A Treatment 

Improvement

Protocol

Substance Abuse Treatment

And Family Therapy

TIP

39
         

           

       

     

   

Substance Abuse Treatment
 

And Family Therapy
 

A Treatment 

Improvement 

Protocol
 

TIP
 39
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857
Acknowledgments

This publication was produced under the

Knowledge Application Program (KAP)

Contract, number 270-99-7072 with the

Substance Abuse and Mental Health Services

Administration (SAMHSA), U.S. Department

of Health and Human Services (HHS). Karl

D. White, Ed.D., and Andrea Kopstein,

Ph.D., M.P.H., served as the Center for

Substance Abuse Treatment (CSAT)

Government Project Officers. Christina

Currier served as the CSAT TIPs Task

Leader.

Disclaimer

The opinions expressed herein are the views

of the consensus panel members and do not

necessarily reflect the official position of

SAMHSA or HHS. No official support of or

endorsement by SAMHSA or HHS for these

opinions or for the instruments or resources

described are 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 specific, written authorization

of the Office of Communications, SAMHSA,

HHS.

Electronic Access and Printed

Copies

This publication may be ordered from or

downloaded from SAMHSA’s Publications

Ordering Web page at

http://store.samhsa.gov. Or, please call

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

4727) (English and Español).

Recommended Citation

Center for Substance Abuse Treatment.

Substance Abuse Treatment and Family

Therapy. Treatment Improvement Protocol

(TIP) Series, No. 39. HHS Publication No.

(SMA) 15-4219. Rockville, MD: Substance

Abuse and Mental Health Services

Administration, 2004.

Originating Office

Quality Improvement and Workforce

Development Branch, Division of Services

Improvement, Center for Substance Abuse

Treatment, Substance Abuse and Mental

Health Services Administration, 1 Choke

Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 15-4219

Printed 2004

Revised 2005, 2006, 2008, 2009, 2010, 2012,

2014, and 2015

ii Contents
Contents
 

What Is a TIP?............................................................................................................vii 

Consensus Panel...........................................................................................................ix
 

KAP Expert Panel and Federal Government Participants ....................................................xi
 

Foreword ..................................................................................................................xiii
 

Executive Summary .....................................................................................................xv 

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

Overview......................................................................................................................1
 

Introduction .................................................................................................................1
 

What Is a Family? ..........................................................................................................2
 

What Is Family Therapy?.................................................................................................4
 

Family Therapy in Substance Abuse Treatment .....................................................................8
 

Goals of This TIP .........................................................................................................18
 

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

Overview ....................................................................................................................21
 

Introduction ................................................................................................................21
 

Families With a Member Who Abuses Substances .................................................................23
 

Other Treatment Issues ..................................................................................................28
 

Chapter 3—Approaches to Therapy................................................................................31
 

Overview ....................................................................................................................31
 

Differences in Theory and Practice ...................................................................................31
 

Family Therapy for Substance Abuse Counselors .................................................................49
 

Substance Abuse Treatment for Family Therapists................................................................64
 

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

Overview ....................................................................................................................73
 

Integrated Substance Abuse Treatment and Family Therapy ...................................................73
 

Integrated Models for Substance Abuse Treatment................................................................85
 

Matching Therapeutic Techniques to Levels of Recovery.......................................................105
 

Chapter 5—Specific Populations..................................................................................109
 

Overview...................................................................................................................109
 

Introduction ..............................................................................................................109
 

Age ..........................................................................................................................110
 

Women .....................................................................................................................114
 

Race and Ethnicity ......................................................................................................116
 

Sexual Orientation.......................................................................................................130
 

People With Physical or Cognitive Disabilities....................................................................131
 

People With Co­Occurring Substance Abuse and Mental Disorders .........................................136
 

Rural Populations.......................................................................................................138
 

Other Contextual Factors..............................................................................................141
 

iii
Chapter 6—Policy and Program Issues .........................................................................147
 

Overview...................................................................................................................147
 

Primary Policy Concerns ..............................................................................................147
 

Program Planning Models .............................................................................................149
 

Other Program Considerations.......................................................................................160
 

Directions for Future Research.......................................................................................161
 

Appendix A: Bibliography...........................................................................................165
 

Appendix B: Glossary.................................................................................................191
 

Appendix C: Guidelines for Assessing Violence................................................................195
 

Appendix D: Resources..............................................................................................199
 

Appendix E: Resource Panel .......................................................................................203
 

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

Appendix G: Field Reviewers.......................................................................................207
 

Appendix H: Acknowledgments....................................................................................209
 

Index ......................................................................................................................211
 

CSAT TIPs and Publications........................................................................................231
 

iv Contents
Figures 

3­1 Overview of Key Elements for Inclusion in Assessment......................................................39
 

3­2 Basic Symbols Used in Genograms ...............................................................................42
 

3­3 Eugene O’Neill Genogram ..........................................................................................43
 

3­4 Individual, Family, and Environmental Systems..............................................................56
 

4­1 Facets of Program Integration.....................................................................................74
 

4­2 Levels of Counselor Involvement With Families...............................................................80
 

4­3 Techniques To Help Families Attain Sobriety ................................................................103
 

4­4 Techniques To Help Families Adjust to Sobriety.............................................................104
 

4­5 Techniques To Help Families in Long­Term Maintenance .................................................106
 

Contents v

What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the

Substance Abuse and Mental Health Services Administration (SAMHSA)

within the U.S. Department of Health and Human Services (HHS). Each

TIP involves the development of topic-specific best-practice guidelines

for the prevention and treatment of substance use and mental disorders.

TIPs draw on the experience and knowledge of clinical, research, and

administrative experts of various forms of treatment and prevention.

TIPs are distributed to facilities and individuals across the country.

Published TIPs can be accessed via the Internet at

http://store.samhsa.gov.

Although each consensus-based TIP strives to include an evidence base

for the practices it recommends, SAMHSA recognizes that behavioral

health is continually evolving, and research frequently lags behind the

innovations pioneered in the field. A major goal of each TIP is to convey

"front-line" information quickly but responsibly. If research supports a

particular approach, citations are provided. When no citation is provided, the information is based on the collective clinical knowledge and

experience of the consensus panel. 

vii
viii
 
     

     

             

   

           

   

       

     

         

       

     

         

             

   

   

       

     

     

         

     

   

     

     

     

     

   

     

     

           

       

       

     

           

     

   

         

   

           

       

       

         

   

       

       

   

                       

                   

Consensus Panel
 

Note: The information given indicates each participant's affiliation during the time the panel

was convened and may no longer reflect the individual's current affiliation.

Chair

Edward Kaufman, M.D.

Editor in Chief

American Journal of Drug and Alcohol Abuse

Dana Point, California

Co­Chair

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

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 Grijalva­Gonzales

Certified Sr. Substance Abuse Case

Manager/Counselor

San Joaquin County – Office 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

Jo­Ann 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

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

Clinician

Licensed Certified Social Worker

Private Practice

Washington, DC

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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, M.Ed., Ph.D.

Associate Professor of Psychiatry

Wake Forest University School of Medicine

Department of Psychiatry and Behavioral

Medicine

Winston­Salem, North Carolina

x Consensus Panel
     

         

     

       

   

     

   

   

   

     

     

   

   

   

   

   

       

   

     

   

         

         

       

       

     

       

   

           

     

   

   

   

   

     

   

     

     

   

     

   

     

   

       

       

                       

                   

KAP Expert Panel and Federal

Government Participants

Note: The information given indicates each participant's affiliation during the time the panel

was convened and may no longer reflect the individual's current affiliation.

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 Officer

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

Eduardo Lopez, B.S.

Executive Producer

EVS Communications

Washington, DC

Holly A. Massett, Ph.D.

Academy for Educational Development

Washington, DC

Diane Miller

Chief

Scientific Communications Branch

National Institute on Alcohol Abuse

and Alcoholism

Bethesda, Maryland

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Harry B. Montoya, M.A.

President/Chief Executive Officer

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 & Quality

Rockville, Maryland

Nedra Klein Weinreich, M.S.

President

Weinreich Communications

Canoga Park, California

Clarissa Wittenberg

Director

Office of Communications and Public Liaison

National Institute of Mental Health

Kensington, Maryland

Consulting Members

of the KAP Expert Panel

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

xii KAP Expert Panel and Federal Government Participants
Foreword

The Substance Abuse and Mental Health Services Administration

(SAMHSA) is the agency within the U.S. Department of Health and

Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA’s mission is to reduce the impact of

substance abuse and mental illness on America’s communities.

The Treatment Improvement Protocol (TIP) series fulfills SAMHSA’s

mission to reduce the impact of substance abuse and mental illness on

America's communities by providing evidence-based and best practice

guidance to clinicians, program administrators, and payers. TIPs are

the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation

requirements. A panel of non-Federal clinical researchers, clinicians,

program administrators, and patient advocates debates and discusses

their particular area of expertise until they reach a consensus on best

practices. Field reviewers then review and critique this panel’s work.

The talent, dedication, and hard work that TIPs 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 scientifically sound and effective

ways, people in need of behavioral health services. We are grateful to all

who have joined with us to contribute to advances in the behavioral

health field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Daryl W. Kade

Acting Director

Center for Substance Abuse Treatment 

Substance Abuse and Mental Health Services Administration

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Executive Summary
 

Family therapy has a long and solid history within the broad mental

health field. Substance abuse treatment, on the other hand, developed in

considerable isolation. Indeed, until the 1970s, alcoholism counselors

typically outright rejected the predominant view of mental health practitioners that alcohol abuse was a symptom of some underlying disorder

rather than a primary disorder on its own account.

Nonetheless, the importance of the family was clear to substance abuse

professionals, and substance abuse programs included activities for family members. In this TIP, these types of participation by family members

in standard treatment programs are referred to as “family­involved”

treatment or techniques. This distinction separates the typically marginal involvement of families in substance abuse treatment programs from

the types of family therapy regularly found in the family therapy field.

Within the family therapy tradition, the family as a whole is the focus of

treatment. Although focusing on the family as a whole has been the

mainstay of the family therapy field, such a focus often resulted in inadequate attention to the significant primary features of addictive disease

and the need for people with substance abuse problems to receive direct

help for their addiction.

Slowly, over the past 20 years or so, sharing has increased between the

substance abuse treatment and family therapy fields. The expert practitioners from both fields who served as consensus panel members for this

TIP recognize that much greater cross­fertilization, if not integration, is

possible and warranted. This TIP represents advice on how both fields

can profit from understanding and incorporating the methods and theories of the other field.

The primary audience for this TIP is substance abuse treatment counselors; family therapists are a secondary audience. The TIP should be of

interest to anyone who wants to learn more about family therapy. The

intent of the TIP is to help counselors and family therapists acquire a

basic understanding of each others’ fields and incorporate aspects of

each others’ work into their own therapeutic repertoire.

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The consensus panel for this TIP drew on its

considerable experience in the family therapy

field. The panel was composed of representatives from all of the disciplines involved in

family therapy and substance abuse treatment,

including alcohol and drug counselors, family

therapists, mental health workers, researchers,

and social workers.

This TIP includes six chapters. Chapter 1

provides an introduction to substance abuse

treatment and family therapy. It introduces the

changing definition of “family,” explores the

evolution of the field of family therapy and the

primary models of family therapy, presents

concepts from the substance abuse treatment

field, and discusses the effectiveness and cost

benefits of family therapy.

Chapter 2 explores the impact of substance

abuse on families. The chapter includes a

description of social issues that coexist with

substance abuse in families and recommendations for ways to address these issues. Chapter

3 discusses approaches to therapy in both substance abuse treatment and family therapy.

One section, directed at substance abuse treatment counselors, provides basic information

about the models, approaches, and concepts in

family therapy. Another section for family therapists provides basic information about theory,

treatment modalities, and the role of 12­Step

programs in substance abuse treatment.

Chapter 4 presents a discussion of integrated

models for substance abuse treatment and family therapy. These models can serve as a guide

for conjoint treatment approaches. Chapter 5

provides background information about substance abuse treatment for various populations

and applications to family therapy for each

population.

Chapter 6, aimed at administrators and trainers, presents information about the importance

of improving services to families and some policy implications to consider for effectively joining family therapy and substance abuse treatment. In addition, the chapter discusses program planning models developed by the consensus panel that provide a framework for

including family therapy in substance abuse

treatment.

Throughout this TIP, the term “substance

abuse” is used to refer to both substance abuse

and substance dependence (as defined by the

Diagnostic and Statistical Manual of Mental

Disorders, 4th edition, Text Revision [DSM­IVTR] [American Psychiatric Association 2000]).

This term was chosen, in part, because substance abuse treatment professionals commonly

use the term “substance abuse” to describe any

excessive use of addictive substances. In this

TIP, the term refers to the use of alcohol as

well as other substances of abuse. Readers

should attend to the context in which the term

occurs to determine what possible range of

meanings it covers; in most cases, however, the

term will refer to all varieties of substance use

disorders described by DSM­IV­TR.

The sections that follow summarize the content

in this TIP and are grouped by chapter.

Substance Abuse

Treatment and 

Family Therapy

There is no single, immutable definition of family. Different cultures and belief systems influence definitions, and because cultures and

beliefs change over time, definitions of what is

meant by family are by no means static. While

the definition of family may change according

to different circumstances, several broad categories encompass most families, including traditional families, extended families, and elected

families. The idea of family implies an enduring

involvement on an emotional level. For practical purposes, family can be defined according

to the individual client’s closest emotional connections.

Family therapy is a collection of therapeutic

approaches that share a belief in the effectiveness of family­level assessment and intervention. Consequently, a change in any part of the

system may bring about changes in other parts

of the system. Family therapy in substance

xvi Executive Summary
             

             

             

               

         

     

               

           

             

             

           

           

       

           

         

         

           

               

             

             

             

           

           

         

       

         

       

             

         

           

     

   

             

           

                 

         

               

         

           

             

         

   

           

           

             

           

             

       

           

         

       

       

           

               

           

       

             

           

     

           

         

         

         

     

     

           

               

             

           

         

             

             

       

     

         

         

         

         

           

         

           

           

       

                   

               

           

         

     

           

           

       

abuse treatment has two main purposes: (1) to

use the family’s strengths and resources to help

find or develop ways to live without substances

of abuse, and (2) to ameliorate the impact of

chemical dependency on both the identified

patient and family.

In family therapy, the unit of treatment is the

family, and/or the individual within the context

of the family system. The person abusing substances is regarded as a subsystem within the

family, the person whose symptoms have serious implications for the family system. The

familial relationships within this subsystem are

the points of therapeutic interest and intervention. The therapist facilitates discussions and

problemsolving sessions, often with the entire

family group or subsets thereof, but sometimes

with a single participant, who may or may not

be the person with a substance use

disorder.

A number of historical models of family therapy have been developed over the past several

decades. These include models such as marriage and family therapy (MFT), strategic family therapy, structural family therapy, cognitive–behavioral family therapy, couples therapy, and solution­focused family therapy. Today

four predominant family therapy models are

used as the bases for treatment and specific

interventions for substance abuse: the family

disease model, the family systems model, the

cognitive–behavioral approach, and multidimensional family therapy.

The full integration of family therapy into standard substance abuse treatment is still relatively rare. Some of the goals of family therapy in

substance abuse treatment include helping families become aware of their own needs and providing genuine, enduring healing for family

members; working to shift power to the

parental figures in a family and to improve

communication; helping the family make interpersonal, intrapersonal, and environmental

changes affecting the person using alcohol or

drugs; and keeping substance abuse from moving from one generation to another (i.e., prevention). Other goals will vary, depending on

which member of the family is abusing substances.

Multiple therapeutic factors probably account

for the effectiveness of family therapy, including acceptance from the therapist, improved

communication, organizing the family structure, determining accountability, and enhancing impetus for change. Another reason family

therapy is effective is that it provides a neutral

forum where family members meet to solve

problems. Additionally, family therapy is applicable across many cultures and religions and is

compatible with their bases of connection and

identification, belonging and

acceptance.

Based on effectiveness data for family therapy

and the consensus panel’s collective experience,

the panel recommends that substance abuse

treatment agencies and providers consider how

to incorporate family approaches, including

age­appropriate educational support services

for children, into their programs. In addition,

while only a few studies have assessed the cost

benefits or compared the cost of family therapy

to other approaches (such as group therapy,

individual therapy, and 12­Step programs), a

small but growing body of data has demonstrated the cost benefits of family therapy specifically for substance abuse problems.

Additional considerations exist for integrating

family therapy into substance abuse treatment.

Family therapy for substance abuse treatment

demands the management of complicated treatment situations. Specialized strategies may be

necessary to engage the identified patient in

treatment. In addition, the substance abuse

almost always is associated with other difficult

life problems, which can include mental health

issues, cognitive impairment, and socioeconomic constraints, such as lack of a job or home. It

can be difficult, too, to work across diverse cultural contexts or to discern individual family

members’ readiness for change and treatment.

These circumstances make meaningful family

therapy for substance abuse problems a complex, challenging task for both family therapists

and substance abuse treatment providers.

Executive Summary xvii
         

             

             

           

     

           

           

           

         

           

           

             

             

           

           

               

                 

         

         

     

             

           

             

         

             

           

           

         

           

           

             

             

           

             

             

           

               

             

   

             

         

             

           

         

         

         

         

         

                   

     

             

           

       

             

           

           

         

             

             

           

         

           

         

             

           

           

           

           

         

             

       

     

         

           

             

             

           

           

         

           

           

             

         

         

             

           

             

Modifications in the treatment approach may

be necessary, and the success of treatment will

depend to a large degree on the creativity,

judgment, and cooperation in and between programs in each field.

Safety and appropriateness of family therapy is

another important issue. Only in rare situations is family therapy inadvisable, but there

are several considerations of which counselors

must be aware. Family or couples therapy

should not take place unless all participants

have a voice and everyone can raise pertinent

issues, even if a dominant family member does

not want them discussed. Engaging in family

therapy without first assessing carefully for violence may lead not only to poor treatment, but

also to a risk for increased abuse. It is the

treatment provider’s responsibility to provide a

safe, supportive environment for all participants in family therapy.

Child abuse or neglect is another serious consideration. Any time a counselor suspects past

or present child abuse or neglect, laws require

immediate reporting to local authorities. Along

the same lines, domestic violence is a serious

issue among people with substance use disorders that must be factored into therapeutic

considerations. Only the most extreme anger

contraindicates family therapy. It is up to

counselors and therapists to assess the potential

for anger and violence and to construct therapy so it can be conducted without endangering

any family members. If, during the screening

interview, it becomes clear that a batterer is

endangering a client or a child, the treatment

provider should respond to this situation first,

and if necessary, suspend the rest of the screening interview until the safety of all concerned

can be ensured.

Impact of Substance

Abuse on Families

People who abuse substances are likely to find

themselves increasingly isolated from their families. A growing body of literature suggests that

substance abuse has distinct effects on different

family structures. The effects of substance

abuse frequently extend beyond the nuclear

family. Extended family members may experience feelings of abandonment, anxiety, fear,

anger, concern, embarrassment, or guilt, or

they may wish to ignore or cut ties with the

person abusing substances.

Various treatment issues are likely to arise in

different family structures that include a

person who is abusing substances:

•Client who lives alone or with a partner. In

this situation, both partners need help. The

treatment of either partner will affect both.

When one person is chemically dependent

and the other is not, issues of codependence

arise.

•Client who lives with a spouse (or partner)

and minor children. Most available data on

the enduring effects of parental substance

abuse on children suggest that a parent’s

drinking problem often has a detrimental

effect on children. The spouse of a person

abusing substances is likely to protect the

children and assume the parenting duties not

fulfilled by the parent abusing substances. If

both parents abuse alcohol or illicit drugs,

the effect on children worsens.

•Client who is part of a blended family.

Stepfamilies present special challenges under

normal circumstances; substance abuse can

intensify problems and become an impediment to a stepfamily’s integration and stability. Clinicians should be aware of the dynamics of blended families and that they require

additional considerations.

•An older client who has grown children. An

older adult with a substance abuse problem

can affect everyone in a household.

Additional family resources may need to be

mobilized to treat the older adult’s substance

use disorder. As with child abuse and neglect,

elder maltreatment can be subject to statutory reporting requirements to local authorities.

•Client is an adolescent and lives with family

of origin. When an adolescent uses alcohol or

drugs, siblings in the family may find their

xviii Executive Summary
           

           

         

             

           

         

             

           

     

             

         

           

             

         

           

           

           

         

   

             

         

             

         

       

               

     

         

           

       

       

       

           

         

       

         

         

         

         

             

             

           

         

             

   

       

           

             

         

             

         

                   

             

         

           

       

         

             

         

           

               

             

           

           

         

         

           

         

         

         

           

             

       

           

         

           

           

           

       

       

         

         

             

         

needs and concerns are ignored or minimized

while their parents react to continuous crises

involving the adolescent who abuses alcohol

or drugs. In many families that include adolescents who abuse substances, at least one

parent also abuses substances. This unfortunate modeling can set in motion a combination of physical and emotional problems that

can be very dangerous.

•Someone not identified as the client is abusing substances. When someone in the family

other than the person with presenting symptoms is involved with alcohol or illicit drugs,

issues of blame, responsibility, and causation

will arise. With the practitioner’s help, the

family should refrain from blaming, but still

be encouraged to reveal and repair family

interactions that create the conditions for

continued substance abuse.

In any form of family therapy for substance

abuse treatment, consideration should be given

to the range of social problems connected to

substance abuse. Problems such as criminal

activity, joblessness, domestic violence, and

child abuse or neglect also may be present in

families experiencing substance abuse. To

address these issues, treatment providers need

to collaborate with professionals in other fields

(i.e., concurrent treatment). Whenever concurrent treatment takes place, communication

among clinicians is vital.

Approaches 

To Therapy

The fields of substance abuse treatment and

family therapy share many common assumptions, approaches, and techniques, but differ

in significant philosophical and practical ways

that affect treatment approaches and goals.

Further, within each discipline, theory and

practice differ. Although substance abuse treatment is generally more uniform in its approach

than is family therapy, in both cases certain

generalizations apply to the practice of the

majority of providers. Two concepts essential

to both fields are denial and resistance presented by clients.

Many substance abuse treatment counselors

base their understanding of a family’s relation

to substance abuse on a disease model of substance abuse. 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. They

should understand that substance abuse creates negative changes in the individual’s 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. It is this

focus on the family system, more than the

inclusion of more people, that defines family

therapy.

Despite these basic differences, the fields of

family therapy and substance abuse treatment

are compatible. Clinicians in both fields

address the client’s interactions with a system

that involves something outside the self.

Multiple systems affect people with substance

use disorders at different levels (individual,

family, culture, and society), and truly comprehensive treatment would take all of them into

consideration. However, some differences exist

among many, but not all, substance abuse

treatment and family therapy settings and

practitioners:

•Family interventions. Psychoeducation and

multifamily groups are more common in the

substance abuse treatment field than in family therapy. Family therapists will focus more

on intrafamily relationships, while substance

abuse treatment providers concentrate on

helping clients achieve and maintain abstinence.

•Process and content. Family therapy generally attends more to the process of family interaction, while substance abuse treatment is

Executive Summary xix
         

   

         

         

         

           

             

         

           

         

           

         

             

               

               

         

           

       

       

         

         

         

           

             

       

               

       

         

         

       

       

       

         

         

       

       

           

         

         

               

         

           

         

           

         

           

       

         

             

         

         

           

     

         

           

           

         

           

           

         

           

           

           

           

           

             

               

             

           

             

   

         

           

             

           

             

             

           

     

             

           

           

         

           

             

             

usually more concerned with the planned
 

content of each session.
 

•Focus. Substance abuse clinicians and family

therapists typically focus on different targets.

Substance abuse treatment counselors see the

primary goal as arresting a client’s substance

use; family therapists see the family system as

an integral component of the substance

abuse.

•Identity of the client. Often, the substance

abuse counselor regards the individual with

the substance use disorder as the primary

person requiring treatment. A family therapist might assume 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. Training in

the boundaries related to the therapist’s or

counselor’s self­disclosure is an integral part

of any treatment provider’s education.

Addiction counselors who are in recovery

themselves are trained to recognize the

importance of choosing to self­disclose their

own addiction histories and to use supervision

appropriately to decide when and what to

disclose. For the family therapist, selfdisclosure is not as integral a part of the

therapeutic process. It is downplayed

because it takes the focus of therapy off of

the family.

•Regulations. Different regulations also affect

the substance abuse treatment and family

therapy fields. This influence comes from

both government agencies and third­party

payors that affect confidentiality, and training

and licensing requirements. Federal regulations attempt to guarantee confidentiality for

people who seek substance abuse assessment

and treatment. Confidentiality issues for

family therapists are less straightforward.

•Licensure and certification. Forty­two States

require licenses for people practicing as family therapists. Although the specific educational requirements vary from State to State,

most require at least a master’s degree for the

person who intends to practice independently

as a family therapist. Certification for substance abuse counselors is more

varied.

Specific procedures for assessing clients in substance abuse treatment and family therapy

vary from program to program and practitioner to practitioner. Assessments for substance

abuse treatment programs focus on substance

use and history. Some of the key elements

examined when assessing a client’s substance

abuse history include important related concerns such as family relations, sexual history,

and mental health.

In contrast, family therapy assessments focus

on family dynamics and client strengths. The

primary assessment task is to observe family

interactions, which can reveal patterns, along

with the family system’s strengths and dysfunction. The sources of dysfunction cannot be

determined simply by asking individual family

members to identify problems within the family. Although most family therapists screen for

mental or physical illness, and for physical,

sexual, or emotional abuse, issues of substance

abuse might not be discovered because the

therapist is not familiar with questions to ask

or cues that are provided by clients. One technique used by family therapists to help them

understand family relations is the genogram, a

pictorial chart of the people involved in a

three­generational relationship system.

Family therapists and substance abuse counselors should respond knowledgeably to a variety of barriers that block the engagement and

treatment of clients. While the specific barriers

will vary for clients in different treatment settings, basic issues arise in both substance abuse

treatment and family therapy. Issues of family

motivation/influence, balance of hierarchal

power, general willingness for the family and its

members to change, and cultural barriers are

essential topics to review for appropriate interventions.

Substance abuse counselors should not practice

family therapy unless they have proper training and licensing, but they should be sufficiently informed about family therapy to discuss it

xx Executive Summary
               

             

           

         

           

             

           

         

         

         

         

     

     

       

   

           

           

         

         

             

               

       

               

         

       

         

             

               

     

           

           

         

         

           

               

           

           

           

       

         

       

         

           

           

         

           

           

           

             

         

           

         

         

         

         

           

               

       

               

         

           

           

             

             

             

             

             

             

           

           

                 

             

         

       

       

           

         

         

           

           

             

           

           

         

           

         

   

         

           

         

with their clients and know when a referral is

indicated.

The family therapy field is diverse, but certain

models have been more influential than others,

and models that share certain characteristics

can be grouped together. Several family therapy models have been adapted for working with

clients with substance use disorders. None was

specifically developed, however, for this integration. These models include behavioral contracting, Bepko and Krestan’s theory, behavioral marital therapy, brief strategic family

therapy, multifamily groups, multisystemic

therapy, network therapy, solution­focused

therapy, Stanton’s approach, and WegscheiderCruse’s techniques.

A number of theoretical concepts that underlie

family therapy can help substance abuse treatment providers better understand clients’ relationships with their families. Perhaps foremost

among these is the acceptance of systems theory

that views the client as a system of parts

embedded within multiple systems—a community, a culture, a nation. The elements of the

family as a system include complementarity,

boundaries, subsystems, enduring family ties,

and change and balance. Other concepts

include a family’s capacity for change, a family’s ability to adjust to abstinence, and the concept of triangles.

Family therapists have developed a range of

techniques that can be useful to substance

abuse treatment providers working with individual clients and families. The consensus

panel selected specific techniques on the basis

of their utility and ease of use in substance

abuse treatment settings, and not because they

are from a particular theoretical model. This

list of techniques should not be considered

comprehensive. Those techniques selected by

the panel include behavioral techniques, structural techniques, strategic techniques, and

solution­focused techniques.

Family therapists would benefit from learning

about the treatment approaches used in the

substance abuse treatment field. Two of the

most common approaches are the medical

model of addiction, which emphasizes the biological, genetic, or physiological causes of substance abuse and dependence; and the sociocultural theories, which focus on how stressors in

the client’s social and cultural environment

influence substance use and abuse. In addition,

many substance abuse treatment providers add

a spiritual component to the biopsychosocial

approach. The consensus panel believes that

effective treatment will integrate these models

according to the treatment setting, but will

always take into account all of the factors that

contribute to substance use disorders.

Integrated Models for

Treating Family

Members

In families in which one or more members has

a substance abuse problem, substance abuse

treatment and family therapy can be integrated

to provide effective solutions to multiple problems. The term integration, for the purposes of

this TIP, refers to 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. This TIP also

assumes that, while a substance abuse problem

manifests itself in an individual, the solution

for the family as a whole will be found within

the family system. Four discrete facets of integration along this continuum include staff

awareness and education, family education,

family collaboration, and family therapy integration.

Clients benefit in several ways from integrated

family therapy and substance abuse treatment.

These benefits include positive treatment outcomes, increased likelihood of the client’s ongoing recovery, increased help for the family’s

recovery, and the reduction of the impact of

substance abuse on different generations in the

family. The benefits for the treatment professionals include reduced resistance from clients,

more flexibility in treatment planning and in

treatment approach, increased skill set, and

improved treatment outcomes.

There are some limitations and challenges,

however, to integrated models of family therapy and substance abuse treatment. These

Executive Summary xxi
               

         

         

           

       

           

         

       

     

           

       

             

             

           

           

             

                 

       

               

             

           

         

           

         

               

         

     

             

     

           

   

         

           

         

           

           

               

           

             

           

           

     

                 

           

               

             

             

             

             

           

           

           

       

     

   

   

   

     

   

         

             

           

             

           

           

           

         

         

         

         

         

   

             

             

       

             

include the risk of lack of structure and compatibility by integrating interventions from

different models, additional training for staff,

achieving a major shift in mindset, agencywide

commitment and coordination, and reimbursement by third­party payors. In sum, agencies

and practitioners must balance the value of

integrated treatment with its limitations.

Substance abuse treatment professionals intervene with families at different levels during

treatment, based on how individualized the

interventions are to each family 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.

In some cases, the family may be ready only for

intermittent involvement with a counselor. In

other cases, as the family reaches the goals set

at one level of involvement, further goals may

be set that require more intensive counselor

involvement. Thus, the family’s acceptance of

problems and its readiness to change determine

the appropriate level of counselor involvement

with that family. There are four levels of counselor involvement with the families of clients

who are abusing substances:

•Level 1: Counselor has little or no involvement with the family.

•Level 2: Counselor provides the family with

psychoeducation and advice.

•Level 3: Counselor addresses family members’ feelings and provides them with support.

•Level 4: Counselor provides family therapy

(when trained at this level of expertise).

To determine a counselor’s level of involvement

with a specific family, two factors must be considered: (1) the counselor’s level of experience

and comfort, and (2) the family’s needs and

readiness to change. Both family and counselor

factors must be considered when deciding a

level of family involvement.

Care must be taken in the choice of an integrated therapeutic model. The model must accommodate the needs of the family, the style and

preferences of the therapist, and the realities of

the treatment context. The model also must be

congruent with the culture of the people it

intends to serve. A great number of integrated

treatment models have been discussed in the

literature. Many are slight variations of others.

Those discussed are among the more frequently

used integrated treatment models:

•Structural/strategic family therapy

•Multidimensional family therapy

•Multiple family therapy

•Multisystemic therapy

•Behavioral and cognitive–behavioral family

therapy

•Network therapy

•Bowen family systems therapy

•Solution­focused brief therapy

Another important consideration in an integrated model is the need to match therapeutic

change to level of recovery. The consensus

panel decided to view levels of recovery by

combining Bepko and Krestan’s stages of treatment for families with Heath and Stanton’s

stages of family therapy for substance abuse

treatment. Together, those levels of recovery

are

•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.

•Long­term maintenance of sobriety. The family must rebalance and stabilize a new and

healthier lifestyle.

Once change is in motion, the individual and

family recovery processes generally parallel

each other, although they may not be perfectly

in synchrony.

xxii Executive Summary
         

               

         

           

               

                   

             

         

               

             

             

     

           

           

           

       

             

         

         

           

           

             

               

               

             

             

     

       

               

               

               

               

           

             

               

       

         

             

                 

           

             

             

             

               

             

           

           

           

         

           

       

         

           

             

         

         

           

           

         

           

           

             

         

             

           

       

         

             

         

           

           

         

               

         

         

             

         

             

       

   

       

         

           

Specific Populations

In this TIP, the term specific populations is

used to refer to the features of families based

on specific, common groupings that influence

the process of therapy. The most important

guideline for the therapist is to be flexible and

to meet the family “where it is.” It is also vital

for counselors to be continuously aware of and

sensitive to the differences between themselves

and the members of the group they are counseling. Sensitivity to the specific cultural norms of

the family in treatment must be respected from

the start of therapy.

Family therapy for women with substance use

disorders is appropriate, except in cases of

ongoing partner abuse. Safety always should be

the primary consideration. Substance abuse

treatment is more effective for women when it

addresses women’s specific needs and understands their daily realities. Particular treatment issues relevant to women include shame,

stigma, trauma, and control over her life.

Women who have lost custody of their children

may need help to regain it once stable recovery

has been achieved. In fact, working to get their

children back may be a strong treatment motivator for women. Finally, childcare is one of

the most important accommodations necessary

for women in treatment.

A sufficient body of research has not yet been

amassed to suggest the efficacy of any one type

of family therapy over another for use with gay

and lesbian people. Family can be a very sensitive issue for gay and lesbian clients.

Therapists must be careful to use the client’s

definition of family rather than to rely on a

heterosexual­based model. Likewise, the therapist should also accept whatever identification

an individual chooses for him­ or herself and

be sensitive to the need to be inclusive and nonjudgmental in word choice. Many lesbian and

gay clients may be reluctant to include other

members of their family of origin in therapy

because of fear of rejection and further distancing.

Although a great deal of research has been conducted related to both family therapy and culture and ethnicity, little research has concentrated on how culture and ethnicity influence

core family and clinical processes. One important requirement is to move beyond ethnic

labels and consider a host of factors—values,

beliefs, and behaviors—associated with ethnic

identity. Among major life experiences that

must be factored into treating families touched

by substance abuse is the complex challenge of

determining how acculturation and ethnic identity influence the treatment process. Other

influential elements include the effects of immigration on family life and the circumstances

that motivated emigration and the sociopolitical

status of the ethnically distinct family.

The TIP also explores specific concerns related

to age, people with disabilities, people with cooccurring substance abuse and mental disorders, people in rural areas, people who are

HIV positive, people who are homeless, and

veterans.

Policy and Program

Issues

Incorporating family therapy into substance

abuse treatment presents an opportunity to

improve the status quo; it also challenges these

two divergent modalities to recognize, delineate, and possibly reconcile their differing outlooks. Another major policy implication is that

family therapy requires special training and

skills that are not common among staff in many

substance abuse treatment programs. A substance abuse treatment program committed to

family therapy will need to consider the costs

associated with providing extensive training to

line and supervisory staff to ensure that everyone understands, supports, and reinforces the

family therapist’s work.

Given the complexity of incorporating full­scale

family therapy consistently in substance abuse

treatment and the finite resources with which

Executive Summary xxiii
         

           

   

         

         

         

         

             

           

             

           

         

             

           

         

     

       

           

         

       

         

           

               

           

         

             

         

         

           

         

       

         

     

         

   

many substance abuse treatment programs are

working, family involvement may be a more

attractive alternative.

The documented cost savings and public health

benefits associated with family therapy support

the idea of reimbursement. However, the

American health care insurance system focuses

care on the individual. Little, if any, reimbursement is available for the treatment of

family members, even less so if “family” is

broadly defined to include a client’s nonfamilial

support network.

Including family therapy issues in substance

abuse treatment settings at any level of intensity requires a systematic and continuous effort.

The consensus panel developed four program

planning models—staff education, family education and participation, provider collaboration, and family integration. These models provide a framework for program administrators

and staff/counselors. These models cover (1)

the issues surrounding staff education about

families and family therapy, (2) family education about the roles of families in treatment and

recovery from substance abuse, (3) how substance abuse treatment providers can collaborate with family therapists, and (4) methods for

integrating family therapy activities into substance abuse treatment programs. The framework identifies key issues: guidelines for implementation, ethical and legal issues, outcomes

evaluation, counseling adaptations, and training and supervision. Other program considerations include cultural competence, outcome

evaluation procedures and reports, and longterm followup.

xxiv Executive Summary
     

   

   

     

                 

                         

                   

                 

                   

                     

                 

     

               

               

                   

                   

                 

         

               

             

                   

                     

                           

               

                   

                       

                     

                   

                     

               

In This
 

Chapter...
 

Introduction
 

What Is a Family?
 

What Is Family
 

Therapy?
 

Family Therapy in
 

Substance Abuse
 

Treatment
 

Goals of This TIP
 

1 Substance Abuse

Treatment and Family

Therapy

Overview

This chapter introduces the changing definition of “family,” the concept

of family in the United States, and the family as an ecosystem within the

larger context of society. The chapter discusses the evolution of family

therapy as a component of substance abuse treatment, outlines primary

models of family therapy, and explores this approach from a systems

perspective. The chapter also presents the stages of change and levels of

recovery from substance abuse. Effectiveness and cost benefits of family

therapy are briefly discussed.

Introduction

The family has a central role to play in the treatment of any health

problem, including substance abuse. Family work has become a strong

and continuing theme of many treatment approaches (Kaufmann and

Kaufman 1992a; McCrady and Epstein 1996), but family therapy is not

used to its greatest capacity in substance abuse treatment. A primary

challenge remains the broadening of the substance abuse treatment focus

from the individual to the family.

The two disciplines, family therapy and substance abuse treatment,

bring different perspectives to treatment implementation. In substance

abuse treatment, for instance, the client is the identified patient (IP)—

the person in the family with the presenting substance abuse problem.

In family therapy, the goal of treatment is to meet the needs of all family

members. Family therapy addresses the interdependent nature of family

relationships and how these relationships serve the IP and other family

members for good or ill. The focus of family therapy treatment is to

intervene in these complex relational patterns and to alter them in ways

that bring about productive change for the entire family. Family therapy

rests on the systems perspective. As such, changes in one part of the

system can and do produce changes in other parts of the system, and

these changes can contribute to either problems or solutions.

1
             

               

           

         

       

             

           

           

         

         

         

               

           

               

         

           

             

           

           

       

       

         

           

           

             

           

             

                 

               

             

         

           

           

         

             

       

   

             

         

             

           

         

           

           

         

         

             

       

         

           

               

             

     

           

           

   

   

         

       

                 

             

       

         

     

           

   

           

           

             

           

             

           

           

It is important to understand the complex role

that families can play in substance abuse

treatment. They can be a source of help to the

treatment process, but they also must manage

the consequences of the IP’s addictive behavior.

Individual family members are concerned

about the IP’s substance abuse, but they also

have their own goals and issues. Providing

services to the whole family can improve

treatment effectiveness.

Meeting the challenge of working together will

call for mutual understanding, flexibility, and

adjustments among the substance abuse treatment provider, family therapist, and family.

This shift will require a stronger focus on the

systemic interactions of families. Many divergent

practices must be reconciled if family therapy

is to be used in substance abuse treatment. For

example, the substance abuse counselor typically facilitates treatment goals with the client;

thus the goals are individualized, focused mainly

on the client. This reduces the opportunity to

include the family’s perspective in goal setting,

which could facilitate the healing process for

the family as a whole.

Working out ways for the two disciplines to

collaborate also will require a re­examination

of assumptions common in the two fields.

Substance abuse counselors often focus on the

individual needs of people with substance use

disorders, urging them to take care of themselves. This viewpoint neglects to highlight the

impact these changes will have on other people

in the family system. When the IP is urged to

take care of himself, he often is not prepared

for the reactions of other family members to

the changes he experiences, and often is

unprepared to cope with these reactions. On

the other hand, many family therapists have

hoped that bringing about positive changes in

the family system concurrently might improve

the substance use disorder. This view tends to

minimize the persistent, sometimes overpowering

process of addiction.

Both of these views are consistent with their

respective fields, and each has explanatory

power, but neither is complete. Addiction is a

major force in people with substance abuse

problems. Yet, people with substance abuse

problems also reside within a powerful context

that includes the family system. Therefore, in

an integrated substance abuse treatment model

based on family therapy, both family functioning

and individual functioning play important roles

in the change process (Liddle and Hogue 2001).

What Is a Family?

There is no single, immutable definition of

family. Different cultures and belief systems

influence definitions, and because cultures and

beliefs change over time, definitions of family

by no means are static. While the definition

of family may change according to different

circumstances, several broad categories

encompass most families:

•Traditional families, including heterosexual

couples (two parents and minor children all

living under the same roof), single parents,

and families including blood relatives,

adoptive families, foster relationships,

grandparents raising grandchildren, and

stepfamilies.

•Extended families, which include grandparents, uncles, aunts, cousins, and other

relatives.

•Elected families, which are self­identified and

are joined by choice and not by the usual ties

of blood, marriage, and law. For many people,

the elected family is more important than the

biological family. Examples would include

■	 Emancipated youth who choose to live
 

among peers
 

■	 Godparents and other non­biologically

related people who have an emotional tie

(i.e., fictive kin)

■	 Gay and lesbian couples or groups (and

minor children all living under the same

roof)

The idea of family implies an enduring involvement on an emotional level. Family members

may disperse around the world, but still be

connected emotionally and able to contribute to

the dynamics of family functioning. In family

2 Substance Abuse Treatment and Family Therapy
     

             

               

     

       

           

               

               

         

             

             

         

           

           

               

         

         

           

         

         

             

         

         

         

               

             

                 

             

           

       

             

           

           

             

         

           

         

           

           

           

             

           

   

   

   

     

     

     

   

   

   

   

     

   

   

   

             

           

           

           

           

           

           

     

           

           

           

   

       

       

             

therapy, geographically distant family members

can play an important role in substance abuse

treatment and need to be brought into the therapeutic process despite geographical distance.

Families must be distinguished from social

support groups such as 12­Step programs—

although for some clients these distinctions may

be fuzzy. One distinction is the level of commitment that people have for each other and the

duration of that commitment. Another distinction is the source of connection. Families are

connected by alliance, but also by blood (usually)

and powerful emotional ties (almost always).

Support groups, by contrast, are held together

by a common goal; for example, 12­Step 

programs are purpose­driven and contextdependent. The same is true of church communities, which may function in some ways like a

family; but similar to self­help programs,

churches have a specific purpose.

For practical purposes, family can be defined

according to the individual's closest emotional

connections. In family therapy, clients identify

who they think should be included in therapy.

The counselor or therapist cannot determine

which individuals make up another person’s

family. When commencing therapy, the counselor or therapist needs to ask the client, “Who

is important to you? What do you consider

your family to be?” It is critical to identify

people who are important in the person’s life.

Anyone who is instrumental in providing

support, maintaining the household, providing

financial resources, and with whom there is a

strong and enduring emotional bond may be

considered family for the purposes of therapy

(see, for example, Pequegnat et al. 2001). No

one should be automatically included or

excluded.

In some situations, establishing an individual in

treatment may require a metaphoric definition

of family, such as the family of one’s workplace.

As treatment progresses, the idea of family

sometimes may be reconfigured, and the notion

may change again during continuing care. In

other cases, clients will not allow contact with the

family, may want the counselor or therapist to

see only particular

family members, or Anyone who is

instrumental in

providing support,

maintaining the

household, providing financial

resources, and

with whom there is
 

a strong and

enduring emotional

bond may be

considered family

for the purposes of

therapy.

may exclude some

family members.

Brooks and Rice

(1997, p. 57) adopt

Sargent’s (1983) definition of family as a

“group of people with

common ties of affection and responsibility

who live in proximity

to one another.” They

expand that definition,

though, by pointing
 

out four characteristics of families central

to family therapy:
 

•Families possess

nonsummativity,

which means that
 

the family as a
 

whole is greater
 

than—and different
 

from—the sum of its

individual members.

•The behavior of

individual members

is interrelated

through the process

of circular causality, which holds that if one family member

changes his or her behavior, the

others will also change as a consequence,

which in turn causes subsequent changes in

the member who changed initially. This also

demonstrates that it is impossible to know

what comes first: substance abuse or behaviors

that are called “enabling.”

•Each family has a pattern of communication

traits, which can be verbal or nonverbal,

overt or subtle means of expressing emotion,

conflict, affection, etc.

•Families strive to achieve homeostasis, which

portrays family systems as self­regulating

with a primary need to maintain balance.

Substance Abuse Treatment and Family Therapy 3
     

               

         

                 

         

             

             

       

       

           

   

         

             

           

               

         

         

         

               

               

             

           

             

       

         

     

             

     

           

           

       

         

             

           

         

               

           

         

           

         

             

     

         

           

           

         

             

           

               

     

           

           

           

       

               

         

           

               

           

             

         

             

       

           

           

           

         

         

         

           

   

             

         

           

             

         

         

       

   

           

           

               

       

     

           

           

             

               

             

The Concept of Family

In the United States the concept of family has

changed during the past two generations.

During the latter half of the 20th century in the

United States, the proportion of married couples

with children shrank—such families made up

only 24 percent of all households in 2000

(Fields and Casper 2001). The idea of family

has come to signify many familial arrangements,

including blended families, divorced single

mothers or fathers with children, never­married

women with children, cohabiting heterosexual

partners, and gay or lesbian families (Bianchi

and Casper 2000).

Some analysts are concerned about indications

of increasing stress on families, such as the

increasing number of births to single mothers

(from 26.6 percent in 1990 to 33 percent in

1999 [U.S. Census Bureau 2001c]). The

increase in single­mother families, which typically

have greater per­person expenses and less

earning power, may help to explain why, in the

general prosperity of the last half of the 20th

century, the percentage of children living in the

poorest families almost doubled, rising from 15

to 28 percent (Bianchi and Casper 2000).

Bengtson (2001) asserts that relationships

involving three or more generations increasingly

are becoming important to individuals and

families, that these relationships increasingly

are diverse in structure and functions, and that

for many Americans, multigenerational bonds

are important ties for well­being and support

over the course of their lives.

The Family as an Ecosystem

Substance abuse impairs physical and mental

health, and it strains and taxes the agencies

that promote physical and mental health. In

families with substance abuse, family members

often are connected not just to each other but

also to any of a number of government agencies,

such as social services, criminal justice, or

child protective services. The economic toll

includes a huge drain on individuals’ employability and other elements of productivity. The

social and economic costs are felt in many

workplaces and homes.

The ecological perspective on substance abuse

views people as nested in various systems.

Individuals are nested in families; families are

nested in communities. Kaufman (1999) identifies

members of the ecosystem of an individual with

a substance abuse problem as family, peers

(those in recovery as well as those still using),

treatment providers, non­family support

sources, the workplace, and the legal system.

The idea of an ecological framework within

which substance abuse occurs is consistent with

family therapy’s focus on understanding

human behavior in terms of other systems in

a person’s life. Family therapy approaches

human behavior in terms of interactions within

and among the subsets of a system. In this

view, family members inevitably adapt to the

behavior of the person with a substance use

disorder. They develop patterns of accommodation and ways of coping with the substance

use (e.g., keeping children extraordinarily

quiet or not bringing friends home). Family

members try to restore homeostasis and

maintain family balance. This may be most

apparent once abstinence is achieved. For

example, when the person abusing substances

becomes abstinent, someone else may develop

complaints and/or “symptoms.” (See box, p. 5,

for an illustration.)

Family members may have a stronger desire to

move toward overall improved functioning in

the family system, thus compelling and even

providing leverage for the IP to seek and/or

remain in treatment through periods of

ambivalence about achieving a sober lifestyle.

Alternately, clarifying boundaries between

dysfunctional family members—including

encouraging IPs to detach from family members

who are actively using—can alleviate stress on

the IP and create emotional space to focus on

the tasks of recovery.

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

4 Substance Abuse Treatment and Family Therapy
               

               

             

       

         

               

           

             

             

                       

                           

                   

                     

                     

                       

                   

                             

                 

                     

                       

                       

             

                     

                     

             

                 

                       

                   

                   

                       

                     

                       

                       

                               

                     

                       

     

                   

                     

     

Homeostasis

A young couple married when they were both 20 years old. One spouse developed

alcoholism during the first 5 years of the marriage. The couple’s life increasingly

became chaotic and painful for another 5 years, when finally, at age 30, the

substance­abusing spouse entered treatment and, over the course of 18 months,

attained a solid degree of sobriety. Suddenly, lack of communication and

difficulties with intimacy came to the fore for the non­substance­abusing spouse,

who now often feels sad and hopeless about the marital relationship. The nonsubstance­abusing spouse finds, after 18 months of the partner’s sobriety, that

the sober spouse is “no longer fun” or still does not want to make plans for

another child.

Almost all young couples encounter communication and intimacy issues during

the first decade of the relationship. In an alcoholic marriage or relationship,

such issues are regularly pushed into the background as guilt, blame, and

control issues are exacerbated by the nature of addictive disease and its effects

on both the relationship and the family.

The possible complexities of the above situation illustrate both the relevance of

family therapy to substance abuse treatment and why family therapy requires a

complex, systems perspective. Many system­related answers are possible:

Perhaps the non­substance­abusing spouse is feeling lonely, unimportant, or an

outsider. With the focus of recovery on the addiction—and the IP’s struggles in

recovery—the spouse who previously might have been central to the other’s

drinking and/or maintaining abstinence, even considered the cause of the drinking,

is now, 18 months later, tangential to what had been major, highly emotional

upheavals and interactions. The now “outsider spouse” may not even be aware

of feeling lonely and unimportant but instead “acts out” these feelings in terms

of finding the now sober spouse “no fun.” Alternatively, perhaps the now sober

spouse is indeed no fun, and the problems lie in how hard it is for the sober

spouse to relax or feel comfortable with sobriety—in which case the resolution

might involve both partners learning to develop a new lifestyle that does not

involve substance use.

The joint use of both recovery and family therapy techniques will improve marital

communication and both partners’ capacity for intimacy. These elements of

personal growth are important to the development of serenity in recovery and

stability in the relationship.

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.

Family therapy in substance abuse treatment

has two main purposes. First, it seeks to use

the family’s strengths and resources to help

find or develop ways to live without substances

of abuse. Second, it ameliorates the impact of

Substance Abuse Treatment and Family Therapy 5
             

         

           

         

               

           

             

             

         

       

           

       

       

             

           

           

       

         

         

         

           

               

         

           

   

       

   

   

   

   

   

   

     

       

         

         

       

   

         

       

   

               

           

           

         

           

           

         

   

     

           

               

       

   

                 

         

           

       

     

       

             

         

             

       

           

             

         

           

           

chemical dependency on both the IP and the

family. Frequently, in the process, marshaling

the family’s strengths requires the provision of

basic support for the family.

In family therapy, the unit of treatment is the

family, and/or the individual within the context

of the family system. The person abusing substances is regarded as a subsystem within the

family unit—the person whose symptoms have

severe repercussions throughout the family

system. The familial relationships within this

subsystem are the points of therapeutic interest

and intervention. The therapist facilitates

discussions and problemsolving sessions, often

with the entire family group or subsets thereof,

but sometimes with a single participant, who

may or may not be the person with the 

substance use disorder.

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. It

typically is limited to

psychoeducation to

Family therapy is

a collection of

therapeutic

approaches that

share a belief in

family­level

assessment and

intervention.

teach the family

about substance

abuse, related

behaviors, and the

behavioral, medical,

and psychological

consequences of use.

Children also need

age­appropriate

psychoeducation

programs prior to

being grouped with

other family 

members in either

education or therapy.

(For more information see chapter 6,

under “Family Education and Participation,”

and see also Children’s Program Kit:

Supportive Education for Children of Addicted

Parents [Substance Abuse and Mental Health

Services Administration (SAMHSA) 2003],

developed by SAMHSA and the National

Association for Children of Alcoholics.)

In addition, programmatic enhancements (such

as classes that teach English as a second language) also are not family therapy. Although

educational family activities can be therapeutic,

they will not correct deeply ingrained,

maladaptive relationships.

The following discussions present a brief

overview of the evolution of family therapy

models and the primary models of family

therapy used today as the basis for treatment.

Chapter 3 provides more detailed information

about these models.

Historical Models of Family

Therapy

Marriage and family therapy (MFT) had its

origins in the 1950s, adding a systemic focus to

previous understandings of the family. Systems

theory recognizes that

•A whole system is more than the sum of its

parts.

•Parts of a system are interconnected.

•Certain rules determine the functioning of a

system.

•Systems are dynamic, carefully balancing

continuity against change.

•Promoting or guarding against system

entropy (i.e., disorder or chaos) is a powerful

dynamic in the family system balancing

change of the family roles and rules.

The strategic school of family therapy

“introduced two of the most powerful insights

in all of family therapy: that family members

often perpetuate problems by their own

actions; and that directives tailored to the

needs of a particular family can sometimes

6 Substance Abuse Treatment and Family Therapy
         

           

         

         

           

       

   

             

     

           

         

         

         

         

           

         

           

     

           

   

               

           

     

           

             

       

         

               

           

             

           

           

           

             

   

           

       

             

               

       

           

     

         

             

           

           

           

         

           

     

   

         

           

           

   

               

         

         

         

     

     

             

       

           

         

         

       

     

           

   

     

           

         

           

             

               

         

         

             

           

             

               

bring about sudden and decisive change”

(Nichols and Schwartz 2001, p. 97).

Based on observations of the relationship

between family structure and behavior, along

with work with inner­city children and their

families, Minuchin (1974) developed another

approach, structural family therapy. Minuchin

and Fishman (1981) believed that families use a

limited repertoire of self­perpetuating relational

patterns and that family members divide into

subsystems with boundaries that regulate family

communication and behavior. They sought to

shift family boundaries so the boundary

between parents and children was clearer.

Intervention is aimed at having the parents

work more cooperatively together and at

reducing the extent to which children assume

parental responsibilities within the family.

One major model that emerged during this

developmental phase was cognitive–behavioral

family and couples therapy. It grew out of the

early work in behavioral marital therapy and

parenting training, and incorporated concepts

developed by Aaron Beck. Beck reasoned that

people react according to the ways they think

and feel, so changing maladaptive thoughts,

attitudes, and beliefs would eliminate dysfunctional patterns and the triggers that set them in

motion (Beck 1976). This union of cognitive

and behavioral therapies in a family setting was

new and useful. The therapist considers not

only how people’s thoughts, feelings, and

emotions influence their behavior, but also the

impact they have on spouses and other family

members. Cognitive­behavioral family therapy

and behavioral couples therapy are two models

that have strong empirical support.

Through the 1980s and 1990s, newer models

of MFT were articulated. In response to the

problem­focused strategic and structural family

therapies, authors such as de Shazer, Berg,

O’Hanlon, and Selkman promulgated solutionfocused family therapy (e.g., Berg and Miller

1992; de Shazer 1988). They asserted that

pinpointing the cause of poor functioning is

unnecessary and that therapy focused on

solutions is sufficient to help families change.

Soon after the introduction of solution­focused

therapy to the MFT landscape, White and

Epston’s Narrative Means to Therapeutic

Ends (1990) heralded the narrative movement

in MFT. This family therapy development has

focused on the way people construct meaning

and how the construction of meaning affects

psychological functioning.

In the early part of the 21st century, MFT

seems poised to undergo another change,

focused on empirically demonstrating the

effectiveness of different approaches to therapy.

The few models that have been tested 

empirically have shown promising results. For

example, functional family therapy, multisystemic therapy, multidimensional family therapy,

and brief strategic family therapy all have

been shown to be highly effective in reducing

acting­out behavior among adolescents and/or

in reducing the risk for problem behavior

among their younger siblings. Among the 

couples therapy models known to have reduced

marital distress and psychological problems are

emotionally focused couples therapy, cognitive–

behavioral couples therapy, behavioral couples

therapy, integrative couples therapy, and

systemic couples therapy. (See chapter 3 for

further information.)

Primary Family Therapy

Models in Use Today

There are numerous variations on the family

therapy theme. Some approaches to family

therapy reach out to multiple generations or

family groups. Some treat just one person, who

may or may not be the IP. Usually, though,

family therapy involves a therapist meeting

with several family members. An expansive

concept of family therapy also might spin off

group programs that, for example, could treat

the IP’s spouse, children in groups (children do

best if they first participate in groups that

Substance Abuse Treatment and Family Therapy 7
           

       

           

         

           

           

             

               

             

             

             

         

   

       

             

       

            

             

           

       

             

     

           

               

           

              

           

       

             

           

           

         

             

     

         

           

  

       

           

     

       

       

         

       

           

      

       

         

       

     

               

             

     

       

           

       

           

     

           

           

         

             

         

             

             

               

         

         

             

         

         

             

               

           

prepare them for family therapy), or members

of a residential treatment setting.

Most family therapy meetings take place in

clinics or private practice settings. Home­based

therapy breaks from the traditional clinical

setting, reasoning that joining the family where

it lives can help overcome shame, stigma, and

resistance. It is a return to the practices of

social workers who, in the early 20th century,

did their work in clients’ homes (Beels 2002).

Meeting the family where it lives also provides

valuable information about how the family

really functions.

Four predominant family therapy models are

used as the bases for treatment and specific

interventions for substance abuse:

1.	 The family disease model looks at substance

abuse as a disease that affects the entire

family. Family members of the people who

abuse substances may develop codependence, which causes them to enable the IP’s

substance abuse. Limited controlled

research evidence is available to support the

disease model, but it nonetheless is influential

in the treatment community as well as in the

general public (McCrady and Epstein 1996).

2.	 The family systems model is based on the

idea that families become organized by their

interactions around substance abuse. In

adapting to the substance abuse, it is possible

for the family to maintain balance, or homeostasis. For example, a man with a substance

use disorder may be antagonistic or unable

to express feelings unless he is intoxicated.

Using the systems approach, a therapist

would look for and attempt to change the

maladaptive patterns of communication or

family role structures that require substance

abuse for stability (Steinglass et al. 1987).

3.	 Cognitive–behavioral approaches are based

on the idea that maladaptive behaviors,

including substance use and abuse, are

reinforced through family interactions.

Behaviorally oriented treatment tries to

change interactions and target behaviors

that trigger substance abuse, to improve

communication and problemsolving, and

to strengthen coping skills (O’Farrell and

Fals­Stewart 1999).

4.	 Most recently, multidimensional family

therapy (MDFT) has integrated several

different techniques with emphasis on

the relationships among cognition, affect

(emotionality), behavior, and environmental

input (Liddle et al. 1992). MDFT is not the

only family therapy model to adopt such an

approach. Functional family therapy

(Alexander and Parsons 1982), multisystemic therapy (Henggeler et al. 1998), and

brief strategic family therapy (Szapocznik et

al. in press) all adopt similar multidimensional approaches.

Family Therapy in

Substance Abuse

Treatment

Goals of Family Therapy

The integration of family therapy in substance

abuse treatment is still relatively rare. Family

therapy in substance abuse treatment helps

families become aware of their own needs and

provides genuine, enduring healing for people.

Family therapy works to shift power to the

parental figures in a family and to improve

communication. Other goals will vary according

to which member of the family is abusing substances. Family therapy can answer questions

such as

•Why should children or adolescents be

involved in the treatment of a parent who

abuses substances?

•What impact does a parent abusing substances

have on his or her children?

•How does adolescent substance abuse impact

adults?

•What is the impact of substance abuse on

family members who do not abuse substances?

Whether a child or adult is the family member

who uses substances, the entire family system

8 Substance Abuse Treatment and Family Therapy
         

   

             

           

           

             

           

         

       

             

     

           

           

                 

           

         

             

   

           

       

           

             

             

             

         

         

           

           

           

         

       

               

           

     

           

         

       

       

       

         

             

           

               

           

         

   

           

           

             

         

         

               

           

       

             

   

     

     

     

     

     

   

     

       

   

   

   

   

   

   

   

           

             

       

           

             

       

           

             

needs to change, not just the IP. Family therapy,

therefore, helps the family make interpersonal,

intrapersonal, and environmental changes

affecting the person using alcohol or drugs. It

helps the nonusing members to work together

more effectively and to define personal goals

for therapy beyond a vague notion of improved

family functioning. As change takes place, family

therapy helps all family members understand

what is occurring. This out­in­the­open understanding removes any suspicion that the 

family is “ganging up” on the person abusing

substances.

A major goal of family therapy in substance

abuse treatment is prevention—especially

keeping substance abuse from moving from one

generation to another. Study after study shows

that if one person in a family abuses alcohol or

drugs, the remaining family members are at

increased risk of developing substance abuse

problems. The single most potent risk factor of

future maladaption, predisposition to substance

use, and psychological difficulties is a parent’s

substance­abusing behavior (Johnson and Leff

1999). A “healthy family structure can prevent

adolescent substance abuse even in the face of

heavy peer pressure to use and abuse drugs”

(Kaufman 1990a, p. 51). Further, if the person

abusing substances is an adolescent, successful

treatment diminishes the likelihood that siblings will abuse substances or commit related

offenses (Alexander et al. 2000). Treating

adolescent drug abuse also can decrease the

likelihood of harmful consequences in adulthood, such as chronic unemployment, continued

drug abuse, and criminal behavior.

Therapeutic Factors

Because of the variety of family therapy models,

the diverse schools of thought in the field, and

the different degrees to which family therapy is

implemented, multiple therapeutic factors

probably account for the effectiveness of family

therapy. Among them might be acceptance

from the therapist; improved communication;

organizing the family structure; determining

accountability; and enhancing impetus for

change, which increases the family’s motivation

to change its patterns of interaction and frees

the family to make changes. Family therapy

also views substance abuse in its context, not as

an isolated problem, and shares some characteristics with 12­Step programs, which evoke

solidarity, self­confession, support, self­esteem,

awareness, and smooth re­entry into the

community.

Still another reason that family therapy is

effective in substance abuse treatment is that

it provides a neutral forum in which family

members meet to solve problems. Such a

rational venue for expression and negotiation

often is missing from the family lives of people

with a substance problem. Though their lives

are unpredictable and chaotic the substance

abuse—the cause of the upheaval and a focal

organizing element of

family life—is not

discussed. If the

subject comes up, the Family therapy in

substance abuse

treatment helps

families become

aware of their own

needs and

provides genuine,

enduring healing

for people.

tone of the exchange is

likely to be accusatory

and negative.

In the supportive

environment of family

therapy, this uneasy

silence can be broken

in ways that feel

emotionally safe. As

the therapist brokers,

mediates, and restructures conflicts among

family members,

emotionally charged

topics are allowed to

come into the open.

The therapist helps

ensure that every

family member is

accorded a voice. In the safe environment of

therapy, pent­up feelings such as fear and concern can be expressed, identified, and validated.

Often family members are surprised to learn

that others share their feelings, and new lines

of communication open up. Family members

gain a broader and more accurate perspective

of what they are experiencing, which can be

Substance Abuse Treatment and Family Therapy 9
           

           

                 

           

         

           

       

       

           

         

         

             

           

           

           

         

           

             

       

       

         

           

         

             

           

           

         

           

         

         

         

           

           

           

                 

           

               

                   

                         

               

               

                     

                   

                         

               

         

         

                 

                 

empowering and may provide enough energy to

create positive change. Each of these improvements in family life and coping skills is a highly

desirable outcome, whether or not the IP’s

drug or alcohol problems are immediately

resolved. It is clearly a step forward for the

family of a person abusing substances to

become a stable, functional environment within

which abstinence can be sustained.

To achieve this goal, family therapy facilitates

changes in maladaptive interactions within the

family system. The therapist looks for

unhealthy relational structures (such as parentchild role reversals) and faulty patterns of

communication (such as a limited capacity for

negotiation). In contrast to the peripheral role

that families usually play in other therapeutic

approaches, families are deeply involved in

whatever changes are effected. In fact, the

majority of changes will take place within the

family system, subsequently producing change

in the individual abusing substances.

Family therapy is highly applicable across

many cultures and religions, and is compatible

with their bases of connection and identification,

belonging and acceptance. Most cultures value

families and view them as important. This

preeminence suggests how important it is to

include families in treatment. It should be

acknowledged, however, that a culture’s high

regard for families does not always promote

improved family functioning. In cultures that

revere families, people may conceal substance

abuse within the family because disclosure

would lead to stigma and shame.

Additionally, the definition, or lack of definition,

of the concept of “rehabilitation” varies greatly

across cultural lines. Cultures differ in their

views of what people need in order to heal. The

identities of individuals who have the moral

Selected Research Outcomes of Family

Approaches to Substance Abuse

Treatment

•Bukstein (2000, p. 74) found that “family­focused interventions are empirically

well­supported for youth with a conduct disorder or substance use disorder.”

He notes that 68 percent of adolescents with a substance use disorder also had

a comorbid disruptive behavior disorder. Bukstein emphasizes that family

therapy interventions can focus on the environmental factors that promote

both disorders.

• Catalano et al. (1999) sought to determine whether family­focused interventions

for parents on methadone would reduce their drug use and prevent children

from starting to use drugs. After studying 144 methadone­treated parents with

78 children for a year, with 33 sessions of family training, the authors found

significant improvements in parenting skills, less parental drug use, fewer

deviant peers, and better family management.

•Cunningham and Henggeler’s 1999 overview of multisystemic therapy, a familybased treatment model, found high rates of substance abuse treatment 

completion among youth with serious clinical problems.

• Diamond et al. (1996) reviewed advances in family­based treatment research.

They cited a growing body of research indicating that family­based treatments

are effective for a variety of child and adolescent disorders, including substance

10 Substance Abuse Treatment and Family Therapy
             

                   

   

                       

                   

                     

               

                   

                 

         

                   

                     

                     

                   

               

             

                     

                 

                       

                     

                     

   

               

                   

                 

           

                     

                 

                   

               

                     

               

                       

                   

                   

                   

                         

                 

                   

                       

                   

                       

             

abuse, schizophrenia, and conduct disorder. The studies all demonstrated the

superiority of brief family treatment over individual and group treatments for

reducing drug use.

•Friedman et al. (1995) conducted a study of 176 adolescent drug abuse clients

and their mothers in six outpatient drug­free programs with family therapy

sessions. The authors found that the more positively the client described the

family’s functioning and relationships at pretreatment, the more client

improvement was reported by client or mother at follow­up. They concluded

that the adolescents with better treatment outcomes began treatment with

more positive perceptions of their families.

• In a review of controlled treatment outcome research, Liddle and Dakof

(1995a) found that different types of family intervention can engage and retain

people who use drugs and their families in treatment, significantly reduce drug

use and other problem behaviors, and enhance social functioning. They also

concluded that family therapy was more effective than therapy without families,

but cautioned against overgeneralizing this finding because of methodological

limitations and the relatively small number of studies.

• McCrady and Epstein (1996) noted that an extensive literature supports familybased models and the effectiveness of treatments based on the family disease,

family systems, and behavioral family models. Research knowledge is limited,

however, by a lack of attention to cultural, racial, sexual, and gender orientation issues among subjects; the lack of couples treatment research on people

using drugs; and the lack of family treatment research on individuals with

alcohol abuse disorders.

• O’Farrell and Fals­Stewart (2000) concluded that behavioral couples therapy

led to more abstinence and better relationships, decreased the incidence of

separation and divorce, reduced domestic violence, and had a favorable

cost/benefit ratio compared to individual therapy.

•Shapiro (1999) describes La Bodega de la Familia, a family therapy approach

used to reduce relapse, parole violations, and recidivism for individuals

released from prison and jail. With intensive family­based therapies, the

18­month rearrest rate dropped from 50 to 35 percent.

•In a study using both family and non­family treatments for substance abuse,

Stanton and Shadish (1997) concluded that (1) when family­couples therapy

was part of the treatment, results were clearly superior to modalities that do

not include families, and (2) family therapy promotes engagement and retention

of clients.

