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Substance Use Disorder Treatment and Family Therapy: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 39.)
Substance use disorders (SUDs) affect not just those with the disorders, but also their families and other individuals who play significant roles in their lives.
Integration of family-based counseling interventions into SUD treatment honors the important role families can play in the change process.
Families can greatly influence the treatment of any illness, including SUDs. Family involvement on any level can:
Motivate individuals facing addiction to receive or continue treatment.
Improve overall family functioning.
Foster healing for family members affected by the consequences of addiction.
Reduce risk in children and adolescents of being exposed to violence and of developing SUDs/mental disorders.
Family counseling in SUD treatment is positively associated with increased treatment engagement and retention rates, treatment cost effectiveness, and improved outcomes for individual clients and their families.
The integration of family counseling into SUD treatment has posed an ongoing challenge since the inception of family therapy in the 1950s. Family counseling has been woven into treatment across the continuum of care, from prevention approaches, to treatment interventions, to continuing care services. Even so, it can be difficult for providers and programs to fit family services into existing schedules filled with the demands of SUD treatment and related services. SUD treatment programs may also face challenges related to funding, training, and other administrative aspects of integration.
To ensure use of family counseling and family services to their greatest potential within SUD treatment, it is essential to broaden the focus of SUD treatment from an individual to a family perspective. It is common to acknowledge the unique individual factors (e.g., environmental, genetic, biological) that may influence a person's substance misuse and SUD treatment outcomes. Yet equally important are interpersonal factors— social, occupational, and familial (relationships, dynamics, and interactions). Both individual and interpersonal factors can affect one's access to, initiation of, and engagement in SUD treatment. These same factors influence SUD treatment outcomes.
Just as others can have an impact on an individual's substance misuse, the individual's substance misuse can likewise affect those around them. People who misuse substances are likely to affect at least a handful of others who have or had some form of relationship with them, such as friends, partners, coworkers, relatives, and members of their communities.
The consequences of a person's substance misuse can be especially powerful for his or her family members. Four main theoretical models inform the SUD treatment approaches and family-based interventions that can best address those consequences:
Family disease
Family systems
Cognitive-behavioral therapy
Multidimensional family therapy (MDFT)
This Treatment Improvement Protocol (TIP) is structured to meet the needs of professionals with a range of training, education, and clinical experience in addressing SUDs. The primary audience for this TIP is SUD treatment counselors— many, but not all, of whom possess certification in addiction counseling or related professional licensing.
Additional providers among this TIP's primary audience are peer support specialists, psychiatric and mental health nurses, primary care providers (such as family physicians, internal medicine specialists, and nurse practitioners), and allied healthcare professionals who may provide SUD treatment—some of whom may have credentials in couples and family therapy, treatment of SUDs or mental disorders, or criminal justice services. The TIP will refer to these audiences collectively as “providers” for brevity.
This TIP also offers guidance for addiction treatment program administrators, supervisors, and clinical/program directors (called “administrators” for brevity) working in behavioral health programs and agencies that provide SUD treatment and recovery support services.
Secondary audiences include educators, researchers, policymakers, and healthcare and social service personnel beyond those specifically mentioned above.
This TIP consists of six chapters (Exhibit 1.1). Some readers may prefer to go directly to chapters most relevant to their areas of interest. However, the TIP starts with core concepts laying the groundwork for understanding families and how SUDs can affect them, before moving to more specific family approaches, counseling techniques, and programmatic considerations.
Exhibit 1.1. TIP Organization.
This TIP will help SUD treatment providers and administrators:
Understand the common concepts of family structure and dynamics, as well as terminology central to these concepts (Exhibit 1.2).
Learn the impact of SUDs on families and how the presence of SUDs affects every family member.
Offer SUD treatment via culturally responsive approaches that involve the family as a whole.
Appreciate the value of family involvement in treatment.
Integrate specific family counseling models, techniques, and concepts into SUD treatment to enhance effective family coping and healthy communication patterns—paving the road toward recovery for everyone in the family.
Train and motivate staff to include family members in treatment.
Support staff in exploring the role of SUDs in family counseling and in developing collaborative relationships to meet the diverse needs of families.
