, C. L., Dakof, G. A., Hawes, 

S. W., & Liddle, H. A. (2009). Parenting practices as 

mediators of treatment effects in an early-intervention 

trial of multidimensional family therapy. American 

Journal of Drug and Alcohol Abuse, 35(4), 220–226. 

doi:10.1080/00952990903005890 

Henggeler, S. W., & Schaeffer, C. M. (2016). Multisystemic 

therapy: Clinical overview, outcomes, and implementation 

research. Family Process, 55, 514–528. doi:10.1111/ 

famp.12232 

Appendix—Bibliography 147 
TIP 39

Henson, M., Sabo, S., Trujillo, A., & Teufel-Shone, N. 

(2017). Identifying protective factors to promote health 

in American Indian and Alaska Native adolescents: A 

literature review. Journal of Primary Prevention, 38(1–2), 

5–26. doi:10.1007/s10935-016-0455-2 

Hernandez, L., Rodriguez, A. M., & Spirito, A. (2015). 

Brief family-based intervention for substance abusing 

adolescents. Child and Adolescent Psychiatric Clinics 

of North America, 24(3), 585–599. doi:10.1016/j. 

chc.2015.02.010 

Hernandez Robles, E., Maynard, B. R., Salas-Wright, C. 

P., & Todic, J. (2018). Culturally adapted substance use 

interventions for Latino adolescents: A systematic review 

and meta-analysis. Research on Social Work Practice, 

28(7), 789–801. doi:10.1177/1049731516676601 

Hinrichs, J., Deffe, J., & Westen, D. (2011). Personality 

subtypes in adolescent and adult children of alcoholics: A 

two-part study. Journal of Nervous and Mental Disease, 

199(7), 487–498. doi:10.1097/NMD.0b013e3182214268 

Hoggatt, K. J., Lehavot, K., Krenek, M., Schweizer, C. A., 

& Simpson, T. (2017). Prevalence of substance misuse 

among US veterans in the general population. American 

Journal on Addictions, 26(4), 357–365. doi:10.1111/ 

ajad.12534 

Hogue, A., Bobek, M., Dauber, S., Henderson, C. E., 

McLeod, B. D., & Southam-Gerow, M. A. (2017). Distilling 

the core elements of family therapy for adolescent 

substance use: Conceptual and empirical solutions. 

Journal of Child and Adolescent Substance Abuse, 26(6), 

437–453. doi:10.1080/1067828X.2017.1322020 

Hogue, A., Dauber, S., Henderson, C. E., Bobek, M., 

Johnson, C., Lichvar, E., & Morgenstern, J. (2015). 

Randomized trial of family therapy versus nonfamily 

treatment for adolescent behavior problems in usual 

care. Journal of Clinical Child and Adolescent Psychology, 

44(6), 954–969. doi:10.1080/15374416.2014.963857 

Horigian, V. E., Anderson, A. R., & Szapocznik, J. (2016). 

Family-based treatments for adolescent substance 

use. Child and Adolescent Psychiatric Clinics of North 

America, 25(4), 603–628. doi:10.1016/j.chc.2016.06.001 

Horigian, V. E., Feaster, D. J., Brincks, A., Robbins, M. S., 

Perez, M. A., & Szapocznik, J. (2015). The effects of Brief 

Strategic Family Therapy (BSFT) on parent substance 

use and the association between parent and adolescent 

substance use. Addictive Behaviors, 42, 44–50. 

doi:10.1016/j.addbeh.2014.10.024 

Horigian, V. E., Feaster, D. J., Robbins, M. S., Brincks, A., 

Perez, M. A., & Szapocznik, J. (2014). Long-term effects 

of brief strategic family therapy for adolescent substance 

users. Drug and Alcohol Dependence, 140, e91. 

doi:10.1016/j.drugalcdep.2014.02.265 

Substance Use Disorder Treatment and Family Therapy 

Horigian, V. E., Feaster, D. J., Robbins, M. S., Brincks, A. 

M., Ucha, J., Rohrbaugh, M. J., . . . Szapocznik, J. (2015). 

A cross-sectional assessment of the long term effects of 

brief strategic family therapy for adolescent substance 

use. American Journal on Addictions, 24(7), 637–645. 

doi:10.1111/ajad.12278 

Huey S. J., Jr., & Polo, A. J. (2017). Evidence-based 

psychotherapies with ethnic minority children and 

adolescents. In J. R. Weisz & A. E. Kazdin (Eds.), 

Evidence-based psychotherapies for children and 

adolescents (3rd ed., pp. 361–378). New York, NY: 

Guilford Press. 

Huibregtse, B. M., Corley, R. P., Wadsworth, S. J., Vandever, 

J. M., DeFries, J. C., & Stallings, M. C. (2016). A 

longitudinal adoption study of substance use behavior in 

adolescence. Twin Research and Human Genetics, 19(4), 

330–340. doi:10.1017/thg.2016.35 

Hummel, A., Shelton, K. H., Heron, J., Moore, L., & van 

den Bree, M. B. (2013). A systematic review of the 

relationships between family functioning, pubertal 

timing and adolescent substance use. Addiction, 108(3), 

487–496. doi:10.1111/add.12055 

Ivanich, J. D., Mousseau, A. C., Walls, M., Whitbeck, L., 

& Whitesell, N. R. (2020). Pathways of adaptation: Two 

case studies with one evidence-based substance use 

prevention program tailored for indigenous youth. 

Prevention Science, 21(Suppl. 1), 43–53. doi:10.1007/ 

s11121-018-0914-5 

Jensen, M. R., Wong, J. J., Gonzales, N. A., Dumka, L. 

E., Millsap, R., & Coxe, S. (2014). Long-term effects 

of a universal family intervention: Mediation through 

parent-adolescent confict. Journal of Clinical Child and 

Adolescent Psychology, 43(3), 415–427. doi:10.1080/1537 

4416.2014.891228 

Jessup, M. A., Ross, T. B., Jones, A. L., Satre, D. D., Weisner, 

C. M., Chi, F. W., & Mertens, J. R. (2014). Signifcant 

life events and their impact on alcohol and drug use: A 

qualitative study. Journal of Psychoactive Drugs, 46(5), 

450–459. doi:10.1080/02791072.2014.962715 

Jewell, T., Carr, A., Stratton, P., Lask, J., & Eisler, I. (2013). 

Development of a children’s version of the SCORE Index 

of Family Function and Change. Family Process, 52(4), 

673–684. doi:10.1111/famp.12044 

Kaiser Permanente. (2019). Alcohol use in older 

adults. Retrieved April 7, 2020, from https:// 

wa.kaiserpermanente.org/healthAndWellness/index.jhtml 

?item=%2Fcommon%2FhealthAndWellness%2FhealthyLiv 

ing%2Flifestyle%2Falcohol-seniors.html 

Kalb, F. M., Vincent, V., Herzog, T., & Austin, J. (2017). 

Genetic counseling for alcohol addiction: Assessing 

perceptions and potential utility in individuals with 

lived experience and their family members. Journal 

of Genetic Counseling, 26(5), 963–970. doi:10.1007/ 

s10897-017-0075-x 

148 Appendix—Bibliography 
Appendix—Bibliography TIP 39

Kang, J. (2019). Do extended family members protect 

children from disadvantaged neighborhoods? Focusing 

on behavioral problems of children. Child and Youth Care 

Forum, 48(3), 427–447. doi:10.1007/s10566-019-09489-6 

Kelly, S., Maynigo, P., Wesley, K., & Durham, J. (2013). 

African American communities and family systems: 

Relevance and challenges. Couple and Family 

Psychology: Research and Practice, 2(4), 264–277. 

doi:10.1037/cfp0000014 

Kepple, N. J. (2017). The complex nature of parental 

substance use: Examining past year and prior use 

behaviors as correlates of child maltreatment frequency. 

