Contents
 

Why a Quick Guide?..........................................2
 

What Is a TIP?...................................................3
 

Substance Abuse Treatment and
 

Family Therapy..................................................4
 

Integrated Treatment: Benefits, 

Limitations, and Levels of Involvement
 

With Families..................................................19
 

Integrated Treatment Models........................25
 

Specific Populations.......................................38
	

Guidelines for Family Violence and
 

Child Abuse Screening...................................45
 

Resources.......................................................52
 

Glossary..........................................................62
 
     

   

Quick Guide
 For Clinicians
 

Based on TIP 39

Substance Abuse

Treatment and Family

Therapy

This Quick Guide is based entirely on information contained in

TIP 39, published in 2004, and based on information updated

through June 2004.  No additional research has been conducted to update this topic since publication of the TIP.
   

   

       

   

   

2 Substance Abuse Treatment and Family Therapy

WHY A QUICK GUIDE?

This Quick Guide was developed to accompany

Substance Abuse Treatment and Family Therapy,

Number 39 in the Treatment Improvement

Protocol (TIP) series published by the Center for

Substance Abuse Treatment (CSAT), Substance

Abuse and Mental Health Services Administration

(SAMHSA). This Quick Guide is based entirely on

TIP 39 and is designed to meet the needs of the

busy clinician for concise, easily accessed “howto” information.

The Guide is divided into nine sections (see

Contents) to help readers quickly locate relevant

material. The Resources section beginning on

page 52 provides contact and background information for relevant organizations in the fields of

substance abuse treatment and family therapy.

For more information on the topics in this Quick

Guide, readers are referred to TIP 39.
     

   

   

What Is a TIP? 3

WHAT IS A TIP?

The TIP series has been in production since 1991.

This series provides the substance abuse treatment and related fields with consensus­based,

field­reviewed guidelines on substance abuse

treatment topics of vital current interest. TIP 39,

Substance Abuse Treatment and Family Therapy:

•Addresses how substance abuse affects the

entire family

•Provides basic information about family therapy

for substance abuse treatment professionals,

and basic information about substance abuse

treatment for family therapists

•Presents the models, techniques, and principles

of family therapy

•Identifies resources for further information, as

well as future directions for both research and

clinical practice

See the inside back cover for information on how

to order TIPs and other related products.
     

   

   

     

4 Substance Abuse Treatment and Family Therapy

SUBSTANCE ABUSE TREATMENT AND

FAMILY THERAPY

The family has a central role to play in the treatment of any health problem, including substance

abuse. Family work has become a strong theme of

many treatment approaches, but a primary challenge remains the broadening of the substance

abuse treatment focus from the individual to the

family. 

Though substance abuse counselors should not

practice family therapy unless they have proper

training and licensing, they can be informed about

family therapy in order to discuss it with their

clients and know when a referral is indicated.

Substance abuse counselors can also benefit

from incorporating family therapy ideas and techniques into their work with individual clients,

groups of clients, and family groups.

What Is a Family?

There is no single definition of family. However,

several broad categories encompass most families:

•Traditional families (two heterosexual parents

and minor children all living under the same

roof).

•Single parents.
       

     

   

   

   

Substance Abuse Treatment and Family Therapy 5

•Foster relationships.

•Grandparents raising grandchildren.

•Stepfamilies.

•Extended families, which include grandparents,

aunts, uncles, cousins, and other relatives.

•Elected families, which are joined by choice and

not by the usual ties of blood, marriage, and law.

Examples include:

–Emancipated youth who choose to live among

peers

–Godparents and other nonbiologically related

people who have an emotional tie

–Gay and lesbian couples (and minor children

all living under the same roof)

For practical purposes, family can be defined

according to the individual’s closest emotional

connections. A counselor or therapist cannot

determine which individuals make up the client’s

family; rather, counselors can ask, “Who is most

important to you?” This allows clients to identify

who they think should be included in therapy.

Impact of Substance Abuse on Families 

When a family member abuses substances, the

effect on the family may differ according to family

structure.
   

   

   

     

     

   

6 Substance Abuse Treatment and Family Therapy

Client Lives Alone or With Partner. The consequences of substance abuse by an adult who lives

alone or with a partner are likely to be economic

and psychological. Money may be spent for drug

use; the partner who is not using substances

often assumes the provider role. Psychological

consequences may include denial or protection of

the person with the substance use disorder,

chronic anger, stress, anxiety, hopelessness, inappropriate sexual behavior, neglected health,

shame, stigma, and isolation.

Client Lives With Spouse (or Partner) and Minor

Children. A parent’s substance use can have cognitive, behavioral, psychosocial, and emotional

consequences for children, including:

•Impaired learning capacity

•A propensity to develop a substance use

disorder

•Adjustment problems, including increased rates

of divorce, violence, and the need for control in

relationships

•Other problems such as depression, anxiety, and

low self­esteem

In addition, the children of women who abuse

alcohol during pregnancy are at risk for the effects

of fetal alcohol spectrum disorders. 
   

   

   

   

   

   

Substance Abuse Treatment and Family Therapy 7

Children of those with substance use disorders

often feel guilty and responsible for the parent’s

substance abuse. Older children may be forced

prematurely to accept adult responsibilities, especially the care of younger siblings.

Client Is Part of a Blended Family. Many people

who abuse substances belong to stepfamilies.

Substance abuse can intensify problems and

become an impediment to a stepfamily’s integration and stability. 

When substance abuse is part of the family,

unique issues can arise, such as parental authority disputes, sexual or physical abuse, and selfesteem problems for children. Substance abuse

by stepparents may undermine their authority,

lead to difficulty in forming bonds, and impair a

family’s ability to address problems and sensitive

issues.

The children of blended families often live in two

households in which different boundaries and

ambiguous roles can be confusing. Without good

communication and careful attention to areas of

conflict, children may be at increased risk of

social, emotional, and behavioral problems.
     

   

   

   

   

           

   

8 Substance Abuse Treatment and Family Therapy

Older Client Has Grown Children. Older adults

often live with or are supported by their adult children because of financial necessity. Whether

grown children and their parents live together or

apart, the children must take on a parental, caretaking role. Adjustment to this role reversal can be

stressful, painful, and embarrassing.

In some cases, grown children may stop providing

financial support because it is the only influence

they have over the parent. Adult children often will

say to “let them have their little pleasure.” In other

instances, children may cut ties with the parent

because it is too painful to have to watch the parent’s deterioration. Cutting ties only increases the

parent’s isolation and may worsen the substance

abuse.

What Is Family Therapy?

Family therapy is a collection of therapeutic

approaches that share a belief in family­level

assessment and intervention. A family is a system,

and in any system each part is related to all other

parts. Consequently, a change in any part of the

system will bring about changes in all other parts.

Therapy based on this point of view uses the

strengths of families to bring about change in a

range of diverse problem areas, including substance abuse. 
   

   

   

   

   

   

   

Substance Abuse Treatment and Family Therapy 9

Note: Family therapy can take place only when the

safety of all participants can be guaranteed and

no legal constraints preclude it. Counselors

should have training in handling families with violence and/or neglect. Guidelines for assessing violence are provided beginning on page 45.