•Walitzer (1999) analyzed two forms of family therapy (behavioral marital therapy

and family systems therapy) for treating substance abuse, concluding that the

model of choice depended on the problem at hand. If problems (such as poor

communication) centered in the marriage, behavioral marital therapy was the

better approach. If the problem involved a whole family organized around

alcohol or illicit drugs, family systems therapy could be a superior strategy. In

either case, her review “strongly indicates the critical role family functioning

can have in both subtly maintaining an addiction and in creating an environment conducive to abstinence” (Walitzer 1999, p. 147).

Substance Abuse Treatment and Family Therapy 11
               

           

             

             

               

             

         

   

           

         

         

           

   

   

   

   

   

   

   

   

   

   

     

   

     

     

   

   

         

         

           

             

           

       

           

           

         

           

           

         

         

         

       

       

       

           

           

       

             

             

           

       

       

           

     

     

           

         

             

           

             

           

           

         

             

             

         

         

           

         

         

             

       

authority to help (for example, an elder or a

minister) can differ from culture to culture.

Therapists need to engage aspects of the

culture or religion that promote healing and to

consider the role that drugs and alcohol play in

the culture. (Issues of culture and ethnicity are

discussed in detail in chapter 5.)

Effectiveness of Family
 

Therapy
 

While there are limited studies of the effectiveness of family therapy in the treatment of

substance abuse, important trends suggest that

family therapy approaches should be considered

more frequently in substance abuse treatment.

Much of the federally funded research into

substance abuse

treatment has

focused on criminal Family therapy is

highly applicable

across many

cultures and

religions, and is

compatible with	 

their bases of connection and identification, belonging

and acceptance.

justice issues, cooccurring disorders,

and individual­specific treatments. One

reason is that

research with families

is difficult and costly.

Ambiguities in

definitions of family

and family therapy

also have made

research in these

areas difficult. As a

result, family therapy

has not been the

focus of much

substance abuse

research. However,

evidence from the

research that has

been conducted,

including that

described below, indicates that substance abuse

treatment that includes family therapy works

better than substance abuse treatments that do

not (Stanton et al. 1982). It increases engagement

and retention in treatment, reduces the IP’s

drug and alcohol use, improves both family and

social functioning, and discourages relapse.

Although the effectiveness of family therapy is

documented in a growing body of evidence,

integrating family therapy into substance abuse

treatment does pose some specific challenges:

•Family therapy is more complex than nonfamily approaches because more people are

involved.

•Family therapy takes special training and

skills beyond those typically required in

many substance abuse treatment programs.

•Relatively little research­based information is

available concerning effectiveness with subsets of the general population, such as

women, minority groups, or people with

serious psychiatric problems (O’Farrell and

Fals­Stewart 1999).

The balance, however, certainly tips in favor

of a family therapy in treating substance abuse.

Based on effectiveness data and the consensus

panel’s collective experience, the consensus

panel recommends that substance abuse treatment agencies and providers consider how they

might incorporate family approaches, including

age­appropriate educational support services

for their clients’ children, into their programs.

Cost Benefits

Only a few studies have assessed the cost 

benefits of family therapy or have compared

the cost of family therapy to other approaches

such as group therapy, individual therapy, or

12­Step programs. A small but growing body of

data, however, has demonstrated the cost benefits of family therapy specifically for substance

abuse problems. Family therapy also has

appeared to be superior in situations that might

in some key respect be similar to substance

abuse contexts.

For example, Sexton and Alexander’s work

with functional family therapy (so called

because it focuses its interventions on family

relationships that influence and are influenced

by, and thus are functions of, positive and

negative behaviors) for youth offenders found

that family therapy nearly halved the rate of

re­offending—19.8 percent in the treatment

12 Substance Abuse Treatment and Family Therapy
             

           

             

             

             

                   

         

             

         

       

               

         

               

           

             

         

           

           

               

             

   

               

       

         

         

         

           

               

           

       

                 

         

           

   

   

       

       

         

       

         

           

           

             

         

           

             

       

         

         

           

         

             

         

             

           

           

           

   

             

       

         

     

           

       

         

             

             

           

       

           

             

             

           

           

             

           

             

group compared to 36 percent in a control

group (Sexton and Alexander 2002). The cost

of the family therapy ranged from $700 to

$1,000 per family for the 2­year study period.

The average cost of detention for that period

was at least $6,000 per youth; the cost of a

residential treatment program was at least

$13,500. In this instance, the cost benefits of

family therapy were clear and compelling

(Sexton and Alexander 2002).

Other studies look at the offset factor; that is,

the relationship between family therapy and

the use of medical care or social costs. FalsStewart et al. (1997) examined social costs

incurred by clients (for example, the cost of

substance abuse treatment or public assistance)

and found that behavioral couples therapy was

considerably more cost effective than individual

therapy for substance abuse, with a reduction

of costs of $6,628 for clients in couples therapy,

compared to a $1,904 reduction for clients in

individual therapy.

Similar results were noted in a study by the

National Working Group on Family­Based

Interventions in Chronic Disease, which found

that 6 months after a family­focused intervention, reimbursement for health services was 50

percent less for the treatment group, compared

to a control group. While this study looked at

chronic diseases such as heart disease, cancer,

Alzheimer’s disease, and diabetes, substance

abuse also is a chronic disease that is in many

ways analogous to these physical conditions

(Fisher and Weihs 2000). Both chronic diseases

and substance abuse

•Are long­standing and progressive

•Often result from behavioral choices

•Are treatable, but not curable

•Have clients inclined to resist treatment

•Have high probability of relapse

Chronic diseases are costly and emotionally

draining. Substance abuse is similar to a

chronic disease, with potential for recovery; it

even can lead to improvement in family functioning. Other cost benefits result from preventive aspects of treatment. While therapy usually

is not considered a primary prevention intervention, family­based treatment that is oriented

toward addressing risk factors may have a

significant preventive effect on other family

members (Alexander et al. 2000). For example,

it may help prevent substance abuse in other

family members by correcting maladaptive

family dynamics.

Other Considerations

Family therapy for substance abuse treatment

demands the management of complicated treatment situations. Obviously, treating a family is

more complex than treating an individual,

especially when an unwilling IP has been mandated to treatment. Specialized strategies may

be necessary to engage the IP into treatment.

In addition, the substance abuse almost always

is associated with other difficult life problems,

which can include mental health issues, cognitive

impairment, and socioeconomic constraints,

such as lack of a job or home. It can be difficult,

too, to work across diverse cultural contexts or

discern individual family members’ readiness

for change and treatment needs.

These circumstances make meaningful family

therapy for substance abuse problems a complex

and challenging task for both family therapists

and substance abuse treatment providers.

Modifications in the treatment approach may

be necessary, and the success of treatment will

depend, to a large degree, on the creativity,

judgment, and cooperation in and between programs in each field.

Complexity

Clinicians treating families have to weigh many

variables and idiopathic situations. Few 

landmarks may be apparent along the way; for

many families, the phases of family therapy are

neither discrete nor well defined. This uncertain

journey is made less predictable because multiple people are involved. For example, in an

adolescent program, a child in treatment might

have a parent with alcoholism. As the parent’s

substance abuse issues begin to surface, the

child is withdrawn from treatment. This is why

Substance Abuse Treatment and Family Therapy 13
               

             

         

     

           

           

           

     

           

         

               

           

             

                 

             

           

           

         

             

           

               

       

         

     

         

         

             

         

           

             

           

               

             

             

                 

           

   

             

           

               

           

         

         

             

           

     

       

           

         

       

         

   

       

         

         

         

               

               

           

               

         

         

           

       

           

               

             

           

           

             

     

         

             

       

         

         

             

       

           

   

         

             

       

children need to participate in a group of their

own. In a family therapy program, the child’s

and the parent’s substance abuse problems

would be addressed concomitantly.

Another factor that can complicate any therapy

process is external coercion, such as courtmandated treatment or mandates arising out of

child protective services requirements. These

situations can affect families in varied ways;

treatment providers should approach mandated

family therapy with heightened vigilance about

the role of coercion in family process. Often in

substance abuse treatment, a legal mandate or

some other form of coercion makes therapy a

requirement. The nature of mandated treatment

is likely to have an effect on the dynamics of

family therapy. It can place constraints on the

therapist and raise distracting issues that have

a negative effect on treatment, requiring more

care, coordination of services, and case management. The legal and ethical thicket is dense

in these circumstances. An exception is when

the client is a minor, the courts can mandate

treatment and family therapy. Practitioners

should avail themselves of all relevant

resources (e.g., professional associations,

supervision, ethical guidelines, local and State

legal and consumer organizations) before

venturing to treat families under court order or

similar situations. Therapists must form a

working alliance with each family member and

establish trust with the family so that sensitive

information can be disclosed. This requires the

therapist to demonstrate that she is on the family’s side therapeutically, but she also needs to

disclose to the family any other obligations she

has as a result of her position. For example, by

agreeing to treat the family under the particular

circumstances at hand, the therapist might be

obligated to make progress reports to probation

or parole agencies.

Co­occurring problems

Even though an individual with a substance use

disorder generally brings a family into treatment, it is possible that more than one person

in the family has substance abuse problems,

mental illness, problems with domestic

violence, or some other major difficulty.

Substance abuse, in fact, may be a secondary

reason for referral for therapy. Changing the

family’s maladaptive patterns of interaction

may help to correct psychosocial problems

among all family members. For more information about co­occurring mental and substance

use disorders see the forthcoming TIP

Substance Abuse Treatment for Persons With

Co­Occurring Disorders (Center for Substance

Abuse Treatment [CSAT] in development k).

Biological aspects of 

addiction

Other important considerations involve the

biological and physiological aspects of addiction

and recovery. The recovery process varies

according to the type of drug, the extent of

drug use, and the extent of acute and chronic

effects. Recovery also may depend, at least

partly, on the extent to which the drugs are

intertwined with antisocial behavior and cooccurring conditions. For the IP, post­acute

withdrawal symptoms also will commonly

present and interfere with family therapy for a

significant period before gradually subsiding.

The biological aspects of addiction also may

affect the type of therapy that can be effective.

For example, family therapy may not be as

effective for someone whose drug use has

caused significant organic brain damage or for

a person addicted to cocaine who has become

extremely paranoid. Severe psychopathology,

however, should not automatically exclude a

client from family therapy. Even in these cases,

with appropriate individual and psychopharmacological treatment, family therapy may be

helpful (O’Farrell and Fals­Stewart 1999) since

other members of the family might need and

benefit from family therapy services.

Socioeconomic constraints

The socioeconomic status of a family in treatment

can have far­reaching ramifications. During

treatment, poverty has two immediate implications. First, therapy will need to address many

survival issues—a therapist cannot explore

14 Substance Abuse Treatment and Family Therapy
         

                 

         

         

           

           

         

         

         

               

             

       

               

           

         

     

           

         

         

       

             

           

     

       

       

       

             

               

           

       

           

   

         

     

           

               

               

           

     

           

               

           

     

     

     

     

   

     

   

             

         

         

             

               

             

     

  

  

  

  

  

         

       

           

               

             

               

             

           

         

aspects of family systems or cognitive–behavioral

traits if a family is being evicted, is not eating

properly, is without financial resources and

employment, or is experiencing some other

threat to daily life. Second, the reimbursement

systems that can be accessed probably will

determine how long treatment will continue,

irrespective of client needs. Therefore, family

therapy treatments for substance abuse must

be designed to be relatively brief and to target

aspects of the family’s environment that may be

maintaining the drug abuse symptomatology

(e.g., Robbins et al. in press). In addition,

family members should be referred to Al­Anon,

Alateen, and NAR­Anon to enhance their

potential for long­term recovery.

Cultural competence

Cultural competence is an important feature in

family therapy because therapists must work

with the structures of families from many 

cultures. Knowledge of and sensitivity to

cultures is involved in determining

•To what extent is the family’s divergence from

mainstream norms a function of pathology or

a different cultural background?

•How is the family arranged—hierarchically?

Democratically? Within this structure, what

are the communication patterns?

•How well is this family functioning? That is,

to what extent can the family meet its own

goals without getting in its own way?

•What therapeutic goals are appropriate?

•What are the culture’s prescribed roles for

each family member?

•Who are the appropriately defined “power

figures” in the family?

The need for cultural competence does not

imply that a therapist must belong to the same

cultural group as the client family. It is possible

to develop cultural competence and work with

groups other than one’s own. A sensitive 

therapist pays attention, senses cultural

nuances, and learns from clients. Even when

the therapist is from the same culture as the

family in treatment, trust cannot be assumed.

It must be built. The expectations regarding the

therapist’s role as an

agent of change must Substance abuse

almost always is

associated with

other difficult life

problems, which

can include mental

health issues, cognitive impairment,

and socioeconomic

constraints.

be clearly discussed in

relation to the developing trust with the

family and individual

members.

Issues related to

cultural sensitivity

and appropriateness

are considered in

greater detail in

chapter 5 and in the

forthcoming TIP

Improving Cultural

Competence in

Substance Abuse

Treatment (CSAT in

development b).

Stages of

change and

levels of

recovery

The process of recovery is complex and multifaceted. One useful framework for understanding

this process involves stages of change

(Prochaska et al. 1992), which can be applied

to an individual or to the whole family and

used as a framework for treatment. The five

stages of change are

1. Precontemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

Individuals typically progress and regress in

their movements through these stages

(Prochaska et al. 1992). Although these stages

can be applied to a whole family, not every

family member necessarily will be at the same

stage at the same time. The therapist needs to

address where each family member is, for these

factors play an important role in assessment

and treatment matching decisions. For addiSubstance Abuse Treatment and Family Therapy 15
     

   

       

       

   

   

   

   

     

   

     

     

   

           

         

           

           

         

           

   

         

             

     

         

     

       

           

       

           

             

         

           

           

       

           

         

         

         

           

   

           

   

           

     

         

       

         

           

         

         

         

           

         

           

             

             

           

             

           

       

               

           

       

           

       

           

             

             

           

           

             

               

               

     

tional information

on the stages of

change, refer to

chapter 3 of this TIP

Treatment must be

customized to the	 

needs of each
 

family and the

person abusing

substances.	 

and see also TIP 35,

Enhancing

Motivation for

Change in Substance

Abuse Treatment

(CSAT 1999b).
 

While Prochaska et

al. (1992) conceptualized readiness for

change, other

researchers have

modeled the stages of

recovery after treatment has begun. One

such model of the

path through treatment is Kaufman’s (1990b) progressive levels of

recovery:

• Dry abstinence is a time when clients must

cope with problems revolving around the cessation of substance use (such as withdrawal,

sudden realization of the actual damage

intoxication has caused, and the shame that

follows).

•Sobriety, or early recovery, concentrates on

maintaining freedom from substances. Bit by

bit, the client is helped to substitute healthsustaining behaviors for relationships and

circumstances that precipitate substance use.

•Advanced recovery shifts from support to

examination of underlying personal issues

that predispose the client to substance use.

Trust and intimacy are re­established, and

the client moves through the termination of

therapy.

This TIP approaches stages of change for

families by combining Bepko and Krestan’s

stages of treatment for families (1985) and

Heath and Stanton’s stages of family therapy

for substance abuse treatment (1998).

Together, the phases of family change are

•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.

•Long­term maintenance of sobriety. The

family must rebalance and stabilize a new

and healthier lifestyle.

Combining these two models provides a simple,

straightforward categorization for a family’s

progress in recovery regarding attainment of,

adjustment to, and long­term maintenance of

sobriety. For additional information on these

phases of family change, see chapter 4.

Unanswered research 

questions

At present, research cannot guide treatment

providers about the best specific matches

between family therapy and particular family

systems or substances of abuse. Research to

date suggests that certain family therapy

approaches can be effective, but no one

approach has been shown to be more effective

than others. In addition, even though the right

model is an important determinant of appropriate treatment, the exact types of family

therapy models that work best with specific

addictions have not been determined. However,

a growing body of evidence over the past 25

years suggests that children benefit from participating in age­appropriate support groups.

These can be offered by treatment programs,

school­based student assistance programs, or

faith­based communities.

Experience and sound judgment can distinguish

many situations in which family therapy alone

would or would not be a workable modality.

Treatment must be customized to the needs of

each family and the person abusing substances.

An adolescent who is primarily smoking marijuana, for instance, is a good candidate for

family systems work. On the other hand, if a

youth is mixing cocaine, amphetamines, alcohol,

and other drugs, the client is likely to need

more extensive services—detoxification, 

residential treatment, or intensive outpatient

16 Substance Abuse Treatment and Family Therapy
             

           

   

             

       

       

         

               

           

           

             

           

           

                 

       

           

               

               

           

       

               

           

           

             

           

         

           

             

           

         

       

           

   

         

           

         

         

               

             

             

             

                 

               

           

           

       

         

         

               

           

             

         

       

               

               

           

             

         

         

         

           

         

           

           

         

     

           

         

           

             

         

           

             

               

           

         

       

           

   

therapy—which can be used in addition to family therapy (Liddle and Hogue 2001).

Safety and Appropriateness of

Family Therapy

Only in rare situations is family therapy inadvisable. Occasionally, it will be inappropriate

or counterproductive because of reasons such

those as mentioned above. Sometimes, though,

family therapy is ruled out due to safety issues

or legal constraints. Family or couples therapy

should not take place unless all participants

have a voice and everyone can raise pertinent

issues, even if a domineering family member

does not want them discussed. Family therapy

can be used when there is no evidence of serious

domestic or intimate partner violence.

Engaging in family therapy without first assessing carefully for violence can lead not only to

poor treatment, but also to a risk for increased

abuse.

A systems approach presumes that all family

members have roughly equal contributions to

the process and have equity in terms of power

and control. This belief is not substantiated in

the research on family violence. Hence, family

therapy only should be used when one family

member is not being terrorized by another.

Resistance from a domineering family member

can be addressed and restructured by first

allying with this family member and then gradually and gently questioning this person (and

the whole family) about the appropriateness of

the domineering behavior (Szapocznik et al.

1988). (See also appendix C, Guidelines for

Assessing Violence.)

It is the treatment provider’s responsibility to

provide a safe, supportive environment for all

participants in family therapy. Children benefit

by attending support groups specifically for

them; it is important to create a safe environment in which they can discuss family violence,

abuse, and neglect. Usually, a way can be

found to include even the family member who

has turned to violence as a way of dealing with

problems. That person is a vital part of the

family and will be pivotal in understanding the

nature of the family violence. For example,

Johnson (1995) distinguishes between common

couple violence and patriarchal terrorism. The

former is characterized by occasional violent

outbursts by either spouse and is not likely to

escalate. It is usually an intermittent response

to conflict, and in therapy can be examined

and channeled into more positive expression.

Patriarchal terrorism, however, is systematic

male violence with the goal of control. It may

not be possible or advisable to include a chronically violent partner in the family therapy

process.

Child abuse or neglect is another serious

consideration. Children in violent homes have

more physical, mental, and emotional health

problems than do children in nonviolent

homes. Children of people with alcohol abuse

disorders suffer more injuries and poisonings

than do children in the general population.

Research has shown that when families exhibit

both of these behaviors—substance abuse and

child maltreatment—the problems must be

treated simultaneously to ensure a child’s safety.

It should be noted that the withdrawal experienced by parents who cease using alcohol or

drugs presents specific risks. The effects of withdrawal often cause a parent to experience

intense emotions, which may increase the likelihood of child maltreatment. During this time, it

is especially important that family support

resources be made available to the family

(Bavolek 1995), and that children know how to

find safe adults to help. Any time a counselor

suspects child abuse or neglect, laws require

immediate reporting to local authorities. For

further information, see TIP 36, Substance

Abuse Treatment for Persons With Child Abuse

and Neglect Issues (CSAT 2000b).

Substance Abuse Treatment and Family Therapy 17
             

             

         

         

           

           

         

                   

               

           

     

               

         

             

         

         

               

           

             

             

             

         

             

             

             

           

               

           

       

             

               

               

             

         

       

           

             

           

         

       

           

         

         

           

               

           

               

           

               

           

             

             

             

           

             

       

         

         

           

       

         

             

           

             

             

             

           

       

         

         

           

       

             

         

           

             

   

         

Domestic violence is a serious issue among people

with substance use disorders, and it must be

factored into therapeutic considerations. If, for

example, a restraining order prohibits spouses

from seeing each other, the treatment provider

must work within this limitation, using therapeutic configurations that make sure that a

client who is abusive is not in a session with the

person he or she has been barred from seeing.

Often when there is concomitant family violence,

the offender is mandated to complete a

Batterer’s Intervention Program before participating in any couple’s work. At the same time,

the victim/spouse is engaged in safety planning

and sometimes treatment for his or her own

issues.

Only the most extreme anger contraindicates

family therapy. Kaufman and Pattison (1981)

developed the concept of the need for a period

of abstinence before sufficient trust can be

built to counteract the anger. Including all family members in treatment and providing them a

forum for releasing their anger may help to

work toward that threshold. Redefining the

problem as residing within the family as a

whole can help transform the anger into motivation for change. In turn, this motivation can

be used to restructure the family’s interactions

so that the substance abuse is no longer

supported. The therapist’s ability to reframe

proposed obstructions by family members is

often the key to creating a positive therapeutic

direction.

It is up to counselors and therapists to assess

the potential for anger and violence and to construct therapy so it can be conducted without

endangering any family members. Because of

the life­and­death nature of this responsibility,

the consensus panel includes guidelines for the

screening and treatment of people caught up in

the cycle of family violence. These recommendations, adapted from TIP 25, Substance

Abuse Treatment and Domestic Violence (CSAT

1997b), are presented in appendix C. However,

these guidelines are not a substitute for training;

counselors and therapists should have training

and supervision in handling family violence

cases.

If, during the screening interview, it becomes

clear that a batterer is endangering a client or

a child, 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 can be

ensured. The provider should refer the client

or child to a domestic violence program and

possibly to a shelter and legal services, and

should take necessary steps to ensure the safety

of affected children. Any outcry of anticipated

danger needs to be regarded with the utmost

seriousness and immediate precautions taken.

Goals of This TIP

General Goals

Connections

The integration of family therapy into substance

abuse treatment is an important development

in the treatment of addictions. Historically,

barriers have separated the fields, among them

differences in credentialing, treatment models,

and cost for higher­trained family therapists.

This TIP is intended to provide an opportunity

for providers from both disciplines to learn

from one another. It provides language that will

help both fields talk about family therapy and

addiction and facilitate a new and more collaborative way of thinking about substance abuse

treatment.

In many States and jurisdictions, credentialing

requirements are raising standards for substance abuse counselors and family therapists.

These changes, which will require further education, provide opportunities for practitioners

to expand their horizons as they upgrade their

professional skills. This process can further

cross­fertilize the fields by making the practitioners of both fields more familiar with each

other’s work.

Coverage for family therapy

The consensus panel hopes that substance

abuse treatment and family therapy 

18 Substance Abuse Treatment and Family Therapy
               

         

       

           

     

     

           

           

       

         

                 

           

       

           

           

             

           

         

           

           

     

       

           

       

           

         

         

         

       

           

               

     

             

         

       

       

               

           

         

               

               

       

     

       

           

             

               

             

           

                 

             

         

             

           

         

             

           

             

   

         

               

             

   

           

   

practitioners will be able to use this TIP to

help educate insurers and behavioral managed

care organizations about the importance of

covering family therapy services for clients with

substance use disorders.

Goals for Specific Groups

Substance abuse treatment

counselors

This TIP will help substance abuse treatment

counselors

•Understand the impact of substance abuse on

families taken as a whole

•Recognize that family members need treatment in the context of the family as a whole

•Appreciate the value of family therapy in

treatment and integrate their interventions

with the greater good of the family

Family therapists and other

clinicians

This TIP will help family therapists become

more aware of the presence and significance of

chemical dependency and work with the substance abuse treatment community so family

environments no longer contribute to or maintain substance abuse. It also is hoped that family

therapists will come to appreciate models of

substance abuse treatment and the context in

which they are delivered.

Clinical supervisors

Clinical supervisors in substance abuse 

treatment programs and in family treatment

programs can use this information to become

aware of and knowledgeable about the potential

connections between substance abuse treatment

and family therapy. These supervisors will then

be better equipped to incorporate appropriate

family approaches into their programs and

evaluate the performance of personnel and

programs in both disciplines.

Treatment program 

administrators

Realizing how beneficial family therapy can be

as an adjunct to or integrated part of substance

abuse treatment, program administrators can

use the TIP to train and motivate substance

abuse treatment clinicians to include family

members in treatment. Likewise, program

administrators in family treatment programs

can use the TIP to motivate and train family

therapists to include the exploration of substance use disorders in family treatment.

Since it is difficult to find counselors who are

expert in both fields, it is hoped that substance

abuse treatment administrators will develop

collaborative relationships with family therapy

programs and manage necessary logistical

issues. For example, finding adequate space is

often an issue. Working hours, too, may have

to be shifted, because staff will need to work

some evenings to meet with family members.

Families

The consensus panel hopes that family therapists

will begin to raise the issue of substance use as

a critical issue that can negatively impact

families and that substance abuse treatment

counselors will use information in this TIP to

inform families about what they can expect

from treatment. The growing consumer health

movement can be part of the education that

emboldens families to ask for adequate treatment. The IP and family members should be

encouraged to identify

•Why is treatment being pursued now?

•What are the costs and benefits of engaging in

therapy now?

•How is “change” defined in the structure of

“progress” in therapy?

•What are the key components of treatment

for the family?

Substance Abuse Treatment and Family Therapy 19

             

               

                   

                 

               

                     

               

               

               

                   

                   

                   

                     

                 

                 

                 

                       

               

                       

                 

             

                 

           

                   

           

In This
 

Chapter...
 

Introduction
 

Families With a
 

Member Who
 

Abuses Substances
 

Other Treatment
 

Issues
 

2 Impact of Substance
 

Abuse on Families
 

Overview

Family structures in America have become more complex—growing from

the traditional nuclear family to single­parent families, stepfamilies, foster

families, and multigenerational families. Therefore, when a family member

abuses substances, the effect on the family may differ according to family

structure. This chapter discusses treatment issues likely to arise in

different family structures that include a person abusing substances. For

example, the non–substance­abusing parent may act as a “superhero” or

may become very bonded with the children and too focused on ensuring

their comfort. Treatment issues such as the economic consequences of

substance abuse will be examined as will distinct psychological consequences that spouses, parents, and children experience. This chapter

concludes with a description of social issues that coexist with substance

abuse in families and recommends ways to address these issues in therapy.

Introduction

A growing body of literature suggests that substance abuse has distinct

effects on different family structures. For example, the parent of small

children may attempt to compensate for deficiencies that his or her substance­abusing spouse has developed as a consequence of that substance

abuse (Brown and Lewis 1999). Frequently, children may act as surrogate

spouses for the parent who abuses substances. For example, children

may develop elaborate systems of denial to protect themselves against

the reality of the parent's addiction. Because that option does not exist in

a single­parent household with a parent who abuses substances, children

are likely to behave in a manner that is not age­appropriate to compensate for the parental deficiency (for more information, see Substance

Abuse Treatment: Addressing the Specific Needs of Women [Center for

Substance Abuse Treatment (CSAT) in development e] and TIP 32,

Treatment of Adolescents With Substance Use Disorders [CSAT 1999e]).

Alternately, the aging parents of adults with substance use disorders may

maintain inappropriately dependent relationships with their grown

21
       

               

         

     

   

   

   

   

     

     

       

   

   

   

     

   

   

   

         

       

             

         

       

             

               

         

             

         

         

           

             

             

             

             

   

             

         

           

           

         

           

               

               

             

             

             

       

             

                 

           

       

         

           

       

           

           

             

               

           

   

        

   

         

           

             

         

   

             

           

             

       

     

           

         

         

           

       

         

         

           

offspring, missing the necessary “launching

phase” in their relationship, so vital to the

maturational processes of all family members

involved.

The effects of

substance abuse

frequently extend

People who abuse

substances are

likely to find

themselves

increasingly

isolated from

their families.	 

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 abusing substances. Some family

members even may

feel the need for

legal protection

from the person

abusing substances.

Moreover, the effects

on families may continue for generations.

Intergenerational effects of substance abuse

can have a negative impact on role modeling,

trust, and concepts of normative behavior,

which can damage the relationships between

generations. For example, a child with a parent

who abuses substances may grow up to be an

overprotective and controlling parent who does

not allow his or her children sufficient autonomy.

Neighbors, friends, and coworkers also

experience the effects of substance abuse

because a person who abuses substances often

is unreliable. Friends may be asked to help

financially or in other ways. Coworkers may be

forced to compensate for decreased productivity

or carry a disproportionate share of the workload. As a consequence, they may resent the

person abusing substances.

People who abuse substances are likely to find

themselves increasingly isolated from their families. Often they prefer associating with others

who abuse substances or participate in some

other form of antisocial activity. These associates

support and reinforce each other’s behavior.

Different treatment issues emerge based on the

age and role of the person who uses substances

in the family and on whether small children or

adolescents are present. In some cases, a family

might present a healthy face to the community

while substance abuse issues lie just below the

surface.

Reilly (1992) describes several characteristic

patterns of interaction, one or more of which

are likely to be present in a family that includes

parents or children abusing alcohol or illicit

drugs:

1.	 Negativism. Any communication that occurs

among family members is negative, taking

the form of complaints, criticism, and other

expressions of displeasure. The overall

mood of the household is decidedly downbeat, and positive behavior is ignored. In

such families, the only way to get attention

or enliven the situation is to create a crisis.

This negativity may serve to reinforce the

substance abuse.

2.	 Parental inconsistency. Rule setting is

erratic, enforcement is inconsistent, and

family structure is inadequate. Children are

confused because they cannot figure out the

boundaries of right and wrong. As a result,

they may behave badly in the hope of getting

their parents to set clearly defined boundaries. Without known limits, children cannot

predict parental responses and adjust their

behavior accordingly. These inconsistencies

tend to be present regardless of whether the

person abusing substances is a parent or

child and they create a sense of confusion—

a key factor—in the children.

3.	 Parental denial. Despite obvious warning

signs, the parental stance is: (1) “What

drug/alcohol problem? We don’t see any

drug problem!” or (2) after authorities

intervene: “You are wrong! My child does

not have a drug problem!”

4.	 Miscarried expression of anger. Children

or parents who resent their emotionally

deprived home and are afraid to express

22 Impact of Substance Abuse on Families
               

     

          

               

           

     

      

       

           

           

         

         

             

                 

               

           

             

         

             

       

         

   

                 

         

         

           

           

           

             

       

           

             

           

               

             

   

             

         

   

         

     

               

           

           

         

             

         

           

           

               

           

             

               

             

           

             

             

           

           

             

       

             

           

   

         

       

           

               

         

             

             

         

           

           

             

             

           

       

             

   

their outrage use drug abuse as one way to

manage their repressed anger.

5.	 Self­medication. Either a parent or child

will use drugs or alcohol to cope with intolerable thoughts or feelings, such as severe

anxiety or depression.

6.	 Unrealistic parental expectations. If

parental expectations are unrealistic, children

can excuse themselves from all future expectations by saying, in essence, “You can’t

expect anything of me—I’m just a

pothead/speed freak/junkie.” Alternatively,

they may work obsessively to overachieve,

all the while feeling that no matter what

they do it is never good enough, or they may

joke and clown to deflect the pain or may

withdraw to side­step the pain. If expectations are too low, and children are told

throughout youth that they will certainly

fail, they tend to conform their behavior to

their parents’ predictions, unless meaningful adults intervene with healthy, positive,

and supportive messages.

In all of these cases, what is needed is a

restructuring of the entire family system,

including the relationship between the parents

and the relationships between the parents and

the children. The next section discusses treatment issues in different family structures that

include a person who is abusing substances.

Families With a

Member Who Abuses

Substances

Client Lives Alone or With

Partner

The consequences of an adult who abuses

substances and 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 abuse problem, chronic anger,

stress, anxiety, hopelessness, inappropriate

sexual behavior, neglected health, shame,

stigma, and isolation.

In this situation, it is important to realize that

both partners need help. The treatment for

either partner will affect both, and substance

abuse treatment programs should make both

partners feel welcome. If a person has no

immediate family, family therapy should not

automatically be ruled out. Issues regarding a

person’s lost family, estranged family, or family

of origin may still be relevant in treatment. A

single person who abuses substances may

continue to have an impact on distant family

members who may be willing to take part in

family therapy. If family members come from a

distance, intensive sessions (more than 2 hours)

may be needed and helpful. What is important

is not how many family members are present,

but how they interact with each other.

In situations where one person is substance

dependent and the other is not, questions of

codependency arise. Codependency has become

a popular topic in the substance abuse field.

Separate 12­Step groups such as Al­Anon and

Alateen, Co­Dependents Anonymous (CoDA),

Adult Children of Alcoholics, Adult Children

Anonymous, Families Anonymous, and

Co­Anon have formed for family members (see

appendix D for a listing of these and other

resources).

CoDA describes codependency as being overly

concerned with the problems of another to the

detriment of attending to one’s own wants and

needs (CoDA 1998). Codependent people are

thought to have several patterns of behavior:

•They are controlling because they believe that

others are incapable of taking care of themselves.

•They typically have low self­esteem and a

tendency to deny their own feelings.

•They are excessively compliant, compromising their own values and integrity to avoid

rejection or anger.

Impact of Substance Abuse on Families 23
         

           

   

             

         

     

           

                 

               

           

     

             

         

           

           

             

           

       

         

             

               

       

     

         

               

           

         

           

           

               

             

           

               

               

             

             

         

             

           

             

       

         

     

           

       

           

           

         

           

         

           

               

           

         

       

             

         

               

         

           

           

   

           

           

           

   

         

             

     

           

           

             

               

             

             

           

         

         

           

           

         

               

           

                 

             

               

         

•They often react in an oversensitive manner,

as they are often hypervigilant to disruption,

troubles, or disappointments.

•They remain loyal to people who do nothing

to deserve their loyalty (CoDA 1998).

Although the term “codependent” originally

described spouses of those with alcohol abuse

disorders, it has come to refer to any relative of

a person with any type of behavior or psychological problem. The idea has been criticized

for pathologizing caring functions, particularly

those that have traditionally been part of

a woman’s role, such as empathy and 

self­sacrifice. Despite the term’s common use,

little scientific inquiry has focused on codependence. Systematic research is needed to establish the nature of codependency and why it

might be important (Cermak 1991; Hurcom et

al. 2000; Sher 1997). Nonetheless, specifically

targeted behavior that somehow reinforces the

current or past using behavior must be identified and be made part of the treatment

planning process.

Client Lives With Spouse (or

Partner) and Minor Children

Similar to maltreatment victims, who believe

the abuse is their fault, children of those with

alcohol abuse disorders feel guilty and responsible for the parent’s drinking problem.

Children whose parents abuse illicit drugs live

with the knowledge that their parents’ actions

are illegal and that they may have been forced

to engage in illegal activity on their parents’

behalf. Trust is a key child development issue

and can be a constant struggle for those from

family systems with a member who has a substance use disorder (Brooks and Rice 1997).

Most available data on the enduring effects of

parental substance abuse on children suggest

that a parent’s drinking problem often has a

detrimental effect on children. These data show

that a parent’s alcohol problem can have cognitive, behavioral, psychosocial, and emotional

consequences for children. Among the lifelong

problems documented are 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; and other

mental disorders such as depression, anxiety,

and low self­esteem (Giglio and Kaufman 1990;

Johnson and Leff 1999; Sher 1997).

The children of women who abuse substances

during pregnancy are at risk for the effects of

fetal alcohol syndrome, low birth weight (associated with maternal addiction), and sexually

transmitted diseases. (For information about

the effects on children who are born addicted

to substances, see TIP 5, Improving Treatment

for Drug­Exposed Infants [CSAT 1993a].)

Latency age children (age 5 to the onset of

puberty) frequently have school­related 

problems, such as truancy. Older children may

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

In adolescence, drug experimentation may

begin. Adult children of those with alcohol

abuse disorders may exhibit problems such as

unsatisfactory relationships, inability to manage

finances, and an increased risk of substance

use disorders.

Although, in general, children with parents

who abuse substances are at increased risk for

negative consequences, positive outcomes have

also been described. Resiliency is one example

of a positive outcome (Werner 1986). Some

children seem better able to cope than others;

the same is true of spouses (Hurcom et al.

2000). Because of their early exposure to the

adversity of a family member who abuses substances, children develop tools to respond to

extreme stress, disruption, and change, including

mature judgment, capacity to tolerate ambiguity,

autonomy, willingness to shoulder responsibility,

and moral certitude (Wolin and Wolin 1993).

Nonetheless, substance abuse can lead to inappropriate family subsystems and role taking.

For instance, in a family in which a mother

uses substances, a young daughter may be

expected to take on the role of mother. When a

child assumes adult roles and the adult abusing

substances plays the role of a child, the boundaries essential to family functioning are

24 Impact of Substance Abuse on Families
   

                   

         

   

             

             

               

       

               

   

           

             

             

           

             

               

             

             

         

         

           

       

   

         

         

       

             

         

           

         

       

             

       

         

           

     

         

           

           

             

         

           

   

   

   

   

     

     

     

   

     

     

   

     

   

   

     

   

             

         

         

         

           

         

               

           

             

           

             

             

         

             

         

             

           

       

         

             

                 

             

       

       

             

           

blurred. The developmentally inappropriate

role taken on by the child robs her of a childhood, unless there is the intervention by

healthy, supportive adults.

The spouse of a person abusing substances is

likely to protect the children and assume parenting duties that are not fulfilled by the parent

abusing substances. If both parents abuse

alcohol or illicit drugs, the effect on children

worsens. Extended family members may have

to provide care as well as financial and psychological support. Grandparents frequently

assume a primary caregiving role. Friends and

neighbors may also 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.

Sometimes it is a neighbor who brings a child

abuse or neglect situation to the attention of

child welfare officials. Most of the time, however,

these situations go unreported and neglected.

Client Is Part of a Blended

Family

Anderson (1992) notes that many people who

abuse substances belong to stepfamilies. Even

under ordinary circumstances, stepfamilies

present special challenges. Children often live

in two households in which different boundaries

and ambiguous roles can be confusing.

Effective coparenting requires good communication and careful attention to possible areas of

conflict, not only between biological parents,

but also with their new partners. Popenoe

(1995) believes that the difficulty of coordinating

boundaries, roles, expectations, and the need

for cooperation, places children raised in

blended households at far greater risk of social,

emotional, and behavioral problems. Children

from stepfamilies may develop substance abuse

problems to cope with their confusion about

family rules and boundaries.

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 issues might include parental authority

disputes, sexual or physical abuse, and

self­esteem problems

for children. Data on the

enduring effects of

parental substance

abuse on children

suggest that a

parent’s drinking

problem often has

a detrimental

effect on children.

Substance abuse by

stepparents may

further undermine

their authority, lead

to difficulty in forming bonds, and impair

a family’s ability to

address problems and

sensitive issues. If the

noncustodial parent

abuses drugs or alcohol, visitation may

have to be supervised.

(Even so, visitation is

important. If contact

stops, children often

blame themselves or

the drug problem for

a parent’s absence.)

If a child or adolescent abuses substances, any

household can experience conflict and continual

crisis. Hoffmann (1995) found that increased

adolescent marijuana use occurs more

frequently when an adolescent living with a

divorced parent and stepparent becomes less

attached to the family. With fewer ties to the

family, the likelihood increases that the adolescent will form attachments to peers who abuse

substances. Weaker ties to the family and

stronger ones to peers using drugs increase

the chances of the adolescent starting to use

marijuana or increasing marijuana use.

Stepparents living in a household in which an

adolescent abuses substances may feel they

have gotten more than they bargained for and

resent the time and attention the adolescent

requires from the biological parent.

Stepparents may demand that the adolescent

leave the household and live with the other

parent. In fact, a child who is acting out and

abusing substances is not likely to be welcomed

in either household (Anderson 1992).

Clinicians treating substance abuse should

know that the family dynamics of blended

families differ somewhat from those of nuclear

families and require some additional 

Impact of Substance Abuse on Families 25
     

           

           

           

         

             

     

         

           

         

           

       

         

         

             

         

           

               

       

           

     

                 

               

       

   

     

     

   

   

   

       

     

     

   

   

     

   

         

           

           

           

             

         

             

   

           

         

       

                 

           

             

             

             

           

         

           

           

         

             

           

           

           

                   

             

               

           

         

               

           

         

           

           

               

         

           

         

           

               

               

           

considerations. Anderson (1992) identifies

strategies for addressing substance abuse in a

stepfamily:

•The use of a genogram, which graphically

depicts significant people in the client’s life,

helps to establish relationships and pinpoint

where substance abuse is and has been

present (see chapter 3).

•Extensive historical work helps family members exchange memories that they have not

previously shared.

•Education can provide a realistic expectation

of what family life can be like.

•The development of correct and mutually

acceptable language for referring to family

relationships helps to strengthen family ties.

The goal of family therapy is to restructure

maladaptive family interactions that are associated with the substance abuse problem. To

do this, the counselor first has to earn the

family’s trust, which means approaching

family members on their own terms.

Older Client Has Grown
 

Children
 

When an adult, age 65 or older, abuses a

substance it is most likely to be alcohol and/or

prescription medication. The 2002 National

Household Survey

on Drug Abuse

found that 7.5 percent of older adults

Many health care reported binge and

providers underestimate the extent

of substance abuse

problems among

older adults.	 

1.4 percent reported

heavy drinking within the past month of

the survey (Office of

Applied Studies

[OAS] 2003a).

Veterans hospital

data indicate that, in

many cases, older

adults may be

receiving excessive

amounts of one class

of addictive tranquilizer (benzodiazepines), even though they should receive

lower doses. Further, older adults take these

drugs longer than other age groups (National

Institute on Drug Abuse [NIDA] 2001). Older

adults consume three times the number of prescription medicine as the general population,

and this trend is expected to grow as children of

the Baby Boom (born 1946–1958) become senior

citizens (NIDA 2001).

As people retire, become less active, and develop

health problems, they use (and sometimes misuse) an increasing number of prescription and

over­the­counter drugs. Among older adults,

the diagnosis of this (or any other) type of substance use disorder often is difficult because

the symptoms of substance abuse can be similar

to the symptoms of other medical and behavioral problems that are found in older adults,

such as dementia, diabetes, and depression. In

addition, many health care providers underestimate the extent of substance abuse problems

among older adults, and, therefore, do not

screen older adults for these problems.

Older adults often live with or are supported

by their adult children because of financial

necessity. An older adult with a substance

abuse problem can affect everyone in the

household. If the older adult’s spouse is present,

that person is likely to be an older adult as well

and may be bewildered by new and upsetting

behaviors. Therefore, a spouse may not be in a

position to help combat the substance abuse

problem. Additional family resources may need

to be mobilized in the service of treating the

older adult’s substance use disorder. As with

child abuse and neglect, elder maltreatment is

a statutory requirement for reporting to local

authorities.

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, chil26 Impact of Substance Abuse on Families
                 

               

           

         

           

               

         

       

       

       

     

       

         

             

           

           

           

             

               

             

             

             

           

         

       

             

               

               

           

           

           

         

         

                 

     

         

       

     

     

             

           

         

     

     

             

       

             

           

         

             

           

             

               

           

           

         

             

             

                 

       

       

             

           

           

         

           

     

         

         

           

           

         

         

         

         

           

           

           

       

dren 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 his predicament.

For a detailed discussion of substance problems

in older adults, see TIP 24, A Guide to

Substance Abuse Services for Primary Care

Clinicians (CSAT 1997a) and TIP 26,

Substance Abuse Among Older Adults (CSAT

1998d). See also chapter 5.

Client Is an Adolescent and

Lives With Family of Origin

Substance use and abuse among adolescents

continues to be a serious condition that impacts

cognitive and affective growth, school and work

relationships, and all family members. In the

National Household Survey on Drug Abuse, of

adolescents ages 12 to 17, 10.7 percent reported binge use of alcohol (five drinks on one

occasion in the last month before the survey)

and 2.5 percent reported heavy alcohol use (at

least five binges in the previous month) (OAS

2003a). In addition, two trends described in

TIP 32, Treatment of Adolescents With

Substance Use Disorders (CSAT 1999e), are

increasing rates of substance use by youth and

first onset of substance use at younger ages.

In a general population sample of 10­ to

20­year­olds, roughly 12.4 percent (96 of 776)

met criteria for a substance use disorder

(Cohen et al. 1993). Alcohol and other 

psychoactive drugs play a prominent role in

violent death for teenagers, including homicide,

suicide, traffic accidents, and other injuries.

Aside from death, drug use can lead to a range

of possible detrimental consequences:

•Violent behavior

•Delinquency

•Psychiatric disorders

•Risky sexual behavior, possibly leading to

unwanted pregnancy or sexually transmitted

diseases

•Impulsivity

•Neurological impairment

•Developmental impairment (Alexander and

Gwyther 1995; CSAT 1999e)

As youth abuse alcohol and illicit drugs, they

may establish a continuing pattern of behavior

that damages their legal record, educational

options, psychological stability, and social

development. Drug use (particularly inhalants

and solvents) may lead to cognitive deficits and

perhaps irreversible brain damage. Adolescents

who use drugs are likely to interact primarily

with peers who use drugs, so relationships with

friends, including relationships with the opposite sex, may be unhealthy, and the adolescent

may develop a limited repertoire of social

skills.

When an adolescent uses alcohol or drugs,

siblings in the family may find their needs and

concerns ignored or minimized while their

parents react to constant crises involving the

adolescent who abuses drugs. The neglected

siblings and peers may look after themselves

in ways that are not age­appropriate, or they

might behave as if the only way to get attention

is to act out.

Clinicians should not miss opportunities to

include siblings, who are often as influential as

parents, in the family therapy sessions treating

substance abuse. Whether they are adults or

children, siblings can be an invaluable

resource. In addition, Brook and Brook (1992)

note that sibling relationships characterized by

mutual attachment, nurturance, and lack of

conflict can protect adolescents against

substance abuse.

Another concern often overlooked in the

literature is the case of the substance­using

adolescent whose parents are immigrants and

cannot speak English. Immigrant parents often

are perplexed by their child’s behavior.

Degrees of acculturation between family

members create greater challenges for the

family to address substance abuse issues and

exacerbate intergenerational conflict.

In many families that include adolescents who

abuse substances, at least one parent also abuses

substances (Alexander and Gwyther 1995).

Impact of Substance Abuse on Families 27
             

       

           

           

           

           

           

             

                 

           

           

               

         

     

         

             

         

           

           

         

                 

           

           

           

             

             

         

                 

         

             

       

             

           

           

             

       

         

         

   

     

     

           

               

             

         

         

             

             

             

         

             

         

         

           

         

         

             

         

             

         

       

               

     

         

           

           

         

     

             

         

       

       

             

     

           

         

               

             

       

           

             

         

           

       

This unfortunate modeling can set in motion a

dangerous combination of physical and emotional problems. If adolescent substance use is

met with calm, consistent, rational, and firm

responses from a responsible adult, the effect

on adolescent learning is positive. If, however,

the responses come from an impaired parent,

the hypocrisy will be obvious to the adolescent,

and the result is likely to be negative. In some

instances, an impaired parent might form an

alliance with an adolescent using substances to

keep secrets from the parent who does not use

substances. Even worse, sometimes in families

with multigenerational patterns of substance

abuse, an attitude among extended family

members may be that the adolescent is just

conforming to the family history.

Since the early 1980s, treating adolescents who

abuse substances has proven to be effective.

Nevertheless, most adolescents will deny that

alcohol or illicit drug use is a problem and do

not enter treatment unless parents, often with

the help of school­based student assistant programs or the criminal justice system, require

them to do so. Often, a youngster’s substance

abuse is hidden from members of the extended

family. Adolescents who are completing treatment need to be prepared for going back to an

actively addicted family system. Alateen, along

with Alcoholics Anonymous, can be a part of

adolescents’ continuing care, and participating

in a recovery support group at school (through

student assistance) also will help to reinforce

recovery.

For more information on substance use among

adolescents, see chapter 5. See also TIP 31,

Screening and Assessing Adolescents for

Substance Use Disorders (CSAT 1999c), and

TIP 32, Treatment of Adolescents With

Substance Use Disorders (CSAT 1999e).

Someone Not Identified as

the Client Abuses Substances

Substance abuse may not be the presenting

issue in a family. Initially, it may be hidden,

only to become apparent during therapy. If any

suspicion of substance abuse emerges, the

counselor or therapist should evaluate the

degree to which substance abuse has a bearing

on other issues in the family and requires

direct attention.

When someone in the family other than the

person with presenting symptoms is involved

with alcohol or illicit drugs, issues of blame,

responsibility, and causation will arise. With

the practitioner’s help, the family needs to

refrain from blaming, and reveal and repair

family interactions that create the conditions

for substance abuse to continue.

Other Treatment Issues

In any form of family therapy for substance

abuse treatment, consideration should be given

to the range of social problems connected to

substance abuse. Problems such as criminal

activity, joblessness, domestic violence, and

child abuse or neglect may also be present in

families experiencing substance abuse. To

address these issues, treatment providers need

to collaborate with professionals in other fields.

This is also known as concurrent treatment.

Whenever family therapy and substance abuse

treatment take place concurrently, communication between clinicians is vital. In addition to

family therapy and substance abuse treatment,

multifamily group therapy, individual therapy,

and psychological consultation might be 

necessary. With these different approaches,

coordination, communication, collaboration,

and exchange of the necessary releases of confidential information are required.

With concurrent treatment, it is important that

goal diffusion does not occur. Empowering the

family is a benefit of family therapy that should

not be sacrificed. If family therapy and substance abuse treatment approaches conflict,

these issues should be addressed directly. Case

conferencing often is an efficient way to deal

constructively with multiple concerns and provides a forum to determine mutually agreeable

priorities and treatment plan coordination.

28 Impact of Substance Abuse on Families
           

             

               

             

               

         

       

           

                 

                   

           

             

                   

             

         

   

           

             

           

               

               

       

       

                       

                         

       

             

                       

                       

                   

                     

Some concurrent treatment may not involve the

person with alcohol or illicit drug problems. Even

if this person is not in treatment, family therapy

with the partner and other family members can

often begin, or family therapy can be an addition

to substance abuse treatment. The detoxification

period also presents valuable opportunities to

involve family members in treatment. Family therapy may have more of an impact on family members than it does on the IP because it enhances all

family members’ ability to work through conflicts.

It may establish healthy family conditions that support the IP moving into recovery later in his or her

life, after the episode of treatment has ended.

Sometimes the person who abuses substances will

not allow contact with the family, which limits the

possibilities of family therapy, but family involvement in substance abuse treatment can still remain

a goal; this “resistance” can be restructured by

allying with the person with the substance use disorder and stressing the importance of and need for

family participation in treatment. Resiliency within

the family system is a developing area of interest (for

more information see, for example,

http://www.WestEd.org).

Chapter 2 Summary Points From a

Family Counselor Point of View

•Consider the “family” from the client’s point of view—that is, who would the

client describe as a family member and who is a “significant other” for the

client.

•Assess the “family”­members’ effectiveness of communications, supportiveness

or negativity, parenting skills, conflict management, and understanding of

addictive disease.

•Don’t give up, and try, try again—many families or family members at first

reject any participation in the treatment process. But, after a period of

separation from the client who is abusing substances, family members often

become willing to at least attend an initial session with the counselor.

Impact of Substance Abuse on Families 29

                 

                         

                     

                   

           

               

                     

                 

               

         

                   

                       

                     

                 

                   

                 

                   

           

             

                 

                   

In This
 

Chapter...
 

Differences in
 

Theory and
 

Practice
 

Family Therapy for
 

Substance Abuse
 

Counselors
 

Substance Abuse
 

Treatment for
 

Family Therapists
 

3 Approaches to

Therapy

Overview 

This chapter discusses the fields of substance abuse treatment and family

therapy. The information presented will help readers from each field

form a clearer idea of how the other operates. It also will present some

of the basic theories, concepts, and techniques from each field so they

can be applied in treatment regardless of the setting or theoretical 

orientation.

Substance abuse treatment and family therapy are distinct in their histories, professional organizations, preferred intervention techniques, and

focuses of treatment. Training and licensing requirements are different,

as are rules (both formal and informal) that govern conduct. The two

fields have developed their own vocabularies. These differences have

significant and lasting effects on how practitioners approach clients,

define their problems, and undertake treatment.

Despite these variations, providers from both fields will continue to treat

many of the same clients. It is useful, therefore, for clinicians in each

field to understand the treatment that the other field provides and to

draw on that knowledge to improve prospects for professional collaboration. The ultimate goal of increased understanding is the provision of

substance abuse treatment that is fully integrated with professional family

therapy.

Differences in Theory and Practice

Theory

The fields of substance abuse treatment and family therapy share many

common assumptions, approaches, and techniques, but differ in significant philosophical and practical ways that affect treatment approaches

and goals for treatment. Further, within each discipline, theory and

practice differ. Although of the two, substance abuse treatment is

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Denial and Resistance

The fields of substance abuse treatment and family therapy often use different

terms and sometimes understand the same terms differently. For example, the

term denial can have different meanings for a substance abuse counselor and a

family therapist. Two family therapists with different theoretical orientations

also may understand the meaning in different ways.

In substance abuse treatment, the term denial is generally used to describe a

common reaction of people with substance use disorders who, when confronted

with the existence of those disorders, deny that they have a substance abuse

problem. This is a complex reaction that is the product of psychological and

physiological factors, especially those concerned with memory and the influence

of euphoria produced by the substance of abuse. It is not a deliberate, willful act

on the part of the person who is abusing substances but is rather a set of defenses

and distortions in thinking caused by the use of substances.

Family therapists’ understanding of the term denial will vary more according to

the particular therapist’s theoretical orientation. For example, structural and

strategic therapists might see denial as a boundary issue (referring to a barrier

within the family structure of relationships), which may be necessary for maintaining an alliance or contributing to relationships that are too close or

enmeshed. On the other hand, a solution­focused therapist might see denial as a

strategy for maintaining stability and therefore not a “problem” at all, while a

narrative therapist will simply see denial as another element in a person’s story.

Resistance is, in contrast, a relatively straightforward negative response to

someone expecting you to do something that you do not want to do. The clinician

can minimize resistance by understanding the client’s stage of change and being

prepared to work with the client based on interventions geared to that stage.

If clinicians treat individual clients (or their families) at their actual stage of

readiness or level of motivation to change, they should encounter minimal client

resistance. In other words, clinicians can only do so much when a client is not

ready to change or try a new behavior. Still, counselors can help the client move

slowly from one stage of change to another. If treatment is in sync with readiness

for that treatment, resistance should not become a significant problem.

Resistance may be based on the client not yet being able to do something. When

therapists can accept that clients are not always “resisting” because they don’t

want to do something, but perhaps because they are unable to do something,

they are better able to enter the client’s world to explore what is causing the

resistance.

There is a difference between the therapist saying (or believing) “You refuse to

do _________” and saying/believing, “Let’s explore what could be in the way of

your doing __________.” One way of dealing with client resistance is to offer the

client some typical reasons for not complying: e.g., “Sometimes, when a client is

unable to talk about his early childhood, it is because he is ashamed or embar32 Appoaches to Therapy
           

           

             

             

     

           

       

                 

               

           

           

           

             

             

               

     

             

       

           

         

         

             

         

                   

               

           

       

         

           

               

               

             

           

       

               

     

             

           

           

     

               

             

         

           

           

             

                 

             

           

               

             

           

         

       

       

       

         

       

       

               

           

           

               

         

           

                           

                             

                   

                       

                           

                     

                           

rassed or afraid of crying or perhaps that I (the therapist) might think the information is bizarre. I wonder if this is something that is going on with you?” The

same technique works with resistance to therapeutic suggestions for carrying out

a plan constructed during a therapy session: “Sometimes, a client does not carry

out the plan we’ve made because I was moving too fast or perhaps didn’t know

all of the dynamics that you find when you get home, or maybe because we didn’t

talk enough about the potential consequences for carrying out the action, for

instance, maybe your child will run away or you need to try some other things

first.”

Source: Consensus Panel.

generally more uniform in its approach, in

both cases certain generalizations apply to the

practice of the majority of providers. Two concepts essential to both fields are denial and

resistance presented by clients.

Clinical research (e.g., Szapocznik et al. 1988)

has demonstrated that resistance (whether on

the part of the person with a substance use disorder or on the part of another family member)

to engaging family members into therapy

accurately may reflect the family dynamics that

help to maintain the substance abuse problem.

Therefore, it may be important to work with

the client and family to restructure this resistance in order to bring the family into treatment

and correct the maladaptive interactional

patterns that are related to the substance abuse

problem.

Many substance abuse treatment counselors

base their understanding of a family’s relation

to substance abuse on a disease model of substance abuse. 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.

In other words, the individual member’s substance abuse and the pain and confusion of the

family relate to each other as cause and effect.

Berenson and Schrier (1998) note that the

disease model is pragmatic in orientation,

having developed typically through practice

and not having been drawn from theory or

controlled experimentation. The disease model

also views substance use disorders as having a

genetic component and as being similar to

recurrent medical diseases in that both are

“chronic, progressive, relapsing, incurable,

and potentially fatal” (Inaba et al. 1997, p. 66).

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 system, more than the

inclusion of more people, that defines family

therapy. The size of the family system can vary

from two (in couples therapy) to an extended

family, and may even involve multiple systems

(for instance, schools and workplaces) that

affect family members (Walsh 1997).

This theoretical perspective emphasizes reciprocal relationships. Substance abuse is believed

to interact with dysfunctional family relationships, thereby maintaining both problems.

Family therapists believe that interpersonal

relationships need to be altered so that the family

becomes an environment within which the person abusing substances can stop or decrease

use and the needs of family members can be

met. Family systems approaches have been

developed out of a strong theoretical tradition,

Appoaches to Therapy 33
   

         

         

       

           

           

           

           

         

         

               

         

             

           

             

         

       

             

       

           

             

           

               

             

     

         

     

           

             

               

         

         

           

           

         

       

           

       

             

           

           

         

       

             

         

           

         

                 

           

             

           

           

           

               

         

         

           

           

           

           

   

       

               

       

       

           

           

         

               

             

               

             

             

             

           

           

       

             

         

           

           

       

         

but do not have many empirical studies 

validating their effectiveness (Berenson and

Schrier 1998). (See TIP 34, Brief Interventions

and Brief Therapies for Substance Abuse

[Center for Substance Abuse Treatment

(CSAT) 1999a], for more information on the

specific approaches to family therapy, all of

which draw on a systems model.)

The fields of family therapy and substance

abuse treatment, despite their basic differences, are compatible. For example, family

therapy may seem to have a monopoly on the

systems approach, and substance abuse

treatment may appear to focus solely on the

individual, with less emphasis on the individual’s relationship to any larger system. In fact,

however, both family therapy and substance

abuse treatment actually understand substance

abuse in relation to systems. They simply focus

treatment on different systems. Substance

abuse treatment providers typically focus on a

system consisting of a person with a substance

use disorder and the nature of addiction.

Family therapists see the system as a person in

relation to the family. Clearly, the reaction of

the family to the client, the reaction of the client

to the family, and the nature of addiction can

be mutually reinforcing dynamics.

Clinicians in both fields address client interactions with a system that involves something

outside the self. It should be noted that neither

substance abuse treatment nor family therapy

routinely considers other, broader systems: culture and society. Multiple systems affect people

with substance use disorders at different levels

(individual, family, culture, and society), and

truly comprehensive treatment would take all

of them into consideration. Family and substance abuse treatment potentially undervalue

the influence and power of gender and stereotypical roles imposed by the culture. Feminist

and cultural family therapists caution that by

ignoring the power differentials within and

between cultures, therapists can potentially

harm the client and family. For example, by

not recognizing the differences in power

between men and women, and advocating for

parity and equality in a relationship, the

therapist might disrupt the power differential

in a family and, if not addressed, cause more

conflict and potential harm to the family.

The mental health field in general now recognizes addiction as an independent illness warranting specific treatment on an equal footing

with mental health treatment (CSAT in development k). So, too, have the majority of family

therapists (and group therapists—see CSAT in

development g) recognized the importance of

direct treatment attention for the addictive disorder in addition to family therapy interventions.

Practice

Following is a general overview of the differences that exist among many, but certainly not

all, substance abuse and family therapy

settings and practitioners.

Family interventions

Substance abuse treatment programs that

involve the family of a person who is abusing

substances generally use family interventions

that differ from those used by family therapists.

Psychoeducation and multifamily groups are

more common in the substance abuse treatment

field than in family therapy. 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 (although some types of family

therapy, such as strategic family therapy, are

brief).

The understanding of the relative importance

of different issues in a client’s recovery

naturally influences the techniques and interventions used in substance abuse treatment

and family therapy. Family therapists will focus

more on intrafamily relationships while 

substance abuse treatment providers concentrate on helping clients achieve abstinence.

34 Appoaches to Therapy
         

             

             

       

         

           

           

             

         

           

           

         

         

             

         

             

           

         

           

             

             

     

           

       

           

           

           

           

         

             

             

         

             

             

                   

       

             

         

           

         

             

           

             

   

     

   

   

     

   

       

   

   

   

     

     

   

   

     

     

   

         

               

           

           

             

             

           

             

   

             

             

         

       

         

       

               

           

             

         

             

           

       

             

             

Spirituality

Spirituality is another practice that clinicians

in the two fields approach differently. In part

because of the role of spirituality in 12­Step

groups, substance abuse treatment providers

generally consider this 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 reduced the

role of spirituality, especially in theory and

largely in clinical practice. The lack of emphasis

on spiritual life in family therapy continues

even though religious affiliation has been

shown to negatively correlate with substance

abuse (Miller et al. 2000; National Center on

Addiction and Substance Abuse 2001; Pardini

et al. 2000). Some family therapy is conducted

within religious settings, often by licensed pastoral counselors. However, a standard concept

of spirituality, whether religious in origin or

otherwise, has not yet been clearly agreed on

by clinicians of any discipline in the substance

abuse treatment field.

Process and content 

Family therapy generally attends more to the

process of family interaction, while substance

abuse treatment is usually more concerned with

the planned content of each session. The family

therapist is trained to observe the interactions

of family members and employ treatment methods in response to those observations. Some

family therapists may even see a client’s substance abuse as a content issue (and therefore

less significant than the family interactions).

For example, a wife might begin describing how

upset and hopeless she felt when her husband

had a slip, only to be interrupted by him in a

subtly threatening tone and/or condescending

manner. The family therapist might zero in on

whether the husband regularly interrupts and

aggressively changes the course of a conversation whenever his wife expresses emotions—in

other words, is what just occurred an instance

of a general pattern of interaction (process)

between husband and wife? And, what is the

purpose/goal of the

process—is it the

Both family

therapy and

substance abuse

treatment

understand substance abuse in

relation to

systems.

husband’s way of

avoiding emotions or

of avoiding his own

disappointment about

the slip and inability

to have protected his

wife from the consequence of illness? On

the other hand, a

substance abuse

counselor might

concentrate on the

content of the issues

raised by the interchange—that is, the

counselor might point

out to the husband

that alcoholism is a

family disease, that

his slip does have serious consequences, and

that his slip and his wife’s initial upset and

hopelessness are how the disease of alcoholism

separates the person with the substance abuse

disorder from what is held dear. The counselor

might further focus on the content issues of

handling slips, learning from them, and

recognizing that they are sometimes part of

a successful recovery.

A number of essential aspects of addictive disease form the general basis for substance abuse

counseling. For addictions, certain themes are

essential and are always explored—shame,

denial, the “cunning, baffling, and powerful”

nature of addiction (Alcoholics Anonymous

[AA] 1976, pp. 58­59)—as well as the fact that

recovery is a long­term proposition. These are

all essential in part because most people with

substance use disorders enter treatment with

beliefs opposite to the facts. In contrast, these

differences support the need for more crosstraining between the two disciplines.

Focus

Even when treating the same clients with the

same problems, clinicians in the fields of family

therapy and substance abuse treatment typically

Appoaches to Therapy 35
             

             

         

           

             

   

     

     

     

   

   

     

   

   

   

   

   

   

   

         

         

           

           

         

               

             

             

           

         

             

                 

         

           

             

           

       

             

                 

             

         

           

               

         

           

           

             

             

               

       

           

               

             

       

         

             

         

         

     

           

             

         

             

       

           

           

             

             

               

           

         

             

         

         

           

           

         

         

         

           

     

focus on different targets. For instance, if a

man who has been abusing cocaine comes with

his wife to a substance abuse treatment program, the counselor will identify the substance

abuse as the presenting problem. Initially, at

least, the substance abuse counselor will see the

primary goal as arresting the client’s 

substance use.

A family therapist,

on the other hand,

will see the family

system—which could

Research suggests	 

that counselors

and therapists

need to balance

their selfdisclosure.	 

be just the

couple—as an

integral component

of the substance

abuse. The goals of

the family therapist

will usually be

broader than the

substance abuse

counselor’s, focusing

on improving

relational patterns

throughout the family

system. Because

families change their

patterns of interaction over the course

of recovery, they are believed to need continued

assistance to avoid developing another

dysfunctional pattern.

Identity of the client

Most often the substance abuse counselor

regards the individual with the substance use

disorder as the primary person requiring treatment. While practitioners from both fields

would generally agree that a client with a

substance use disorder needs to stop using

substances, they may not agree on how that

end can best be accomplished. A common

assumption in substance abuse treatment is

that the problems of other family members do

not need to be resolved for the client to achieve

and maintain abstinence. The substance abuse

treatment provider may involve the family to

some degree, but the focus remains on the

treatment needs of the person abusing substances. 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.

Unfortunately, such integrated treatment is not

always possible because of lack of funding.

Who is seen in treatment also varies by field.

Even though many substance abuse treatment

programs feature a component for family members, most counselors and programs will not

involve a client’s family in early treatment (an

exception is the type of interventions that use

family and friends to motivate a client to enter

treatment). Most substance abuse treatment

programs will work with the client’s family

once a client has achieved some level of abstinence. At the time the client enters treatment,

however, substance abuse treatment providers

often refer family members, including children,

to a separate treatment program or to self­help

groups such as Al­Anon, Nar­Anon, and

Alateen (see appendix D). While educational

support groups offer age­appropriate understanding about addiction as well as opportunities

for participants to share their experiences and

learn a variety of coping skills, few treatment

programs provide such groups. School­age

children can also be referred to student assistance programs at their schools.

In contrast, family therapists may not treat

clients who are actively abusing substances, but

may carry on therapy with other family members. Family therapists do not always meet with

all members of the family but with several

subgroups at different times, depending on the

issues under discussion. For instance, children

would likely not be present when parents are

discussing marital conflict issues or struggling

with the decision to separate or to stay together.

However, when the issues under discussion

include the behavior of the children, they

would be expected to be present. However,

children first need age­appropriate services so

they can develop the necessary understanding

about addiction, sort through their experiences

and feelings, and become prepared to participate in family therapy.

36 Appoaches to Therapy
         

           

         

           

           

         

               

             

         

               

               

           

             

             

         

         

         

               

                 

             

       

         

           

         

           

             

       

         

           

               

         

             

               

           

           

       

               

           

             

           

         

             

         

           

     

           

         

             

         

       

           

         

       

               

           

       

         

         

           

         

       

       

       

         

           

         

             

       

     

         

         

             

       

         

         

       

           

         

   

         

           

             

             

           

Self­disclosure by the 

counselor

Training in the boundaries related to the

therapist’s or counselor’s self­disclosure is an

integral part of any treatment provider’s education. Addiction counselors in recovery themselves are trained to recognize the importance

of choosing to self­disclose their own addiction

histories, and to use supervision appropriately

to decide when and what to disclose. An oftenused guide for self­disclosure is to consider the

reason for revealing personal addiction history

to the client, asking the question, “What is the

purpose of the revelation? To assist the client in

recovery or for my own personal needs?”

Many people who have been in recovery for

some time and who have experience in self­help

groups have become paraprofessional or professional treatment providers. Clients, it should

be emphasized, must be credited and acknowledged for their ability to effect change in their

own lives so that they might lay claim to their

own change. 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,

where people seek help from other recovering

people. As a result, clients usually feel comfortable with the counselors’ self­disclosure.