Substance Use and Misuse, 52(6), 811–821. doi:10.1080/1 

0826084.2016.1253747 

Kepple, N. J. (2018). Does parental substance use always 

engender risk for children? Comparing incidence 

rate ratios of abusive and neglectful behaviors across 

substance use behavior patterns. Child Abuse and 

Neglect, 76, 44–55. doi:10.1016/j.chiabu.2017.09.015 

Kidorf, M., Latkin, C., & Brooner, R. K. (2016). Presence 

of drug-free family and friends in the personal social 

networks of people receiving treatment for opioid use 

disorder. Journal of Substance Abuse Treatment, 70, 

87–92. doi:10.1016/j.jsat.2016.08.013 

Kim, J. S., Brook, J., & Akin, B. A. (2018). Solutionfocused brief therapy with substance-using 

individuals: A randomized controlled trial study. 

Research on Social Work Practice, 28(4), 452–462. 

doi:10.1177/1049731516650517 

Kim-Spoon, J., Lauharatanahirun, N., Peviani, K., Brieant, A., 

Deater-Deckard, K., Bickel, W. K., & King-Casas, B. (2019). 

Longitudinal pathways linking family risk, neural risk 

processing, delay discounting, and adolescent substance 

use. Journal of Child Psychology and Psychiatry, 60(6), 

655–664. doi:10.1111/jcpp.13015 

Klostermann, K., Chen, R., Kelley, M. L., Schroeder, V. 

M., Braitman, A. L., & Mignone, T. (2011). Coping 

behavior and depressive symptoms in adult children of 

alcoholics. Substance Use and Misuse, 46(9), 1162–1168. 

doi:10.3109/10826080903452546 

Klostermann, K., Kelley, M. L., Mignone, T., Pusateri, L., & 

Wills, K. (2011). Behavioral couples therapy for substance 

abusers: Where do we go from here? Substance Use and 

Misuse, 46(12), 1502–1509. doi:10.3109/10826084.2011. 

576447 

Klostermann, K., & O’Farrell, T. J. (2013). Treating substance 

abuse: Partner and family approaches. Social Work in 

Public Health, 28(3–4), 234–247. doi:10.1080/19371918.2 

013.759014 

Kogan, S. M., Lei, M. K., Brody, G. H., Futris, T. G., Sperr, 

M., & Anderson, T. (2016). Implementing family-centered 

prevention in rural African American communities: A 

randomized effectiveness trial of the Strong African 

American Families Program. Prevention Science, 17(2), 

248–258. doi:10.1007/s11121-015-0614-3 

Korcha, R. A., Polcin, D. L., & Bond, J. C. (2016). Interaction 

of motivation and social support on abstinence among 

recovery home residents. Journal of Drug Issues, 46(3), 

164–177. doi:10.1177/0022042616629514 

Kuhn, C. (2015). Emergence of sex differences in the 

development of substance use and abuse during 

adolescence. Pharmacology and Therapeutics, 153, 

55–78. doi:10.1016/j.pharmthera.2015.06.003 

Kuntsche, S., & Kuntsche, E. (2016). Parent-based 

interventions for preventing or reducing adolescent 

substance use—A systematic literature review. Clinical 

Psychology Review, 45, 89–101. doi:10.1016/j. 

cpr.2016.02.004 

Lam, W. K., Fals-Stewart, W., & Kelley, M. L. (2008). 

Effects of parent skills training with behavioral couples 

therapy for alcoholism on children: A randomized 

clinical pilot trial. Addictive Behaviors, 33(8), 1076–1080. 

doi:10.1016/j.addbeh.2008.04.002 

Lam, W. K., Fals-Stewart, W., & Kelley, M. L. (2009). 

Parent training with behavioral couples therapy 

for fathers’ alcohol abuse: Effects on substance 

use, parental relationship, parenting, and CPS 

involvement. Child Maltreatment, 14(3), 243–254. 

doi:10.1177/1077559509334091 

Lam, W. K. K., O’Farrell, T. J., & Birchler, G. R. (2012). Family 

therapy techniques for substance abuse treatment. In S. 

T. Walters & F. Rotgers (Eds.), Treating substance abuse: 

Theory and technique (3rd ed., pp. 256–280). New York, 

NY: Guilford Press. 

Lambie, G. W., Mullen, P. R., Swank, J. M., & Blount, A. 

(2018). The counseling competencies scale: Validation 

and refnement. Measurement and Evaluation in 

Counseling and Development, 51(1), 1–15. doi:10.1080/0 

7481756.2017.1358964 

Lander, L., Howsare, J., & Byrne, M. (2013). The impact of 

substance use disorders on families and children: From 

theory to practice. Social Work in Public Health, 28(3–4), 

194–205. doi:10.1080/19371918.2013.759005 

Laqueur, H. P., Laburt, H. A., & Morong, E. (1964). Multiple 

family therapy. Current Psychiatric Therapies, 4, 150–154. 

Lassiter, P. S., Czerny, A. B., & Williams, K. S. (2015). 

Working with addictions in family therapy. In D. Capuzzi 

& M. D. Stauffer (Eds.), Foundations of couples, marriage, 

and family counseling (pp. 389–417). Hoboken, NJ: Wiley. 

Lebensohn-Chialvo, F., Rohrbaugh, M. J., & Hasler, B. P. 

(2019). Fidelity failures in brief strategic family therapy for 

adolescent drug abuse: A clinical analysis. Family Process, 

58(2), 305–317. doi:10.1111/famp.12366 

Lee, J. O., Cho, J., Yoon, Y., Bello, M. S., Khoddam, R., & 

Leventhal, A. M. (2018). Developmental pathways from 

parental socioeconomic status to adolescent substance 

use: Alternative and complementary reinforcement. 

Journal of Youth and Adolescence, 47(2), 334–348. 

doi:10.1007/s10964-017-0790-5 

Appendix—Bibliography 149 
TIP 39

Lei, N., & Pellitteri, J. (2017). Help-seeking and coping 

behaviors among Asian Americans: The roles of 

Asian values, emotional intelligence, and optimism. 

Asian American Journal of Psychology, 8(3), 224–234. 

doi:10.1037/aap0000086 

Lent, J., P., & Otto, A. (2018). Grandparents, grandchildren, 

and caregiving: The impacts of America’s substance use 

crisis. Generations, 42(3), 15–22. 

Lester, P., Aralis, H., Sinclair, M., Kiff, C., Lee, K. 

H., Mustillo, S., & Wadsworth, S. M.. (2016). The 

impact of deployment on parental, family and child 

adjustment in military families. Child Psychiatry and 

Human Development, 47(6), 938–949. doi:10.1007/ 

s10578-016-0624-9 

Leventhal, A. M., Lee, W., Bergen, A. W., Swan, G. E., 

Tyndale, R. F., Lerman, C., & Conti, D. V. (2014). Nicotine 

dependence as a moderator of genetic infuences 

on smoking cessation treatment outcome. Drug and 

Alcohol Dependence, 138, 109–117. doi:10.1016/j. 

drugalcdep.2014.02.016 

Liddell, J., & Burnette, C. E. (2017). Culturally-informed 

interventions for substance abuse among indigenous 

youth in the United States: A review. Journal of EvidenceInformed Social Work, 14(5), 329–359. doi:10.1080/23761 

407.2017.1335631 

Liddle, H. A. (2010). Multidimensional family therapy: A 

science-based treatment system. Australian and New 

Zealand Journal of Family Therapy, 31(2), 133–148. 

doi:10.1375/anft.31.2.133 

Liddle, H. A., Dakof, G. A., Henderson, C., & Rowe, C. 

(2011). Implementation outcomes of Multidimensional 

Family Therapy-Detention to Community: A 

reintegration program for drug-using juvenile 

detainees. International Journal of Offender Therapy 

and Comparative Criminology, 55(4), 587–604. 

doi:10.1177/0306624x10366960 

Liddle, H. A., Dakof, G. A., Rowe, C. L., Henderson, 

C., Greenbaum, P., Wang, W., & Alberga, L. (2018). 