Differences Between Substance Abuse

Treatment and Family Therapy

Although compatible in many ways, the fields of

substance abuse treatment and family therapy

often use different terms, sometimes understand

the same terms differently, have different professional requirements and expectations, and are

governed by different assumptions. Some of the

basic differences are outlined below.

Family­Involved Therapy and Family Therapy. A

distinction should be made between family therapy and family­involved therapy. Family­involved

therapy attempts to educate families about the

relationship patterns that typically contribute to

the formation and continuation of substance

abuse. It differs from family therapy in that the

family is not the primary therapeutic grouping, nor

is there intervention in the system of family relationships. Most substance abuse treatment centers offer such a family educational approach.
   

     

   

   

   

     

       

     

   

   

   

10 Substance Abuse Treatment and Family Therapy

Denial. In substance abuse treatment, the term

denial is generally used to describe a common

and complex reaction of people with substance

use disorders who, when confronted with the existence of those disorders, deny having the problem. Family therapists’ understanding of the term

denial will vary more according to the particular

therapist’s theoretical orientation; some may see

it as a strategy for maintaining stability and therefore not a “problem” at all.

Substance Abuse. Many substance abuse treatment counselors base their understanding of a

family’s relation to substance abuse on a disease

model. Within this model, practitioners have come

to appreciate substance abuse as a “family disease”—that is, a disease that affects all members

of a family as a result of the substance abuse of

one or more members and that creates negative

changes in their own moods, behaviors, relationships with the family, and sometimes even physical or emotional health.

Family therapists, on the other hand, for the most

part have adopted a family systems model. It conceptualizes substance abuse as a symptom of

dysfunction in the family—a relatively stable symptom because in some way it serves a purpose in

the family system. It is this focus on the family
   

   

     

   

   

     

   

   

   

Substance Abuse Treatment and Family Therapy 11

system, more than the inclusion of more people,

that defines family therapy.

Family Interventions. Family interventions in substance abuse treatment typically refer to a confrontation that a group of family and friends have

with a person abusing substances. Their goal is to

convey the impact of the substance abuse and to

urge entry into treatment. The treatment itself is

likely to be shorter and more time­limited than

that of a family therapist, who will focus more on

intrafamily relationships in an effort to improve

family functioning.

Spirituality. In part because of the role of spirituality in 12­Step groups, substance abuse treatment providers generally consider a spiritual

emphasis more important than do family therapists. Family therapy developed from the mental

health medical field, and as such the emphasis on

the scientific underpinnings to medical practice

has reduced the role of spirituality, especially in

theory and largely in clinical practice.

Process and Content. Compared to substance

abuse counselors, family therapists tend to focus

more on the process of family interactions and the

dynamics among family members than on the

content of each session. For example, a family

therapist might comment more on how family
   

   

   

   

       

   

       

   

   

   

12 Substance Abuse Treatment and Family Therapy

members ignore or pay attention to one another in

conversation, rather than what specifically was

being discussed.

Focus. The focus for substance abuse counselors

is the substance abuse. For family therapists, it is

the family system.

Identity of the Client. Most often the substance

abuse counselor regards the individual with the

substance use disorder as the primary person

requiring treatment (though the family may be

involved in treatment to some degree). The family

therapy community assumes that if long­term

change is to occur, the entire family must be treated as a unit, so the family as a whole constitutes

the client.

Self­Disclosure by the Counselor. Many people

who have been in recovery for some time and who

have experience in self­help groups have become

paraprofessional or professional treatment

providers. As a result, it is common for substance

abuse treatment counselors to disclose information about their own experiences with recovery.

Clients in substance abuse treatment often have

some previous contact with self­help groups, and

usually feel comfortable with counselors’ self­disclosure.
   

   

   

     

     

Substance Abuse Treatment and Family Therapy 13

The practice of sharing personal history receives

much less emphasis in family therapy. For the

family therapist, self­disclosure is downplayed

because it takes the focus of therapy off of the

family.

For more information on differences in theory and

practice, see chapter 3 of TIP 39.

Family Therapy Concepts and Techniques

That Substance Abuse Counselors Can Use

The field of family therapy has developed a number of theoretical concepts and techniques that

can help substance abuse treatment providers

better understand clients’ relationships with their

families.

Complementarity. Complementarity refers to an

interactional pattern in which members of an intimate relationship establish roles and take on

behavioral patterns that fulfill the unconscious

needs and demands of the other. An implication

when treating substance abuse is that the results

of one family member’s recovery need to be

explored in relation to the rest of the family’s

behavior.
   

   

   

   

   

     

14 Substance Abuse Treatment and Family Therapy

Boundaries. Boundaries delineate one family

member from another, generations within families,

or the family from other systems. Boundaries also

regulate the flow of information in the family and

between systems outside the family. 

Dysfunctional patterns can arise in boundaries

ranging from extremes of enmeshment (smotheringly close) to disengagement (unreachably aloof).

When boundaries are too strong, family members

can become disengaged and the family will lack

the cohesion needed to hold itself together. When

boundaries are too weak, family members can

become psychologically and emotionally enmeshed and lose their ability to act as individuals.

Appropriate boundaries vary from culture to culture, and the clinician needs to consider whether

a pattern of disengagement or enmeshment is a

function of culture or pathology.

Subsystems. Within a family system, subsystems

are separated by clearly defined boundaries that

fulfill particular functions. These subsystems have

their own roles and rules within the family system.

For example, in a healthy family, a parental subsystem (which can be made up of one or more
   

     

     

   

     

         

   

Substance Abuse Treatment and Family Therapy 15

individual members) maintains a degree of privacy, assumes responsibility for providing for the

family, and has power to make decisions for the

family. These subsystem rules and expectations

can have a strong impact on client behavior and

can be used to motivate or influence a client in a

positive direction. 

Enduring Family Ties. Another important principle

of family therapy is that families are connected

through more than physical proximity and frequent

interactions. Strong emotional ties connect family

members, even when they are separated. It is possible to involve a client in a form of family therapy

even if family members are not physically present.

Change and Balance. Family rules and scripts are

not unchangeable, but families exhibit different

degrees of adaptability when faced with the need

to change patterns of behavior. A tendency in all

families is homeostasis—a state of equilibrium

that balances strong, competing forces in families

as they tend to resist change—that must be overcome if change is to occur. In order to function

well, families need to be able to preserve order

and stability without becoming too rigid to adapt.
       

   

   

     

       

     

16 Substance Abuse Treatment and Family Therapy

Adjusting to Abstinence. The family of a client

who has a substance use disorder can be expected to act differently (and not always positively)

when the individual with a substance use disorder

enters recovery. A family may react negatively to

an individual member’s cessation of substance

use (e.g., children may behave more aggressively

or lie and steal to regain homeostasis), or there

may be a period of relative harmony that is disrupted when other problems that have been suppressed begin to surface. 

If these other problems are not dealt with, the

family’s reactions may trigger relapse. Family therapy techniques can resolve problems formerly

masked by substance abuse to ensure that the

family helps, rather than hinders, a client’s longterm recovery.

Triangulation. Triangulation occurs when two family members need to discuss a sensitive issue.