The practice of sharing personal history

receives much less emphasis in family therapy,

in part because of the influence of a psychoanalytic tradition in family therapy. For the family

therapist, self­disclosure is not as integral a

part of the therapeutic process. It is downplayed because it takes the focus of therapy off

of the family. (More recent post­modern therapies such as narrative therapy and collaborative

language systems emphasize the meaning of

language and the subjectivity of truth. The

therapist’s talking about personal experiences

to gain some shared truth with the client(s) is

part of the process. “Truth” is co­created

between therapist and client, so sharing is

natural and represents what the client perceives and understands, and the therapist

attempts to open up different truths or stories

that challenge the client’s dominant story.)

Perhaps neither field has taken the best

approach to therapist self­disclosure. Research

suggests that counselors and therapists need to

balance their self­disclosure. If the therapist

never discloses anything, the result may be less

self­disclosure by the client (Barrett and

Berman 2001). Too much self­disclosure, on

the other hand, might shut down conversation

and decrease client self­disclosure. In addition,

such information may be inappropriate for

children who are present since they may not be

able to process or comprehend the information,

therefore adding to their confusion.

Regulations 

Finally, different regulations also affect the

substance abuse treatment and family therapy

fields. This influence comes from both government agencies and third­party payors that

affect confidentiality and training and licensing

requirements. Federal regulations attempt to

guarantee confidentiality for people who seek

substance abuse assessment and treatment (42

U.S.C. §290dd­2 and 42 CFR Part 2).

Treatment providers should be familiar with

regulations in their State that may affect both

confidentiality and training and licensing

requirements. Confidentiality issues are

complex; readers interested in additional

information should see TAP 13, Confidentiality

of Patient Records for Alcohol and Other Drug

Treatment (Lopez 1994), and TAP 18,

Checklist for Monitoring Alcohol and Other

Drug Confidentiality Compliance (CSAT

1996a).

Confidentiality issues for family therapists are

less straightforward. For example, family therapists working with adolescents will have more

trouble dealing with issues of client­therapist

boundaries and confidentiality. Sometimes

when treating adolescents who abuse substances, past or planned criminal behavior is

evident. A strong interest in family therapy is

restoring the authority of parents, yet State law

might restrict the therapist’s right to divulge

Appoaches to Therapy 37
         

         

                 

           

           

           

             

         

             

   

   

         

         

         

           

           

           

     

           

         

             

       

             

             

     

       

     

         

         

           

           

         

       

         

           

           

           

       

         

           

         

       

         

           

       

           

         

           

           

           

         

   

       

           

               

           

       

           

           

           

           

           

           

             

           

                 

information to parents unless the adolescent

signs a properly worded release document.

Laws differ from State to State, but they can be

specific and strict about what therapists are

required or permitted to do about reporting

crime or sharing information with parents. For

more information on this subject see TIP 32,

Treatment of Adolescents With Substance Use

Disorders (CSAT 1999e).

Licensure and certification

Forty­two States require licenses for people

practicing as family therapists (American

Association for Marriage and Family Therapy

[AAMFT] 2001). Although the specific educational requirements vary from State to State,

most require at least a Master’s degree for the

person who intends to practice independently as

a family therapist. Certain States, such as

California, also require particular courses for

licensure. Training in substance abuse treatment

is generally not required, although the

Commission on Accreditation for Marriage and

Family Therapy Education of the AAMFT does

suggest that family therapists receive some training in substance abuse counseling. (More information on the licensing and certification requirements of the various States is available online at

http://www.aamft.org/iMIS15/AAMFT/—this

Web site also features links to State agencies

that oversee certification.)

The International Certification and Reciprocity

Consortium (IC&RC) on Alcohol and Other

Drug Abuse is the most far­reaching, providing

credentials in prevention and/or counseling to

counselors in 41 States, Puerto Rico, three

branches of the military, 11 foreign countries,

and the Indian Health Service. IC&RC has

created standards for credentialing substance

abuse counselors that require 270 hours of

classroom education (on knowledge of substance abuse, counseling, and ethics, as well as

assessment, treatment planning, clinical evaluation, and family services), 300 hours of onsite

training, and 3 years of supervised work

experience (IC&RC 2002).

NAADAC (The Association for Addiction

Professionals, formerly the National

Association of Alcohol and Drug Abuse

Counselors) also provides certification in many

States that also have IC&RC reciprocity. For

substance abuse counselors at the most basic

level, NAADAC demands less monitoring and

fewer requirements than does IC&RC, though

its higher­level credentials have many more

requirements than those at the basic level.

NAADAC offers the only Master’s level credential based on education and not experience.

NAADAC’s Web site is http://www.naadac.org.

In addition, the Addiction Technology Transfer

Centers, which are partially funded by CSAT,

provide information at the Web site

http://www.nattc.org with links to State,

national, and international bodies that credential counselors. However, there is little training

and few credentialing requirements for understanding the impact of addiction on children

and effective ways to help them.

Assessment

Specific procedures for assessing clients in substance abuse treatment and family therapy will

vary from program to program and practitioner

to practitioner. However, an overview of these

activities is useful.

Assessment in substance

abuse treatment

Assessments for substance abuse treatment

programs focus on substance use and history.

Figure 3­1 presents an overview of some of the

key elements that are examined when assessing

a client’s substance abuse history—including

important related concerns such as family

relations, sexual history, and mental health.

Substance abuse counselors may not be familiar

with ways family therapy can complement substance abuse treatment. Because of their focus

on substances of abuse and the intrapsychic

dynamics of the identified patient (IP), counselors simply may not think of referral for family

therapy. Other counselors may view conflict in

a family as a threat to abstinence and a reason

38 Appoaches to Therapy
                 

           

                 

                   

   

                   

         

               

                 

     

         

                 

           

   

                   

     

       

       

                 

                   

   

                         

               

             

           

Figure 3­1

Overview of Key Elements for Inclusion in

Assessment

Standard Medical History and Physical Exam, With Particular Attention to

the Presence of Any of the Following

•Physical signs or complaints (e.g., nicotine stains, dilated or constricted

pupils, needle track marks, unsteady gait, tattoos that designate gang

affiliation, “nodding off”)

•Neurological signs or symptoms (e.g., blackouts or other periods of memory

loss, insomnia or other sleep disturbances, tremors)

•Emotional or communicative difficulties (e.g., slurred, incoherent, or too

rapid speech; agitation; difficulty following conversation or sticking to the

point)

Skinner Trauma History

Since your 18th birthday, have you

•Had any fractures or dislocations to your bones or joints?

•Been injured in a road traffic accident?

•Injured your head?

•Been injured in an assault or fight (excluding injuries during sports)?

•Been injured after drinking?

Source: Skinner et al. 1984.

Alcohol and Drug Use History

•Use of alcohol and drugs (begin with legal drugs first)

•Mode of use with drugs (e.g., smoking, snorting, inhaling, chewing, injecting)

•Quantity used

•Frequency of use

•Pattern of use: date of last drink or drug used, duration of sobriety, longest

abstinence from substance of choice (when did it end?)

•Alcohol/drug combinations used

•Legal complications or consequences of drug use (selling, trafficking)

•Craving (as manifested in dreams, thoughts, desires)

Appoaches to Therapy 39
   

         

                 

                           

                     

             

   

         

                 

           

           

                   

                     

   

               

                 

         

             

   

                   

     

                 

               

                     

                           

                             

           

                     

   

                   

                 

           

                 

                       

Family/Social History

•Marital/cohabiting status

•Legal status (minor, in custody, immigration status)

•Alcohol or drug use by parents, siblings, relatives, children, spouse/partner

(probe for type of alcohol or drug use by family members since this is frequently an important problem indicator: “Would you say they had a drinking

problem? Can you tell me something about it?”)

•Alienation from family

•Alcohol or drug use by friends

•Domestic violence history, child abuse, battering (many survivors and

perpetrators of violence abuse drugs and alcohol)

•Other abuse history (physical, emotional, verbal, sexual)

•Educational level

•Occupation/work history (probe for sources of financial support that may

be linked to addiction or drug­related activities such as participation in

commercial sex industry)

•Interruptions in work or school history (ask for explanation)

•Arrest/citation history (e.g., DUI [driving under the influence], legal

infractions, incarceration, probation)

Sexual History: Sample Questions and Considerations

•Sexual orientation/preference—“Are your sexual partners of the same sex?

Opposite sex? Both?”

•Number of relationships—“How many sex partners have you had within the

past 6 months? Year?”

•Types of sexual activity engaged in; problems with interest, performance, or

satisfaction—“Do you have any problems feeling sexually excited? Achieving

orgasm? Are you worried about your sexual functioning? Your ability to function as a spouse or partner? Do you think drugs or alcohol are affecting your

sex life?” (A variety of drugs may be used or abused in efforts to improve

sexual performance and increase sexual satisfaction; likewise, prescription

and illicit drug use and alcohol use can diminish libido, sexual performance,

and achievement of orgasm.)

•Whether the patient practices safe sex (research indicates that substance abuse

is linked with unsafe sexual practices and exposure to HIV).

•Women’s reproductive health history/pregnancy outcomes (in addition to

obtaining information, this item offers an opportunity to provide some counseling about the effects of alcohol and drugs on fetal and maternal health).

40 Appoaches to Therapy
             

           

             

             

           

         

             

         

             

         

         

           

             

           

             

             

           

                 

                 

         

           

         

         

       

               

               

           

           

         

           

                 

               

       

         

             

           

             

         

         

           

         

         

         

           

                 

                   

                 

                   

                           

               

                       

                     

                     

                     

                       

                     

               

Mental Health History: Sample Questions and Considerations

•Mood disorders—“Have you ever felt depressed or anxious or suffered from

panic attacks? How long did these feelings last? Does anyone else in your family

experience similar problems?” (If yes, do they receive medication for it?)

•Other mental disorders—“Have you ever been treated by a psychiatrist,

psychologist, or other mental health professional? Has anyone in your family

been treated? Can you tell me what they were treated for? Were they given

medication?”

•Self­destructive or suicidal thoughts or actions—“Have you ever thought

about committing suicide?” (If yes: “Have you ever made an attempt to kill

yourself? Have you been thinking about suicide recently? Do you have a

plan?” [If yes, “What means would you use?”] Depending on the patient’s

response and the clinician’s judgment, a mental health assessment tool such as

the Beck Depression Inventory or the Beck Hopelessness Scale may be used to

obtain additional information, or the clinician may opt to implement his own

predefined procedures for addressing potentially serious mental health issues.)

Source: CSAT 1997a.

to keep that family out of the treatment

process. For safety reasons, the seriousness of

conflict should be assessed, and the client will

need some time to adjust and build rapport

with the counselor before being introduced to

family therapy.

Eventually, almost all clients with substance

use disorders can benefit from some form of

family therapy, because the educational sessions for families that are commonly used in

substance abuse treatment settings are not

always sufficient to bring about necessary,

lasting systemic changes in the client’s family

relationships. A number of factors will influence a decision about the types and relative

intensity of treatment the client should receive.

The client’s level of recovery may have the

greatest effect on her ability to participate both

in substance abuse treatment and family therapy, as well as the usefulness of that therapy for

all members of the family. (See chapter 4 for a

discussion of the levels of recovery.)

While family therapy in addition to substance

abuse treatment is highly desirable, managed

care guidelines and government regulations are

certain to affect referrals. The decisions of

payors will consequently be a major determinant of the services a program offers and the

services a client is willing to seek. If funding

agencies do not support family therapy, the

counselor may decide to work on family

dynamics only through the single symptomatic

individual. There is a great need for the training

of substance abuse counselors to do family

therapy as well. This can be done if the counselor is trained to do family treatment with a

single individual. Additionally, family therapists need better preparation in graduate

school plus supervised work in order to work

effectively in the field of substance treatment

specifically. (See chapter 4 for a discussion of

integrated treatment.) These are vital first

steps toward integrating the two approaches.

An integrated approach might well have an

important effect on funding policies, allowing

more individuals to receive substance abuse

treatment integrated with family therapy.

Appoaches to Therapy 41
         

         

           

           

             

           

     

         

           

           

         

       

     

         

       

           

       

           

   

             

         

         

               

         

         

           

           

           

               

         

             

             

             

             

           

         

       

       

       

             

             

         

             

         

             

           

             

           

           

               

       

         

               

           

           

             

         

         

           

         

         

           

Family therapists and screening, assessment, and referral

for substance abuse

Family therapy assessments focus on family

dynamics and client strengths. The primary

assessment task is the observation of family

interactions, which can reveal patterns such as

triangulation (which is a means of evading

confrontation between two people by bringing a

third person into the issue) along with the family

system’s strengths and dysfunction. The

sources of dysfunction cannot be determined

simply by asking individual family members to

identify problems within the family. The family

therapist needs to observe family interactions

to determine alliances, conflicts, interpersonal

boundaries, communication and meaning, and

other relational patterns. Therapists with different theoretical orientations give different

degrees of attention to particular aspects of

family interaction. Methods for evaluating

these interactions also vary with the therapist’s

theoretical orientation.

In addition to an assessment of dysfunction and

strengths, family therapists should be trained

and experienced in screening for substance

abuse and be familiar with the role that

substance abuse plays in family dynamics.

Although most family therapists screen for

mental or physical illness and physical, sexual,

or emotional abuse, issues of substance abuse

might not be discovered because the therapist

is not familiar with questions to ask or cues

provided by clients. Some family therapists

may extend the evaluation to how multiple systems (family of origin, family of choice, schools,

workplaces) affect the client family at hand.

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

(McGoldrick and Gerson 1985). This is typically

explained to the client during an initial session

and developed as sessions progress, is used for

discussion points, and is especially helpful

when client and therapist reach a point of

being “stuck“ in the therapeutic process.

Genograms can be used to help identify root

causes of behaviors, loyalties, and issues of

shame within a family. Working on a genogram

can create bonding and increased trust between

the therapist and client (see Figure 3­2).

The genogram has become a basic tool in many

family therapy approaches. Significant physical, social, and psychological dysfunction may

be added to it. Though the preparation of a

genogram is not standardized, most of them

begin with the legal and biological relationships

of family members. They may also note family

members’ significant events (such as births,

deaths, and illnesses), attributes (religious

affiliation, for instance), and the character of

relationships (such as alliances and conflicts).

Different genogram styles search out different

information and use different symbols to depict

Figure 3­2

Basic Symbols Used in a Genogram

42 Appoaches to Therapy
relationships. In addition, a genogram can

show “key facts about individuals and the relationships of family members. For example, in

the most sophisticated genogram one can note

the highest school grade completed, a serious

childhood illness, or an overly close or distant

relationship. The facts symbolized on the

genogram offer clues to the family’s secrets and

mythology since families tend to obscure what

is painful or embarrassing in their history”

(McGoldrick 1995, p. 36). A family map is a

variation of the genogram that arranges family

members in relation to a specific problem (such

as substance abuse). 

Figure 3­3

Eugene O’Neill Genogram

Source: Reprinted with permission from McGoldrick 1995.

Appoaches to Therapy 43
   

   

   

       

   

   

     

   

     

       

     

   

           

               

   

             

         

             

         

             

             

             

             

             

             

       

     

             

             

             

           

                 

         

             

       

         

               

             

           

               

           

               

         

           

           

             

         

             

           

       

       

           

             

               

           

         

       

           

         

         

                 

         

   

         

           

             

           

             

         

           

                 

         

             

               

             

             

               

             

           

Genograms enable

clinicians to ascertain the complicated Family therapists

should be

prepared to	 

integrate ongoing

family therapy

with treatment for

substance abuse.

relationships, problems, and attitudes

of multigenerational

families. Genograms

can also be used to

help family members

see themselves and

their relationships

in a new way

(McGoldrick and

Gerson 1985). The

genogram can be

a useful tool for

substance abuse

treatment counselors

who want to understand how family

relationships affect

clients and their substance abuse. Figure 3­2

(p. 42) shows the basic symbols used to construct a genogram.
 

The genogram reproduced in Figure 3­3 (p. 43)

depicts five generations in Eugene O’Neill’s

family. The family history shows a pattern of

substance abuse and suicide. O’Neill described

his own family, in slightly fictionalized terms, in

Long Day’s Journey Into Night, in which readers can see how the dysfunctional pattern of

fusion resulted in a family with a “desperate

need to distort reality to reassure themselves of

their closeness [yet the distortion was] the very

thing that prevent[ed] their connection”

(McGoldrick 1995, p. 107).

Rarely will an IP and/or family enter treatment

with the detailed knowledge of their family over

generations as revealed in the above diagram of

Eugene O’Neill’s family. At the first interview

an attempt is made to fill in as much genogram

information as possible about the extended

family, particularly the family of origin and if

present, the family of procreation. Family

members are given assignments to interview

other family members to fill in the gaps, often

an insightful experience as more and more of

the family’s history is uncovered and

understood.

Screening and assessment

issues

When a family therapist refers a client to

specialized treatment for a substance use disorder, the client need not be excluded from

participation in family therapy. Family therapists instead should be prepared to integrate

ongoing family therapy with treatment for substance abuse. When first meeting a family that

includes someone who is abusing substances,

family therapists can take specific steps to

evaluate the situation and prepare the family

for involvement in substance abuse treatment.

O’Farrell and Fals­Stewart (1999) suggest

holding an interview before beginning therapy

during which the family therapist can determine whether a family member who is abusing

substances is in treatment or what his stage of

readiness for treatment is. (TIP 35, Enhancing

Motivation for Change in Substance Abuse

Treatment [CSAT 1999b], has information and

instruments for assessing a client’s readiness to

change substance abuse behavior, and for

information on screening for substance abuse,

see chapter 2 of TIP 24, A Guide to Substance

Abuse Services for Primary Care Clinicians

[CSAT 1997a].)

Next, the therapist should determine whether

an immediate intervention is needed or whether

the family can return for a more thorough

assessment later. In the former instance, the

therapist should refer the individual to a detoxification program or other appropriate treatment. In the latter instance, the therapist

should tell the family what will be involved in a

more extensive assessment, which will take

place at the first therapy session. The therapist

also should assess the appropriateness of including any children in the process and when would

be the most effective time to include them.

All family therapists should be able to perform

a basic screening for substance abuse. In a survey of its membership, the AAMFT found that

the great majority (84 percent) reported screen44 Appoaches to Therapy
           

         

             

           

   

         

         

         

         

         

             

     

           

             

         

       

           

             

         

   

     

     

         

           

           

           

             

         

           

           

     

           

             

       

           

           

       

       

           

           

       

         

           

               

         

           

               

             

         

       

           

           

             

               

             

         

             

       

             

         

       

           

           

             

           

       

           

           

             

   

                 

           

         

         

               

           

           

ing someone for abuse within the previous year

(Northey 2002). An overwhelming majority (91

percent) had referred a client to a substance

abuse treatment provider, though few of the

therapists routinely diagnosed or treated substance abuse (Northey 2002). As part of their

professional preparation, AAMFT­certified

family therapists are trained to use the

American Psychiatric Association’s (APA’s)

Diagnostic and Statistical Manual of Mental

Disorders, 4th edition, Text Revised (DSMIV­TR) (APA 2000), which presents standard

definitions of substance use disorders. Some

simple screening instruments for substance

use disorders can be found in TIP 11, Simple

Screening Instruments for Outreach for

Alcohol and Other Drug Abuse and Infectious

Diseases (CSAT 1994f), and TIP 24, A Guide to

Substance Abuse Services for Primary Care

Clinicians (CSAT 1997a). More specific information on screening instruments for use with

adolescents can be found in TIP 31, Screening

and Assessing Adolescents for Substance Use

Disorders (CSAT 1999c).

Constraints and Barriers to

Family Therapy and Substance

Abuse Treatment

Family therapists and substance abuse counselors should respond knowledgeably to a variety

of barriers that block the engagement and

treatment of clients. While the specific barriers

the provider will encounter will vary for clients

in different treatment settings, basic issues

arise in both substance abuse treatment

and family therapy. Issues of family

motivation/influence, balance of hierarchal

power, and general willingness for the family

and its members to change are essential topics

to review for appropriate interventions.

Contextual factors that

affect motivation and 

resistance

The differential influence of power

The approaches used by the substance abuse

treatment and family therapy fields to motivate

clients typically have been different.

Traditional substance abuse treatment models

often have adopted the 12­Step practice that

requires people in recovery to accept their

powerlessness over the substance formerly

abused—after all, despite repeated efforts to

control the substance, it regularly has defeated

the person using it and disrupted the user’s life

and family. Realizing powerlessness over the

substance and the damage it causes provides

motivation to break free of it. Within the 12­

Step tradition, a person is empowered by the

program and by “surrendering.” Though somewhat paradoxical, the addicted person regains

empowerment by giving up the struggle with

something he cannot control (the outcome following the use of drugs) for something over

which he does have control (the ability to work

his program of recovery and do those tasks

that strengthen and foster ongoing recovery).

Confusion over the use of the 60­year­old term

“powerlessness“ within 12­Step programs has

often led people erroneously to feel that 12­

Step programs were antithetical to empowerment points of view.

Family therapy has a tradition of empowerment. Family therapy grew from a perceived

need to bring to the therapy session respect

and attention to each individual’s needs, interests, expressions, and worth. Family therapists

have historically accomplished this by making a

special effort to “bring out” those members

who might remain in the background, such as

adolescents and children.

Of course, it is not desirable to cast a person

abusing substances as a totally powerless entity.

Many clients who abuse substances already

may feel economically or socially powerless,

and some others may belong to a culture that

does not emphasize individual control over

destiny. For these clients, especially, it is

Appoaches to Therapy 45
             

             

           

               

         

             

     

         

               

             

               

               

               

             

           

               

     

               

     

             

             

               

           

     

         

         

     

           

           

             

             

           

         

             

         

           

             

           

           

   

             

       

         

           

           

             

         

             

         

           

           

             

           

           

           

             

       

           

           

               

         

           

           

           

           

           

       

               

           

           

             

       

             

       

         

             

             

             

               

         

               

             

             

             

               

         

         

important to stress that recovery is within their

power to accomplish and that it is something

that they can choose to accomplish (Krestan

2000).

No simple rule governs the existence and use of

hierarchical power relations in therapeutic

settings, but clinicians need to be aware that

power relationships exist. Therapists always

have more power in therapeutic interactions

than clients do. This reality has no easy solution. While client autonomy is a primary value

in all clinical work, at times therapists must act

from a position of overt power to prevent violence or suicide, or to protect an abused child.

Clinicians need to be aware that such power

differences exist and use these differences in

such a way as to establish trust and promote

client self­determination and autonomy as

much as possible. Clients need to be able to

trust clinicians—which involves according them

power—but clients also need to believe in their

personal capacity to change and to learn to

manage their own lives effectively. It is especially

important that the client come to feel that she

has the power to successfully handle treatment

and recovery program activities.

Stages of change 

Families with substance abuse problems

constitute a vulnerable population with many

complicating psychosocial issues. For example,

job­related or legal troubles might result in

someone being sent for treatment who has

never considered the need for or possibility of

treatment. In the ideal situation, the family

voluntarily seeks help; most frequently, when a

family member requests substance abuse help

for another member there is great variation in

client motivations for substance abuse treatment. Substance abuse treatment can be

initiated by the person with a substance use

disorder, a family member, or even through

mandated treatment by an employer or the

legal system.

The stages of change model has been helpful

for understanding how to enhance clients’

motivation. During the recovery process, individuals typically progress and regress in their

movement through the stages. Stages of change

have been described in several ways, but one

especially helpful concept (Prochaska et al.

1992) divides the process of changing into five

stages:

•Precontemplation. At this stage, the person

abusing substances is not even thinking about

changing drug or alcohol use, although others

may recognize it as a problem. The person

abusing substances is unlikely to appear for

treatment without coercion. If the person is

referred, active resistance to change is probable. Otherwise, a person at this stage might

benefit from non­threatening information to

raise awareness of a possible problem and

possibilities for change. While families in this

stage may think, “This has to stop!” they

frequently resort to often­used defenses such

as protecting, hiding, and excusing the IP.

When the IP is in the precontemplation

stage, the therapist works to establish

rapport and offer support for any positive

change.

•Contemplation. A person in this stage is

ambivalent and undecided, vacillating over

whether she really has a problem or needs to

change. A desire to change exists simultaneously with resistance to change. A person

may seek professional advice to get an objective assessment. Motivational strategies are

useful at this stage, but aggressive or premature confrontation may provoke strong resistance and defensive behaviors. Many contemplators have indefinite plans to take action in

the next 6 months or so. In this stage, families

waver between “She can’t help it” and “She

won’t do anything.” The level of tension and

threat rises. The role of the therapist is to

encourage ambivalence. Helping the IP to see

both the pros and cons of substance use and

change helps her to move toward a decision.

Client education is an effective tool for

creating ambivalence.

•Preparation. In this stage, a person moves to

the specific steps to be taken to solve the

problem. The person abusing substances has

increasing confidence in the decision to

46 Appoaches to Therapy
                 

               

             

           

           

               

         

             

               

               

           

           

           

       

               

       

           

       

           

             

             

       

             

             

         

         

   

           

           

               

             

       

         

           

       

             

           

               

                   

         

       

               

           

           

           

               

           

           

     

       

   

   

       

     

   

   

     

   

   

       

   

   

   

           

             

                 

       

       

   

       

                 

         

             

             

             

               

               

     

       

             

         

         

           

         

         

change and is ready to take the first steps on

the road to the next stage, action. Most people

in this stage are planning to take action within

the next month and are making final adjustments before they begin to change their

behavior. One or more family members in

this stage begin to look for a solution. They

may seek guidance and treatment options.

Here, the therapist’s role is to encourage the

person to work toward his goal. The goal may

be as simple as creating a written record of

every drink during the time between sessions.

•Action. Specific actions are initiated to bring

about change. Action may include overt

modification of behavior and surroundings.

This stage is the busiest, and it requires the

greatest commitment of time and energy.

Commitment to change is still unstable, so

support and encouragement remain important in preventing dropout and regression in

readiness to change. At this point the forces

for change in a family reach critical proportions. Ultimatums and professional interventions are often necessary. The role of the

therapist is to encourage the person and continue providing client education to reinforce

the decision to stop substance abuse.

•Maintenance. Day­to­day maintenance sustains the changes prior actions have accomplished, and steps are taken to prevent

relapse. This stage requires a set of skills different from those that were needed to initiate

change. Alternative coping and problemsolving strategies must be learned. Problem

behaviors need to be replaced with new,

healthy behaviors. Emotional triggers of

relapse have to be identified and planned for.

Gains have been consolidated, but this stage

is by no means static or invulnerable. It lasts

as briefly as 6 months or as long as a lifetime.

In maintenance the family adjusts to life

without the involvement of substances

(Prochaska et al. 1992). During this stage it is

important to maintain contact with the family

to review changes and potential obstacles to

change. Reminding family members that it is

a strength, not a weakness, to use support to

maintain changes can help them relate to

what should be the therapist’s enthusiasm for

recovery of not only
 

the IP, but for the
 During the

recovery process,

individuals typically progress and

regress in their

movement through

the stages of

change.

entire family. The

therapist’s goal is

relapse prevention;

to teach the IP and

family about

relapse, how to

prepare for difficult

times and places,

and to never give

up.

During recovery from

substance abuse,

relapse and regression

to an earlier stage of

recovery are common

and expected—though

not inevitable

(Prochaska et al.

1992). When setbacks

occur, it is important for the person in recovery

to avoid getting stuck, discouraged, or demoralized. Clients can learn from the experience

of relapse and then commit to a new cycle of

action. Treatment should provide comprehensive, multidimensional assessment to explore all

reasons for relapse.

Termination (entered from the maintenance

stage) is the exit—the final goal for all who seek

freedom from dependence on substances. The

individual (or family) exits the cycle of change,

and the danger of relapse becomes less acute.

In the substance abuse field, some dispute the

idea that drug or alcohol problems can be

terminated and prefer to think of this stage as

remission achieved through maintenance

strategies.

Confrontation

Generally, substance abuse treatment has

relied on confrontation more than family

therapy has. For a long time, within the

substance abuse treatment community it was

believed that confronting clients and breaking

through their defenses was necessary to overcoming denial. Some preliminary research has

suggested that a confrontational approach is

Appoaches to Therapy 47
           

         

             

           

       

         

           

           

               

     

               

               

               

             

           

             

             

             

         

   

   

     

     

     

   

   

   

   

       

     

   

   

     

   

   

     

               

             

               

           

               

             

           

             

             

                 

             

         

             

               

             

               

             

         

             

             

                 

             

           

           

           

           

             

               

           

         

             

           

         

               

           

       

             

                 

   

               

             

           

       

         

         

         

         

sometimes the least effective method for getting

certain clients to change substance abuse

behavior (Miller et al. 1998). Treatment of

substance abuse has shifted away from

confrontational approaches and moved toward

more empathic approaches, such as those

favored in family therapy. Still, family therapists should be aware of how confrontation has

been used and is still used in some substance

abuse treatment programs.

Motivation levels

Motivating a person or a family to enter and

remain in treatment is a complex task, made all

the more complicated by the fact that the IP

and the family may have different levels of

motivation (as may different members of the

family). Many factors related to a client’s family,

such as maintaining custody of children or

preserving a marriage, can be used to motivate

clients. All the same, group and family loyalty

will affect people differently. These loyalties

may motivate some

to enter treatment,

but the same loyalties can deter others.

To some extent,

Motivating a

person or a family

to enter and	 

remain in treatment is a complex

task.

realizing one’s powerlessness over the

substance and the

damage it causes

provides motivation

to break free of it,

although it might be

noted that simple

awareness may not

be enough alone to

provide sufficient

motivation.

Clinicians in both

substance abuse

treatment and family

therapy also need to

consider the motivation level of the family of a

person abusing substances. The fact that a

person with a substance use disorder is motivated to seek treatment is not evidence that the

person’s family is equally motivated. The family

members may have been discouraged by

treatment in the past, and they may no longer

believe or hope that any treatment will enable

their family member to stop abusing substances. They may also conclude that the treatment system did not respond to their needs.

On the other hand, some or all of the family

members might also gain some benefit from the

family’s continued dysfunction, so they may

deny that the whole family needs treatment and

urge clinicians to focus only on the problems of

the person who abuses substances. It may even

be harder to motivate family members than it is

to prompt the person with the substance use

disorder.

Family members may also fear treatment

because there are specific issues in the family

(such as sexual abuse or illegal activity) that

they do not wish to reveal or change. In such

cases, the therapist must be clear with family

members about his ethical obligations to reveal

information if certain topics are raised. For

example, the law and ethics require therapists

to report child abuse. Moreover, the therapist

must not push family members to talk about

difficult issues before they are ready to do so.

A family’s resistance to treatment might stem

from the treatment system’s replication of

problems it has encountered at other levels of

society. Large agencies and systems may seem

untrustworthy and threatening. A family may

fear that the system will disrupt it, leading to

such consequences as losing custody of a child.

Mandated treatment and treatment providers

who work in conjunction with the criminal justice system may add a layer to a family’s sense

of injustice.

Principles of motivational interviewing, which

can be used with both the person abusing substance and the family system, are discussed in

TIP 35, Enhancing Motivation for Change in

Substance Abuse Treatment (CSAT 1999b,

p. 40).

Psychoeducational groups are also useful for

helping family members understand what to

expect from treatment. Participation in

psychoeducational groups often helps to

48 Appoaches to Therapy
           

         

             

                 

         

             

               

         

           

       

           

             

         

           

         

             

           

             

         

       

           

           

       

         

     

       

           

             

         

               

       

             

     

       

           

               

         

     

       

           

         

     

         

         

         

             

           

                 

             

           

             

           

               

               

             

       

               

             

             

               

             

           

     

         

           

             

             

             

         

       

         

             

         

         

motivate them to become more involved in

treatment (Wermuth and Scheidt 1986) by

making them aware of the dynamics of substance abuse and the role the family can play in

recovery. Multifamily groups help families see

that they can benefit from treatment as others

have (even if the family member who uses substances does not maintain abstinence) (Conner

et al. 1998; Kaufmann and Kaufman 1992b).

These two frequently used interventions are

particularly useful for involving a family early

in treatment and motivating it to continue

treatment.

Cultural barriers to 

treatment

Cultural background can affect attitudes concerning such factors as proper family behavior,

family hierarchy, acceptable levels of substance

use, and methods of dealing with shame and

guilt. Forcing families or individuals to comply

with the customs of the dominant culture can

create mistrust and reduce the effectiveness of

therapy. A knowledgeable treatment provider,

however, can work within a culture’s customs

and beliefs to improve treatment rather than

provoke resistance to treatment.

To develop effective treatment strategies for

diverse populations, the treatment provider

must understand the role of culture and cultural

backgrounds, recognize the cultural backgrounds of clients, and know enough about

their culture to understand its effect on key

treatment issues. This sensitivity is important

at every stage of the treatment process, and the

clinician’s knowledge must continually improve

in work with people of different ethnicities, sexual orientations, functional limitations, socioeconomic status, and cultural backgrounds (all

of which are considered cultural differences for

the purposes of this TIP). (Chapter 5 of this

TIP and the forthcoming TIP Improving

Cultural Competence in Substance Abuse

Treatment [CSAT in development b] will provide more information on working with people

from various cultures and providing culturally

competent treatment.)

Integrating Substance Abuse

Treatment and Family Therapy

The integration of substance abuse treatment

and family therapy may be accomplished at

several levels (see chapter 4 for a full discussion

of integrated models of treatment). Agencies

may opt for full integration that would offer

both family therapy and substance abuse treatment in the same location with the same or different sets of staff members. As an alternative,

agencies might create a partial integration by

setting up a system of referral for services.

Regardless of the form integration takes, clinicians working in either field need to be aware

of the practices and ideas of the other field.

There should be mutual respect and a willingness to communicate between practitioners.

They should know when to make a referral and

when to seek further consultation with a practitioner from the other field. Clinicians in each

field need to tailor their approaches to be optimally effective for clients who have received or

are receiving treatment from a practitioner in

the other field.

Family Therapy for

Substance Abuse

Counselors 

Substance abuse counselors should not practice

family therapy unless they have proper training and licensing, but they should be informed

about family therapy 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. In

order to promote integrated treatment, training

in family therapy techniques and concepts

Appoaches to Therapy 49
   

   

     

   

     

   

   

   

   

   

   

   

     

   

   

   

         

       

     

             

           

         

           

             

           

       

           

           

           

         

         

           

         

           

             

   

               

           

       

           

           

           

       

           

             

         

             

             

         

           

           

               

           

             

             

           

     

   

     

         

         

           

         

           

           

               

           

           

     

           

         

                                     

                             

         

should be provided

to substance abuse 

Substance abuse

counselors can

also benefit from

incorporating

family therapy

ideas and

techniques into

their work.	 

counselors.

This section builds

on content presented

in chapter 1 that

explained the potential role of family

therapy in substance

abuse treatment

programs. This section presents the

basic principles of

family therapy models and suggested

ways to apply these

principles in one’s

practice. Chapter 4

discusses the specific

integrated family

therapy models developed for treating clients
 

with substance use disorders.
 

Traditional Models of Family
 

Therapy
 

The family therapy field is diverse, but certain

models have been more influential than others,

and models that share certain characteristics

can be grouped together. Family therapy theories

can be roughly divided into two major groups.

One includes those that focus primarily on

problemsolving, where therapy is generally

brief, more concerned with the present situation,

and more pragmatic. The second major group

includes those that are oriented toward intergenerational, dynamic issues; these are longerterm, more exploratory, and concerned with

family growth over time. Within these larger

divisions, other categories can be developed

based on the assumptions each model makes

about the source of family problems, the specific

goals of therapy, and the interventions used to

induce change.

In recent years, calls for the use of evidencebased treatment models have increased. It may

be necessary to use evidence­based approaches,

especially for adolescents, to get managed care

organizations to pay for services. A declaration

that a provider is using an evidence­based

model, however, may become complicated

because the majority of family therapists are

eclectic in their use of techniques, and few

adhere strictly and exclusively to one

approach. Furthermore, evidenced­based

approaches may not be appropriate for all

cultures or adaptable to practice in all settings.

It is important that the research­to­practice

issues should be addressed and that research,

conducted under conditions that may be artificial to the practice of therapy, be carefully

critiqued. The Journal of Marital and Family

Therapy devoted a full issue (Vol. 28, No. 1,

January 2002) to a discussion of “best practice” models and the challenges of developing

research based in practice.

Family Therapy Approaches

Sometimes Used in Substance

Abuse Treatment

Several family therapy models are presented

below.1 These have been adapted for working

with clients with substance use disorders. None

was specifically developed, however, for this

integration. A number of self­help programs or

programs that address issues related to having

a family member who has a substance use

disorder, such as Adult Children of Alcoholics

programs or Al­Anon, are also available (see

also appendix D).

Behavioral contracting

Theorist: Steinglass. See Steinglass et al. 1987.

View of substance abuse

•Substance abuse stresses the whole family

system.

1

The theories presented in this section are those of the authors and do not necessarily reflect the positions, views, and

opinions of the CSAT, the Substance Abuse and Mental Health Services Administration (SAMHSA), or the Department

of Health and Human Services (HHS).

50 Appoaches to Therapy
         

     

           

               

               

         

     

         

           

       

   

           

           

     

             

         

           

           

       

       

           

             

               

     

   

           

       

   

             

     

       

         

       

         

           

           

       

       

           

         

             

       

       

  

       

   

       

     

    

         

       

         

         

  

     

       

       

         

   

             

   

•Substance abuse is the “central organizing

principle” for a “substance­abusing“ family

(as distinguished from a family with a member who has a substance use disorder, but in

which substance use is not yet woven into the

family system).

•Families with members who abuse substances

are a highly heterogeneous group.

Goals of therapy

•Identify and address the family’s problems

(including substance abuse by one or more

family members) as family problems.

•Develop a substance­free environment.

•Help families cope with the emotional distress

(the “emotional desert”) that the removal of

substance abuse can cause.

Strategies and techniques

•Develop a written contract to ensure a

drug­free environment.

•Use enactments and rehearsals to enlighten

the family system about triggers of substance

use, to anticipate problems, and avoid them.

•Use family restabilization or reorganization

to change functioning and organization.

Bepko and Krestan’s theory

Theorists: Bepko and Krestan. See Bepko and

Krestan 1985.

View of substance abuse

•Focus is on the person who abuses substances

and the substance of abuse as a system (while

also looking at intrapersonal, interpersonal,

and gender systems).

Goals of therapy

•Help everyone in the family achieve appropriate responsibility for self and decrease

inappropriate responsibility for others.

•Three phases of treatment, each with a

separate set of goals:

■	 Presobriety: Unbalance the system that

was balanced around substance abuse in

order to promote sobriety.

■	 Early Sobriety: Balance the system around

a self­help group; maintain people in a

corrective context (a zone of right relationship, avoiding overinflated pride and

abject self­loathing) with a recognition that

no one stays there all the time.

■	 Maintenance: Rebalance the system in a

deep way by going back and working on

developmental tasks that were previously

missed.

•Clarify adaptive consequences of substance

abuse.

Strategies and techniques

(1) Presobriety

■ Interrupting and blocking emotional and

functional over­responsibility using the

pride­system of the spouse and the individual with a substance use disorder.

■ Referring to self­help group.

(2) Early sobriety

■ Same­sex group therapy with a specific

model.

■ Reparative and restorative work with

children (in order to have children

express feelings in a safe environment).

(3) Maintenance

■ Anger management; dealing with toxic

issues such as sexual abuse.

■ Looking at gender stereotypes with

respect to sex, power, anger, and control.

Behavioral marital therapy

Theorists: McCrady and Epstein. See Epstein

and McCrady 2002.

View of substance abuse

•Developed to treat alcohol problems in a

couples counseling framework.

Appoaches to Therapy 51
         

         

     

       

         

         

     

       

           

       

   

         

   

             

           

           

           

             

           

         

         

               

           

           

           

   

         

     

       

     

     

   

     

         

       

         

       

   

           

           

             

             

           

         

         

           

     

           

         

         

       

         

     

         

           

               

           

             

             

         

           

           

         

         

               

         

     

         

                                   

                   

•Uses a social­learning framework to conceptualize drinking (or other substance use)

problems and family functioning.

•Examines current factors maintaining

substance use, rather than historical factors.

•Cognitions and affective states mediate the

relationship between external antecedents

and substance use, and expectancies about

the reinforcing value of substances play an

important role in determining subsequent

substance use.

•Substance abuse is maintained by physiological,

psychological, and interpersonal consequences.

•Substance use is part of a continuum that

ranges from abstinence to nonproblem use to

different types of problem use. From this

perspective, problems may be exhibited in a

variety of forms, some of which are consistent

with a formal diagnosis, and some of which

are milder or more intermittent. This perspective differs significantly from the psychiatric diagnostic approach of the DSM­IV­TR

(APA 2000) in that it does not assume that

certain symptoms cluster, nor that an underlying syndrome or disease state is present

(although it does not exclude that possibility,

either).

Goals of therapy

•Abstinence is the preferred goal for treatment.

•Other goals include

■	 Developing coping skills for both partners

to address substance abuse.

■	 Developing positive reinforcers for
 

abstinence or changed use.2
 

■	 Enhancing the functioning of the 

relationship.
 

■	 Developing general coping skills.

■	 Developing effective communication and

problemsolving skills.

■	 Developing relapse prevention skills.

•Other couple­specific goals may also be

identified.

Strategies and techniques

•Intervene at multiple levels, with

■	 The individual who is abusing substances

■	 The spouse

■	 The relationship as a unit

■	 The family

■	 Other social systems

•Begin with a detailed assessment to determine

the primary factors contributing to the maintenance of the substance use, the skills and

deficits of the individual and the couple, and

the sources of motivation to change.

•Help the client assess individual psychological

problems associated with use, potential and

actual reinforcers for continued use and for

decreased use2 or abstinence, negative consequences of use and abstinence, and beliefs

and expectations about substance use and its

consequences.

•Teach individual coping skills (e.g., selfmanagement planning, stimulus control,

substance refusal, and self­monitoring of use

and impulses to use).

•Teach behavioral and cognitive coping skills

individually tailored to the types of situations

that are the most common antecedents to use.

•Provide clients with a model for conceptualizing substance abuse and how it can be

changed.

•Teach spouses a variety of coping skills based

on an individualized assessment of behaviors

that may either cue or maintain substance

use (for instance, learning new ways to discuss

use and learning new responses to partner’s

use).

•Use substance­related topics (such as how to

manage a situation where substances are

being used or what to tell family and friends

about the treatment) to teach problemsolving

and communication skills.

•Help clients identify interpersonal situations

and people associated with substance use,

2

Harm reduction concepts (e.g., reduced or decreased use as opposed to abstinence) discussed in this TIP are those of

the authors and do not reflect SAMHSA/HHS policy or program directions.

52 Appoaches to Therapy
           

     

       

             

     

         

         

           

           

             

               

             

               

         

         

               

     

       

       

         

       

           

     

           

           

           

           

     

       

           

         

       

           

         

           

         

         

   

     

       

     

           

         

     

   

   

   

   

   

   

   

                                   

           

and situations and people supportive of

abstinence or decreased use.3

Brief strategic family therapy 

Theorists: Szapocznik and Kurtines. See

Santisteban et al. 1996; Szapocznik et al. 2003;

Szapocznik and Williams 2000.

Kurtines, Santisteban, Szapocznik, and

Williams have researched family therapy for

adolescents and their families with specific

focus on the family environment. They feel

their manualized approach has a strong evidence

base for use with such families; however, they

do not suggest the use of the approach with

adults with addictions, as there have been no

efforts to study the approach with adult clients.

View of substance abuse

•Adolescents’ lack of success dealing with

developmental challenges leads them to

substance abuse.

•Rigid family structures can increase substance

abuse (as parents need to be able to renegotiate

as the adolescent grows).

•Intrafamily and acculturation conflict impact

relationships negatively and increase substance abuse.

Goals of therapy

•Change parenting practices (such as leadership,

behavior control, nurturance, and guidance).

•Improve the quality of relationship and bonding between parents and the adolescent(s).

•Improve conflict resolution skills.

Strategies and techniques

•Do preliminary phone work to determine who

will be resistant to treatment and engagement.

•Identify the normal processes of acculturation

and then help families learn to transcend

these differences.

•Block or reframe negativity and promote

supportive interactions.

•Modify program based on data and research.

•Provide culturally competent treatment.

•Actively work on engaging family.

•Intervene in the family system through the

parents rather than directly intervening (and

therefore put traditional hierarchies back

into place).

Multidimensional family

therapy (MDFT)

Theorist: Liddle. See Liddle 1999; Liddle and

Hogue 2001.

View of substance abuse

•Developed to treat adolescent drug problems

and related behavioral problems such as

conduct disorder from a multiple systems

perspective.

•Adolescent substance abuse is a multidetermined and multidimensional disorder.

•Uses an integrative developmental,

environmental, and contextual framework

to conceptualize the beginning, progression,

and cessation of drug use and abuse.

•Uses knowledge about risk and protective

factors to arrive at

a case conceptualization that includes

and integrates

individual, familial,

and environmental The family therapy field is diverse,

but certain models

have been more

influential than

others.
 

factors.

•Both normative (failure to meet developmental challenges
 

and transitions) and
 

nonnormative
 

(abuse, trauma,
 

mental health, and
 

substance abuse in
 

the family) crises
 

are instrumental in

starting and maintaining adolescent
 

drug problems.
 

3

Harm reduction concepts (e.g., reduced or decreased use as opposed to abstinence) discussed in this TIP are those of

the authors and do not reflect SAMHSA/HHS policy.

Appoaches to Therapy 53
             

           

         

       

         

             

         

     

           

     

   

         

       

       

         

       

         

         

   

         

         

         

           

           

     

           

             

       

       

           

   

         

         

       

         

   

   

         

             

         

       

         

           

         

         

       

         

             

               

         

       

   

           

     

   

     

             

           

         

           

     

         

         

     

         

Goals of therapy

•To facilitate a process of adaptation to the

youth’s and family’s developmental challenges

since drug use and other problem behavior

will desist when sufficient adaptive developmentally appropriate functioning is restored

or created.

•To enhance and bolster the psychosocial

functioning of the youth and family in their

key developmental domains.

•To improve adolescent functioning in several

realms, including individual developmental

adaptation, coping skills relative to drug and

problemsolving situations, peer relations,

and family relationships.

•To improve parents’ functioning in several

realms including their own personal

functioning (e.g., substance abuse or mental

health issues) and functioning in their

parental role (e.g., parenting practices).

•To improve family functioning as evidenced

by changes in day­to­day family environment

and family transactional patterns.

•To improve adolescent and parent functioning

in the extrafamilial domain, including more

adaptive and positive transactions with key

systems such as school and juvenile justice.

Strategies and techniques

•The overall therapeutic strategy calls for multilevel, multidomain, multicomponent interventions.

•Treatment is flexible; MDFT is a therapy

system rather than a one­size­fits­all model.

As such, therapy length, number, and frequency of the sessions is determined by the

treatment setting, provider, and family.

•Treatment format includes individual and

family sessions, and sessions with various and

extra familial sessions.

•Treatment begins with an indepth,

multisystems assessment that uses a

developmental/ecological and risk and protective factor framework to establish an

MDFT case conceptualization.

•The case conceptualization individualizes the

treatment system and pinpoints areas of

strength and deficit in the multiple and

interlocking realms of a teen’s psychosocial

ecologies.

Multifamily groups

Theorist: Kaufman. See Kaufman and

Kaufmann 1992.

View of substance abuse

•Traditional medical model and disease

concept.

Goals of therapy

•Work to achieve abstinence for family

member(s) with substance use disorders.

•Consolidate abstinence by focusing on resolving

dysfunctional rules, roles, and alliances.

•After sobriety is achieved, deepen intimacy

through appropriate expression of suppressed

feelings (such as mourning of losses or

hostility).

•Maintain a sober family core that acts as a

central homeostatic organizer for the client

who abuses substances, especially during

times of stress.

Strategies and techniques

•Therapy begins with an assessment of substance abuse, individual psychopathology,

and family systems.

•Address developmental issues and individual

Axis I and II disorders, and include these

issues as part of a family contract.

•Prepare a family relapse prevention plan.

•Make use of 12­Step and other self­help

modalities.

Multisystemic therapy

Theorist: Henggeler. See Cunningham and

Henggeler 1999; Henggeler et al. 1998.

View of substance abuse

•Understand fit between substance abuse and

the broader systemic context:

■	 Understand specific problems in a
 

real­world context.
 

54 Appoaches to Therapy
         

     

         

             

           

         

   

             

           

           

             

           

       

       

       

         

   

             

       

       

         

             

       

           

         

             

       

             

     

           

       

       

         

             

             

         

     

     

     

     

   

     

     

     

   

     

     

   

       

     

             

         

             

             

       

               

         

     

             

               

■	 Serious clinical problems, such as substance abuse, are multi­determined and

influenced by variables from multiple

systems.

Goals of therapy

•The initial goal is to engage family members

and, if necessary, to identify barriers to

engagement and develop strategies for

overcoming those barriers.

•Examine the strengths and needs of each

system and their relationship to the identified

problem.

•Address risk and protective factors as they

impact the family from a range of sources.

•Family members and caregivers have a major

role in defining treatment goals.

Strategies and techniques

•Interventions are designed to promote

responsible behavior.

•Interventions are present­focused and actionoriented, targeting specific and well defined

problems.

•Provide developmentally appropriate

interventions.

•Daily or weekly effort by family members is

required.

•Place responsibility on therapist for overcoming barriers.

Network therapy

Theorist: Galanter. See Galanter 1993.

View of substance abuse

•Traditional medical model and disease

concept.

Goals of therapy

•Balance the family system in terms of gender,

age, relationship, and so on.

•Family and significant others work to help

the individual who abuses substances maintain his abstinence and a stable support

system that promotes his recovery.

•Focus is on the individual’s efforts to

maintain abstinence.

Strategies and techniques

•Create secure, stable, substance­free residence.

•Avoid people, places, and things that promote

substance use. Encourage self­help group

attendance.

•Establish a healthy support system.

•Avoid areas of conflict and negative

exchanges.

•Family and significant others work as a team

and are coached to help the person abusing

substances to achieve and maintain

abstinence.

Solution­focused therapy

Theorists: Berg,

Miller, and de Shazer.

See Berg and Miller

1992; Berg and Reuss

1997; de Shazer 1988.

View of sub­ Few family

therapists adhere

strictly and

exclusively to one

approach.

stance abuse

•Emphasis is placed	 

on the solutions that

are available to the

family, not on how
 

the problem developed or what function it might serve.
 

Goals of therapy

•A therapeutic

relationship needs

to be built on trust

and respect.

•Help client to realize

that she can maintain sobriety and has done

so on occasions in the past.

•Goals of therapy are defined by the client.

•Focus on exceptions (such as times when

substance abuse does not occur).

•Focus on problems that can be solved and on

finding unique solutions to those problems

that can enhance optimism.

•The focus is on solution, not problems. Focus

on solutions by asking the IP how she will

Appoaches to Therapy 55
             

           

       

             

       

         

         

           

             

         

       

           

     

             

         

             

     

           

         

         

         

         

           

     

           

   

   

     

     

     

Figure 3­4

Individual, Family, and Environmental Systems

Source: Adapted from Isaacson 1991a.

know the problem is improved. What will she

be doing? How will she be feeling?

Strategies and techniques

•Use solution­focused techniques to help the

family system realize its ability to help the

member abusing substances to maintain

abstinence.

•Make rapid transitions to identifying and

developing solutions intrinsic to the family.

Stanton’s therapeutic 

techniques

Theorist: Stanton. See Stanton et al. 1982.

View of substance abuse

•Substance abuse is part of a cyclical process

that takes place between connected people

who form an intimate, interdependent, and

interpersonal system.

•Substance use often begins in adolescence as

an attempt at individuation.

•Within the family there is a “complex

homeostatic system” of feedback that serves

to maintain stability and in the process

maintains substance abuse behavior.

Goals of therapy

•Specific goals are negotiated with the family

at the beginning of treatment.

•There are, though, three primary stated

goals:

■	 The IP should be substance free.

■	 The IP should be either gainfully

employed or involved in some sort of

school or training program.

■	 The IP should establish a stable and
 

autonomous living situation.
 

Strategies and techniques

•Emphasize present situation.

•Alter repetitive behavioral sequences.

•Emphasize process over content.

56 Appoaches to Therapy
•Therapist joins with family but takes active	 

role in directing therapy.

■ Lost child

■	 Mascot

   

       

         

   

           

         

   

         

             

         

           

             

     

           

         

           

           

           

           

           

       

   

         

       

     

     

   

             

           

       

       

           

             

         

           

                 

                   

                     

                   

                       

                     

                   

                     

                   

                   

     

•Therapist assigns behavioral tasks.

•Therapist may attempt to “unbalance” the

system in order to prompt change.

Wegscheider­Cruse’s theory

Theorist: Wegscheider­Cruse. See Wegscheider

1981.

View of substance abuse

•Substance abuse is a progressive family

disease affecting every member and every

facet of life.

•In the substance­abusing family system, the

members, in the interests of their own survival, assume behavioral patterns that maintain a balance. When one member becomes

dependent on a substance, it affects the others,

causing psychological and/or biological symptoms. As the member who abuses substances

progressively experiences a sense of worthlessness, so do all other family members.

•There are six basic roles family members

assume:

■	 Substance abuser

■	 Enabler

■	 Hero

■	 Scapegoat

Goals of therapy

•Make the family system more open, flexible,

and whole—as the family system begins to

change, other problems will subside as well.

Strategies and techniques

•Educate every family member about the

disease.

•Break through the family’s denial.

•Confront any crisis.

•Treat the immediate problems of substance

abuse.

•Offer concrete recommendations for help,

including self­help group attendance.

Family Therapy Concepts That

Substance Abuse Counselors

Can Use

The field of family therapy has developed a

number of theoretical concepts that can help

substance abuse treatment providers better

understand clients’ relationships with their

families. In addition, a number of therapeutic

practices can assist in the treatment of substance

use disorders in the context of family systems.

This section provides information about some

of these concepts and practices. For more

Family Therapy With an Individual

Client

Szapocznik and colleagues studied a one­person family approach for treating

adolescents who abused substances (Szapocznik et al. 1983, 1986). They compared one­person family therapy with a family group; in both treatments therapists used structural and strategic therapy techniques. (There was, however, no

nontherapy control group, nor was there a control that used a different therapeutic approach.) After a 6­month follow­up that included 61 percent of original

participants, adolescent clients in both groups were found to have decreased

their substance use, and the families improved their ability to function. The

authors note, however, that one­person family therapy was most effective when

carried out by an experienced therapist proficient in strategic family therapy

(Robbins and Szapocznik 2000).

Appoaches to Therapy 57
   

     

   

   

   

   

   

     

   

     

   

     

   

     

           

                 

         

                 

           

         

               

           

       

   

         

         

           

           

         

             

               

       

       

           

           

         

     

           

             

           

         

         

       

     

           

     

     

           

             

           

           

   

               

     

             

         

       

           

         

             

               

           

             

           

             

           

         

             

               

             

       

             

         

           

         

             

             

             

                 

               

             

information, refer to

citations in the The field of family

therapy has developed a number of

theoretical

concepts that can

help substance

abuse treatment

providers better

understand	 

clients’ relationships with their

families.

previous section. In

addition, Nichols

and Schwartz’s The

Essentials of Family

Therapy (2001)

provides an overview

of the background,

theory, and practices

of family therapy.

Also, see appendix

D, which lists

further sources of

information.

There are a number

of theoretical

approaches to family

therapy, but most of

them share many

concepts and

assumptions.

Perhaps foremost

among these is the

acceptance of the principles of systems theory

that views the client as a system of parts embedded within multiple systems—a community, a

culture, a nation. (See Figure 3­4, p. 57, for a

graphic depiction of the relationship of these

multiple systems.) The family system has

unique properties that make it an ideal site for

assessment and intervention to correct a range

of problems, including substance abuse.

Elements of the family as 

a system
 

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.

Boundaries. Structural and strategic models of

family therapy stress the importance of paying

attention to boundaries within the family system,

which delineate one family member from

another; generational boundaries within

families; or boundaries between the family

and other systems, and regulate the flow of

information in the family and between systems

outside the family. Ideally, boundaries should

be clear, flexible, and permeable, allowing

movement and communication (Brooks and

Rice 1997). However, 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 individual members)

maintains a degree of privacy, assumes responsibility for providing for the family, and has

power to make decisions for the family

(Richardson 1991). 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 daily interactions. Strong emotional ties

connect family members, even when they are

separated. Counselors need to address issues,

such as family loyalty, that continue to shape

behavior even if clients have detached in other

ways from their families of origin. With regard

to treatment, it is possible to involve a client in

a form of family therapy even if family members are not physically present (see below), and

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the focus of the therapy is on the family system

and not the individual client.

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, though, is homeostasis—a

state of equilibrium that balances strong,

competing forces in families as they tend to

resist change so as to maintain the family’s

balance—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. Flexibility

therefore is an important quality for a highfunctioning family, although too much flexibility

can lead to a chaotic family environment

(Walsh 1997).

Capacity for change

Families that have members who abuse

substances are more likely to show a lack of

flexibility, rather than an excess. In a family

organized around substance abuse, the tendency

toward homeostasis means that other family

members, in a misguided attempt to prevent

disruption in the family, may enable continued

abuse and keep the person using substances

from attaining abstinence. Families that are

adjusted to substance use—called an alcoholic

family by Steinglass and colleagues (1987)—

have found ways to accommodate a person’s

substance abuse and perhaps gain something

from the abuse. Steinglass and colleagues

(1987) found that alcoholic families generally

have limited ideas of acceptable behavior and

are particularly wary of change. In many

cases, the presence of alcohol (or other

substances of abuse) is necessary for family

members to express emotion, communicate

with one another, have a short­term resolution

of conflicts, or express intimacy. It is important

to note that the client maintains a consistent

“set point” for a level of success in his role

within the family.

Adjusting to abstinence

Mostly because of policy and funding, family

interventions in substance abuse treatment

often target a client’s family for a limited period

of time. Family therapists, however, can present

a good case for long­term family therapy. In a

systems model, a problem such as substance

abuse can have both beneficial and harmful

effects, and a family will adapt its behavior to

the substance abuse. In addition to explaining

the phenomenon of enabling, this model also

explains why 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 restabilize the family dynamics),

or there may be a period of relative harmony

that is disrupted when other problems that

have been suppressed begin to surface. For

example, family members may express resentment and anger more directly to the recovering

person. 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 abstinence (Kaufman 1999).

Triangles

Murray Bowen developed the concept of triangulation, which 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 (Nichols and

Schwartz 2001). 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. In such a triangle,

one person, often the child, will actively abuse

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BMT Exercises To Increase Commitment

and Goodwill

Catch Your Partner Doing Something Nice: Clients are initially asked to notice

and record at least one act each day that shows love or caring from their partners. After the next session, clients are instructed to notice and then tell their

partner what they have observed. Each client is then asked to pick a favorite

caring behavior from the list and act it out in a role­playing exercise. The therapist

gives positive feedback and constructive suggestions based on the role­playing

exercise. The person acting out the activity can repeat it, incorporating the therapist’s suggestions. This exercise is designed to improve spouses’ care­taking and

communication skills as well as build appreciation for one another (O’Farrell

1993).

Caring Days: Each partner is told to select 1 day of the week when he or she will

shower the other with acts of kindness and caring. At the next session, the other

partner is asked to guess which day was selected. This exercise helps partners

notice and understand what each does for the other, while increasing positive

actions within the relationship.

Shared Rewarding Activities: Conflict or dysfunction resulting from substance

abuse can lead to a significant decline in the amount of time couples spend

together in recreational activities. To change this pattern, this exercise first

requires couples to list activities they enjoy doing with their partner (either with

or without children, inside or outside the home).

At their next session the couple shares their lists, and the therapist points out

areas of agreement on both lists. Cotherapists then role­play how they would go

about agreeing on and planning a shared activity. The therapist models ways to

present activities in a positive manner, plan for potential problems, and learn to

agree on activities. Couples subsequently plan and carry out a mutually enjoyable activity (Noel and McCrady 1993).

Source: Adapted from Walitzer 1999.

substances (Brooks and Rice 1997).

Triangulation is especially common in families

that have low levels of differentiation (that is,

high levels of enmeshment), but it does occur to

some extent in all families (Brooks and Rice

1997; Nichols and Schwartz 2001).

The third party in a triangle need not be a family

member. As Nichols and Schwartz note,

“Whenever two people are struggling with conflict they can’t resolve, there is an automatic

tendency to draw in a third party” (2001, p.

21). 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. Triangulation

involving the counselor leaves a client feeling

torn between the family and the treatment

program, and for this reason, the client often

terminates treatment (Stanton 1997). A substance of abuse can also be considered an entity with which the client triangulates to avoid

deeper levels of intimacy.

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Family Therapy Techniques

That Substance Abuse

Counselors Can Use

Family therapists have developed a range of

techniques that can be useful to substance

abuse treatment providers working with individual clients and families. The techniques listed

are drawn from the range of family therapy

approaches described earlier. The consensus

panel selected the techniques on the basis of

their usefulness and ease of use in substance

abuse treatment settings, and not because they

are from a particular theoretical model. This

list of techniques should not be considered

comprehensive.

Some family therapy techniques are similar to

those already used in substance abuse treatment, but they are directed toward a different

group of clients. For example, behavioral family

therapy uses behavioral contracting, positive

reinforcement, and skill building, all of which

would be familiar to practitioners who use

behavioral and cognitive–behavioral approaches

with individual clients. The major difference is

that behavioral family therapy focuses on how

the family influences one member’s substance

abuse behaviors and how the family can be

taught to respond differently.

Behavioral techniques

Behavioral Marital Therapy (BMT) is a

behavioral family approach for the treatment

of substance use disorders. BMT attempts to

increase commitment and positive feelings within a marriage and improve communication and

conflict resolution skills (Walitzer 1999). This is

important because marital relationships where

one partner abuses substances are typically

marked by conflict and dissatisfaction.

Improvements in the quality of marital interactions can increase motivation to seek treatment

and decrease the likelihood of marital dissolution after abstinence is achieved. In situations

where one or both partners are unable to participate sincerely because they are too angry or

where there is violence, these techniques may

not be suitable. Specific techniques include

exercises designed to increase a couple’s positive feelings toward one another (see below),

improve communication skills by teaching

reflective listening techniques (described in

more detail in TIP 35, Enhancing Motivation

for Change in Substance Abuse Treatment

[CSAT 1999b]), and teach negotiation skills

(Noel and McCrady 1993; O’Farrell 1993).

BMT and related approaches have been shown

to improve both a client’s participation in

substance abuse treatment and treatment outcomes (Steinglass 1999), as well as improving

relations between partners (Jacobson et al.

1984).

Structural techniques

In structural family therapy, family problems

are viewed as the result of an imbalanced or

malfunctioning hierarchical relationship with

indistinct or enmeshed, too rigid, or flexible

interpersonal boundaries. The complexities of

these approaches defy any brief, simple review.

Though it well oversimplifies the complexities,

one could say that the primary goal is to

strengthen or rearrange the structural 

foundation so the family can function smoothly

(Walsh 1997). After an assessment stage, the

therapist generally begins by preparing, with

the family, a written contract that clearly

describes the goals of treatment and explains

the steps necessary to reach them. This contract increases the likelihood that the family

will return after the first session because they

have a clear idea of how they will resolve their

problems (Kaufman 1999).

The structural family therapist generally tries

to be warm and empathic while at the same

time remaining firm and objective (Huycke

2000) in therapeutic relationships with clients.

The therapist motivates clients to change

through a process of joining with the family.

During this process, the therapist

•Identifies and adjusts to the family’s way of

relating to each other, which will make resistance less likely.

•Conveys understanding and acceptance to

each person in the family so that everyone

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will trust the therapist enough to take his or

her advice.

•Shows respect to each person by virtue of

their family role, which could mean, for

example, asking parents first for their views

on the problem at hand.

•Listens as each person expresses feelings,

because most people in therapy think that no

one understands or cares how they feel.

•Makes a special effort to form linkages with

family members who are angry, powerful, or

doubtful about therapy so that they are

engaged (Nichols and Schwartz 2001).

According to Minuchin and Fishman (1981)

joining is “more an attitude than a technique”

(p. 31), and Kaufmann and Kaufman (1992a)

indicate that the process is very deliberate at

first, becoming more natural as therapy progresses. While joining typically confirms the

family’s positive traits and supports the family

so that members have the confidence and

strength to change, it can also mean challenging

the family to provide an impetus to change.

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

When appropriate, the therapist will take

action necessary to stop behaviors that

contribute to enmeshment in the family.

The therapist needs to observe the family closely

by tracking family interactions or by having

the family enact a dysfunctional behavior pattern within the therapy session. The therapist

then acts accordingly either to restructure

boundaries that are too rigid or strengthen

boundaries that have become enmeshed or

fused. For example, in families where substance abuse is present, one parent often

becomes over­involved with a child. In such

cases, the therapist needs to strengthen boundaries that support the parents as a unit (or subsystem) capable of maintaining a hierarchical

relation with their children and able to resist

interference from older generations of the family

or people outside the family (Kaufman 1999).

Structural therapists motivate and teach a

family new ways of behaving using structuralization. Using this process, the therapist sets an

example for how family members should

behave toward one another. After observing a

problem behavior, such as the family’s ignoring

one family member’s thoughts and needs, the

therapist acts in a contrary way (paying special

attention to what the usually ignored person

thinks, feels, or desires). By setting an example

in this manner, the therapist provides a model

for how the family can behave and applies gentle pressure on family members to change their

behavior.

Other important techniques for restructuring

family relations include system recomposition,

structural modification, and system focusing

(Aponte and Van Dusen 1981). System recomposition helps family members build new systems

(perhaps outside the family) or remove themselves from existing systems (which can imply

physical separation or changing existing patterns of interaction and communication).

Structural modification is the process of

constructing or reorganizing patterns of interaction (for instance, by shifting triangles to

develop better functioning alliances). System

focusing, also called reframing or relabeling, is

the process of presenting another perspective

on an apparent problem so that it appears

solvable or as having positive effects for those

who look at it as a problem. Relabeling can

help family members see their own complicity

in one member’s relapse by showing them what

they might lose if the recovery were to succeed.

For example, the therapist might show children

that they gain greater freedom if their parents

abuse substances. Relabeling also makes new

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Adjunctive Pharmacotherapy for

Substance Use Disorders

A variety of pharmacological interventions have been developed to aid in the

treatment of substance use disorders, and many more are in development. The

information provided here is merely an introduction to this topic. Further, the

information is subject to change as new medications are approved by the Food

and Drug Administration.

Medications are available that can help:

•Discourage continued substance use. These include disulfiram (Antabuse) for

alcohol use and naltrexone (Revia) for alcohol and opioid abuse.

•Suppress withdrawal symptoms. These include benzodiazepines for alcohol

withdrawal and methadone maintenance for opioid addiction.

•Block or alleviate cravings or euphoric effects. These include methadone,

levo­alpha­acetyl­methadol (LAAM), and buprenorphine for opioids, and

naltrexone for alcohol and opioids.

•Replace an illicit substance with one that can be administered legally. These

include methadone and other forms of opioid replacement therapy.

•Treat co­occurring psychiatric disorders.

Medications should be used in conjunction with other therapeutic interventions

(CSAT 1998c). Research findings indicate that the use of medication in substance

abuse treatment is much more effective when combined with psychosocial

interventions (McLellan et al. 1993).

Appendix A of TIP 24, A Guide to Substance Abuse Services for Primary Care

Clinicians (CSAT 1997a), details specific pharmacological interventions for

substance abuse treatment. TIP 28, Naltrexone and Alcoholism Treatment

(CSAT 1998c), is also a reference on this topic. See also the forthcoming TIP

Medication­Assisted Treatment for Opioid Addiction (CSAT in development d).

options for solving problems more apparent

and can act to provoke family members to

change their behavior. Overall, structural

intervention techniques may be difficult to use

without some further training. However, they

can be employed easily in assessment to understand the ways by which the organization of

the family may be structured to support the

substance use.