Multidimensional Family Therapy as a community-based 

alternative to residential treatment for adolescents with 

substance use and co-occurring mental health disorders. 

Journal of Substance Abuse Treatment, 90, 47–56. 

doi:10.1016/j.jsat.2018.04.011 

Liddle, H. A., Dakof, G. A., Turner, R. M., Henderson, 

C. E., & Greenbaum, P. E. (2008). Treating adolescent 

drug abuse: A randomized trial comparing 

multidimensional family therapy and cognitive 

behavior therapy. Addiction, 103(10), 1660–1670. 

doi:10.1111/j.1360-0443.2008.02274.x 

Liddle, H. A., Rowe, C. L., Dakof, G. A., Henderson, C. E., & 

Greenbaum, P. E. (2009). Multidimensional family therapy 

for young adolescent substance abuse: Twelve-month 

outcomes of a randomized controlled trial. Journal 

of Consulting and Clinical Psychology, 77(1), 12–25. 

doi:10.1037/a0014160 

Substance Use Disorder Treatment and Family Therapy 

Liddle, H. A., Rowe, C. L., Dakof, G. A., Ungaro, R. A., & 

Henderson, C. E. (2004). Early intervention for adolescent 

substance abuse: Pretreatment to posttreatment 

outcomes of a randomized clinical trial comparing 

Multidimensional Family Therapy and peer group 

treatment. Journal of Psychoactive Drugs, 36(1), 49–63. 

doi:10.1080/02791072.2004.10399723 

Liepman, M. R., Flachier, R., & Tareen, R. S. (2008). Family 

behavior loop mapping: A technique to analyze the grip 

addictive disorders have on families and to help them 

recover. Alcoholism Treatment Quarterly, 26(1–2), 59–80. 

doi:10.1300/J020v26n01_04 

Lipari, R., Palen, L. A., Ashley, O. S., Penne, M., Kan, M., & 

Pemberton, M. (2017). Examination of veteran fathers’ 

parenting and their adolescent children’s substance use 

in the United States. Substance Use and Misuse, 52(6), 

698–708. doi:10.1080/10826084.2016.1253748 

Lipari, R. N., & Van Horn, S. L. (2017, August 24). Children 

living with parents who have a substance use disorder: 

The CBHSQ Report. Rockville, MD: Center for Behavioral 

Health Statistics and Quality, Substance Abuse and 

Mental Health Services Administration. 

Lloyd-Hazlett, J., Honderich, E. M., & Heyward, K. J. 

(2016). Fa-MI-ly: Experiential techniques to integrate 

motivational interviewing and family counseling. Family 

Journal, 24(1), 31–37. doi:10.1177/1066480715615666 

Loveland, D. (2014, June). Creating a front door to engage 

and retain individuals with a SUD. In Engagement 

strategies: Supporting wellness and recovery conference. 

Presentation at the Meeting of Community Care and 

Western Psychiatric Institute & Clinic. State College, PA. 

Lucero, N. M., & Bussey, M. (2015). Practice-informed 

approaches to addressing substance abuse and trauma 

exposure in urban native families involved with child 

welfare. Child Welfare, 94(4), 97–117. 

Ma, M., Malcolm, L. R., Díaz-Albertini, K., Sánchez, J. C., 

Simpson, B., Cortes, L., & Kibler, J. L. (2017). Cultural 

assets and substance use among Hispanic adolescents. 

Health Education and Behavior, 44(2), 326–331. 

doi:10.1177/1090198116659440 

MacNicol, B. (2017). The biology of addiction. Canadian 

Journal of Anesthesia, 64(2), 141–148. doi:10.1007/ 

s12630-016-0771-2 

Magette, A. L., Durtschi, J. A., & Love, H. A. (2018). 

Lesbian, gay, and bisexual substance use in emerging 

adulthood moderated by parent-child relationships in 

adolescence. American Journal of Family Therapy, 46(3), 

272–286. doi:10.1080/01926187.2018.1493958 

Mahalik, J. R., Lombardi, C. M., Sims, J., Coley, R. L., & 

Lynch, A. D. (2015). Gender, male-typicality, and social 

norms predicting adolescent alcohol intoxication and 

marijuana use. Social Science and Medicine, 143, 71–80. 

doi:10.1016/j.socscimed.2015.08.013 

150 Appendix—Bibliography 
Appendix—Bibliography TIP 39

Marmorstein, N. R., Iacono, W. G., & McGue, M. (2012). 

Associations between substance use disorders and major 

depression in parents and late adolescent-emerging 

adult offspring: An adoption study. Addiction, 107(11), 

1965–1973. doi:10.1111/j.1360-0443.2012.03934.x 

Marsiglia, F. F., Nagoshi, J. L., Parsai, M., & Castro, F. 

G. (2014). The effects of parental acculturation and 

parenting practices on the substance use of Mexicanheritage adolescents from southwestern Mexican 

neighborhoods. Journal of Ethnicity in Substance Abuse, 

13(3), 288–311. doi:10.1080/15332640.2014.905215 

Martinez, M. J., Ayers, S. L., Kulis, S., & Brown, E. (2015). 

The relationship between peer, parent, and grandparent 

norms and intentions to use substances for urban 

American Indian youths. Journal of Child and Adolescent 

Substance Abuse, 24(4), 220–227. doi:10.1080/106782 

8X.2013.812529 

Mathew, K. J., Regmi, B., & Lama, L. D. (2018). Role of 

family in addictive disorders. International Journal of 

Psychosocial Rehabilitation, 22(1), 65–75. 

McCollister, K. E., French, M. T., Sheidow, A. J., Henggeler, 

S. W., & Halliday-Boykins, C. A. (2009). Estimating the 

differential costs of criminal activity for juvenile drug 

court participants: Challenges and recommendations. 

Journal of Behavioral Health Services and Research, 36(1), 

111–126. doi:10.1007/s11414-007-9094-y 

McCollum, E. E., & Trepper, T. S. (2013). Family solutions 

for substance abuse: Clinical and counseling approaches. 

New York, NY: Routledge Publishers. 

McCrady, B. S., Tonigan, J. S., Ladd, B. O., Hallgren, K. A., 

Pearson, M. R., Owens, M. D., & Epstein, E. E. (2019). 

Alcohol behavioral couple therapy: In-session behavior, 

active ingredients and mechanisms of behavior change. 

Journal of Substance Abuse Treatment, 99, 139–148. 

doi:10.1016/j.jsat.2019.01.018 

McCrady, B. S., Wilson, A. D., Muñoz, R. E., Fink, B. 

C., Fokas, K., & Borders, A. (2016). Alcohol-focused 

behavioral couple therapy. Family Process, 55(3), 

443–459. doi:10.1111/famp.12231 

McCutcheon, V. V., Agrawal, A., Kuo, S. I., Su, J., Dick, D. 

M., Meyers, J. L., . . . Bucholz, K. K. (2018). Associations 

of parental alcohol use disorders and parental separation 

with offspring initiation of alcohol, cigarette and cannabis 

use and sexual debut in high-risk families. Addiction, 

113(2), 336–345. doi:10.1111/add.14003 

McFarlane, W. R., Dixon, L., Lukens, E., & Lucksted, A. 

(2003). Family psychoeducation and schizophrenia: A 

review of the literature. Journal of Marital and Family 

Therapy, 29(2), 223–245. doi:10.1111/j.1752-0606.2003. 

tb01202.x 

McGoldrick, M. (1995). You can go home again: 

Reconnecting with your family. New York, NY: Norton. 

McHugh, R. K., Votaw, V. R., Sugarman, D. E., & Greenfeld, 

S. F. (2018). Sex and gender differences in substance 

use disorders. Clinical Psychology Review, 66, 12–23. 

doi:10.1016/j.cpr.2017.10.012 

McLaughlin, K. A., Green, J. G., Gruber, M. J., Sampson, N. 