Instead of facing the issue, they divert their energy to a third member who acts as a go­between,

scapegoat, object of concern, or ally. By involving

this other person, they reduce their emotional tension, but prevent their conflict from being resolved

and miss opportunities to increase the intimacy in

their relationship. 
     

   

     

     

   

Substance Abuse Treatment and Family Therapy 17

In families organized around substance abuse, a

common pattern is for one parent to be closely

allied with a child while the other parent remains

distant. Triangulation is especially common in

families that are highly enmeshed, but it does

occur to some extent in all families.

The third party in a triangle need not be a family

member. Counselors should be aware of the possibility of becoming involved in a triangle with

clients by competing with the client’s family over

the client. This process is especially common in

programs that treat only the client without involving the family. A substance of abuse can also be

considered an entity with which the client triangulates to avoid deeper levels of intimacy.

See pages 58–60 of TIP 39 for a more detailed

discussion of these concepts.

Genograms. One technique used by family therapists to help them understand family relations is

the genogram, a pictorial chart of the people

involved in a three–generational relationship system, marking marriages, divorces, births, geographical location, deaths, and illness.

Though the preparation of a genogram is not standardized, most of them begin with the legal and

biological relationships of family members.
   

   

   

   

18 Substance Abuse Treatment and Family Therapy

Different genogram styles search out different

information and use different symbols to depict

relationships. For instance, a family map is a variation that arranges family members in relation to

a specific problem (such as substance abuse). 

Genograms can help family members see themselves and their relationships in a new way, and

can be a useful tool for substance abuse treatment providers who want to understand how family relationships affect clients and their substance

abuse.

See chapter 3 of TIP 39 for a more extensive discussion of genograms and how they are developed.
   

   

       

   

   

   

   

Integrated Treatment: Benefits, Limitations, and Levels of

Involvement With Families 19

INTEGRATED TREATMENT: BENEFITS,

LIMITATIONS, AND LEVELS OF

INVOLVEMENT WITH FAMILIES

Benefits to Clients

Examining substance use disorders through the

dynamics of the whole family has a number of

advantages.

•Treatment outcomes. Family involvement in substance abuse treatment is positively associated

with increased rates of entry into treatment,

decreased dropout rates during treatment, and

better long­term outcomes.

•Client recovery. When family members understand how they have participated in the client’s

substance abuse and are willing to actively support the client’s recovery, the likelihood of successful, long­term recovery improves.

•Family recovery. When families are involved in

treatment, the focus can be on the larger family

issues, not just the substance abuse.

•Intergenerational impact. Integrated models can

help reduce the impact and recurrence of substance use disorders in different generations.
   

   

   

   

20 Substance Abuse Treatment and Family Therapy

Benefits to Providers

In addition to the benefits for clients and their

families, integrated models are advantageous to

treatment providers. The practical advantages

include:

•Reduced resistance. Integrated models permit

counselors to attend to the specific circumstances of each family in treatment, thus reducing resistance.

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

to reflect individual and family factors. 

•Flexibility in treatment approach. Integrated

models enable counselors to adjust treatment

approaches according to their own personal

styles and strengths. In this way, different treatment models can be used even within the same

agency to meet both client and counselor needs.

•Increased skill set. Drawing from different traditional therapy models challenges counselors to

be creative in their treatment approaches. With

integrated models, for instance, substance

abuse treatment counselors can work with family members and see how each of their problems

reverberates throughout the family system.

Limitations of Integrating Treatment 

Despite their obvious value and demonstrated

efficacy, integrated models for substance abuse

treatment have some limitations. 
   

     

   

   

       

   

   

         

Integrated Treatment: Benefits, Limitations, and Levels of

Involvement With Families 21

•Lack of structure. If the various modalities in

integrated models are not consistent and compatible, the combination can end up as little

more than a series of disconnected interventions.

•Additional training. Integrated models require

greater knowledge of more treatment modalities, so additional training is necessary.

•Mindset. The major mindset shift necessary to

using integrated models is from an individual

model concentrating on pathology to a systemic

(relational or behavioral) model focused on

changing patterns of family interaction.

Levels of Involvement With Families

Substance abuse treatment professionals intervene with families at different levels during treatment. These levels vary according to how individualized the interventions are to each family, the

extent to which the substance abuse treatment

provider is trained and supervised in family therapy techniques, and the extent to which family therapy is integrated into the process of substance

abuse treatment.

At each level, family intervention has a different

function and requires its own set of competencies.

The family’s acceptance of problems and its readiness to change determine the appropriate level of

counselor involvement with that family.
   

 

     

   

   

22 Substance Abuse Treatment and Family Therapy

Level 1—Counselor has little or no involvement

with family. 

•The counselor contacts families for practical and

legal reasons and provides no services to them. 

•The counselor views the individual in treatment

as the only client and may even feel that during

treatment, the client must be protected from

family contact.

Level 2—Counselor provides psychoeducation 

and advice.

Typical skills:

•Advising families about how to handle the rehabilitative needs of the client

•For large or demanding families, knowing how to

channel communication through one or two key

members

•Identifying gross family dysfunction that interferes with substance abuse treatment

•Referring the family for specialized family therapy treatment

Level 3—Counselor addresses family members’

feelings and provides support. 

Typical skills:

•Asking questions that elicit family members’

expressions of concern and feelings related to

the client’s condition and its effect on the family

•Empathically listening to family members’ concerns and feelings and, where appropriate, normalizing them
   

   

     

Integrated Treatment: Benefits, Limitations, and Levels of

Involvement With Families 23

•Forming a preliminary assessment of the family’s level of functioning as it relates to the

client’s problem

•Encouraging family members in their efforts to

cope with their situation as a family

•Tailoring substance abuse education to the

unique needs, concerns, and feelings of the

family

•Identifying family dysfunction and fitting referral

recommendations to the unique situation of the

family

Level 4—Counselor provides systematic assessment and planned intervention. 

Typical skills:

•Engaging family members, including reluctant

ones, in a planned family conference or a series

of conferences

•Structuring a conference with even a poorly communicating family in such a way that all members have a chance to express themselves

•Systematically assessing the family’s level of

functioning

•Supporting individual members while avoiding

coalitions

•Reframing the family’s definition of its problem

in a way that makes problemsolving more

achievable

•Helping family members view their difficulties as

requiring new forms of collaborative efforts
     

     

   

   

   

24 Substance Abuse Treatment and Family Therapy

•Helping family members generate alternative,

mutually acceptable ways to cope with

difficulties

•Helping the family balance its coping efforts by

calibrating various roles so that members can

support each other without sacrificing autonomy

•Identifying family dysfunction beyond the scope

of primary care treatment; orchestrating a referral by informing the family and the specialist

about what to expect from each other

Level 5—Family therapy. 

Typical skills:

•Interviewing families or family members who are

difficult to engage

•Efficiently generating and testing hypotheses

about the family’s difficulties and interaction

patterns

•Escalating conflict in the family in order to break

a family impasse

•Temporarily siding with one family member

against another

•Constructively dealing with a family’s strong

resistance to change

•Negotiating collaborative relationships with professionals from other systems that are working

with the family, even when these groups are at

odds with one another

For more information on counselor involvement

with families, see Figure 4­2 in TIP 39. 
     

