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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.)
You can help clients and their family members initiate and sustain recovery from substance use disorders (SUDs) by actively involving family members in treatment.
When family members change their thinking about substance misuse and their behavioral responses to substance misuse, the entire family system changes.
Family-based SUD interventions focus on encouraging clients with SUDs to initiate and sustain recovery, improving their family communication and relationships to support and sustain their recovery, and helping family members engage in self-care and their own recovery.
All family counseling approaches for SUD treatment refect the principles of systems theory. Systems theory views the client as an embedded part of multiple systems—family, community, culture, and society. Family counseling approaches specific to SUD treatment require SUD treatment providers to understand and manage complex family dynamics and communication patterns. They must also be familiar with the ways family systems organize themselves around the substance use behaviors of the person with an SUD. Substance misuse is often linked with other difficult life problems— for example, co-occurring mental disorders, criminal justice involvement, health concerns including sexually transmitted diseases, cognitive impairment, and socioeconomic constraints (e.g., lack of a job or home). The addiction treatment field has adapted family systems approaches to address the unique circumstances of families in which substance misuse and SUDs occur.
It is beyond the scope of this TIP to cover all family therapy theories and counseling approaches. This chapter reviews the most relevant and research-based family counseling approaches specifically developed for treating couples and families where the primary issue within the family system is an SUD. It describes the underlying concepts, goals, and techniques for each approach. This chapter covers the following family-based treatment methods (Exhibit 3.1):
Exhibit 3.1. BCT Interventions.
Family counseling had its origins in the 1950s, adding a systemic focus to previous understandings of the family's influence on an individual's physical health, behavioral health, and well-being. The models of family counseling that have developed over the years are diverse. They generally focus on either long-term treatment emphasizing intergenerational family dynamics and the family's growth and well-being over time or brief counseling emphasizing current family issues and cognitive-behavioral changes of family members that influence the way the family system operates.
Family-based counseling in SUD treatment refects the latter family systems model. For example, in SUD treatment, family counseling focuses on how the family influences one member's substance use behaviors and how the family can learn to respond differently to that person's substance misuse.
When family members change their thinking about and responses to substance misuse, the entire family system changes. These systems-level changes lead to positive outcomes for the family member who is misusing substances and improved health and well-being for the entire family.
Family counseling in SUD treatment also differs from more general family systems approaches because it shifts the primary focus from being on the process of family interactions to planning the content of family sessions. The counselor primarily emphasizes substance use behaviors and their effects on family functioning. For example, in a couples session in which the couple discusses the husband's return to drinking after a period of abstinence, the counselor would note the interactions between the husband and wife but zero in on the return to use. In doing so, the counselor can develop strategies the couple can use as a team to learn from the experience and prevent another return to use.
Although the specific family-based methods this chapter describes refect different strategies and techniques for addressing substance use behaviors, they share the same core principles of working with family systems. These core principles include (Corless, Mirza, & Steinglass, 2009):
Recognizing the therapeutic value of working with family members, not just the individual with SUD, as they deal with SUDs.
Incorporating a nonblaming, collaborative approach instead of an authoritative, confrontational approach in which the counselor is the expert.
Having harm reduction goals other than abstinence, which can bring positive physical and behavioral health benefits to the individual and entire family.
Expanding outcome measures of “successful” treatment to include the health and well-being of the entire family, as well as the individual with the SUD.
Acknowledging the value of relationships within the family and extrafamilial social networks as critical sources of support and positive reinforcement.
Appreciating the importance of adapting family counseling methods to ft family values and the cultural beliefs and practices of the family's larger community.
Understanding the complexity of SUDs and the importance of working with families to manage SUDs, as with any chronic illness that affects family functioning, physical and behavioral health, and well-being.
Some family-based interventions in the following sections are SUD-specific adaptations of general family systems approaches. Others were developed specifically to address SUDs from a family perspective. Each description includes an overview and goals of the approach, supporting research specific to SUD treatment, and relevant techniques and counseling strategies.
As an SUD treatment provider incorporating family-based interventions into your practice, you should take care to work within the limits of your training, license, and scope of practice. Also take note of the specific licensure and other treatment-related professional requirements specific to your state.
Much research on family-based SUD treatment interventions is on adolescents. A meta-analysis found family counseling for adolescent SUDs to be more effective than several individual and group approaches or treatment as usual (Tanner-Smith, Wilson, & Lipsey, 2013). Advances in family-based treatment approaches for adolescent SUDs can serve as pilot models for adult treatment.
For example, MST was specifically developed as a method for treating adolescents with SUDs who are involved in the criminal justice system. A
recent adaptation of MST for emerging adults who are aging out of the child welfare system follows the principles of MST but shifts the primary agent of change from parents to the emerging adult and the emerging adult's social network, which may or may not include the parents. Pilot testing of this adapted approach shows promising outcomes (Sheidow, McCart, & Davis, 2016). Another pilot study of MST adapted for mothers with SUDs (MST-Building Stronger Families) found significant reductions in substance use among adults and significantly fewer symptoms of anxiety among children paired with their mothers (Schaeffer, Swenson, Tuerk, & Henggeler, 2013).
Systemic-motivational therapy is a model of SUD family counseling that combines elements of systemic family therapy and MI. It was developed by Steinglass (2009) to treat alcohol use disorder (AUD) in the family but can be applied to other substance misuse. Goals include assessing the relationship between substance misuse and family life, understanding family beliefs about substance misuse, and helping the family work as a team to develop family-based strategies for abstinence.
You can help the family make a hypothesis about the causes of SUDs and create “mini-experiments” to address alcohol misuse in the family. You and the family will collaborate to develop specific criteria to assess the relative success of the mini-experiments. Then adjust treatment strategies according to how successful the mini-experiments were in addressing misuse (Steinglass, 2009).