A., Zaslavsky, A. M., & Kessler, R. C. (2010). Childhood 

adversities and adult psychiatric disorders in the 

National Comorbidity Survey Replication II: Associations 

with persistence of DSM-IV disorders. Archives of 

General Psychiatry, 67(2), 124–132. doi:10.1001/ 

archgenpsychiatry.2009.187 

Menon, J., & Kandasamy, A. (2018). Relapse prevention. 

Indian Journal of Psychiatry, 60(Suppl. 4), S473–S478. 

doi:10.4103/psychiatry.IndianJPsychiatry_36_18 

Mignon, S. I., & Holmes, W. M. (2013). Substance abuse 

and mental health issues within Native American 

grandparenting families. Journal of Ethnicity in Substance 

Abuse, 12(3), 210–227. doi:10.1080/15332640.2013.798 

751 

Mignone, T., Klostermann, K., Mahadeo, M., Papagni, E., 

& Jankie, J. (2017). Confdentiality and family therapy: 

Cultural considerations. ARC Journal of Psychiatry, 2(1), 

9–16. 

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: 

Helping people change (3rd ed.). New York, NY: Guilford 

Press. 

Milne, B. J., Caspi, A., Harrington, H., Poulton, R., Rutter, 

M., & Mofftt, T. E. (2009). Predictive value of family 

history on severity of illness: The case for depression, 

anxiety, alcohol dependence, and drug dependence. 

Archives of General Psychiatry, 66(7), 738–747. 

doi:10.1001/archgenpsychiatry.2009.55 

Mojtabai, R., Stuart, E. A., Hwang, I., Eaton, W. W., 

Sampson, N., & Kessler, R. C. (2017). Long-term effects 

of mental disorders on marital outcomes in the National 

Comorbidity Survey ten-year follow-up. Social Psychiatry 

and Psychiatric Epidemiology, 52(10), 1217–1226. 

doi:10.1007/s00127-017-1373-1 

Moon, Z. (2016). Pastoral care and counseling with military 

families. Journal of Pastoral Care Counseling, 70(2), 

128–135. doi:10.1177/1542305016633663 

Moos, R. H. (2011). Processes that promote recovery from 

addictive disorders. In J. F. Kelly & W. L. White (Eds.), 

Addiction recovery management: Theory, research, and 

practice (pp. 45–66). New York, NY: Humana Press. 

Moos, R. H., & Moos, B. S. (2007). Protective resources 

and long-term recovery from alcohol use disorders. Drug 

and Alcohol Dependence, 86(1), 46–54. doi:10.1016/j. 

drugalcdep.2006.04.015 

Moran, P. (2017). Selecting self-report outcome measures 

for use in family and systemic therapy. Journal of Family 

Therapy, 39(1), 41–56. doi:10.1111/1467-6427.12082 

Appendix—Bibliography 151 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Morgan, T. B., & Crane, D. R. (2010). Cost-effectiveness 

of family-based substance abuse treatment. Journal 

of Marital and Family Therapy, 36(4), 486–498. 

doi:10.1111/j.1752-0606.2010.00195.x 

Morgan, T. B., Crane, D. R., Moore, A. M., & 

Eggett, D. L. (2013). The cost of treating 

substance use disorders: Individual versus family 

therapy. Journal of Family Therapy, 35(1), 2–23. 

doi:10.1111/j.1467-6427.2012.00589.x 

Myhra, L. L., Wieling, E., & Grant, H. (2015). Substance 

use in American Indian family relationships: Linking past, 

present, and future. American Journal of Family Therapy, 

43(5), 413–424. doi:10.1080/01926187.2015.1069133 

Nadel, E. L., & Thornberry, T. P. (2017). Intergenerational 

consequences of adolescent substance use: Patterns 

of homotypic and heterotypic continuity. Psychology 

of Addictive Behaviors, 31(2), 200–211. doi:10.1037/ 

adb0000248 

National Academies of Sciences, Engineering, and 

Medicine. (2016). Families caring for an aging America. 

Washington, DC: National Academies Press. 

National Alliance on Mental Illness. (2019). NAMI 

family support group. Retrieved from https://www. 

nami.org/Support-Education/Support-Groups/ 

NAMI-Family-Support-Group 

National Association of Social Workers. (2015). 

Standards and indicators for cultural competence 

in social work practice. Retrieved April 7, 

2020, from www.socialworkers.org/LinkClick. 

aspx?fleticket=7dVckZAYUmk%3d&portalid=0 

National Domestic Violence Hotline. (2014, August 1). 

Why we don’t recommend couples counseling for 

abusive relationships. Retrieved April 6, 2020, from www. 

thehotline.org/2014/08/01/why-we-dont-recommendcouples-counseling-for-abusive-relationships/ 

National Institute on Alcohol Abuse and Alcoholism. (n.d.). 

Drinking levels defned. Retrieved from www.niaaa. 

nih.gov/alcohol-health/overview-alcohol-consumption/ 

moderate-binge-drinking 

National Institute on Drug Abuse. (2018). Is drug 

addiction treatment worth its cost? Retrieved April 

6, 2020, from www.drugabuse.gov/publications/ 

principles-drug-addiction-treatment-research-basedguide-third-edition/frequently-asked-questions/ 

drug-addiction-treatment-worth-its-cost 

Nichols, M. P., & Davis, S. (2017). Family therapy: Concepts 

and methods (11th ed.). Boston, MA: Pearson. 

Nicosia, N., Wong, E., Shier, V., Massachi, S., & Datar, 

A. (2017). Parental deployment, adolescent academic 

and social-behavioral maladjustment, and parental 

psychological well-being in military families. Public Health 

Reports, 132(1), 93–105. doi:10.1177/0033354916679995 

Novins, D. K., Ferron, C., Abramson, L., & Barlow, A. (2018). 

Addressing substance-use problems in tribal home 

visiting. Infant Mental Health Journal, 39(3), 287–294. 

doi:10.1002/imhj.21706 

O’Farrell, T. J., & Clements, K. (2012). Review of outcome 

research on marital and family therapy in treatment for 

alcoholism. Journal of Marital and Family Therapy, 38(1), 

122–144. doi:10.1111/j.1752-0606.2011.00242. 

O’Farrell, T. J., Murphy, M., Alter, J., & Fals-Stewart, W. 

(2010). Behavioral family counseling for substance 

abuse: A treatment development pilot study. Addictive 

Behaviors, 35(1), 1–6. doi:10.1016/j.addbeh.2009.07.003 

O’Farrell, T. J., & Schein, A. Z. (2011). Behavioral couples 

therapy for alcoholism and drug abuse. Journal of Family 

Psychotherapy, 22(3), 193–215. doi:10.1080/08975353.20 

11.602615 

O’Farrell, T. J., Schreiner, A., Schumm, J., & Murphy, M. 

(2016). Do outcomes after behavioral couples therapy 

differ based on the gender of the alcohol use disorder 

patient? Addictive Behaviors, 54, 46–51. 

O’Farrell, T. J., Schumm, J. A., Murphy, M. M., & 

Muchowski, P. M. (2017). A randomized clinical trial of 

behavioral couples therapy versus individually-based 

treatment for drug-abusing women. Journal of Consulting 

and Clinical Psychology, 85(4), 309–322. 

Ohannessian, C. M., Flannery, K. M., Simpson, E., & 

Russell, B. S. (2016). Family functioning and adolescent 

alcohol use: A moderated mediation analysis. 

Journal of Adolescence, 49, 19–27. doi:10.1016/j. 

adolescence.2016.02.009 

Olmstead, T. A., Abraham, A. J., Martino, S., & Roman, P. 

M. (2012). Counselor training in several evidence-based 

psychosocial addiction treatments in private US substance 

abuse treatment centers. Drug and Alcohol Dependence, 

120(1–3), 149–154. doi:10.1016/j.drugalcdep.2011.07.017 

Orford, J., Hodgson, R., Copello, A., Wilton, S., Slegg, 

G., & UKATT Research Team. (2009). To what factors do 

clients attribute change? Content analysis of follow-up 

interviews with clients of the UK Alcohol Treatment Trial. 