   

   

   

Integrated Treatment Models 25

INTEGRATED TREATMENT MODELS

Examples of Integrated Treatment Models

A number of integrated treatment models have

been discussed in the literature. Those discussed

in this section are among the more frequently

used integrated treatment models. For a more

detailed discussion of these and other models of

family therapy, see chapter 4 of TIP 39.

Structural/Strategic Family Therapy

In this model, family structure (defined as repeated patterns of interaction) is the focus of interventions. It is based on two assumptions:

•Family structure largely determines individual

behavior.

•The power of the system is greater than the ability of the individual to resist. 

This system can be used to

•Identify the function that substance abuse

serves in maintaining family stability.

•Guide appropriate changes in family structure

(e.g., because the patterns in dysfunctional families are typically rigid, the counselor must take a

directive role and coach family members to

develop, then practice, different patterns of

interaction).
       

   

   

26 Substance Abuse Treatment and Family Therapy

One of the basic techniques of structural family

therapy is to mark boundaries so that each member of the family can be responsible for him­ or

herself while respecting the individuality of others.

One of the ways to make respectful individuation

possible is to make the family aware when a family member: 

•Speaks about, rather than to, another person

who is present

•Speaks for others, instead of letting them speak

for themselves

•Sends nonverbal cues to influence or stop

another person from speaking

For more information about structural/strategic

family therapy, see pp. 86–90 of TIP 39.

Multidimensional Family Therapy

Multidimensional family therapy (MDFT) was

developed as a stand­alone, outpatient therapy to

treat adolescent substance abuse and associated

behavioral problems of clinically referred

teenagers. The model integrates several different

techniques with emphasis on the relationships

among cognition, affect (emotionality), behavior,

and environmental input.
   

Integrated Treatment Models 27

For the adolescent who abuses substances, the

goals include:

•Positive peer relations

•Healthy identity formation

•Bonding to school and other prosocial institutions

•Autonomy within the parent–adolescent relationship

For parents, the goals are:

•Increasing parental commitment and preventing

parental abdication

•Improving relationship and communication

between parent and adolescent

•Increasing knowledge of parenting practices

(e.g., limit­setting, monitoring, and appropriate

autonomy granting)

Fore more information about MDFT, see pp.

90–91 of TIP 39.

Behavioral Family Therapy and

Cognitive–Behavioral Family Therapy

Behavioral family therapy (BFT) combines individual interventions within a family problemsolving

framework. The approach assumes that:

•Families of people abusing substances may

have problemsolving skill deficits.
   

   

   

   

   

     

28 Substance Abuse Treatment and Family Therapy

•The reactions of other family members influence

behavior.

•Distorted beliefs lead to dysfunction and distorted behaviors.

•Therapy helps family members develop behaviors that support nonusing and nondrinking.

Over time, these new behaviors become more

and more rewarding, promoting abstinence.

Cognitive–behavioral family therapy views substance abuse as a conditioned behavioral

response, one which family cues and contingencies reinforce.

To facilitate behavioral change within a family to

support abstinence, the counselor can use the following techniques:

•Contingency contracting. These agreements

stipulate what each member will do in exchange

for rewarding behavior from other family members. For example, a teenager may agree to call

home regularly while attending a concert in

exchange for permission to attend it.

•Skills training. The counselor may start with general education about communication or conflict

resolution skills, then move to skills practice during therapy, and end with the family’s agreement

to use the skills at home.
   

   

       

   

   

   

   

Integrated Treatment Models 29

•Cognitive restructuring. The counselor helps

family members voice unrealistic or self­limiting

beliefs that contribute to substance abuse or

other family problems. Family members are

encouraged to see how such beliefs threaten

ongoing recovery and family tranquility. Finally,

the family is helped to replace these self­defeating beliefs with those that facilitate recovery and

individual and family strengths.

For more information about behavioral family therapy and cognitive–behavioral family therapy, see

pp. 93–95 of TIP 39.

Family/Larger System/Case Management

Therapy

This model is primarily for families who are or

should be involved intensely with larger systems,

which include the workplace, schools, health care,

courts, foster care, etc. The goal is to empower

the family in working with the larger system by

designating the family as the major expert on its

own needs. Counselors help the family navigate

various systems, serving to some extent as a community liaison.

Counselors utilizing this model will need to determine:

•What larger systems affect the family?
   

     

     

       

     

30 Substance Abuse Treatment and Family Therapy

•What agencies and agency subsystems regularly

interact with family members?

•How is the family moved from one larger system

to another?

•Is there a history of significant involvement with

larger systems, and if so, regarding what issues?

For example, families with substance abuse problems interact more regularly with the judicial system, because of arrests (e.g., for driving under the

influence, loss of parental rights, and domestic

violence).

For more information about family/larger system/case management therapy, see pp. 97–98 of

TIP 39.

Network Therapy

Network therapy harnesses the potential of therapeutic support from people outside the immediate

family, including friends, extended family, and 12­

Step groups such as Alcoholics Anonymous (AA).

The counselor works to mobilize the client’s network, to keep the people in the network informed

and involved, and to encourage the client to

accept help from the network.

For more information about network therapy, see

p. 98 of TIP 39.
   

       

   

       

   

       

   

       

     

Integrated Treatment Models 31

Bowen Family Systems Therapy

Bowen family systems therapy often works

through one person, on the premise that a change

on the part of just one family member will affect

the family system. The model attempts to reduce

anxiety throughout the family by encouraging people to become more differentiated, more

autonomous, and less enmeshed in the family

emotional system. 

In Bowen’s view, specific and problematic anxiety

and relationship patterns are handed down from

generation to generation. Some intergenerational

patterns that may require therapeutic focus are:

•Creating distance. Alcohol and drugs are used to

manage anxiety by creating distance in the

family.

•Triangulation. As previously discussed, triangulation is an emotional pattern that can involve

either three people or two people and an issue

(such as the substance abuse). In the latter situation, the substance is used to displace anxiety

that exists between the two people.

•Coping. Substance abuse is used to mute emotional responses to family members and to create a false sense of family equilibrium.

For more information about Bowen family systems

therapy, see pp. 98–100 of TIP 39.
       

   

   

     

   

   

   

       

     

   

     

   

   

   

32 Substance Abuse Treatment and Family Therapy

Solution­Focused Brief Therapy

Rather than focusing on an extensive description

of the problem, solution­focused brief therapy

(SFBT) encourages client and therapist to focus

instead 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. Exceptions

to the problem—that is, times when the problem

does not happen and a piece of the future solution is present—are elicited and built on.

Perhaps the most representative of the SFBT techniques is the miracle question, which elicits

clients’ vision of life without the problems that

brought them to therapy. The miracle question traditionally takes this form:

The Miracle Question

Suppose that while you are sleeping tonight

and the entire house is quiet, a miracle happens: The problem that brought you here is

solved. Because you are sleeping, however,

you don’t know that the miracle has happened. When you wake up tomorrow morning,

what will be different that will tell you a miracle has happened, and the problem that

brought you here has been solved?
   