Family interventions are good options in SUD treatment. Use them starting with the least intensive (e.g., counseling and Al-Anon or CRAFT) before moving to the most intensive.
Psychoeducation was the first family-based SUD treatment approach providers used extensively. It introduced the value of engaging family systems in treatment and has been an auxiliary part of SUD treatment programming for decades. Psychoeducation is more than just giving families information about the course of addiction and the recovery process. Goals include engaging family members in treatment, providing information, enhancing social support networks, developing problem-solving and communication skills, and providing ongoing support and referrals to other community-based services (McFarlane, Dixon, Lukens, & Lucksted, 2003). Psychoeducation can take place in individual or group sessions with family members, single family group sessions, and multiple family group sessions.
Engaging family members in more intensive SUD treatment is a possible outcome of psychoeducation, but many family members benefit just from learning about addiction, recovery, and ways to respond to a family member's substance misuse. Psychoeducation can include providing Internet access and links to information and family recovery resources such as pamphlets, multimedia, and recovery-oriented books. Psychoeducational interventions can also inform families about and provide referral to community-based family supports like Al-Anon and Nar-Anon.
Psychoeducation helps family members:
Understand the biopsychosocial effects of SUDs on the client and family.
Learn what to expect from SUD treatment and
the ongoing recovery process of their relative.
Grasp the importance of their support in helping the client initiate and sustain SUD recovery.
Build their own support systems and learn coping strategies and skills from other family members.
Increase a sense of support and reduce feelings of isolation and shame.
Including family members in psychoeducation can improve treatment outcomes for clients, reduce returns to use, and enhance the entire family's functioning and well-being. Family psychoeducation has emerged as a primary treatment choice for people with serious co-occurring SUDs and mental disorders (McFarlane et al., 2003). It has demonstrated effectiveness in reducing returns to use in medium-term outcomes in this population (Zhao, Sampson, Xia, & Jayaram, 2015) and is an empirically supported cognitive-behavioral therapy (CBT) approach to SUD relapse prevention (Sudhir, 2018).
Psychoeducation is a useful component of relapse prevention in individual, family, and group work. Psychoeducational strategies that can help prevent returns to substance use include:
Offering brief in-session education on SUDs, returns to use, and strategies for relapse prevention.
Assigning homework in the session for the client and family members to do between sessions.
Teaching and practicing problem-solving and communication skills during sessions.
Providing educational handouts for the client and family members to take home and review.
Suggesting reading, audio, or video material the client and family members can review at home.
Creating a family recovery maintenance notebook with educational handouts, homework exercises, in-session exercises, and journal notes on new insights and awareness, the effectiveness of problem-solving and communication strategies, and topics and questions for further exploration.
MDFT is a flexible, family-based counseling approach that combines individual counseling and multisystem methods to treating adolescent substance misuse and conduct-related behaviors (Horigian, Anderson, & Szapocznik, 2016). MDFT targets both intrapersonal processes and interpersonal factors that increase the risk of adolescent substance misuse (Horigian et al., 2016).
Counselors work in four MDFT treatment domains (Liddle et al., 2018). Each domain has specific goals:
Adolescents: Enhance their emotional regulation, social, and coping skills; communicate more effectively with adults; discover alternatives to substance use; reduce involvement with peers who use substances, antisocial peers, or both; and improve school performance.
Parents: Increase their behavioral and emotional involvement with the adolescent, reduce parental conflict, work as a team, discover positive and practical ways to influence the adolescent, improve the relationship and communication between parent and adolescent, and increase knowledge about positive parenting practices.
Family members and relevant extrafamilial others (e.g., neighbors, teachers, coaches, spiritual mentors): Decrease family conflict, increase emotional attachments, improve communication, and enhance problem-solving skills.
Community: Enhance family members’ competence in advocating for themselves in larger social systems such as school and criminal justice systems.
The multidimensional approach suggests that behavior change occurs via multiple pathways, in different contexts, and through diverse mechanisms. MDFT “retracks” the adolescent's development via treatment in the four domains. Knowledge of adolescent development and family dynamics guides overall counseling strategies and interventions.
In MDFT, counselor focus shifts as the adolescent and family progress through three stages. The stages and related counseling strategies are (Horigian et al., 2016; Liddle et al., 2018):
Stage I: Build the foundation.
Develop therapeutic alliances with all family members.
Explain the MDFT process.
Assess risk and protective factors of the individual, parents, family, and extrafamilial systems.
Identify personally relevant treatment goals of family members.
Use crises and stress to build motivation for change.
Stage II: Prompt action/activate change.
Promote positive change in feelings, thoughts, and behaviors of all family members.
Use active listening to empathize and raise hope that change is possible and aligned with goals.
Encourage the adolescent to share inner thoughts and experiences.
Enhance parenting skills through psychoeducation and behavioral coaching.
Encourage parents to set limits on, monitor, and support the adolescent.
Teach parents to manage difficult family interactions in the session.
Teach advocacy skills to improve family interactions with extrafamilial community systems.
Engage community-based supports to help family members sustain family system changes.
Stage III: Seal the change and exit.
Reinforce behavioral changes of all family members.
Explore strategies to maintain change and prevent recurrence of adolescent substance misuse and conduct-related behaviors.
End treatment when changes have stabilized.
The MDFT treatment format includes individual and family sessions, sessions with various family members, and extrafamilial sessions. Sessions are held in the clinic; in the home; or with family members at the court, school, or other community location. The format of MDFT has been 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.