Strategic techniques

Strategic family therapy shares many techniques

and concepts with structural family therapy,

which are often used together. For example,

reframing or relabeling is a process common to

both approaches. The structural therapist

seeks to alter the basic structure of family

relations working on the theory that this will

improve the presenting problem. The strategic

therapist, however, focuses on solving one specific problem that the family has identified and

is concerned only with basic family interactions

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and behavior that perpetuate the presenting

problem. To the strategic therapist, interactions

are not the result of underlying structural

problems (Walsh 1997).

Different approaches fit into the strategic

approach. All of them have in common relabeling/reframing and a focus on sequence of interactions. They differ in the scope (length) of the

interaction they observe; however they all look

for the sequence of interaction and then develop a directive to modify the sequence.

Directives are part of strategic therapy’s

emphasis on change taking place outside of

therapy sessions. Indirect techniques are specific types of directives that may seem unrelated or contradictory to the task at hand but that

actually help the family move toward its goal.

Reframing is an indirect technique.

Solution­focused techniques

Solution­focused approaches to family therapy

build on many of the ideas and techniques used

in strategic therapy (Berg and Miller 1992;

Berg and Reuss 1997; de Shazer 1988). This

approach is less concerned with the origins of

problems and more oriented toward future

changes in family interactions. The solutionfocused therapist fosters confidence and optimism, so solution­focused approaches do not

focus on problems and deficiencies, but rather

on solutions and clients’ competencies. A

variety of solution­focused therapies have been

developed specifically for the treatment of substance abuse. Because of its narrow focus on

the presenting problem, solution­focused family

therapy works well with many existing substance abuse treatment approaches.

Although solution­focused therapy appears to

be somewhat at odds with traditional substance

abuse treatment approaches, Osborn (1997)

found that many alcoholism counselors endorse

the fundamental assumptions and approach of

solution­focused therapy. Even if one does not

completely adopt the solution­focused therapy

approach, some of this model’s techniques can

be used with a variety of other approaches,

including a focus on the past. One such technique is to ask the client to remember a time

when problem behaviors were not present and

then to examine what behaviors occurred during these times. “Can you think of a time when

the problem was not happening or happening

less? What was happening? What were things

like at that point? How can that behavior be

repeated now?” The focus on past exceptions,

whether deliberate (cases where the clients controlled the problem) or random (cases where

the problem disappeared temporarily because

of factors beyond the client’s control), helps

clients to see that change is possible and that at

times, the apparent problems abated.

Another technique is to use the “miracle

question,” which is, “If a miracle occurred,

and the presenting problem disappeared, how

would you know that the problem had disappeared?” The miracle question is useful

because it helps clients see how their lives can

be different. This technique is described in

greater detail in chapter 4.

Additional information on strategic and

solution­focused approaches to the treatment of

substance use disorders can be found in TIP

34, Brief Interventions and Brief Therapies for

Substance Abuse (CSAT 1999a).

Substance Abuse

Treatment for Family

Therapists

The causes of substance abuse are multidetermined, with biological, psychological, social,

and spiritual components. Within the substance abuse treatment field, a variety of different approaches are used. Two of the most

common are described in this section.

Traditional Theoretical

Understandings of Substance

Abuse

Two models have contributed to our contemporary understanding of substance abuse and

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dependence: the medical (or disease) model and

the sociocultural model.

Medical model

The medical model of addiction emphasizes the

biological, genetic, or physiological causes of

substance abuse and dependence. A body of

biological research suggesting a genetic component to substance abuse supports this theory

(Cloninger 1999), particularly in the case of

alcoholism, since it is the type of substance

abuse that has been most thoroughly

researched (Li 2000) and it is the type involved

in the vast majority of substance use disorders.

The model is also supported by research that

demonstrates how various substances of abuse

can cause long­term changes in brain chemistry

(Blum et al. 2000; London et al. 1999). From a

medical perspective, treatment involves medical

care and can include the use of pharmacotherapy to help manage withdrawal and

assist in behavior change. (See below for more

information on pharmacological treatments for

substance use disorders.)

The ideas of the medical model can be incorporated into family therapy. For example, the

model is based in part on a belief in a genetic

predisposition to substance abuse, which can

just as easily be understood as one element in

family therapists’ idea of the transgenerational

transmission of problems. In family therapy,

the recognition is growing, too, that the field

needs to develop a better understanding of

pharmacological treatments for disorders that

affect family dynamics. For this reason, family

therapists need some knowledge of the medical

issues related to substance abuse and need to

know when to refer clients for an assessment of

a potential substance use disorder.

Sociocultural theories

Sociocultural approaches to substance abuse

focus on how stressors in the social and cultural

environment influence substance use and

abuse. Theorists from this school propose that

environmental influences such as socioeconomic

status, employment,

level of acculturation,

legal penalties, family

norms, and peer The causes of substance abuse are

multidetermined,

with biological,

psychological,

social, and spiritual components.

expectations can have

a significant influence

on a person’s substance use and abuse.

Treating substance

abuse, according to

these theories,

requires changing a

person’s physical and

social environment.

Particular interventions include economic

empowerment, job

training, social skills

training, and other

activities that can

improve a client’s

socioeconomic environment. Other interventions may involve community­ and faith­based

activities or participation in self­help groups,

all of which can help the client regain hope and

connect with other people. Sociocultural interventions often stress the strengths of clients and

families.

Holistic approach

Each of the two models presented above—

medical and sociocultural—has some validity

and research to support its credibility. Most

treatment providers, however, do not believe

that any one of these approaches adequately

describes the causes or suggests a single preferred treatment for substance use disorders.

The holistic model, a biopsychosocial model,

has been presented as a way to understand the

multifaceted problem of substance abuse

(Wallace 1989).

Many providers also add a spiritual component

to the biopsychosocial approach, making it a

biopsychosocial­spiritual approach. This is a

fourth model for understanding substance

abuse, one that regards recovery from substance

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abuse as, at least in

part, a spiritual

journey. This fourth

Family therapists

should be familiar

with at least the

most common

substance abuse

treatment

modalities.

model is heavily

influenced by the

12­Step approach

to recovery. The

consensus panel

believes that effective treatment will

integrate these models according to the

treatment setting,

but will always take

into account all of

the factors that contribute to substance

use disorders.

Common Treatment

Modalities

A variety of treatment modalities are widely

used in substance abuse treatment. Family

therapists should be familiar with at least the

most common substance abuse treatment

modalities in order to be able to make effective

referrals and understand other components of

clients’ treatment regimens. When referring a

client to a particular substance abuse treatment

program, however, a number of factors must

be considered in addition to the necessary

intensity of treatment and the specific services

available. Some main considerations are

•The client’s expressed needs and desires

•A recommendation from a substance abuse

treatment professional (if there is any doubt

about the treatment modality to which the

client should be referred)

•The client’s insurance or other available

funding sources and the types of treatment

they cover

•The client’s work setting and family arrangements, especially whether they allow the

client to leave for an extended period of time

Nonetheless, the consensus panel believes that

family therapy (as distinguished from family

education programs or visiting programs) has a

place in all treatment modalities. The panel has

highlighted ways to use family interventions in

most of the treatment settings described here.

Detoxification services

People who have a substance use disorder will

likely require a period of detoxification before

they can begin intensive treatment.

Detoxification is not substance abuse treatment,

but for many clients it is an essential precursor

to treatment. Without subsequent treatment,

detoxification is unlikely to have any lasting

effect (Gerstein 1999). Not all clients with substance use disorders require the same intensity

of detoxification services. Detoxification services

range from medically managed inpatient services

to services that can take place in outpatient or

even social service settings.

The most intensive detoxification service is a

medically managed inpatient program set in a

facility with medical resources. Medically

managed programs can treat a wide range of

medical complications that can arise in people

detoxifying from dependence on substances of

abuse. Inpatient programs have the advantage

of allowing clinicians to limit clients’ access to

substances of abuse and to observe them

around the clock if necessary. Clients who

require this level of care include those who

have had severe overdoses, have acute or

chronic medical or psychiatric conditions, are

pregnant, or have developed considerable

physical dependence (CSAT in development a;

Inaba et al. 1997). Providers should also be

aware that most insurers do not cover this level

of service unless the client meets certain clearly

defined medical criteria.

Medically managed outpatient programs can

provide medication and a range of medical

services, but patients are free to leave the

premises and are not as closely monitored as

are those in inpatient programs. This option is

useful for clients who have conditions that

require medication and treatment, but not

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24­hour observation. Compared to inpatient

services, outpatient detoxification is much less

expensive and causes less disruption in the

client’s life.

Many clients do not require medically managed

services, and for them, social detoxification

programs (either residential or outpatient) may

be the best option. Social detoxification programs provide counseling and other forms of

nonpharmacological assistance for managing

withdrawal, but generally do not have any

onsite medical services. Furthermore, most

social detoxification is carried out without the

use of medications. Staff members do, however,

observe a client closely (especially in residential

settings) and can contact a physician or nurse if

necessary. It is rare, however, to find any of

these modalities in their pure form; most are a

blend of methods and modalities.

Detoxification programs typically involve

families by providing psychoeducational family

groups or similar short­term activities, but they

lack the time and resources for more extensive

family treatment.

For more information on detoxification procedures in both community and hospital settings,

see the forthcoming TIP Detoxification and

Substance Abuse Treatment (CSAT in development a), a revision of TIP 19 (CSAT 1995d).

Short­term residential

Short­term residential programs provide

intensive treatment to clients who live onsite

for a relatively short period (usually 3 to 6

weeks). The majority of these programs provide

multiple treatment interventions, including

group and individual counseling, assessments,

the development of a strong connection with

self­help groups and instruction in its principles,

psychoeducational groups, and pharmacological

interventions to reduce craving and discourage

use.

Short­Term Inpatient Treatment (SIT) is the

therapeutic approach predominantly used in

programs oriented toward insured populations

(Gerstein 1999). SIT is a highly structured 3­ to

6­week inpatient program. Patients receive

psychiatric and psychological evaluations,

assist in developing a recovery plan based on

the tenets of AA, attend educational lectures

and groups, meet individually with counselors

and other professionals, and participate in

family or codependent therapy. Patients also

receive intensive follow­up care lasting from 3

months to 2 years, with less intensive follow­up

after that.

Many short­term residential programs feature

some sort of treatment intervention for clients’

family members. The Hazelden Family Center,

for example, is a 5­ to 7­day residential family

program that explores relationship issues common among families with a member who abuses

substances. A majority of the family programs

used in short­term residential treatment

involve psychoeducational family groups. Most

such programs do not provide traditional family

therapy, even if they offer some other form of

family­oriented treatment.

There is no reason family therapy cannot be

integrated into short­term residential programs, though the short duration of therapy

may require more intensive and longer (than 1

hour) sessions because work with a family will

often end when the client with the substance

use disorder leaves treatment. Unfortunately,

clients may have to become engaged in an

entirely different system for their continuing

care, as funding for services may not carry

over. Further, family therapy would need to be

highly structured (as other activities in these

programs are) and the therapist would need to

work around a schedule of other activities in

the treatment program. If family therapy is

being added to an inpatient residential program,

it should not take the place of family visiting

hours. Clients also need recreational time with

their families.

Some short­term residential programs may

intentionally refrain from including family

therapy because providers believe that clients

in early recovery are unable to manage painful

issues that often arise in family therapy. That

may be true in some cases, but even if a client

Appoaches to Therapy 67
             

           

               

   

         

       

         

           

             

         

             

           

       

       

                 

             

           

             

             

               

           

       

         

           

             

           

             

       

           

           

           

             

           

         

       

         

             

           

     

           

       

                 

           

         

           

       

         

   

               

             

           

         

           

           

             

           

           

           

         

   

       

           

               

             

         

         

           

               

             

           

             

           

           

       

               

                   

           

           

           

           

         

             

is unable to deal simultaneously with the

cessation of substance use and family issues,

the family of the client can still benefit from

family therapy.

Long­term residential 

treatment (or therapeutic

community)

A long­term residential (LTR) program will

provide round­the­clock care (in a nonhospital

setting), along with intensive substance abuse

treatment for an extended period (ranging from

months to 2 years). Most LTR programs consider

themselves a form of therapeutic community

(TC), but LTRs can make use of additional

treatment models and approaches, such as

cognitive–behavioral therapy, 12­Step work,

or relapse prevention (Gerstein 1999).

The traditional TC program provides residential

care for 15 to 24 months in a highly structured

environment for groups ranging from 30 to

several hundred clients. According to the TC

model, substance abuse is a form of deviant

behavior, so the TC works to change the

client’s entire way of life. In addition to helping

clients abstain from substance abuse, TCs work

on eliminating antisocial behavior, developing

employment skills, and instilling positive social

attitudes and values (De Leon 1999).

TC treatment is not limited to specific interventions, but involves the entire community of

staff and clients in all daily activities, including

group therapy sessions, meetings, recreation,

and work, which may involve vocational training

and other support services. Daily activities are

highly structured, and all participants in the

TC are expected to adhere to strict behavioral

rules. Group sessions may sometimes be quite

confrontational. A TC ordinarily also features

clearly defined rewards and punishments, a

specific hierarchy of responsibilities and privileges, and the promise of mobility through the

client hierarchy and to staff positions. The TC

has become a treatment option for incarcerated

populations (see the forthcoming TIP

Substance Abuse Treatment for Adults in the

Criminal Justice System [CSAT in development

j]) and a modified version of the TC has been

demonstrated to be effective with clients with

co­occurring substance use and other mental

disorders (for more information on the

modified TC, see the forthcoming TIP

Substance Abuse Treatment for Persons With

Co­Occurring Disorders [CSAT in development

k], a revision of TIP 9 [CSAT 1994b]).

Clients in TCs often lack basic social skills,

come from broken homes and deprived environments, have participated in criminal activity, have poor employment histories, and abuse

multiple substances. For these reasons, the TC

process is more a matter of providing habilitation than rehabilitation (De Leon 1999). As

Gerstein notes, the TC environment in many

ways “simulates and enforces a model family

environment that the patient lacked during

developmentally critical preadolescent and

adolescent years“ (1999, p. 139).

Family therapy is not generally an intervention

provided in TCs (at least not in the United

States), but TC programs can use family therapy

to assist clients, especially when preparing

them to return to their homes and communities.

Outpatient treatment

Outpatient treatment is the most common

modality of substance abuse treatment. It is

also the most diverse, and the type of treatment

provided, as well as its frequency and intensity,

can vary greatly from program to program.

Some, such as those that offer walk­in services,

may offer only psychoeducation, while intensive

day treatment can rival residential programs in

range of services, assessment of client needs,

and effectiveness (National Institute on Drug

Abuse 1999a).

The most common variety of outpatient program

is one that provides some kind of counseling or

therapy once or twice a week for 3 to 6 months

(Gerstein 1999). Many of these programs rely

primarily on group counseling, but others offer

a range of individual counseling and therapy

options, and some do offer family therapy.

Some outpatient programs offer case management and referrals to needed services such as

68 Appoaches to Therapy
         

           

               

           

         

           

       

             

             

             

               

           

             

             

         

           

       

               

             

         

         

   

           

           

             

       

               

         

           

         

           

         

       

         

           

               

         

       

         

               

   

   

   

   

   

   

     

   

     

     

   

       

     

     

   

     

     

           

         

     

             

                 

       

     

         

         

     

           

             

           

         

           

     

             

           

           

       

       

         

             

         

vocational training and housing assistance, but

rarely provide such services onsite, not because

they do not see the need, but because funding

is unavailable. The services are often offered in

specialized programs for clients with co­occurring

substance use and other mental disorders.

Outpatient treatment has distinct advantages.

Compared to inpatient treatment, it is less costly and allows more flexibility for clients who

are employed or have family obligations that do

not allow them to leave for an extended period

of time. Research has demonstrated, as with

many other modalities, that the longer a client

is in outpatient treatment the better are his

chances for maintaining abstinence for an

extended period of time. Studies of outpatient

treatment have documented high drop­out

rates in this modality, so many clients do not

remain in treatment long enough to receive the

optimal benefit (Gerstein 1999). For this reason,

exit planning, resource information, and

community engagement should start in the

beginning of treatment.

Because of the great diversity in services

offered by outpatient treatment programs it is

difficult to generalize about the use of family

therapy. Certainly, however, family therapy

can be implemented in this setting, and a number

of outpatient treatment programs offer various

levels of family intervention for their clients.

(For more information see the forthcoming TIP

Intensive Outpatient Treatment for Alcohol and

Other Drug Abuse [CSAT in development c].)

Opioid addiction outpatient

treatment

A specific type of outpatient treatment known

as opioid addiction treatment or methadone

maintenance involves the administration of

opioid substitutes, such as methadone and

LAAM, to clients who are opioid­dependent.

(Methadone requires a daily dosage, but LAAM

only needs to be administered every 2 or 3

days.) This pharmaceutical substitute acts to

prevent withdrawal symptoms, reduce drug

craving, eliminate euphoric effects, and stabilize mood and mental states. The side effects of

these prescribed medications are minimal,
 

and they are administered orally, thereby
 

eliminating many of A number of outpatient treatment
 

programs offer
 

various levels of

family intervention

for their clients.

the hazards associated
 

with injection drug

use. Methadone
 

maintenance programs

require daily attendance for new clients,
 

but many programs

allow clients to take

doses home if they

have complied with

treatment requirements for a period of

time (for example, if

urine tests are

negative for illicit

drugs and clients have

attended counseling sessions regularly).

In October 2002, the Food and Drug

Administration (FDA) approved the use of

buprenorphine for opioid dependence.

Physicians may dispense it or prescribe it to

clients in their offices if they (1) obtain a waiver

exempting them from Federal requirements

regarding prescribing controlled substances

and (2) obtain subspecialty board certification

or training in treatment and management of

patients with opioid dependence. Information

and training are available at SAMHSA’s Web

site (http://www.buprenorphine.samhsa.gov). A

physician locator at this Web site can help

clients find qualified physicians in their area

(Clay 2003).

SAMHSA’s CSAT is engaged with treatment

experts, State and other Federal officials, and

patient representatives to develop guidelines

and other educational materials on the use of

medications such as methadone and LAAM and

alternative therapies in the treatment of

addictions. CSAT’s Division of Pharmacologic

Therapies manages the day­to­day regulatory

oversight activities necessary to implement new

SAMHSA regulations (42 C.F.R. Part 8) on the

use of opioid agonist medications (methadone

Appoaches to Therapy 69
             

       

           

         

           

               

         

               

           

         

         

       

               

               

           

         

       

         

               

         

   

   

   

           

                 

             

           

         

         

           

   

           

         

           

         

         

           

           

           

               

             

           

             

               

                 

                   

               

         

         

           

             

         

             

       

           

           

           

             

             

             

           

             

         

         

         

             

         

           

           

       

           

       

         

                 

         

       

               

       

         

           

             

           

         

and LAAM) approved by the FDA for addiction

treatment. These activities include supporting

the certification and accreditation of more than

1,000 opioid treatment programs that collectively

treat more than 200,000 patients annually

(more information can be found at

http://www.dpt.samhsa.gov).

Opioid addiction treatment has been shown to

be an effective way to mitigate the harmful consequences of substance abuse, reduce criminal

activity, slow the spread of AIDS in the treated

population, reduce the client death rate, and

curb illicit substance use (Effective Medical

Treatment of Opiate Addiction 1997; Gerstein

1999). Despite these findings, approximately 1

in 4 individuals do not respond well to this

treatment for a variety of reasons that are not

apparent in clients prior to treatment (Gerstein

1999). Retention rates and outcomes are

improved, however, if methadone maintenance

programs offer more frequent counseling and

provide higher doses (an average of 60 to 120

milligrams per day) of methadone (Gerstein

1999). (For more information see the forthcoming TIP Medication­Assisted Treatment for

Opioid Addiction [CSAT in development d]).

Understanding 12­Step

Self­Help Programs

Family therapists would benefit from attendance

at 12­Step programs to understand the concepts

and to see in action the principles that might be

helpful to their clients. Anyone can attend an

open 12­Step meeting (see a local telephone

directory or AA’s Web site at

http://www.aa.org, and click on “contact local

AA”), and therapists who attend meetings and

process the information with knowledgeable

supervisors or colleagues are able to converse

with clients about meeting attendance, problems, benefits, and methods of utilizing 12­Step

meetings in conjunction with the therapeutic

process. Experience with attendance at 12­Step

meetings helps therapists to address issues of

resistance when clients say that the meetings

are not appropriate for them (e.g., “everyone

is different from me,” or “they make me tell

things I don’t want to talk about.”) Another

benefit of therapists’ attendance at meetings is

the ability to prepare a client for attendance.

The therapist can give an overview of what to

expect; for example, it is not necessary to put a

donation in the basket as it is passed; it is okay

to say “pass” if people are taking turns talking

by going around the room, seat­by­seat; how

people use sponsors, and so on.

Considering how common substance abuse is in

our society, all family therapists need to

understand the philosophy behind the disease

concept of substance abuse; the concepts of

12­Step programs (such as powerlessness and

surrender); the signs, symptoms, and stages of

substance abuse; and the specific issues, problems, and needs of children. Some evidence

suggests that these ties are already strong. For

example, Northey (2002) found in a recent

survey that 89 percent of family therapists do

refer clients to self­help groups. Family therapists also need to understand the language and

terminology of the substance abuse treatment

field and DSM­IV­TR’s definitions of substance

use disorders.

It is important that therapists realize that family

therapy organized around substance abuse will

not be effective unless the substance abuse is

dealt with directly. Therapy should also

address the substance abuse problem first if

other changes are to take place successfully

(O’Farrell and Fals­Stewart 1999). Therapists

should also understand that substance use

disorders are typically chronic, progressive,

relapsing conditions. Relapse should be viewed

as part of the recovery process and not as a

cause for automatic termination of treatment.

Family therapists must be apprised of 

community services for people with substance

use disorders and be able to refer clients to

them.

Substance abuse treatment providers recognize

the importance that spirituality (regardless of

the particular faith or spiritual path chosen)

can have in recovery. The use of spirituality

and self­help principles may seem foreign to

some family therapists’ conception of treat70 Appoaches to Therapy
             

         

         

       

           

   

           

           

         

             

               

       

             

             

             

               

             

       

           

     

   

     

           

   

               

           

           

         

         

       

     

   

                   

             

                   

                 

                     

                     

                       

             

         

                   

   

                 

ment, but these ideas are widely used and

accepted within the substance abuse treatment

community. Family therapists can use spirituality

by recommending that families connect (or

reconnect) with their spiritual traditions or

discuss spiritual beliefs.

Some self­help ideas, such as sponsorship (a

mentoring component for clients), can also be

applied within a family therapy setting.

Connecting a family who is new to treatment

with another more experienced family in treatment can help both, encouraging the new family

to see the possible gains and helping the more

experienced family reaffirm its commitment to

treatment and the difference it has made.

12­Step groups are the mutual self­help modality

most commonly used, but there are other selfhelp groups that go beyond the substance abuse

field. In fact, some of these groups are called

mutual aid groups because they go beyond the

traditional AA self­help 12­Step programs.

Examples include Deaf and Hard of

Hearing 12­Step Recovery Resources

(http://www.michdhh.org/health_care/

recovery_community.html), Depression and

BiPolar Support Alliance (http://www.dbsalliance.org), and the National Alliance for the

Mentally Ill (http://www.nami.org). The

Internet can serve as a good point for finding

out local information about these kinds of

groups. A listing of various mutual aid

resources by the Behavioral Health Recovery

Management project can be found at

http://www.bhrm.org. See also the National

Mental Health Consumer’s Self­Help

Clearinghouse at http://www.mhselfhelp.org.

Chapter 3 Summary Points From a

Family Counselor Point of View

•If background and training are largely within the family therapy tradition,

develop an ever­deepening understanding of the subtleties and pervasiveness

of denial.

•If background and training are largely within the substance abuse treatment

field, develop an ever­deepening understanding of the subtleties and impact of

family membership and family dynamics on the client and the members of the

client’s family.

•When the going gets tough, get help. Both substance abuse counselors and

family therapists are likely to need help from each other with different

situations. Consultations and collaboration are key elements in ensuring

clients’ progress.

•Develop thorough and effective assessment processes.

•Consider specialized training on one or more specific family therapy

techniques or approaches.

•Match techniques to stage of change and phase of treatment.

Appoaches to Therapy 71

                   

               

                 

               

               

                       

                       

             

                 

                       

       

                     

                         

           

                 

                 

                   

                     

                   

                     

                   

                   

                   

               

                 

In This
 

Chapter...
 

Integrated
 

Substance Abuse
 

Treatment and
 

Family Therapy
 

Integrated Models
 

for Substance
 

Abuse Treatment
 

Matching
 

Therapeutic
 

Techniques to
 

Levels of Recovery
 

4 Integrated Models 

for Treating Family
 

Members

Overview 

In families in which one or more members has a substance abuse problem,

substance abuse treatment and family therapy can be integrated to provide effective solutions to multiple problems. Counselors and therapists

from the two disciplines seldom share similar professional training;

consequently, the integrated treatment models described in this chapter

can serve as a guide for conjoint treatment approaches.

The two disciplines can be integrated to a greater or lesser extent, ranging from simple staff awareness of the importance of the family to fully

integrated treatment programs. This chapter discusses the advantages

and limitations of integrated treatment models. The extent to which

counselors are involved with families also can vary, and the extent of this

involvement depends on several factors.

Care must be taken in the choice of an integrated therapeutic model.

The theoretic basis of a number of models is given along with the techniques and strategies that are commonly used.

Integrated Substance Abuse

Treatment and Family Therapy 

Most substance abuse treatment agencies serve a variety of clients—men

and women, young and old, homeless and affluent individuals, from

every racial and ethnic majority and minority group—with a wide range

of substance abuse profiles. On any given day, a substance abuse treatment counselor may work with a 15­year­old girl caught with marijuana

in her school locker, a 45­year­old woman whose drinking spiraled out of

control after her husband's death, and a 35­year­old man faced with

legal trouble stemming from his chronic use of crack cocaine. Some

clients may be new immigrants with language and cultural barriers that

affect treatment. Others with co­occurring medical or psychiatric disorders may require integrated treatment for the two problems. Some

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clients may have decided to stop abusing substances, while others may wonder “what the big

deal is about smoking a little dope.” When families are included in substance abuse treatment,

the needs, problems, and motivations are

exponentially increased.

The array of client needs, multiple family influences, and differences in counselors’ training

and priorities, along with the difficult nature of

most substance abuse problems, suggest that

the family therapy and substance abuse treatment fields should work closely together. The

resources and insights each discipline can bring

to treatment are the best arguments for integrating substance abuse treatment and family

therapy. Integrated models of treatment would

also avoid duplication of services, discourage

an artificial split between therapy for family

problems and substance abuse treatment, and

effectively and efficiently provide services to

clients and their families.

Combining substance abuse treatment and

family therapy requires an integrated model.

This term, for the purposes of this TIP, refers

to a constellation of interventions that takes

into account (1) each family member’s issues as

Figure 4­1

Facets of Program Integration

Staff awareness and education. Staff develops awareness of and participates in

training designed to enhance their knowledge and conceptualization of the

importance of the family as a strength and positive resource in substance abuse

treatment. Staff generally understands that clients require support systems to

maintain recovery and avoid relapse, but at this level, resources are almost

completely informational in nature.

Family education. Educational opportunities, information, and informal referrals

are presented to the general public and potential clients and families to learn

about the role of families in the substance abuse treatment process. The substance abuse program generally lacks the financial and human resources to

provide direct services to family members. Although some educational seminars

may be offered, they are not mandatory for clients and families as part of a

formal substance abuse treatment program. The focus is limited to providing

information to a wider audience and a potential client pool about the role of the

family in substance abuse treatment. Also, the agency offers high­quality referral lists to interested parties for follow­up.

Family collaboration. At this level, clients’ families are actively involved and

understand their importance as a resource in the substance abuse treatment

program. Substance abuse programs refer clients for family therapy services

through coordinated substance abuse treatment efforts that maintain 

collaborative ties.

Family therapy integration. All components of the programs and policies related

to full integration of family therapy into substance abuse treatment are in place.

Systemwide, strengths­based, and family­friendly approaches are operational,

culturally competent, and “one­stop assistance” for clients and families. A

family culture pervades the organization at all levels and is supported by the

appropriate infrastructure, specifically human and financial resources.

74 Integrated Models for Treating Family Members
             

           

               

               

             

             

           

           

               

           

         

       

           

       

               

         

         

               

             

           

               

         

           

             

         

           

         

           

             

           

             

           

               

       

     

           

             

         

           

             

         

         

             

           

       

         

       

         

           

       

             

             

       

         

           

           

           

               

             

           

             

             

       

   

           

             

           

           

           

         

         

           

       

   

         

       

         

           

they relate to the substance abuse (perhaps a

spouse who drinks excessively, a spouse who

enables the drinking, and a child who acts out

in reaction to the drinking), and (2) the effect

of each member’s issues on the family system.

This TIP also assumes that while a substance

abuse problem manifests itself in an individual

(such as one person smoking crack cocaine),

the solution will be found within the family

system (for instance, new interactions that

support not smoking crack cocaine).

Substance abuse counselors have developed

specialized knowledge of addiction and recovery.

They also may draw on personal recovery

experiences. However, substance abuse counselors may not be familiar with the theories and

techniques associated with family systems interventions. Though they generally are familiar

with the influence a family exerts on one

member’s use of alcohol or illicit drugs,

substance abuse counselors at times may see

family issues as a threat to a client’s recovery,

particularly if the person abusing substances

feels overwhelmed and unable to cope with the

reactions of the family to treatment and the

intense emotions evoked by treatment. The

substance abuse counselor’s goal is the client’s

recovery, and such issues as family pressures

that threaten attainment of that goal should not

be allowed to distract the client.

Family therapists, on the other hand, are well

acquainted with the operation of family systems.

However, they may not fully understand the

needs and stresses of people with substance use

disorders. Clients themselves may see the

suggestion of family therapy as a return to

repetitive intrafamily conflicts and emotional

turmoil.

Family therapy or family­involved interventions and substance abuse treatment can be

integrated to greater or lesser degrees along a

continuum. Figure 4­1 presents four discrete

facets of integration along this continuum. This

model is not a prescriptive recipe for “how­to”

integration, but a guide to strategies, 

descriptions, and activities involved in the

different facets. Further discussion of these

facets is presented in chapter 6, Policy and

Program Issues.

In the family collaboration level of program

integration, substance abuse treatment clients

are referred to various agencies for family

therapy and other services. An alternative is

the integration of a family­oriented case

management approach, which uses referral to

outside resources for family therapy as needed.

Family­oriented case management can serve

many of the purposes that family therapy does.

For example, both work from the core premise

that understanding any individual requires an

appreciation of that person’s entire ecological

context.

Even when components of the treatment plan

are mandated by other agencies, getting families’

opinions on how to meet these requirements or

preferences is imperative to keep their motivation to adhere to or follow through with the

treatment plan. If the treatment plan is taken

totally out of their hands, resistance naturally

will become an issue. Wherever possible

providers need to allow the family to make

choices, even if it means providing only two

alternatives to meet the requirements.

Value of Integrated Models

for Clients

Models of family therapy have been evolving

over the past 60 years as counselors and

researchers have worked to identify the determinants of substance use disorders, the factors

that maintain these disorders, and the complex

relationships between people with the disorders

and their family members (McCrady and

Epstein 1996). Paying attention to such issues

has a number of advantages:

•Treatment outcomes. Family involvement in

substance abuse treatment is positively

associated with increased engagement rates

for entry into treatment, decreased dropout

rates during treatment, and better long­term

Integrated Models for Treating Family Members 75
             

                 

                   

                     

                       

                   

                         

                       

                 

                         

                             

                   

                     

                       

                             

           

                 

                       

                           

                       

                         

                         

               

                       

                   

                     

                   

                     

                 

                 

Coordinating Services Among 

Multiple Agencies

When families receive services from several providers, coordinating appointments, paperwork, and requirements in the family’s primary language becomes

a necessity. Indeed, coordination and service delivery are even more challenging

and critical when families are refugees or immigrants who are unfamiliar with

the language and culture. The following methods can be used to accomplish this

coordination:

•Families involved with several agencies can become confused about who provides which services, or which deadlines are in effect. It is important for the

larger system players to coordinate their efforts to help the family and clearly

communicate the treatment plan to the family. Sometimes, a formal staff meeting

attended by all service providers and the family can accomplish this function.

•Different agencies may recommend or require conflicting courses of action.

For example, the social worker says go to school, the probation officer says get

a job, and the children’s school says be home when they are out of school. The

counselor can resolve such conflicting demands by working with all service

providers to develop a treatment plan that prioritizes tasks (for example, for

an adolescent, attending school may be the first priority, followed by getting a

job). At times, the therapist may need to act as an advocate for the family if

other providers demand conflicting courses of action.

•Encourage the family to keep an up­to­date calendar, with appointments and

requirements listed.

•If service providers leave an agency or new professionals are assigned to work

with a family, the counselor should set up a meeting between the old and new

providers and the family so that important information is made known to the

new professional and the family has a chance to say goodbye to the departing

practitioner.

•As a way to advocate for the client, monthly reports to all service providers

can document treatment attendance, compliance with mandated activities, and

progress toward goals. Monthly reports can also bring attention to parts of the

treatment plan that are not working and need to be reformulated.

•Memos and reports can be used as interventions. For instance, sending a

memo after a session reiterates what happened during the session, reinforces

the positive, and can ask questions such as, “Did you realize such­and­such

was happening?”

•Regularly scheduled meetings can help coordinate services for agencies that

often work together, with paperwork documenting actions before and after

these meetings.

76 Integrated Models for Treating Family Members
       

     

   

           

           

         

       

         

               

           

           

             

           

             

   

               

       

       

       

         

           

         

         

           

   

     

         

           

           

         

               

         

           

             

                     

                     

                   

                       

         

                 

                   

                 

             

               

     

                     

                         

       

outcomes (Edwards and Steinglass 1995;
 

Stanton and Shadish 1997).
 

•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.

Both the individual with the substance use

disorder and the family members get the help

they need to achieve and maintain abstinence

(Collins 1990).

•Intergenerational impact. Integrated models

can help reduce the impact and recurrence

of substance use disorders in different 

generations.

Value of Integrated Models

for Treatment Professionals

In addition to the benefits for clients and their

families, integrated models are advantageous to

treatment providers. The practical advantages

include

•Reduced resistance. In addition to the promise of better treatment outcomes, integrated

models permit counselors to attend to the

specific circumstances of each family in treatment. This focus accommodates the whole

family and helps to diminish the family’s

resistance to treatment.

•Flexibility in treatment planning. Integrated

models enable counselors to tailor treatment

plans to reflect individual and family factors.

For instance, each family member’s stage of

change can be taken into consideration (see

chapter 3 for a description of the stages of

change). Early in treatment, families may

need education about substance abuse and its

effects, while families in later stages of

Benefits of an Integrated Substance

Abuse and Family Therapy Program

The Family Intervention Program (FIP) is a good example of an integrated

model for substance abuse treatment and family therapy. Jointly funded by New

Jersey’s Department of Human Services and Department of Health and Senior

Services, FIP was designed to test the effectiveness of pairing a structural family

therapist with a community resource specialist.

The program treated multiproblem families with adolescents (Fishman et al.

2001) whose presenting problems were substance abuse (by the adolescents or

other family members), delinquency, and domestic violence. When compared to

a family­therapy­only intervention, FIP was found to produce better results:

Adolescents’ substance abuse and delinquency declined, while academic

performance and family relationships improved.

In one case, a 17­year­old client was suspended from school because of substance

abuse. The community resource specialist was able to convince his school principal to lift the suspension provided the client continued to participate in the FIP

program.

Source: Consensus Panel Member Fred Andes.

Integrated Models for Treating Family Members 77
           

           

             

       

             

           

   

     

           

         

         

         

         

           

         

           

         

         

           

             

       

       

       

           

       

       

           

             

       

       

         

       

   

           

           

         

         

           

     

     

           

         

       

         

       

   

         

         

       

           

         

           

           

       

             

         

         

           

     

             

       

                 

                 

                   

                     

                     

     

       

treatment may need help as they address

such issues as trust, forgiveness, the acquisition of new leisure skills, changing roles, the

reestablishment of boundaries within the

family and at work, and changing the specific

interaction patterns in the family that

support substance abuse.

•Flexibility in treatment approach. Apart

from the freedom to tailor treatment plans,

integrated models enable counselors to adjust

treatment approaches according to their own

personal styles and strengths. For instance,

counselors who enjoy working with adolescents and families can choose structural and

strategic models that concentrate on family

interactions, while those who prefer to capitalize on client competencies and strengths

can choose solution­focused therapy. 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 a client’s family

members and see how each of their problems

reverberates throughout the family system.

Similarly, family therapists can experience

working with people whose primary problems

are substance use disorders.

•Administration. Integrated models enable

administrators to get more for less. Despite

the obvious cost to cross­train family therapists and substance abuse counselors, the

improved treatment outcomes more than offset the investment. New Jersey’s Division of

Addiction Training recently demonstrated

this cost­to­benefit relationship (Fishman et

al. 2001). In this process, integrated models

accommodated the differences in theory,

philosophy, and funding across multiple

agencies. Further, models with proven efficacy

could be duplicated across agencies, which

added to the long­term cost­effectiveness.

Limitations of Integrated

Models

Despite their obvious value and demonstrated

efficacy, integrated models for substance abuse

treatment have some limitations:

•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. Integrating interventions from different models to create a coherent and powerful treatment plan individually tailored to

clients and their families requires knowledge

of which therapies to use under particular

circumstances and a sound protocol for

therapy selection. Further, when high­risk

threats such as suicide or family violence are

present, more regimented protocols than

usual may be needed to govern therapy

selection. 

Collaborating To Treat 

American Indians

First Nations Community HealthSource, a nonprofit urban health clinic in

Albuquerque, New Mexico, developed a co­therapist system that links family

therapy and substance abuse treatment. A family therapist and a substance

abuse counselor work with families together in an outpatient setting. The counselor teaming has helped decrease the number of treatment sessions needed to

successfully treat substance abuse.

Source: Consensus Panel Member Greer McSpadden.

78 Integrated Models for Treating Family Members
         

         

         

           

             

       

             

       

         

           

       

         

           

           

               

         

           

         

         

       

     

         

         

             

       

         

             

           

           

           

         

         

       

       

           

       

         

           

         

       

         

         

           

       

             

           

             

           

           

             

           

         

       

             

               

             

           

     

   

     

           

           

           

           

           

           

                 

         

     

       

           

           

           

               

               

             

             

           

               

               

           

     

             

         

       

•Additional training. Integrated models

require greater knowledge of more treatment

modalities so additional training is necessary.

Further, if substance abuse counselors and

family therapists are to work together effectively, to some extent, they must learn each

other’s trade.

•Mindset. The major mindset shift necessary

to using integrated models is between an

individual model concentrating on pathology

and a systemic (relational or behavioral)

model focused on changing patterns of family

interaction. Integrated models require both

substance abuse counselors and family therapists to venture into new territory. Substance

abuse counselors may be hesitant to engage

the entire family either because they feel it is

inappropriate or because they feel unprepared

to manage sessions with an entire family. By

the same token, family therapists’ training

runs counter to an emphasis on individuals

within the family. Both substance abuse

counselors and family therapists will need

supervisory and administrative support to

make necessary changes.

•Administration. Using several treatment

models within an agency requires an agencywide commitment to provide this variety of

services. The use of multiple models within a

single agency complicates scheduling for

staff, clients, and families. Scheduling staff

training for several models, as well as evaluating clients for the appropriateness of models available and the progress being made

become more difficult. In addition, the collection and interpretation of treatment outcome data, including client outcomes, model

efficacy, and cost­effectiveness, are more

complex processes. However, these processes

can be less complicated when the Patient

Placement Criteria recommended by the

American Society for Addiction Medicine are

utilized by the agency to validate decisionmaking regarding the treatment of clients.

•Reimbursement. Third parties typically do

not pay for family therapy interventions for

substance abuse. Often, current funding pays

either for mental health or substance abuse

treatment. Without reimbursement for work

done with families, most such work will not

be done, and potential substance abuse outcomes will not be realized. (This critical issue

is discussed more fully in chapter 6.)

In sum, agencies and practitioners must balance the value of integrated treatment with its

limitations. They must weigh flexibility and the

potential for better treatment outcomes against

the administrative challenge of additional training and its associated expenditures. In the end,

agencies will need to decide what level of intervention they choose to bring to families in

treatment and what integrated models they will

use to do it.

Levels of Involvement With

Families

Substance abuse treatment professionals intervene with families at different levels during

treatment (Conner et al. 1998; Levin 1998).

The levels vary according to how individualized

the interventions are to each family and the

extent to which family therapy is integrated

into the process of substance abuse treatment

(see Figure 4­2, p. 80). At a low level of

involvement, for example, a counselor might

undertake an educational intervention, presenting general information about substance

abuse that seems applicable to most families.

With greater involvement with the family, a

counselor might use a family therapy intervention that helps a family to define specific, collective changes it wants to make, which may or

may not directly relate to substance abuse.

At each level, family intervention has a different

function and requires its own set of competencies. In some cases, the family may be ready

only for intermittent involvement with a counselor. In other cases, as the family reaches the

goals set at one level of involvement, they may

set further goals that require more intensive

counselor involvement. The family’s acceptance

of problems and its readiness to change determine the appropriate level of counselor

involvement with that family.

Integrated Models for Treating Family Members 79
                       

                       

                           

                   

                       

                         

                           

                       

                           

                     

                         

                   

                   

                     

                     

                 

         

                 

             

                 

                         

Figure 4­2

Levels of Counselor Involvement With Families

Level 1—Counselor has little or no involvement

with family

At this level, 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. Interventions focus largely on the client’s substance abuse and its effects on the individual. Funding and policies necessary for

providing services to families are not in place, so the impact of substance abuse

on the family is not a primary consideration. It is not uncommon for the family

of a client to be regarded as a liability for the client.

Level 2—Counselor provides psychoeducation and

advice

Knowledge base

The counselor’s primary focus is on the client’s substance abuse, but he or she is

aware that it affects family relationships and that counseling will change family

dynamics. For example, the family may increase its blaming of the person who is

abusing drugs or alcohol, substance abuse problems among other family members may be exposed, and family secrets may be revealed.

Relationship to family system

The counselor is open to engaging clients and families in a collaborative way:

•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

Knowledge base

The counselor understands normal family development and family reactions to

stress.

Relationship to family system

The counselor is aware of personal feelings in relating to the client and family.

80 Integrated Models for Treating Family Members
                   

                     

                 

     

                     

       

                       

   

               

       

   

             

                         

                 

     

                   

         

                     

                 

           

         

                       

   

                     

               

   

                     

               

                 

                     

       

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

•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

Knowledge base

The counselor understands the concept of family systems.

Relationship to family system

The counselor is aware of his or her own participation in systems, including the

therapeutic relationship, the treatment system, his or her own family system,

and larger community systems.

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

•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

Integrated Models for Treating Family Members 81
         

           

         

             

         

         

           

           

           

             

       

           

           

     

             

                   

           

     

             

           

           

           

           

             

       

       

         

         

           

       

           

           

               

                 

             

       

                       

                 

                 

                         

                   

     

                 

                 

                     

             

               

         

                           

               

Level 5—Family therapy

Knowledge base

The counselor has received training and supervision to move to this level of

expertise. He understands family systems and patterns typical of dysfunctional

families and interacts with professionals in other health care systems.

Relationship to family system

The counselor can handle intense emotions in families and in him­ or herself and

maintain neutrality despite strong pressure from family members (or other

professionals) to take sides.

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

Source: Adapted from Doherty and Baird 1986. Used with permission.

Working with family physicians, Doherty and

Baird (1986) established five levels of involvement with families for medical intervention. In

Figure 4­2, the authors’ work has been adapted

to show levels of counselor involvement with

the families of clients abusing substances.

Following are some specific examples for implementing the levels discussed in Figure 4­2:

•A Level 1 family intervention in substance

abuse treatment may be conducted informally

but is carefully thought out and planned to

ensure clinical appropriateness. For example,

rather than scheduling an appointment, the

counselor could speak to a client’s family

members while they wait for the client

attending a group.

•At Level 2, the counselor could provide education or advice to the family in the form of a

short discussion of the stages of substance

abuse and recovery.

•At Level 3, the counselor could educate the

family on how substance abuse affects parenting, discussing how the mother and father

could each improve their parenting skills and

supporting them as they made changes.

• At Level 4, a counselor could intervene to

define and change the interactional patterns

and behavioral sequences around substance

abuse or determine the exact behavioral

sequence associated with drinking and establish ways to interrupt that sequence.

•At Level 5, the counselor might help the family

define specific goals for change—goals that

might or might not focus on substance

abuse—and then help the family make those

changes. The focus at Level 5 is broader than

that at Level 4, and the counselor is apt to

draw on wider skills and approaches to help

the family meet its goals.

82 Integrated Models for Treating Family Members
           

               

               

               

             

           

         

               

                 

             

       

           

                 

           

         

               

             

           

         

           

               

           

       

         

           

           

               

       

           

           

             

             

             

         

           

   

           

     

       

             

           

           

         

           

             

       

             

         

   

             

           

             

         

   

               

             

                 

                 

         

         

               

         

     

           

               

       

           

       

         

           

       

         

             

       

       

   

           

Determinants of the level of

involvement

To determine a counselor’s level of involvement

with a specific family, two factors must be

considered:

The counselor’s level of experience and comfort.

Figure 4­2 can be used to determine the knowledge base and skills that a counselor needs to

implement each of the five levels of family

involvement.

The family’s needs and readiness to change.

Prochaska and colleagues’ stages of change

model (Prochaska et al. 1992; see chapter 3 for

a description of the five stages) can be used to

assess a family’s readiness to change and suggests

a level of counselor involvement appropriate

for that change. A family in precontemplation,

for instance, would do best with a lower level of

intervention—Level 2 or 3—while a family in

the maintenance phase might be ready for

Level 5 family therapy—sorting out relationship

issues that may not be directly related to

substance abuse.

Both family and counselor factors must be

considered when deciding a level of family

involvement. Families should not be pushed

rapidly toward change when they are not

ready. If they are pushed too fast, their

resistance increases, and they may leave

treatment prematurely. Staff should not be

placed unprepared in positions outside their

level of development—even when no other staff

is available. When therapists attempt to function in a level that is beyond their training,

their interventions are typically ineffective, and

they grow frustrated and demoralized. This is

likely to affect the family negatively.

Figure 4­2 can be used to determine training

needs to prepare counselors to intervene at

different levels. Agencies can draw on the skills

that substance abuse counselors and family

therapists already have and develop the additional competencies listed. Credentialing bodies

can also use systematic training to develop

appropriate competencies in substance abuse

and family therapy counselors.

Using the family to engage

the client in treatment

In some treatment models, such as the Johnson

model and the Thomas and Yoshioka model,

family members are used in a confrontive,

unilateral intervention to engage the client in

treatment. This can be a one­time intervention

and has been shown to be successful (Johnson

1986; Thomas and Yoshioka 1989).

To engage the client in treatment, Kirby and

colleagues (1999) recommend using the community reinforcement training intervention. This

type of intervention has been shown to significantly improve the retention of family members

in treatment and to induce people who use

drugs to enter treatment. This behavioral

intervention “provides motivational training”

for family members (Kirby et al. 1999, p. 86)

by showing them how to give positive rewards

to the client for not using drugs and to ignore

the client who uses drugs so that he or she

experiences the negative consequences of use.

When the client experiences particularly

difficult times as a result of drug abuse, family

members are encouraged to suggest counseling

(Kirby et al. 1999).

Approaches to engagement 

A number of specific interventions have been

developed to help clinicians use family members

and other significant figures in a person’s life to

engage the person in substance abuse treatment.

The following descriptions of interventions are

adapted from a National Institute on Drug

Abuse (NIDA) research monograph (Stanton

1997, pp. 161­168). Although only Unilateral

Family Therapy relies on family therapy models,

the Johnson Intervention and Community

Reinforcement Training emerged from the substance abuse treatment field based on a range

of background influences including pastoral

and family counseling, community psychology,

and behavioral reinforcement theories.

Following are brief descriptions of each

intervention:

Integrated Models for Treating Family Members 83
             

         

           

         

           

             

           

         

           

           

           

           

         

           

           

       

     

         

           

           

         

         

         

               

         

           

         

         

     

       

           

               

               

           

             

           

       

       

             

           

           

         

       

   

           

         

             

           

             

         

             

           

             

           

           

           

           

           

           

               

               

   

             

           

               

               

       

           

         

             

             

       

               

         

             

                 

         

                                   

                                 

               

•Johnson Intervention. Originally developed

in the 1960s (Johnson 1973, 1986) at the

Johnson Institute in Minneapolis, this intervention is a method for mobilizing, coaching,

and rehearsing with family members, friends,

and associates to help them confront someone

they believe to have a substance use disorder.

At that time, they voice their concerns,

strongly urge entry into treatment, and

explain the consequences in the event of

refusal (which could include divorce or loss

of a job). Interveners usually prepare in

secret to use the element of surprise.

Although the approach has mostly been

applied with problem drinking, it has also

been adapted for other types of substance

abuse (Leipman et al. 1982).

•Unilateral Family Therapy. Developed by

Thomas and colleagues (Thomas and Ager

1993; Thomas and Yoshioka 1989; Thomas et

al. 1987), this approach has been applied

with spouses (usually wives) of uncooperative

family members who are abusing substances

(typically alcohol). The therapist meets with

the spouse over some months, with a focus on

spousal coping, reducing the individual’s

substance use, and inducing the person with

alcoholism to enter treatment. The method

was influenced by the Johnson Intervention

and the Community Reinforcement Approach

(CRA), although the spouse usually carries

this intervention out, which is called a

“programmed confrontation.”

By the fifth month, some open attempt (or a

series of attempts) is made to get the person

who is abusing alcohol into treatment. When

other cases were added in which the potential

clients had not entered treatment but had

achieved and maintained clinically meaningful

reductions in their drinking levels,1 37 percent

of the people who abused alcohol and whose

spouse was treated immediately had entered a

program, compared with 11 percent for a

group for which treatment was delayed

(Thomas et al. 1990).

•Community Reinforcement Training (CRT).

This method was adapted from the original

CRA to alcoholism treatment developed by

Azrin and colleagues (Azrin 1976; Azrin et al.

1982; Hunt and Azrin 1973; Meyers and

Smith 1995) and has been applied to cocaine

dependence by Higgins and others (Higgins

and Budney 1993; Higgins et al. 1993, 1994).

CRT involves seeing a distressed family

member (usually the spouse) the day that she

telephones to get help for a family member

with alcoholism. It also requires being available during nonworking hours in case the

family member reaches a crisis point when

the person who is abusing alcohol requests

help. The approach attempts to take advantage

of a moment when the person is motivated to

get treatment by immediately calling a meeting at the clinic with the counselor, even in

the middle of the night (Sisson and Azrin 1993).

This generally nonconfrontational program

includes a number of sessions with the spouse

in which checklists are completed and the

spouse is taught how to implement a safety plan

if the risk of physical abuse is high, encourage

abstinence, encourage treatment seeking, and

assist in treatment. Sisson and Azrin (1986)

examined the effectiveness of this approach

with 12 cases—seven in which a family member

received CRT and five in which the person

received traditional (e.g., Al­Anon) counseling.

In six of the seven CRT cases, the individual

who abused alcohol entered treatment, whereas

none of the traditional cases entered treatment.

Selecting an integrated

model for substance abuse

treatment

Care must be taken in the choice of an integrated

therapeutic model. The model must accommodate

the needs of the family, the style and preferences

1

Harm reduction concepts (e.g., reduced or decreased use as opposed to abstinence) discussed in this TIP are those of

the authors and do not necessarily reflect policy or program directions of the Substance Abuse and Mental Health

Services Administration or the Department of Health and Human Services.

84 Integrated Models for Treating Family Members
               

           

             

         

             

         

           

               

               

           

             

               

         

             

       

     

         

           

           

               

             

         

         

             

     

         

                 

             

       

         

     

               

             

               

         

               

         

                 

           

             

             

           

               

   

     

     

       

     

   

     

   

     

     

   

     

     

             

                   

         

         

           

         

             

             

         

           

           

             

         

     

           

             

           

           

       

of the therapist, and the realities of the

treatment context (e.g., in a residential treatment

setting one would not select an approach that

demanded frequent contact with family

members when clients come from a wide

geographical area and family members would

not be able to visit often).

The model also must be congruent with the

culture of the people that it intends to serve.

For example, some parents from Asian cultures

may be perplexed by the assumption that

children have a “voice” in the family (e.g.,

children who take on adult­like responsibilities

by interpreting for parents, but do not hold

adult­like responsibilities in the family). The

model selected must accommodate differences

in family structure, hierarchies, and beliefs

about what is appropriate and expected

behavior.

When choosing and applying a family systems

model, certain basic questions must be

considered:

•Does the model fit what is observed in the

family? For instance, a general lack of predictable structure may call for structural

family therapy, which would be inappropriate for a distant and conflicted couple who

instead may need emotion­focused couples

therapy. Further, does the model provide

direction as to where to go with the family?

Is the direction simple enough to address a

chaotic family system, yet encompassing

enough to address multiple presenting

problems and family structures?

•Can the model be used when not all family

members attend all sessions? Can it be used

with only one family member, if only that one

person is ready for treatment?

•Will the model work with the family of origin

and address intergenerational issues, such as

how the family got where it is, and how does

that history influence the family now?

•Will the model help the counselor manage the

amount of change in the family system? Will

the counselor be able to manage the competing

homeostatic and change needs of the family?

If not, the result may be too much resistance

or too
 

little change to
 A model must

accommodate the

needs of the

family, the style

and preferences of

the therapist, and

the realities of the

treatment context.

satisfy the family.

•If the model uses a

directive technique,

will it increase the

family’s resistance?

Further, will that

model’s directive

nature fit the

counselor’s style?

Would the counselor,

for example, be

comfortable saying,

“Say this to him

now”? Or does the
 

counselor need a
 

model with a less
 

directive style?
 

•How much time is

required to implement the model? Is it applicable in the short term, such as 8 to 12 sessions? Do the model’s time requirements

match the time available for therapeutic

intervention?

•Is the model compatible with a particular

family’s cultural characteristics? If the

counselor were to use the model, would family

members be inclined to view the counselor as

a good match for their cultural practices and

values? Some models suggest, directly or

implicitly, that one and only one family

organization or structure is healthy, and all

others are inferior. Such views may be

inappropriate for families whose cultural or

ethnic belief system conflicts with a particular

model’s assumptions and standards.

Integrated Models for

Substance Abuse

Treatment

A great number of integrated treatment models

have been discussed in the literature. Many are

slight variations of others. Those discussed in

this section are among the more frequently

used integrated treatment models:

Integrated Models for Treating Family Members 85
     

         

     

         

       

         

   

     

     

         

       

             

   

     

       

         

       

         

             

         

     

     

     

             

                 

             

         

       

       

         

             

             

               

             

             

       

     

           

             

         

         

           

                 

                     

                     

                 

               

                       

                     

                           

                   

                 

•Structural/strategic family therapy (Stanton

1981a; Stanton et al. 1982)

•Multidimensional family therapy (Liddle

1999; Liddle et al. 1992, 2001)

•Multiple family therapy (Kaufman and

Kaufmann 1992)

•Multisystemic therapy (Henggeler et al. 1996)

•Behavioral and cognitive­behavioral family

therapy (O’Farrell and Fals­Stewart 2000)

•Network therapy (Galanter 1993)

•Bowen family systems therapy (Bowen 1974)

•Solution­focused brief therapy (Berg and

Miller 1992)

Structural/Strategic Family

Therapy

Theoretical basis

Structural/strategic family therapy assumes

that (1) family structure—meaning repeated,

predictable patterns of interaction—determines

individual behavior to a great extent, and

(2) the power of the system is greater than the

ability of the individual to resist. The system

can often override any family member’s

attempt at nonengagement (Stanton 1981a;

Stanton et al. 1978).

Integrated Structural/Strategic Family

Therapy for Substance Abuse

Therapy begins with an assessment of substance abuse, individual psychopathology,

and family systems. If chemical dependence or serious substance abuse is

discovered, therapy begins by working with the family to achieve abstinence.

In the next phase, abstinence is consolidated by resolving dysfunctional rules,

roles, and alliances. Then developmental issues and personal psychopathology

are treated as part of the family contract. For example, an adolescent client’s

trouble accepting responsibility and a parent’s depression can be part of what

the family contracts to change. With that in place, a family plan for relapse

prevention is incorporated. Finally, in the abstinence phase, intimacy deepens as

families learn to appropriately express feelings, including hostility and mourning

of losses.

Among the models in the above list, several

have demonstrated effectiveness in treating

substance use disorders: structural/strategic

family therapy, multidimensional family therapy,

multisystemic therapy, and behavioral and

cognitive–behavioral family therapy. The

others have not demonstrated research­based

outcomes for substance abuse treatment at this

point, but appear to have made inroads into

the substance abuse treatment field.

Roles, boundaries, and power establish the

order of a family and determine whether the

family system works. For example, a child may

assume a parental role because a parent is too

impaired to fulfill that role. In this situation,

the boundary that ought to exist between

children and parents is violated.

Structural/strategic family therapy would

attempt to decrease the impaired parent’s

substance abuse and return that person to a

parenting role.

Whenever family structure is improperly

balanced with respect to hierarchy, power,

boundaries, and family rules and roles,

86 Integrated Models for Treating Family Members
         

         

               

         

               

           

         

         

           

       

         

             

           

           

         

   

       

       

             

             

         

           

             

           

           

           

   

   

     

         

         

       

     

   

           

         

       

             

             

       

         

         

           

             

       

         

           

       

         

           

             

         

         

               

             

         

     

             

     

             

       

       

         

     

     

           

         

           

             

         

           

           

       

     

           

         

           

         

structural/strategic family therapy can be used

to realign the family’s structural relationships.

This type of treatment is often used to reduce

or eliminate substance abuse problems. As

McCrady and Epstein (1996) explain, the family

systems model can be used to (1) identify the

function that substance abuse serves in

maintaining family stability and (2) guide

appropriate changes in family structure.

Techniques and strategies

In this treatment model, the counselor uses

structural/strategic family therapy to help

families change behavior patterns that support

substance abuse and other family problems.

Because these patterns in dysfunctional families

are typically rigid, the counselor must take a

directive role and have family members develop, then practice, different patterns of interaction. Counselors using this treatment model

require extensive training and supervision to

direct families effectively.

One modification that flows from structural/

strategic family therapy is strategic/structural

systems engagement (SSSE). In SSSE, the family

is helped to exchange one set of interactions

that maintains drug use for another set of

interactions that reduces it. In particular,

SSSE targets the interactions linked to specific

behaviors that, if changed, will no longer support the presenting problem behavior. Once the

family, including the person with a substance

use disorder, agrees to participate in therapy,

the counselor can refocus the intervention on

removing problem behaviors and substance

abuse.

Another modification, brief strategic family

therapy (BSFT), also flows from structural/

strategic family therapy. In BSFT, structural

family therapy “has evolved into a time­limited,

family­based approach that combines both

structural and strategic [problem­focused and

pragmatic] interventions“ (Robbins and

Szapocznik 2000). BSFT is known to be effective

among youth with behavioral problems and is

commonly used for that purpose among

Hispanic families (Robbins and Szapocznik

2000).

BSFT is used to help counselors attract families

that are difficult to engage in substance abuse

treatment (Szapocznik and Williams 2000). In

Hispanic families with adolescents using drugs,

Szapocznik and colleagues reported that 93

percent of families were brought into treatment

using standard BSFT, versus 42 percent in a

control group. Treatment completion rates

were higher among those receiving BSFT

(Szapocznik et al. 1988). To achieve this

improvement, BSFT was modified to a oneperson family technique. The technique is

based on the idea of complementarity

(Minuchin and Fishman 1981), that is, when

one family member changes, the rest of the

family system will respond. Szapocznik and

Williams (2000) used the one­person family

technique with the first person in the family

to request help. Once the whole family was

engaged, they refocused attention on problem

behavior and drug abuse.

One of the specific techniques used in structural/

strategic family therapy is illustrated on p. 88.

While structural/strategic family therapy has

been shown to be effective for substance abuse

treatment, counselors must carefully consider

using this approach with multiproblem families

and families from particular cultures. Some

points to consider are

•Culture. Counselors should become familiar

with the roles, boundaries, and power of

families from cultures different from their

own. These will influence the techniques and

strategies that will be most effective in therapy.

•Age and gender. Cultural attitudes toward

younger people and women can affect how

the counselor can best assume the directive

role that structural/strategic family therapy

requires.

•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

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Structural/Strategic Family Therapy’s

Technique of Joining and Establishing

Boundaries

Family: The client is a 22­year­old Caucasian female who abuses prescribed

medication and has problems with depression and a thought disorder. 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 detoxification, 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 subsystems of parents. She had

artfully played one against the other. This was possible because the birth parents did not communicate.

Treatment: The first task was to persuade the father to contact the mother and

request that she attend a family meeting. He, along with the stepmother, agreed,

though it took great courage to make the request because the father believed his

daughter’s negative stories about her relationship with the mother. In the next

session, the older brother (the intermediary for the past 4 years) and his wife

also attended. Because the relationship between the counselor and the paternal

subsystem had already been established, it was critical to also join with the

maternal subsystem before attempting any family system work. The counselor

knew that nothing could be accomplished until the mother and stepfather felt an

equal parental status in the group. This goal was reached, granting 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. Specifically, the counselor sought to join the separate parental subsystems into a single system of adult parents and to remove the client’s brother and

sister­in­law as a part of that subsystem. This exclusion was accomplished by

leaving them and the client out of the first 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. By the end of the first hour of a 3­hour session, the parents

were comparing information, routing incorrect assumptions about each other’s

beliefs and behaviors, and forming a healthy, reliable, and cooperative support

system that would work for the good of their daughter.This outcome would have

been impossible without taking the time to join 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

had committed themselves to communicating with each other and to speaking to

their daughter in a single voice.

Source: Consensus Panel.

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Structural/Strategic Family Therapy in

the Criminal Justice System

Darius, a 21­year­old male from the San Juan pueblo in New Mexico, was

referred to a clinic for court­mandated substance abuse counseling. He had just

received his third violation for driving under the influence (DUI). Darius had

been on probation since age 13 for various charges, including burglary and

domestic violence, and he had a long history of alcohol and drug abuse. He had

been on his own for 8 years and had no family involvement in his life. Darius

had participated in several residential treatment programs, but he had been

unable to maintain abstinence on his own.

When Darius entered outpatient treatment, he was extremely angry at “the

system” and refused initially to cooperate with the therapist or his treatment

plan. The therapist was pleasantly surprised 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 finally

get off probation. At the time, he still had 18 months of probation remaining.

•The counselor helped Darius see the relationship of alcohol and drugs to his

involvement with the criminal justice system.

•The counselor constructed a genogram depicting three generations of Darius’

family of origin. This portrayal illustrated a great deal of family disintegration

linked to poverty, substance abuse, and his parents’ and grandparents’ boarding

school experience.

•The counselor initiated couples therapy to help Darius stabilize a significant

relationship.

•After conferring with the probation officer, the counselor decided that Darius

would benefit from a 6­month trial of Antabuse treatment.

•The probation officer required that Darius find 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 abuse

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 to examine how the behaviors and responsibilities

he took on in his family shaped his substance use.

Source: Consensus Panel.

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the parent notices

they are not there. The MDFT

treatment format

includes individual

and family

sessions, sessions	 

with various

family members,	 

and extrafamilial

sessions.

The professional

needs to be attentive

to who is who in the

family. Who is

revered? Who are

friends? What is its

history? Place of

origin? All these are

clues to understanding a family’s

hierarchy.

Counselors who use

structural/strategic

family therapy need

to appreciate how a

particular intervention might be

experienced by

family members.

If family members

experience the intervention as duplicitous,

manipulative, or deceitful, the counselor may

have broached a possible ethical line. As discussed in the section on informed consent in

chapter 6, family therapists or substance abuse

counselors might wish to explain in advance

that such interventions could be part of the

therapeutic process and obtain the client’s

informed consent for their possible inclusion. If

clients have questions about the use of such

interventions, they should be answered ahead

of time and included as part

of the informed consent.

For more detailed information about structural/

strategic family therapy, refer to Charles

Fishman’s manual Intensive Structural

Therapy: Treating Families in Their Social

Context (1993) and Szapocznik and colleagues’

Brief Strategic Family Therapy (in press).

The case study on p. 89 demonstrates how

structural/strategic family therapy might work

with a client from the criminal justice system.

Multidimensional Family

Therapy

Theoretical basis

The multidimensional family therapy (MDFT)

approach was developed as a stand alone, outpatient therapy to treat adolescent substance

abuse and associated behavioral problems of

clinically referred teenagers. MDFT has been

applied in several geographically distinct

settings with a range of populations, targeting

ethnically diverse adolescents at risk for abuse

and/or abusing substances and their families.

The majority of families treated have been

from disadvantaged inner­city communities.

Adolescents in MDFT trials have ranged from

high­risk early adolescents to multiproblem,

juvenile justice­involved, dually diagnosed

female and male adolescents with substance

use problems.

As a developmentally and ecologically oriented

treatment, MDFT takes into account the interlocking environmental and individual systems

in which clinically referred teenagers reside

(Liddle 1999). The clinical outcomes achieved

in the four completed controlled trials include

adolescent and family change in functional

areas that have been found to be causative in

creating dysfunction, including drug use, peer

deviance factors, and externalizing and internalizing variables. The cost of this treatment

relative to contemporary estimates of similar

outpatient treatment favors MDFT. The clinical

trials have not included any treatment as usual

or weak control conditions. They have all tested

MDFT against other manualized, commonly

used interventions. The approach is manualized

(Liddle 2002), training materials and adherence

scales have been developed, and have demonstrated that the treatment can be taught to

clinic therapists with a high degree of fidelity

to the model (Hogue et al. 1998).

Research basis

MDFT has been developed and refined over

the past 17 years (Liddle and Hogue 2001).

MDFT has been recognized as one of the most

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promising interventions for adolescent drug

abuse in a new generation of comprehensive,

multicomponent, theoretically­derived and

empirically­supported treatments (Center for

Substance Abuse Treatment [CSAT] 1999c;

NIDA 1999a; Waldron 1997). MDFT has

demonstrated efficacy in four randomized

clinical trials, including three treatment studies

(one of which was a multisite trial) and one

prevention study. Investigators have also

conducted a series of treatment development

and process studies illuminating core

mechanisms of change.

Techniques and strategies

Targeted outcomes in MDFT include reducing

the impact of negative factors as well as promoting protective processes in as many areas of

the teen’s life as possible. Some of these risk

and protective factors include improved overall

family functioning and a healthy interdependence among family members, as well as a

reduction in substance abuse, drastically

reduced delinquency and involvement with

antisocial peers, and improved school performance. Objectives for the adolescent include

transformation of a drug using lifestyle into a

developmentally normative lifestyle and

improved functioning in several developmental

domains, including positive peer relations,

healthy identity formation, bonding to school

and other prosocial institutions, and autonomy

within the parent­adolescent relationship. For

the parent(s), objectives include increasing

parental commitment and preventing parental

abdication, improved relationship and communication between parent and adolescent, and

increased knowledge about parenting practices

(e.g., limit­setting, monitoring, appropriate

autonomy granting).

Core components

MDFT is an outpatient family­based drug

abuse treatment for teenagers who abuse substances (Liddle 2002). From the perspective of

MDFT, adolescent drug use is understood in

terms of a network of influences (i.e., individual,

family, peer, community). This multidimensional

approach suggests that reductions in target

symptoms and increases in prosocial target

behaviors occur via multiple pathways, in

differing contexts, and through different mechanisms. The therapeutic process is thought of

as retracking the adolescent’s development in

the multiple ecologies of his or her life. The

therapy is organized according to stage of

treatment, and it relies on success in one phase

of the therapy before moving on to the next.

Knowledge of normal development and developmental psychopathology guides the overall

therapeutic strategy and specific interventions.