       

   

   

       

   

   

Integrated Treatment Models 33

The miracle question serves several purposes. It

helps the client imagine what life would be like if

his or her problems were solved, gives hope of

change, and previews the benefits of that change.

Its most important feature, however, is its transfer

of power to clients. It permits them to create their

own vision of the change they want. It does not

require them to accept a vision composed or suggested by an expert.

For more information about solution­focused brief

therapy, see pp. 100–105 of TIP 39.

Matching Therapeutic Techniques to Points

of Family Recovery

TIP 39 combines Bepko and Krestan’s stages of

treatment for families (1985)1 and Heath and

Stanton’s stages of family therapy for substance

abuse treatment (1998)2 to describe how families

cope at different points in the progression of treatment. Three points are described:

•Attainment of Sobriety: The family system is

unbalanced but healthy change is possible.

•Adjustment to Sobriety: The family works on

developing and stabilizing a new system. 

1

Bepko, C., and Krestan, J.A. The Responsibility Trap: A Blueprint for

Treating the Alcoholic Family. New York: Free Press, 1985.

2

Heath, A.W., and Stanton, M.D. Family­based treatment: Stages and

outcomes. In: Frances, R.J., and Miller, S.I., eds. Clinical Textbook of

Addictive Disorders. 2d ed. New York: Guilford Press, 1998. pp.

496–520.
     

     

   

   

   

   

34 Substance Abuse Treatment and Family Therapy

•Long­Term Maintenance of Sobriety: The family

must rebalance and stabilize a new and 

healthier lifestyle.

The following summary lists techniques from the

previously summarized treatment models that can

be used with families at these different recovery

points.

Attainment of Sobriety

Multidimensional Family Therapy

•Motivate family to engage client in detoxification.

•Contract with the family for abstinence.

•Contract with the family regarding its own 

treatment.

•Define problems and contract with family members to curtail the problems.

•Employ Al­Anon, spousal support groups, and

multifamily support groups.

Behavioral Family Therapy

•Conduct community reinforcement training interviews (e.g., with area clergy to help them develop ways to impact the community).

Network and Family/Larger System

•Use the network (including courts, parole officers, employer, team staff, licensing boards,

child protective services, social services,

lawyers, schools, etc.) to motivate treatment.
   

   

     

   

Integrated Treatment Models 35

•Interview the family in relation to the larger

system.

•Interview the family and people in other larger

systems that assist the family.

•Interview larger system representatives (e.g.,

school counselors) without the family present

(provided that issues of confidentiality have

been addressed).

Bowen Family Systems Therapy

•Reduce levels of anxiety.

•Create a genogram showing multigenerational

substance abuse; explore family disruption from

system events, such as immigration or holocaust.

•Orient the nuclear family toward facts versus

reactions by using factual questioning.

•Alter triangulation by coaching families to take

different interactional positions.

•Ask individual family members more questions,

so the whole family learns more about itself.

Adjustment to Sobriety

Structural/Strategic Systems

•Restructure family roles (the main work of this

model).

•Realign subsystem and generational boundaries.

•Reestablish boundaries between the family and

the outside world.
   

36 Substance Abuse Treatment and Family Therapy

Multidimensional Family Therapy

•Stabilize the family.

•Reorganize the family.

•Teach relapse prevention.

•Identify communication dysfunction.

•Teach communication and conflict resolution

skills.

•Assess developmental stages of each person in

the family.

•Consider family system interactions based on

personality disorders.

•Consider whether to refer to an appropriate professional to assess if medication is needed for

depression, anxiety, or posttraumatic stress disorder.

•Consider whether to address loss and mourning,

along with sexual or physical abuse.

Cognitive–Behavioral Family Therapy

•Conduct community reinforcement training interviews.

•Establish a problem definition.

•Employ structure and strategy.

•Use communication skills and negotiation skills

training.

•Employ conflict resolution techniques.

•Use contingency contracting.
   

   

     

Integrated Treatment Models 37

Network Interventions

•Use organizations such as AA, Al­Anon, Alateen,

and Families Anonymous as part of the network.

•Delineate and redistribute tasks among all service providers working with the family.

•Use rituals when clients are receiving simultaneous and conflicting messages.

Solution­Focused Family Therapy

•Employ the miracle question.

•Ask scaling and relational questions.

•Identify exceptions to problem behavior.

•Identify problem and solution sequences.

Long­Term Maintenance of Sobriety

Family/Larger Systems/Case Management

•Renegotiate relationships with larger systems

(e.g., agree with Child Protective Services that

once the family has completed treatment, the

child[ren] can be returned to the home).

Network Therapy

•Employ Al­Anon, spousal support groups, and

multifamily support groups.

For more information on matching therapeutic

techniques to points of family recovery, see

pages 103–106 of TIP 39, including Figures 4­3, 

4­4, and 4­5.
   

   

   

   

   

38 Substance Abuse Treatment and Family Therapy

SPECIFIC POPULATIONS

Women

Family therapy for women with substance use disorders is appropriate except in cases in which

there is ongoing partner abuse. Safety should

always be the primary consideration. This could

mean that the abusive partner progresses through

treatment directed at impulse control or a batterers’ program before any family or couples therapy

is initiated.

Racial and Ethnic Minorities

Although a great deal of research exists on both

family therapy and culture and ethnicity, little

research has concentrated on how culture and

ethnicity influence core family and clinical

processes. 

Generalizations about barriers to treatment for

racially and ethnically diverse men and women

should be made with caution. Nevertheless, some

barriers to treatment, particularly among African

Americans and Hispanics/Latinos, have been

investigated. They include: 

•Problem recognition or perceptions of problem

severity

•Doubt about the efficacy of treatment
       

   

       

     

Specific Populations 39

•Inaccurate perceptions about the cost or availability of treatment (especially for people who

lack insurance)

•A cultural need to maintain dignity

•Negative beliefs about treatment (e.g., harsh

rules in residential programs)

•Structural problems (e.g., too little treatment for

people with no or inadequate insurance, inadequate detoxification facilities, bureaucratic red

tape)

Gay, Lesbian, and Bisexual Clients

Available data suggest that lesbian and gay sexual

orientation increases a person’s risk for substance use and abuse. However, research is insufficient to suggest the efficacy of any one type of

family therapy over another for use with gay and

lesbian clients.

Possibly more important than the school of therapy is the therapist’s knowledge, understanding,

and acceptance of differing sexual orientations.

Treatment providers often are not trained in the

specific needs of these populations, even though

gay, lesbian, and bisexual individuals in treatment

for substance abuse often take part in family 

therapy.
   

   

     

   

   

     

40 Substance Abuse Treatment and Family Therapy

People With Physical or Cognitive

Disabilities

The life challenges facing family members with

disabilities increases their risk of substance use,

makes treatment more complex, and heightens

the possibility of relapse.

Because family members may feel responsible for

the individual’s condition and present mostly with

negativity, providers must address guilt and anger.

Researchers suggest that a therapist assist both

the family and the member with a disability to

focus on the choices at their disposal. Such questions as “What are you doing that perpetuates the

situation?” and “Are you aware of other choices

that would have a different result?” can empower

clients to understand that they retain the powerful

option of making choices.