Research supports the efficacy of MDFT, and counselor adherence to the MDFT model improves substance use treatment outcomes (Rowe et al., 2013). MDFT has been applied in geographically distinct settings with diverse populations (it is available in Spanish and French as well as English), including ethnically diverse adolescents at risk for substance misuse. Most families in MDFT studies have been from low-income, inner-city communities; adolescents in these studies have ranged from youth in early adolescence who are at high risk to older adolescents with multiple problems, juvenile justice involvement, and co-occurring SUDs and mental disorders.
Several randomized clinical trials have shown clinically significant effects of MDFT on reducing adolescents’ drug use and related behavioral problems in controlled and community-based settings (Rowe, 2012). Data also show that family functioning improves during MDFT, and families and adolescents maintain these gains at follow-up (Rowe, 2012). For some adolescents, MDFT may be an effective alternative to residential treatment (Liddle et al., 2018).
Behavioral couples and family counseling promote the recovery of the family member with an SUD by improving the quality of relationships, teaching communication skills, and promoting positive reinforcement within relationships. Two variations of this approach are BCT and BFT.
BCT is a structured counseling approach for people with SUDs and their intimate partners. It focuses on an intimate partner's ability to reward abstinence and other efforts to change and to promote continuing recovery for the person with an SUD. BCT aims to lessen relationship distress, improve partners’ patterns of interaction, and build more cohesive relationships to reduce risk of returns to use for the partner with an SUD (Klostermann & O'Farrell, 2013). The goals of BCT are to support abstinence from substances and improve relationship functioning (O'Farrell & Schein, 2011).
Typically, clients with SUDs and their partners attend 12 to 20 weekly sessions. Although there are exceptions to these criteria (McCrady et al., 2016), appropriate participants for BCT are generally couples in which (Klostermann & O'Farrell, 2013):
Partners are married or living together for at least 1 year.
Neither partner has a co-occurring mental disorder that would significantly affect participation.
Only one member of the couple has a current problem with substance misuse.
There is no indication of risk of severe intimate partner violence.
The overall counseling approach has two main components (O'Farrell & Clements, 2012):
Substance-focused interventions to build support for abstinence.
Relationship-focused interventions to enhance caring behaviors, shared activities, and communication.
“[T]he goal of BCT is to create a ‘virtuous cycle’ (i.e., enlisting the … partner's support in the client's recovery) between substance use recovery and relationship functioning by using interventions designed to address both sets of issues concurrently and reinforcepositive behaviors.”
(Klostermann, Kelley, Mignone, Pusateri, & Wills, 2011, p. 1503)
RESOURCE ALERT: MDFT ONLINE.
Counselors begin with substance-focused interventions to promote abstinence, then add relationship-focused interventions after abstinence is stable, with an emphasis on teaching communication skills and increasing positive relationship activities (O'Farrell & Schein, 2011). Relapse prevention interventions occur during the final phase of BCT (Klostermann & O'Farrell, 2013).
There is a mutual relationship between substance use and marital conflict. Unpredictable behavior associated with substance misuse contributes to high levels of relationship dissatisfaction, instability, conflict, and stress—all linked to returns to use in people with SUDs. Substance use and relationship conflict reinforce each other in a damaging cycle of interactions that partners have difficulty breaking.
Couples counseling helps couples take substance misuse out of the equation, harness partner support to positively reinforce the client's efforts to remain abstinent, and change relationship dynamics to promote a family environment that is more conducive to ongoing recovery. Stress decreases, the risk of return to use for the person with the SUD is lowered, and interpersonal violence and other relationship problems are reduced (Klostermann, Kelley, et al., 2011).
BCT sessions are very structured. Each session has three counselor tasks: (1) review any substance use, relationship concerns, and homework assignments; (2) introduce new material; and (3) assign home practice (Klostermann, Kelley, et al., 2011). Much of the work in BCT happens during completion of out-of-session assignments. The counselor initially works with the couple to develop a recovery contract that lays the foundation for the ongoing couples work. Counseling strategies include a recovery contract between the couple and counselor, activities and homework exercises that increase positive feelings between partners, shared activities, constructive communication, and relapse prevention planning. Exhibit 3.2 describes counseling strategies and interventions for different stages of treatment.
Exhibit 3.2. BCT Interventions.
BCT is a family-based treatment with strong evidence of efficacy in treating SUDs. BCT is significantly more effective than individual treatment for both men and women with SUDs in reducing substance use, increasing abstinence, and improving relationship functioning and satisfaction (O'Farrell & Clements, 2012). A review of the research on BCT also found that it is a cost-effective approach to SUD treatment, especially when the cost of fewer returns to use is factored in (Fletcher, 2013). Although earlier research focused on men with SUDs and their female partners, BCT used with female clients with SUDs is also associated with better substance- and relationship-related outcomes than the use of individual therapy (O'Farrell, Schreiner, Schumm, & Murphy, 2016; O'Farrell, Schumm, Murphy, & Muchowski, 2017). Some evidence shows that BCT is effective in treating lesbian and gay couples (Fletcher, 2013).
It is generally recommended that BCT be used when only one partner has an SUD (Klostermann & O'Farrell, 2013), but BCT appears as effective in couples when both partners have a current SUD and are pursuing recovery as in couples when just one partner is in treatment (Schumm, O'Farrell, & Andreas, 2012). Research on elements of BCT that are related to treatment outcomes found that the partner's involvement in couples treatment, less confrontation, and more supportive language for the client's efforts to change drinking behaviors were associated with greater couple satisfaction and reduced drinking (McCrady et al., 2019). Thus, BCT treatment may be particularly effective when both partners are motivated to change and are willing to support each other.
The following sections discuss adaptations of BCT that have been found to be effective in pilot studies. These adaptations open up possibilities for SUD treatment programs to integrate BCT in ways that might better fit your treatment philosophy and approach than standard BCT.