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 relevant

community locations. Change for the adolescents

and parents is intrapersonal and interpersonal,

with neither more important than the other.

The therapist helps to organize treatment by

introducing several generic themes. These are

different for the parents (e.g., feeling abused

and without ways to influence their child) and

adolescents (e.g., feeling disconnected and

angry with their parents). The therapist uses

these themes of parent­child conflict as assessment tools and as a way to identify workable

content in the sessions.

The format of MDFT has been modified 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 in a variety of contexts including in­home, in­clinic, or

by phone. The MDFT approach is organized

according to five assessment and intervention

modules, and the content and foci of sessions

vary by the stage of treatment.

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Multiple Family Therapy

Theoretical basis 

Multiple family therapy (MFT) is an eclectic

variety of family therapy that is psychoeducational in nature, with roots in social network

intervention, multiple impact therapy, and

group meeting approaches. It is often used in

residential settings and involves family members

from groups of clients in treatment at the same

time coming together (Kaufman and Kaufmann

1992b).

Techniques and strategies 

In general, families are personally invited to

attend the MFT meeting and are oriented

before the first session. Family members who

are currently abusing drugs or alcohol are

excluded. Families sit together in a circle, with

several therapists interspersed among the

group. The session starts with self­introductions.

After the purpose of the meeting is described

and the need for open communication is

stressed, one family’s situation is discussed for

about an hour. Three or four families are the

subject for each session, although all the families

participate in the discussion (Kaufman and

Kaufmann 1992).

In early treatment, families “support each

other by expressing the pain they have experienced” (Kaufman and Kaufmann 1992, p. 76).

Later, the ways the family has contributed to

and enabled the client’s substance abuse are

identified. Homework is often assigned that

gives family members new tasks, shifts their

roles, and works to restructure the family.

Techniques to improve communication that

Kaufman finds useful are psychodrama, the

“empty chair,” and family sculpture (Kaufman

and Kaufmann 1992).

The MFT group can be used as a means to

identify when a couple would benefit from couples therapy (Kaufmann and Kaufman 1992b).

To make use of group interactions in this way

and to ensure that the counselor feels comfortable in the role of coleading this type of large

group, the counselor should receive adequate

supervision.

Multisystemic Family Therapy

Theoretical basis

This model originated in the simple observation

of high treatment dropout rates among 

adolescents in family therapy for their substance

abuse. Programmatic features that seemed to

lower dropout rates were identified and implemented to maximize accessibility of services

and make treatment providers more accountable for outcomes (Henggeler et al. 1996).

Techniques and strategies

Multisystemic therapy has proven useful as a

method for increasing engagement in treatment

in a study in which adolescents randomly

assigned to this treatment were compared to a

group receiving treatment as usual (Henggeler

et al. 1996). Features of this therapy that are

designed to make it successful include the

following:

•Multisystemic therapy is provided in the

home.

•Low caseloads allow counselors to be available on an as­needed basis around the clock.

•Family members are full collaborators with

the therapist.

•It has a strengths­based orientation in which

the family determines the treatment goals.

•It is responsive to a wide range of barriers to

achieving treatment goals.

•Services are designed to meet individual

needs of clients, with the flexibility to change

as needs change.

•The counselor and other members of the

treatment team assume responsibility for

engaging the client and using creative

approaches to achieve treatment goals

(Henggeler et al. 1996).

Multisystemic therapy has influenced the development of other therapies, including functional

family therapy, a brief prevention and treatment

intervention used with delinquent youth and

those with substance abuse problems (Sexton

and Alexander 2000).

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Example of Behavioral and

Cognitive–Behavioral Family Therapy

Family: Peter, a 17­year­old white male, was referred for substance abuse treatment. He acknowledged that he drank and smoked marijuana, but minimized

his substance use. Peter’s parents reported he had come home 1 week earlier

with a strong smell of alcohol on his breath. The following morning, when the

parents confronted Peter about drinking and drug use he denied using marijuana

steadily, declaring, “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 abusing drugs. Their

concern was based on Peter’s falling grades (from a B to a C student), his

appearance (from meticulous grooming to poor hygiene), and unprecedented

borrowing (he had borrowed a lot of money from relatives and friends, most of

the time without repaying it).

For the first two family sessions, Peter, his older sister Nancy, 18, and their

parents attended. 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 the related conflict between the parents about the

unequal treatment of Peter and Nancy. In fact, the father often was sarcastic

and sometimes hostile toward Peter, disparaging his attitude and problems.

Peter viewed himself as a failure and experienced depression, frustration, anger,

and low self­esteem. Furthermore, Peter wanted to retaliate against his father

by causing problems in the family. In this respect, Peter was succeeding. His

substance abuse and falling grades had created a hostile environment at home.

Treatment: The counselor used cognitive–behavioral therapy to focus on Peter’s

irrational thoughts (such as viewing himself as a total failure) and to teach Peter

and other family members communication and problemsolving skills. The counselor also used behavioral family therapy to strengthen the marital relationship

between Peter’s parents and to resolve conflicts between family members.

Although the family terminated treatment prematurely after eight sessions, some

positive treatment outcomes were realized. They included an improved relationship between Peter and his father, improved academic performance, and an

apparent cessation of drug use (a belief based on negative urine test results).

Source: Consensus Panel.

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Behavioral Family Therapy

and Cognitive–Behavioral

Family Therapy

Theoretical basis of behavioral

family therapy

Behavioral family therapy (BFT) combines

individual interventions within a family

problemsolving framework (Falloon 1991).

BFT helps each family member set individual

goals since the approach assumes that

•Families of people abusing substances may

have problemsolving skill deficits.

•The reactions of other family members influence behavior.

•Distorted beliefs lead to dysfunctional and

distorted behaviors (Walitzer 1999).

•Therapy helps family members develop

behaviors that support nonusing and nondrinking. Over time, these new behaviors

become more and more rewarding, leading to

abstinence.

Theoretical basis of cognitive–

behavioral family therapy

This approach integrates traditional family

systems therapy with principles and techniques

of BFT. The cognitive­behavioral combination

views substance abuse as a conditioned behavioral response, one which family cues and

contingencies reinforce (Azrin et al. 1994). The

approach is also based on a conviction that distorted and dysfunctional beliefs about oneself

or others can lead people to substance abuse

and interfere with recovery. Cognitive–

behavioral therapy is useful in treating

adolescents for substance abuse (Azrin et al.

1994; Waldron et al. 2000).

Techniques and strategies of

behavioral family therapy 

To facilitate behavioral change within a family

to support abstinence from substance use, 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 her

parents’ 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.

•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.

Techniques and strategies of

cognitive­behavioral family

therapy

In addition to the behavioral techniques mentioned above, one effective cognitive technique

is to find and correct the client’s or the family’s

distorted thoughts or beliefs. Distorted personal

beliefs may be an idea such as “In order to fit

in (or to cope), I have to use drugs.” Distorted

messages from the family might be, “He uses

drugs because he doesn’t care about us,” or,

“He’s irresponsible. He’ll never change.” Such

messages can be exposed as incorrect and more

accurate statements substituted.

An example of a technique used in behavioral

family therapy to improve communication is

presented on p. 95.

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Behavioral Family Therapy: Improving

Communication

Family: Delbert, a 49­year­old man with alcohol dependence, had stopped

drinking during a 28­day inpatient treatment program, which he entered after a

DUI arrest. He attended Alcoholics Anonymous (AA), worked every day, and

saw his probation officer regularly. In many ways, Delbert was progressing well

in his recovery. However, 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 finally sought help from the continuing care program at the substance abuse treatment facility where Delbert was a client. Their

counselor, using a behavioral family therapy approach, met with them and

began to assess their difficulty.

What became obvious was that their prerecovery communication style was still

in place, despite the fact that 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 first 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 them new

communication skills. Each partner learned to listen and summarize what their

partner had said to make sure the point was understood prior to response.

To eliminate the overuse of blaming, the couple instead learned to report how

their partner’s actions affected them. For example, they learned to say, “I feel

anxious when you don’t come home on time,” rather than to impugn their

partner’s character or motivation with invectives such as, “You are still as

irresponsible as ever; that’s why I can’t trust you.”

In addition, since both Delbert and Renee were focused on the negative aspects

of their interactions, the therapist suggested they try a technique known as

“Catch Your Partner Doing Something Nice.” Each day, both Delbert and

Renee were asked to notice one pleasing thing that their partner did. As they

were able to do so, their views of each other slowly changed. After 15 sessions of

marital therapy, their arguing had decreased, and both saw enough positive

aspects of their relationship to merit trying to save it.

Source: Consensus Panel.

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La Bodega de la Familia, New York

Family strengths and supports can be enhanced by resources in the criminal

justice system. Strengthening families of offenders who use substances, and

building partnerships among family, government, and community, form the

methodology of La Bodega de la Familia, a community­based storefront program

for offenders with substance use disorders on probation or parole and their families in New York City’s Lower East Side. Research indicates that this program

engages participants in treatment, decreases the use of incarceration because of

relapse, and helps families use community resources to address issues such as

substance abuse, domestic violence, mental illness, and HIV/AIDS.

La Bodega was created in 1996 as a demonstration project of the Vera Institute

of Justice and recently incorporated as Family Justice, Inc., a national nonprofit

organization. La Bodega’s methodology tested the proposition that strengthening

the families of those who abuse substances and who are under community­based

criminal justice supervision can enhance treatment outcomes, reduce incarceration because of relapse, and lessen domestic abuse within families that often

accompanies substance abuse. La Bodega has served more than 600 families,

using Family Partnering Case Management (FPCM), an innovative technique

that identifies and mobilizes a family’s inherent strengths and resources as well

as those of the community and government. La Bodega’s storefront services also

include counseling and relapse prevention training, walk­in assessment and

referral for all neighborhood residents, and 24­hour crisis intervention in

drug­related emergencies.

The participants define their “family,” and are encouraged to use the broadest

definition to capture the entire support network. Participants and their families

help design and implement their service plans, increasing the likelihood of compliance with the plan and success in rehabilitation and reconnecting with their

communities. La Bodega also serves a prevention function, exposing children,

other family members, and neighbors to the ideas and skills needed to live

without alcohol and illicit drugs.

La Bodega’s staff is diverse in background, education, and experience. Most

case managers hold advanced degrees and have special training in family work.

A field manager focuses on creating and maintaining partnerships with 

probation, parole, housing police, service providers, and community­based

organizations. The milieu is carefully managed and monitored to model the

principles and behavior that families are encouraged to integrate into their daily

lives. Constant training and supervision are provided to support the paradigm

shift required to consider participants, their families, and government partners

in a new light: as supports and resources. For example, when participants

relapse or otherwise fail to comply with justice mandates, the justice and

treatment systems usually narrow their focus. Using the principles and tools of

FPCM, however, La Bodega widens the focus to consider the participant and the

relapse in a broader context of family, neighborhood, and community.

Source: Sullivan et al. 2002.

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The Counselor as Advocate in the

Network

Debbie, a 24­year­old single mother of a 4­year­old, received general public

assistance, which kept her involved with the child welfare system. It became

apparent to the social worker at the child welfare agency that her financial and

parenting difficulties were related to her alcohol dependence. After multiple failures in outpatient treatment, Debbie was faced with losing custody of her child.

It was at this time that Debbie entered a 30­day inpatient program for women

with substance use disorders.

After Debbie’s successful completion of the inpatient program, she made the

transition to a continuing care program. In this program, family therapy was

initiated, with Debbie asking a female friend from a church she had been

involved in to attend these sessions. The counselor initiated supervised visits

between Debbie and her daughter, with the assistance of Debbie’s friend. As

Debbie made progress in substance abuse treatment, the frequency and length of

the visits increased. After a year of sobriety, the counselor set the goal of reuniting the mother and child, with a court hearing scheduled for 3 weeks after the

start of the pre­kindergarten program the child was enrolled in.

The substance abuse counselor took on the role of advocate to appeal the unfortunate timing of the hearing. The child’s late entry into the class, she recognized,

could create unnecessary adjustment problems for the child and result in school

problems. The unnecessary stress could tax Debbie’s new and tenuous parenting

skills, which might lead to relapse. The counselor acted as an advocate for the

client in a system that was not considering the full impact of its actions on a

newly sober mother.

Family/Larger System/Case

Management Therapy

Theoretical basis 

Family/larger system/case management therapy

is for families who are or should be involved

intensely with larger systems, which include the

workplace, schools, health care, courts, foster

care, child welfare, mental health, and religious

organizations. The therapy also helps families

interact with the larger systems in their lives.

For many families, dealing with larger systems

is not a problem. Their dealings with the larger

systems are routine and positive; when they

have occasional difficulties they can navigate

within larger systems. Other families, however,

have recurrent problems and more frequent

dealings with larger systems. Often, interaction

with large systems is intense and extensive

throughout the family’s life cycle, in many

cases because of issues such as poverty, chronic

illness, legal problems, and cultural and

language barriers.

The goal of family/larger systems therapy is to

empower the family in its dealings with larger

systems. The empowerment begins when the

counselor designates “the family as the major

expert on the family” (Imber­Black 1991,

p. 601). Imber­Black further suggests that

counselors determine

•What larger systems affect the family?

•What agencies and agency subsystems

regularly interact with family members?

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•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? (Imber­Black 1991)

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). This connection

can have an adverse effect on the family. It

may limit finances, time together, and unity;

stress family relationships; and result in loss of

child custody. It can also complicate the therapeutic process, especially if the family is ordered

to come to treatment. However, even though a

family may resist and feel coerced, the judicial

system can be the stimulus that gets the family

treated and reconnected with social services.

Family/larger system/case management therapy

can be used effectively by probation and parole

officers and by drug court officials. (See TIP 27,

Comprehensive Case Management for

Substance Abuse Treatment [CSAT 1998a].)

Techniques and strategies 

In family/larger system/case management

therapy the counselor assumes a role similar to

that of a case manager. The counselor helps

initiate contact with other systems, including

agencies that can provide services to the client

and his or her family members. The counselor

can help the client navigate the maze of systems

that he is involved with, including courts, law

enforcement, social service agencies, and child

welfare. To some extent, the counselor is a

community liaison, who can provide information

to clients about the resources in the community

and advocate in the community for more funding

and other support for substance abuse treatment.

Network Therapy

Theoretical basis 

Network therapy harnesses the potential of

therapeutic support from people outside of the

immediate family, especially when conducting

effective substance abuse interventions. By

gathering those who genuinely care about the

individual with a substance use disorder—

especially friends and extended family

members—the counselor helps encourage the

individual who uses drugs to stop using and

remain abstinent. Galanter (1993) also points

to the importance of AA in network therapy.

Network therapy also attempts to connect people

to the larger community. Network therapy is

compatible with traditional healing practices,

alternative medicine, AA attendance, and

participation in community events such as

pueblo feast days and arts and crafts fairs.

Network therapy is especially useful for reconnecting urban American Indians with the larger

community.

Techniques and strategies 

A counselor using network therapy is responsible

for mobilizing the client’s network. The 

counselor keeps people in the network

informed and involved and encourages the

client to accept help from the network and to

accept the rewards that the network can offer.

Bowen Family Systems

Therapy

Theoretical basis

Bowen family systems therapists believe that all

family dysfunctions, including substance abuse,

come from ineffective management of the anxiety

in a family system. More specifically, substance

abuse is viewed as one way for both individuals

and the family as a group to manage anxiety.

The person who abuses alcohol or drugs does

so in part to reduce anxiety temporarily, and

when the entire family can justifiably focus on

the individual who uses drugs as the problem,

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Use of Bowen Family Systems Therapy

With Immigrant Populations

Although no demonstrated outcomes substantiate Bowenian therapy to address

substance abuse, counselors have often used it to treat clients with substance use

disorders who have immigrated to this country. It is believed that this therapeutic

approach is a good match for such clients because it emphasizes the intergenerational transmission of anxiety and the effects of trauma that are passed down

through generations.

The perspective that the “past is the present“ provides a mechanism to understand the lowered self­esteem of a person who has lost everything of importance:

language, homeland, culture, possessions, and often, a sense of cultural identity.

For many the circumstances of migration are traumatic. Such losses are not only

carried from the past, but continue to occur in the present as family members

are subject to the indirect consequences of migration, such as unemployment or

underemployment, marginal or overcrowded housing, untreated health problems, and poverty. In this situation, alcohol and drugs can provide an expedient

way to blot out pain and hopelessness. Healing cannot begin until both the

counselor and the client understand the significance of the loss of past cultural

identification in light of a current substance use disorder.

it can deflect attention from other sources of

anxiety.

A major source of anxiety can be a family’s

reactivity, or the intensity with which the family

reacts emotionally to relationship issues instead

of carefully thinking them through. Ideally,

family members are able to strike a balance

between emotional reactivity and reason and

are aware of which is which. This is called

differentiation. Further, family members are

autonomous, that is, neither fused with nor

detached from others in the family.

Bowen family systems therapy is also based on

the premise that a change on the part of just

one family member will affect the family system.

To reduce the family’s reactivity, for example,

counselors coach the most motivated family

members in ways to curb their reactivity and

behave differently in their relationships. Such

changes can decrease or even eliminate the

problem that brought the family into treatment.

In Bowenian therapy, it is assumed that the

past influences the present. In fact, it is still

“alive.” It is present in the form of emotional

responses that can be passed down from one

generation to another (Friedman 1991).

Techniques and strategies 

The Bowenian approach to substance abuse

often works through one person, and its scope

is highly systemic. For instance, Bowen

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. An emotional pattern that can

involve either three people or two people and

an issue (such as the substance abuse). In the

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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.

Solution­Focused Brief

Therapy

Theoretical basis

Solution­focused brief therapy (SFBT) replaces

the traditional expert­directed approach aimed

at correcting pathology with a collaborative,

solution­seeking relationship between the counselor and client. Rather than focusing on an

extensive description of the problem, 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. This counters the client’s view that the

problem is always present at the same intensity

and helps build a sense of hope about the

future.

Rooted in the strategic therapy model, de

Shazer and Berg, along with colleagues at the

Brief Family Therapy Center in Milwaukee,

shifted solution­focused brief therapy away

from its original focus, which was how problems are maintained (Watzlawick et al. 1974;

Zeig 1985), to its current emphasis on how

solutions develop (de Shazer 1988, 1991, 1997).

SFBT has been increasingly used to treat substance use disorders since the publication of

Working with the Problem Drinker: A

Solution­Focused Approach (Berg and Miller

Asking the Miracle Question

If the answer to the miracle question (see p. 101) is “I don’t know,” as it often is,

the client should be encouraged to take all the time needed before answering.

The client can also be prompted, if necessary, with questions such as, “As you

were lying in bed, what would you notice that would tell you a miracle had

occurred? What would you notice during breakfast? What would you notice

when you got to work?” Then the therapist should

•Expand on each change noticed. For example, the therapist 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 without narrowing it. Some clients say their miracle

would be to win the lottery. The counselor should not narrow 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, “As your miracle starts to come true, what

would other people 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 influence of those

small parts of the miracle?”

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1992). Berg and Miller challenged the assumptions that problem drinkers want to keep

drinking, are unaware of the damage drinking

causes, and require an expert’s help and

information if they are to recover. Quite the

contrary, SFBT counselors insist, people who

abuse substances can direct their own treatment,

provided they participate in the process of

developing goals for therapy that have meaning

for them and that they believe will make

significant change in their lives.

SFBT is consistent with research that stresses

the importance of collaborative, nonconfrontational therapeutic relationships in substance

abuse treatment (Miller et al. 1993) and 

treatment matching as a means of increasing

motivation for change (Prochaska et al. 1992).

In fact, even substance abuse counselors who

firmly believe in the disease model also accept

and use SFBT as one component of substance

abuse treatment (Osborn 1997). Further,

McCollum and Trepper (2001) have put forth a

system­based variation of the therapy specifically for use with families of people with substance use disorders.

As yet, however, little definitive research has

confirmed the effectiveness of SFBT for substance abuse. Gingerich and Eisengart (2000)

found and evaluated 15 studies on the outcome

of SFBT in treating various problems. They

concluded that “the 15 studies provide preliminary support for the efficacy of SFBT, but do

not permit a definitive conclusion” (Gingerich

and Eisengart 2000, p. 477), especially for

substance abuse. Of the 15 studies, only two

poorly controlled ones looked at the substance

abuse population. One of them described a

man with a 10­year drinking history. He

achieved more days abstinent and more days at

work per week during treatment as compared

to before treatment (Polk 1996). The other

study involved a therapist who used SFBT with

27 clients in treatment for substance use 

disorders. A larger percentage of the SFBT

clients recovered (by study definitions) after

two sessions and after seven sessions than did

the comparison clients, but no details were

given about the severity of the cases or specific

client outcomes (Lambert et al. 1998).

Techniques and strategies

In SFBT, the counselor helps the client develop

a detailed, carefully articulated vision of what

the world would be like if the presenting problem

were solved. The counselor then helps the

client take the necessary steps to realize that

vision.

In addition, the counselor encourages clients to

recall exceptions to problems, that is, times

when the problem did not occur, and to examine and increase those exceptions. In this way,

the client moves closer to the problem­free

vision.

The techniques of solution­focused brief

therapy are designed to be quite simple. They

include the miracle question, exception questions, scaling questions, relational questions,

and problem definition questions.

The miracle question. Perhaps the most representative of the SFBT techniques, the miracle

question elicits clients’ vision of life without the

problems that brought them to therapy. The

miracle question traditionally takes this form:

•I want to ask you a strange question. Suppose

that while you are sleeping tonight and the

entire house is quiet, a miracle happens. The

miracle is that 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?

(De Jong and Berg 1997).

The miracle question serves several purposes.

It helps the client imagine what life would be

like if his 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

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Case Study of Exceptions to Problem 

Family: Darcy had been diagnosed with an alcohol use disorder. In family therapy,

she and her husband Steve came to recognize a problem sequence known as a

pursuer­distancer pattern. When Steve sensed Darcy distancing from him

emotionally, he would begin to worry that she was in danger of going on another

drinking binge. His response to this fear was to suggest that Darcy call her

sponsor or go to extra AA meetings.

Steve’s concern made Darcy feel her independence was threatened. She would

get angry, refuse to take Steve’s advice, and distance herself even more. Steve

would then insist that she call her sponsor, and the tension between them would

escalate into an argument. The quarrel often ended when Darcy stormed out of

the house to spend the night with her sister, who was not a healthful influence.

She would suggest a drink to calm Darcy’s nerves—and then join her in a binge.

Treatment: After Darcy and Steve defined this sequence, the therapist helped

them look for exceptions to it—times when the sequence started, but did not end

in a binge. Both Darcy and Steve were able to identify a solution sequence.

Darcy remembered a time when Steve was pestering her. Instead of going to her

sister’s house, she spent an hour online reading passages and trading messages

and suggestions with the online recovery community. Then she called and had

lunch with her sponsor before going to an AA meeting where her sponsor was the

speaker that day. When she came home, she was able to reassure Steve that she

was not tempted to drink at that point and suggested they go to a movie together.

Steve recalled an occasion when he was getting anxious about Darcy, but instead

of pestering Darcy, he mowed the lawn. The physical activity dissipated his anxiety, and he was then able to talk to Darcy calmly about his concerns without

pressuring her to take any specific action. The therapist helped Darcy and Steve

to build on these successful times, identifying ways to more positive sequences of

behavior.

vision composed or suggested by an expert

(Berg 1995).

Exception questions. Sometimes a continual

problem is less severe or even absent. Hence,

the substance abuse counselor might inquire,

“Tell me about the times when you decided not

to use, even though your cravings were

strong.” The answer will set the stage for examining how the client’s own actions have helped

lead to that different outcome.

Scaling questions. As a clear vision of change

emerges, techniques begin to focus on helping

the client make change happen. At this point,

one especially useful technique is the scaling

question. It might ask, On a scale of 1 to 10,

where 1 means one of your goals is met and 10

means all your goals are completely met, where

would you rate yourself today? A good followup question is, What would it take for you to

move from a 4 to a 5 on our 10­point scale?

Such questions help clients gauge their own

progress toward their goals and see change as a

process rather than an event.

Relational questions. Helping clients set goals

that take the views of important others into

account can extend the benefits of change into

the client’s environment. A good relational

question is, What will other people notice

about you as you move closer and closer to

your goal? For instance, an adolescent client

might declare that he is completely confident

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Figure 4­3

Techniques To Help Families Attain Sobriety

Techniques useful during the stage when the client and the family are preparing

to make changes in their lives include the following:

Multidimensional family therapy (Liddle 1999)

•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 (Kirby et al. 1999)

•Conduct community reinforcement training interviews such as interviews with

area clergy to help them develop ways to impact the community.

Network and family/larger system (Galanter 1993; Imber­Black 1988)

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

licensing boards, child protective services, social services, lawyers, schools,

etc.) to motivate treatment.

•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, such as school counselors, without the

family present.

Bowen family systems therapy (Bowen 1978)

•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.

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Figure 4­4

Techniques To Help Families Adjust to Sobriety

During the time that the client and the family are getting used to the changes in

their lives, the following techniques are suggested by different models of family

therapy:

Structural/strategic systems (Stanton et al. 1982)

•Restructure family roles (the main work of this model).

•Realign subsystem and generational boundaries.

•Reestablish boundaries between the family and the outside world.

Multidimensional family therapy (Liddle 1999; Liddle et al. 1992)

•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, and

consider whether to medicate for depression, anxiety, or posttraumatic stress

disorder.

•Consider whether to address loss and mourning, along with sexual or physical

abuse.

Cognitive–behavioral family therapy (Azrin et al. 2001; Kirby et al. 1999;

Waldron et al. 2000)

•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.

Network interventions (Favazza and Thompson 1984; Galanter 1993)

•Use 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.

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Solution­focused family therapy (Berg and Miller 1992; Berg and Reuss 1997;

de Shazer 1988; McCollum and Trepper 2001)

•Employ the miracle question.

•Ask scaling and relational questions.

•Identify exceptions to problem behavior.

•Identify problem and solution sequences.

that he will not relapse. In reply, he might be

asked, “Do you think your father is that confident?” Being urged to look at his situation from

the perspective of the parent, who might only

be somewhat confident that the client will not

relapse, motivates the client to think about how

he must behave to instill more confidence in

this important other figure.

Problem definition questions. This technique,

used with the families of people with substance

use disorders, defines the steps that each person

takes to produce an outcome that is not a

problem (McCollum and Trepper 2001). The

therapist helps the family define a problem it

would like to solve, and then constructs the

part each member plays in the sequence of

behaviors leading up to that problem. Next, the

therapist helps the family examine exceptions

to the problem sequence and uses the exceptions to construct a solution sequence.

Matching Therapeutic

Techniques to Levels

of Recovery 

Both individuals and families go through a

process of change during substance abuse

treatment.

The consensus panel decided that one way of

looking at levels of recovery for families is to

combine Bepko and Krestan’s stages of treatment for families (1985), and Heath and

Stanton’s stages of family therapy for substance abuse treatment (1998). Together, the

levels of family recovery are

•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.

•Long­term maintenance of sobriety. The

family must rebalance and stabilize a new

and healthier lifestyle.

Once change is in motion, the individual and

family recovery processes generally parallel

each other, although they may not be perfectly

synchronized (Imber­Black 1990). For

instance, family members may be aware of a

drinking problem sooner than the person who

is doing the drinking. When a person who

drinks excessively comes to treatment, both the

client and the family need education about

alcohol abuse, and both need to think about

seeking help to stop the drinking. Similarly,

once the person who drinks decides to stop

drinking and makes plans to do so, the family

must learn to stop supporting the drinking.

Familiar ways of interacting must change if the

family is to maintain a healthy emotional balance and support abstinence. In short, as both

the individual and the family change, both

have to adjust to a change in lifestyle that supports sobriety or abstinence, the changes needed to maintain sobriety or abstinence, and a

stable family system.

Different models of integrated treatment

suggest different techniques that can be used at

different levels of recovery. As the family

addresses its challenges and the client addresses a substance use disorder, they will progress

from attainment of sobriety to maintenance.

The following summary figures, 4­3 (p. 103),

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4­4 (p. 104), and 4­5, list techniques from a

variety of treatment models that can be used

with families at different levels of recovery in

substance abuse treatment and family therapy.

Treatment goals for children in alcoholic families and adult children of people with substance

use disorders include educating children about

drinking; helping parents assume appropriate

responsibility as parents; and examining the

role the adult played in his family of origin and

how that role affects current relationships

(Bepko and Krestan 1985). For more information, refer to TIP 36, Substance Abuse

Treatment for Persons With Child Abuse and

Neglect Issues (CSAT 2000b), and the Adult

Children of Alcoholics Web site,

http://www.adultchildren.org.

Figure 4­5

Techniques To Help Families in Long­Term Maintenance

The following techniques are suitable during the period when the gains made by the

client and the family during treatment are being solidified and safeguards against

relapse or returning to old habits are being implemented:

Family/larger system (Imber­Black 1988)

•Renegotiate relationships with larger systems. For instance, agree with Child

Protective Services that once the family has completed treatment, the child(ren) can

be returned to the home.

Network therapy (Galanter 1993)

•Employ Al­Anon, spousal support groups, and multifamily support groups.

•AA, Al­Anon, and Alateen are interventions long used to break the cycle of substance

abuse and can complement other interventions.

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Chapter 4 Summary Points From a

Family Counselor Point of View

•For the successful integration of family­involved interventions or family therapy, treatment program design must be inclusive of the needs of all family members and the family as a whole. Adequate therapeutic time, trained clinicians,

and an informed staff serve to increase effectiveness.

•Families can be used to foster client engagement and retention in treatment.

•In much the same way that group counseling helps clients by bringing together

clients in different phases of the treatment process, multiple family therapy

groups can help families see how progress is achieved by others and also serve

as a reminder of what the early days of treatment were like.

•Integrating family techniques into substance abuse treatment is possible along

a broad continuum from the utilization of specific techniques to the fullfledged adaptation of particular models.

Integrated Models for Treating Family Members 107

                 

                   

                 

                 

           

               

                   

     

             

               

                   

                 

                   

               

                   

                 

                 

                     

                     

         

                       

                   

                 

                 

In This
 

Chapter...
 

Introduction

Age

Women

Race and Ethnicity

Sexual Orientation

People With
 

Physical or
 

Cognitive
 

Disabilities
 

People With
 

Co­Occurring
 

Substance Abuse
 

and Mental
 

Disorders
 

Rural Populations
 

Other Contextual
 

Factors
 

5 Specific Populations
 

Overview

Culturally competent practices and attitudes can be implemented at all

levels of a treatment program to ensure appropriate treatment for families

with substance abuse issues. The effectiveness of substance abuse

treatment is undermined if treatment does not include community and

cultural aspects—the broadest components of an ecological approach.

Concerted efforts are instituted to identify and change preconceived

notions or biases that people may have about other people’s cultural

beliefs and customs.

This chapter provides information about several specific populations:

children, adolescents, and older adults; women; cultural, racial, and

ethnic groups; gays and lesbians; people with physical and cognitive disabilities; people in rural locations; and people with co­occurring substance

use and mental disorders. In addition, information is provided regarding

people who are HIV positive, people who are homeless, and veterans.

Each section discusses relevant background issues and applications to

family therapy.

Introduction

This TIP uses the term specific populations to examine features of families

based on specific, common groupings that influence the process of

therapy. Whenever people are categorized or classified in this way, it is

important to remember that individuals belong to multiple groups,

possess multiple identities, and live their lives within multiple contexts.

Different statuses may be more or less prominent at different times. The

most important general guideline for the therapist is to be flexible and

meet the family “where it is.”

It is vital that counselors be continuously aware of and sensitive to the

differences between themselves and the members of the group they are

counseling. Therapists bring their own cultural issues to therapy, and

the therapist's age, gender, ethnicity, and other characteristics may

109
             

           

             

         

           

             

         

             

             

             

   

             

         

             

         

           

           

             

             

           

       

           

           

             

       

     

           

                 

             

           

         

       

             

             

             

               

         

       

         

           

         

     

       

             

           

         

         

         

               

               

             

     

           

                 

             

             

           

           

               

             

         

           

             

             

               

             

             

     

         

           

             

           

             

           

               

       

             

           

         

           

figure in the therapeutic process in some way.

Differences within the family also should be

explored. Is the family a homogeneous group or

one that represents several different backgrounds? What is the significance that family

members assign to their own identities and to

the identity of the therapist? These considerations and sensitivity to the specific cultural

norms of the family in treatment must be

respected from the start of therapy. If these

factors are not apparent or explicit, the

therapist should ask.

Age

Age is an important factor in the therapeutic

process. Substance use may have different

causes and different profiles based on an individual’s age and developmental stage. For

example, a teenager may drink for different

reasons than does a middle­aged father. The

age of the person abusing substances is also

likely to have different effects on the family.

This TIP discusses three age groups: children,

adolescents, and older adults.

Children

Background issues

While actual numbers of children who abuse

substances are small compared to other age

groups, children who use drugs are an underserved population—one as poorly identified as

it is poorly understood. Nonetheless, substance

abuse among children is of grave importance.

Drug or alcohol use can have a severe effect on

the developing brain and can set a potential

pattern of lifelong behavior (Oxford et al. 2001).

The use of inhalants is especially prevalent

among children. The National Institute on

Drug Abuse (NIDA)­funded 2001 Monitoring

the Future survey found that more than 17

percent of eighth graders said they had abused

inhalants at least once in their lives (Johnston

et al. 2002). In a recent policy statement,

the American Academy of Pediatrics

(AAP) described inhalant abuse as “an 

under­recognized form of substance abuse with

a significant morbidity and mortality” (AAP

1996, n.p.). For more information, see also

TIP 31, Screening and Assessing Adolescents

for Substance Use Disorders (Center for

Substance Abuse Treatment [CSAT] 1999c).

Application to family therapy

When a child is abusing substances, single

family therapy is probably the most useful

approach. Regardless of the approach, the

therapist will need to make accommodations

and adjustments for children in therapy. For

instance, 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.

Stith et al. (1996) interviewed 16 children

between the ages of 5 and 13 who were involved

in family therapy with their parents and siblings

and found these children wanted to be involved

in therapy, even when they weren't the identified

patient (IP). They were aware that important

things were happening in therapy and wanted

to be part of them. They did, however, indicate

that being part of family sessions often had

been an unsatisfying experience dominated by

adult conversation and time spent out of the

session in the waiting room. The personal

qualities of the therapist were important to the

children. Finally, they said that if they were to

be part of therapy, they needed to participate

in ways that fit their styles of communication—

activity and play.

Approaches to incorporate children in therapy

via play—such as family puppet shows, family

art projects, and board games with a therapeutic

focus—can be modified to fit family therapy,

and play therapy can be a valuable component

of family sessions. The Association for Play

Therapy defines play therapy as “the systematic

use of a theoretical model to establish an

interpersonal process wherein trained play

therapists use the therapeutic powers of play

to help clients prevent or resolve psychosocial

difficulties and achieve optimal growth and

development” (Bratton et al. n.d., p. 1).

110 Specific Populations
           

           

             

               

               

             

       

                 

           

         

             

             

       

         

           

             

           

     

       

     

               

         

             

           

             

             

           

               

           

             

             

       

             

           

           

               

             

             

               

               

                 

         

         

       

       

                 

           

               

     

   

           

     

   

     

   

   

   

   

   

       

   

           

           

           

         

         

     

Cooklin (2001) points out that play therapy

does not mean playful interactions in therapy,

but refers to more structured and often nonverbal processes such as the use of toys, games,

puppets, models, or role playing. Its goal is to

reduce the child’s anxiety and to facilitate

emotional processing. He also emphasizes,

though, that when the client is a child, a level

of playfulness is helpful in the therapist­client

relationship.

Adolescents

Background issues

Youthful substance use is usually transitory,

episodic, or experimental, but for some, it may

be a serious, long­lasting indicator of other life

problems (Furstenberg 2000). A growing body

of research, primarily using animals, addresses

the sensitivity of adolescents’ brains to alcohol

(see, e.g., Spear 2000). Substance use in the

teen years is associated with disruptive behaviors

such as conduct disorders, oppositional 

disorders, eating disorders, and attention

deficit disorder (ADD) or attention

deficit/hyperactivity disorder (AD/HD).

The United States has the highest rate of

adolescent drug abuse of all industrialized

nations (Liddle et al. 2001). The Overview of

Findings From the 2002 National Survey on

Drug Use and Health found that 17.6 percent

of 12­ to 17­year­olds reported drinking in the

month preceding the survey, and 11.6 percent

of 12­ to 17­year­olds said they had used an

illicit drug (Office of Applied Studies [OAS]

2003a). More than 65 percent of young people

who were classified as heavy drinkers were also

using illicit drugs (OAS 2002b).

Alcohol is the substance most often used and

abused by adolescents, and its usage reflects

troubling patterns (AAP 2001). In 2001, of

people age 12 to 17, 10.7 percent reported

binge alcohol use in the past month and 2.5

percent reported heavy alcohol use in the past

month (binge drinking is defined as five or

more drinks on the same occasion; heavy use is

five or more drinks on the same occasion at

least 5 days in the past month) (OAS 2003a).

Substance use among adolescents is associated

with poor school performance, problems with

authority, and high­risk behaviors, including

driving while intoxicated and unprotected sexual

activity. Fifteen­year­olds who drink have been

found to be seven times as likely to have sexual

intercourse as their nondrinking contemporaries

(AAP 2001). Sexually active teenagers who use

alcohol or drugs are at greater risk of acquiring

sexually transmitted diseases, including

HIV/AIDS (AAP 2001).

Some specific risk factors for adolescent

substance abuse

include

•Antisocial behavior Age is an important

factor in the

therapeutic

process. Substance

use may have different causes and

different profiles

based on an

individual’s age

and developmental

stage.

at a young age,
 

especially aggression
 

•Poor self­esteem

•School failure

•ADD and AD/HD

•Learning disabilities

•Peers who use drugs

•Alienation from

peers or family

•Depression and

other mood disorders (e.g., bipolar
 

disorder)
 

•Physical or sexual

abuse (AAP 2001)

Application

to family

therapy

A growing body of evidence supports family

therapy’s capacity to engage and retain clients

in therapy and its efficacy in ameliorating

adolescent drug use, as compared to other

approaches (Liddle and Dakof 1995a). Specific

family therapy approaches such as Brief

Strategic Family Therapy (Szapocznik and

Specific Populations 111
     

             

             

           

           

         

           

             

           

           

         

               

           

       

             

         

           

           

         

     

             

     

     

   

   

   

     

   

   

     

     

   

     

   

     

   

   

   

     

   

           

         

           

         

           

         

       

         

         

       

       

         

     

         

             

                 

             

           

           

             

           

             

               

           

       

       

         

                 

       

           

             

         

               

           

             

               

           

           

             

           

Williams 2000) and Multidimensional Family

Therapy (Liddle et al. 2001) have shown great

promise in terms of usage reduction in adolescents and improvements in family functioning.

Part of the treatment process involves teaching

adolescents to make choices and encouraging

them to find alternatives to substance use.

Parents can be instrumental in this process and

the importance of modeling behavior should be

emphasized. Siblings also should be drawn into

therapy—sometimes the problems of an adolescent IP will overwhelm the needs of a quieter

sibling. In general, family therapists can

support families by providing opportunities for

them to work on negotiation skills with their

adolescent child. Therapists can teach parents

techniques to decrease reactivity and ways to

provide real and acceptable choices for their

children. Children should 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 the adolescent is familiar and comfortable

can be a helpful

strategy. Conducting

sessions at an adolesUp to 17 percent

of older adults are

estimated to have

problems with	 

alcohol or prescription drugs.

Older men are

much more likely

than older women

to abuse alcohol.

cent’s home may

promote a more

open and sharing

tone than sessions in

a therapist’s office.

Scheduling of

sessions must be

sensitive not only to

school obligations,

but to extracurricular and social

activities as well.

Such flexibility is an

important attribute

for any therapist

working with adolescents. When teens

are not willing to

engage in

therapy/treatment,

parents may be

encouraged to attend therapy to examine ways

of working with their troubled teen.

Gender also may have implications in family

groupings for therapy sessions, particularly in

families where abuse has occurred. There may

be cases where father/son or mother/daughter

sessions will be helpful.

For more information on substance abuse

treatment with adolescents, see TIP 31,

Screening and Assessing Adolescents for

Substance Use Disorders (CSAT 1999c) and

TIP 32, Treatment of Adolescents With

Substance Use Disorders (CSAT 1999e).

Older Adults

Background issues

Although definitions of “older adults” vary,

they typically refer to individuals age 60 and

older. Up to 17 percent of older adults are

estimated to have problems with alcohol or

prescription drugs. Older men are much more

likely than older women to abuse alcohol

(Atkinson et al. 1990; Bucholz et al. 1995;

Myers et al. 1984); women typically experience

later onset of problem drinking than do men

(Gomberg 1995; Hurt et al. 1988; Moos et al.

1991). For both men and women, substance

abuse can lead to social isolation and loneliness,

reduced self­esteem, family conflict, sensory

losses, cognitive impairment, reduced coping

skills, decreased economic status, and the

necessity to move out of one’s home and into a

more supervised setting (CSAT 1998d).

There are two patterns of substance abuse

among older adults. The first includes those for

whom drug or alcohol abuse has been a chronic,

lifelong pattern leading to significant impairment by the time they are older. The second

includes older adults who have recently begun

misusing alcohol or drugs in response to life

transition issues, such as the death of a spouse.

Through reduced tolerance and the decrease in

the amount of body water (associated with

aging) in which to dilute alcohol (Dufour and

Fuller 1995; Kalant 1998), alcohol use

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considered moderate and nonproblematic

through a person’s middle years can cause

intoxication and dysfunction in an older person.

In general, treatment is more effective and the

prognosis more optimistic for people with

later­onset substance disorders.

Diagnosis can be difficult in this age group (and

misdiagnosis is more likely) because symptoms

easily can be confused with age­related organic

brain disorders or effects and interactions of

prescribed medications. Depression or bone

fractures from falls may be incorrectly

attributed to the natural aging process. Family

members may hide the older person’s substance

abuse. A retired person will not have problems

at work related to substance abuse, and the

behavior of those living alone often will go

unobserved. Moreover, although older people

often have many contacts with the health care

system, they are not routinely screened for

substance abuse (CSAT 1998d).

Ageism also contributes to the underdetection

of substance abuse and mental disorders (e.g.,

depression) in older people. One study found

that different expectations of younger and

older people contributed to minimizing

problems of older adults. Substance abuse

and other problems were perceived as more 

significant when they were experienced by

younger people (Ivey et al. 2000).

Prescription drug misuse and abuse are higher

among older adults than any other age category.

For some individuals, the misuse may be unintentional, because of confusion and the sheer

amount of medicines they must manage. Some

studies estimate that more than 80 percent of

those over 65 take at least one prescription

drug (Ray et al. 1993) and nearly one­third

take eight or more prescription drugs daily

(Sheahan et al. 1989). Older adults also take a

disproportionately large amount of psychoactive

mood­changing drugs (such as antidepressants,

tranquilizers, and hypnotics). Moreover, they

typically take these drugs longer than younger

adults (Sheahan et al. 1995; Woods and Winger

1995). The cost of medication also is a factor

related to compliance for older adults.

Application to family therapy

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 Alcohol use

considered

moderate and

nonproblematic

through a person’s

middle years can

cause intoxication

and dysfunction in

an older person.

family context and

reduce feelings of

isolation. Although

family ties can be

beneficial at any stage

of life, some older

adults may regard

involvement of their

long­grown children

in their lives as intrusive and threatening

to their independence

(Sluzki 2000). 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.

Such reports of physical, psychological, financial, or emotional mistreatment or neglect have

increased dramatically in the past 15 years, yet

only a fraction of cases are ever reported.

While a common perception is that elder abuse

is a nursing home­related phenomenon, the fact

is that perpetrators are most often the victims’

family members (Brandl and Horan 2002).

Even when abuse is not a factor, older adults

sometimes are infantilized and trivialized within

the family. Likewise, family therapists must be

cognizant of their own tendencies to infantilize

Specific Populations 113
               

           

       

       

           

               

               

           

             

             

             

           

         

       

     

         

         

           

         

       

           

           

   

   

           

     

           

             

         

           

       

           

         

           

               

           

             

             

           

             

           

           

           

       

           

         

             

           

                 

               

                 

             

       

         

           

               

     

         

             

       

         

           

           

     

           

             

             

         

             

             

         

           

             

the elderly (Sluzki 2000). It is helpful to refrain

from framing the substance abuse in pejorative

terms, such as heavy and problem drinking.

Instead, a less stigmatizing classification system

may refer to a person as at­risk. Linking at­risk

use to existing or potential medical conditions

also places the problem in a medical framework

and identifies it as a danger to health.

The family therapist working with older adults

may also find it helpful to make extensive use

of home visits. It is important to respect clients

and their life experiences. Older people,

especially those who feel isolated, may have a

need to tell their stories (for example, growing

up during the Great Depression), and the

therapist needs to listen attentively. Telling

stories is important and a developmentally

appropriate behavior.

Other accommodations that are helpful for

many older clients include

•Involving the older adult’s physician and/or

nursing staff.

•Recognizing and addressing barriers to

treatment, such as ageism, lack of awareness,

comorbidity of physical or mental disorders,

transportation problems, client’s time

constraints, lack of staff expertise, and

economic limitations.

•Addressing issues of loss, grief, death, and

dying.

•Addressing concomitant substance use,

including tobacco.

•Using supportive, nonconfrontational

intervention approaches. Motivational interviewing is appropriate for some older adults.

•Acknowledging the cultural expectations

regarding use to better understand the older

client’s perceptions of his or her own using.

For more information about substance abuse

treatment and older adults, see TIP 26,

Substance Abuse Among Older Adults (CSAT

1998d).

Women

Background Issues

According to data from the 2002 National

Household Survey on Drug Abuse (OAS

2003a), 6.4 percent of American women reported

using an illicit drug in the month preceding the

survey, while 9.9 percent of women reported

binge drinking in the same timeframe. In 2002,

men continued to have higher rates of illicit

drug use than women—10.3 percent of men

compared to 6.4 percent of women (OAS 2003a).

Despite the significant number of women who

abuse substances, the substance abuse treatment

and research fields have been grounded

historically in the needs and experiences of

middle­aged, white males with alcoholism.

Recent studies suggest that the causes,

consequences, and costs of women’s substance

abuse are in many ways different from men’s.

For example, the onset of substance abuse

among women is more likely to be tied to

specific events, such as divorce or the death

of a loved one. Women also tend to enter

treatment at later stages than men, and women

continue to encounter many gender­related

barriers to treatment (Brady and Randall

1999; Chaney and White 1992). Moreover, in

addition to the risks shared with men (i.e.,

hepatitis, HIV infection, malnutrition, unemployment, criminal acts, and arrests), women

have been found to develop more severe

alcohol­related medical problems while

consuming smaller amounts of alcohol than

men. Sexual, physical, or emotional abuse of

women can increase their risk of substance

abuse (Covington 2002).

In some respects, the psychological burden of

women’s substance abuse is likely to be greater

than for men. One of the biggest psychosocial

differentials between men and women who

abuse substances is stigma. For a man, especially

in certain cultures, drinking may be part of

manhood. Women with substance use disorders

often are referred to in derogatory and sexually

charged terms. A mother with a substance

abuse problem quickly is regarded as unfit and

114 Specific Populations
           

               

           

             

           

               

             

         

           

         

           

           

         

       

           

         

       

         

               

         

             

         

           

         

         

             

         

           

           

           

         

           

         

           

           

             

         

             

           

             

             

   

             

           

             

         

         

             

           

           

           

           

         

             

               

             

         

             

         

       

         

   

     

           

           

           

         

             

       

           

             

   

   

   

     

   

   

     

     

     

   

   

     

   

     

   

may be confronted with losing her children.

Although 9 out of 10 women stay with male

partners who abuse substances, men are more

likely to leave relationships with a woman who

abuses substances (Hudak et al. 1999).

A recurring theme in the lives of women with

substance use disorders is a lack of healthy

relationships (Covington 2002). Brown et al.

(1995) found that when women were drinking,

they often lacked social support, particularly

from their partners, and that their families

often were opposed to their getting treatment.

For more information, see the forthcoming TIP

Substance Abuse Treatment and Trauma

(CSAT in development i) and TIP 36,

Substance Abuse Treatment for Persons With

Child Abuse and Neglect Issues (CSAT 2000b).

An important distinction in women’s substance

abuse has to do with their traditional roles as

caretakers of children. Even before children

are born, women who abuse illicit drugs and

alcohol experience a variety of gynecological

problems that can make birth control and

pregnancy detection difficult, adding to the

probability of infertility and problem pregnancies and births. Many studies of substance use

and pregnancy have found poor pregnancy

outcomes such as preterm delivery, fetal

distress, and hemorrhage, whether the drug is

alcohol, cocaine, opioids, marijuana, or nicotine

(Brady and Randall 1999; Bry 1983).

A variety of other ills may influence the children

of mothers who abuse substances, including

increased risk for depression, anxiety, and

conduct disorders (Brady and Randall 1999;

Merikangas and Dierker 1998), higher rates of

lifetime suicidal ideation (Pfeffer et al. 1998),

and more frequent periods of living outside the

nuclear family during childhood (Goldberg et

al. 1996). Child abuse and neglect are also

often associated with women’s drug and alcohol

abuse (Bijur et al. 1992; Casado­Flores et al.

1990; Famularo et al. 1986, 1992; Murphy et

al. 1991).

Bays (1990) suggests a number of factors

associated with drug abuse that put parents

who abuse substances at greater risk of abusing

or neglecting their children. These include

diverting family resources from meeting the

needs of the children to supporting the

substance abuse, criminal activity to support a

substance use disorder, mental and physical

illness, poor parenting skills, side effects of

drugs, and family violence. In addition, the

effects of prenatal drug exposure may produce

characteristics in the children that interfere

with attachment and put them at greater risk

for abuse (Cook et al. 1990) and the development of substance abuse problems later in life

(Merikangas and Dierker 1998; Muetzell 1995;

Su et al. 1997). For further information about

women’s issues in substance abuse treatment,

see the forthcoming TIP Substance Abuse

Treatment: Addressing the Specific Needs of

Women (CSAT in development e).

Application to Family Therapy

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 to

address the woman’s

substance abuse problem. This decision

should be made after

careful A recurring theme

in the lives of

women with

substance use

disorders is a lack
 

of healthy
 

relationships.
 

consultation with the

professional staff

overseeing the abusive

partner’s treatment.

While the abusive

partner’s treatment is

ongoing, it may be
 

helpful for the client
 

who has been

victimized to participate in individual

therapy or some type
 

of group therapy

focused on her experience with abuse.
 

Specific Populations 115
         

             

         

         

           

         

             

           

         

       

             

             

         

       

         

         

           

               

             

                 

         

             

         

         

             

               

               

           

                 

             

           

             

         

           

         

                 

             

           

         

         

             

               

               

             

           

       

           

             

           

       

               

           

           

           

       

       

   

           

             

         

         

           

           

         

         

       

             

         

                 

         

         

             

             

             

         

           

         

         

     

         

         

               

                 

             

         

               

           

       

           

Covington (2002) notes that substance abuse

treatment is more effective for women when it

addresses women’s specific needs and understands their daily realities. Finkelstein (1994)

likewise emphasizes the need for a holistic

approach to achieve successful outcomes. Farreaching changes, she points out, are needed in

many areas of a woman’s life, including

employment, housing, health care, child care,

children’s services, family supports, legal

rights, and division of labor within the family.

To be responsive to a woman’s needs, family

therapy should address these broad areas.

Amaro and Hardy­Fanta (1995), Covington

(2002), and Finkelstein (1996), among other

researchers and clinicians who work with

female clients, also stress the importance of

relationships in a woman’s life and the need for

a model to meet these needs. Family therapy,

with its focus on the family unit and the

relationships therein, can clearly help address

these needs for women and help them improve

their relationships.

Particular treatment issues relevant to women

include shame, stigma, trauma, and control

over her life. Women tend to hide their drinking

and substance abuse because of the shame that

is associated with it. It is important that women

feel they are being treated with respect and

dignity in treatment (Covington 2002; Hudak

et al. 1999). Because of the high rates of

victimization in women’s lives, it is critical

that the therapist addresses trauma in women’s

therapy in order for it to be successful.

Substance abuse recovery and trauma recovery

should occur together, and safety must be

ensured in therapy (Covington 2002). Related

is the issue of control in the woman’s life in

areas such as sex, money, food, and religion.

Some control problems for women are internal

and manifested in self­abusive behaviors, such

as eating disorders or self­cutting.

Women who have lost custody of their children

may need help to regain it once stable recovery

has been achieved. In fact, working to get their

children back may be a strong treatment

motivator for women. Finally, childcare is one

of the most important accommodations necessary

for women in treatment. Children must be

allowed to come to therapy sessions, or when

such attendance is not appropriate, to be

placed in suitable childcare.

Race and Ethnicity

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 the core family and clinical

processes (Santisteban et al. 2002). Rigorous

investigations are needed to explore the dynamic

interplay between “ethnicity, family functioning,

and family intervention” (Santisteban et al.

2002, p. 331).

One important requirement is to move beyond

ethnic labels and consider a host of factors—

values, beliefs, and behaviors—that are

associated with ethnic identity. Among major

life experiences that must be factored into

treating families touched by substance abuse is

the complex challenge of determining how

acculturation and ethnic identity influence the

treatment process. Other influential elements

include the effects of immigration on family life

and the circumstances that motivated emigration

(migration due to war or famine is a far more

stressful process than voluntary migration to

pursue upward mobility), and the sociopolitical

status of the ethnically distinct family, in particular how the host culture judges people of

the family’s ethnicity (Santisteban et al. 2002).

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

(for example, the belief that one’s alcohol use is

not a problem, or not a severe one, and that

those affected can handle the problem on their

own), costs associated with seeking treatment,

as well as doubt about the efficacy of treatment

(Kline 1996). Other barriers to treatment for

these groups include inaccurate perceptions

about the cost or availability of treatment

116 Specific Populations
           

         

             

       

               

       

     

           

     

       

   

         

             

     

       

           

           

           

         

       

             

             

     

       

         

       

     

         

           

         

       

         

           

             

             

             

         

       

           

         

             

         

         

               

             

       

             

       

         

         

           

             

     

               

                       

                 

                     

                   

                   

               

               

                   

(especially for people who lack insurance), a

cultural need to maintain dignity, negative

beliefs about treatment (such as harsh rules in

residential programs), and structural problems

(such as too little treatment for people with no

or inadequate insurance, inadequate detoxification facilities, and bureaucratic red

tape) (Kline 1996). For more information about

cultural competency, see the forthcoming TIP

Improving Cultural Competence in Substance

Abuse Treatment (CSAT in development b).

African Americans

Background issues

Many African Americans were able to overcome

the destabilizing trauma of slavery by relying

on the support of affectional ties, extended

kinship ties, and multigenerational networks,

among other strengths (Wilkinson 1993).

Kinship bonds continue to provide support in

coping with the difficulties of a discriminating

society (Sue and Sue 1999). Paniagua (1998)

states that family therapy is recommended with

African­American families, and should specifically include emphasis on assigning tasks to be

completed at home as well as role­playing scenarios to develop intrafamilial communication.

To work effectively with African­American

families, family therapists must become familiar

with the complex interactions, strengths, and

problems of extended families (Boyd­Franklin

1989). Many extended African­American

families incorporate various related people

into a network that provides emotional and

economic support. Numerous adults and older

children participate in raising younger children,

often interchanging family functions and roles

(Hines and Boyd­Franklin 1996). The practice

of exchanging assistance, or reciprocity, is an

essential part of extended family life. Such

reciprocity may take the form of caring for

another’s child, knowing that the favor will be

returned when necessary, or providing and

receiving emotional support (Wright 2001).

Many extended families also take in secondary

members, such as cousins, siblings of the 

parents, elders of the parents, or grandchildren. In other cases, families take in children

who are not biologically related. Approximately

1.4 percent of African­American children live

in homes where they are unrelated to the head

of the household (U.S. Census Bureau 2001b).

Application to family therapy

As with all individuals, African­American

clients are sensitive to whether they are being

treated with respect. Cultural information

should be considered hypotheses rather than

knowledge. Techniques shown to be effective

with African Americans will be rendered ineffective if the therapist assumes an attitude that

is alienating to clients.

Within­Group Diversity: Caribbean

Black Populations

Interventions deemed appropriate and effective with African Americans born

and raised in the United States may be inappropriate for other groups. For

example, single­family therapy may not be effective with Caribbean Black

populations. Because this culture values privacy so keenly, families may not

discuss problems at all, even among themselves (Harris­Hastick 2001). In order

to minimize the discomfort of West Indian clients, Harris­Hastick (2001)

recommends offering an educational orientation about treatment, alcohol, and

other drugs, scheduling individual sessions until clients can comfortably talk

about themselves or be assigned to groups with other Caribbean members.

Specific Populations 117
           

         

       

               

         

           

     

       

           

       

         

       

         

             

           

             

   

   

   

   

     

   

   

   

   

   

   

     

               

         

     

   

           

           

         

       

         

         

           

             

     

             

           

                 

             

           

         

             

           

           

               

             

           

               

           

   

     

           

         

     

         

       

           

           

           

         

             

             

           

       

       

   

People of African ancestry are widely divergent.

Therapies effective for African Americans may

be inappropriate for immigrants from the

Caribbean or Africa (see box, p. 117). The

personal connection between family and

therapist is the single most important element

in working with African­American families.

Without rapport, treatment techniques are

worthless and the family will likely terminate

therapy early (Wright 2001).

African­American families also are sensitive to

a patronizing approach that Boyd­Franklin

(1989) refers to as missionary racism.

Therapists should be sensitive to the ways in

which this message may be conveyed. Clinicians

must be aware of any biases or attitudes

regarding their

African­American

clients. To address To work effectively

with AfricanAmerican

families, family

therapists must

become familiar

with the complex

interactions,

strengths, and

problems of	 

extended families.

this issue effectively,

therapists may need

assistance from

supervisors or colleagues or training in

cross­cultural situations (Wright 2001).

Santisteban et al.

(1997) found that

single­family therapy

improved family

relationships and

reduced behavioral

problems in AfricanAmerican youngsters.

African Americans

also function very

successfully in

multiple family

therapy. For many

African­American

Christians, the Bible

is a longstanding

source of truth and

solace that helps them make sense of life (Reid

2000). Because of the church’s centrality to

their lives, a Bible­related recovery program has

been found to be effective for African­American

Christian families (Reid 2000).

African­American women 

Mothers in African­American communities

often are characterized in terms of their

strength and devotion to family (Hines and

Boyd­Franklin 1996). This role often proves

stressful and destructive for African­American

women with substance use disorders because

they are committed to an exceptionally high

level of responsibility. Perhaps as an additional

result, they exhibit a high level of denial

regarding their substance abuse.

Reid (2000) maintains that in African­American

families where the mother has a substance use

disorder, the family may react by persecuting

her because of her failure to uphold the role as

mother. Most often, however, the family will act

to protect the mother’s image, becoming her

caretakers, keeping her substance abuse secret,

and taking care of her children. This assistance

may ultimately enable the mother’s denial to

become so strong that she considers treatment

to be a violation of her self­respect and

obligation to her family. In this scenario, a

mother’s loyalty to the family may eventually

lead to a crisis, when the pressure of presenting

a functional front becomes too great

(Reid 2000).

Because the mythical role of the AfricanAmerican superwoman prevents many mothers

from seeking help, therapy must address these

expectations. Addressing shame and guilt, and

giving African­American women permission to

acknowledge their personal needs, are essential

points for recovery (Reid 2000).

Parenting issues

Therapists often take exception to the strict

parental discipline meted out in some AfricanAmerican families. Sue and Sue (1999) warn

against therapists’ imposing their own beliefs

and values on these parents; they say that

“physical discipline should not be seen as

necessarily indicative of a lack of parental

warmth or negativity” (p. 241).

Many African­American families are headed by

women. Functional single­parent AfricanAmerican families are characterized by certainty

118 Specific Populations
           

           

           

             

             

         

       

             

               

         

         

               

             

   

     

           

           

       

         

           

             

     

       

             

             

           

     

             

         

         

       

         

   

       

     

           

           

           

     

     

       

           

         

           

     

           

           

           

           

         

           

   

             

     

           

         

           

           

         

         

         

         

         

         

       

         

       

           

         

             

         

           

           

             

         

about who is in charge, precise understanding

of roles and responsibilities, clear and flexible

boundaries, children having access to the parent,

children being cared for and having their needs

met, and parents and children feeling free to

seek and provide nurturance and communicate

their needs. Some functional single­parent

amilies have a parental child who helps the

mother take care of other children, particularly

while the mother is working. The existence of a

parental child does not necessarily indicate

dysfunction. These families may operate

successfully as long as the child has access to

activities with peers and the parent does not

abandon responsibilities or inappropriately

burden the child (Boyd­Franklin 1989).

Other factors

Such factors as AIDS, violence, and disrupted

families have had a profoundly negative effect

on the African­American community. To counter

this, effective substance abuse treatment

should be life­affirming and emphasize an

acquisition of power that moves the person

with a substance use disorder, the family, and

the community toward increased selfdetermination (Rowe and Grills 1993).

Effective substance abuse treatment and

recovery should “emphasize the positive

potential of human behavior based on a value

system and sense of order committed to the

greater good of humankind” (Rowe and Grills

1993, pp. 26­27).

Counselors should also be aware of how racism

impacts the family. Boyd­Franklin (1989) notes

that even middle­class African Americans may

experience diminished self­esteem and anxiety

about maintaining their position. Some middleclass African­American families experience

particularly intense pressure to maintain

appearances (Boyd­Franklin 1989). These

families often place a strong emphasis on

respectability where causing shame for the

family is considered to be particularly

reprehensible and damaging.

Hispanics/Latinos

Tremendous demographic and cultural

heterogeneity exists within the Hispanic/Latino

population. Indeed, even within a specific

subgroup, there will be substantial variation

based on regional, social, economic, and

acculturation­related differences. “Most

analyses have treated Hispanics as a single

group, despite the fact that traditional alcohol

use patterns vary among Hispanics with different

countries of origin. In addition, studies among

Hispanics typically have focused on male

drinking patterns" (Caetano et al. 1998, p.

234).

An understanding of Hispanic/Latino subgroups must begin with knowledge of their

families’ immigration history. Some people

leave their home country voluntarily in order

to pursue adventure or escape poverty.

Refugees, on the other hand, may flee persecution, fear for their safety, and have much

more pain and anger associated with their

migration. Those who come from war­torn

countries may show symptoms of posttraumatic

stress disorder and other associated trauma.

Substance use in

Hispanic/Latino communities

Substance use and abuse varies between

Hispanic and Latino communities. Level of

acculturation has a strong positive association

with substance use. Specifically, more 

acculturated individuals report greater use of

alcohol and other substances. Cuadrado and

Lieberman (1998) assert that English­speaking

Mexican Americans are eight times more likely

to use marijuana than their Spanish­speaking

peers, and among Puerto Ricans the same

circumstances effect a fivefold increase.

The role of acculturation in

family functioning

In attempting to navigate their new environment,

many immigrants experience a loss in confidence, as well as shame, anger, and confusion.

These emotional reactions generally result from

Specific Populations 119
     

       

       

           

           

   

       

         

             

               

         

             

           

       

           

             

       

         

     

             

           

           

           

         

         

             

       

           

         

       

         

                 

           

             

             

         

           

           

           

     

     

       

       

     

         

           

           

         

           

             

           

       

       

           

         

       

           

           

             

           

         

     

         

       

       

       

         

             

           

         

           

       

           

             

         

           

         

         

         

         

     

             

     

       

           

poverty, unemployment, social isolation,

discrimination, lack of resources, sociopolitical

marginality, and cultural shock (Hernandez

and McGoldrick 1999). Any of these factors

may contribute to substance abuse and impact

family functioning.

Cultural characteristics that

impact family therapy

Perhaps the most widely acknowledged common

thread among Hispanics/Latinos is the importance placed on family unity, the family’s

well­being, and the use of family as a support

network. Familialism or familismo are terms

that refer to a core construct among Hispanic

and other ethnic­minority cultures. It has three

components: (1) perceived obligations toward

helping family members, (2) reliance on

support from family members, and (3) the use

of family members as behavioral and attitudinal

referents (Marín and Marín 1991).

Generally, the typical nuclear family is

embedded in an extended family with flexible

and open boundaries. Hispanics/Latinos place

a strong emphasis on extended family and clustering (Kaufman and Borders 1988), and there

tend to be fluid boundaries between family

members such as cousins, aunts, uncles, and

grandparents. “The family is usually an

extended system that encompasses not only

those related by blood and marriage, but also

compadres (godparents) and hijos de crianza

(adopted children, whose adoption is not

necessarily legal)” (Garcia­Preto 1996, p. 151).

Extended family members perform parental

duties and functions, providing the children

with the adult attention that is hard to come by

in a large family (Falicov 1998). Relationships

between siblings and cousins are strong and it

is not uncommon to have few peer friendships

outside the sibling subgroup. Godparents are

practically an additional set of parents, acting

as guardians or sponsors of the godchildren

and maintaining a strong relationship with the

natural parents (Falicov 1998).

Application to family therapy

Despite substantial research documenting the

underutilization of services by Hispanic/Latino

families, single­family therapy can be used

effectively with troubled Hispanic/Latino

children and adolescents and their families.

Santisteban et al. (1997) showed that family

therapy could be effective in reducing behavior

problems and improving family functioning in

Hispanic/Latino children who were at high risk

for drug abuse. Santisteban et al. (1996) and

Szapocznik et al. (1988) demonstrated that single­family therapy using specialized engagement

strategies could successfully engage reluctant

families into treatment. Family therapy is consistent with the family orientation of

Hispanics/Latinos, who welcome the involvement of all family members. Paniagua (1998)

believes that family therapy “should be considered as the first therapeutic approach with all

Hispanic clients” because it fits well with

Hispanics’ “view of familismo and extended

family” (p. 51).

To the non­Hispanic family therapist, extended

family relationships may at times appear

enmeshed and over­involved. Therapists must

understand the intensive emotional involvement among extended families (Guiao and

Esparza 1997). Everyone who is relevant to the

extended family network (i.e., whoever is central to the family’s day­to­day functioning)

should be involved within the family therapy

session. Conducting multiple family therapy

may meet with more success through focusing

on the broader issues of strong relevance to

Hispanic/Latino families that may be contributing to presenting problems. For example, these

issues may include the powerful intrafamilial

stresses due to acculturation and immigration

(Santisteban et al. 2002). However, when

bringing Hispanic families together, the family

therapist must address confidentiality to

enhance a sense of trust and privacy, particularly in small communities.

Respeto and conflict

The respeto (respect) that Hispanic/Latino

parents command from children has a different

120 Specific Populations
         

         

           

       

         

           

         

           

           

             

           

           

           

       

           

           

             

             

           

             

         

         

             

     

             

               

     

             

           

             

         

         

           

       

         

           

   

         

         

         

       

     

   

   

     

   

     

   

     

     

   

       

   

   

   

   

       

             

           

   

         

             

           

                 

         

         

         

           

         

   

         

       

       

         

           

           

internal meaning and set of expectations than

the more egalitarian Anglo­American notion of

“respect” (Falicov 1996). The extent to which

parents prefer markedly hierarchical family

relations has powerful implications for families

and family therapy. When parents view good

family functioning as consisting of marked levels

of authority (nonegalitarian), they can perceive

any type of open disagreements between parents

and adolescents as disrespectful and 

unacceptable.

This view may clash with traditional Western

models of family therapy in which full conflict

emergence with resolution is valued, and in

which both negative and positive emotions tend

to be more easily expressed and tolerated.

Hispanics/Latinos may perceive therapy interventions as incompetent or misguided if they

openly encourage young people to speak their

mind or tell parents what they really think.

Care must be taken to ensure that children,

who are generally encouraged to speak openly

during sessions, do not violate the family’s

disciplines and thereby prompt premature

termination (Santisteban et al. 2002). The

therapist should ask the family how it resolves

conflict.