A strengths­based approach to treatment is especially important for people with disabilities,

because such clients may have so frequently been

viewed in terms of what they cannot or should not

attempt that they may have learned to define

themselves in terms of their limitations and inabilities. Well­intentioned family members and friends

may encourage dependence and may even feel

threatened when the member with a disability

attempts to achieve a measure of independence.
   

   

   

   

   

   

   

   

   

   

   

Specific Populations 41

Children and Adolescents

TIP 39 indicates several possible approaches to

treatment involving an adolescent or child and her

family.

•Providers will need to make accommodations for

children in therapy (e.g., children should not be

left too long in the waiting room and should not

be expected to sit still for an hour while adult

conversation takes place around them).

•Parents can be taught techniques to decrease

reactivity and ways to provide real and acceptable choices for their children.

•Children can be encouraged to handle developmentally appropriate tasks and to understand

that outcomes are tied to behavior.

•Moving therapy from the clinic to settings with

which an adolescent is familiar and comfortable

can be helpful. Conducting sessions at an adolescent’s home may promote a more open and

sharing tone than sessions in an office.

•Scheduling of sessions must be sensitive not

only to school obligations, but to extracurricular

and social activities as well.

•Gender also may have implications in family

groupings, particularly in families where abuse

has occurred. There may be cases where

father/son or mother/daughter sessions will be

helpful.
   

   

     

   

   

   

   

       

   

42 Substance Abuse Treatment and Family Therapy

Ultimately, treatment for adolescents and children

is challenging and may require referral.

Older Adults

While the efficacy of family therapy to treat older

adults has not been extensively examined, some

indications suggest it is an effective method to

draw even the older person who lives alone back

into a family context and reduce feelings of isolation. At the same time, the therapist must respect

the elder’s autonomy and privacy, and obtain specific permission from the client to contact family

members and communicate with them about substance abuse problems. The therapist also should

be aware that adult children may have their own

substance use problems and screen them 

carefully.

Therapists must be sensitive to the possibility of

elder abuse, which is pervasive, though often

overlooked. In some States, it is mandatory for all

helping professionals to report elder abuse.

Rural Populations

The geographic dispersion of families in rural

areas may require them to travel great distances

in order to access treatment. A provider has several options for addressing distance barriers:

•Contract with the family for a limited number of

sessions and be very focused in the work. 
   

   

     

   

   

   

   

   

Specific Populations 43

•Alternate sessions at the office with sessions at

the client’s home or choose a location in

between (e.g., a local church or community center).

•Schedule extended sessions that allow bigger

chunks of therapeutic work to occur every 2 or 3

weeks instead of weekly.

Homeless Clients

Many homeless people do not have a family group

to bring into therapy, even by the most inclusive

interpretations. Still, family dynamics remain integral to the functioning of even the most isolated

individuals, and one­person family therapy may be

an effective approach in substance abuse treatment if family members are not reachable or

amenable to being in treatment.

It might seem at first that a family genogram

would yield little useful information, but constructing one can allow for surprising insights. It should

look at not only an individual’s family of origin, but

also the family of choice, if such a structure

exists.

Veterans

Little specific family therapy research about veteran populations exists. The therapist can help the

veteran locate services, including benefits to

which they are entitled. Therapists also need to
   

     

       

   

   

   

44 Substance Abuse Treatment and Family Therapy

know where local veteran centers are. If treatment

is difficult to access, it may be hard to get families

involved.

Veterans’ wives, particularly, may need support,

and support groups can be helpful. Children may

face a number of issues related to a parent’s veteran status. Therapists have observed, for example, that as the children of Vietnam veterans

approach the age their fathers were when they

went to Vietnam (usually late teens), the fathers

begin pressuring them to learn to be tough.

The issue of abandoned children may also be difficult for veterans. A number of veterans fathered

children while in the service, and these lost families often need to be addressed in family therapy.

For more information about these and other specific populations as they relate to family therapy,

see chapter 5 of TIP 39.
   

     

   

   

Guidelines for Family Violence and Child Abuse Screening 45

GUIDELINES FOR FAMILY VIOLENCE

AND CHILD ABUSE SCREENING

Therapists must assess the potential for anger

and violence and construct therapy so it can be

conducted without endangering any family members. Because of the critical nature of this responsibility, included here are guidelines for the

screening of families for violence and neglect.

These guidelines have been adapted from a more

extensive version included in TIP 25, Substance

Abuse Treatment and Domestic Violence (CSAT

1997), and in appendix C of TIP 39. Providers who

encounter family violence issues in practice

should refer to these more comprehensive discussions for further guidance.

If during the screening interview, it becomes clear

that a batterer is endangering a client or other

abuse is occurring in the family, the treatment

provider should respond to this situation before

any other issue, and if necessary, suspend the

rest of the screening interview until the safety of

the client or family member can be ensured. The

provider should refer the client to a domestic violence program and possibly to a shelter and legal

services.
     

   

   

   

   

46 Substance Abuse Treatment and Family Therapy

Screening for Domestic Violence and Other

Abusive Behavior

•To determine if someone has endured domestic

violence, look for physical injuries, especially

patterns of untreated injuries to the face, neck,

and throat. Other indicators may include: 

— Inconsistent explanations for injuries and evasive answers when questioned about them

— Complications in pregnancy, including miscarriage, premature birth, and infant illness or

birth defects

— Stress­related illnesses and conditions such

as headache, backache, chronic pain, gastrointestinal distress, sleep disorders, eating

disorders, and fatigue

— Anxiety­related conditions, such as heart palpitations, hyperventilation, and panic attacks

— A sad, flat affect or talk of suicide

— History of relapse or noncompliance with substance abuse treatment plans

•Always interview clients about domestic violence

in private. Ask about violence using concrete

examples and hypothetical situations rather

than vague, conceptual questions. Screening

questions should convey to survivors that no

battering is justified and that substance abuse

is not an acceptable excuse for violent behavior.

•Referrals should be made when appropriate for

psychotherapy and specialized counseling. Staff
   

   

     

   

   

   

   

     

   

   

Guidelines for Family Violence and Child Abuse Screening 47

training in domestic violence is important so

that substance abuse treatment counselors can

respond effectively to a domestic violence crisis.

•Because batterers in treatment frequently

harass their partners, telephone and visitation

privileges of batterers and survivors in residential substance abuse treatment programs should

be carefully monitored.

•A good initial question to investigate the possibility that a client is abusing family members is,

“Do you think violence against a partner is justified in some situations?” A third­person example

may be used, followed by specific, concrete

questions that define the extent of the violence:

— What happens when you lose your temper?

— When you hit [name of family member], was it

a slap or a punch?

—Do you take car keys away? Damage property? Threaten to injure or kill [name of family

member]?

•Once it has been confirmed that a client has

been abusive—whether physically, sexually, or

psychologically—the provider should contact a

domestic violence expert, either for referral or

consultation. Treatment providers should ensure

that the danger the batterer poses is carefully

assessed.
     

       

   

   

   

48 Substance Abuse Treatment and Family Therapy

•Become familiar with batterers’ rationalizations

and excuses for their behavior:

— Minimizing: “I only pushed her.” “She exaggerates.”

— Claiming good intentions: “When she gets

hysterical, I have to slap her to calm her

down.”