Exhibit 1.2. Key Terms.
The TIP consensus panel developed this publication from its extensive experience, knowledge, and review of the literature. The panel included representatives from several disciplines involved in family counseling and SUD treatment, including alcohol and drug counselors, family therapists, mental health practitioners, researchers, and social workers. Other professionals also generously contributed their time and commitment to this project. In encouraging counselors, administrators, and others who work in the field to acknowledge substance misuse as a critical issue that can negatively affect families, the consensus panel hopes the guidance in this TIP will help families move toward recovery.
Family counseling is a collection of family-based interventions that reflect family-level assessment, involvement, and approaches. A systems model underlies family counseling. The model views families as systems, and in any system, each part is related to all other parts. A change in any part of the system will bring about changes in all other parts (Becvar & Becvar, 2018). Family counseling uses family dynamics and strengths to bring about change in a range of diverse problem areas, including SUDs.
A family is a complex system that attempts to keep equilibrium (or “homeostasis,” in family therapy terms). When substance misuse occurs in the family, members will try to manage the behavior of the person who is using drugs or alcohol and the consequences of that use for the family. A family may go through a range of responses to keep the family functioning. Some may view these responses as unhealthy, enabling, compensatory, or counterproductive, but they serve a purpose— to keep the system operating. This operating system directly influences treatment engagement, treatment outcomes, use of support systems, and sustained recovery for each family member.
When a person has an SUD, his or her family members experience significant effects, some more powerfully than others (e.g., older siblings with less direct exposure to parental SUDs may be less affected than younger siblings still living in the home). Families experience hardships, losses, and trauma as a consequence of a member's SUD (Black, 2018; Reiter, 2015). Some families tend to blame or create excuses for the person's substance misuse. They generally have strong feelings, whether they express them or not, toward the family member who drinks or uses drugs. Family members may direct these feelings toward the substance rather than the person. If families minimize the impact of the SUD, they may blame another family member or stressful situation for the presenting problem (Reiter, 2015).
Integrating family counseling into SUD treatment leverages the important role families can play in helping their family members change their substance use. Integrated SUD treatment and family counseling acknowledges that SUDs affect others beyond those with the disorder (Lassiter, Czerny, & Williams, 2015). Whether an adolescent or adult has the SUD, the entire family system needs assistance.
Family counseling helps each family member understand:
How the SUD affects him or her as an individual.
How the SUD affects the whole family.
How he or she adjusts or changes certain behaviors in response to the individual's progressing SUD.
How to make changes as an individual and as a family to address the impact of the SUD.
Rather than focusing solely on individuals who have SUDs, family counseling widens the focus by shifting attention to clients and their whole families. This shift in focus supports identification of goals as a family group and as individuals within that group. It also creates a transparent atmosphere that helps individuals with SUDs see that their families are not blaming them for their addiction or ganging up on them to seek treatment. Exhibit 1.3 describes some of the benefits and challenges of this approach.
Exhibit 1.3. Benefts and Challenges of Family Counseling in SUD Treatment.
This section summarizes some of the core objectives of family-based interventions for SUDs.
Core objective: Leverage the family to influence change. From the outset, family-focused interventions encourage family members to motivate each other to make important lifestyle changes, including shifts away from alcohol and drug misuse. Family counseling for SUDs also helps families develop effective coping and communication skills that will promote recovery for each member. Family counseling takes advantage of the strength of family relationships to support all family members in their initiation of and engagement in treatment, continuing care services, mutual aid, and peer support services.
Core objective: Use a strengths-based approach to involve families in treatment. Family involvement can have a positive influence on treatment engagement—and lack of family involvement can derail SUD treatment. Families can have negative effects on SUD treatment in other ways, too. Certain aspects of family relationships and parenting practices can worsen alcohol and drug misuse, relapse risk, stress, and behavioral problems. Using a strengths-based approach, family counseling addresses such problematic family dynamics (e.g., parent-child role reversals), as well as inconsistent or ineffective parenting practices. Family counseling can encourage parenting practices that help prevent SUDs in children, improve SUD treatment outcomes in adolescents, and enhance the family recovery process.