Although Hispanic/Latina women generally are

accorded a great deal of respect, Hispanic society

is more concerned with the needs of the social

group as a whole than the needs of the 

individual. As a result, Hispanic/Latina women

may be more strongly invested in others, as

opposed to self­invested, a concept that grows

out of the more individualistic goals of dominantculture therapy (Trepper et al. 1997).

Communication styles

Because open disagreement and demands for

clarification are viewed as rude and insensitive,

indirect communication is sometimes viewed as

preferable. The use of impersonal third­person

pronouns is one method of indirect communication. Sometimes Hispanic/Latino culture’s

emphasis on smooth relationships may become

excessive, leading to concealment and lies

(Falicov 1998). Family therapists must gauge

the extent to which communication patterns

present such a hindrance.

Falicov (1998) urges

family therapists to Perhaps the most

widely acknowledged common

thread among

Hispanics/Latinos

is the importance

placed on family

unity, the family’s

well­being, and the

use of family as a

support network.

adopt a tone of

acceptance and

eschew direct

confrontation and

demands for extensive

disclosure throughout

treatment. Therapists

can ease the confrontational nature of

therapy by employing

humor, allusions, and

diminutives.

Disclosure is made

easier when the family

therapist takes a

philosophical

approach through

storytelling, anecdotes,

and metaphors. Other

culturally harmonic

tools include analogies,

proverbs, popular

songs, and unexpected

statements that convey

a sense of the absurdity of life (Falicov 1998). However, direct

communication can and should be used when

seeking informed consent or when an emergency

situation exists.

Counseling strategies

Family therapists should have a working

knowledge of how substance abuse is defined in

the families’ 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 U.S.

may alter family members’ attitudes toward

substance use. Any such changes must be

addressed, given their immediate impact on

family relations.

Clinicians should also explore family members’

experiences of migration, cultural transition,

and ethnic­minority status. Holding an open

discussion about these experiences allows

therapists to analyze family stories and leads

directly to issues affecting substance abuse. For

Specific Populations 121
   

   

   

     

   

   

   

   

   

       

         

     

   

     

           

             

           

         

       

         

         

           

         

             

         

         

           

       

           

             

         

     

           

         

           

   

         

       

         

           

     

           

         

           

         

     

         

           

     

       

         

           

             

           

       

         

           

           

         

       

     

           

           

           

             

           

               

             

   

instance, a discussion

concerning how

Hispanic/Latino

family members

will be much more

forthcoming when	 

the therapist solicits their feelings

through subtle and

indirect means.	 

family members

reconcile their

culture of origin and

American culture

will reveal differing

acculturation levels

within the family.

Therapists may 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. Naturally, in all

cases, therapists

must make arrangements so that

language does not impede a family member’s

participation.

Therapists who plan to work with Latino families

who have migrated from Mexico should 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. Since the curanderos are considered to

be holy, they invoke God’s and the Saints’

blessings on people seeking their help.

Other considerations include the following:

•A businesslike approach to treatment will
 

not appeal to Hispanic/Latino families. A
 

personable tack will yield much more
 

effective results.
 

•Hispanic/Latino family members will be much

more forthcoming when the therapist solicits

their feelings through subtle and indirect

means. Encouraging clients to speak forcefully

and directly may have the unintended effect

of inhibiting their participation (Paniagua

1998).

•The establishment of behavioral contracts

may be an overly task­oriented approach for

this population. Scheduling time ahead to

resolve intimate issues may also not be

acceptable to clients. Falicov (1998)

recommends making homework assignments

conditional because it is more collaborative,

less presumptive, and more in keeping with a

cultural affinity for spontaneity.

•Hernandez (2000) recommends that family

therapists adopt a broader perspective than

the disease model, to incorporate the impact

of a toxic social environment and the effects

of oppression as factors contributing to substance dependency. While still holding people

with substance use disorders accountable for

their actions, this approach helps to frame

substance abuse as a communal problem and

spur family members into learning more

about the effects of oppression.

•Using fundamental spiritual precepts can

inspire hope and patience. The endurance of

suffering, the practice of forgiveness, and the

importance of repentance may be fertile

values to use in working with families with

substance abuse. This strategy should only be

used when it is in harmony with the spiritual

views of the individual family or family

member (Hernandez 2000).

122 Specific Populations
       

           

             

           

         

           

         

       

       

           

           

     

         

         

         

   

     

         

             

           

               

         

         

               

         

         

               

             

         

         

     

   

         

         

               

           

             

         

       

                 

         

     

         

     

           

         

             

     

         

           

           

         

         

         

         

           

       

   

       

         

         

           

           

               

             

             

         

         

             

       

               

           

Asian Americans

Background issues

Asians are culturally diverse, with great 

variations of language, history, religion, and

values. Caution should be used when addressing

any of these groups as a whole.

Asians comprise more than 45 distinct

subgroups (Barnes and Bennett 2002; Grieco

2001), speaking more than 60 languages (New

York State Education Department 1997). The

tremendous cultural differences between these

groups make generalizations difficult. This

complexity is increased by key variables such

as reasons for migration, degree of acculturation,

English­speaking capacity, family composition

and intactness, education, and adherence to

religious beliefs. Despite this diversity, Asian

immigrants and refugees share many traits,

including

•Deference to authority

•Emotional inhibition

•Adherence to specified roles

•Hierarchical families

•Gender­specific roles

•Extended family involvement (Sue and

Sue 1999)

Asian family structure

Filial piety is highly valued in Asian cultures

(Fang and Wark 1998; Herrick and Brown

1998). However, “filial piety can be a source of

great anxiety when family obligations conflict

with individual interests” (Fang and Wark

1998, p. 67). In Asian families, women tend to

have fewer decisionmaking abilities than their

Western counterparts. Families are patriarchal,

with the eldest son having decisionmaking powers

when parents reach old age. Elders are seen as

wise, and as such are revered (Herrick and

Brown 1998). However, the more acculturated

an Asian­American family is, the more Western

intrafamily relationships may become (Fang

and Wark 1998).

Rates of substance abuse in

Asian communities

Substance use within individual Asian

communities has received scant attention with

most studies placing Asians into a single ethnic

category rather than as separate ethnic groups

(Uehara et al. 1994) or categorizing Asians as

“others.”

As seen with most immigrant communities,

second­ and third­generation Asian Americans,

born in the United States, are at higher risk to

begin using substances (Mercado 2000). As

individuals become increasingly acculturated,

their drinking patterns resemble those of

European Americans. This acculturation may

lead to intergenerational conflict, which in turn

spurs the acculturated family member’s

substance abuse in order to alleviate the

conflict (Bhattacharya 1998; Makimoto 1998).

Application to family therapy

The contemporary image of Asian Americans is

of a highly successful minority who experience

little or no difficulty in American society.

Mercado (2000) states that this “model­minority”

myth, Asian Americans’ cultural values, and

typical underutilization of mental health services

have influenced substance abuse therapists into

believing that Asian­American families are

psychologically healthier and in less need than

other ethnic groups. The model­minority myth

also prevents Asian­American communities

from receiving adequate financial commitment

and increases Asian Americans’ alienation from

other minority groups. Looking beyond this

myth can help family therapists to better

understand the Asian experience in America.

Asians may be hesitant to admit to having a

substance use disorder, believing that to do so

is an imposition and risks shaming the family.

Family members are disinclined to confront

people with substance use disorders preferring

to minimize, deny, reject, or even ostracize the

offending individual (Chang 2000). Inevitably,

the result is a cycle of enabling that perpetuates

the addictive process and leads to advanced

Specific Populations 123
         

         

           

           

                 

   

         

           

             

           

                 

         

           

           

               

     

         

             

         

         

             

           

         

       

       

           

         

           

             

         

             

             

             

       

     

     

             

         

         

           

           

             

         

           

             

           

             

           

           

             

         

         

         

           

             

           

     

       

             

           

             

         

                 

         

               

               

         

           

             

     

       

           

       

     

               

         

       

           

           

         

       

           

stages before coming to outside attention

(Chang 2000). Unfortunately, for many Asian

Americans with substance use disorders, this is

the point at which treatment often commences.

The opportunity for the IP to “save face” is a

critical element in making therapy an acceptable

part of healing.

Because Asian cultures are so intensively familycentered, the responsibility of maintaining filial

obligations is perhaps the dominant concern in

the life of most Asians (Herrick and Brown

1998). Given the central importance of family

in Asian cultures, it is critical to assess the

family’s part when treating Asian Americans

with substance use disorders. The psychological

influence of the family, particularly the older

members, is considerable even when key

members are missing as a result of loss,

nonmigration, or emotional estrangement

(Chang 2000). Family therapy with Asian

Americans is least likely to include older

generations. The primary reason for this

absence, younger family members say, is that

they hope to spare their elders any discomfort.

Working delicately and tactfully with elders is

of foremost importance. When treating

unresolved issues among older generations,

therapists must demonstrate respect, reveal

genuine empathy, and above all, avoid embarrassing older family members. Often family

members, particularly the person with the

substance use problem, will try to shield older

family members from shame. Family therapists

must be cognizant not to rush into exploration

of sensitive areas. One method is to initially

join with the family at a broad experiential

level—sharing their salient traumatic incident—without prying for embarrassing or

threatening details (Chang 2000).

Opinions vary on whether family therapy is an

appropriate vehicle with which to counsel

Asian Americans with substance use disorders.

Paniagua (1998) states that family therapy is

effective because the family is more important

than the individual in Asian families and the

act of withholding information from family

members is unfamiliar to many Asians. May

Lai (2001) urges therapists to work with the

client’s family, but to use individual counseling

rather than family therapy. Debates on the

efficacy of involving Asian families in treating

substance abuse often revolve around the

presumed skill level of the therapist, not the

fundamental importance of the client’s relationship to his or her family. Clearly, counseling

Asian­American families requires skill, delicacy,

and knowledge of cultural factors.

Issues of acculturation

As is common among immigrants, AsianAmerican families present widely varying levels

of acculturation within the nuclear and extended

family. The process of acculturation varies with

each of the Asian groups, depending on their

reasons for immigrating (e.g., for political or

economic reasons) (Inouye 1999).

Acculturation places traditional values and

customs out of context (Chang 2000). It results

in intensified isolation, removal of social

supports, and a sense of alienation from the

dominant culture. Asian immigrants may be

psychologically maladjusted, despite the perception of their being part of a “model­minority”

(May Lai 2001). The loss of family, and of the

traditional conception of family, engenders a

further loss of identity and place in the world.

The presence of the family will help the family

therapist determine the individual’s and the

family’s degree of adherence to traditional

values and to assess the family conflicts that

result from differential acculturation patterns

between family members. Effective pretreatment assessment that includes key questions

of acculturation must also include Asian

Americans’ most significant psychological unit,

the family (see for example Huff and Kline 1999).

Factors attributable to acculturation that cause

conflict within Asian families are women

receiving increased status, children no longer

demonstrating the highest regard for their

elders, and older family members losing their

preeminence as the keepers of tradition.

Additionally, Asian fathers’ traditional

emotional distance from the family can become

124 Specific Populations
             

       

         

             

           

               

             

         

           

           

           

           

               

               

             

         

               

               

         

           

       

             

           

         

           

           

             

         

           

       

         

       

           

       

             

             

                 

               

             

             

           

           

             

   

           

             

         

       

     

   

   

     

   

   

   

       

     

   

     

   

   

     

     

   

   

   

   

         

           

         

           

           

             

         

             

             

           

a detriment in the United States, where family

systems experience different demands.

Communication styles 

Western­style therapy often requires a frank

and open discussion of feelings and problems

to be effective. For Asians, directness risks

confrontation and rudely ignores one’s obligation to help maintain face. On the other hand,

to be indirect enables one to convey meaning

without challenging or insulting another. To

underscore this point, Asian languages tend to

be more metaphoric, while English words tend

to have precise meanings (Chang 2000).

Furthermore, Asian culture places a high value

on “saving face.” A family striving to avoid the

shame of a family member with a substance use

disorder will likely perceive that member as a

tremendous liability to the family’s structure.

Discussing such an issue in therapy with a

nonfamily member (no matter how professional)

can be interpreted as a sign of weakness for

many Asian families (Lee 1996; Paniagua

1998).

For Asians, discussing one’s inner feelings is

often unfamiliar and culturally unacceptable.

It is overly confrontational to seek open discussion of personal issues prior to establishing

trust (Sue and Sue 1999). Intervention models

that stress direct and explicit exchange between

family members or client and therapist are

likely to be either ineffective or harmful

(Chang 2000). For example, traditional substance abuse therapy often teaches families to

detriangulate by challenging one another

directly (Mercado 2000). Asian Americans view

such behavior, particularly across generations,

as disrespectful.

Because traditional Asian families are grounded

on a hierarchical structure, they negotiate

differences through mediation. This hierarchy

requires the counselor to function as a negotiator

and follow the family structure when doing so

(Sue and Sue 1999). The father, as head of the

family, should be spoken to first in order to

gather his insight into the family’s problem.

It is important for therapists to focus most

heavily on specifics when working with Asian

families. Rather than discussing feelings, it is

more effective to be problem focused and goal

oriented (Paniagua 1998).

Engagement

Attempts to underscore the influence of family

dynamics as a key contributor to the family

member’s substance abuse may be received

with disapproval and possible termination. Kim

(1985) recommends

an approach to pace

the family’s cultural Given the central

importance of

family in Asian

cultures, it is critical to assess the

family’s part when

treating Asian

Americans with

substance use

disorders.

expectations and limitations in relation to

traditional Western

psychotherapy, in an

effort to continue

engagement with the

family.

The first step is to

assert that the IP’s

ailment is indeed the

problem—by implication not the client

him­ or herself.

Complaining about

physical ailments is an

accepted means of

communicating

psychological stress.

Rather than discussing anxiety and

depression, Asians

may complain about

headaches, fatigue,

restlessness, or disturbances in sleep and

appetite (Sue 1997; Toarmino and Chun 1997).

Taking the patient’s blood pressure, ordering

vitamins, or advising on minor physical

ailments will increase the Asian patient’s trust

in the treatment facility (May Lai 2001). Sue

and Sue (1999) also recommend acknowledging

and treating physical problems before moving

on to possible emotional factors. For example,

focusing on the physical symptoms of the person

with a substance use disorder (such as high

liver enzyme) rather than substance abuse is

Specific Populations 125
   

   

   

     

     

   

     

   

   

     

   

     

           

             

         

           

               

           

         

       

         

                 

           

           

         

       

   

       

       

         

           

         

           

   

             

           

           

     

         

         

     

         

             

       

               

         

         

           

       

     

           

           

           

       

         

             

           

         

             

         

             

   

             

           

               

           

           

         

           

   

           

               

more culturally

acceptable for Asian

Americans. In addition, therapists

Counseling AsianAmerican families

requires skill,

delicacy, and

knowledge of

cultural factors.	 

should respect the

client’s need to use

culturally relevant

health care such as

acupuncture and

herbal medicines.

The second step in

the engagement

process is to

acknowledge and

strengthen the family’s wishes to assist

the family member

in changing his or

her behavior.

Treatment planning

for Asians with substance use disorders should

consider the family’s role as early as possible.

Although involving the family adds complexity

to the therapist’s task, its integral importance

cannot be overstated. It is critical to assess the

individual’s substance abuse in regard to the

family’s level of functioning (Chang 2000).

Given cultural mandates to show deference to

authority figures, Asian families may present

as particularly compliant in treatment.

The third step is for the therapist to stress that

each family member’s contribution is vital to

helping the family member, and that without

each family member’s participation the problem

will persist or worsen, further exacerbating the

family’s difficulties.

Other considerations in engaging Asian families

are noted below:

•Family therapists should be careful that

therapy does not breach proscribed gender

roles or boundaries between generations. The

first appointment should be made with the

decisionmaker of the family, who will most

likely be the father (Lee 1996).

•Asian clients respond best to credible experts

who provide specific suggestions for alleviating

distress (Lee 1996).

•Sensitivity to clients’ privacy is just as

important at a macro level. Because different

Asian­American clients may live in the same

tight­knit community, therapists should

assure them of confidentiality and avoid

sharing information regarding one client with

another (May Lai 2001).

•Family therapists should not presume that

therapy sessions will move forward on a

regular basis. Counselors must choose

between making the most of the first or initial

sessions and scheduling ongoing regular

sessions. Many Asians are unfamiliar with

Western treatment models and will adopt a

more infrequent, crisis­oriented approach to

therapy (Lee 1996).

•Clients may feel slighted if the therapist

spends limited time with the family without

providing a thorough explanation of his or

her plan for treatment.

•Lee (1996) recommends the therapist proceed

on the assumption that the first session with

the entire family will likely be the last,

scheduling ample time beyond 1 hour to

gather important family history and

information.

•It may be effective to leverage the family’s

willingness and arrange a rapid follow­up

(sooner than 1 week) to strengthen the

budding therapeutic relationship.

In itself, successfully engaging the family of an

Asian person with a substance use disorder

goes a long way toward alleviating the IP’s

profound shame (Chang 2000). For the therapist, the challenge is successfully facilitating the

engagement of family members while stretching

them to improve their methods of interrelating.

American Indians

Background issues

There are 2.5 million American Indians living

in the United States and an additional 1.6

126 Specific Populations
         

             

         

       

       

         

           

                 

     

       

         

               

           

         

           

       

               

       

             

   

           

           

       

             

       

             

           

       

         

           

           

             

           

   

             

           

         

             

     

       

           

           

       

   

     

             

         

       

         

             

         

               

             

           

         

       

         

           

           

         

         

             

   

         

             

             

           

                   

         

         

         

     

             

           

       

             

       

             

           

             

         

     

       

         

million people who reported being American

Indian and at least one other race (Ogunwole

2002). American Indians and Alaska Natives

are an exceptionally heterogeneous group. The

Federal government recognizes 562 distinct

tribes in the United States (Indian Entities

Recognized 2002), and each has its own culture.

For many American Indians, spirituality is a

way of life rather than a part of life. American

Indians differentiate between spirituality and

religion. However, because Christian missionaries have been working in American­Indian

communities for years, there is also a great deal

of blended spiritual belief and modern religion

(Coyhis 2000). Mixing spirituality and religion

enables American Indians to pull from both

sources for recovery (Coyhis 2000).

It is difficult to discuss specific values given the

overwhelming diversity of American Indians.

Sue and Sue (1999) offer a generalized description of American­Indian values:

•Sharing. Honor and respect are both gained

by sharing and giving. When sufficient money

is accumulated, some American Indians may

stop working and spend time and energy in

ceremonial activities. Refusing to share

drinks or substances with a member of the

same tribe may be considered an insult.

•Cooperation. Many American Indians value

the tribe and family more than the individual.

Instead of going to an appointment, some

may instead assist a family member needing

help. In a counseling setting, though they

may agree with the counselor, they often will

not follow through with the suggestions.

•Noninterference. Generally, American

Indians do not like to interfere with others

and prefer to observe rather than react

impulsively. Rights of others are respected.

They are often seen as permissive in child

rearing.

•Time orientation. American Indians are often

present­oriented. Punctuality or planning for

the future may be de­emphasized. Tasks are

completed according to a rational order and

not according to deadlines.

•Extended family orientation.

Interrelationships between relatives are

important, and there is a strong respect for

elders and their wisdom and knowledge.

•Harmony with nature. Rather than seeking

to control the environment, many American

Indians accept things as they are (Sue and

Sue 1999).

Substance abuse patterns

American Indians and Alaska Natives report

more illicit drug use and more binge and heavy

alcohol use than any other ethnic group (OAS

2002d). During the period 1994­1999, 70 percent

of American­Indian men and 59 percent of

American­Indian women who entered

treatment entered because of alcohol abuse.

Marijuana was the illicit substance with the

most admissions—13 percent of male admissions

and 11 percent of female admissions (OAS

2001b). Peyote and other intoxicants traditionally used for American­Indian ceremonies

continue to be used specifically for these sacred

purposes (Weaver 2001).

American Indians are significantly more likely

to die of alcohol­related causes than the general

population (Penn et al. 1995). From 1994 to

1996, the alcoholism death rate of American

Indians was 7 times the rate of all races in the

United States (Indian Health Service 2002).

Other relevant issues

American Indians have experienced 500 years

of historical trauma including the purposeful

disruption of the multigenerational family

process and loss of land, language, culture, and

identity (Duran and Duran 1995). When family

therapists understand this historical oppression

and validate in therapy the dysfunction that it

has imposed on the multigenerational processes

of American Indians, it may create an atmosphere of increased honesty and empower

families to understand that some of their

difficulties stem from external forces (Duran

and Duran 1995).

Although many American Indians practice

abstinence from alcohol and drugs, substance

Specific Populations 127
           

             

           

             

         

           

         

           

             

           

         

           

         

             

         

       

         

   

         

       

         

         

           

           

         

               

   

           

           

         

               

       

         

     

           

         

           

           

     

         

         

         

           

       

           

         

     

   

       

         

           

     

               

         

               

           

               

               

           

           

       

         

       

         

   

           

           

         

           

             

           

     

           

               

                 

           

           

           

         

           

           

abuse remains a tremendous problem with this

population. Nearly one third of people of childbearing age report heavy drinking, a major

factor in the development of fetal alcohol

syndrome (Sue and Sue 1999).

Application to family therapy

In general, the structure of the traditional

American­Indian family focuses on all living

generations and members of the extended family.

Since children are highly valued in this ethnic

group, the entire extended family ensures that

they are provided guidance, discipline, and

control (Attneave 1982). The primary tasks of

the executive subsystem are shared responsibilities delegated among aunts, uncles, grandparents, and parents. The high level of involvement

of the non­parent adults frees up the natural

parents to have a more relaxed and spontaneous

relationship with their children. Often, the

emotional bond created between grandparents

and grandchildren is a deep and long­lasting

one (Attneave 1982).

There are numerous tribal differences among

American­Indian families, with the phenomenon of the trigenerational extended family

being the most fundamental and important

constant. Families may be matriarchal or

patriarchal in structure. No matter how this

complex family organization varies, there is

usually an older man or woman who holds a

key administrative role (McGoldrick 1982).

The usual family therapy intervention of

separating the generations would not necessarily

be the most appropriate intervention for this

ethnic family group (McGoldrick 1982). It

should be noted, too, that owing to the private

nature of American­Indian families, multiple

family involvement is likely not beneficial, and

best confined to psychosocial education.

Many tribes do not make any distinction

between the nuclear family and grandparents,

uncles, aunts, and cousins (Brucker and Perry

1998; Napoliello and Sweet 1992). Many tribes

characterize great uncles, great aunts, 

godparents, and biological grandparents as

grandparents (Brucker and Perry 1998).

Sometimes the family includes medicine people

and nonrelated people (Brucker and Perry

1998).

Within Indian culture, families work together

to address problems. Family therapy’s emphasis

on systems and relationships is in particular

cultural harmony with American Indians

(Sutton and Broken Nose 1996). Sutton and

Broken Nose (1996) emphasize the preferred

use of culturally appropriate, nondirective

approaches involving “storytelling, metaphor,

and paradoxical interventions” (p. 33).

Networking and ritual approaches are preferable

to strategic or brief interventions (Sutton and

Broken Nose 1996).

In certain cases a family member must go into

inpatient treatment for substance abuse before

family therapy can make any real impact. It is

always possible, however, to continue to work

with the family in preparation for the return of

the family member to the home, with the goal

of modifying family relations that may have

contributed to the maintenance of the problem.

The historical trauma experienced by

American Indians combined with the usual

considerations of codependency and enabling,

for example, make family therapy for substance

abuse treatment a challenging endeavor (Duran

and Duran 1996).

Acculturation 

Acculturation should be determined on an

individual basis, as the problems, process, and

goals for traditional and more acculturated

American Indians may be quite different (Sue

and Sue 1999). “More than 50 percent of

American Indians and Alaska Natives reside in

large metropolitan areas” (Hodge and

Fredericks 1999, p. 279). There are urban

Indians who may never have been to a reservation or do not know their tribal language. As a

result, American Indians who are isolated from

reservations or other areas of traditional living

may experience a breakdown of social support

systems (Hodge and Fredericks 1999).

Sue and Sue (1999) recommend that therapists

delve into the ethnic differences between the

128 Specific Populations
             

         

           

         

             

           

               

         

         

         

       

           

         

           

         

           

             

           

             

               

         

       

       

         

             

             

               

         

           

         

             

             

             

           

             

           

       

             

                   

   

     

       

           

             

               

           

     

             

         

       

         

     

   

   

     

     

     

   

   

   

     

     

   

     

   

     

   

   

   

           

         

     

         

         

         

         

               

           

           

           

       

family and the therapist in an indirect manner.

Therapists should also explore the family’s

value structure and examine any potential

cultural or identity conflicts. Initial questions

may ascertain whether the family lives on or

near a reservation, and whether being connected

to the tribe is of importance. Sue and Sue

(1999) assert that mainstream therapies may

well fit more acculturated Indian families.

More traditional families, however, will first

have to navigate trust issues.

Communication styles

Gaining an individual’s trust is essential. Many

American Indians have experienced poor

treatment, including racism, and will have a

tendency to withdraw. Coyhis (2000) emphasizes

that gaining an American Indian’s trust

involves aligning one’s “spirit and intent" in

such a manner that one’s words and feelings

are internally congruent or truthful (p. 86).

Speaking with an American Indian as a human

being, rather than as an "Indian,” will help to

build trust.

American Indians place greater emphasis on

listening and observation than verbal

exchange. Therapists should understand that

clients "will communicate feelings and emotions

through clues with their bodies, eyes, and tone

of voice" (Paniagua 1998, p. 82). Direct eye

contact can be a sign of disrespect for many

American Indians (Paniagua 1998). Because of

this communication style, it is important to be

patient when working with American Indians.

When a therapist asks an American Indian a

question, she should wait for the answer before

asking another question. American Indians

listen carefully to the person to whom they are

speaking, and sometimes enough time will pass

after the therapist has asked a question that

she may mistakenly believe the individual is

nonresponsive. Paniagua (1998) suggests that

therapists not take notes at the beginning of

therapy as it can be taken as a sign that they

are not listening.

Historically, the therapeutic relationship

between American Indians and non­Indian

therapists has been marked by racism (Sutton

and Broken Nose 1996). Placed in this context,

it is then clear that most American Indians will

not discuss sensitive matters until trust has

developed.

Culturally competent approaches

Therapists working with American­Indian

families must be aware of how Western values

conflict with traditional Indian culture. For

example, while Western culture

values an adolescent’s steadily increasing independence from his or

her parents, traditional Native

culture does not. For In general, the

structure of the

traditional

American­Indian

family focuses on

all living

generations and

members of the

extended family.

traditional American

Indians the goal for

an adolescent may be

precisely the opposite:

increasing interdependence with the

extended family (Sue

and Sue 1999).

American Indians

may require a greater

degree of guidance

than is usually

provided in clientcentered approaches

(Sue and Sue 1999).

Many American

Indians arrive in

treatment hoping for

a culturally sensitive

therapist who can offer practical and specific

advice about their problems (Sutton and

Broken Nose 1996).

While overly directive interventions may be

seen as disrespectful and intrusive, therapists

who combine family therapy with substance

abuse treatment must be somewhat directive.

Often, they are being forced to follow the

mandates of the judicial system. So therapists

must be very skillful, balancing cultural needs

for an indirect approach with external needs

demanding a more direct approach.

Specific Populations 129
       

     

     

       

       

     

       

     

   

   

   

       

   

           

             

       

               

       

             

         

         

         

       

           

       

     

           

           

         

           

           

               

         

           

         

         

           

         

           

             

           

                 

       

             

           

                 

         

             

       

           

           

           

       

             

             

         

             

           

           

         

         

       

     

           

               

             

             

     

           

         

               

           

         

Just as people in the

dominant culture Therapists working

with AmericanIndian families

must be aware of

how Western

values conflict

with traditional

Indian culture.	 

may seek the guidance of a counselor,

American Indians

will turn to an elder.

It is also useful to

find out whether the

IP has an elder who

will support him in

the recovery process

(Coyhis 2000).

The more traditional

an American Indian

is, the more difficulty

he or she will have

with Alcoholics

Anonymous (AA)

concepts (Coyhis

2000). For many

American Indians, the source of difficulty with

AA is that the concepts derive from a

European, Christian mindset (Duran and

Duran 1995). White Bison is one example of an

American­Indian alternative to the traditional

AA approach that “integrates the medicine

wheel with the twelve­step teachings of AA to

adapt substance abuse recovery to Native

American culture” (Krestan 2000, p. 36).

Paniagua (1998) suggests the following
 

guidelines for therapists working with
 

American­Indian clients:
 

•The therapist should involve all nuclear and

extended family members, including tribal

leaders and traditional healers.

•The therapist should present suggestions in a

slow and calm manner, indicating attention to

clients’ time­oriented approach.

•The therapist should determine whether all

family members belong to the same tribe.

Intertribal issues could be a source of conflict.

•The therapist should allow family members to

be involved in directing the process of therapy.

Sexual Orientation

Background Issues

Sexual orientation refers to an individual’s

identification as a heterosexual, lesbian, or gay

person. Because of varying definitions and

problems of identification, substance abuse in

these populations has been difficult to quantify.

Neither the National Household Survey on

Drug Abuse (OAS 2003a) nor the Monitoring

the Future survey (Johnston et al. 2002) has

categories related to sexual orientation. Most of

the work that has been done has looked at gay

men and lesbian women.

Available data suggest that lesbian and gay

sexual orientation increases a person’s risk for

substance use and abuse. In a review of the

literature, Hughes and Eliason (2002) report

that gay and bisexual men use more inhalants

and stimulant drugs than heterosexuals. They

report that lesbian and bisexual women are

more likely than heterosexual women to use

marijuana and cocaine. The Gay and Lesbian

Medical Association (GLMA) (2001) indicates

that gay men and lesbians report alcohol

problems nearly twice as often as heterosexuals,

although drinking patterns do not seem to

differ substantially because of a person’s sexual

identity. Gay men and lesbians also are less

likely to abstain from alcohol (GLMA 2001).

For more information about working with the

gay and lesbian population, see A Provider’s

Introduction to Substance Abuse Treatment for

Lesbian, Gay, Bisexual, and Transgender

Individuals (CSAT 2001).

Application to Family Therapy

Research is insufficient to suggest the efficacy

of any one type of family therapy over another

for use with gay and lesbian people. Possibly

more important than the school of therapy is

the therapist’s knowledge, understanding, and

acceptance of gay and lesbian people (Bepko

and Johnson 2000). Treatment providers often

are not trained in the specific needs of these

populations, even though gay and lesbian

individuals in treatment for substance abuse

130 Specific Populations
             

             

     

             

               

           

           

           

             

       

                   

                 

   

             

             

             

           

         

         

           

           

           

         

           

         

                 

           

             

         

           

           

                 

         

             

           

           

   

             

       

             

         

     

             

             

             

           

           

             

             

           

           

           

           

         

           

           

           

         

             

               

             

                 

   

         

             

         

           

           

             

       

     

         

   

         

       

         

           

         

   

     

         

often take part in family therapy (CSAT 2001).

Lee (2000) suggests a dozen ways for therapists

to create a nonthreatening environment for

their clients. Tactics range from a sticker on

the clinic door that states “This is a lesbian/gay

safe place,” to explicit assurances of confidentiality, staff education about gay and lesbian

issues and resources, and reassurances for gay

and lesbian clients that they are not abnormal

or deviant. Among Lee’s recommendations are,

“Do not try to guess who is gay or lesbian” and

“Do not try to persuade a client to choose a

sexual orientation” (Lee 2000).

It is important for therapists to assess themselves for their own potential biases. To further

bridge the gap when the sexual orientation of

the therapist differs from that of clients,

Bernstein (2000) suggests a cultural literacy

model for heterosexual therapists working with

gay and lesbian clients. When the therapist

becomes familiar with the milieu of clients’

lives, the insight necessary for trusting therapeutic alliances may result. Most communities

have some sort of visible gay organizations, and

there are myriad Internet resources readily

available.

Family can be a very sensitive issue for gay and

lesbian clients. Therapists must be careful to

use the client’s definition of family rather than

rely on a heterosexual­based model. Likewise,

the therapist should also accept whatever

identification an individual chooses for himor herself and be sensitive to the need to be

inclusive and nonjudgmental in word choice.

For example, gender­neutral words and phrases

are preferred, such as partner rather than

husband or wife. Such an approach will ensure

a greater likelihood that people will continue

with therapy.

Family therapists also must be careful not to

overpathologize issues of boundaries and

fusion. Many gay or lesbian 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 difficulties with a

current partner more often than would typically

be seen in a heterosexual female. When violence between partners is a treatment issue,

safety must be the therapist’s main concern.

Many lesbian and gay clients may be reluctant

to include other members of their families of

origin in therapy because they fear rejection

and further distancing. At a Minnesota treatment

center for gay, lesbian, and bisexual people

with substance use disorders, more than half

were disinclined to involve their families

because they feared rejection if their sexual

orientation were revealed (Pinsof et al. 1996).

In these cases, therapists can use one­person

family therapy, which incorporates a family

focus without treating the whole family of

origin. It also should be stressed that gays and

lesbians should not be encouraged to come out

when they are not ready or when the family is

not ready.

People With Physical

or Cognitive

Disabilities 

Background Issues

There are four primary disability categories.

Some conditions may be more difficult to

categorize and some people may experience

multiple conditions:

•Physical impairments are caused by congenital

or acquired diseases and disorders or by

injury or trauma. For example, spinal cord

injury is a disorder that can cause paralysis.

Physical disabilities include spina bifida,

spinal cord injury, amputation, diabetes,

chronic fatigue syndrome, carpal tunnel

syndrome, and arthritis.

•Sensory impairments may be caused by

congenital disorders, diseases such as

encephalopathy or meningitis, or trauma to

the sensory organs or brain. Sensory disabilities include blindness, deafness, and visual

and hearing impairments.

•Cognitive impairments are disruptions of

thinking skills, such as inattention, memory

Specific Populations 131
     

   

             

       

   

       

     

       

         

           

           

           

       

         

         

       

     

     

       

       

             

         

       

           

           

             

           

           

       

           

       

         

               

     

             

           

         

           

             

           

             

             

             

     

         

       

         

             

             

       

             

             

           

               

             

     

         

               

             

           

         

       

             

             

               

           

         

         

       

         

         

         

         

       

         

             

         

       

     

           

               

         

problems, perceptual problems, disruptions

in communication, spatial disorientation,

problems with sequencing (the ability to 

follow a set of steps to accomplish a task),

misperception of time, and perseveration

(inappropriate repetitions). Cognitive disabilities include learning disability, traumatic

brain injury, mental retardation, and

AD/HD.

•Affective impairments are disruptions in the

way emotions are processed and expressed.

In this TIP, affective impairments are considered to include problems caused by both

affective and mood disorders, such as major

depression and mania. These impairments

include the symptoms of mental disorders,

such as disorganized speech and behavior,

markedly depressed mood, and anhedonia

(joylessness). Affective disabilities include

depression, bipolar disorder, schizophrenia,

anxiety, and posttraumatic stress disorder

(PTSD) (CSAT 1998e, pp. 3­4).

People with disabilities are at much higher risk

than the general population for substance

abuse or substance dependence (Rehabilitation

Research and Training Center on Drugs and

Disability [RRTC] 1996). While 10 percent of

the general population has a substance use

disorder, studies consistently find that 20 percent

of people qualifying for State vocational

rehabilitation services meet diagnostic criteria

for substance dependency (Moore and Li 1994;

RRTC 1996; Robert Wood Johnson

Foundation 1994; Schwab and DiNitto 1993).

Other studies have found that the use of

prescription medication in combination with

alcohol and the use of other people’s prescription medications are common for some people

with physical disabilities (Moore and Polsgrove

1991). The routine of taking particular medications may itself provide feelings of control,

stability, or safety. Additionally, some physicians

prescribe medications in a palliative manner in

an attempt to assist with disabilities they

cannot cure, such as chronic pain or multiple

sclerosis.

People with disabilities are more likely to use

alcohol or drugs in part because they experience

unemployment, reduced recreational options,

social isolation, homelessness, and abuse more

frequently than the general population

(DeLoach and Greer 1981; Marshak and

Seligman 1993; Susser et al. 1991; Vash 1981).

If these people also have substance use disorders,

such problems are further exacerbated. People

with disabilities are at risk for social isolation.

They may be isolated because of their families’

efforts to protect them, the physical difficulty

of getting out to social settings, lack of opportunities to practice social skills, lack of physical

stamina, trouble finding activities and 

negotiating transportation, poverty, and/or the

discomfort people without disabilities experience

when interacting with people with disabilities.

An altered body image can make those with a

recent disability onset (such as people using a

wheelchair for the first time) reluctant to

socialize.

In addition, physical limitations make some

people fear violence or exploitation. People

with disabilities are at greater risk of sexual

abuse and domestic or other violence (Glover et

al. 1995; Varley 1984). They are more likely to

be victimized because they are perceived as

unable to protect themselves. Depression and

low self­esteem associated with their disabilities

can also play a role in some people’s 

victimization and substance use. Isolation and

functional limitations leave many people with

disabilities with few recreational options, yet

they often have much unstructured time

available. For example, people who have a

visual impairment may face increased isolation,

excess free time, and underemployment (MotetGrigoras and Schuckit 1986; Nelipovich and

Buss 1989). For more information, see TIP 29,

Substance Use Disorder Treatment for People

With Physical and Cognitive Disabilities (CSAT

1998e).

Application to Family Therapy

Frequently, people who do not have disabilities

are uncertain how best to respond to those who

do (Sue and Sue 1999).

132 Specific Populations
           

           

             

           

           

           

           

           

           

               

             

                 

         

               

           

         

           

           

         

           

             

           

         

               

             

         

             

           

               

               

             

       

         

         

           

   

         

         

           

                   

             

           

         

           

       

         

         

   

         

           

           

             

               

         

   

     

   

     

   

   

   

   

   

   

   

   

     

     

       

     

           

           

             

           

           

                 

               

             

           

         

           

         

               

Family therapists should take care to ensure

that the language they use in describing physical

and cognitive disabilities is sensitive and appropriate. As a general rule, one should always

put people first, before their disabilities, referring to “people with disabilities” rather than

“disabled people.” One should never refer to

the disability in place of the person—not “the

schizophrenic” but rather “a person with schizophrenia.” A person with a disability should

not be called a “patient” or “case,” unless the

context refers to a relationship with a doctor.

It is key that the therapist learns how well a

person understands his or her disability. Some

people will have a clear knowledge of the ways

in which they are functionally limited, whereas

others may deny having any limitations.

Similarly, in the area of individual strengths,

some people will have received extensive

support from family, friends, and professional

caregivers to pursue their interests and develop

unique talents, but others may have been overly sheltered or may have experienced repeated

failures. A treatment provider should confer

with a disability expert on the delicate topic of

how to discuss a client’s disability with him.

Providers may be uncomfortable when first

confronted with a person with a physical or

cognitive disability. That unease can lead them

to err in one of two directions: either enabling

the person to use his disability to avoid treatment or refusing to recognize that a legitimate

need for accommodation exists. Accommodation

does not mean giving special preferences—it

means reducing barriers to equal participation

in the program. If a client believes that he or

she needs an accommodation, the treatment

provider will still need to determine if the

request is legitimate or an attempt to manipulate

the treatment program. However, a provider’s

vigilance in avoiding enabling may predispose

him to reject legitimate requests for accommodation. If there is any doubt on the part of the

provider regarding the legitimacy of the person’s

request, he or she should consult a disability

expert in order to make this determination.

Failure to make good faith efforts at 

accommodation could result in significant legal

difficulties for programs or providers (for more

information about the Americans With

Disabilities Act see TIP 29, Substance Use

Disorder Treatment for People With Physical

and Cognitive Disabilities [CSAT 1998e]).

Appropriate approaches may depend on the

type of disability. For example, multiple family

therapy may help families to normalize and

process the feelings of guilt and shame that

stem from having a family member with a

disability and a substance use disorder.

Perez and Pilsecker

(1989) note the usefulness of integrating

family therapy into an Family therapists

should take care to

ensure that the

language they use

in describing physical and cognitive

disabilities is

sensitive and

appropriate.

inpatient treatment

program for people

with substance use

disorders and spinal

cord injuries. Family

therapy helped reduce

client propensity to

manage their injuries

through substance

abuse and reduced

the likelihood of

overdependency or

overachievement

(Perez and Pilsecker

1989).

For any number of

reasons, whether it is

to make life easier for

themselves or to

maintain the current patterns of a relationship,

family members may contribute to the individual’s continued substance use. They may do so

with the best of intentions. Family members

may feel responsible for the individual’s condition (Sue and Sue 1999), or they may feel sorry

for him and even encourage substance use as a

way for him to feel better about himself

(Schaschl and Straw 1989). The family and

other caregivers may also be overprotective

and undermine the potential for a greater

degree of independence. In other instances,

they may be weary from the strain of providing

Specific Populations 133
           

           

           

           

     

         

           

       

           

           

           

         

         

               

             

           

             

               

                 

               

             

               

   

   

     

       

   

   

   

     

   

   

   

     

     

   

       

     

             

             

               

               

             

     

             

         

             

           

             

       

         

           

         

         

     

             

               

     

       

       

   

           

       

         

           

       

           

     

         

           

         

           

           

             

             

care and appear indifferent to the recovery

process. For these reasons, family and caregivers should be included in family therapy,

and their relationship patterns should be

targets of treatment interventions.

Most substance use disorder treatment professionals already have extensive knowledge of the

complex ways in which psychological denial

and substance abuse are intertwined, and they

have developed methods of working with clients

whose denial presents a significant obstacle to

treatment. However, for people with disabilities,

denial has additional dimensions. Some people

with co­existing disabilities may experience two

types of denial at once: denial of the substance

use disorder and denial of the disability. The

presence of a co­occurring disability can alter

how a person manifests denial of his substance

use disorder or can cause denial to be focused

solely on the disability. For a person with a

disability, substance use may also be a form of

bargaining. He or she may think that substance

use is something that is “allowed” in order to

compensate for facing

a disability. For

clients, recognizing A strengths­based

approach to treatment is important

for people with

disabilities,

because such	 

clients may have

been viewed in

terms of what they

cannot or should

not attempt.

their substance

abuse forces them to

cope with all of the

often painful emotions typically experienced by any person in recovery, in

addition to those

related to disability.

For most people with

severe disabilities,

adjustment to this

condition is

considered a lifelong

process (DeLoach

and Greer 1981).

If the family therapist

treating substance

abuse is experiencing

difficulty confronting

the denial of the

disability, he or she

should consider a referral to a peer counselor

at a Center for Independent Living (see appendix

D), whose job is to help people with disabilities

come to terms with the limitations of their

disability. The two counselors can then work

as a team.

The host of life challenges facing family members

with disabilities increases their risk of substance

use disorder, makes treatment more complex,

and heightens the possibility of relapse. If the

family therapist’s agency does not provide

services to assist clients in dealing with these

challenges, coordination with an agency

providing case management services for people

with disabilities should be a priority. People

with co­existing disabilities and substance use

disorders may need assistance and individualized

accommodations to

•Escape from abusive situations

•Learn to protect themselves from victimization

•Find volunteer work or other means of

gaining a sense of productivity in lieu of paid

employment (although paid employment is

generally preferred)

•Develop prevocational skills such as basic

grooming, dressing appropriately, using

public transportation, and cooking

•Learn social skills missing because of

substance use disorders and disability­related

problems

•Learn to engage in healthy recreation

•Become educated about their legal rights to

accessible environments and services as well

as employment

•Obtain financial benefits to which they are

entitled

•Build new peer networks

Because family members may feel responsible

for the individual’s condition and present

mostly with negativity, family therapists must

address guilt and anger (Hulnick and Hulnick

1989). Hulnick and Hulnick (1989) suggest that

family therapists assist both the family and the

member with a disability to focus on the choices

at their disposal. Such questions as “What are

134 Specific Populations
           

             

           

           

               

           

           

               

       

           

               

             

             

     

         

             

         

       

             

             

             

     

             

         

           

         

         

           

           

         

             

                 

     

           

           

           

           

               

           

         

           

           

         

             

         

           

     

           

           

           

             

         

         

         

           

           

             

         

         

             

             

           

               

         

         

     

             

             

           

               

       

         

           

             

   

         

                   

         

             

       

               

               

     

         

               

           

               

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 (Sue and Sue 1999,

p. 325). Another effective strategy is reframing

the disability through examination of the ways

in which it may afford a learning or growth

experience.

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.

However, people with disabilities must also

understand their functional limitations,

especially in relation to their risk for relapse.

One of the overriding goals of treatment for

people with disabilities is that they gain and

maintain self­awareness about their functional

limitations and capacities, as well as their substance use disorders. A better understanding of

one’s unique learning needs is an important

step toward abstinence. For example, some

people with cognitive disabilities experience a

great deal of difficulty learning from written

material. This can be a particularly difficult

limitation to acknowledge, especially in group

settings or the workplace. The client who

discovers that it is a sign of personal strength to

make adjustments and seek accommodation for

reading difficulties is not only more empowered

to make important decisions relative to abstinence, but also understands the importance of,

for example, expanding the repertoire of skills

used to compensate for a low reading level.

Specific recommendations include the following:

•During the intake process, people with

certain physical or cognitive disabilities may

require a longer interview, and rest periods

may need to be scheduled. Flexibility should

be built into interview scheduling. Counseling

session times should also be flexible, so that

sessions can be shortened, lengthened, or

made more frequent, depending on the

individual treatment plan.

•For people with cognitive impairments, it is

important to remember to ask simple questions, repeat questions, and ask clients to

repeat, in their own words, what has been

said. Discussions should be kept concrete.

People with mental retardation or traumatic

brain injury may not understand abstract

concepts. They should be asked to provide

specific examples of a general principle.

•The use of verbal and nonverbal cues will

help increase participation and learning for

people with cognitive disabilities and make

the group sessions run more smoothly for all.

The counselor and the person with a disability

can design the cues together but should keep

them simple, such as touching the person’s

arm and saying a code word (such as,

“interrupting”).

• Clients with cognitive disabilities will often

benefit from techniques such as expressive

therapy or roleplaying. Assignments that

require the use of alternative media in place

of writing may work best with clients who

have cognitive disabilities as well as those

who are deaf. Clients who are blind will need

assignments translated into their preferred

method of communication (perhaps Braille or

an audiotape). No matter what method is

used, they will generally require more time to

complete reading assignments.

•Regardless of the model of communication

used by a person who is deaf or hard of hearing, the visual aspect of communication will

be important. It is important to look directly

at the person when communicating. This

courtesy will allow a deaf person to try to

read the lips of the counselor and to receive

cues from facial expressions.

•Interpreters should usually be provided for

people who are deaf or hard of hearing. The

interpreter should be a neutral third party

hired specifically to interpret for the counselor

and the person who is deaf. A family member

Specific Populations 135
                 

       

             

             

           

                 

           

         

             

           

             

           

           

       

           

           

               

               

     

           

       

           

             

         

             

   

       

       

               

               

             

         

           

           

               

           

       

                 

         

               

       

           

       

         

           

       

             

             

       

       

           

         

           

     

           

           

               

           

           

         

         

       

               

         

         

         

         

             

       

           

             

           

         

       

       

           

             

       

           

or friend of the client should not be used as

an interpreter. Only qualified interpreters

should be used, as determined by either a

chapter of the Registry of Interpreters for the

Deaf or a State interpreter screening organization. If a person who is deaf is using an

interpreter, group members will need to take

turns during discussions. When addressing a

person who is deaf, the counselor or group

members should speak directly to the person

as if the interpreter is not present.

• When working with an individual with a

physical disability, table surfaces must be the

correct height. In particular, wheelchairs

should be able to fit beneath them.

Counselors should try to place themselves so

that they are no higher than the client. They

should be aware of the pace of the interview,

and attempt to gauge when clients are

becoming fatigued. Counselors should

periodically inquire how the client is doing

and offer frequent breaks.

•People who use wheelchairs often come to

regard the chair as an extension of themselves,

and touching the chair may be offensive to

them. Therapists should never take control

of the wheelchair and push the person

without permission.

•For people with cognitive disabilities,

providers must systematically address what

has been learned in the program and how it

will be applicable in the next stage of treatment or aftercare. Some people are very context­bound in their learning, and providers

cannot assume that the lessons learned in

treatment will be applied in aftercare.

•If a person with a disability has limited transportation options, a therapist may arrange to

conduct individual counseling by telephone,

go to the person’s house, or meet at a

rehabilitation center or other alternative site.

Going to the residence of an individual with a

disability also provides valuable information

about a client’s lifestyle, interests, and immediate environmental challenges.

• Therapists should recommend literature to

families that addresses enabling behavior in

general and for people with disabilities in

particular. Disability resource agencies may

be able to provide helpful literature. For a

full discussion of these categories, see TIP 29,

Substance Use Disorder Treatment for

People With Physical and Cognitive

Disabilities (CSAT 1998e).

People With 

Co­Occurring

Substance Abuse 

and Mental Disorders

Background Issues

Clients with substance use disorders often have

a co­occurring mental disorder. Over the past

10 years, concern and attention to co­occurring

conditions has increased sharply—focusing on

the clinical and societal implications of treatment and understanding of people who have

both a mental disorder and a substance use

disorder. The importance of treatment for both

disorders is now widely recognized. TIP 9,

Assessment and Treatment of Persons With

Coexisting Mental Illness and Alcohol and

Other Drug Abuse (CSAT 1994b) addressed

“dual diagnosis” and a revision of that TIP is

underway. (See the forthcoming TIP Substance

Abuse Treatment for Persons With Co­Occurring

Disorders [CSAT in development k]. The

complexities and difficulties of diagnosis and

treatment planning for people with co­occurring

disorders are explored in detail in the revised

TIP.)

Substance abuse treatment counselors and

family therapists working with clients who have

both a substance use disorder and a severe

mental illness will want to be thoroughly familiar

with the new advances related to co­occurring

conditions, and the consensus panel recommends the new TIP Substance Abuse

Treatment for Persons With Co­Occurring

Disorders (CSAT in development k) as a good

place to start. In addition, counselors and

therapists working with anyone with 

co­occurring substance use and mental

disorders will need to understand the complex

136 Specific Populations
           

         

         

               

   

       

             

             

             

         

         

               

       

           

               

           

             

           

         

           

     

           

       

         

           

       

         

       

       

         

       

           

       

           

       

           

             

   

         

         

       

             

             

           

   

             

       

       

       

               

             

           

           

   

   

   

     

   

     

     

   

   

   

     

   

     

   

     

   

       

           

     

         

         

             

         

         

         

         

and varied ways the disorders interact within

individuals and the necessary adaptations to

treatment. The new TIP offers considerable

background and detail on the main types of

co­occurring conditions.

Prevalence data regarding co­occurring 

disorders are difficult to describe. The 

symptoms and behaviors associated with

mental disorders are often caused by alcohol or

drugs, or such drug or alcohol use exacerbates

mental health symptoms. At least 30 percent of

people with alcohol dependency meet criteria

for an antisocial personality disorder (Schuckit

2000). In a review of studies related to cooccurring disorders, Sacks and colleagues

found that in general, substance abuse treatment programs report that 50 to 75 percent of

clients have a co­occurring disorder and mental

health clinicians report 20 to 50 percent of

clients with a co­occurring substance use

disorder (Sacks et al. 1997).

Modern attention to treatment for people with

co­occurring disorders emphasizes integrated

treatment for both disorders by programs and

staff knowledgeable and respective of each

other’s disciplines. When treatment for both

conditions cannot be delivered by one treatment program, collaboration and consultations

with other providers are considered essential

(see the forthcoming TIP Substance Abuse

Treatment for Persons With Co­Occurring

Disorders [CSAT in development k] for more

detailed information).

Application to Family Therapy

The most appropriate approach to single family

therapy for people with co­occurring disorders

is an integrated approach that combines family

interventions and substance abuse interventions

(Sheils and Rolfe 2000). Psychoeducational

family therapy that focuses on both psychosis

and substance use is also helpful. Effective

psychoeducation combines fundamental

information, guidance and support, and allows

for “low­key” engagement and continued

assessment opportunities (Ryglewicz 1991). It

is important to educate family members on the

ways that one disorder, if not properly 

monitored and treated, can set off the other.

In using an integrated family therapy model

with co­occurring schizophrenia and substance

use disorder, it is important to avoid strong

confrontation and interventions that require

high levels of insight, concentration, attention,

and information processing. Multifamily groups

may be well suited because of the benefit of

family support, but may run into some trouble

when symptoms of anxiety and paranoia are

prominent. Sheils and Rolfe (2000) report that

an integrated family

therapy model for

people with co­ It is important to

educate family
 

members on the

ways that one 

disorder, if not

properly monitored and treated,

can set off the

other disorder.

occurring schizophrenia and substance use
 

disorder is currently

being tested.
 

Treatment can be

substantially supported and enhanced by

direct involvement of

the client’s family.

Family therapy is

often necessary to

address the feelings of

guilt, sadness, and

rage that may have

accumulated among

all family members.

Family members

should be encouraged

to participate in

Al­Anon and related

self­help groups. When necessary, individual

family members should be referred for

treatment of specific problems.

For adolescents who have substance abuse

problems with co­occurring disorders (primarily

disruptive disorder and conduct disorder)

family therapy is among the most well tested

and efficacious interventions (Goyer et al.

1979; Szapocznik and Kurtines 1989; Waldron

1997). Liddle and Dakof (1995b) emphasize

behavioral family techniques such as parentmanagement training and contingency 

Specific Populations 137
       

           

           

       

           

             

         

           

       

       

         

           

           

           

           

         

         

         

               

           

         

         

     

     

   

   

       

     

     

   

     

   

   

     

     

   

           

           

         

       

         

             

         

           

           

         

               

             

           

         

         

         

         

             

           

         

             

         

           

           

               

           

           

           

           

       

               

       

         

         

               

         

                 

         

contracting, and strategic­structural approaches

including engagement strategies and restructuring family interaction for these adolescents.

Behavioral, strategic, and structural techniques

combine to form a functional family approach

that targets the variety of problems markedly

present in families of adolescents with cooccurring conduct disorder and substance use

disorder (Alexander et al. 1990). Santisteban

et al. (2003) have developed a family therapy

model specifically designed for adolescents who

meet criteria for both drug abuse and

Borderline Personality Disorder (BPD). This

model integrates concepts from Structural

Family Therapy, Linehan’s (1993) work with

BPD adults, and substance abuse treatment.

An important feature of these treatment models

contributing to their effectiveness is the blending

of both mental health and substance abuse

treatment models, with each applied at appropriate times and in appropriate situations

according to the client’s needs.

For example, in substance abuse treatment,

clinical staff and fellow clients often aggressively

confront clients who deny that they have a

substance abuse problem or who minimize the

severity of their problem. However, treatment

of people with co­occurring disorders first

requires innovative

approaches to

engage them in

Traditionally, selfreliance is a strong

value among rural

citizens; receiving	 

treatment can be

perceived as an

indication of

weakness.	 

treatment as a

prerequisite to

confrontation. The

role of confrontation

may need to be

substantially modified, particularly in

the treatment of

disorganized clients

or clients with

psychosis who may

tolerate confrontation

only in later stages

of treatment (when

their symptoms are

stable and they are

engaged in the treatment process).

For clients who require medication, it is

important to understand the use of medication

from the client’s perspective. Clients should be

educated and thoroughly informed about the

specific medication being prescribed, expected

results, the medication’s time course, possible

side effects, and the possible results of combined

medication and substance use. It is also critical

to discuss with clients their understanding of

the purpose for the medication, their beliefs

about the meaning of medication, and their

understanding of the meaning of adherence.

Finally, it is important to ask clients what they

expect from the medication and what they have

been told about the medication. Whenever

possible, family members and significant others

should be educated regarding the medication.

Rural Populations

Background Issues

Rural America has experienced decimation of

family farms and erosion of infrastructure (i.e.,

schools, mental health care). As a result,

financial limitations may make it difficult to

pay for treatment, for transportation to 

treatment sessions (particularly when long

distances must be traveled to reach the nearest

provider), or for necessary childcare during

treatment. In addition, rural families are less

likely to be covered by medical insurance

(Rhoades and Chu 2000). Geographical isolation

makes it difficult for families to build a

consistent network of social support outside

the family and to access available community

resources.

The intimacy of the rural community affects

both the confidentiality and the desirability of

accessing mental­health services. The fact that

people know the vast majority of members in a

close­knit community creates additional stigma

around addressing mental health or substance

abuse issues. For instance, medical records

may be reviewed by people who are friends or

neighbors. In addition, therapy or counseling

may be new to the rural area and not yet

accepted as a normal process.

138 Specific Populations
             

               

             

         

         

           

         

               

               

               

         

       

             

     

         

           

               

   

         

         

         

           

         

             

     

             

             

       

     

           

           

         

           

             

           

             

             

         

       

           

         

             

         

             

         

       

         

         

           

               

     

         

           

         

         

         

       

         

           

         

       

             

       

             

             

     

           

         

         

         

             

         

           

           

           

             

         

         

Because rural communities may have a tendency

to tolerate more extreme forms of behavior, the

impact of substance abuse on the user and his

or her significant others may also be more

extreme. Bagarozzi (1982) notes that rural

people are often referred to treatment not

because their behavior is considered deviant,

but because it has exceeded acceptable community limits. For example, alcohol dependency

itself may not be addressed as a problem until

the individual who is abusing alcohol is arrested

for criminal behavior or until he or she commits an extreme act of violence against a family

member. Because rural communities may allow

substance dependencies to worsen by keeping

serious problems out of the reach of service

providers and/or law enforcement, conditions

often deteriorate until dramatic and tragic

events cause the problem to surface. Public

education may be useful if framed in a

culturally acceptable manner.

Traditionally, self­reliance is a strong value

among rural citizens. As a consequence,

receiving treatment can be perceived as an

indication of weakness (Bushy 1997). Tatum

(1995) notes that along with self­reliance and

pride, fatalism is a key Appalachian attitude

that affects a therapist’s ability to offer

effective intervention and treatment strategies.

Rural families also tend to be more doubtful

about the effectiveness of mental health or

substance abuse treatment services (Wagenfeld

et al. 1994).

Rural women who are dependent on alcohol

report a profound alienation that they describe

as an “all­consuming” sense of the meaninglessness of their existence that involves intense

feelings of despair and self­loathing (Boyd and

Mackey 2000, p. 136). Many of these women

grew up in family situations where alcoholism

and abuse were prevalent. Forced at an early

age to take on adult responsibilities that their

dysfunctional parents could not maintain, these

women report becoming intensely depressed,

often leading lonely, joyless lives (Boyd and

Mackey 2000).

Patterns of substance abuse

Substance abuse rates for rural populations

generally equal or exceed those of urban populations (Kearns and Rosenthal 2001). Alcohol

appears to be the most commonly abused substance among rural people, and alcohol­related

problems such as arrests, hospitalization, and

unintentional injuries are more common among

rural populations (Kelleher et al. 1992).

Several studies have suggested that rural youth

are more likely to have used drugs than their

urban counterparts (National Center on

Addiction and Substance Abuse [CASA] 2000;

Edwards 1997; Stevens et al. 1995).

Although rural communities may have similar

substance abuse rates, quite frequently the

consequences are more pronounced and severe

(CASA 2000). Because rural communities often

combine reduced resources with low population

density, they often have shortages of trained

substance abuse professionals and great

challenges providing accessible treatment

programs. In 1993, 55 percent of U.S. counties

were without a practicing psychologist,

psychiatrist, or social worker, and all of these

counties were rural (Pion et al. 1997).

Application to Family Therapy

Overcoming barriers to 

treatment

There are a number of barriers encountered by

substance abuse counselors and mental health

practitioners when attempting to treat families

in rural communities; however, counselors can

work with families to overcome many of them

(Bagarozzi 1982; Cutler and Madore 1980;

Sayger and Heid 1990). For example, families

that experience distress associated with a lack

of financial resources may need help getting

their basic needs met. Therapists can assist in

finding resources for families through food

banks, clothing banks, and health care

resources.

Specific Populations 139
           

           

           

         

           

             

                 

     

             

               

             

             

           

                 

           

           

       

           

           

           

             

         

             

             

                 

         

             

       

           

                   

           

         

           

           

             

       

       

       

         

             

         

           

               

         

           

         

             

             

               

           

             

         

           

             

               

       

           

           

       

             

           

             

       

             

             

     

       

           

       

           

           

           

         

       

       

   

     

       

       

           

         

         

           

The geographic dispersion of families in rural

areas may require them to travel great distances

in order to access treatment (Human and

Wasem 1991). A family therapy provider has

several options for addressing distance barriers

(Bagarozzi 1982). The therapist may decide to

contract with the family for a limited number

of sessions and be very focused in the work. To

address transportation barriers, the therapist

may 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). It may be helpful to schedule extended

sessions that allow bigger chunks of therapeutic

work to occur every 2 or 3 weeks instead of

weekly.

In­home family therapy may be of tremendous

use in addressing problems of client isolation

and inaccessibility to treatment. In addition,

home­based services facilitate the initial step of

accessing mental health services, a step that

may be exceptionally difficult for rural clients

due to fear of stigmatization or the rigorous

work schedule associated with agriculture, mining, etc. Tatum (1995) asserts that taking programs to families, instead of expecting people to

travel to an office, may go a long way toward

overcoming reluctance to work with bureaucracy. Home visits may help therapists learn

about clients within the context of their

environment by witnessing their day­to­day

reality. For example, a therapist may decide

not to see a client because of body odor, but the

issue takes on another dimension when the

therapist understands that the client has no

running water or electricity. Home visits may

also help therapists and families to build

increased rapport.

Tatum (1995) emphasizes that the key to

successfully delivering therapeutic services in

rural communities is gaining acceptance from

the community and client population.

Sometimes a therapist’s lack of understanding

of rural values and customs can create mistrust

among residents and hinder effective treatment

(Bushy 1997). For example, rural people may

have a mistrust of outsiders and a fear of

becoming involved in the “system” (Tatum

1995). Working to increase family and community involvement in the therapeutic process can

help overcome obstacles such as the lack of

social support and the stigma of receiving mental

health services. It is essential for the therapist

to identify all the important people in the

family’s life. This includes extended family and

close friends who may become key players in

the target family’s change process. However,

because of the intimacy of rural communities,

therapists must balance the need to effect

family change on a macro level with the equally

important need of maintaining confidentiality.

Use of self­help groups

AA and similar self­help groups are frequently

the only accessible resource available in rural

communities. AA’s family­like solidarity can

instill hope and provide a valuable support

system for people with substance abuse

problems. For the family of the IP, 12­Step

support groups include Al­Anon, Alateen,

NarcAnon, Co­Dependents Anonymous, and

Families Anonymous.

Family therapists can reframe AA in order to

make its principles more in harmony with rural

values. Tatum (1995) recommends the following:

•Self­reliance—this feature involves learning

how to care for oneself.

•Family system—this element involves learning

how one can create healthy families.

•Working with faith­based (religious), community, and spiritual groups is an opportunity

to be mutually supportive and let others

know about the importance of family therapy

in substance abuse treatment. Though no

precise definitions distinguish between the

terms faith­based, spiritual, self­help, and

community initiatives, conventional and

practical distinctions do differentiate them.

Faith­based programs have clear religious

orientations. They may be community­oriented

as well. Many churches, for example,

coordinate substance abuse services in their

communities, and their activities may involve

people in the community and include spiritual

and faith­based underpinnings as part of the

140 Specific Populations
         

           

       

                 

         

         

             

           

           

           

         

         

                 

           

           

               

           

             

         

         

       

           

             

               

             

               

             

         

             

   

           

           

     

             

           

           

               

           

           

           

           

               

           

         

             

             

             

           

             

     

   

   

       

   

     

   

   

     

   

   

     

   

   

   

   

   

     

       

       

             

           

             

               

               

           

             

               

         

         

       

               

       

         

   

recovery approach. Because of the spiritual

focus of 12­Step programs, they are sometimes confused with faith­based programs,

but AA does not refer to or promote any

religion or denomination. It only encourages

connection with a higher power.

Every family therapist should be aware of the

general distinctions among the groups and the

sensitivities related to them. For example,

people who belong to AA commonly dislike

being characterized as religious or even as

faith­based. The family therapist should be

able to explain to a client that the various 12­

Step programs are spiritual but not religious

(and what the difference is). Therapists also

need to know the specifics of their local groups

that may well include understanding the

availability of special AA groups, such as nonsmoker meetings, young adult meetings, etc.

Other Contextual

Factors

HIV Status

The Centers for Disease Control and

Prevention (CDC) estimates that between

800,000 and 900,000 people in the United

States are living with HIV infection, and about

625,000 are aware of their infection. As of June

2001, more than 457,000 people in this country

had died of the disease (CDC 2002). The epidemic has had an impact far beyond mortality

statistics, with far­reaching effects on systems

as diverse as health care, food service,

economics, and education.

HIV/AIDS has always been closely related to

substance abuse, and the two have become

increasingly intertwined. From July 2000

through June 2001, 25 percent of all reported

AIDS cases were among people who also

reported injection drug use (CDC 2002). The

CDC also estimates that 25 percent of all new

HIV infections were in people who reported

injection drug use (CDC 2002). People who

exchange sex for drugs represent another substantial at­risk group. The direct and indirect

role of substance abuse in the spread of AIDS

was clearly established early in the American

AIDS epidemic, and HIV/AIDS has changed

the face of substance abuse treatment services.

In the 1980s the early reports about HIV/AIDS

identified injection drug use (IDU) as a direct

route of HIV infection. Cases directly attributed to IDU continued to rise through the

1990s. The number of

estimated AIDS cases

diagnosed annually

declined substantially

from 1996 through HIV/AIDS has

always been closely

related to substance

abuse, and the two

have become

increasingly

intertwined.

1999, but the rate of

decline slowed during

1999 and 2000. The

leveling in overall

AIDS incidence is

occurring as the

composition of the

epidemic is changing.

AIDS incidence

declined in most populations but increases

were observed in

some groups, notably

women and persons

infected through heterosexual contact

(CDC 2002). For further information, see TIP 37, Substance Abuse
 

Treatment for Persons With HIV/AIDS (CSAT
 

2000c).
 

Most likely, the IP in family therapy with
 

HIV/AIDS will be an adult. Pediatric cases
 

remain a small percentage of the total number.
 

It is not uncommon, however, for an adult with
 

AIDS to return to the parents’ home for care,
 

reverting to the offspring role. Children of
 

these adults may need help as they anticipate
 

the loss of their parent. HIV/AIDS has a
 

profound effect on infected individuals. The
 

severe medical effects are well documented.
 

Psychological effects include adjustment disorders with anxiety and depression at the time of
 

diagnosis, ongoing depression, grief and
 

mourning, suicidal ideation and attempts, and
 

cognitive and neurological impairment.
 

Specific Populations 141
   

   

   

   

   

   

   

   

   

   

   

   

       

           

             

       

         

             

         

           

           

             

     

             

               

             

         

               

           

                   

             

             

         

           

           

             

           

               

           

         

     

               

                 

             

         

             

             

             

           

             

             

             

           

           

         

   

             

         

           

           

       

           

             

               

       

       

           

           

             

             

             

             

               

               

             

       

         

             

             

         

   

The impact of

infection and

disease on

The therapist must

be aware of the

multiple family

obligations and

pressuresfor people

with HIV and their

family members.

family members is also

wide and deep.

Significant

others will

grapple with

fear of infection and possibly reactions

to having been

exposed to

HIV. Grief and

mourning are

also likely to

be present, as

are stress and

loss similar to

that experienced with other chronic illnesses. Finally,

there are the financial and emotional burdens

that ongoing medical care of a person with

HIV/AIDS places on a family.

Application to family therapy

While integrated models are applicable, in

addition the therapist must be aware of the

multiple family obligations and pressures for

people with HIV and their family members.

Issues differ for different groups and individuals;

for example, gay men, people who use drugs

intravenously, and transfusion recipients.

Stigma is almost always part of the picture,

although it may vary according to the source of

HIV infection; IDU is likely to be associated

with the greatest amount of stigma.