— Blaming intoxication: “I’m not myself when I

drink.” 

— Pleading loss of control: “I can only take so

much.” “I was so angry, I didn’t know what I

was doing.”

— Faulting the partner: “She drove me to it.”

“She really knows how to get to me.”

— Shifting blame to someone or something

else: “I was raised that way.” “My probation

officer is putting a lot of pressure on me.”

“I’ve been out of work.”

Screening for Child Abuse

•Federal and State laws require health care

providers, and in some cases “any person,” to

report suspected child abuse or neglect.

Consequently, substance abuse treatment

providers must notify a child protective services

agency if they suspect child abuse or neglect.

Providers that fail to carry out this mandate are

subject to loss of license, fines, or imprisonment, as well as civil liability. In order to avoid

any client feeling that they have been betrayed,
   

   

   

     

   

   

   

   

   

     

Guidelines for Family Violence and Child Abuse Screening 49

notification regarding Federal and State reporting requirements should be clearly stated during

the admission process, and should be prominently written or stated for those parts of any

treatment program that involve participation of

the client’s family, friends, or others.

•When discussing the limits of confidentiality as

set forth in Title 42, Part 2, of the Code of

Federal Regulations (or 42 C.F.R, Part 2), treatment programs should be sure that clients

understand that those requirements do not

affect the absolute reporting requirement of suspected child abuse or neglect. Clients should

understand that their permission is not needed

in any way, as child abuse or neglect reporting

laws must be adhered to regardless of the concerns of the client or others. 

•During initial screening, the interviewer should

attempt to determine whether a client’s children

have been physically or emotionally harmed and

whether their behavior has changed. Have they

become mute? Do they scream, cry, or act out?

[See also TIP 36, Substance Abuse Treatment

for Persons With Child Abuse and Neglect

Issues, p. 79, “Clues That the Client May Be

Endangering Children,” for additional guidance.]

•The substance abuse treatment provider should

not assess children for abuse or incest. Only personnel with special expertise should perform
     

   

   

     

   

   

   

     

   

50 Substance Abuse Treatment and Family Therapy

this delicate function (e.g., a psychologist, psychiatrist, social worker, or other care provider

authorized by State child protective services).

The treatment provider should, however, note

any indications of child abuse occurring in a

client’s household and pass these suspicions on

to the appropriate agency.

•Indications of child abuse that can crop up in a

client interview include:

— A protective services agency has been

involved with anyone who lives in the home

— The children’s behaviors are indicative of

abuse (e.g., bedwetting, sexual acting out)

— Extraordinary closeness is noted between a

child and another adult in the household

— The client reports blackouts (batterers often

claim to black out during a violent episode)

•If a treatment provider suspects that a client’s

child has been abused, the provider must immediately refer the child to a health care provider. If

the parent will not take the child to a doctor

(who is required by law to report suspected

abuse), the provider must contact home health

services or child protective services.

•If the treatment provider reports suspected or

definite child abuse or neglect, the provider

must assess the impact on any client also being
   

   

Guidelines for Family Violence and Child Abuse Screening 51

battered and develop a safety plan if one is
 

deemed necessary.
 

•Providers should be aware that if a child has

been or is being abused by the mother’s partner,

it is likely that the mother is also being abused. 
52 Substance Abuse Treatment and Family Therapy

RESOURCES

This list of resources is not exhaustive, and does

not necessarily signify endorsement by CSAT,

SAMHSA, or the U.S. Department of Health and

Human Services (DHHS).

Addiction Technology Transfer Centers

(ATTCs) 

National Office

University of Missouri, Kansas City

5100 Rockhill Road

Kansas City, MO 64110

Phone: (816) 482­1200

Fax: (816) 482­1101

Web site: http://www.nattc.org

The Addiction Technology Transfer Centers are a

nationwide, multidisciplinary resource that draws

upon the knowledge, experience, and latest work

of recognized experts in the field of addictions.

Launched in 1993 and funded by CSAT, the

Network today is composed of 14 independent

Regional Centers and a National Office.
Resources 53

Adult Children of Alcoholics (ACA) 

World Services Organization, Inc.

P.O. Box 3216

Torrance, CA 90510

Phone: (310) 534­1815

Web site: http://www.adultchildren.org

Adult Children of Alcoholics is a 12­Step, 

12 Tradition program of men and women who

grew up in alcoholic or otherwise dysfunctional

homes.

Adult Children Anonymous

ACA General Service Network

P.O. Box 25166

Minneapolis, MN 55458

Web site: http://www.12stepforums.net/acoa.html

Adult Children Anonymous is a 12­Step program

modeled after Alcoholics Anonymous. It is a spiritual program designed to help adults raised in

families where either substance addiction, mental

illness, or generalized dysfunction was present. 
   

   

54 Substance Abuse Treatment and Family Therapy

Al­Anon and Alateen

Al­Anon Family Group Headquarters, Inc.

1600 Corporate Landing Parkway

Virginia Beach, VA 23454

Phone: (757) 563­1600

Fax: (757) 563­1655

Web site: http://www.al­anon.org

Al­Anon is a group of relatives and friends of alcoholics who share their experience, strength, and

hope to solve their common problems. The purpose of Al­Anon is to help families of alcoholics by

practicing the 12 steps, by welcoming and giving

comfort, and by providing understanding and

encouragement.

Alateen, which can be contacted through Al­Anon,

is a group made up of young Al­Anon members,

usually teenagers, whose lives have been affected

by someone else’s drinking.
   

   

   

   

Resources 55

American Association for Marriage and Family

Therapy (AAMFT)

112 South Alfred Street

Alexandria, VA 22314

Phone: (703) 838­9808

Fax: (703) 838­9805

Web site: http://www.aamft.org/iMIS15/AAMFT/

The American Association for Marriage and Family

Therapy represents the professional interests of

more than 23,000 marriage and family therapists

throughout the United States, Canada, and

abroad.

Co­Anon Family Groups

Co­Anon Family Groups World Services

P.O. Box 12722

Tucson, AZ 85732

Phone: (800) 898­9985

Voice recorder: (520) 513­5028 

Web site: http://www.co­anon.org/

Co­Anon Family Groups are a fellowship of men

and women who are husbands, wives, parents,

relatives, or close friends of someone who is

chemically dependent.
56 Substance Abuse Treatment and Family Therapy

Co­Dependents Anonymous, Inc. (CoDA)

P.O. Box 33577

Phoenix, AZ 85067

Web site: http://coda.org/

Co­Dependents Anonymous, Inc. is a fellowship of

men and women whose common purpose is to

develop healthy relationships. CoDA relies on the

12 Steps and 12 Traditions for knowledge and

wisdom.

Families Anonymous

P.O. Box 3475

Culver City, CA 90231

Infoline: (800) 736­9805

Fax: (310) 815­9682

Web site: http://www.familiesanonymous.org

Families Anonymous is a nonprofit organization

that provides emotional support for relatives and

friends of individuals with substance or behavioral

problems using the 12 steps.
   