Core objective: Change family behaviors and responses that may support continued substance misuse. Another core objective is assessing and reorganizing families’ behavioral, cognitive, and emotional responses that may unintentionally support the continued misuse of alcohol and drugs, and that place significant stress and responsibility on family members who do not have an SUD. Most families experience stress, loss, and trauma as a direct or indirect consequence of addiction in the family; family counseling focuses on addressing these consequences to improve family functioning and to potentially prevent further stress-related symptoms, substance misuse of spouse or children, and other biopsychosocial effects. Family counseling in SUD services adopts a trauma-informed stance. It also identifies and addresses safety concerns (e.g., domestic or sexual violence), the unique needs of the family, and the potential obstacles a family may face in accessing and using family services.
Core objective: Prevent SUDs from occurring across family relationships and generations. Family counseling aims to keep SUDs from moving from one generation or relationship to another. If a parent misuses alcohol or drugs, the remaining family members are at increased risk of developing SUDs and mental disorders or establishing relationships with someone who misuses alcohol or drugs. If the person misusing substances is an adolescent, successful treatment reduces the likelihood that siblings will misuse substances or commit related offenses (Whiteman, Jensen, Mustillo, & Maggs, 2016).
Although many people view “family” as the group of people with whom they share close emotional connections or kinship, there is no single definition of family. Diverse cultures and belief systems influence definitions, and because cultures and beliefs change over time, concepts of family are not static. In some cultures, the definition of family is narrow and determined by birth, marriage, or adoption. In other cultures, more expansive definitions include in the concept of family those individuals who share a household, values, emotional connections, and commitments. The level of commitment people have to each other and the duration of that commitment also vary across definitions of family.
Just as there is no single definition of family, there is also no typical family type. Families are quite diverse in organizational patterns and living arrangements. Some families consist of single parents, two parents, or grandparents serving as parents. Many families are blended, including children from previous relationships. Many others are intergenerational within the household and include extended family members, such as grandparents, uncles, aunts, cousins, other relatives, and close friends. Still other types are adoptive or foster and other families whose members are not biologically related and instead come together by choice. Different family constellations often present specific and predictable challenges. For instance, in newly formed blended families, conflicts are typical between parents on how to parent and between a parent and stepchild on the rights of who can discipline, who holds authority, and so forth. Common challenges for single parents include the stress of balancing many responsibilities while parenting. Understanding family types can help counselors anticipate expected and normative family issues that SUDs can complicate (Exhibit 1.4).
Exhibit 1.4. Treatment Issues According to Family Type.
A systems view of families assumes that some core characteristics influence functioning across all family types. In systems theory, the family is a system of parts that is itself embedded in multiple systems—a community, a culture, a nation. Families strive for balance and self-regulate accordingly (Nichols & Davis, 2017). The next sections summarize key characteristics of families from a systems perspective.
Subsystems are groupings in the family that form according to roles, needs, interests, and so forth. Subsystems appear in most families among parents, siblings, and couples (Gehart, 2018). A subsystem can be one person or several family members. Subsystems have their own roles and rules in the family. For example, in a healthy family, a parental subsystem (including one or more members) maintains some privacy, takes responsibility for providing for the family, and has power to make family decisions.
Subsystems can significantly affect individuals’ behavior in the family. They can motivate and positively influence a family member. But some subsystems are unhealthy, even if they serve a necessary function in the family—as with a parentified child assuming adult roles that are not age-appropriate (Exhibit 1.5).
Exhibit 1.5. Homeostasis.
Families operate with rules. Rules provide guidance on acceptable behaviors and exchanges, and they reflect family values. Most rules are unspoken, but some are more prescriptive, such as not allowing a child to date until he or she is 16 (Goldenberg, Stanton, & Goldenberg, 2017). The structure of rules creates a sense of safety—as long as those rules are not too rigid.
Some families hold rules rigidly even when circumstances call for reevaluation. Other families experiencing duress or operating chaotically may not have enough rules. In families with SUDs, unspoken rules develop in response to the effects of drinking or drug use. For example, children may come to understand that they don't ask permission from their mother when she is drinking.
Each family holds certain beliefs and values (e.g., specific moral beliefs). Children may move away from these values and beliefs as adolescents or adults, but they are nonetheless influenced by them.