An AIDS patient may return to his family system

because his medical needs make it impossible

for him to continue to live on his own. In many

cases, the returning family member was at one

time alienated from the family (e.g., because of

sexual orientation or drug use). Reconciliation

can be difficult, especially when complicated by

medical crises. The family therapist needs to

recognize this and consider when it is appropriate

to involve family members in therapy.

A person with HIV/AIDS is likely to have

complicated physical and medical needs. If

necessary, the therapist should facilitate appropriate medical and pharmacological treatment.

It is also important to determine if anyone else

has been exposed to HIV by the client and if

safe sex is being practiced. This inquiry can

lead to difficult confidentiality issues. Specific

regulations vary from State to State, and there

may be gray areas between ethics and legality.

While a therapist has some responsibility to the

larger community, the primary obligation is to

the client. To date, insufficient case law exists

to say definitively that the Tarasoff ruling of

the obligation to inform is directly applicable to

behavior of people with HIV/AIDS. For further

information, see the Legal Issues chapter of

TIP 37, Substance Abuse Treatment for

Persons With HIV/AIDS (CSAT 2000c).

Homelessness

In 1998, an estimated 38 percent of the

Nation’s homeless were families, with approximately 100,000 children sleeping each night in

shelters, abandoned buildings, or on the street

(Vanderbilt University Institute for Public

Policy Studies 1999). Homelessness can take a

variety of forms, from spending nights in

shelters and days on the street, to setting up

“housekeeping” in abandoned buildings, to

moving around among friends, acquaintances,

and relatives. Douyon et al. (1998) define

homelessness as “the inability to secure regular

housing when such housing is desired” (p. 210).

Studies have found that more than a million

teenagers live in emergency shelters or on the

streets on any given night. Many have families

that would take them back, but some have been

kicked out of their homes, and others are

running from sexual or physical abuse or

similarly intolerable circumstances. One study

found that compared to adult counterparts,

homeless teens were more likely to be female,

and their behaviors were more likely to include

sexual promiscuity, prostitution, unplanned

pregnancy, and suicide attempts (Coco and

Courtney 1998).

142 Specific Populations
             

               

       

             

               

         

           

               

   

             

           

               

           

           

           

         

           

           

         

           

               

           

       

           

               

           

     

         

   

           

         

             

         

           

         

           

             

           

           

   

           

                 

               

         

           

           

             

           

         

             

               

         

           

             

       

           

           

             

             

         

             

             

             

               

             

             

                 

               

             

       

             

               

             

             

           

                 

               

           

           

         

           

Most homeless people have a history of some

sort of abuse. In a look at previously homeless

people in shelter­based therapeutic communities, Jainchill et al. (2000) determined that 84

percent of women and 68 percent of men had

either been physically or sexually abused.

Their study found that homelessness was more

likely to be episodic than constant in a

person’s life.

While it has long been presumed that the

prevalence of substance use by homeless people

is high, no definitive data are available on this

subject. Some early studies have been called

into question because they used lifetime rather

than current measures of substance abuse. The

National Coalition for the Homeless (NCH)

concluded that “there is no generally accepted

‘magic number’ with respect to the prevalence

of substance use disorders among homeless

adults” (NCH 1999, n.p.). Some studies have

found as many as two thirds of homeless people

abuse alcohol, and half use illicit drugs.

Surveys in shelters found 90 percent of residents

with alcohol problems and more than 60 percent

with illicit drug problems. Co­occurring psychiatric disorders are also common in homeless

people, as are lack of education and job skills

(Jainchill et al. 2000). (For more information

on homelessness see the forthcoming TIP

Substance Abuse Treatment for Persons

With Co­Occurring Disorders [CSAT in

development k].)

Application to family therapy 

The homeless are people with multiple and

complex needs. First consideration must be

given to their basic human concerns, such as

health, shelter, and safety. Many homeless

women and children have fled situations of

domestic violence. Social service and health

needs are best addressed by networking with

the range of agencies that provide services to

meet their needs. Connecting clients with

funding agencies will also address concerns of

paying for treatment.

A therapist must address homelessness early on

to find the homeless family a place to live and

help apply for services for which it is eligible.

Following these initial steps, therapists can

then assess substance abuse and the particular

factors that have led to the homelessness.

Homelessness does not have a single cause. The

counselor should look for strengths by using

such tools as perseverance, creativity, and

humor.

Many homeless people do not have a family

group to bring into therapy, even by the most

inclusive interpretations of family. It may be

impossible to reconnect families of origin with

some clients who have been cut off due to

substance abuse, mental illness, and related

problems. 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 glance that a family

genogram would yield little useful information,

but constructing one can be helpful and it may

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.

It is important for the therapist to consider

how reality is defined. For example, a homeless

person may talk of how she was thrown out by

her family, while her family speaks of her leaving voluntarily. The therapist needs to help sort

through these alternate realities, although

absolute truth may be elusive. Even what seems

an obvious fact (e.g., a person’s life would be

better if he stopped abusing substances) may be

hard for an individual to recognize and accept.

Veterans

The statistics relating to veterans and substance

abuse do little more than provide snapshots

that hint at the extent of the problem and the

efforts being made to treat it. For example, in

fiscal year 2000, the Department of Veterans

Affairs (VA), which provides health services for

the Nation’s veterans, counted 366,429 clients

diagnosed with a substance use disorder. In

Specific Populations 143
           

         

           

           

         

                 

             

         

             

             

         

         

   

         

       

         

               

     

         

     

           

             

         

             

             

           

             

           

         

             

           

               

             

             

           

             

           

           

               

       

         

         

               

         

         

           

           

         

               

             

         

           

               

           

             

             

           

           

             

               

         

         

           

           

           

         

           

               

         

         

               

   

         

           

             

           

             

         

             

     

2000, more than 55,000 veterans were admitted

to publicly funded substance abuse treatment

facilities (OAS 2003b). According to the VA

studies, 76 percent of homeless veterans have

experienced alcohol, drug, or mental disorders

in the past month and 93 percent at some time

in their life. Most homeless veterans (98 percent)

are male (National Coalition for Homeless

Veterans 2002).

In 2000, alcohol was the primary substance of

abuse (68 percent). Cocaine was the next most

commonly reported substance used (15

percent), followed by heroin/opioids (8 percent)

(OAS 2003b).

PTSD results from experiencing or witnessing

traumatic life­threatening events such as combat,

terrorist acts, natural disasters, or personal

violence and is characterized by a set of cognitivebehavioral symptoms (i.e., hypervigilence,

emotional avoidance and numbing, and intrusive

memories). Researchers have recognized the

high risk for PTSD among veteran populations

since studies of Vietnam War veterans began to

emerge. Studies comparing Vietnam veterans to

World War II and Korean War veterans found

that Vietnam veterans were more likely to

experience distress related to loss of friends

and memories of brutality, while the older

veterans’ symptoms were more often related to

physical injuries or capture (Johnston 2000).

PTSD is associated with an increased rate of

substance abuse. One study found that 34.5

percent of men and 26.9 percent of women with

a lifetime history of PTSD reported drug or

alcohol abuse or dependence at some point in

their lives. This rate compares to substance

abuse incidence of 15.1 percent and 7.6 percent

in men and women, respectively, who did not

have PTSD. Stress of any sort is a potent trigger

for substance abuse and relapse, not only

because of the psychological effects of stress,

but because it is now understood to initiate a

biological process, thereby increasing certain

brain chemicals (NIDA 2002). Veterans who

experienced domestic violence as children and

then the trauma of war have a double burden

to bear.

Application to family therapy

Little specific family therapy research about

veteran populations exists. The most common

path to substance abuse treatment for veterans

is the criminal justice system (including driving

while intoxicated referrals), especially for

veterans under the age of 25 (OAS 2001b). A

technique that might be helpful in tracking and

changing family behavior is family behavior

loop mapping. Liepman et al. (1989) describe

this tool as a method of diagramming the

repetitive behavior cycles specific to wet

and dry phases in substance abuse affected

families.

The therapist can help the veteran locate

services, including benefits to which they are

entitled. Therapists need to know where local

veteran centers are. If treatment is difficult to

access, it may be hard to get families involved.

A psychological issue that many veterans must

address is survivor guilt—having lived while

their comrades perished. The issue of abandoned

children may also be difficult for veterans. A

number of veterans fathered children while in

the service. For example, American military

men in Vietnam fathered many offspring. These

lost families often need to be addressed in family therapy. Therapy sessions with

veterans can become graphic and horrifying.

The therapist must be able to work with high

levels of intensity.

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.

144 Specific Populations
                   

                   

                   

         

                       

             

     

             

     

Chapter 5 Summary Points From a

Family Counselor Point of View

•Children and adolescents can represent a number of challenging concerns and

might require referral, especially for concerns about inhalant abuse or abuse

and neglect.

•Older adults may require referral to distinguish organic mental disorders that

are substance­related from other organic brain disorders.

•The complex roles and demands that can be placed on women within some

families requires special attention, including enhanced assessment processes

and possible ancillary services.

•Diversity, disability, and co­occurring disorders often require administrative,

clinical, and supervisory sensitivity.

Specific Populations 145

               

                 

                 

                       

                 

           

               

       

                 

                   

                 

                 

                 

                 

             

           

                   

                   

                 

                 

                   

   

               

                 

                     

               

                           

In This
 

Chapter...
 

Primary Policy
 

Concerns
 

Program Planning
 

Models
 

Other Program
 

Considerations
 

Directions for
 

Future Research
 

6 Policy and Program

Issues

Overview

This chapter provides information about the importance of improving

services to families and discusses some policy implications for effectively

joining family therapy and substance abuse treatment. Of special

importance in this effort is the inclusion of key stakeholders in the

substance abuse treatment and family therapy fields, among them the

Federal government, insurance companies, frontline and executive staff

members from both disciplines, researchers, consumers, and others who

make decisions about service delivery.

This chapter also presents program planning models developed by the

consensus panel that provide a framework for the broad inclusion of

family therapy into substance abuse treatment. These models cover (1)

the issues surrounding staff education about families and family therapy,

(2) family education about the roles of families in treatment and recovery

from substance abuse, (3) how substance abuse treatment providers can

collaborate with family therapists, and (4) methods for integrating family

therapy activities into substance abuse treatment programs.

Considerations for substance abuse treatment program administrators,

such as guidelines for implementation, ethical and legal issues, and

evaluating outcomes are addressed for each of the four program planning models. The chapter also discusses the counseling adaptations and

training and supervision issues that arise for substance abuse counselors

and other staff when programs promote attention to family issues and

family therapy techniques.

Primary Policy Concerns

Though many substance abuse counselors and family therapists have

learned to incorporate aspects of each system’s approaches, to be

instructive this TIP finds it necessary to proceed as if “family therapy”

and “substance abuse treatment” have heretofore existed in isolation

from each other and as if each were reducible to a specific limited set of

147
     

                 

           

         

             

           

       

               

         

         

       

         

     

           

         

     

     

   

         

               

               

           

             

             

           

       

           

             

         

           

         

         

           

         

             

         

         

         

             

         

             

           

         

             

           

             

         

           

           

             

         

             

           

         

         

   

           

             

             

             

         

             

           

           

       

           

         

           

   

         

       

           

         

         

           

         

     

       

     

       

         

           

         

           

     

techniques, approaches, attitudes, and points

of view. The reader should keep in mind that it

is an overly simplified presentation that follows

and that the overlap among practitioners and

the fields is probably much greater than the

artificial separation employed as a vehicle for

the presentation of primary policy concerns.

With this caveat in mind, the merging of family

therapy techniques with substance abuse treatment warrants consideration of three primary

policy questions:

•When is family therapy appropriate?

•What are the funding and reimbursement

options for family modalities?

•What role does the criminal justice system

play in mandating substance abuse treatment

with a family focus?

Challenges to Merging Family

Therapy and Substance Abuse

Treatment

There is considerable evidence to support

treatment that taps the power of the family and

the community but, at the same time, weaving a

different modality with its own distinct values

into a treatment program can be a challenge.

This may explain in part why many substance

abuse treatment programs have been slow to

integrate the strengths­based approach

essential to effective work with families.

One major impediment to merging the two

disciplines effectively is identifying the

underlying values of each and then determining

whether alternatives would work better. The

different values associated with previous forms

of substance abuse treatment and family therapy

have important implications for combining the

two in the future. These implications will affect

the entire organizational spectrum. Though the

incorporation of family therapy into substance

abuse treatment presents an opportunity to

improve the status quo, it also challenges these

two divergent modalities to recognize, delineate,

and possibly reconcile their differing outlooks.

At a basic level, for example, agencies can

develop common action plans founded on

evidence­based research and goals to ensure

more success for the client. Such plans could

be developed according to the four­tier model

described in chapter 4, which guides the

development of different levels of family

involvement.

Another major policy implication, as noted by

O’Farrell and Fals­Stewart (1999), is that family

therapy requires special training and skills that

are not common among staff in many substance

abuse treatment programs. A substance abuse

treatment program committed to family therapy

will need to consider the costs associated with

providing extensive training to line and

supervisory staff to ensure that everyone

understands, supports, and reinforces the

family therapist’s work.

For a traditional family therapy approach to

be successful, it is necessary to consider how

everyone who works in and with a program

treats clients and their families. The entire

substance abuse treatment program must be

examined to verify that the ideas espoused in

family therapy are fully integrated into all

aspects of the program, including forms,

policies, procedures, and mission statement.

Further, in providing some level of family

involvement or therapy within substance abuse

treatment, other problems may need to be

resolved, such as

•Substance abuse counselors and family

therapists sometimes have different goals.

•Research to support the integration of classic

family therapy into substance abuse treatment is not definitive, although recent

research studies have shown support for

certain types of family­based treatments with

certain types of client/family groups.

•Conflicting interests and standards regarding

confidentiality must be reconciled.

Given the complexity of incorporating full­scale

family therapy consistently in substance abuse

treatment and the finite resources with which

many substance abuse treatment programs are

working, family involvement may be a more

attractive alternative. Family involvement and

148 Policy and Program Issues
             

       

       

   

         

         

           

           

         

           

               

             

       

           

             

             

       

     

         

           

           

     

               

           

           

           

               

             

         

   

             

           

             

             

           

           

           

           

         

         

             

           

           

       

     

     

   

     

     

   

   

     

     

   

   

   

   

   

     

   

     

     

   

   

   

     

   

               

               

           

           

             

   

         

         

         

         

family therapy are two points on a continuum

rather than completely distinct.

What Are the Funding and

Reimbursement Options for

Family Modalities?

The documented cost savings and public health

benefits associated with family therapy support

the idea of reimbursement (O’Farrell et al.

1996a, b). However, like the substance abuse

treatment system, the American health care

insurance system focuses care on the individual.

Little, if any, reimbursement is available for

the treatment of family members, even less so if

“family” is broadly defined to include a client’s

nonfamilial support network. For example,

under Medicare, family therapy is a covered

expense, when done by a licensed and certified

Medicare mental health provider, but the system

does not certify and therefore does not

reimburse family therapists. With Medicaid,

administered by States, reimbursement policies

vary. Also, the Elementary and Secondary

Education Act does not recognize family

therapists as qualified mental health or

substance abuse services providers.

If a family wants services, and the client is

unwilling to participate, the family should not

be excluded. Ideally, family members should be

able to receive appropriate services, if requested. What must be changed so that families can

receive those benefits? Who would fund a more

inclusive process? The known and interactive

barriers—reimbursement and attitudes—must

be resolved in order to include families more

fully in the treatment process. Regardless of

the context in which family therapy is delivered, if the operational policy of States or

insurance companies is not to reimburse, then

policy discussions need to develop processes to

remove that barrier. Recent evidence of the

effectiveness of family involvement, as well as

clinical and research evidence that supports

family therapy for substance abuse treatment

(Liddle et al. 2001; Stanton and Shadish 1997),

may eventually move funders to alter payment

systems so that families can be included.

What Role Does the Criminal

Justice System Play in

Mandating Substance Abuse

Treatment With a Family

Focus?

The criminal justice

system is a major

source

of referrals to substance abuse treatment, There is

considerable

evidence to

support treatment

that taps the

power of the family

and the

community.

especially among people with low incomes.

Such legally coerced

referrals come with

powerful leverage that

strongly affects the

treatment process.

Providers should be

prepared to address

several issues: If a

treatment program

requires family member participation and

the client refuses to

involve them, or the

treatment episode is

not successful, what

are the consequences

to both client and

family? What happens

if a family­focused approach is in place and the

family does not show up? Do you punish the

client? If such questions are not anticipated

and answered adequately, the result may be

harm to, rather than assistance for, the client

and/or the family.

Program Planning

Models 

Including family therapy issues in substance

abuse treatment settings at any level of intensity

requires a systematic and continuous effort.

The four program planning models presented

in this section—staff education, family

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education and participation, provider The goal for educating staff about

family therapy and

family issues is to	 

increase staff

awareness of the

role of family

involvement in

substance abuse,

dependence, treatment, recovery,	 

and relapse.

collaboration, and

family integration—

were developed by

the consensus panel

and provide a

framework for program administrators

and staff/counselors.

The framework

identifies key issues:

guidelines for implementation, ethical

and legal issues,

outcomes evaluation,

counseling adaptations, and training

and supervision.

Some programs may

be limited to educating staff about family

therapy and how

family issues relate

to substance abuse,

treatment, and

recovery.

Many programs

already involve families in the treatment

process in some way, and those programs might

wish both to promote ongoing staff education

about family therapies and to increase or

improve the ways in which families participate

in the substance abuse treatment program and

continuing care. A program might decide to

create or expand its collaborations with family

therapy providers and other social service

agencies. Although integrating family therapy

into substance abuse treatment might require a

significant investment of time and resources,

the consensus panel hopes that treatment programs can use the integration models suggested

to facilitate such changes.

Staff Education

The goal for educating staff about family therapy

and family issues is to increase staff (and

therefore client) awareness of the role of family

involvement in substance abuse, dependence,

treatment, recovery, and relapse. Increasing

staff’s knowledge of the family as a unit and the

influence of the ecological setting within which

the substance abuse occurs should be one

outcome of the staff education activities.

Support for becoming knowledgeable about

family therapy issues, as well as for program

changes designed to integrate or enhance the

delivery of such services to clients and their

families, begins with the chief administrative

and clinical staff. These staff members need to

demonstrate their value of such knowledge and

activities and that they are willing to commit

the necessary resources in an ongoing fashion.

Issues for substance 

abuse treatment program 

administrators

Program administrators must assess the

amount of effort and support required to

develop staff education activities related to

family issues. When the agency does not have

in­house resources, it might be best to seek

input from the entire staff about any staff

knowledge of resources in the community

and/or specific providers worth considering for

participation in the educational activities. To

be sure, program administrators will need to

gauge the compatibility of outside presenters’

views of addiction against the substance abuse

treatment program’s viewpoints and materials.

Although viewpoints regarding substance abuse

and its treatment need not be identical for all

family therapy presenters, the program

administrator might wish to give advanced

thought to how to address issues that could

arise over conflicting views. Administrators

need to be aware of the costs that are involved;

sometimes the resources are not readily

available and can be costly, especially in areas

where access to care is restricted.

In some locations there might be numerous

inexpensive or even free educational activities

that relate to family issues and family

therapy—from local college courses to evening

presentations given by various community

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organizations. In other locations it may be

much more difficult and expensive to access

direct presentations, and program administrators may seek resources through e­learning

possibilities. Of course, this TIP itself and

other State and Federal resources, such as one

of the regional Addiction Technology Transfer

Centers (http://www.nattc.org), which receive

funding from the Center for Substance Abuse

Treatment (CSAT), are good places to start.

Though it is unlikely that there will be any legal

or ethical issues associated with providing

education on family issues to substance abuse

counselors or staff, it is certainly the best

practice in terms of credentialing to check with

licensing or certification agencies. This will

ensure that any professional invited into one’s

agency is in good standing and has the background and training that are represented in the

person’s resume. As far as outcome evaluation,

many presenters have their own “pre­ and

post­” questionnaires to demonstrate that

participants have acquired certain information

from the presentation. Certain accrediting

organizations require such program evaluation

components in order for a presentation to be

eligible for consideration as continuing education

credits. Of equal, if not greater, importance

would be formal or informal mechanisms for

obtaining participants’ own assessments of the

educational activities.

And finally, some time and attention will need

to be devoted to help staff digest the family

therapy education they receive, especially in

terms of their comfort level about what the

training implies as far as their counseling or

treatment. Along these same lines, staff might

have concerns about the amount of training

and supervision necessary to employ any or all

of the techniques described or suggested.

Again, resources to meet these concerns might

be available in­house, in the community, or

through distance learning possibilities.

Designing a set of educational and training

activities so that these activities can help staff

satisfy their various education requirements

and compensation for any extra time devoted

to such endeavors are important ways to support

staff interest and appreciation of family therapy educational training. The provision of

opportunities for ongoing supervision could be

a powerful way to communicate a program’s

commitment to families and the family’s role in

treatment and recovery and to show support of

staff in becoming familiar with new techniques

and approaches.

Issues for staff and trainers

Treatment center staff—from substance abuse

counselors to supervisors, nurses, and

physicians—are likely to have varied backgrounds in terms of familiarity with family

issues and/or family therapy. Therefore,

educational activities will need to be appropriate

for the participants. Many substance abuse

treatment counselors will be familiar with the

“family disease model” of substance abuse.

Such familiarity is likely to range from being

familiar with certain terminology to using the

family disease model in individual and group

substance abuse treatment, including family

involvement. Some counselors or staff will be

trained and thoroughly familiar with one or

more family therapy treatment systems.

In addition to being sensitive to staff’s level of

familiarity with the material, trainers must also

understand and be sensitive to staff culture.

Ways of adapting material for staff to understand and development of new strategies of

teaching are the responsibilities of the trainer.

Staff may not have the basic knowledge to

adapt the new material and might need assistance in understanding how the information is

meaningful and applicable to their populations

and cultures.

Family Education and

Participation

Many substance abuse treatment facilities offer

“family counseling” as part of the therapies

employed by the treatment program (Office of

Applied Studies 2002a). However, the nature of

such family counseling can vary widely from

one facility or treatment provider to another.

The consensus panel recognizes that some

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treatment programs may have no or limited

family involvement and other programs may

vary in the extent of family participation. The

consensus panel’s focus is on family education

and involvement that is informed by the full

range of family therapy information and the

possibilities presented throughout the TIP.

Consequently, family education and participation stresses the importance of the family in

substance abuse treatment and calls for

changes in the intake assessment process,

education of the family, counselor training and

caseloads, confidentiality issues, and special

followup and outcome measures.

Assessment is one of the most important

components of any substance abuse treatment

program. When focused on families, an assessment instrument generates data that can help

the substance abuse professional identify

resources in the family that may promote

treatment success. Collecting data about the

client’s family serves several purposes:

•It yields a more thorough, and perhaps more

accurate, family history.

•It presents an opportunity to confirm and

clarify information on the client.

•It can provide insight into the context where

substance abuse most often occurs and where

it may have started or accelerated.

•It sets the tone for a continuing focus on the

family.

•It identifies family resources to help plan

long­term care.

•It documents specific information that can

determine treatment goals.

The importance of enhancing family involvement

can be emphasized by staff. The following types

of questions encourage further discussion

about family dynamics and involvement,

emphasizing a strengths­based model.

However, staff should be careful about asking

for details in a way that may be experienced by

the client as an interrogation:

•Who can support you in treatment?

•Do you know someone who is abstinent who

can support you?

•Who in the past has been the most helpful to

you?

•Tell me about a safe place where you can live.

•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

substance abuse?

•Have your family members noticed a decline

in your substance use?

•How would your family react to your recovery from substance abuse?

•What does your family think about you being

here? Did you tell them? Why or why not?

•Is substance use an important part of your

family life?

•Who in your family has jobs? Goes to school?

•Who is the last person in your family who saw

you cry?

•Where did you eat dinner last Sunday?

Education of the family proceeds along a

continuum that includes strategies such as

providing Internet access, informal referral

and educational opportunities, and printed

materials such as pamphlets, videotapes, and

reference books. Some tools can help families

understand their importance in substance

abuse treatment. Modified genograms, for

example, help families understand substance

abuse from the focus on its history to the larger

context of clients’ lives (see chapter 3 for more

information on genograms). Another example is

psychoeducational groups, which can focus on

families’ strengths and help family members

change common behavior patterns that may

contribute to conflicts. A family therapy directed

strengths­based perspective may help families

learn skills to solve conflicts and identify

common feelings or thoughts related to substance abuse and families. Psychoeducation

can be conducted in groups with several

families in a single session, making the

approach highly cost­effective. From a clinical

perspective, psychoeducational groups may

increase a family’s sense of support and reduce

stigma within and between families.

152 Policy and Program Issues
         

               

           

       

           

       

     

         

           

       

             

         

         

     

         

         

           

         

             

             

             

           

           

               

           

           

                 

       

             

       

             

         

       

       

         

   

             

         

           

           

           

       

             

           

           

             

       

           

               

   

       

   

     

       

     

     

     

   

   

     

   

   

   

   

   

   

   

     

   

             

           

       

   

               

         

           

               

     

Family involvement in treatment can also be

construed as a continuum based on the level of

background and training required for staff to

implement family activities into treatment.

From the perspective of the treatment process,

the introduction of family activities requires

accommodation from traditional program

activities and orientation. Minimal family

activities, such as the construction of a

genogram, require limited counselor training

and virtually no changes in any other substance

abuse program aspects. Family therapy techniques that require a detailed examination of

community influences and contingencies for

rewarding recovery activities might require

significant staff training, significant shifts in

program scheduling, and shifts in the relationships among program staff and community

resources.

Issues for substance 

abuse treatment program 

administrators

Counselor training and caseloads

If counselors improve their skills and are able

to do more complex clinical work with families,

such expansion of their roles as counselors will

place added burdens on them. Working with

families will increase the amount of clinical

time for each client so overall adjustments in

a counselor’s caseload might be necessary,

especially when one considers that work with

families can at times bring with it a heavy

emotional burden. Staff burnout prevention

needs to be considered, and difficulties with the

stressors associated with additional training,

information, and so on need to be monitored.

Confidentiality

Informed consent and confidentiality issues will

require careful consideration by program

administrators. Ideally, clients in substance

abuse treatment will sign informed consent

forms, acknowledging their understanding of

the potential risks and benefits of family program activities, and family members (including

children, when appropriate) will also sign such

forms. Informed consent forms can 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—depending on the

particular laws of the State or locale and

Federal laws). Additionally, separate confidentiality warnings might be included in the

informed consent form so that clients and their

families realize and

agree that the loss of

confidentiality result­ Education of the

family proceeds

along a continuum

that includes

strategies such as

providing Internet

access, informal

referral and

educational

opportunities, and

printed materials.

ing from families

meeting in groups is

understood and

agreed to by all.

In regard to confidentiality, there must be

strict adherence to all

confidentiality laws,

including the specific

requirements for any

and all releases of

information.

Substance abuse

treatment centers

bear a responsibility

for ensuring that

treatment providers

or outside presenters

understand the strict

requirements of confidentiality imposed by

direct Federal laws,

State law, and professional ethics within

the substance abuse field. For example, if these

issues are not clarified, family members may

regard sign­up sheets as violating their confidentiality. If family members sign a log sequentially, the program will illegally disclose to client

B that client A is in treatment. These issues

become especially complicated when a client

identifies as “family” people who are neither

related by blood nor by law and wishes to

include friends or coworkers.

Policy and Program Issues 153
             

         

           

         

         

         

         

         

     

         

   

             

             

               

         

             

           

           

           

             

             

           

           

         

   

   

   

   

     

     

   

     

   

   

     

   

   

   

     

       

       

           

             

         

         

       

         

         

         

         

             

           

           

           

             

         

       

   

       

       

       

                 

               

         

     

           

         

         

     

               

             

     

         

         

           

             

           

       

             

Outcomes

Evaluating the outcome benefits and drawbacks

of family education activities and new ways of

incorporating family techniques into the

treatment process can be qualitative or

quantitative, simple or complex. Simple

questionnaires and feedback sessions are what

many program administrators want to

consider; some administrators might want to

pursue more intensive analyses that employ

focus groups and performance measurement

techniques that are developed by outside

experts. Such performance measurements

might include a change in the percentage of

clients who agree to have their families participate in treatment, an increase in the number of

contacts counselors have with family members,

monitoring the number of requests for the

program’s free materials related to families and

treatment, and a host of other possibilities.

Issues for staff and trainers

Training and supervision issues are similar to

those that arise from staff education, but such

concerns can reach a higher level of intensity.

Being educated about family issues and family

therapy might imply certain changes or expectations for counselor behaviors, whereas the

inclusion of family

education and family

involvement in the

Provider treatment process

collaborations will

ensure high­quality

referrals, effective

outreach, and

meaningful partnerships with community resources.

brings the responsibilities and expectations for the counselors to a much

higher level.

Counselors and staff

will be expected to

know more, explain

nuances to family

members, and incorporate any new family

program activities

into their general

style and treatment

approach. For this

level of family

participation, substance abuse counselors will

require significant training and supervision.

The professional associations of staff members

may offer guidance in terms of suggested or

required background or training to meet

acceptable standards; and, of course,

organizations that traditionally include family

therapy modalities usually have standard

curricula and training requirements that they

promote.

Provider Collaboration

Collaboration goes beyond referral; it indicates

that the substance abuse treatment program

and the family social service agency have

established an ongoing relationship so that the

treatment that takes place at one provider

agency is communicated to and influences the

course of treatment or services at the other.

Such provider collaborations will ensure

high­quality referrals, effective outreach, and

meaningful partnerships with community

resources. Such relationships should encourage

family participation in both substance abuse

and family­oriented services. Of course, determining what a family needs is a decision to be

made in the family and not by the substance

abuse treatment provider. From this perspective,

the provider encourages empowerment within

families to determine their own direction.

Given the complexities of informed consent and

confidentiality that arise from adding family

education to a program’s offerings, developing

collaborative relationships with family therapy

and related agencies is no easy task. Staff

members will be called on to be knowledgeable

about family­involved treatment models and

services and be familiar with community

resources. Matching the resources of various

providers with a family’s needs and providing

the family with information about the pros and

cons of various alternatives will require a

strong community perspective and resource

commitment on the part of the substance abuse

treatment agency.

154 Policy and Program Issues
             

       

           

           

     

         

           

       

         

       

         

           

         

       

       

           

           

         

             

     

       

             

   

         

         

             

             

     

           

       

         

             

           

           

       

           

         

       

       

             

     

         

           

     

           

     

           

           

       

           

     

       

             

       

       

             

               

             

     

     

           

   

         

           

           

         

     

     

       

         

         

         

               

             

             

             

         

           

         

           

           

Issues for substance 

abuse treatment program 

administrators

Resources need to be provided to monitor and

ensure that high­quality referrals, outreach,

and partnership components are in place

within the agency and community. Examples

of such resources include

•Family education sessions where families can

learn more about substance abuse and family

involvement.

•A comprehensive referral system that can

facilitate the participation of families and

clients in treatment­based, family therapeutic

activities.

•Expanded informed consent, which will often

be necessary.

•Client and family education about both the

benefits and challenges of using any particular

provider or service, and clients should

understand the relationships among service

systems. In addition, program administrators

may need to develop “disclaimers” for clients

so they understand that a substance abuse

treatment agency cannot be responsible for

the actions of another agency’s staff or policies.

For many provider collaboration arrangements

a memorandum of understanding (MOU) can

be developed to help clarify and guide the

interrelationships. Coordinated efforts include

active involvement of substance abuse staff in

the therapeutic process and continuous contact

with the family therapist at the external agency.

Detailed understanding of each other’s processes

and protocols, as well as detailed MOUs, can

avoid redundancies and improve quality—for

example, if each program screens for mental

health issues, coordinating the screening

processes will avoid duplication and unnecessary confusion on the part of clients, especially

if the different screening approaches were to

yield different results. Another example is how

the MOU establishes separate responsibilities

for on­call service provision and responses to

crises.

To ensure adequate communication flow to

meet the challenges of coordinating provider

activities, program administrators face allocating

personnel resources for a variety of tasks, from

documentation and information coordination

to joint public speaking and presentations.

Someone could be designated as the provider

collaboration coordinator—perhaps as part of

quality assurance duties or a position that

implements, monitors, evaluates, supervises,

updates, and educates staff about the relationships with other providers. Staff could be

assigned duties related to cross­training efforts

and participate in each other’s boards,

committees, or multiagency efforts.

Program administrators would also have to

consider other costs and the taxing of resources

by the responsibilities of collaborating with

other providers. Confidentiality and informed

consent will be repetitive issues, whether it is

how to manage group forms of treatment in the

other agency or how to address the Health

Insurance Portability and Accountability Act

(HIPAA) requirements (for more information

on HIPAA see the following Web site:

http://www.hhs.gov/ocr/hipaa). Additional considerations might include policies for nonclients on the treatment premises, space considerations, security, insurance issues to be sure

that one’s liability protection remains secure,

as well as reimbursement issues.

Evaluation and outcome measurement remain

challenges for administrators; yet, provider

collaboration might offer opportunities to use

instruments developed by other providers, gain

feedback from other professionals, and offer

clients a chance to express themselves to a neutral party by having one agency survey clients

about the client’s views of the other agencies.

Supervisors from each agency are likely to be

interested in the views of each other’s personnel.

The following evaluative questions can be

asked in any outcome scenario that involves

referring families to other agencies:

•What family members are actually going to

the other agency to which they were

referred?

Policy and Program Issues 155
               

           

   

             

   

             

       

           

         

         

           

           

           

           

     

         

             

             

               

       

           

         

             

         

             

             

             

         

           

                 

       

           

       

             

       

         

   

         

         

         

         

           

             

             

               

         

             

         

         

           

             

           

           

         

       

         

         

       

           

         

           

     

         

     

           

           

   

                 

         

             

           

       

         

           

           

           

           

         

           

           

             

       

   

•What does the family like about going to the

other agency?

•What aspects of treatment from the other

agency are helpful?

•What does the other agency provide that this

agency also provides?

Issues for staff and trainers

Staff in both agencies can expand their

knowledge about substance abuse education

and family resources in the community. Staff

members should be informed about familyinvolved treatment models and provide information using collateral resources to build trust

with family members. Supervisors are likely to

be called on to help staff accommodate the

changes and new information generated by

collaboration with other providers.

Staff should learn to avoid “splitting”—that is,

where a client regards one provider as “good”

and the other as “bad,” with the implicit

attempt to get the “good” provider to agree that

the other provider is incompetent,

ineffective, or corrupt. Sometimes a variant of

triangulation, splitting regularly results in the

client becoming upset or attempting to use the

“split” to avoid responsibility or consequences

for behavior. In any case, staff profit from

being as well informed as possible about the

details of the programs and resources of

collaborative providers, especially in terms of

cultural competency issues. For example, it can

be important to know the extent to which a

collaborating provider can provide accommodations for people with disabilities, from

accessible bathrooms to assistive technologies.

Recommendations for 

collaboration

Cross­training

Generally speaking, there is a shortage of (1)

well­trained substance abuse treatment professionals, (2) well­trained substance abuse treatment professionals knowledgeable about family

issues, and (3) well­trained family therapists

who are proficient in traditional substance

abuse treatment techniques. The integration of

family therapy into substance abuse treatment

programs will have to address these shortages,

a goal that could be accomplished—at least in

part—through cross­training. Cross­training

needs to be addressed in the educational system

as well. Requiring a variety of core class work

would enable both substance abuse counselors

and family therapists to be better equipped to

address both substance abuse and mental

health issues.

Though ideally counselors would be adequately

trained in both family therapy and substance

abuse treatment, that ideal is likely to remain

the exception rather than the rule. Family

therapists can certainly obtain some training in

substance abuse treatment, especially in the

areas of screening, assessment, motivational

enhancement, and relapse prevention, as well

as in specific approaches such as

cognitive–behavioral therapy or 12­Step

programs. Perhaps the first four levels of

involvement with families suggested in chapter

4 could accommodate a training approach for

family­oriented substance abuse counselors

with various levels of training. Additionally,

many family therapy techniques—such as

telling family stories—can be of great

importance in the process of substance

abuse treatment engagement.

Partnerships 

A shift from the individual to the family in

substance abuse treatment models would

necessitate collaboration, partnership, and

joint funding at all levels. One such example

was announced in July 2002, involving the

Department of Housing and Urban

Development (HUD), the Department of Health

and Human Services, and the Department of

Veterans Affairs, who have joined together to

end chronic homelessness within 10 years (U.S.

HUD 2002). Collaborations such as this one

highlight how the Federal government has

begun to recognize and address the fragmentation, duplication, and isolation that exist within

and among agencies, a model that could be

transposed to the family therapy/substance

abuse treatment arena.

156 Policy and Program Issues
     

       

         

       

       

         

             

         

         

             

             

             

             

         

         

             

             

           

             

           

           

     

               

             

             

     

           

         

                 

               

           

                   

             

               

       

           

             

       

           

             

             

           

     

   

   

   

   

   

   

   

   

     

     

     

   

   

     

   

   

               

         

         

           

               

               

           

         

       

           

           

             

         

     

             

         

           

         

           

               

           

In the community. One empowering partnership

model is a consumer­based collaboration that

incorporates community perspectives in the

development of substance abuse treatment

programs. Inclusion of community members’

perspectives can heighten their commitment as

key stakeholders, involve them in their own

care, and reduce the levels of opposition to

substance abuse treatment. It inherently validates the listening process of communities and

develops trust. La Bodega de la Familia (see

chapter 4 for a more complete description) was

the first treatment center accepted unanimously

by the community board on the Lower East

Side of New York. More than 200 meetings

were conducted with community members and

police, probation, city council, and community

providers, the results of which were used to

start the program. This process allowed for the

possibility of creating an innovative system of

intervention that people want and will use, and

does not impose a middle­class family therapy

model or a “one­size­fits­all” approach on the

community it serves.

It remains to be seen whether a model that

shifts the power to the consumer provides

reliable outcome or impact data, but it does

allow communities to tailor interventions with

positive impact. Focus groups and other

methods are used to engage communities and

learn about how people do or do not use services.

A major precaution is that often in an open

forum, participants may say what they want,

but then do not use the service. It falls on the

lead agency to validate the consumer and to

operate from the perspective that this is a

community­led movement, not a professionally

led one. Including consumer voices grounds the

validity of the program and shifts the traditional

paradigm, while also heeding the voices of

substance abuse providers, therapists, and

other key stakeholders. An additional benefit

is that a consumer­led movement is a strategy

that can engage legislators and lay the

groundwork for policy shifts related to

community­based substance abuse treatment

and family involvement.

In the workplace.

The workplace is Staff profit from

being as well

informed as 

possible about the

details of the

programs and

resources of

collaborative

providers.

another potential

partnership area for

family therapy and

substance abuse treatment. Many Employee

Assistance Programs

(EAPs) know and

make referrals to family therapists who are

also knowledgeable

about substance

abuse. Ongoing

research by EAPs on

the effectiveness of

such referrals and

treatment episodes

could stimulate others

to be more inclusive

of familial involvement in substance

abuse treatment.

An ancillary issue to this kind of partnership is

the potential need for large

numbers of people trained in family­involved

or family therapy systems work. For example,

if the number of families who are served at

Level 4 of the model discussed in chapter 4

increases, there may not be enough welltrained clinicians to provide those services.

Also, competencies should be designated to

guide training on family issues, general family

therapy, and family therapy to treat substance

abuse.

Family Integration

Programs at the ideal level are fully functional

and culturally competent in their operations,

policies, procedures, and philosophical

approaches as they relate to the integration of

family therapy into substance abuse treatment.

At this level, adequate infrastructure, financing,

and human resources are available to implement and sustain the integrative project.

Program activities are based on the strengths

of families and an enhanced view of the family

as a positive influence and resource. Social,

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individual, and family supports are in place to

improve family dynamics and prevent relapse.

At this level, a “family culture” is promoted

with certain principles about families and

substance abuse treatment present throughout

the organization and client interactions. Fully

integrated programs have multiple staffing

patterns with clinical personnel who are

educated, comfortable, and competent in

substance abuse treatment and family therapy.

These programs also have nonclinical staff educated on the importance of family involvement

in substance abuse treatment. All clinical staff

are cross­trained in family work, substance

abuse, and family case management, as well as

knowledgeable about social services and other

available resources in the community.

Issues for substance 

abuse treatment program 

administrators
 

The total integration of substance abuse

treatment and family­based approaches

throughout the organization, its policies, and

program practices is a challenge at all

levels. Ideally, best practice is formed from

evidence­based,

family­supported

Programs at the therapeutic modalities

ideal level are fully

functional and

culturally competent in their operations, policies,

procedures, and	 

philosophical

approaches.

that have been replicated across a variety

of populations, have

been evaluated

rigorously, and are

monitored for

adherence.

Culturally competent

practices are present

throughout the

organization, its

policies, practices,

and procedures at

this level. In the

course of substance

abuse treatment and

family therapy, close

attention is paid to

racial and ethnic influences, class, gender, and

spiritual values.

Agency administrators prioritize the integration

of families into substance abuse treatment and

identify model(s) and therapeutic interventions

that best address community needs.

Throughout the agency, the staff has a

thorough understanding of how family will be

engaged in the substance abuse treatment and

family therapy processes, and implementation

of treatment is well coordinated.

A comprehensive range of program activities

are available, including

•Screening and assessment for substance

abuse and family issues

•Substance abuse treatment

•Family therapy or family­involved interventions

•Information and outreach, using multimedia

approaches such as the Internet and videos

•Community partnerships

•Education and psychoeducation

•Therapeutic home­based interventions and

family case management services

•Individual and family counseling and parent

education

•Process and outcome evaluation

Linkages are established with social services

agencies, or those that interact with child

welfare agencies, to provide assistance with

transportation, housing, health care, food, and

childcare. Infrastructural concerns are also

addressed, such as the availability and use of

physical space; the use of multimedia, including

the Internet and videos; and the availability of

bilingual informational materials.

With full integration, the notion and practice of

informed consent are rigorously implemented

and enforced. Fundamentally, this requirement

means each family member receives clear,

accurate information about what will happen

when, or if, they engage in substance abuse

treatment and family therapy. Informed

consent protects clients before, during, and

158 Policy and Program Issues
         

           

         

         

           

       

             

         

         

       

           

       

           

         

         

           

           

             

           

         

           

         

           

             

       

             

   

             

         

         

           

         

               

               

       

           

       

             

           

           

           

           

             

         

         

             

         

               

         

           

             

             

         

   

     

           

         

         

           

             

         

         

       

           

             

       

         

             

   

             

     

   

           

             

           

       

             

           

         

         

           

         

           

       

   

       

after treatment. Clients should grant informed

consent only when an agreement about treatment objectives has been reached; treatment

and available services have been explained;

and benefits, risks, possible side effects, and

complications are discussed thoroughly (Barker

1998). Clients are also informed of the potential

risks of forgoing services, possible alternatives

to proposed treatment, and information that

links evidence­based support with various

services (Marsh 2001). In family therapy, each

competent participant gives informed consent

for therapy to proceed (Barker 1998).

Confidentiality extends to all individuals in

treatment. Exceptions include the need to

reveal information to protect clients from harm

(such as suicide, homicide, and physical and

sexual abuse). Every agency is required to have

a formal confidentiality policy to avoid

violations of laws, statutes, and accreditation

requirements. Policies are also subject to

outside mandates. Those agencies that receive

Federal funding must comply with Federal

regulations, or 42 C.F.R., Part 2, which

guarantees strict confidentiality of information

about people who have been in treatment for

substance abuse. Participant­identifying information must not be disclosed either to other

participants (including family members) or to

other service providers without a specific

release form that complies with the regulations.

Program staff may disclose confidential information to other staff members in the same

program if it is necessary for the provision of

treatment. The regulations stipulate exceptions

to the prohibition on disclosure, including

medical emergencies, mandated reports of child

abuse or neglect, and, in States that mandate

it, elder abuse and neglect. The balance

between individual needs and those of family

members can often turn individual family members against each other during conflict.

If staff members are required to divulge such

information, all family members should be

informed of agency policy and practices.

Issues for staff and trainers

At this level, all staff—from the receptionist to

the executive director—are trained about the

important role of the family as a positive

influence in the substance abuse treatment

process. They have varying degrees of familiarity

with the models described in chapter 4. Clinical

staff are trained more thoroughly in the tools

and techniques of traditional family therapy

and multisystemic approaches, public speaking

and presentation skills, the relationship

between substance abuse and families and

partners, and relating with the surrounding

ecosystem.

Staff understand the cultural, social, political,

and economic forces that affect the various

racial and ethnic groups (CSAT 1999b). A

culturally competent model of substance abuse

treatment and family therapy addresses the

sociocultural factors affecting substance abuse

patterns among members of various racial and

ethnic groups as a crucial prerequisite in

providing adequate treatment (CSAT 1999b).

From this perspective, adequate treatment is

characterized by

•Staff knowledge of the native language of the

client, whenever possible

•Staff sensitivity to the cultures of the client

populations

•Staff backgrounds representative of those of

the client population

Staff are trained in culturally competent strategies that promote respect and dignity for clients

and encourage them to discuss issues without

inhibition or fear of termination.

At this level, all substance abuse counselors are

certified and clinicians are licensed family therapists or licensed professionals with advanced

training in family therapy. Continuing education

about various approaches to family work and

substance abuse treatment is necessary and

supported. Ongoing training in other topics such

as domestic violence, child abuse and neglect,

elder abuse and neglect, posttraumatic stress

disorder, and cardiopulmonary resuscitation is

also recommended. All staff members are

Policy and Program Issues 159
       

     

         

         

           

       

         

       

             

         

         

     

         

           

           

           

           

         

               

             

       

         

           

         

         

         

   

       

       

       

   

       

         

       

       

       

           

       

       

         

         

             

           

         

             

   

           

         

               

           

           

         

         

           

       

         

             

         

         

         

         

       

           

         

       

               

           

       

     

             

             

           

         

       

         

           

           

         

             

         

cross­trained in family­based approaches and

substance abuse treatment.

Clinical supervisors are licensed family therapists or have completed advanced specialized

training and coordinate the work in substance

abuse treatment and family therapy.

Supervisors should have specific experience in

family­based modalities and family therapy.

Supervisors also need to be informed about a

range of auxiliary topics, including childcare,

liability concerns related to children, provision

of space, and documentation.

Other Program

Considerations

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 staffing patterns,

language, and cultural issues related to families

and substance abuse. Concerted efforts should

be made to hire staff and build an organizational culture that reflects the diversity of the

client populations served. Program assessments

are achieved by exploring institutional assumptions regarding services for specific racial and

ethnic communities. This information is used to

reduce bias resulting from institutional misperceptions and cultural ignorance or inexperience.

For more information about cultural competence,

including organizational cultural competence,

see the forthcoming TIP Improving Cultural

Competence in Substance Abuse Treatment

(CSAT in development b).

Outcome Evaluation

Procedures and Reports

Some outcome evaluation procedures include

the development of standard measures to

determine the treatment program’s efficacy;

data collection and database development,

which generally require more intensive

procedures; and the examination of the

relationship between utilization and outcome

for every family member treated.

To determine the substance abuse treatment

program’s efficacy, tracking procedures can be

used to record the number of clients returning

to the workforce, those involved with medical

service providers, and whether treatment

correlates with a reduction in the number of

client arrests.

Outcomes for family members are examined by

the relationship between utilization and outcome,

the number of times the client and family

members were seen, and the relationship to

outcomes. Because the treatment program is

in­house, utilization rates can be monitored

closely.

Culturally competent evaluation plays a significant role in facilitating outcome evaluation. To

be effective, culturally competent evaluation

relies heavily on an in­depth understanding of

the role that culture plays in substance abuse

(Cervantes and Pena 1998). Evaluators should

incorporate cultural factors such as acculturation, language, family values, and community

attitudes into evaluation design (Cervantes and

Pena 1998). Additionally, culturally relevant

instruments are critical to the overall evaluation effort. Knowledge of the sociocultural,

demographic, and psychological factors specific

to the cultural group is necessary. If the

evaluation design does not include cultural

differences, incorrect conclusions may be

drawn about program effectiveness (Cervantes

and Pena 1998). An understanding of risk and

protective factors as they relate to culture is

important in evaluation efforts as well as

understanding resiliency factors in a culture.

Long­Term Followup

Monitoring rearrests, recidivism, and readmission to substance abuse treatment programs

can serve as measures of long­term functioning.

Collection of long­term followup data is

difficult and rare in healthcare treatment

research in general, and especially in the

substance abuse field. Vaillant (1995) provides

160 Policy and Program Issues
           

           

       

         

             

   

             

         

           

           

         

             

           

           

         

             

           

         

           

           

       

   

               

       

               

           

           

           

       

         

       

             

           

         

           

         

           

     

         

                   

         

   

     

         

           

         

     

             

   

       

   

       

     

   

     

     

   

   

     

   

   

   

         

   

               

         

           

         

           

           

         

             

         

           

family related outcome measures such as

marital happiness. Though Hser et al. (2001)

present significant long­term research outcomes

in narcotics treatment, the consensus panel

knows of no such long­term followup with a

focus on family.

Directions for Future

Research 

Since its advent in the 1950s, family therapy

has been characterized as having theoretical

roots that are anecdotal, intuitive, and empirical,

rather than scientific (Barker 1998). That

opinion may stem mainly from (1) the separation

between researcher and therapist, which exists

in all mental health disciplines, and (2) the

development of family therapy as an outgrowth

of studies conducted on family research into

schizophrenia, the mostly unscientific results of

which were then extrapolated to a wider range

of family problems (Barker 1998). In the

absence of a well­articulated conceptual

framework, it is impossible to draw definitive

conclusions about the efficacy of family therapy

(Collins 1990). Research in several areas could

serve to address this issue.

New Treatment and

Therapy Models

Many advances are being made in the field of

family­based treatment for adolescent drug

abuse that can serve as pilot models for adult

treatment. One valuable insight has been the

general shift from focusing exclusively on

individual or family variables to change or

improve treatment outcomes for adolescents

and adults to more complex, multicomponent

interventions that incorporate more dimensions

and domains in and outside the family (Liddle

and Dakof 1995a). This movement has culminated in the perspective that multicomponent,

comprehensive, community­based, multisystemic approaches must be supported to reap

the best outcomes. Ideally, such comprehensive

coordinated efforts can be meshed with other

related ones—domestic violence, for example—

to develop a coordinated community response

to a variety of issues that can fit well with

multisystemic responses to substance abuse and

family involvement. Unfortunately, within the

family therapy and family­focused intervention

domains, the need for more comprehensive

strategies is often outweighed by the complexity

of making them viable and implementing them

within communities. Cultural and linguistic

barriers and a lack of trained bilingual and

bicultural staff make

this task even more

challenging. An organizational

culture that is

infused with the

values of cultural

competence and

diversity on every

level will highlight

and implement

such values

concretely.

Another possible

research area relates

to the critical need to

describe, measure,

and report on the

process of therapy

itself. Investigators

would have to make

sure that the therapy

methods chosen are

actually being implemented, making it

possible to determine

outcomes and identify

reliable, therapeutic

methods that can help

families make desirable changes. As

newer forms of family 

therapy emerge, it is

unknown whether

radically new

approaches to research will be required.

Assessment and Classification

A second area for future research is in the

assessment and classification process used to

determine the type, duration, and intensity of

family therapy. Currently, no valid, reliable,

acceptable way to categorize families by the

way they interact has emerged (Barker 1998).

Developing one has been difficult primarily

because the diversity of families defies easy

categorization. Blended families, gay and

lesbian families, adoptive families, as well as

Policy and Program Issues 161
   

   

   

       

   

   

   

   

   

   

   

     

     

   

   

           

   

           

             

               

             

         

       

           

       

             

         

       

   

             

         

           

           

       

           

         

   

   

       

           

                 

           

           

             

         

   

       

       

         

             

             

         

         

       

         

       

           

             

           

       

           

             

         

           

                 

         

       

           

             

       

         

           

           

         

       

         

             

     

               

those with divergent

religious beliefs and Another possible

research area

relates to the

critical need to

describe, measure,	 

and report on the

process of therapy

itself.

cultural norms and

values, are just a few

variations (Barker

1998). Despite

attempts at categorization,

classifications have

relied typically on

uncritical understandings of developmental models that

purport to designate

the particular stage

families should have

reached, based on

the ages of children

and the stage the

family has reached

(Barker 1998).

Classical definitions notwithstanding, what

researchers and therapists need to classify and

assess are relationships and the measurement of

change in relationships in valid, reliable ways.

Should success be measured in terms of the

presenting problem of the client or in terms of

the change in the family system? Specifying the

goals and interventions used would permit

clearer comparisons of the two approaches

(Collins 1990). Further, how do culturally competent understanding and values regarding the

role of families figure into traditional models of

family development? The need for more explicit

categorizations and assessment methods must

be addressed.

Outcome Measurement

A third research area concerns the need for

outcome research. Many researchers have

proposed guidelines for the design of family

therapy research, including the need for studies

to have clinical relevance, standardized treatment manuals, and resolve the debate between

the reliability of comparative studies and

“within­model comparisons” (Barker 1998).

Collins (1990) recommends consideration of

objective outcomes (not just self­reported

information) and the measurement of a wide

range of outcomes, such as the ability to hold

a job, manage finances, or stay married.

Prevention

Prevention strategy is another area that holds

promise for future research. A small but

growing number of programs are testing

whether family­based interventions can serve

as prevention or early intervention strategies

(particularly with problem drinking). Family

therapy researchers could benefit from more

clearly defining what a healthy family is as

much as what a dysfunctional family is. All

these efforts are important in exploring

whether preventive strategies can improve

family functioning and prevent family pathology.

Prevention opportunities exist in schools

(truancy, deviant behaviors, expulsion), in the

workplace (poor attendance, identified mental

health and substance abuse problems), and in

churches (families might ask for help around a

specific family problem from a pastor, priest,

or other spiritual leader).

Technology

A fifth research area relates to technological

advances that have the potential to benefit

substance abuse treatment efforts, namely the

Internet and e­mail. King and colleagues (1998)

explored the use of the Internet as a tool to

assist family therapy, especially where family

members are geographically separated. The

researchers also studied the potential value and

use of e­mail and writing to facilitate family

therapy.

The advantages of e­mail communication in

family therapy include allowing family members

to contribute whenever their schedules permit,

delay responses until they have been fully

thought out, and create a permanent record,

which reduces the risk of misunderstanding.

One drawback for e­mail communication is

possible misinterpretation due to lack of tonal

cues. Other uses of writing in family therapy

include personal narrative, programmed

writing, and letter writing, all of which can be

162 Policy and Program Issues
           

           

             

             

         

             

               

           

         

             

   

           

           

             

     

             

           

         

     

           

             

   

           

             

       

           

         

           

           

   

           

               

           

         

                   

         

                 

             

               

           

                 

                 

               

           

           

communicated via e­mail. The use of e­mail

may make family therapy possible at times

when it would otherwise not be feasible.

Another key element that is being used is

remote telemedicine. This use of cameras and

monitors has been an excellent way to overcome some of the barriers in rural areas where

both coverage and transportation have in the

past prevented consistent involvement in

treatment.

Additional Possibilities

Clear information is also needed in the

following areas:

•How effective are various approaches to

family therapy in substance abuse treatment?

•How should family therapy be tailored to be

appropriate with specific populations?

•How do agencies increase the rate of engagement of families? What role does cultural

competence play in the engagement and

retention of clients?

•Does the classic family therapy model fit

across ethnic groups? If not, what are more

feasible options?

•How can competence with families be

developed?

•How can the resources of families and

communities be identified and mobilized?

•What family differences are important in the

treatment of youth, adults, and specifically

children?

•What kinds of research and models can

increase our understanding of the family role

in relapse?

•How will these efforts be funded?

•What changes need to take place for both private and public payment of these services?

The oversimplification of the above might lead

some readers to feel as if there is a wide gap

between family therapy and substance abuse

treatment and that it is a giant leap to move

from doing one to doing the other. However,

this is not the case. Many people have amended

and augmented their customary way of doing

their job with input from the other field, and it

is certainly not the intent of this TIP to leave

the reader with the idea that drawing from the

other field requires great change or effort.

Rather, the exact opposite is the goal.

Policy and Program Issues 163

       

                   

               

                 

     

     

             

         

                 

               

             

             

             

                     

       

                 

   

           

   

                 

             

               

     

           

             

           

   

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Appendix B: 

Glossary

Affect

Feeling or emotion, especially as manifested by facial expression or

body language.

Affective/spiritual acculturation

A family’s sense of connectedness to its ethnic traditions.

BCT

Behavioral couples therapy.

Behavioral acculturation

The degree to which a family participates in traditional or dominantculture activities as opposed to other culture­specific activities.

BMT

Behavioral marital therapy.

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.

CBT

Cognitive–behavioral therapy.

Codependence

A state of being overly concerned with the problems of another, to

the detriment of one’s own wants and needs.

Cognitive acculturation

A client’s grasp of and the extent of his involvement in the customs,

beliefs, values, and language of a given culture.

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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.

Ecological view of substance abuse

A conception of substance abuse that is

analogous to that of an ecological system in

nature. Substance abuse occurs within a

complex of systems, including families,

communities, and societies. It may be

assumed that all of the elements of this

“ecological” system will have some influence on all the other elements.

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.

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.

Family­involved therapy

The programmatic involvement of family

members in the substance abuse treatment

program to correct family relationships

that provoke or support continued substance abuse. Family­involved therapy is

distinct from family therapy in that it may

not view the entire family as the object of

therapeutic interest and may not always

intervene in the family’s relational system.

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).

Idiopathic

Of, relating to, or designating a disease

having no known cause.

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.

IP

Identified patient.

MFT

Marriage and family therapy.

One­person family therapy

Therapy incorporating a family focus

without treating the whole family.

192 Glossary
     

           

           

         

       

       

         

       

         

         

         

       

       

           

           

   

             

     

           

           

         

   

         

             

             

             

                 

       

             

         

           

         

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.

Psychoeducation

A combination of information about substance abuse and recovery, group support,

and examination of interactions that result

in conflict. Facilitators collaborate with the

family to change these provocative interactions, reduce household stress, and create

an atmosphere conducive to recovery.

Social/environmental acculturation

A family’s patterns of socialization or

acquisition of familiarity with its social and

environmental elements.

Somatic

Of, relating to, or affecting the body.

Stages of change

One model of the phases of substance abuse

recovery: precontemplation, contemplation,

preparation, action, and maintenance.

Traditional family

The nuclear family (two parents and minor

children all living under the same roof),

single parent, and families including blood

relatives, foster relationships, grandparents

raising grandchildren, and stepfamilies.

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.

Glossary 193

                         

                   

               

               

                     

               

               

                     

                   

                       

                       

                     

           

                   

                 

               

             

   

           

         

             

             

   

   

Appendix C: Guidelines
 

for Assessing Violence
 

It is up to therapists to assess the potential for anger and violence and

construct therapy so it can be conducted without endangering any family

members. Because of the life­and­death nature of this responsibility, the

consensus panel included recommended guidelines for the screening and

treatment of people caught up in the cycle of domestic violence. These

recommendations are adapted from TIP 25, Substance Abuse Treatment

and Domestic Violence (Center for Substance Abuse Treatment 1997b).

If during the screening interview, it becomes clear that a batterer is

endangering a client, 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 can be ensured. The

provider should refer the client to a domestic violence program and

possibly to a shelter and legal services.

Screening guidelines for domestic violence

and other abusive behavior

1. To determine if someone has endured domestic violence, look for

physical injuries, especially patterns of untreated injuries to the face,

neck, throat, and breasts. 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

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•A sad, flat affect or talk of suicide

•History of relapse or noncompliance with

substance abuse treatment plans

2. 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.

3. As soon as it is clear that a client has been or

is being battered, domestic violence experts

should be contacted.

4. The provider should contact a forensics

expert to document the physical evidence of

battering.

5. Referrals should be made whenever

appropriate for psychotherapy and specialized counseling. Staff training in domestic

violence is important so that substance abuse

treatment counselors can respond effectively

to a domestic violence crisis.

6. A survivor of domestic violence who relocates

to another community should be referred to

the appropriate shelter programs within that

community.

7. Because batterers in treatment frequently

harass their partners (threatening them by

phone, mail, and messages sent through

approved visitors), telephone and visitation

privileges of batterers and survivors in

residential substance abuse treatment

programs should be carefully monitored.

8. The discussion of family relationships, which

is an element of all substance abuse screening

interviews, can be used to identify domestic

violence and gauge its severity.

9. 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 (person), was it a slap or a

punch?

•Do you take car keys away? Damage

property? Threaten to injure or kill (person)?

10. Once it has been confirmed that a client has

been abusive­whether 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.

11. The provider should be direct and candid,

avoiding vague or euphemistic language,

such as, “Is your relationship with your

partner troubled?” Instead, ask about

“violence,” and keep the focus on behavior.

12. Become familiar with batterers’ rationalization and excuses for their behavior:

•Minimizing: “I only pushed her.” “She

bruises easily.” “She exaggerates.”

•Claiming good intentions: “When she gets

hysterical, I have to slap her to calm her

down.”

•Blaming intoxication: “I was drunk.” “I’m

not myself when I drink.”

•Pleading loss of control: “Something

snapped.” “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.” Substance abuse

treatment providers should frame screening

questions so that they do not allow a batterer

to blame the person battered or a drug.

196 Guidelines for Assessing Violence
           

             

             

         

           

     

         

         

           

             

         

       

       

       

       

           

             

       

             

           

               

             

         

       

       

         

             

             

       

       

         

             

       

           

         

             

         

           

           

         

             

     

         

           

           

                 

           

           

         

           

       

         

           

         

         

         

         

       

         

             

         

           

         

       

           

             

         

               

       

         

               

           

             

       

           

         

             

13. When treating a client who batters,

providers should try to ensure the safety of

those who have been or may be battered

(partners and children, usually) during any

crisis that precedes or occurs during the

course of his treatment.

14. Treatment providers should mandate that

batterers sign a “no­violence contract”

stating that the client will refrain from

using violence in­ and outside the program.

15. Treatment providers should determine the

relationship between the substance abuse

and the violent behavior:

•When you take/drink (substance), exactly

when does the violence occur?

•How much of your violent behavior occurs

while you are drinking or on other drugs?

•What substances lead to violence?

•What feelings do you have before and during

the use of alcohol or other drugs?

•Do you use substances to get over the violent

incident?

16. After identifying the chain of events that

precedes or triggers violent episodes, the

provider and client should formulate

strategies for modifying those behaviors

and recognizing emotions that contribute to

violent behavior.

17. Providers of services to clients who batter

should watch for signs that the clients are

misinterpreting the 12­Step philosophy to

excuse continued violence. For example,

the first step is admitting powerlessness

over alcohol. Thus the client may be one

short rationalization away from excusing a

violent act while intoxicated, which is later

justified because the substance “made me

do it.” Another danger is that batterers will

call their partners “codependent” to shift

blame for battering to the person harmed.

18. Referrals to self­help aftercare groups such

as Batterers Anonymous should be made

only after the client has completed a

batterers’ intervention program and has

remained nonviolent for a specified period

of time.

Screening for child abuse

19. Inquiries into possible child abuse should

not occur until the limits of confidentiality,

as defined in Title 42, Part II, of the Code

of Federal Regulations (or 42 C.F.R, II)

have been explained and the client has

acknowledged receipt of this information in

writing. Clients also must be informed that

mandated reporters (such as substance

abuse treatment providers) are required to

notify a child protective services agency if

they suspect child abuse or neglect.

20. 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?

21. The substance abuse treatment provider

should not assess children for abuse or

incest. Only personnel with special expertise

should perform this delicate function. 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.

22. Indications of child abuse that can crop up

in a client interview include:

•Has a protective services agency been

involved with anyone who lives in the home?

•Do the children’s behaviors, such as bedwetting or sexual acting out, indicate abuse?

•Is extraordinary closeness noted between a

child and another adult in the household?

•Does the client report blackouts? (Batterers

often claim to black out during a violent

episode.)

Guidelines for Assessing Violence 197
             

           

         

               

               

           

         

       

           

           

           

           

           

               

               

               

   

23. If a treatment provider suspects that a

client’s child has been violently 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.

24. If the treatment provider reports suspected

or definite child abuse or neglect, the

provider must assess the impact on any

client also being battered and develop a

safety plan if one is deemed necessary.

25. 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.

198 Guidelines for Assessing Violence
                       

               

           

           

         

         

   

     

   

   

   

               

             

                   

                   

                   

           

       

   

   

   

   

   

                   

                       

Appendix D: 

Resources

The list of resources in this appendix is not exhaustive. The inclusion of

selected resources does not necessarily signify endorsement by the

Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services.

Addiction Technology Transfer Center National Office

University of Missouri ­ Kansas City

5100 Rockhill Road

Kansas City, MO 64110

Phone: (816) 482­1200

Fax: (816) 482­1101

E­mail: no@nattc.org

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

The Addiction Technology Transfer Centers (ATTCs) 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 the Center for Substance Abuse

Treatment (CSAT), part of SAMHSA, the Network today is composed of

14 independent Regional Centers and a National Office.

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 (ACA) is a 12­Step, Twelve Tradition program of men and women who grew up in alcoholic or otherwise dysfunctional homes.

199
   

     

   

   

           

       

               

           

         

     

     

     

     

   

               

         

             

               

             

             

       

     

     

     

     

   

               

         

         

       

     

    

   

   

   

         

         

             

       

           

         

   

       

     

   

   

   

             

             

               

       

           

   

       

   

   

       

           

   

           

             

             

   

   

   

   

   

       

           

         

             

       

Adult Children Anonymous

ACA General Service Network

P.O. Box 25166

Minneapolis, MN 55458­6166

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.

Al­Anon

Al­Anon Family Group Headquarters, Inc.

1600 Corporate Landing Parkway

Virginia Beach, VA 23454­5617

Phone: 1­888­4AL­ANON

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 Twelve Steps, by welcoming and giving comfort to families of alcoholics, and by providing understanding and

encouragement to the alcoholic.

Alateen

Al­Anon Family Group Headquarters, Inc.

1600 Corporate Landing Parkway

Virginia Beach, VA 23454­5617

Phone: 1­888­4AL­ANON

Web site: http://www.al­anon.alateen.org/

Alateen is a group made up of young Al­Anon

members, usually teenagers, whose lives have

been affected by someone else's drinking.

American Association for Marriage and

Family Therapy

112 South Alfred Street

Alexandria, VA 22314

Phone: (703) 838­9808

Fax: (703) 838­9805

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

The American Association for Marriage and

Family Therapy (AAMFT) is the professional

association for the field of marriage and family

therapy. AAMFT represents the professional

interests of more than 23,000 marriage and

family therapists throughout the United States,

Canada, and abroad.

Association for Play Therapy (APT)

2050 North Winery Avenue

Suite 101

Fresno, CA 93703

Phone: (559) 252­2278

E­mail: info@a4pt.org

Web site: http://www.a4pt.org

The Association for Play Therapy is an organization that was formed to help children and

others in need. Its mission is to advance the

psychosocial development and mental health of

all people through play and play therapy.

Co­Anon Family Groups

Co­Anon Family Groups World Services

P.O. Box 12722

Tucson, AZ 85732­2722

Voice recorder: (520) 513­5028 Tucson,

Arizona or (800) 898­9985 Toll Free

E­mail: info@co­anon.org

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.

Co­Dependents Anonymous, Inc. (CoDA)

P.O. Box 33577

Phoenix, AZ 85067­3577

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

Co­Dependents Anonymous, Inc. (CoDA) is a

fellowship of men and women whose common

purpose is to develop healthy relationships.

CoDA relies on the Twelve Steps and Twelve

Traditions for knowledge and wisdom.

200 Resources
   

     

   

   

         

           

           

           

         

       

   

         

   

   

         

           

         

               

           

   

     

             

   

   

           

             

         

         

           

           

     

             

           

           

             

         

           

       

       

   

   

         

           

       

         

           

       

       

           

   

   

     

           

         

             

               

     

           

           

               

         

     

Families Anonymous

P.O. Box 3475

Culver City, CA 90231­3475

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.