CLINICAL SCENARIO: COUPLES COMMUNICATION SKILLS.
BCT not only positively affects the couple, but also has a secondary effect on children in the family (e.g., enhancing children's psychosocial adjustment) even when the children do not participate in treatment (Fletcher, 2013). Adding specific content to BCT on parenting skills enhances the positive effects of this approach, not only on the couple but on the entire family. A randomized controlled study of BCT plus parenting skills training (PSBCT) found significant differences in child adjustment measures between PSBCT and individual treatment of the parent with an SUD and clinically meaningful effects between PSBCT and standard BCT (Lam, Fals-Stewart, & Kelley, 2008). Adding six sessions of parent training, which reinforced the skills training sessions in BCT (e.g., adding a “Catch Your Child Doing Something Nice” exercise after the couple practiced the “Catch Your Partner Doing Something Nice” activity), did not compromise the effectiveness of traditional BCT for the couple and enhanced parenting skills to a greater degree than BCT alone (Lam, Fals-Stewart, & Kelley, 2009).
Many clients live with a family member other than an intimate partner. Behavioral family counseling is an adaptation of BCT (O'Farrell, Murphy, Alter, & Fals-Stewart, 2010) in which a client and a family member (usually a parent of an adult child) attend 12 adapted behavioral family counseling sessions. The sessions focus on helping the client and family member establish a “daily trust discussion.” The family member reinforces the client's intention to remain abstinent from substances, reduce conflict, improve communication, and increase positive alternative activities for the client.
Behavioral family counseling emphasizes daily support for abstinence as in BCT, but focuses less on sharing rewarding activities and practicing communication skills at home. These adaptations provide a better ft with the developmental needs (e.g., increased autonomy, separation) of an emerging adult living with a parent. Research supports the efficacy of this adaptation over individual treatment on treatment retention, increased abstinence, and reduced substance misuse (O'Farrell & Clements, 2012).
BFT treatment approaches are based on social learning and operant conditioning (i.e., using positive and negative reinforcements to change behavior) theories. BFT emphasizes clients’ substance use behaviors in a family context (Lam, O'Farrell, & Birchler, 2012). Counselors view substance misuse as a learned behavior that peers, parents, and role models may reinforce (Lam et al., 2012).
To counteract these influences, treatment emphasizes contingency management strategies that reward abstinence, reduce reinforcement of alcohol and drug use, and increase positive behaviors and social interactions incompatible with substance use (Lam et al., 2012). The counselor coaches family members to engage in new behaviors that increase positive interactions and improve communication and problem-solving skills (Lam et al., 2012). BFT is not manual based, but it applies evidence-based practices in SUD treatment (e.g., contingency management, communication skills training, CBT) to family counseling.
To facilitate behavioral change in a family to support abstinence, use BFT techniques, including:
Contingency contracting: These agreements stipulate what each member will do in exchange for rewarding behavior from other family members. For example, an adolescent might agree to call home regularly while attending a concert in exchange for her parents’ permission to attend it.
Skills training: The counselor may start with general education on communication or conflict resolution skills, practice skills in sessions, and get the family to agree to use the skills at home.
Cognitive restructuring: The counselor helps family members voice unrealistic or self-limiting beliefs that contribute to substance misuse or other related family problems. An example of a self-defeating personal belief might be: “To ft in (or to cope), I have to use drugs.” Distorted messages from the family might include: “He uses drugs because he doesn't care about us.” or “He's irresponsible; he'll never change.” The counselor helps the family replace these self-defeating beliefs with those that facilitate recovery and individual and family strengths.
The family behavior loop map is a step-by-step behavioral chain analysis of the family's interactions and the sequence of events that lead to substance use behaviors and episodes when the client with an SUD refrains from substance use (Liepman, Flachier, & Tareen, 2008). The entire family is involved in the mapping process. Older children and adolescents contribute verbally to mapping, and younger children offer information about family interactions via their behavior (Liepman et al., 2008). This visual representation helps family members see their contributions to this systemic, interactive process. It emphasizes that no one person is the cause or victim of the negative effects of substance use behaviors (Liepman et al., 2008). The map identifies alternative behaviors, thoughts, and feelings that lead to “not using” and presents possibilities for discussing ways to break the chain of events.
CLINICAL SCENARIO: INDIVIDUAL COUNSELING WITH A FAMILY FOCUS.
This strategy is rather involved. Providers who wish to use it in their work with families in SUD treatment should seek training by a family counselor experienced in its application.
A lack of parental involvement in the activities of their children predicts later substance use, according to research. Conversely, research consistently shows that parental monitoring and parent-child communication about substance use reduces the risk of early initiation of substance use and lowers rates of adolescent substance use (Hernandez, Rodriguez, & Spirito, 2015).
Family Check-Up (FCU) is a brief assessment and feedback intervention that targets family risk factors linked to substance use, including lack of parental monitoring and low-quality parent-child relationships (Hernandez et al., 2015). FCU integrates principles and techniques of MI and individualized feedback to motivate families to change current family practices to prevent future substance use in children and address current substance use in adolescents (Hernandez et al., 2015).
FCU for adolescents consists of two family sessions (Hernandez et al., 2015):
An initial intake interview to identify family strengths and challenges, engage the family, and videotape a structured assessment protocol of parent-adolescent interactions.
A feedback session using MI to support parents to maintain positive parenting practices and change parenting practices associated with adolescent substance misuse.
CLINICAL SCENARIO: COGNITIVE RESTRUCTURING AND PROBLEM-SOLVING.
The feedback session has four components
Self-assessment: Parents are asked what they learned about their family from participating in the family interactional assessment.
Support and clarification: The counselor provides support and clarifies family issues and practices that reduce the risk of adolescent substance use.