Journal of Substance Abuse Treatment, 36(1), 49–58. 

Osilla, K. C., Trail, T. E., Pedersen, E. R., Gore, K. L., Tolpadi, 

A., & Rodriguez, L. M. (2018). Effcacy of a web-based 

intervention for concerned spouses of service members 

and veterans with alcohol misuse. Journal of Marital and 

Family Therapy, 44(2), 292–306. doi:10.1111/jmft.12279 

Padilla, Y. C., Crisp, C., & Rew, D. L. (2010). Parental 

acceptance and illegal drug use among gay, lesbian, 

and bisexual adolescents: Results from a national survey. 

Social Work, 55(3), 265–275. doi:10.1093/sw/55.3.265 

Papernow, P. L. (2018). Clinical guidelines for working with 

stepfamilies: What family, couple, individual, and child 

therapists need to know. Family Process, 57(1), 25–51. 

doi:10.1111/famp.12321 

152 Appendix—Bibliography 
Appendix—Bibliography TIP 39

Park, S. Y., Anastas, J., Shibusawa, T., & Nguyen, D. (2014). 

The impact of acculturation and acculturative stress on 

alcohol use across Asian immigrant subgroups. Substance 

Use and Misuse, 49(8), 922–931. doi:10.3109/10826084.2 

013.855232 

Partnership for Drug-Free Kids. (2015). How to build 

effective community partnerships to prevent teen 

substance abuse: Implementing PACT360 in your 

community. Washington, DC: Offce of Community 

Oriented Policing Services. 

Pina, A. A., Polo, A. J., & Huey, S. J. (2019). Evidence-based 

psychosocial interventions for ethnic minority youth: The 

10-year update. Journal of Clinical Child and Adolescent 

Psychology, 48(2), 179–202. doi:10.1080/15374416.2019 

.1567350 

Platt, L. F., & Skowron, E. A. (2013). The family 

genogram interview: Reliability and validity of a new 

interview protocol. Family Journal, 21(1), 35–45. 

doi:10.1177/1066480712456817 

Prado, G., Cordova, D., Huang, S., Estrada, Y., Rosen, A., 

Bacio, G. A., . . . McCollister, K. (2012). The effcacy 

of Familias Unidas on drug and alcohol outcomes for 

Hispanic delinquent youth: Main effects and interaction 

effects by parental stress and social support. Drug 

and Alcohol Dependence, 125(Suppl. 1), S18–S25. 

doi:10.1016/j.drugalcdep.2012.06.011 

Prochaska, J. O., & DiClemente, C. C. (1984). The 

transtheoretical approach: Crossing traditional 

boundaries of therapy. Homewood, IL: Dow Jones-Irwin. 

Prom-Wormley, E. C., Ebejer, J., Dick, D. M., & Bowers, M. 

S. (2017). The genetic epidemiology of substance use 

disorder: A review. Drug and Alcohol Dependence, 180, 

241–259. doi:10.1016/j.drugalcdep.2017.06.040 

Rambo, A., & Hibel, J. (2013). What is family therapy? 

Underlying premises. In A. Rambo, C. West, A. Schooley, 

& T. V. Boyd (Eds.), Family therapy review: Contrasting 

contemporary models (pp. 3–8). New York, NY: 

Routledge, Taylor & Francis Group. 

Rapp, C. A., & Goscha, R. J. (2012). The strengths model: A 

recovery-oriented approach to mental health services (3rd 

ed.). New York, NY: Oxford University Press. 

Rapp, R. C., Van Den Noortgate, W., Broekaert, E., 

& Vanderplasschen, W. (2014). The effcacy of case 

management with persons who have substance abuse 

problems: A three-level meta-analysis of outcomes. 

Journal of Consulting and Clinical Psychology, 82(4), 

605–618. doi:10.1037/a0036750 

Reczek, C., Thomeer, M. B., Kissling, A., & Liu, H. (2017). 

Relationships with parents and adult children’s substance 

use. Addictive Behaviors, 65, 198–206. doi:10.1016/j. 

addbeh.2016.10.014 

Reilly, M. T., Noronha, A., Goldman, D., & Koob, G. F. 

(2017). Genetic studies of alcohol dependence in the 

context of the addiction cycle. Neuropharmacology, 122, 

3–21. doi:10.1016/j.neuropharm.2017.01.017 

Reiter, M. D. (2015). Substance abuse and the family. New 

York, NY: Routledge. 

Reyes, H. L., Foshee, V. A., Tharp, A. T., Ennett, S. T., & 

Bauer, D. J. (2015). Substance use and physical dating 

violence: The role of contextual moderators. American 

Journal of Preventive Medicine, 49(3), 467–475. 

doi:10.1016/j.amepre.2015.05.018 

Rigazio-DiGilio, S. A. (2016). MFT supervision: An overview. 

In K. Jordan (Ed.), Couple, marriage, and family therapy 

supervision (pp. 25–49). New York, NY: Springer 

Publishing. 

Robbins, M. S., Feaster, D. J., Horigian, V. E., Rohrbaugh, 

M., Shoham, V., Bachrach, K., . . . Szapocznik, J. (2011). 

Brief strategic family therapy versus treatment as usual: 

Results of a multisite randomized trial for substance 

using adolescents. Journal of Consulting and Clinical 

Psychology, 79(6), 713–727. doi:10.1037/a0025477 

Rogers, R. G., Lawrence, E. M., & Montez, J. K. (2016). 

Alcohol’s collateral damage: Childhood exposure to 

problem drinkers and subsequent adult mortality risk. 

Social Forces, 95(2), 809–836. doi:10.1093/sf/sow074 

Roozen, H. G., de Waart, R., & van der Kroft, P. (2010). 

Community reinforcement and family training: An 

effective option to engage treatment-resistant substanceabusing individuals in treatment. Addiction, 105(10), 

1729–1738. doi:10.1111/j.1360-0443.2010.03016.x 

Rothenberg, J. L., Sullivan, M. A., Church, S. H., Seracini, A., 

Collins, E., Kleber, H. D., & Nunes, E. V. (2002). Behavioral 

naltrexone therapy: An integrated treatment for opiate 

dependence. Journal of Substance Abuse Treatment, 

23(4), 351–360. 

Rowan, M., Poole, N., Shea, B., Gone, J. P., Mykota, D., 

Farag, M., . . . Dell, C. (2014). Cultural interventions to 

treat addictions in indigenous populations: Findings from 

a scoping study. Substance Abuse Treatment, Prevention, 

and Policy, 9, 34. doi:10.1186/1747-597x-9-34 

Rowe, C., Rigter, H., Henderson, C., Gantner, A., Mos, K., 

Nielsen, P., & Phan, O. (2013). Implementation fdelity of 

Multidimensional Family Therapy in an international trial. 

Journal of Substance Abuse Treatment, 44(4), 391–399. 

doi:10.1016/j.jsat.2012.08.225 

Rowe, C. L. (2012). Family therapy for drug 

abuse: Review and updates 2003-2010. Journal 

of Marital and Family Therapy, 38(1), 59–81. 

doi:10.1111/j.1752-0606.2011.00280.x 

Russell, B. S., Simpson, E., Flannery, K. M., & Ohannessian, 

C. M. (2019). The impact of adolescent substance use 

on family functioning: The mediating role of internalizing 

symptoms. Youth and Society, 51(4), 504–528. 

doi:10.1177/0044118X16688708 

Santisteban, D. A., Mena, M. P., & Abalo, C. (2013). 

Bridging diversity and family systems: Culturally informed 

and fexible family-based treatment for Hispanic 

adolescents. Couple and Family Psychology: Research 

and Practice, 2(4), 246–263. doi:10.1037/cfp0000013 

Appendix—Bibliography 153 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Satir, V. (1988). The new peoplemaking. Mountain View, CA: 

Science and Behavior Books. 

Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). The 

Satir model: Family therapy and beyond. Palo Alto, CA: 

Science and Behavior Books. 

Savage, J. E., & Mezuk, B. (2014). Psychosocial and 

contextual determinants of alcohol and drug use 

disorders in the National Latino and Asian American 

Study. Drug and Alcohol Dependence, 139, 71–78. 

doi:10.1016/j.drugalcdep.2014.03.011 

Schaeffer, C. M., Swenson, C. C., Tuerk, E. H., & 

Henggeler, S. W. (2013). Comprehensive treatment for 

co-occurring child maltreatment and parental substance 

abuse: Outcomes from a 24-month pilot study of 

the MST-Building Stronger Families Program. Child 

Abuse and Neglect, 37(8), 596–607. doi:10.1016/j. 

chiabu.2013.04.004 

Schinke, S. P., Fang, L., Cole, K. C., & Cohen-Cutler, S. 

(2011). Preventing substance use among Black and 

Hispanic adolescent girls: Results from a computerdelivered, mother-daughter intervention approach. 

Substance Use and Misuse, 46(1), 35–45. doi:10.3109/108 

26084.2011.521074 

Schuckit, M. A. (2014). A brief history of research on the 

genetics of alcohol and other drug use disorders. Journal 

of Studies on Alcohol and Drugs. 75(Suppl. 17), 59–67. 

Schumm, J. A., Monson, C. M., O’Farrell, T. J., Gustin, N. 

G., & Chard, K. M. (2015). Couple treatment for alcohol 

use disorder and posttraumatic stress disorder: Pilot 

results from U.S. military veterans and their partners. 

Journal of Traumatic Stress, 28(3), 247–252. doi:10.1002/ 

jts.22007 

Schumm, J. A., & O’Farrell, T. J. (2013a). Behavioral couples 

therapy for alcoholism. In P. M. Miller et al. (Eds.), 

Comprehensive addictive behaviors and disorders: Vol. 3. 

Interventions for addiction (pp. 57–65). San Diego, CA: 

Elsevier Academic Press. 

Schumm, J. A., & O’Farrell, T. J. (2013b). Families and 

addiction. In P. M. Miller et al. (Eds.), Comprehensive 

addictive behaviors and disorders: Vol. 1. Principles 

of addiction (pp. 303–312). San Diego, CA: Elsevier 

Academic Press. 

Schumm, J. A., O’Farrell, T. J., & Andreas, J. B. (2012). 

Behavioral couples therapy when both partners have 

a current alcohol use disorder. Alcoholism Treatment 

Quarterly, 30(4), 407–421. doi:10.1080/07347324.2012.7 

18963 

Schumm, J. A., O’Farrell, T. J., Kahler, C. W., Murphy, M. 

M., & Muchowski, P. (2014). A randomized clinical trial 

of behavioral couples therapy versus individually based 

treatment for women with alcohol dependence. Journal 

of Consulting and Clinical Psychology, 82(6), 993–1004. 

doi:10.1037/a0037497 

Shaw, D. J., Warren, T. B., & Johnson, M. E. (2019). Family 

structure and past-30 day opioid misuse among justiceinvolved children. Substance Use and Misuse, 54(7), 

1226–1235. doi:10.1080/10826084.2019.1573839 

Sheidow, A. J., & Henggeler, S. W. (2008). Multisystemic 

therapy for alcohol and other drug abuse in delinquent 

adolescents. Alcoholism Treatment Quarterly, 26(1–2), 

125–145. doi:10.1300/J020v26n01_07 

Sheidow, A. J., McCart, M. R., & Davis, M. (2016). 

Multisystemic therapy for emerging adults with serious 

mental illness and justice involvement. Cognitive 

Behavioral Practice, 23(3), 356–367. doi:10.1016/j. 

cbpra.2015.09.003 

Shellenberger, S. (2007). Use of the genogram with families 

for assessment and treatment. In F. Shapiro, F. W. Kaslow, 

& L. Maxfeld (Eds.), Handbook of EMDR and family 

therapy processes (pp. 76–94). Hoboken, NJ: Wiley. 

Shih, R. A., Tucker, J. S., Miles, J. N., Ewing, B. A., 

Pedersen, E. R., & D’Amico, E. J. (2015). Differences in 

substance use and substance use risk factors by Asian 

subgroups. Asian American Journal of Psychology, 6(1), 

38–46. doi:10.1037/a0036251 

Slesnick, N., Erdem, G., Bartle-Haring, S., & Brigham, G. 

S. (2013). Intervention with substance-abusing runaway 

adolescents and their families: Results of a randomized 

clinical trial. Journal of Consulting and Clinical 

Psychology, 81(4), 600–614. doi:10.1037/a0033463 

Smith, J. M., & Estefan, A. (2014). Families parenting 

adolescents with substance abuse—Recovering 

the mother’s voice: A narrative literature review. 

Journal of Family Nursing, 20(4), 415–441. 

doi:10.1177/1074840714554397 

Smith, T. E., Malespin, T. S., Pereira, M. G., & Richards, K. 

V. (2016). Factors relating to the use of family therapy 

with adolescent marijuana abusers. Child and Adolescent 

Social Work Journal, 33(3), 237–243. doi:10.1007/ 

s10560-015-0417-1 

Smith, V. C., Wilson, C. R., & Committee on Substance 

Use and Prevention. (2016). Families affected by 

parental substance use. Pediatrics, 138(2), e20161575. 

doi:10.1542/peds.2016-1575 

Smith-Genthôs, K. R., Logue, E. M., Low, B. E., & Hendrick, 

S. S. (2017). The forgotten ones: Siblings of substance 

abusers. Journal of Loss and Trauma, 22(2), 120–134. doi: 

10.1080/15325024.2016.1202005 

Soper, R. G. (2014, October 6). Intimate partner violence 

and co-occurring substance abuse/addiction. ASAM 

Magazine, 1–9. 

Sparks, S. N., Tisch, R., & Gardner, M. (2013). Familycentered interventions for substance abuse in Hispanic 

communities. Journal of Ethnicity in Substance Abuse, 

12(1), 68–81. doi:10.1080/15332640.2013.759785 

154 Appendix—Bibliography 
Appendix—Bibliography TIP 39

Stanton, M., & Welsh, R. (2012). Systemic thinking in couple 

and family psychology research and practice. Couple and 

Family Psychology: Research and Practice, 1(1), 14–30. 

doi:10.1037/a0027461 

Steinglass, P. (2009). Systemic-motivational therapy 

for substance abuse disorders: An integrative 

model. Journal of Family Therapy, 31(2), 155–174. 

doi:10.1111/j.1467-6427.2009.00460.x 

Steinglass, P., Sanders, C., & Wells, F. (2019). Multiple family 

group therapy. In B. H. Fiese, M. Celano, K. DeaterDeckard, E. N. Jouriles, & M. A. Whisman (Eds.), APA 

handbook of contemporary family psychology: Family 

therapy and training (Vol. 3, pp. 155–169). Washington, 

DC: American Psychological Association. 

Steinka-Fry, K. T., Tanner-Smith, E. E., Dakof, G. A., & 

Henderson, C. (2017). Culturally sensitive substance use 

treatment for racial/ethnic minority youth: A meta-analytic 

review. Journal of Substance Abuse Treatment, 75, 22–37. 

doi:10.1016/j.jsat.2017.01.006 

Stormshak, E. A., Connell, A. M., Véronneau, M. 

H., Myers, M. W., Dishion, T. J., Kavanagh, K., & 

Caruthers, A. S. (2011). An ecological approach to 

promoting early adolescent mental health and social 

adaptation: Family-centered intervention in public 

middle schools. Child Development, 82(1), 209–225. 

doi:10.1111/j.1467-8624.2010.01551.x 

Strunin, L., Díaz-Martinez, A., Díaz-Martinez, L. R., Kuranz, 

S., Hernández-Ávila, C. A., Pantridge, C. E., & FernándezVarela, H. (2015). Natural mentors and youth drinking: 

A qualitative study of Mexican youths. Health Education 

Research, 30(4), 660–670. doi:10.1093/her/cyv030 

Substance Abuse and Mental Health Services 

Administration. (2010). Recovery-oriented systems of care 

(ROSC) resource guide – Working draft. 

Substance Abuse and Mental Health Services 

Administration. (2013). Substance abuse treatment: 

Addressing the specifc needs of women. Treatment 

Improvement Protocol (TIP) Series 51. HHS Publication 

No. (SMA)13-4426. Rockville, MD: Substance Abuse and 

Mental Health Services Administration. 

Substance Abuse and Mental Health Services 

Administration. (2015). Using technology-based 

therapeutic tools in behavioral health services. Treatment 

Improvement Protocol (TIP) Series 60. HHS Publication 

No. (SMA) 15-4924. Rockville, MD: Substance Abuse and 

Mental Health Services Administration. 

Substance Abuse and Mental Health Services 

Administration. (2017, August 1). Complex connections: 

Intimate partner violence and women’s substance abuse 

and recovery. PowerPoint slides presented as part of 

Relationships Matter, a webinar series on women’s 

behavioral health. Rockville, MD: Substance Abuse and 

Mental Health Services Administration and Administration 

for Children and Families. Retrieved September 10, 2020, 

from https://www.youtube.com/watch?v=IE13p5GgW0E 

Substance Abuse and Mental Health Services 

Administration. (2018). Behavioral health services 

for American Indians and Alaska Natives. Treatment 

Improvement Protocol (TIP) Series 61. HHS Publication 

No. (SMA) 18-5070. Rockville, MD: Substance Abuse and 

Mental Health Services Administration. 

Substance Abuse and Mental Health Services 

Administration. (2019a). Enhancing motivation for 

change in substance use disorder treatment. Treatment 

Improvement Protocol (TIP) Series 35. HHS Publication 

No. PEP19-02-01-003. Rockville, MD: Substance Abuse 

and Mental Health Services Administration. 

Substance Abuse and Mental Health Services 

Administration. (2019b). Substance abuse confdentiality 

regulations. Retrieved April 6, 2020, from www. 

samhsa.gov/about-us/who-we-are/laws-regulations/ 

confdentiality-regulations-faqs 

Substance Abuse and Mental Health Services 

Administration. (2020). National Survey of Substance 

Abuse Treatment Services (N-SSATS): 2019. Data 

on substance abuse treatment facilities. Rockville, 

MD: Substance Abuse and Mental Health Services 

Administration. Retrieved September 10, 2020, from 

https://www.samhsa.gov/data/sites/default/fles/reports/ 

rpt29389/NSSATS-2019.pdf 

Sudhir, P. M. (2018). Cognitive behavioural interventions 

in addictive disorders. Indian Journal of Psychiatry, 

60(Suppl. 4), S479–S484. doi:10.4103/psychiatry. 

IndianJPsychiatry_15_18 

Sullivan, K., Capp, G., Gilreath, T. D., Benbenishty, R., 

Roziner, I., & Astor, R. A. (2015). Substance abuse and 

other adverse outcomes for military-connected youth 

in California: Results from a large-scale normative 

population survey. JAMA Pediatrics, 169(10), 922–928. 

doi:10.1001/jamapediatrics.2015.1413 

Szapocznik, J., Hervis, O., & Schwartz, S. (2003). Brief 

strategic family therapy for adolescent drug abuse. 

Therapy Manuals for Drug Addiction. Bethesda, MD: 

National Institute on Drug Abuse. 

Szapocznik, J., Muir, J. A., Duff, J. H., Schwartz, S. J., 

& Brown, C. H. (2015). Brief strategic family therapy: 

Implementing evidence-based models in community 

settings. Psychotherapy Research, 25(1), 121–133. 

Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2013). 

The comparative effectiveness of outpatient treatment 

for adolescent substance abuse: A meta-analysis. 

Journal of Substance Abuse Treatment, 44(2), 145–158. 

doi:10.1016/j.jsat.2012.05.006 

Teeters, J. B., Lancaster, C. L., Brown, D. G., & Back, S. 

E. (2017). Substance use disorders in military veterans: 

Prevalence and treatment challenges. Substance Abuse 

and Rehabilitation, 8, 69–77. doi:10.2147/sar.S116720 

Appendix—Bibliography 155 
TIP 39 Substance Use Disorder Treatment and Family Therapy 

Thapa, S., Selya, A. S., & Jonk, Y. (2017). Time-varying 

effects of parental alcoholism on depression. Preventing 

Chronic Disease, 14, E136. doi:10.5888/pcd14.170100 

Trail, T. E., Martin, L. T., Burgette, L. F., May, L. W., Mahmud, 

A., Nanda, N., & Chandra, A. (2017). An evaluation of 

U.S. military non-medical counseling programs. Santa 

Monica, CA: RAND. 

Trone, D. W., Powell, T. M., Bauer, L. M., Seelig, A. D., 

Peterson, A. V., Littman, A. J., . . . Boyko, E. J. (2018). 

Smoking and drinking behaviors of military spouses: 

Findings from the Millennium Cohort Family Study. 

Addictive Behaviors, 77, 121–130. doi:10.1016/j. 

addbeh.2017.09.015 

Tucker, J. S., Edelen, M. O., & Huang, W. (2017). 

Effectiveness of parent-child mediation in improving 

family functioning and reducing adolescent problem 

behavior: Results from a pilot randomized controlled 

trial. Journal of Youth and Adolescence, 46(3), 505–515. 

doi:10.1007/s10964-015-0412-z 

Tuerk, E. H., McCart, M. R., & Henggeler, S. W. (2012). 

Collaboration in family therapy. Journal of Clinical 

Psychology, 68(2), 168–178. doi:10.1002/jclp.21833 

U.S. Census Bureau. (2017a). Grandchildren under 18 

years living with a grandparent householder by age of 

grandchild, 2013-2017. American Community Survey 

5-year estimates. Retrieved August 13, 2019. 

U.S. Census Bureau. (2017b). Grandparents, 2013-2017. 

American Community Survey 5-year estimates. Retrieved 

August 13, 2019. 

U.S. Census Bureau. (2019a). Grandchildren characteristics. 

2018 American Community Survey 1-year estimates. 

Retrieved April 6, 2020, from https://data.census. 

gov/cedsci/table?q=S10&d=ACS%201-Year%20 

Estimates%20Subject%20Tables&tid=ACSST1Y2018. 

S1001&vintage=2018 

U.S. Census Bureau. (2019b). Grandparents. 2018 

American Community Survey 1-year estimates. 

Retrieved April 6, 2020, from https://data.census. 

gov/cedsci/table?q=S10&d=ACS%201-Year%20 

Estimates%20Subject%20Tables&tid=ACSST1Y2018. 

S1002&vintage=2018 

U.S. Census Bureau. (2019c). Relationship to householder 

for children under 18 years in households. 2018 

American Community Survey 1-year estimates. 

Retrieved April 6, 2020, from https://data.census.gov/ 

cedsci/table?hidePreview=true&tid=ACSDT1Y2018. 

B09018&vintage=2018 

U.S. Department of Health and Human Services, Centers 

for Disease Control and Prevention. (2011). Cognitive 

impairment: A call for action now. Retrieved April 7, 2020, 

from www.cdc.gov/aging/pdf/cognitive_impairment/ 

cogimp_poilicy_fnal.pdf 

U.S. Department of Health and Human Services, Offce of 

Minority Health. (2018). Brief strategic family therapy. 

Retrieved April 6, 2020, from https://minorityhealth.hhs. 

gov/npa/materials/briefstrategyfamilytherapy.pdf 

U.S. Department of Health and Human Services, Offce of 

the Surgeon General. (2016). Facing addiction in America: 

The Surgeon General’s report on alcohol, drugs, and 

health. Washington, DC: Author. 

Vaeth, P. A., Wang-Schweig, M., & Caetano, R. (2017). 

Drinking, alcohol use disorder, and treatment access and 

utilization among U.S. racial/ethnic groups. Alcoholism: 

Clinical and Experimental Research, 41(1), 6–19. 

doi:10.1111/acer.13285 

van Eeden-Moorefeld, B., & Pasley, B. K. (2013). 

Remarriage and stepfamily life. In G. W. Peterson & K. R. 

Bush (Eds.), Handbook of marriage and the family (3rd 

ed., pp. 517–546). New York, NY: Springer Science + 

Business Media. 

van Wormer, K. S., & Davis, D. R. (2018). Addiction 

treatment: A strengths perspective. Boston, MA: 

Cengage Learning. 

Ventura, A. S., & Bagley, S. M. (2017). To improve substance 

use disorder prevention, treatment and recovery: Engage 

the family. Journal of Addiction Medicine, 11(5), 339–341. 

doi:10.1097/adm.0000000000000331 

Vermeulen-Smit, E., Verdurmen, J. E., & Engels, R. C. 

(2015). The effectiveness of family interventions in 

preventing adolescent illicit drug use: A systematic review 

and meta-analysis of randomized controlled trials. Clinical 

Child and Family Psychology Review, 18(3), 218–239. 

doi:10.1007/s10567-015-0185-7 

Vernig, P. M. (2011). Family roles in homes with alcoholdependent parents: An evidence-based review. 

Substance Use and Misuse, 46(4), 535–542. doi:10.3109/1 

0826084.2010.501676 

Villatoro, A. P., Morales, E. S., & Mays, V. M. (2014). Family 

culture in mental health help-seeking and utilization in a 

nationally representative sample of Latinos in the United 

States: The NLAAS. American Journal of Orthopsychiatry, 

84(4), 353–363. doi:10.1037/h0099844 

Ward, K. P., Dennis, C. B., & Limb, G. E. (2018). The impact 

of stepfamily relationship quality on emerging adult 

non-medical use of prescription drugs. American Journal 

of Drug and Alcohol Abuse, 44(4), 463–471. doi:10.1080/ 

00952990.2017.1405010 

Watkins, C. E., Hook, J. N., Jr., Owen, J., DeBlaere, C., 

Davis, D. E., & Van Tongeren, D. R. (2019). Multicultural 

orientation in psychotherapy supervision: Cultural 

humility, cultural comfort, and cultural opportunities. 

American Journal of Psychotherapy, 72(2), 38–46. 

doi:10.1176/appi.psychotherapy.20180040 

156 Appendix—Bibliography 
Appendix—Bibliography TIP 39

Wegscheider-Cruse, S. (1989). Another chance: Hope and 

health for the alcoholic family (2nd ed.). Palo Alto, CA: 

Science and Behavior Books. 

Wells, E. A., Kristman-Valente, A. N., Peavy, K. M., & 

Jackson, T. R. (2013). Social workers and delivery of 

evidence-based psychosocial treatments for substance 

use disorders. Social Work in Public Health, 28(3–4), 

279–301. doi:10.1080/19371918.2013.759033 

Welsh, J. W., Knight, J. R., Hou, S. S., Malowney, M., 

Schram, P., Sherritt, L., & Boyd, J. W. (2017). Association 

between substance use diagnoses and psychiatric 

disorders in an adolescent and young adult clinic-based 

population. Journal of Adolescent Health, 60(6), 648–652. 

doi:10.1016/j.jadohealth.2016.12.018 

Werner, D., Young, N. K., Dennis, K., & Amatetti, S. (2007). 

Family-centered treatment for women with substance 

use disorders: History, key elements and challenges. 

Rockville, MD: Substance Abuse and Mental Health 

Services Administration. 

White, M., & Epston, D. (1990). Narrative means to 

therapeutic ends (1st ed.). New York, NY: Norton. 

White, W., & Cloud, W. (2008). Recovery capital: A primer 

for addictions professionals. Counselor, 9(5), 22–27. 

White, W. L. (2014). Slaying the dragon: The history of 

addiction treatment and recovery in America (2nd ed.). 

Bloomington, IL: Chestnut Health Systems. 

White, W. L., & Sanders, M. (2006). Recovery management 

and people of color: Redesigning addiction treatment for 

historically disempowered communities. In W. L. White, 

E. Kurtz, & M. Sanders (Eds.), Recovery management (pp. 

58–86). Chicago, IL: Great Lakes Addiction Technology 

Transfer Center. 

Whiteman, S. D., Jensen, A. C., Mustillo, S. A., & Maggs, J. 

L. (2016). Understanding sibling infuence on adolescents’ 

alcohol use: Social and cognitive pathways. Addictive 

Behaviors, 53, 1–6. 

Wilkinson, A. L., Fleming, P. J., Halpern, C. T., Herring, 

A. H., & Harris, K. M. (2018). Adherence to gendertypical behavior and high frequency substance use 

from adolescence into young adulthood. Psychology 

of Men and Masculinity, 19(1), 145–155. doi:10.1037/ 

men0000088 

Williamson, E., Smith, M., Orford, J., Copello, A., & Day, 

E. (2007). Social Behavior and Network Therapy for drug 

problems: Evidence of benefts and challenges. Addictive 

Disorders and Their Treatment, 6, 167–179. 

Wlodarczyk, O., Schwarze, M., Rumpf, H. J., Metzner, F., 

& Pawils, S. (2017). Protective mental health factors in 

children of parents with alcohol and drug use disorders: 

A systematic review. PloS One, 12(6), e0179140. 

doi:10.1371/journal.pone.0179140 

Wong, E. C., Derose, K. P., Litt, P., & Miles, J. N. V. (2018). 

Sources of care for alcohol and other drug problems: 

The role of the African American church. Journal of 

Religion and Health, 57(4), 1200–1210. doi:10.1007/ 

s10943-017-0412-2 

Worley, M. J., Trim, R. S., Tate, S. R., Roesch, S. C., Myers, 

M. G., & Brown, S. A. (2014). Self-effcacy and social 

networks after treatment for alcohol or drug dependence 

and major depression: Disentangling person and timelevel effects. Psychology of Addictive Behaviors, 28(4), 

1220–1229. doi:10.1037/a0037901 

Yap, M. B. H., Cheong, T. W. K., Zaravinos-Tsakos, F., 

Lubman, D. I., & Jorm, A. F. (2017). Modifable parenting 

factors associated with adolescent alcohol misuse: A 

systematic review and meta-analysis of longitudinal 

studies. Addiction, 112(7), 1142–1162. doi:10.1111/ 

add.13785 

Yoon, G., Westermeyer, J., Kuskowski, M. A., & Nesheim, 

L. (2013). Impact of the number of parents with alcohol 

use disorder on alcohol use disorder in offspring: A 

population-based study. Journal of Clinical Psychiatry, 

74(8), 795–801. doi:10.4088/JCP.13m08350 

Zhao, S., Sampson, S., Xia, J., & Jayaram, M. B. (2015). 

Psychoeducation (brief) for people with serious mental 

illness. Cochrane Database of Systematic Reviews, (4), 

CD010823. doi:10.1002/14651858.CD010823.pub2 

Zweben, J. E., Moses, Y., Cohen, J. B., Price, G., Chapman, 

W., & Lamb, J. (2015). Enhancing family protective factors 

in residential treatment for substance use disorders. Child 

Welfare, 94(5), 145–166. 

Appendix—Bibliography 157 
’

SAMHSA Publication No. PEP20-02-02-012 

Published 2020 

Substance Abuse and Mental Health Services Administration 

SAMHSAs mission is to reduce the impact of substance abuse 

and mental illness on America’s communities. 

1-877-SAMHSA-7 (1-877-726-4727) I 1-800-486-4889 (TDD) 

www.samhsa.gov