The National Association for Children

of Alcoholics

11426 Rockville Pike, Suite 100

Rockville, MD 20852

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

Fax: (301) 468­0987

E­mail: nacoa@nacoa.org

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

NACoA is the national nonprofit membership

organization working on behalf of children of

alcohol and drug dependent parents. NACoA's

mission is to advocate for all children and families affected by alcoholism and other drug

dependencies.

Nar­Anon Family Group

Nar­Anon World Service Office

302 West 5th Street, #301 San Pedro, CA

90731

Phone: (310) 547­5800

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

Nar­Anon Family Group is a 12­Step Recovery

program for the families and friends of individuals addicted to drugs and alcohol.

Substance Abuse and Mental Health Services

Administration (SAMHSA)

http://www.samhsa.gov

SAMHSA is the Federal agency charged with

improving the quality and availability of prevention, treatment, and rehabilitative services

in order to reduce illness, death, disability, and

cost to society resulting from substance abuse

and mental illnesses. SAMHSA is composed of

three Centers to carry out this mission: the

Center for Substance Abuse Treatment, the

Center for Mental Health Services, and the

Center for Substance Abuse Prevention.

U.S. Department of Health and Human

Services

Families & Children
 

Web site: http://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), for
 

low­income families, HHS 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 or toll­free at

(877) 4­WestEd

WestEd is a nonprofit research, development,

and service agency. The agency traces its history back to 1966 when Congress created a network of Regional Educational Laboratories.

WestEd is committed to improving learning at

all stages of life­from infancy to adulthood,

both in school and out. The agency’s work is

far­reaching because its purpose is ambitious:

success for every learner.

Resources 201

     

         

   

         

   

       

       

     

     

   

       

       

           

   

     

       

       

     

       

       

       

    

     

       

         

   

         

   

     

         

         

   

   

         

       

         

         

         

                       

                 

Appendix E: 

Resource Panel

Note: The information given indicates each participant's affiliation during the time the panel

was convened and may no longer reflect the individual's current affiliation.

Shirley Beckett, NCAC II

Certification Administrator

National Association of Alcohol and Drug

Abuse Counselors

Alexandria, Virginia

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

Senior Program Management Officer

Substance Abuse and Mental Health

Services Administration

Center for Substance Abuse Treatment

Rockville, Maryland

Frank Canizales, M.S.W.

Management Analyst, Alcohol Program

Indian Health Service

Rockville, Maryland

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

Centers for Medicare and Medicaid

Services

Center for Medicaid and State Operations

Baltimore, Maryland

Christina Currier

Public Health Analyst

Substance Abuse and Mental Health

Services Administration

Center for Substance Abuse Treatment

Rockville, Maryland

James Gil Hill

Director

Office of Evaluation, Scientific Analysis

and Synthesis

Center for Substance Abuse Treatment

Rockville, Maryland

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

Substance Abuse and Mental Health

Services Administration

Center for Substance Abuse Treatment

Rockville, Maryland

Karen Urbany

Public Health Advisor

Substance Abuse and Mental Health

Services Administration

Center for Substance Abuse Treatment

Rockville, Maryland

Steve Wing

Senior Advisor for Drug Policy

Substance Abuse and Mental Health

Services Administration

Office of Policy and Program Coordination

Rockville, Maryland

203

           

     

     

     

   

   

     

         

   

     

   

     

         

       

   

   

     

   

                       

                 

Appendix F: Cultural

Competency and Diversity

Network Participants

Note: The information given indicates each participant's affiliation during the time the network

was convened and may no longer reflect the individual's current affiliation.

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

Ting­Fun May Lai, M.S.W., CSW, CASAC

Director

Chinatown Alcoholism Center

Hamilton­Madison 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

205

   

       

         

       

   

     

       

       

   

     

   

         

   

             

    

   

   

   

       

       

         

         

     

     

           

   

   

   

     

   

     

             

     

   

       

          

   

         

       

     

     

       

     

   

     

   

   

     

                         

                 

Appendix G: 

Field Reviewers

Note: The information given indicates each participant's affiliation during the time the review was

conducted and may no longer reflect the individual's current affiliation.

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

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 Officer

Substance Abuse and Mental Health

Services Administration

Center for Substance Abuse Treatment

Rockville, Maryland

Paula Corey

Senior Vice President

Palladia, Inc.

New York, New York

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

Professor of Nursing

University of Cincinnati

College of Nursing

Cincinnati, Ohio

Jo­an M. Fox

Nashville, Tennessee

Joel Frank

Milwaukee, Wisconsin

Anne M. Herron, M.S.

Director

New York State Office 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 Office
 

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 Officer
 

Arapahoe House, Inc.
 

Thornton, Colorado
 

207
         

     

     

         

   

   

     

   

   

       

   

     

      

         

         

   

     

   

         

   

         

       

     

   

           

   

         

     

       

     

       

     

           

     

       

           

  

     

     

       

       

   

           

         

       

       

   

     

   

       

       

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
 

Gwen M. Olitsky, M.S.

Founder and C.E.O.

The Self­Help 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

National Association of Alcoholism and

Drug Abuse Counselors
 

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 University­Bloomington

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

ND Department of Human Services

Jamestown, North Dakota

Ann S. Yabusaki, Ph.D.

Substance Abuse Director

Psychologist

Coalition for a Drug­Free Hawaii

Substance Abuse Programs and Training

Kaneohe, Hawaii

208 Field Reviewers
                         

                       

                         

                       

       

                             

                   

         

                       

                   

               

                   

                   

                       

                       

                         

                       

           

Appendix H:

Acknowledgments

Numerous people contributed to the development of this TIP, including the TIP Consensus Panel

(see page ix), the Knowledge Application Program (KAP) Expert Panel and Federal Government

Participants (see page xi), the SAMHSA Resource Panel Meeting attendees, (see Appendix E), the

KAP Cultural Competency and Diversity Network participants (see Appendix F), and TIP Field

Reviewers (see Appendix G).

This publication was produced under KAP, a Joint Venture of The CDM Group, Inc. (CDM), and

JBS International, Inc. (JBS), for the Substance Abuse and Mental Health Services

Administration, Center for Substance Abuse Treatment.

CDM KAP personnel included Rose M. Urban, M.S.W., J.D., LCSW, LCAS, KAP Executive

Deputy Project Director; Susan Kimner, Managing Project Co­Director; Elizabeth Marsh, former

KAP Deputy Project Director; Sheldon Weinberg, KAP Senior research/Applied Psychologist;

Raquel Witkin, M.S., former Deputy Project Manager; Pamela Dronka, former Editor/Writer;

Michelle Myers, Editor/Writer; Sonja Easley, former Editorial Assistant; Jason Merritt, former

KAP Manager of Collateral Products, and Virgie Paul, M.L.S., librarian. In addition, Sandra

Clunies, M.S., I.C.A.D.C., served as Content Advisor. Special thanks go to Rosemary McGinn,

J.D., CASAC, for her contributions to chapter 6, Program and Policy Issues. Jonathan Max

Gilbert, M.A., Helen Oliff, B.S., David Sutton, B.A., Catalina Bartlett, M.A., and Randi

Henderson, B.A., B.S. served as writers.

209

   

     

     

   

       

         

     

     

   

         

       

         

       

   

   

   

           

       

           

       

       

         

         

         

           

   

         

     

           

   

   

     

   

   

       

   

     

     

   

       

   

       

   

     

           

   

       

     

     

Index
 

A

AA. see Alcoholics Anonymous

AAMFT. see American Association for

Marriage and Family Therapy

AAP. see American Academy of Pediatrics

abstinence
 

enabling phenomenon and, 59
 

ACA. see Adult Children of Alcoholics

action stage of change, 15, 47
 

Addiction Technology Transfer Centers
 

certification information, 38
 

National Office contact information, 201
 

Web site, 151
 

adolescents. see also children
 

American Indians and Alaska Natives goals
 

for, 129
 

application to family therapy, 111–112
 

brief strategic family therapy and, 53
 

co­occurring substance abuse and mental
 

disorders and, 137–138
 

confidentiality issues, 37–38
 

homelessness and, 142
 

interaction with peers who use drugs, 27
 

living in blended families, 25
 

living with the family of origin, 27–28
 

multidimensional family therapy and, 53–54,
 

90–91
 

multisystemic family therapy and, 92
 

parents who abuse substances and, 27–28
 

percentage reporting drug and alcohol use,
 

111
 

risk factors for substance abuse, 111
 

role of psychoactive drugs in violent death
 

of, 27
 

rural youth, 139
 

sensitivity of adolescents’ brains to alcohol,
 

111
 

session scheduling for, 112
 

siblings in the family and, 27, 112
 

Adult Children Anonymous
 

codependency and, 23
 

contact information, 202
 

Adult Children of Alcoholics
 

codependency and, 23
 

contact information, 201
 

Web site, 106
 

affect
 

definition, 193
 

affective impairments
 

description, 132
 

affective/spiritual acculturation
 

definition, 193
 

African Americans
 

application to family therapy, 117–119
 

background issues, 117
 

Bible­related recovery programs, 118
 

extended families and, 117
 

functional single­parent families, 118–119
 

importance of therapist rapport, 118
 

kinship bonds, 117
 

life­affirming nature of effective substance
 

abuse treatment, 119
 

missionary racism and, 118
 

parental child taking care of other children,
 

119
 

parenting issues, 118–119
 

practice of reciprocity and, 117
 

role of women, 118
 

single­family therapy and, 118
 

211
   

         

       

           

   

         

     

   

         

         

   

     

         

     

       

   

   

         

     

     

   

     

       

         

       

       

       

       

   

       

   

   

   

   

       

     

   

     

       

   

     

     

         

       

   

       

     

             

       

   

     

   

   

   

       

     

     

       

   

             

   

         

     

     

Al­Anon
 

codependency and, 23
 

contact information, 202
 

family members of people with co­occurring
 

substance abuse and mental disorders
 

and, 137
 

referral of family members to, 15, 36
 

Alateen
 

codependency and, 23
 

contact information, 202
 

recovery reinforcement, 28
 

referral of family members to, 15
 

alcohol use and abuse
 

adolescents and, 111
 

American Indians and Alaska Natives and,
 

127–128
 

gay and lesbian persons and, 130
 

genetic component, 65
 

older adults and, 112–113
 

persons with physical or cognitive disabilities
 

and, 132
 

rural populations and, 139
 

solution­focused brief therapy and, 100–101
 

veterans and, 144
 

women and, 114
 

“alcoholic families”
 

description, 59
 

Alcoholics Anonymous

American Indians and Alaska Natives and,

130
 

network therapy and, 98
 

recovery reinforcement, 28
 

rural populations and, 140–141
 

Web site, 70
 

American Academy of Pediatrics
 

inhalant use by children, 110
 

American Association for Marriage and Family
 

Therapy
 

Commission on Accreditation for Marriage
 

and Family Therapy Education, 38
 

contact information, 202
 

screening for substance abuse, 44–45

American Indians and Alaska Natives
 

acculturation and, 128–129
 

application to family therapy, 128–130
 

background issues, 126–127
 

communication styles, 129
 

cooperation and, 127
 

culturally competent approaches, 129–130
 

direct eye contact and, 129
 

emotional bonds between grandparents and
 

grandchildren and, 128
 

emphasis on listening, 129
 

extended families and, 127, 128
 

family structure, 128
 

First Nations Community HealthSource
 

integrated models example, 78
 

guidelines for therapists working with, 130
 

harmony with nature and, 127
 

heterogeneity of, 127
 

historical trauma and, 127, 128
 

network therapy and, 98
 

respect for the rights of others and, 127
 

sharing and giving and, 127
 

spirituality and, 127
 

substance abuse patterns, 127
 

time orientation, 127
 

trigenerational extended family
 

phenomenon, 128
 

urban Indians, 128
 

value of children to, 128
 

values of, 127, 129
 

American Psychiatric Association, 45
 

Americans With Disabilities Act, 133
 

anger expression. see also domestic violence;
 

violence
 

in families with a member with a substance
 

use disorder, 22
 

family members and persons with physical
 

or cognitive disabilities, 134–135
 

anxiety management. see Bowen family systems

therapy

212 Index
   

     

     

     

       

   

   

     

     

   

   

   

           

         

     

     

       

       

     

     

         

       

         

         

   

     

       

     

       

   

   

       

     

   

   

       

     

   

     

         

       

     

         

   

     

         

   

   

     

       

           

   

     

       

     

     

   

   

       

           

     

   

APA. see American Psychiatric Association

APT. see Association for Play Therapy

Asian Americans
 

acculturation and, 123, 124–125
 

alternative medicine and, 126
 

application to family therapy, 123–126
 

communication styles, 125
 

confidentiality issues, 126
 

considerations for counseling, 126
 

cultural diversity of, 123
 

engagement with, 125–126
 

family structure, 123
 

filial obligations, 124
 

focusing on physical symptoms of the person
 

with a substance use disorder, 125–126
 

hierarchical family structure, 125
 

“model minority” myth, 123
 

rates of substance abuse, 123
 

“saving face” and, 124, 125
 

scheduling of sessions, 126
 

assessment. see also outcome evaluation

in family therapy, 42–45

overview of key elements (figure), 39–41

in substance abuse treatment, 38–41

Assessment and Treatment of Persons With
 

Coexisting Mental Illness and Alcohol and
 

Other Drug Abuse, 136
 

Association for Addiction Professionals
 

certification for substance abuse treatment
 

counselors, 38
 

Association for Play Therapy
 

contact information, 202
 

definition of play therapy, 110
 

ATTCs. see Addiction Technology Transfer

Centers

B

barriers to treatment

power relationships, 45–46

race and ethnicity and, 116–117

rural populations and, 139–140

Batterer’s Intervention Programs, 18
 

BCT. see behavioral couples therapy
 

behavioral acculturation, 193
 

behavioral contracting
 

behavioral family therapy and, 61
 

description, 50–51
 

behavioral couples therapy, 7
 

behavioral family therapy
 

for adolescents with co­occurring substance
 

abuse and mental disorders and, 137–138
 

case study examples, 93, 95
 

improving communication, 95
 

techniques and strategies, 94
 

techniques to help families attain sobriety
 

(figure), 103
 

theoretical basis, 94
 

Behavioral Health Recovery Management
 

listing of mutual aid resources, 71
 

Behavioral Marital Therapy
 

description, 61
 

goals of, 52
 

strategies and techniques, 52–53
 

view of substance abuse, 51–52
 

Bepko and Krestan’s theory of substance abuse
 

description, 51
 

BFT. see behavioral family therapy
 

biologic aspects of addiction
 

effect on family therapy, 14
 

blended families
 

effective coparenting, 25
 

family dynamics of, 25–26
 

substance abuse by stepparents, 25
 

BMT. see Behavioral Marital Therapy
 

boundaries
 

description, 58, 193
 

family therapy and, 32, 58
 

generational, 58
 

structural family therapy and, 62, 86, 88
 

Bowen family systems therapy
 

immigrants and, 99
 

Index 213
 
     

         

   

     

   

   

   

     

     

       

       

   

     

   

         

       

       

         

     

   

           

   

       

       

     

         

           

     

           

         

   

   

     

           

   

         

   

             

   

   

   

   

       

   

     

             

         

       

       

     

       

       

   

   

   

     

         

     

         

         

       

   

   

C

techniques and strategies, 99–100
 

techniques to help families attain sobriety
 

(figure), 103
 

theoretical basis, 98–99
 

brief strategic family therapy
 

for adolescents, 111–112
 

description, 53, 87
 

effectiveness of, 7
 

multidimensional approach of, 8
 

Brief Strategic Family Therapy, 90
 

BSFT. see brief strategic family therapy

buprenorphine
 

opioid addiction outpatient treatment, 69
 

Caribbean Black populations
 

therapy issues, 117, 118
 

case management therapy. see family/larger

system/case management therapy

CDC. see Centers for Disease Control and

Prevention

Center for Substance Abuse Treatment

Division of Pharmacologic Therapies, 69–70

Centers for Disease Control and Prevention
 

estimates of HIV/AIDS, 141
 

Centers for Independent Living
 

referral of persons with physical or cognitive
 

disabilities to, 134
 

certification
 

substance abuse treatment and family
 

therapy, 38
 

change and balance in families
 

substance abuse and, 59
 

Checklist for Monitoring Alcohol and Other
 

Drug Confidentiality, 37
 

child abuse or neglect. see also elder abuse or
 

neglect
 

family therapy and, 17–18
 

legal and ethical requirement to report, 48,
 

159
 

mothers who abuse substances and, 115
 

screening guidelines, 199–200
 

child protective services
 

family therapy and, 14
 

children. see also adolescents; infants
 

adult children of older adults with substance
 

abuse problems, 26–27
 

of American Indians and Alaska Natives,
 

128
 

custody issues, 116
 

effect of drug or alcohol use on the
 

developing brain, 110
 

in Hispanic/Latino families, 120–121
 

HIV/AIDS and, 141
 

homelessness and, 142
 

inappropriate role­taking by, 21, 24
 

inhalant use, 110
 

involvement in therapy, 110
 

living with a parent with a substance use
 

disorder, 24
 

of mothers who abuse substances, 115
 

parenting issues among African Americans,
 

118–119
 

parent’s veteran status and, 144
 

play therapy for, 110–111
 

prenatal drug exposure and, 115
 

referral to age­appropriate services, 36
 

resiliency in, 24
 

school­related problems, 24
 

sibling relationships and, 27
 

support groups for, 17
 

treatment goals for children in alcoholic
 

families, 106
 

12­Step programs and, 70
 

of women who abuse substances during
 

pregnancy, 24
 

chronic disease
 

cost­effectiveness of family therapy and, 13
 

circular causality of families, 3
 

Co­Anon Family Groups
 

codependency and, 23
 

contact information, 202
 

Co­Dependents Anonymous, Inc.
 

214 Index
       

         

   

     

     

     

   

   

     

           

   

       

   

         

     

     

   

         

   

   

   

   

   

     

         

       

       

     

     

     

         

     

       

   

         

     

       

       

       

   

         

     

   

     

             

         

       

         

     

   

   

       

     

       

   

         

contact information, 202

patterns of behavior of codependent people,

23–24

cocaine use
 

among lesbian and bisexual women, 130
 

CoDA. see Co­Dependents Anonymous, Inc.

codependence
 

description, 24, 193
 

12­Step programs and, 23–24
 

cognitive acculturation, 193
 

cognitive–behavioral family and couples
 

therapy
 

case study example, 93
 

description, 7, 8
 

focus of, 61
 

techniques and strategies, 94
 

techniques to help families adjust to sobriety
 

(figure), 104
 

theoretical basis, 94
 

cognitive disabilities. see people with physical

or cognitive disabilities

communication

American Indians and Alaska Natives and,

129
 

Asian Americans and, 125
 

e­mail, 162–163
 

family patterns of, 3
 

Hispanics/Latinos and, 121
 

Community Reinforcement Approach
 

influence on other integrated models, 84
 

Community Reinforcement Training
 

description, 83, 84
 

complementarity
 

description, 58, 194
 

Comprehensive Case Management for
 

Substance Abuse Treatment, 98
 

concurrent treatment

description, 28–29

confidentiality issues. see also informed consent
 

for Asian Americans, 126
 

family education and participation and, 153
 

family integration programs and, 159
 

government and State regulations, 37–38
 

integrated models and, 148
 

provider collaboration and, 154, 155
 

rural populations and, 138
 

Confidentiality of Patient Records for Alcohol
 

and Other Drug Treatment, 37
 

confrontation

substance abuse treatment and family

therapy comparison, 47–48

consumer­based collaboration efforts, 157
 

contemplation stage of change, 15, 46
 

content of the session
 

substance abuse treatment and, 35
 

couples therapy. see also marriage and family
 

therapy
 

multiple family therapy and, 92
 

types of, 7
 

coworkers
 

effects of substance abuse on, 22
 

CRA. see Community Reinforcement Approach

criminal justice system. see also legal issues

family/larger system/case management

therapy and, 96, 98
 

La Bodega de la Familia program, 96, 157
 

role in mandating substance abuse treatment
 

with a family focus, 149
 

source of referrals to substance abuse
 

treatment, 149
 

structural/strategic family therapy case
 

study, 89
 

veterans and, 144
 

cross­training
 

provider collaboration and, 156
 

CRT. see Community Reinforcement Training

cultural competency and diversity network
 

participants
 

names and contact information, 207
 

cultural factors. see also race and ethnicity
 

Asian Americans, 123
 

family therapy and, 10, 12, 34
 

Index 215
 
     

   

       

     

           

     

       

   

         

         

     

   

         

     

     

       

       

     

   

     

         

   

     

         

   

         

   

         

         

   

       

         

       

   

       

         

       

           

   

   

         

   

       

   

       

       

         

       

       

       

Hispanic/Latino family functioning and,
 

119–120
 

integrated models, 85
 

policy considerations, 160
 

structural/strategic family therapy and, 87,
 

90
 

substance abuse treatment, 34
 

D

Deaf and Hard of Hearing 12­Step Recovery
 

Resources, 71
 

definitions of terms, 193–195

denial
 

family therapy and substance abuse
 

treatment terminology comparison, 32–33
 

persons with physical or cognitive disabilities
 

and, 134
 

Depression and BiPolar Support Alliance, 71
 

Detoxification and Substance Abuse
 

Treatment, 67
 

detoxification programs
 

family involvement, 67
 

inpatient, 66
 

outpatient, 66–67
 

referral to, 44
 

social, 67
 

Diagnostic and Statistical Manual of Mental
 

Disorders, 4th ed., Text Revised
 

diagnostic approach of, 52
 

screening for substance abuse, 45
 

disease model of substance abuse
 

description, 33, 65, 151
 

disengagement
 

definition, 194
 

domestic violence. see also anger expression;
 

violence
 

family therapy and, 17–18
 

gay and lesbian couples and, 130
 

homelessness and, 143
 

integrated models and, 78
 

persons with physical or cognitive disabilities
 

and, 132
 

screening guidelines, 197–199

women with substance use disorders and,

115–116

DSM­IV­TR. see Diagnostic and Statistical

Manual of Mental Disorders, 4th ed., Text

Revised

E

e­mail
 

uses for communication in the therapy
 

setting, 162–163
 

EAPs. see Employee Assistance Programs
 

ecological view of substance abuse
 

definition, 194
 

ecosystem concept of the family, 4
 

educational requirements. see also crosstraining; family education and participation;
 

psychoeducation; staff education
 

family integration programs and, 159–160
 

integrated models and, 78, 79, 83
 

substance abuse treatment and family
 

therapy, 38
 

elder abuse or neglect. see also child abuse or
 

neglect; older adults
 

reporting requirements, 113, 159
 

elderly persons. see elder abuse or neglect;
 

older adults
 

elected families
 

description, 2
 

emancipated youth, 2
 

emotionally focused couples therapy, 7
 

Employee Assistance Programs
 

referrals to family therapists, 157
 

empowerment differential in family therapy
 

and substance abuse treatment, 45–46, 70,
 

86
 

enabling phenomenon, 59
 

Enhancing Motivation for Change in
 

Substance Abuse Treatment, 16, 48, 61
 

enmeshment
 

definition, 194
 

The Essentials of Family Therapy, 58
 

216 Index
     

       

       

     

         

           

   

         

         

     

   

   

     

         

       

           

     

   

   

           

         

       

       

     

   

       

         

   

     

   

       

       

     

     

         

       

   

   

     

   

         

       

       

     

       

   

   

   

     

         

         

   

   

     

     

           

             

ethnicity. see race and ethnicity
 

Eugene O’Neill genogram, 43, 44
 

exception questions
 

solution­focused brief therapy and, 102
 

extended families
 

African Americans and, 117
 

American Indians and Alaska Natives and,
 

127, 128
 

description, 2
 

effects of substance abuse on, 22, 25
 

Hispanics/Latinos and, 120
 

F

families
 

change in the concept of, 4
 

characteristics of families central to family
 

therapy, 3
 

circular causality and, 3
 

communication traits, 3
 

as ecosystems, 4
 

geographically distant members, 2–3
 

homeostasis and, 3, 4, 5, 59
 

intergenerational effects of substance abuse,
 

22
 

isolation of the substance abuser from, 22
 

metaphoric definition of, 3
 

multigenerational bonds, 4
 

nonsummativity of, 3
 

patterns of interaction in families with a
 

member with a substance use disorder,
 

22–23
 

role in treatment, 1, 2
 

social support groups and, 3
 

types of, 2, 4
 

Families Anonymous
 

codependency and, 23
 

contact information, 203
 

family behavior loop mapping, 144
 

family disease model of family therapy
 

description, 8, 33
 

family education and participation
 

confidentiality issues, 153
 

counselor training and caseloads, 153
 

“family counseling” offered by substance
 

abuse treatment facilities, 151–152
 

in integrated models, 74
 

issues for staff and trainers, 154
 

issues for substance abuse treatment
 

program administrators, 153–154
 

outcome evaluation, 154
 

family integration
 

confidentiality issues, 159
 

description, 157–158
 

informed consent and, 158–159
 

infrastructure concerns, 158
 

issues for staff and trainers, 159–160
 

issues for substance abuse treatment
 

program administrators, 158–159
 

range of program activities, 158
 

Family Intervention Program
 

integrated model example, 77
 

family interventions
 

substance abuse treatment and family
 

therapy comparison, 34
 

family­involved therapy
 

description, 6, 194
 

family/larger system/case management therapy
 

goal of, 97
 

techniques and strategies, 98
 

techniques to help families attain sobriety
 

(figure), 103
 

techniques to help families in long­term
 

maintenance (figure), 106
 

theoretical basis, 97–98
 

family maps, 43, 144
 

Family Partnering Case Management
 

description, 96
 

family structures
 

adolescent clients living with the family of
 

origin, 27–28
 

clients as part of a blended family, 25–26
 

Index 217
 
             

             

         

       

     

         

           

     

   

   

         

             

     

   

   

       

         

   

     

       

   

     

     

   

       

   

   

       

   

           

   

   

   

   

     

     

         

     

     

     

       

   

       

   

     

         

         

   

     

   

   

   

       

     

   

         

     

         

       

           

       

   

         

     

     

       

     

     

     

   

clients who live alone or with a partner,
 

23–24
 

clients who live with a spouse and minor
 

children, 24–25
 

definition, 194
 

families with a member who abuses
 

substances, 23–28
 

hidden substance abuse and, 28
 

multigenerational patterns of substance
 

abuse, 27–28
 

older clients with grown children, 26–27
 

family systems model of family therapy. see
 

also Bowen family systems therapy
 

abstinence and, 59
 

basis of, 17
 

description, 1, 6, 8, 33–34, 58
 

elements of the family as a system, 58–59
 

individual, family, and environmental
 

systems (figure), 56
 

triangulation concept, 59–60
 

family therapy
 

assessment procedures and issues, 42–45
 

biologic aspects of addiction and, 14
 

boundary issues, 32
 

chronic disease and, 13
 

client identification of family members to
 

include, 3, 29
 

co­occurring problems and, 14
 

compatibility with substance abuse
 

treatment, 34
 

complexity issues, 13–14
 

concepts that substance abuse counselors
 

can use, 57–60
 

concurrent treatment, 28–29
 

constraints and barriers to, 45–49
 

cost benefits, 12–13
 

cultural and religious factors and, 10, 12
 

cultural competence of the therapist and, 15
 

customizing treatment, 16–17
 

description, 4–5, 194
 

effectiveness of, 12
 

empowerment and, 45
 

evolution of, 6–8, 75
 

external coercion and, 14
 

factors in referring clients to substance
 

abuse treatment programs, 66
 

family­involved therapy and, 6
 

focus of, 1, 35–36
 

goals of, 1, 8–9, 36
 

insurance issues, 149
 

integrating into substance abuse treatment,
 

12, 41, 44
 

levels of recovery, 16
 

one­person family approach, 57, 87, 131
 

practice of compared with substance abuse
 

treatment, 34–38
 

prevention and, 9
 

primary models of, 7–8
 

psychoanalytic tradition, 37
 

purposes of, 5–6
 

safety issues, 17–18
 

screening for substance abuse, 44–45
 

selected research outcomes, 10–11
 

settings for, 8
 

social costs incurred by clients, 13
 

socioeconomic status and, 14–15
 

stages of change and, 15–16, 46–47
 

substance abuse treatment and, 1–2
 

systems model, 1, 6, 8, 56, 58
 

techniques that substance abuse counselors
 

can use, 61–64

theory of compared with substance abuse

treatment, 31–34
 

therapeutic factors, 9–10, 12
 

traditional models of, 50–57
 

12­Step programs and, 9, 70–71
 

unanswered research questions, 16–17
 

unit of treatment, 6
 

family ties
 

description, 58–59
 

fetal alcohol syndrome, 24
 

fictive kin, 2
 

218 Index
     

   

     

     

     

         

     

   

   

     

   

   

         

   

   

       

     

     

       

           

         

     

   

         

         

         

   

   

       

     

       

   

         

     

     

     

     

     

     

       

     

   

           

         

   

   

     

   

       

   

       

   

     

   

     

     

         

field reviewers

names and contact information, 209–211

FIP. see Family Intervention Program

First Nations Community HealthSource
 

integrated models example, 78
 

folk healing
 

among Hispanics/Latinos, 122
 

FPCM. see Family Partnering Case

Management

friends
 

effects of substance abuse on, 22
 

involvement in caregiving, 25
 

functional family therapy
 

description, 12–13
 

effectiveness of, 7
 

multidimensional approach of, 8
 

future research directions
 

assessment and classification, 161–162
 

new treatment and therapy models, 161
 

outcome evaluation, 162
 

prevention strategies, 162
 

technology, 162–163
 

telemedicine, 163
 

G

gay and lesbian couples. see also sexual
 

orientation
 

domestic violence and, 130
 

elected family example, 2
 

Gay and Lesbian Medical Association
 

alcohol use among gays and lesbians, 130
 

genetic factors
 

alcoholism, 65
 

genograms
 

basic symbols used in (figure), 42
 

description, 26, 42, 194
 

elements of, 42–43
 

Eugene O’Neill genogram (figure), 43, 44
 

family education and participation and, 152
 

for people who are homeless, 143
 

training requirements and, 153
 

uses, 42, 44
 

GLMA. see Gay and Lesbian Medical

Association

glossary of terms, 193–195

goals
 

of Behavioral Marital Therapy, 52
 

of family/larger system/case management
 

therapy, 97
 

of family therapy, 1, 8–9, 36
 

of multidimensional family therapy, 54
 

of multisystemic family therapy, 55
 

of play therapy, 111
 

of staff education, 150
 

of this TIP, 18–19
 

government and State regulations
 

affecting substance abuse treatment and
 

family therapy, 37–38, 41
 

confidentiality issues, 159
 

A Guide to Substance Abuse Services for
 

Primary Care Clinicians, 27, 44, 45, 63
 

H

Hazelden Family Center
 

program description, 67
 

Health Insurance Portability and
 

Accountability Act
 

provider collaboration and, 155
 

HIPAA. see Health Insurance Portability and

Accountability Act

Hispanics/Latinos
 

acculturation levels, 121–122
 

application to family therapy, 120–122
 

communication styles, 121
 

considerations for counseling, 122
 

counseling strategies, 121–122
 

cultural characteristics that impact family
 

therapy, 120
 

curanderismo, 122
 

demographic and cultural heterogeneity, 119
 

emphasis on extended family and clustering,
 

120
 

Index 219
 
           

     

       

         

   

   

           

       

   

       

       

   

       

         

   

   

     

       

     

   

   

         

   

         

         

       

     

       

   

   

       

           

       

     

   

       

         

   

         

       

     

   

         

   

   

         

       

       

familialism or familismo as a core construct, I
 120
 

family’s immigration history and, 119
 

respeto and conflict and, 120–121
 

role of acculturation in family functioning,
 

119–120
 

substance use, 119
 

HIV/AIDS
 

adolescents and, 111
 

adults returning to the parents’ home and,
 

141
 

application to family therapy, 142
 

children and, 141
 

impact on family members, 142
 

injection drug use and, 141
 

psychological effects, 141
 

relation to substance abuse, 141
 

reporting requirements, 142
 

holistic approach to substance abuse treatment
 

description, 65
 

spiritual component, 65–66
 

women and, 116
 

home visits
 

for older adults, 114
 

homelessness
 

application to family therapy, 143
 

co­occurring psychiatric disorders, 143
 

forms of, 142
 

genograms and, 143
 

prevalence of substance use by homeless
 

people, 143
 

veterans and, 144
 

homeostasis
 

definition, 194
 

families and, 3, 4, 5, 59
 

hospitalization. see inpatient programs

HUD. See U.S. Department of Housing and

Urban Development

IC&RC. see International Certification and

Reciprocity Consortium

ID. see identity of the client

identity of the client
 

substance abuse treatment and family
 

therapy comparison, 36
 

idiopathic
 

definition, 194
 

IDU. see injection drug use

immigrants
 

Asian Americans, 125
 

Bowen family systems and, 99
 

from the Caribbean or Africa, 117, 118
 

Hispanics/Latinos, 121–122
 

Improving Cultural Competence in Substance
 

Abuse Treatment, 117, 160
 

Improving Treatment for Drug­Exposed
 

Infants, 24
 

in­home therapy
 

for rural populations, 140
 

incarcerated populations. see also criminal
 

justice system
 

therapeutic community option for, 68
 

infants. see also children
 

of women who abuse substances during
 

pregnancy, 24
 

informed consent. see also confidentiality issues
 

family education and participation and, 153
 

family integration programs and, 158–159
 

provider collaboration and, 154, 155
 

inhalant use
 

among children, 110
 

among gay and lesbian men, 130
 

injection drug use
 

HIV/AIDS and, 141
 

inpatient programs
 

for detoxification, 66
 

integrating family therapy into an inpatient
 

treatment program for persons with
 

physical or cognitive disabilities, 133
 

insurance issues

220 Index
     

   

   

     

   

         

     

   

   

   

         

         

   

   

     

   

     

     

       

         

         

   

     

         

       

       

   

   

         

     

       

   

   

     

   

       

   

       

           

         

         

   

   

             

         

       

           

       

         

       

     

     

       

   

       

       

   

     

       

       

       

     

       

       

           

for family therapy, 149
 

for rural populations, 138
 

integrated models. see also family integration;
 

provider collaboration
 

administration issues, 78, 79
 

approaches to engagement, 83–84
 

challenges to merging family therapy and
 

substance abuse treatment, 148–149
 

community reinforcement training
 

intervention, 83
 

confidentiality issues, 148
 

cost benefits, 78
 

couples therapy, 7
 

definition, 194
 

determinants of the level of involvement, 83
 

facets of program integration (figure), 74
 

family collaboration, 74, 75
 

family education, 74
 

Family Intervention Program example, 77
 

family­oriented case management, 75
 

family therapy integration, 74
 

First Nations Community HealthSource
 

example, 78
 

flexibility in treatment planning and
 

approach, 77–78
 

levels of counselor involvement with families
 

(figure), 80–82
 

levels of involvement with families, 79–85
 

limitations of, 78–79
 

mandated treatment and, 75
 

matching therapeutic techniques to levels of
 

recovery, 105–106
 

meaning of the term, 74–75
 

methods to coordinate services among
 

multiple agencies, 76
 

mindset and, 79
 

for people with co­occurring substance abuse
 

and mental disorders, 137
 

for persons with HIV/AIDS, 142
 

reasons for, 74
 

reimbursement issues, 79
 

resistance issue, 75, 77
 

selection criteria, 84–85
 

staff awareness and education, 74
 

structure issues, 78
 

for substance abuse treatment, 85–105
 

techniques to help families adjust to sobriety
 

(figure), 104–105
 

techniques to help families attain sobriety
 

(figure), 103
 

techniques to help families in long­term
 

maintenance (figure), 106
 

training issues, 78
 

using the family to engage the client in
 

treatment, 83
 

value of for clients, 75, 77
 

value of for treatment professionals, 77–78
 

variation in types of clients and, 73–74
 

views of family therapists, 75
 

views of substance abuse counselors, 75
 

Intensive Outpatient Treatment for Alcohol
 

and Other Drug Abuse, 69
 

Intensive Structural Therapy: Treating
 

Families in Their Social Context, 90
 

International Certification and Reciprocity
 

Consortium
 

credentials in prevention and/or counseling
 

in substance abuse treatment, 38
 

J

Johnson Intervention
 

description, 83, 84
 

joining process, 61–62, 88
 

L

La Bodega de la Familia
 

description of program, 96, 157
 

LAAM. see levo­alpha­acetyl­methadol

Latinos. see Hispanics/Latinos

legal issues. see also criminal justice system
 

child protective services requirements, 14
 

government and State regulations affecting
 

substance abuse treatment and family
 

therapy, 37–38
 

reporting child abuse or neglect, 48, 159
 

Index 221
 
           

       

       

       

         

   

     

     

   

         

       

       

         

       

     

   

   

       

   

     

       

   

     

     

   

   

       

     

           

         

       

       

         

       

       

       

     

   

     

     

       

   

   

   

   

   

   

   

       

       

   

     

     

           

         

   

reporting elder abuse or neglect, 113, 159
 

levels of recovery, 16, 105–106
 

levo­alpha­acetyl­methadol
 

description, 63
 

opioid addiction outpatient treatment, 69
 

licenses
 

substance abuse treatment and family
 

therapy, 38
 

long­term followup data for programs, 160–161
 

long­term residential treatment
 

length of program, 68
 

traditional structure of, 68
 

LTR. see long­term residential treatment
 

M

maintenance stage of change, 15, 47
 

managed care
 

referrals for treatment and, 41
 

marijuana use
 

among American Indians and Alaska
 

Natives, 127
 

among lesbian and bisexual women, 130
 

marriage and family therapy. see also couples
 

therapy
 

narrative movement in, 7
 

origins of, 6
 

marriage counseling. see Behavioral Marital
 

Therapy; marriage and family therapy
 

MDFT. see multidimensional family therapy
 

Medicaid
 

family therapy payment, 149
 

medical model of substance abuse
 

description, 33, 65
 

Medicare
 

family therapy payment, 149
 

Medication­Assisted Treatment for Opioid
 

Addiction, 63, 70
 

memorandum of understanding
 

provider collaboration and, 155
 

men
 

Asian fathers’ traditional emotional distance
 

from the family, 124–125
 

older adult men and alcohol abuse, 112
 

substance abuse compared with women, 114
 

mental disorders. see also people with cooccurring substance abuse and mental

disorders

among people who are homeless, 143
 

therapeutic community programs and, 68
 

metaphoric definition of family, 3
 

methadone
 

description, 63
 

opioid addiction outpatient treatment, 69
 

MFT. see marriage and family therapy;

multiple family therapy

minority populations. see race and ethnicity

miracle question
 

in solution­focused therapy, 64, 100,
 

101–102
 

motivation

substance abuse treatment and family

therapy comparison, 48–49

MOU. see memorandum of understanding

multidimensional family therapy
 

for adolescents, 112
 

core components, 91
 

costs of, 90
 

description, 8
 

effectiveness of, 7
 

goals of, 54
 

length of, 91
 

objectives for the adolescent, 91
 

objectives for the parent, 91
 

research basis, 90–91
 

strategies and techniques, 54
 

techniques and strategies, 91
 

techniques to help families adjust to sobriety
 

(figure), 104
 

techniques to help families attain sobriety
 

(figure), 103
 

theoretical basis, 90
 

222 Index
   

       

   

   

   

   

     

       

   

       

   

     

     

   

           

         

           

         

         

   

       

         

   

       

   

         

     

       

       

             

   

         

     

   

           

         

         

   

       

     

       

       

           

   

         

       

       

           

     

   

   

     

         

       

           

   

       

         

       

treatment format, 91
 

view of substance abuse, 53
 

multifamily groups
 

description, 54
 

multiple family therapy
 

description, 92
 

multisystemic family therapy
 

effectiveness of, 7
 

goals of, 55
 

multidimensional approach of, 8
 

techniques and strategies, 55, 92
 

theoretical basis, 92
 

view of substance abuse, 54–55
 

N

NAADAC. see Association for Addiction

Professionals

NACoA. see National Association for Children

of Alcoholics

Naltrexone and Alcoholism Treatment, 63
 

Nar­Anon Family Group
 

contact information, 203
 

referral of family members to, 15, 36
 

narrative movement in marriage and family
 

therapy, 7
 

National Alliance for the Mentally Ill, 71
 

National Association for Children of Alcoholics
 

contact information, 203
 

National Association of Alcohol and Drug

Abuse Counselors. see Association for

Addiction Professionals

National Coalition for the Homeless
 

prevalence of substance use disorders among
 

homeless adults, 143
 

National Institute on Drug Abuse
 

integrated models descriptions, 83–84
 

2001 Monitoring the Future survey, 110
 

National Mental Health Consumer
 

Self­Help Clearinghouse, 71
 

National Working Group on Family­Based
 

Interventions in Chronic Disease, 13
 

negativism
 

in families with a member with a substance
 

use disorder, 22
 

neighbors
 

effects of substance abuse on, 22
 

involvement in caregiving, 25
 

network therapy
 

description, 55, 98
 

techniques to help families adjust to sobriety
 

(figure), 104
 

techniques to help families attain sobriety
 

(figure), 103
 

techniques to help families in long­term
 

maintenance (figure), 106
 

NIDA. see National Institute on Drug Abuse
 

nonsummativity of families, 3
 

O

older adults

ageism and underdetection of substance

abuse and mental disorders, 113
 

ages included in the definition of, 112
 

alcohol use, 112–113
 

American Indians and Alaska Natives and,
 

130
 

among Asian Americans, 123, 124
 

application to family therapy, 113–114
 

children in a parental role and, 26–27
 

cost of medication, 113
 

elder abuse, 113
 

helpful accommodations for, 114
 

home visits for, 114
 

infantalizing or trivializing within the family,
 

113–114

percentage with substance abuse problems,

112
 

prescription drug misuse and abuse, 26, 113
 

social isolation, 112
 

substance abuse problems and, 26–27
 

one­person family approach to family therapy
 

description, 57, 87, 131, 194
 

Index 223
 
     

       

   

         

     

   

   

     

     

   

     

     

             

   

             

   

             

   

     

       

     

   

         

       

   

   

   

   

     

       

     

         

     

         

       

       

   

   

   

         

           

         

   

           

         

       

       

     

         

         

     

     

   

       

       

       

   

     

   

opioid addiction outpatient treatment
 

administration of opioid substitutes, 69–70
 

effectiveness, 70
 

outcome evaluation. see also assessment
 

family education and participation and, 154
 

future research directions, 162
 

procedures, 160
 

provider collaboration and, 155–156
 

purpose of, 152
 

staff education and, 151
 

types of questions, 152
 

outpatient programs
 

advantages, 69
 

for detoxification, 66–67
 

drop­out rates, 69
 

opioid addiction treatment, 69–70
 

substance abuse treatment, 68–69
 

P

parental denial
 

in families with a member with a substance
 

use disorder, 22
 

parental expectations
 

in families with a member with a substance
 

use disorder, 23
 

parental inconsistency
 

in families with a member with a substance
 

use disorder, 22
 

partnerships
 

in the community, 157
 

with Federal government agencies, 156
 

in the workplace, 157
 

patriarchal terrorism, 17
 

people with co­occurring substance abuse and
 

mental disorders
 

application to family therapy, 137–138
 

background issues, 136–137
 

integrated treatment, 137
 

prevalence of, 137
 

role of confrontation, 138
 

single­family therapy for, 137
 

understanding the complex way the

disorders interact within individuals,

136–137

understanding the use of medication from
 

the client’s perspective, 138
 

people with physical or cognitive disabilities
 

accommodations for, 133, 134, 135–136
 

affective impairments, 132
 

application to family therapy, 132–136
 

background issues, 131–132
 

caregiver issues, 133–134
 

cognitive impairments, 132
 

denial and, 134
 

domestic and other violence and, 132
 

family’s feelings of guilt and anger and,
 

134–135
 

integrating family therapy into an inpatient
 

treatment program, 133
 

interpreters for persons who are deaf or
 

hard­of­hearing, 135–136
 

language to use in describing, 133
 

overprotection by family and other
 

caregivers, 133
 

person’s understanding of his disability, 133
 

person’s understanding of his functional
 

limitations, 135
 

physical impairments, 131
 

provider unease when dealing with, 133
 

risk for substance abuse or dependence, 132
 

sensory impairments, 131
 

sexual abuse and, 132
 

social isolation and, 132
 

specific recommendations for, 135–136
 

strengths­based approach to treatment, 135
 

peyote use
 

among American Indians and Alaska
 

Natives, 127
 

pharmacotherapy for substance use disorders
 

medications available, 63
 

phases of family change
 

definition, 86, 195
 

224 Index
         

   

     

         

   

       

       

     

   

       

     

   

       

     

     

   

   

   

       

           

       

       

       

       

       

       

         

       

     

         

       

         

   

       

     

     

   

     

   

   

   

     

         

       

       

   

   

     

       

         

         

   

       

         

     

physical disabilities. see people with physical or

cognitive disabilities

play therapy

description, 110–111

goals of, 111

policy and program issues

challenges to merging family therapy and

substance treatment, 148–149

costs of specialized training, 148

criminal justice system role, 149

cultural competence, 160

family education and participation, 151–154

family integration, 157–160

funding and reimbursement options, 149

future research directions, 161–163

long­term followup, 160–161

outcome evaluation procedures and reports,

160
 

primary policy concerns, 147–149
 

program planning models, 149–160
 

provider collaboration, 154–157
 

staff education, 150–151
 

posttraumatic stress disorder

among veterans, 144

poverty. see also socioeconomic status

implications for family therapy, 14–15

increase in the percentage of children living

in, 4

practice

content of the session, 35

family interventions, 34

family therapy and substance abuse

treatment comparison, 34–38

focus, 35–36

government and State regulations, 37–38

identity of the client, 36

process of family interaction, 35

self­disclosure by the counselor, 37

spirituality, 35

precontemplation stage of change, 15, 46

pregnancy

fetal alcohol syndrome and, 24

substance abuse and, 24

preparation stage of change, 15, 46–47

prescription drugs

older adults and, 26, 113

persons with physical or cognitive disabilities

and, 132

problem definition questions

solution­focused brief therapy and, 105

process of family interaction

family therapy and, 35

program planning models

family education and participation, 151–154

family integration, 157–160

provider collaboration, 154–157

staff education, 150–151

provider collaboration

cross­training and, 156

informed consent and confidentiality and,

154, 155
 

issues for staff and trainers, 156
 

issues for substance abuse treatment
 

program administrators, 155–156

memorandum of understanding to guide

interrelationships, 155
 

outcome evaluation, 155–156
 

partnerships, 156–157
 

recommendations for, 156–157
 

resources for referrals, 155
 

“splitting” by staff and, 156
 

A Provider’s Introduction to Substance Abuse

Treatment for Lesbian, Gay, Bisexual, and

Transgender Individuals, 130

psychoeducation

cost­effectiveness of, 152

description, 6, 48–49, 92, 195

for people with co­occurring substance abuse

and mental disorders, 137

Index 225
     

       

     

   

     

       

   

           

       

     

       

       

         

         

     

       

     

       

   

       

     

       

   

     

   

   

     

       

   

   

       

           

   

   

         

       

     

   

       

       

         

     

     

       

     

             

   

   

         

       

     

   

     

         

       

   

   

   

     

R

race and ethnicity. see also cultural factors;

specific racial and ethnic groups

barriers to treatment, 116–117
 

effects of immigration, 116
 

sociopolitical status and, 116
 

structural/strategic family therapy and, 87
 

recovery process, 15–16

Registry of Interpreters for the Deaf, 136
 

regulations affecting substance abuse treatment

and family therapy, 37–38

relabeling

in strategic family therapy, 63–64

in structural family therapy, 62–63

relational questions
 

solution­focused brief therapy and, 102, 105
 

religion. see also spirituality

American Indians and Alaska Natives and,

127
 

Bible­related recovery programs, 118
 

faith­based programs and rural populations,
 

140–141

resiliency of children, 24
 

resistance
 

family therapy and substance abuse
 

treatment terminology comparison, 32–33
 

integrated models and, 75, 77
 

resource panel

names and contact information, 205–206

rural populations
 

application to family therapy, 139–141
 

background issues, 138–139
 

barriers to treatment, 139–140
 

confidentiality issues, 138
 

fatalism and, 139
 

financial limitations, 138, 139
 

geographical isolation and, 138, 140
 

in­home therapy, 140
 

insurance issues, 138
 

patterns of substance abuse, 139
 

rural women who are dependent on alcohol,
 

139
 

self­reliance and, 139
 

telemedicine and, 163
 

understanding of rural values and customs,
 

140
 

use of self­help groups, 140–141
 

S

SAMHSA. see Substance Abuse and Mental

Health Services Administration

scaling questions
 

solution­focused brief therapy and, 102
 

Screening and Assessing Adolescents for
 

Substance Use Disorders, 28, 45, 110, 112
 

screening issues

family therapy and, 44–45

self­disclosure by the counselor
 

substance abuse treatment and family
 

therapy comparison, 37
 

self­help programs. see 12­Step programs

self­medication
 

in families with a member with a substance
 

use disorder, 23
 

sexual abuse
 

homelessness and, 143
 

persons with physical or cognitive disabilities
 

and, 132
 

sexual orientation. see also gay and lesbian
 

couples
 

application to therapy, 130–131
 

background issues, 130
 

domestic violence and, 130
 

family as a sensitive issue, 130
 

one­person family therapy and, 130
 

SFBT. see solution­focused brief therapy

Short­Term Inpatient Treatment
 

description, 67
 

short­term residential programs
 

family involvement, 67–68
 

Hazelden Family Center, 67
 

length, 67
 

226 Index
       

         

         

         

     

   

         

     

   

         

           

           

   

   

     

   

     

       

   

     

   

         

     

     

   

       

           

   

   

   

       

     

         

     

   

         

         

   

       

   

       

         

   

   

         

       

   

   

   

   

     

   

Short­Term Inpatient Treatment (SIT), 67

sibling relationships
 

adolescents who abuse substances and, 27,
 

112
 

Simple Screening Instruments for Outreach for
 

Alcohol and Other Drug Abuse and
 

Infectious Diseases, 45
 

single­family therapy
 

African Americans and, 118
 

Hispanics/Latinos and, 120
 

for people with co­occurring substance abuse
 

and mental disorders, 137
 

single­mother families
 

African American, 118–119
 

increase in the number of, 4
 

single persons

clients with a substance use disorder who

live alone or with a partner, 23–24

SIT. see Short­Term Inpatient Treatment

social detoxification programs
 

description, 67
 

social/environmental acculturation
 

definition, 195
 

social support groups
 

families compared with, 3
 

socioeconomic status. see also poverty
 

family therapy and, 14–15
 

substance abuse treatment and, 65
 

solution­focused brief therapy
 

description, 7, 55–56, 64
 

effectiveness, 101
 

exception questions, 102
 

miracle question and, 64, 100, 101–102
 

problem definition questions, 105
 

relational questions, 102, 105
 

scaling questions, 102
 

techniques and strategies, 101–102, 105
 

techniques to help families adjust to sobriety
 

(figure), 105
 

theoretical basis, 100–101
 

somatic

definition, 195

specific populations

age groups, 110–114

HIV status, 141–142

homelessness, 142–143

people with co­occurring substance abuse

and mental disorders, 136–138

people with physical or cognitive disabilities,

131–136
 

race and ethnicity, 115–130
 

rural populations, 138–141
 

sexual orientation, 130–131
 

TIP use of the term, 109
 

veterans, 143–144
 

women, 114–116
 

spiritual healing
 

among Hispanics/Latinos, 122
 

spirituality. see also religion

American Indians and Alaska Natives and,

127
 

Hispanics/Latinos and, 122
 

holistic approach to substance abuse
 

treatment and, 65–66
 

substance abuse treatment and family
 

therapy comparison, 35
 

12­Step programs and, 66, 70–71, 141
 

SSSE. see strategic/structural systems

engagement

staff education
 

costs of, 150
 

goals of, 150
 

issues for staff and trainers, 151
 

issues for substance abuse treatment
 

administrators, 150–151

stages of change
 

action, 15, 47
 

confrontation and, 47–48
 

contemplation, 15, 46
 

definition, 195
 

integrated models and, 83
 

maintenance, 15, 47
 

Index 227
 
     

   

   

   

       

   

     

   

   

       

   

     

   

     

         

   

   

     

   

   

     

   

   

       

           

   

     

         

   

   

   

   

       

       

     

     

         

           

           

       

       

       

       

       

     

   

         

     

   

         

       

   

         

     

   

       

         

   

   

       

     

       

       

           

   

         

     

motivation levels and, 48–49
 

precontemplation, 15, 46
 

preparation, 15, 46–47
 

termination, 47
 

Stanton’s therapeutic techniques

description, 56–57

State regulations. see government and State

regulations

stepfamilies. see blended families

strategic family therapy. see also
 

structural/strategic family therapy
 

description, 6–7
 

directives and, 64
 

reframing or relabeling and, 63–64
 

strategic/structural systems engagement
 

description, 87
 

structural family therapy. see also
 

structural/strategic family therapy
 

for adolescents with co­occurring substance
 

abuse and mental disorders and, 138
 

assessment stage, 61
 

boundaries and, 62
 

description, 7
 

joining process, 61–62, 88
 

relabeling, 62–63
 

structural modification, 62
 

structuralization technique, 62
 

system recomposition, 62
 

structural/strategic family therapy
 

cultural factors, 87, 90
 

joining process, 88
 

modifications of, 87
 

techniques and strategies, 87, 90
 

techniques to help families adjust to sobriety
 

(figure), 104
 

theoretical basis, 86–87
 

therapy phases, 86, 195
 

Substance Abuse and Mental Health Services
 

Administration
 

contact information, 203
 

substance abuse treatment

adjunctive pharmacotherapy for substance
 

use disorders, 63
 

assessment procedures, 38–41
 

compatibility with family therapy, 34
 

constraints and barriers to, 45–49
 

detoxification services, 44, 66–67
 

disease model, 33, 151
 

education and licensing of counselors, 38
 

essential aspects of addictive disease and, 35
 

factors in referring clients to programs, 66
 

family therapy approaches sometimes used
 

in, 50–57
 

family therapy concepts that substance
 

abuse counselors can use, 57–60
 

family therapy techniques that substance
 

abuse counselors can use, 61–64
 

focus of, 35–36, 38
 

holistic approach, 65–66
 

integrating with family therapy, 41, 44
 

long­term residential treatment or
 

therapeutic community, 68
 

medical, or disease, model, 33, 65
 

opioid addiction outpatient treatment, 69–70
 

outpatient treatment, 68–69
 

practice of compared with family therapy,
 

34–38
 

short­term residential programs, 67–68
 

sociocultural theories, 65
 

stages of change and, 46–47
 

theory of compared with family therapy,
 

31–34
 

traditional theoretical understandings of
 

substance abuse, 64–66
 

Substance Abuse Treatment: Addressing the
 

Specific Needs of Women, 115
 

Substance Abuse Treatment and Domestic
 

Violence, 18
 

Substance Abuse Treatment and Trauma, 115
 

Substance Abuse Treatment for Adults in the
 

Criminal Justice System, 68
 

Substance Abuse Treatment for People With
 

Physical and Cognitive Disabilities, 133
 

228 Index
         

           

         

     

         

         

       

   

       

     

     

       

       

       

     

     

   

         

   

     

   

         

     

   

       

     

       

       

   

         

       

     

         

     

             

     

   

   

         

   

         

   

       

   

       

         

   

       

     

     

         

   

             

       

Substance Abuse Treatment for Persons With
 

Child Abuse and Neglect Issues, 17, 106, 115
 

Substance Abuse Treatment for Persons With
 

Co­Occurring Disorders, 14, 136, 137, 143
 

Substance Abuse Treatment for Persons With
 

HIV/AIDS, 141, 142
 

Substance Use Disorder Treatment for People

With Physical and Cognitive Disabilities,

132, 136
 

subsystems of families
 

description, 58
 

system recomposition
 

in structural family therapy, 62
 

systemic couples therapy, 7
 

T

TC. see therapeutic community

telemedicine

uses in rural populations, 163
 

termination stage of change, 47
 

theory
 

denial and resistance and, 32–33
 

family therapy and substance abuse
 

treatment comparison, 31–34
 

therapeutic community
 

description of treatment, 68
 

traditional families
 

blended families and, 25–26
 

description, 2, 195
 

training. see educational requirements
 

Treatment of Adolescents With Substance Use
 

Disorders, 27, 28, 38
 

triangulation concept
 

description, 59–60, 99–100, 195
 

“splitting” and, 156
 

12­Step programs
 

benefits of therapists’ attendance at, 70
 

description, 70–71
 

empowerment and, 45, 70
 

families distinguished from, 3
 

family therapy and, 9, 12
 

rural populations and, 140–141
 

spirituality and, 66, 70–71, 141

2001 Monitoring the Future survey
 

inhalant abuse, 110
 

2002 National Household Survey on Drug
 

Abuse
 

percentage of adolescents reporting binge
 

use of alcohol, 27
 

percentage of older adults reporting binge
 

use of alcohol, 26
 

2002 National Survey on Drug Use and Health
 

Overview of Findings, 111
 

U

Unilateral Family Therapy
 

description, 83, 84
 

U.S. Department of Health and Human

Services

contact information, 203
 

partnerships with, 156
 

U.S. Department of Housing and Urban

Development
 

partnerships with, 156
 

U.S. Department of Veterans Affairs
 

partnerships with, 156
 

V
 

veterans
 

application to family therapy, 144
 

estimate of substance abuse among, 143
 

homeless veterans, 144
 

posttraumatic stress disorder and, 144
 

survivor guilt and, 144
 

violence. see also child abuse or neglect;
 

domestic violence; elder abuse or neglect
 

assessment guidelines, 197–200
 

role of psychoactive drugs in violent death of
 

adolescents, 27
 

W

Wegscheider­Cruse’s theory of substance abuse
 

description, 57
 

WestEd
 

contact information, 203
 

Index 229
 
     

       

     

       

       

     

   

   

       

     

       

           

       

       

           

           

           

     

         

         

       

         

   

White Bison
 

American­Indian alternative to Alcoholics
 

Anonymous, 130
 

women
 

application to family therapy, 115–116
 

childcare provision for, 116
 

custody of children and, 116
 

domestic violence and, 17–18, 115–116
 

gynecological problems associated with
 

substance abuse, 115
 

healthy relationships and, 115
 

Hispanic/Latino women and respect, 121
 

holistic approach and, 116
 

mothers with substance use disorders,
 

114–115
 

older adult women and alcohol use, 112
 

percentage using illicit drugs, 114
 

posttraumatic stress disorder and, 144
 

role of women in African American families,
 

118
 

role of women in Asian American families,
 

124
 

rural women who are dependent on alcohol,
 

139
 

spouses of veterans, 144
 

substance abuse compared with men, 114
 

traditional role as caretakers of children,
 

115
 

treatment issues relevant to, 116
 

Working with the Problem Drinker: A

Solution­Focused Approach, 100–101

workplace­based collaboration efforts, 157
 

230 Index
231

SAMHSA TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians, researchers,

program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs

are developed under the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Knowledge Application Program (KAP)

to improve the treatment capabilities of the Nation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized booklet. Each Quick Guide is

divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page

numbers from the original TIP are referenced so providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening in-struments, checklists, and

summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept

within a treatment provider’s reach and consulted fre-quently. The Keys allow you, the busy clinician or program administrator, to

locate information easily and to use this information to enhance treatment services.

Ordering Information

Publications may be ordered or downloaded for free at http://store.samhsa.gov. To order over the phone, please call 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

TIP 1 State Methadone Treatment Guidelines—Replaced by

TIP 43

TIP 2 Pregnant, Substance-Using Women—Replaced by

TIP 51

TIP 3 Screening and Assessment of Alcohol- and Other

Drug-Abusing Adolescents—Replaced by TIP 31

TIP 4 Guidelines for the Treatment of Alcohol- and Other

Drug-Abusing Adolescents—Replaced by TIP 32

TIP 5 Improving Treatment for Drug-Exposed Infants

TIP 6 Screening for Infectious Diseases Among Substance

Abusers—Archived

TIP 7 Screening and Assessment for Alcohol and Other

Drug Abuse Among Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 8 Intensive Outpatient Treatment for Alcohol and

Other Drug Abuse—Replaced by TIPs 46 and 47

TIP 9 Assessment and Treatment of Patients With

Coexisting Mental Illness and Alcohol and Other

Drug Abuse—Replaced by TIP 42

TIP 10 Assessment and Treatment of Cocaine- Abusing

Methadone-Maintained Patients—Replaced by TIP 43

TIP 11 Simple Screening Instruments for Outreach for

Alcohol and Other Drug Abuse and Infectious

Diseases—Replaced by TIP 53

TIP 12 Combining Substance Abuse Treatment With

Intermediate Sanctions for Adults in the Criminal

Justice System—Replaced by TIP 44

TIP 13 Role and Current Status of Patient Placement

Criteria in the Treatment of Substance Use

Disorders

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians

TIP 14 Developing State Outcomes Monitoring Systems for

Alcohol and Other Drug Abuse Treatment

TIP 15 Treatment for HIV-Infected Alcohol and Other Drug

Abusers—Replaced by TIP 37

TIP 16 Alcohol and Other Drug Screening of Hospitalized

Trauma Patients 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 17 Planning for Alcohol and Other Drug Abuse

Treatment for Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues

for Alcohol and Other Drug Abuse Treatment

Providers—Archived

TIP 19 Detoxification From Alcohol and Other Drugs—

Replaced by TIP 45

TIP 20 Matching Treatment to Patient Needs in Opioid

Substitution Therapy—Replaced by TIP 43

TIP 21 Combining Alcohol and Other Drug Abuse

Treatment With Diversion for Juveniles in the

Justice System 

 Quick Guide for Clinicians and Administrators 
232

TIP 22 LAAM in the Treatment of Opiate Addiction—

Replaced by TIP 43

TIP 23 Treatment Drug Courts: Integrating Substance Abuse

Treatment With Legal Case Processing 

 Quick Guide for Administrators 

TIP 24 A Guide to Substance Abuse Services for Primary

Care Clinicians 

 Concise Desk Reference Guide 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 25 Substance Abuse Treatment and Domestic Violence 

 Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Treatment Providers 

 Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Administrators 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 26 Substance Abuse Among Older Adults 

 Substance Abuse Among Older Adults: A Guide for

Treatment Providers 

 Substance Abuse Among Older Adults: A Guide for

Social Service Providers 

 Substance Abuse Among Older Adults: Physician’s

Guide 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

TIP 27 Comprehensive Case Management for Substance

Abuse Treatment

 Case Management for Substance Abuse Treatment: A

Guide for Treatment Providers 

 Case Management for Substance Abuse Treatment: A

Guide for Administrators 

 Quick Guide for Clinicians 

 Quick Guide for Administrators

TIP 28 Naltrexone and Alcoholism Treatment—Replaced by

TIP 49

TIP 29 Substance Use Disorder Treatment for People With

Physical and Cognitive Disabilities

 Quick Guide for Clinicians

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 30 Continuity of Offender Treatment for Substance Use

Disorders From Institution to Community 

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 31 Screening and Assessing Adolescents for Substance

Use Disorders

 See companion products for TIP 32.

TIP 32 Treatment of Adolescents With Substance Use

Disorders 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 33 Treatment for Stimulant Use Disorders

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 34 Brief Interventions and Brief Therapies for Substance

Abuse 

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 35 Enhancing Motivation for Change in Substance Abuse

Treatment

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 36 Substance Abuse Treatment for Persons With Child

Abuse and Neglect Issues

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

 Helping Yourself Heal: A Recovering Woman’s Guide to

Coping With Childhood Abuse Issues 

 Also available in Spanish

 Helping Yourself Heal: A Recovering Man’s Guide to

Coping With the Effects of Childhood Abuse 

 Also available in Spanish

TIP 37 Substance Abuse Treatment for Persons With

HIV/AIDS

 Quick Guide for Clinicians

 KAP Keys for Clinicians 

 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide 

 Also available in Spanish

 Drugs, Alcohol, and HIV/AIDS: A Consumer Guide for

African Americans

TIP 38 Integrating Substance Abuse Treatment and

Vocational Services

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 39 Substance Abuse Treatment and Family Therapy

 Quick Guide for Clinicians

 Quick Guide for Administrators

 Family Therapy Can Help: For People in Recovery

From Mental Illness or Addiction
233

TIP 40 Clinical Guidelines for the Use of Buprenorphine in

the Treatment of Opioid Addiction

 Quick Guide for Physicians 

 KAP Keys for Physicians 

TIP 41 Substance Abuse Treatment: Group Therapy

 Quick Guide for Clinicians 

TIP 42 Substance Abuse Treatment for Persons With CoOccurring Disorders

 Quick Guide for Clinicians 

 Quick Guide for Administrators 

 KAP Keys for Clinicians 

TIP 43 Medication-Assisted Treatment for Opioid Addiction

in Opioid Treatment Programs

 Quick Guide for Clinicians 

 KAP Keys for Clinicians 

TIP 44 Substance Abuse Treatment for Adults in the

Criminal Justice System

 Quick Guide for Clinicians

 KAP Keys for Clinicians 

TIP 45 Detoxification and Substance Abuse Treatment

 Quick Guide for Clinicians

 Quick Guide for Administrators

 KAP Keys for Clinicians 

TIP 46 Substance Abuse: Administrative Issues in

Outpatient Treatment

 Quick Guide for Administrators

TIP 47 Substance Abuse: Clinical Issues in Outpatient

Treatment

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

TIP 48 Managing Depressive Symptoms in Substance Abuse

Clients During Early Recovery

TIP 49 Incorporating Alcohol Pharmacotherapies Into

Medical Practice

 Quick Guide for Counselors 

 Quick Guide for Physicians 

 KAP Keys for Clinicians 

TIP 50 Addressing Suicidal Thoughts and Behaviors in

Substance Abuse Treatment

 Quick Guide for Clinicians 

 Quick Guide for Administrators

TIP 51 Substance Abuse Treatment: Addressing the Specific

Needs of Women

 KAP Keys for Clinicians

 Quick Guide for Clinicians

 Quick Guide for Administrators

TIP 52 Clinical Supervision and Professional Development

of the Substance Abuse Counselor

 Quick Guide for Clinical Supervisors

 Quick Guide for Administrators

TIP 53 Addressing Viral Hepatitis in People With Substance

Use Disorders

 Quick Guide for Clinicians and Administrators

 KAP Keys for Clinicians 

TIP 54 Managing Chronic Pain in Adults With or in

Recovery From Substance Use Disorders

 Quick Guide for Clinicians 

 KAP Keys for Clinicians

 You Can Manage Your Chronic Pain To Live a Good

Life: A Guide for People in Recovery From Mental

Illness or Addiction

TIP 55 Behavioral Health Services for People Who Are

Homeless

TIP 56 Addressing the Specific Behavioral Health Needs of

Men 

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 57 Trauma-Informed Care in Behavioral Health

Services 

 Quick Guide for Clinicians

 KAP Keys for Clinicians

TIP 58 Addressing Fetal Alcohol Spectrum Disorders

(FASD)

TIP 59 Improving Cultural Competence

This TIP, Substance Abuse Treatment and Family Therapy, addresses

how substance abuse affects the entire family and how substance

abuse treatment providers can use principles from family therapy

to change the interactions among family members. The TIP 

provides basic information about family therapy for substance

abuse treatment professionals, and basic information about 

substance abuse treatment for family therapists. The TIP presents

the models, techniques, and principles of family therapy, with 

special attention to the stages of motivation as well as to 

treatment and recovery. Discussion also focuses on clinical decision

making and training, supervision, cultural considerations, special

populations, funding, and research. The TIP further identifies

future directions for both reasearch and clinical practice.

Collateral Products

Based on TIP 39

Quick Guide for Clinicians

Quick Guide for Administrators

Substance Abuse Treatment

And Family Therapy

HHS Publication No. (SMA) 15-4219

Printed 2004

Revised 2005, 2006, 2008, 2009, 2010, 

2012, 2014, and 2015

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment