What follows is the executive summary of the guideline; for more detailed information on the recommendations, please see the original guideline document.
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 family-level 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 abuse treatment has two main purposes: (1) to use 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 problem-solving 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 solution-focused 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 age-appropriate 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 12-Step 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. 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 for 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 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 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 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 long-term change is to occur, the entire family must be treated as a unit, so the family as a whole constitutes the client.
- Self-disclosure by the counselor. Training in the boundaries related to the therapist’s or counselor’s self-disclosure 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 self-disclose their own addiction histories and to use supervision appropriately to decide when and what to disclose. For the family therapist, self-disclosure 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 third-party 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. Forty-two 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 three-generational 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 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, solution-focused therapy, Stanton’s approach, and Wegscheider-Cruse’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. These techniques selected by the panel include behavioral techniques, structural techniques, strategic techniques, and solution-focused 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 Treatment Improvement Protocol (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 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, agency-wide commitment and coordination, and reimbursement by third-party 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 that 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
- Solution-focused 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.
- Long-term 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.
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 among 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 rely on a heterosexual-based 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 co-occurring substance abuse and mental disorders, people in rural areas, people who are human immunodeficiency virus (HIV) positive, people who are homeless, and veterans.