Families have shared histories and often develop defining narratives around past familial events. Individual family members can adopt these narratives even when they were not personally present for key events within that narrative, such as by hearing stories of past events about ancestors. Events in each family member's life can be incorporated into the defining family narrative over time as well.
Based on their values, histories, and significant life events, families assume certain characteristics and identities, such as always having been risk-takers. These translate across generations and influence the selection of partners, hobbies, and occupations (e.g., intergenerational vocations as first responders, military personnel, or healthcare professionals).
Family members assume certain roles, which often relate to generation (e.g., parent, grandparent), cultural attitudes, family beliefs, gender, and overall family functioning. Some roles develop in response to stress or the underfunctioning of a family member.
Historically, the addiction field has used role and birth order theory to help families explore how they have adjusted or reacted to SUDs in the family. Roles help families maintain homeostasis, yet certain roles affect the individuals in that role negatively or distract from underlying issues. For example, a family may see a child as the root of their problems, although one or both parents have significant SUDs.
Family boundaries regulate the flow of information in and outside the family. There are individual and generational boundaries within families, as well as boundaries between families and other systems. Appropriate boundaries vary from culture to culture. Families may present with boundaries that initially appear unhealthy but turn out to be a function of culture. Boundary types range from rigid or fixed to diffused. Ideally, boundaries are clear, flexible, and permeable, allowing movement and communication in and outside the family as needed.
However, some families have very strict boundaries that keep people outside the family from engaging with or providing support to family members. Similarly, rigid boundaries can restrict communication or discussions across generations. For example, a father may state, “This is just the way it is in this house,” without allowing discussion of the rule or boundary in question.
Other families’ boundaries are too loose or too enmeshed. They may reduce privacy and allow inappropriate access to information. For instance, a sister may have a private conversation with her sibling, which the sibling then shares with everyone in the family without the sister's permission. Another example is a child privy to too much adult information about a sibling, parent, or other person.
Some family members have more power or influence than others. Power differences are expected across generations (e.g., between parent and child) but can also occur between parents. There can also be differences in which parent makes which types of decisions for the family.
Sometimes, families give decision-making power to children or to a specific child, allowing the child to control relationships between the two parents, between parents and other siblings, and so forth. This occurs often when a family is under stress, or when a parent who had more influence disengages with the family because of an illness, divorce, or SUD.
Counselors can harness family power structures to foster change. To do so, counselors should realize that power is not always obvious. A family member who seems uninfluential may have more power than one assumes. For example, a family member who appears more subservient may have learned to use somatic complaints to curtail an activity or to communicate disregard for a course of action nonverbally.
Each family has patterns of communication. These can be verbal or nonverbal, overt or subtle, and they may refect cultural influences. They are families’ unique means of expressing emotion, conflict, and affection. Communication patterns may not be obvious to one outside the family but can significantly influence how family members act toward each other and toward people outside the family.
Communication patterns refect relationship dynamics, including alliances. They can indicate support and respect, or lack thereof, between family members. For example, a teenager in family counseling may look to a parent before answering a question; a husband may roll his eyes when his wife speaks.
Directionality is important in family communication patterns. One directional pattern that frequently occurs is called triangulation (Bowen, 1978). Triangulation happens when, instead of communicating directly with a family member who has an SUD, families who are under stress or lack coping skills instead talk around the person or with a third party in the family system. An example would be a mother who calls her daughter to talk about her son's drinking rather than talking to the son himself about his problem with alcohol.
The daughter, in turn, does not redirect or set a boundary with her mother. Triangulation often includes a third person as a go-between, an object of concern, or a scapegoat. Triangulation can involve someone who is not considered a family member.
Families are durable; membership in a family never expires. Even family members who have moved far away, disengaged emotionally, or become estranged from the family are still a part of it. Some family theorists would go so far as to say, “once in the family, always in the family.” Even divorced or deceased family members remain a part of their families’ shared histories.
Families also tend to be loyal. It can be difficult for family members to divulge secrets or express differences outside the family. Family members can and will oppose certain family beliefs or report certain family incidents, but when they do so, they normally experience shame, fear, or feelings of disloyalty. Loyalty can be a strength or a limitation for counselors in addressing family problems.
All families are engaged in one or more family developmental stages. Families are not static across the life span. Marked by transitions, aging, births, and deaths, extended families undergo developmental stages that predicate the normative stresses, tasks, and conflicts they may face. Understanding these normative stages will help counselors better perceive a family's presenting problems, including SUDs.
Counselors can tailor SUD treatment to meet family needs through developmental tasks. Following is an example of a couple who could benefit from treatment that aligns with their family development stage.
A couple met 25 years ago through a shared interest in the club scene, and they married after 2 years of dating. They have three children who are now in college or living independently. Before having their children, the couple's relationship centered around their use of alcohol and drugs.
Their substance misuse was curtailed throughout the parenting years but escalated after the last child left the home. In recent months, the husband stopped drinking and began receiving treatment at an intensive outpatient counseling program. The husband's abstinence has amplified the couple's sense of being strangers in the same house, which initially became apparent when their children moved out. They feel as if they no longer know what to do with each other or how to be together.
The couple first connected through substance use. Now, they must reconnect with each other through different interests and activities and rework their relationship to center on emotional connection. They would likely benefit from the therapeutic tasks suited to new relationships. Such tasks may include prescribed activities, such as formal dates, and spending time without others to get reacquainted.
Many systems significantly influence family members and the functioning of the family unit. These include educational, community, employment, legal, and government systems. Families operate as parts of these sociocultural systems, which themselves exist in diverse environments. A family-informed, systemsbased approach to SUD treatment will take into consideration questions such as:
What are the current community or geographic stressors?
What are the effects of acculturation?
What economic and supportive resources are available to the family?
Does the family have access to services?
How do culture, race, and ethnicity influence the family (e.g., how are issues of power or oppression at play for the family)?
Sociocultural interventions often stress the strengths of clients and families in specific contexts; such interventions include job training, education and language services, social skills training, and supports to improve clients’ socioeconomic circumstances. Other interventions may involve community- and faith-based activities or participation in mutual-help groups to alleviate stress and provide support.
After War World II, research started to explore the role of families in the development and maintenance of mental disorders. In part, family therapy was an outgrowth of research on communication patterns within families who had a family member with schizophrenia (Bregman & White, 2011). Interest in the role of families, family dynamics, and family theoretical approaches appeared to emerge simultaneously in the 1950s among practitioners and researchers in the United States and other countries.
Thereafter, family models started to incorporate the concept of systems, which was grounded primarily in psychoanalytic theory (Gladding, 2019). This systems-informed theory of the family evolved into several new schools of thought, each of which began to inform specific treatment strategies and training centers. At first, it was typical for practitioners to subscribe to just one model of family therapy. Yet, as more therapists began endorsing an eclectic approach that synthesized several family treatment models, the field witnessed a burgeoning of family therapy applications. Treatment for SUDs, eating disorders, and adolescent behavioral problems increasingly reflected aspects of family therapy.
Family counseling is a collection of treatment approaches and techniques founded on the understanding that if change occurs with one person, it affects everyone else in the family and creates a “change” reaction.
At the same time, treatment of SUDs as a primary condition was taking hold. As with family therapy's view of SUDs as a symptom of family issues, SUD treatment often viewed substance misuse as a symptom of underlying pathology. As the SUD treatment field evolved, it started to recognize the influence of biological, familial, cultural, and other psychosocial factors on substance use.
SUD treatment services, which at first were mainly residential, began to incorporate family activities into their programs. The goal was to rally individual clients’ family members in supporting their recovery and to address the ways in which family members, particularly spouses, contributed to clients’ substance misuse. It is no accident that the terms “co-alcoholic” and “codependent” were applied to spouses. Early SUD treatment programs began incorporating family psychoeducation, but there was an inherent attitude of “them” (family) versus “us” (those in recovery or treatment).
Drug and alcohol counselors were often in recovery themselves, yet had no experience addressing their own family histories. In earlier attempts to involve families in SUD treatment, spouses were invited to sessions of groups that the family member with the SUD attended regularly with other individuals in residential treatment. This did not often foster a welcoming environment for spouses, who were generally ill-prepared and had no alliances to create a sense of safety in the group. The objective of including spouses and other family members in this way was to gain collateral information from them about patterns of substance misuse in the individual with the SUD—and to highlight spouse or family behaviors that contributed to past use or could trigger a relapse. The focus was on the individual's, rather than the whole family's, recovery from addiction and its effects.
By the 1980s, family psychoeducation programs became the hallmark of family-based interventions in SUD treatment programs. As these specialized programs developed, they increasingly addressed the effects of parental SUDs on children and adult children (Wegscheider-Cruse, 1989). Virginia Satir's communication family model (Satir, 1988), adapted by Sharon Wegscheider-Cruse, gained prominence in SUD treatment; programs adopted a systemic perspective to explore how family dynamics and roles shifted in response to family members with SUDs. Some programs included the individual with the SUD and his or her entire family, whereas others involved everyone except the family member with the SUD; some were couples oriented, and still others treated individuals affected by substance misuse (e.g., children and adult children programs).
Many specialized family SUD programs began to close in the 1990s as a result of managed care, pressure to shorten treatment length, and limited funding sources (White, 2014). A persistent view of family services as ancillary meant little or no reimbursement from insurance and other funding sources. Programs self-funded family services or offered them on a cash basis, which was usually unsustainable.
Recognition of family-based SUD interventions as effective has since increased, and funding has improved. In 2018, about 60 percent of SUD treatment programs offered marital/couples counseling; 81 percent provided some family-based interventions (SAMHSA, 2020). Recently, family counseling has thrived, as has research into family-based SUD treatment for adolescents and behavioral couples therapy (Lassiter et al., 2015). Family psychoeducation (Exhibit 1.6), multifamily groups, and limited family sessions are common approaches to integrating family counseling with SUD treatment, and objectives have expanded to support healing of entire families.
Exhibit 1.6. The Matrix Intensive Outpatient Approach.
Four theories predominantly inform current family-based approaches in SUD treatment:
The chronic disease model views SUDs as similar to other chronic medical conditions and acknowledges the role of genetics in SUDs (White, 2014). Practitioners of this model approach SUDs as chronic illnesses that affect all members of a family and that cause negative changes in moods, behaviors, family relationships, and physical and emotional health.
Family systems theory holds that families organize themselves through their interactions around substance misuse. In adapting to substance misuse, the family tries to maintain homeostasis (Klostermann & O'Farrell, 2013).
Cognitive-behavioral theory assumes that behaviors, including substance misuse, are reinforced through family interactions. Treatment under this model works to change interaction patterns, identify and target behaviors that could trigger substance misuse, improve communication and problem-solving skills, and strengthen coping skills and family functioning (O'Farrell & Clements, 2012).
MDFT integrates techniques that emphasize the relationships among cognition, affect (emotionality), behavior, and environment (Liddle, Rowe, Dakof, Ungaro, & Henderson, 2004). MDFT is not the only family therapy model to adopt such an approach; functional family therapy (Alexander & Parsons, 1982), multisystemic therapy (Henggeler & Schaeffer, 2016), and BSFT (Szapocznik, Muir, Duff, Schwartz, & Brown, 2015) reflect similar multidimensional approaches.
Family counseling and family-based interventions can be an addition to SUD treatment. Parallel approaches deliver family counseling and SUD treatment independently, but at the same time. Some concurrent treatment approaches involve the person with SUD; others treat families separately from the family member with SUD. This depends on providers’ philosophy and program logistics.
When family counseling and SUD treatment occur at the same time, communication between providers is vital. To prevent treatment goals from conflicting, both providers should have competency in family processes and SUDs. In keeping with the principles of recovery-oriented systems of care (ROSCs), they should work together, in collaboration with the client and family, to improve family functioning, address the dynamics and effects of addiction in the family, and build a family environment that supports recovery for all. Case conferencing is an efficient way for family counselors and SUD treatment providers to address conflicting service objectives and other concerns constructively in a forum that fosters identification of mutually agreeable priorities and coordination of treatment.
RESOURCE ALERT: SAMHSA'S ROSC RESOURCE GUIDE.
Integrated interventions embed family counseling within SUD treatment. The individual with the SUD participates in family approaches as part of the SUD treatment program. Integrated family counseling for SUDs can effectively address multiple problems by taking into account each family member's issues as they relate to the substance misuse, as well as the effects of each member's issues on the family system. The integrated framework assumes that, although SUDs occur in individuals, solutions to substance misuse exist within the family system that will support recovery among all family members.
Exhibit 1.7 explores integrated family SUD counseling for individuals who may not initially wish to include family members in their treatment process.
Exhibit 1.7. Understanding Client Reluctance Toward Family Involvement.
Sequential treatment implements family-based approaches after initial SUD treatment. Some SUD treatment programs keep family involvement minimal until the individual with the SUD has obtained and maintained recovery. Sometimes, such an approach results from a lack of program resources. Other times, this approach may refect the outdated idea that sobriety or recovery must come first, regardless of an individual's unique circumstances and family dynamics—despite family-based SUD treatment interventions typically enhancing outcomes for individuals and families.
In some cases, circumstances and dynamics do warrant treating the SUD before involving the family—as when a family member with an SUD also has a co-occurring disorder not yet stabilized in treatment. In this scenario, it may be best to limit or postpone family-based interventions until stabilization. In other cases, sequential treatment is just the natural course of a family's path to recovery.
Families and couples may seek family counseling after SUD treatment. Many families struggle in early recovery, particularly the first year or two, even if they felt united in hope, motivation, and support during SUD treatment. The reality of recovery sets in; couples and families realize that it takes time and can dramatically change interpersonal dynamics, roles, and relationships. For instance, members of a couple in recovery may have different expectations for emotional and sexual intimacy; one partner may want more intimacy, whereas the other may find intimacy uncomfortable without using substances.
Contrasting expectations may produce stress in couples unaccustomed to supporting each other emotionally; some couples at this stage are still relearning how to talk productively with one another. Families and couples may need family counseling and therapy well after their initial recovery from SUDs.
Although family-based interventions vary widely from one treatment facility or provider to another, they are applicable across settings. As primary or ancillary approaches to address SUDs, such interventions can be integrated at many points along the continuum of care (e.g., inpatient or outpatient detoxification, outpatient SUD treatment services, medication-assisted treatment settings, short- or long-term inpatient or residential SUD treatment).
Family-based interventions are flexible. Providers can tailor them to match specific family needs and to suit specific treatment settings. The intensity and format of the family-based intervention should align with the stage and duration of an individual's SUD treatment, and should also address the presenting needs of that individual's family. These interventions can be brief, emphasizing psychoeducation, parenting skills training, and supportive services. They can also be intensive, with case management and outpatient or inpatient programming that explores family dynamics and relational issues.
Across settings, families may engage in individual family sessions and educational programs or counseling services involving multiple families. Exhibit 1.8 describes multifamily approaches to address SUDs.
Exhibit 1.8. Multifamily Groups.
SUD treatment programs can intervene with families at different treatment phases and levels of engagement. In detoxification, a counselor may first offer psychoeducation and general information about substance misuse and treatment options that seems applicable. Residential treatment programs may provide family intakes, family counseling sessions, and MFT groups to improve family functioning, address effects of SUDs in households, and help families identify their needs in recovery.
Family-based interventions have different functions and require specific counselor and programmatic competencies. For example, in continuing care services, parenting skills training may be implemented after discussing how the SUD and related family dynamics have affected parenting. In residential treatment, family sessions may explore the relational patterns and behavioral consequences of substance misuse or identify specific behaviors associated with drinking or drug use to establish ways for interrupting those patterns and behaviors. In intensive outpatient treatment, a family component can help individual family members define specific goals to help with family functioning.
This chapter provided fundamental information on historical perspectives as well as current models and theories of the family; rationales for including families in SUD treatment; and an overview of family-based interventions. In Chapter 2, readers will find a more detailed exploration of the effects of SUDs on families, family roles and dynamics, and long-term outcomes. Chapter 2 addresses the effects of SUDs on diverse family groups, including those with adolescents who have SUDs and parents who have SUDs.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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