     

   

Resources 57 

The International Certification and Reciprocity

Consortium/Alcohol and Other Drug Abuse

(IC&RC) 

6402 Arlington Boulevard, Suite 1200

Falls Church, VA 22042

Phone: (703) 294­5827

Fax: (703) 875­8867

Web site: http://internationalcredentialing.org/

The IC&RC is a not­for­profit voluntary membership organization composed of certifying agencies

involved in credentialing alcohol and drug abuse

counselors, clinical supervisors, and prevention

specialists. 

IC&RC member boards are currently located in 40

States, the District of Columbia, and 10 countries

outside the United States. Members also include

the U.S. Army, U.S Air Force, U.S. Navy, U.S. Marine

Corps, the Indian Health Service, and the U.S.

Administrative Office of the Courts.

There are currently five reciprocal certifications

offered through IC&RC including Alcohol and Drug

Counselor, Advanced Alcohol and Drug Counselor,

Certified Clinical Supervisor, Criminal Justice

Addictions Professional, and Certified Prevention

Specialist. 
   

   

   

58 Substance Abuse Treatment and Family Therapy

NAADAC (The Association for Addiction

Professionals)

901 N. Washington Street, Suite 600

Alexandria, VA 22314

Phone: (703) 741­7686 

or Toll­Free (800) 548­0497

Fax: (703) 741­7698 

or Toll­Free (800) 377­1136

Web site: http://www.naadac.org

Formerly the National Association of Alcohol and

Drug Abuse Counselors, NAADAC provides certification in many States that also have IC&RC reciprocity. NAADAC offers the only Master’s level credential based on education and not experience.

Nar­Anon Family Group

Nar­Anon World Service Office

22527 Crenshaw Boulevard, Suite 200B

Torrance, CA 90505 

Phone: (310) 547­5800

Web site: http://www.naranon.com

Nar­Anon Family Group is a 12­Step recovery program for the families and friends of individuals

with substance use disorders. 
   

   

Resources 59

The National Association for Children of

Alcoholics (NACoA)

11426 Rockville Pike, Suite 100

Rockville, MD 20852

Phone: (888) 55­4COAS or (301) 468­0985

Fax: (301) 468­0987

Web site: http://www.nacoa.org

NACoA is a national nonprofit membership organization working on behalf of children whose parents have substance use disorders. NACoA’s mission is to advocate for all children and families

affected by alcoholism and other drug dependencies.
   

   

   

60 Substance Abuse Treatment and Family Therapy

National Center on Substance Abuse and Child

Welfare (NCSACW)

Web site: https://www.ncsacw.samhsa.gov/

default.aspx

E­mail questions to ncsacw@samhsa.gov

The National Center on Substance Abuse and

Child Welfare is an initiative of DHHS and jointly

funded by SAMHSA, CSAT, and the Administration

on Children, Youth and Families, Children’s

Bureau’s Office on Child Abuse and Neglect. 

One of NCSACW’s primary goals is to develop

materials and resources that serve to advance

knowledge and practice in the linkages among

substance abuse, child welfare, and family court

systems. A wealth of products and services—

including curricula, tutorials, and training materials, publications, technical assistance, and presentations—can be accessed via its Web site.
Resources 61

U.S. Department of Health and Human Services

Families & Children Web Site
 

Web site: https://www.acf.hhs.gov/
 

This Web site provides information and resources
 

for and about families and children under several
 

categories, including adoption, babies, children,
 

family issues (child support, child care, domestic
 

violence, child abuse), low­income families, DHHS
 

agencies, immunizations/vaccinations, kids’ Web
 

sites, pregnancy, safety and wellness, teenagers,
 

teen Web sites, and other resources.
 

WestEd

730 Harrison Street

San Francisco, CA 94107

Phone: (415) 565­3000 

Toll­Free (877) 4­WestEd

Web site: http://www.wested.org

WestEd is a nonprofit research, development, and

service agency formed in 1966 when Congress

created a network of Regional Educational

Laboratories. WestEd is committed to improving

learning at all stages of life—from infancy to adulthood, both in school and out. 
   

     

   

     

   

   

       

62 Substance Abuse Treatment and Family Therapy

GLOSSARY

Affect: Feeling or emotion, especially as manifested by facial expression or body language. 

Boundary: An invisible though often effective barrier within a relationship that governs the level of

contact. Boundaries can appropriately shape and

regulate relationships. Two dysfunctional types of

boundaries are those that are (1) so rigid, inhibiting meaningful interaction so that the people in

the relationship are said to be “disengaged” from

each other, or (2) so loose that individuals lose a

sense of independence so that the “enmeshed”

relationship stifles individuality and initiative.

Complementarity: A pattern of human interactions in which partners in an intimate relationship

establish roles and take on behavioral patterns

that fulfill the unconscious needs and demands of

the other.

Disengagement: The state of being unreachably

aloof or distant from others.

Enmeshment: The state of being in which two

people are so close emotionally that one perceives the other as “smothering” him or her with

affection, concern, attention, etc. Enmeshment

also can occur without a conscious sense of it.
     

   

   

   

       

Glossary 63 

Family Structure: Repeated, predictable patterns

of interaction between family members that influence individual behavior to a considerable extent.

Family Therapy: An approach to therapy based on

the idea that a family is—and behaves as—a system. Interventions are based on the presumption

that when one part of the system changes, other

parts will change in response. Family therapists

therefore look for unhealthy structures and faulty

patterns of communication.

Genogram: A pictorial chart of the people involved

in a three­generational relationship system, marking marriages, divorces, births, geographical location, deaths, and illness. Significant physical,

social, and psychological dysfunction may be

added. A genogram assists the therapist in understanding the family and is used to examine a family’s relationships.

Homeostasis: A natural process in which multigenerational competing forces seek to maintain a

state of equilibrium (i.e., balance).

Integrated Models: A constellation of interventions that takes into account (1) each family member’s issues as they relate to the substance abuse

and (2) the effect of each member’s issues on the

family system.
   

     

   

64 Substance Abuse Treatment and Family Therapy

Phases of Family Change: A model of family

change that includes three elements occurring in

a series: attainment of sobriety, adjustment to

sobriety, and long­term maintenance of sobriety.

Triangulation: This occurs when two family members dealing with a problem come to a place

where they need to discuss a sensitive issue.

Instead of facing the issue, they divert their energy to a third member who acts as a go­between,

scapegoat, object of concern, or ally. By involving

this other person, they reduce their emotional tension, but prevent their conflict from being resolved

and miss opportunities to increase the intimacy in

their relationship.

For additional terms, see appendix B of TIP 39.

Other HHS products that are relevant 

to this Quick Guide: 

TIP 25: Substance Abuse Treatment and Domestic 

Violence SMA 12-4076
 

TIP 32: Treatment of Adolescents With Substance 

Use Disorders SMA 12-4080
 

TIP 35: Enhancing Motivation for Change in 

Substance Abuse Treatment SMA 13-4212
 

TIP 36: Substance Abuse Treatment for Persons With 

Child Abuse and Neglect Issues SMA 12-3923
 

TIP 41: Substance Abuse Treatment: Group Therapy 

SMA 15-3991
 

See the inside back cover for ordering 

information for all TIPs and related products. 

HHS Publication No. (SMA) 15-4032
 

Printed 2005
 

Revised 2009, 2011, and 2015