Feedback: The counselor provides personalized feedback on family expectations about substance use, parental supervision and monitoring, and parent-adolescent communication.
Parenting plan: The counselor facilitates a discussion of the adolescent's strengths and the importance of parents praising positive behavior. The counselor works with the parent to develop a brief written plan to improve family communication and monitor the adolescent's behavior.
Research shows lower levels of adolescent substance use and risk for SUD diagnosis when parents complete the FCU intervention (Hernandez et al., 2015). A systematic review and meta-analysis found that FCU as part of a larger school-based approach reduced marijuana use among adolescents (Stormshak et al., 2011; Vermeulen-Smit, Verdurmen, & Engels, 2015).
BSFT aims to reduce or eliminate youth drug misuse and change family interactions that support drug misuse through its problem-focused, directive, and practical approach (Gehart, 2018; Horigian et al., 2016). Drawing on structural and strategic family theory and interventions, Szapocznik, Hervis, and Schwartz (2003) first developed BSFT to address drug misuse among Cuban youth in Miami. The central assumption of BSFT is that adolescent substance misuse and other risk behaviors are linked to dysfunctional family interactions (e.g., inappropriate alliances, boundaries that are too rigid or loose, parents’ tendency to blame adolescents for family problems) (Horigian et al., 2016). Exhibit 3.3 summarizes the underlying concepts that shape BSFT interventions.
Exhibit 3.3. Concepts Underlying BSFT.
BSFT interventions target family interactions that are most likely to affect youth substance misuse and other risk behaviors. Structural family counseling strategies in BSFT include (Gehart, 2018):
Joining: The counselor establishes a working alliance with each family member and connects with the family system. The counselor identifies and adjusts to family members’ ways of relating to one another, conveys understanding and respect, and listens as each family member expresses feelings.
Enactments: The counselor invites the family to recreate dysfunctional interactional patterns that support substance misuse to assess and then restructure them through coaching, modeling alternative ways of interacting, or both. These patterns are typically rigid, so the counselor must take a directive role and have family members develop and practice different interaction patterns.
Working in the present: The counselor emphasizes current interactions and focuses less on the past. The family is more likely to get stuck in negative interactional patterns if the conversation focuses on past events. The discussions emphasize events happening in the present.
Reframing negativity: The counselor reframes negative interpretations of thoughts, feelings, and actions to promote caring and concern in the family. For example, a counselor may reframe a parent's insistence on a 9:00 p.m. curfew as an act of caring, not a way of controlling the adolescent.
Reversals: The counselor may coach one or more family members to do or say the opposite of what they typically do or say to shake up typical interactional patterns. Doing so encourages other family members to change their position in the interaction as well. The counselor then explores the effect on the family's typical interactional pattern.
Working with boundaries and alliances: Roles, boundaries, and power establish the order of a family and determine whether the family system works. Standard structural techniques are used to loosen or strengthen boundaries to better meet the developmental needs of family members. The counselor helps family members mark individual boundaries while respecting the individuality of others. To strengthen boundaries, the counselor supports parents’ efforts to reestablish authority as a parental unit and makes the family aware when a family member:
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 what another person says or to stop that person from speaking.
Detriangulation: In families dealing with SUDs, a child or less powerful person in a conflict is often involved in interactions that can defect or diffuse tension between two family members who are in conflict. This involvement is called “triangulation.” One strategy is to literally or metaphorically remove the third, less powerful person from a conflict between two other family members so they can resolve the conflict directly.
Opening closed systems: Families dealing with SUDs tend to be “closed” systems that disallow open conflict. Counselors should “open” the system to let each family member express feelings and coach the family on constructive ways to resolve differences instead of avoiding or diffusing conflict.
Research over more than three decades shows the effectiveness of BSFT in engaging and retaining adolescents and family members in treatment, addressing cultural factors related to engagement, reducing adolescent drug use, reducing parental alcohol use, and improving family functioning (Horigian, Feaster, Robbins, et al., 2015; Rowe, 2012). BSFT is effective in long-term reductions in adolescent arrests, incarcerations, and externalizing behaviors like aggression and rule-breaking (Horigian, Feaster, Brincks, et al., 2015).
BSFT is a somewhat complex, manual-based treatment approach. Fidelity in community-based settings tends to be low (Lebensohn-Chialvo, Rohrbaugh, & Hasler, 2019). Implementation requires extensive training and ongoing supervision.
Functional family therapy is another behaviorally based family counseling approach. Its goals are to change the dysfunctional family's behavioral and interactional patterns that maintain the adolescent's substance misuse and reinforce positive problem-solving responses to adolescent risk behaviors (Rowe, 2012). It is based on an ecological model of risk and protective factors.
This approach has three treatment phases and associated counseling strategies: engagement and motivation, behavior change, and generalization (Hartnett, Carr, Hamilton, & O'Reilly, 2017; Horigian et al., 2016):
Phase 1: Engagement and motivation
Engage all members of the family to enhance motivation.
Frame the counselor-family therapeutic relationship as a cooperative effort between experts.
Reduce negativity and blaming interactions through reframing.
Phase 2: Behavior change
Assess risk factors and evaluate relational patterns.
Help families develop behavioral competencies for parenting, communication, and supervision.
Encourage active listening and clear communication.
Help parents develop/implement rules and consequences for substance use and risk behaviors.
Phase 3: Generalization
Teach families how to generalize the skills they developed in Phase 2 to new situations and contexts other than the initial target behavior.
Anticipate and plan for the possibility of future problems.
Reframe continuing challenges as normal, not as failures of the family or the counseling process.
Actively link family members to community-based supports.
COUNSELOR NOTE: CULTURAL CONSIDERATIONS.
CLINICAL SCENARIO: JOINING AND ESTABLISHING BOUNDARIES.
Functional family therapy has been widely disseminated in the United States and other countries. A meta-analysis of comparison and randomized controlled studies found significant support for the effectiveness of functional family therapy compared with other treatment approaches, including CBT, psychodynamic, individual, and group counseling for adolescents, parenting education groups, and probation and mental health services (Hartnett et al., 2017).
In the 1980s and 1990s, Berg and Miller (1992) and de Shazer (1988) developed a family counseling approach to help family members find solutions to their problems instead of using the problemsolving approach of structural and strategic counseling. The main assumptions of solution-focused therapy are that pinpointing the cause of problematic family functioning is unnecessary and that counseling focused on solutions to specific problems is enough to help families change.
In solution-focused brief therapy, families generate treatment goals. The role of the counselor is to emphasize times when the problem (e.g., substance use behavior) does not occur and help the family identify achievable solutions that enhance motivation and optimism for behavioral change (Klostermann & O'Farrell, 2013).
In solution-focused brief therapy, the counselor helps the family develop a detailed, carefully articulated vision of what the world would be like if the presenting problem were solved. The counselor then helps the family take the necessary steps to realize that vision. Because of its narrow focus on a specific target problem, this therapeutic approach works well with many SUD treatment strategies.
Many family counseling strategies and techniques in solution-focused therapy are basic to any family counseling approach—joining with the family, managing the emotional intensity of family sessions, negotiating treatment goals with the family, and attending to family patterns of interaction (McCollum & Trepper, 2013). The following techniques characterize solution-focused therapy, specifically.
Developing a vision of the future: The counselor invites family members to envision what life would be like without the problem, such as substance misuse. This process engages family members in using their imagination to open up new possibilities for generating solutions to the problem, enhances the family's hope that things can and will change, and highlights the benefits of change.
Asking the miracle question: This is perhaps the most representative of the solution-focused therapy techniques. It elicits each family member's vision of life without substance misuse. The miracle question traditionally takes this form (De Jong & Berg, 1998):
I want to ask you a strange question. Suppose that while you're sleeping tonight and the house is quiet, a miracle happens. The miracle solves the problem that brought you here. But you're asleep, so you don't know that the miracle has happened. When you awake tomorrow morning, what will be different to show you that a miracle happened and that the problem that brought you here has been solved?
Envisioning interpersonal change: Counselors help family members set goals that respect the views and needs of other family members. Ask the person with the SUD questions like (McCollum & Trepper, 2013):
What will other family members notice about you as you move closer to your goal to stop drinking?
If we video recorded your family at Sunday dinner after you quit drinking, what would it look like?
How would family members be interacting differently?
Identifying exceptions to the problem: Sometimes the substance use behavior that brings the family to counseling is absent or less severe. It is important to help the family identify these exceptions and build solutions from there. For example, you might ask each family member about a time when the substance use behavior did not happen. You might ask a spouse, “Can you tell me about a time when you and your spouse were arguing, but he did not grab a beer from the refrigerator?”
Identifying problem sequences: The counselor helps the family identify a specific target behavior, like the adolescent leaves the house and smokes marijuana to reduce stress during a parental argument. You then ask a series of questions to identify the sequence of behaviors of all family members that contributed to the problems. These questions might include (McCollum & Trepper, 2013):
When does Tony typically leave the house to get high with his friends?
Who is there during this event?
What happens first?
What did each of you do first?
What happened next?
How did this situation end?
Identifying solution sequences: The next step is to identify the solution sequence of family member behaviors during an exception to the problem sequence. This helps the family shift the focus from the problem to the solution. Families often get stuck in the problem sequence and begin to believe that there is only one outcome to the problem. Questions you can ask to identify the solution sequence during an exception might include (McCollum & Trepper, 2013):
Can you tell me about a time when the sequence started, but Tony didn't go get high with his friends?
How was this different?
What did each of you do differently to short-circuit the problem sequence and help with a solution?
What did each of you do first?
What happened next?
What can each of you do differently to make the solution sequence happen again?
Solution-focused brief therapy replaces the traditional expert-directed approach aimed at correcting pathology with a collaborative, solution-seeking relationship between the counselor and the family. It encourages the family to focus on what life will be like when the problem is solved. The emphasis is on the development of a solution in the future, rather than on understanding the development of the problem in the past or its maintenance in the present.
COUNSELOR NOTE: ASKING THE MIRACLE QUESTION.
Research supports the effectiveness of solution-focused brief therapy. A review of controlled outcome studies found that it provided significant positive benefits to adults with mental disorders and showed promise for improving family functioning, particularly for families under stress of having a family member with a mental disorder (Gingerich & Peterson, 2013). A study of parents with SUD and trauma-related symptoms who were involved in the child welfare system found that solution-focused brief therapy was effective in reducing substance use and trauma-related symptoms (Kim, Brook, & Akin, 2018).
Another much-studied family-based intervention that focuses on CSOs is CRAFT. CRAFT is a structured, family-focused, positive reinforcement approach, usually four to six sessions in length, that teaches family members and CSOs strategies for encouraging the family member who is misusing substances to change his or her substance use behaviors and enter SUD treatment. For example, a positive reinforcer may tell the family member how much the CSO enjoys spending time with him when he is not smoking marijuana or going to a movie with him after a day without drinking. The underlying assumption of CRAFT is that environmental contingencies are important in promoting treatment entry (Bischof, Iwen, Freyer-Adam, & Rumpf, 2016). The counselor's role in CRAFT is to work with family members to change the way they interact with the person who has an SUD and that, in turn, will have an impact on his or her substance use behaviors. The focus of this intervention is the family.
CRAFT is a prime example of an SUD treatment approach that uses community reinforcement, which promotes SUD recovery by engaging family members and other natural supports in treatment. The goal of community reinforcement is to work together to provide positive incentives for people with SUDs to stop using substances; get progressively involved in alternative, meaningful, positive social activities not associated with substance use; and enter or stay in treatment. Community reinforcement helps family, friends, and social supports positively reinforce behavior change instead of confronting continued substance use or other risk behaviors. People pressed into SUD treatment by confrontation are more likely to return to use than those encouraged to enter through positive reinforcement. CRAFT is effective for clients with SUDs, people with co-occurring SUDs and mental disorders, and people in urban and rural communities.
CRAFT is highly structured, which works well in some scenarios. It can also be adapted to provide a less structured family-focused approach. This involves providing families and CSOs with psychoeducation on the effects of substance misuse on the family and coaching on communication skills, which include:
Refraining from blaming and shaming the family member.
Expressing concern about the family member's substance use behavior and its effects on the family.
Expressing hope that the family member will get help.
Offering affirmations and positive reinforcement for any positive change in substance use behaviors.
Family members and CSOs may need encouragement to attend community-based recovery support groups like Al-Anon and Nar-Anon. Research has associated Al-Anon with positive psychosocial and physical outcomes for family members and CSOs (Roozen, de Waart, & van der Kroft, 2010).
Network Therapy combines aspects of individual, group, and family-based counseling by enlisting the help of a client's family and friends (ideally, three or four people) to work with the counselor to help the client achieve and maintain abstinence (Galanter, 2014; Galanter, 2015). It uses three key elements to help people with substance misuse attain lasting recovery: cognitive-behavioral relapse prevention techniques, the client's existing supportive social “networks,” and community-based resources that support abstinence (e.g., mutual-aid support programs).
Goals and objectives of Network Therapy designed to help clients stabilize and abstain from substance use include (Galanter, 2014; Galanter, 2015):
Having the client participate in individual sessions with the counselor as well as group sessions with the counselor and the network of family and friends.
Making abstinence the immediate and primary treatment goal from the outset. This is achieved by using an ecological approach (that is, focusing on engaging family and social resources) or a problem-solving family therapy approach (that is, focusing on the substance misuse problem itself rather than the inner workings and relationships within the family).
Helping clients achieve long-term stability using a variety of SUD treatment tools. For example, avoiding relationships with others who are actively misusing substances, initiating medication-based treatment, attending mutual-aid support programs, and developing contingency contracts are all potential options.
Ensuring sessions have a “teamwork” feel and not a confrontational feel to them. Unlike some family-based therapy approaches, the goal is not to work out unhealthy dynamics, personality conflicts, or relationship problems between
the client and the network. Network Therapy is also not intended to be an “intervention” in the sense that there is no confrontation of the client or threats to withdraw support if the client does not seek abstinence. The goal is simply for the network to remain supportive and engage in behaviors that help the client become and remain abstinent.
Emphasizing to the network the importance of solidarity and remaining committed as a group to supporting the client. For instance, counselors should emphasize the importance of all network members regularly attending sessions and engaging in supportive activities designed to help the client abstain from substances.
Research has found Network Therapy is associated with decreased substance use as refected by opioid-free and cocaine-free urine tests over time (Galanter, Dermatis, Glickman, et al., 2004; Galanter, Dermatis, Keller, & Trujillo, 2002). Some research on Network Therapy suggests these outcomes result from improvements to the therapeutic alliance (Glazer, Galanter, Megwinoff, et al., 2003). Researchers have adapted Network Therapy by combining it with behavioral therapy and naltrexone (Rothenberg, Sullivan, Church, et al., 2002) as well as by combining it with community reinforcement approaches (known as Social Behavior and Network Therapy [Orford, Hodgson, Copello, et al., 2009; Williamson, Smith, Orford, et al., 2007]).
You can integrate family-based interventions into SUD treatment to greater or lesser degrees along a continuum. Counseling approaches to involve family in treatment and continuing care may include:
Engaging family members and CSOs in helping the individual with an SUD get into treatment.
Engaging family members and CSOs while those with an SUD are in treatment.
Linking actively to family/CSO recovery supports and comprehensive case management services.
Facilitating behavioral contracting between family members and clients around such issues as abstinence and medication adherence.
Improving communication to help clients and partners address relationship conflicts and stressors.
Enhancing family members’ problem-solving skills and supportive behaviors to avoid returns to use.
It is well documented that family, social supports, and community resources are keys to successful long-term recovery for people with SUDs and co-occurring disorders. Recovery is not a solo endeavor; it is a social process. Recovery supports can include spouses, intimate partners, CSOs, parents, extended family members, friends, community members, spiritual mentors, teachers, clergy, recovering peers, employers and coworkers, case managers, and primary care and behavioral health service providers.
Moos (2011) noted that social factors protect people from developing SUDs and may also help them initiate and maintain recovery. These include forging emotional bonds; establishing social cohesion and support; maintaining goal direction; gaining structure through school, work, or faith-based organizations; monitoring by family, friends, and other recovery supports; observing and imitating positive role models; expecting negative consequences for engaging in risk behaviors; building self-efficacy; developing effective coping skills; and participating in rewarding, substance-free social activities. These processes “are reflected in the active ingredients that underlie how community contexts, especially family members, friends, and self-help groups, promote recovery” (Moos, 2011, p. 45).
Although family members can be a source of support for the person with the SUD, they also need their own recovery support. Family structure, roles, relationships, rules, and rituals are altered by addictive and risk behaviors associated with SUDs. These changes are “deeply imbedded within family members and habitual patterns of family interaction and will not spontaneously remit with recovery initiation” (White & Sanders, 2006, p. 63). Family members can experience stress related to the behaviors of the person with an SUD, increased dependence on them, and difficulties dealing with the complexities and limitations of SUD treatment services. In addition, financial stressors for families can include high healthcare costs; lost jobs; and large losses of family income, savings, and assets. These stressors take a tremendous toll on families.
You can help clients and family members initiate and sustain recovery by actively involving family members in treatment. The following are some guidelines for engaging family members in SUD treatment:
Talk with your client in the early stages of treatment about the importance of having family members, CSOs, and recovery support people involved in his or her treatment.
Discuss issues around safety and cultural appropriateness of inclusion of family members and recovery supports, including boundaries around confidentiality.
Have your client sign releases to have family members and recovery supports involved.
Work collaboratively with your client to develop a plan for identifying supportive family members and recovery supports; inviting them to an initial counseling, family group session, or psychoeducational session; and deciding what issues will be addressed.
During initial recovery support sessions, offer culturally appropriate information regarding the nature of your client's substance use or mental disorders; early warning signs of returns to use; the impact of these chronic conditions on family members and recovery supports; and the importance of family and recovery support involvement in treatment.
Facilitate behavioral contracting between family members and the client around such issues as abstinence and medication adherence.
Improve communication skills to help the client and his or her spouse or intimate partner address conflicts and stressors in their relationship.
Ask recovery supports to share positive, non-substance-using experiences with the client.
Get input from family and recovery supports on the client's early warning signs of returns to use.
Discuss the importance of self-care with recovery supports.
Share information on community resources and mutual-help groups for family members and CSOs.
Discuss the purpose and location of resources, and what to expect at support group meetings.
Facilitate contact between your client's recovery supports and a peer recovery support specialist, if available, to link them actively with and expedite participation in community-based programs.
Plan for follow-up meetings to address ongoing recovery and relapse prevention concerns.
When appropriate, refer for assessment or individual counseling family members or recovery supports who have their own substance use or mental health concerns—or refer them to family therapy to address family issues beyond your scope of practice.
Involve supportive family members and other recovery supports in developing and implementing the continuing care plan; ask for their help to address barriers to continued treatment engagement.
Work collaboratively with your client and recovery supports to develop a relapse prevention and emergency plan (in the event of a lapse) that includes appropriate roles for recovery supports (take care not to burden them with responsibilities that your client should handle).
Strategies for incorporating family recovery support group participation in family counseling include:
Exploring family member's understanding of and prior participation in mutual-aid (referred to as recovery support or mutual-help) groups.
Discussing and dispelling misconceptions about family recovery support groups.
Exploring the challenges and benefits of participation in family recovery support groups.
Actively linking family members to community-based recovery support groups that are in alignment with the recovery support the client is participating in.
Offering space in family counseling sessions to explore family members’ refections on recovery support group participation (e.g., likes and dislikes, education on SUDs and their effects on families, coping strategies, differences between recovery support and family counseling approaches).
There are a number of family-focused, community-based mutual-aid groups with which you should be familiar. The mostly widely available U.S. groups are 12-Step groups like Al-Anon.
However, other family-focused mutual-aid groups are available in some areas and online, including Families Anonymous and SMART Recovery Family and Friends. You should be familiar with both local and online family recovery support groups and maintain up-to-date contact information so that you can easily link family members to appropriate recovery supports.
The oldest mutual-help group for family members is Al-Anon Family Groups. It was started in 1951 (Al-Anon Family Group Headquarters, Inc., 2016) in recognition of the need among family members of people recovering from AUD to gather together and help one another learn how to cope with the stress of living with a person who has a chronic, debilitating illness. Al-Anon is based on the 12 Steps of AA (Al-Anon Family Group Headquarters, Inc., n.d.) and helps family members learn self-care and stress coping strategies, such as letting go of responsibility for a relative's substance use and allowing him or her to experience its natural consequences. Family members learn to focus on their own mental, physical, emotional, social, and spiritual needs while still supporting their relative's recovery.
Other 12-Step recovery groups for family members are based on the Al-Anon model. Nar-Anon is for family members of people with SUDs other than AUD; Co-Anon, for family members of people with cocaine use disorder. Adult Children of Alcoholics is for adults with a parent who has AUD, and Alateen is for adolescents with a parent who has AUD.
The National Alliance on Mental Illness (NAMI) offers peer-led psychoeducation courses for families, partners, and friends of people with mental illness to help them understand the illness and increase their coping skills. These activities, which vary in length and in frequency of meeting, empower participants to become advocates for their family members. These groups can help family members (NAMI, 2019):
Improve coping skills.
Find strength in sharing their experiences.
Avoid judging another's pain.
Reject guilt and find greater self-acceptance.
Embrace humor as healthy.
Accept that they cannot solve every problem.
Understand that mental disorders are chronic illnesses.
COUNSELOR NOTE: SEE FOR YOURSELF! ATTEND OPEN RECOVERY SUPPORT GROUP MEETINGS.
Case management is a psychosocial intervention that assesses major life concerns (e.g., substance misuse), develops an action plan, actively links clients to community-based resources, coordinates care, and monitors participation in services (Rapp, Van Den Noortgate, Broekaert, & Vanderplasschen, 2014). A meta-analysis of studies on clients with SUDs found that case management interventions were associated with better outcomes than standard treatment in active linkage to and retention in ancillary and SUD treatment services (Rapp et al., 2014).
Family case management addresses not only the needs of the client with an SUD, but also family issues related to the client's substance misuse. For example, criminal behavior, unemployment, financial and food insecurity, domestic violence, and child maltreatment are often present in families where one or more family members are misusing substances. Family case management is for families who are or should be involved intensely with larger systems, which include the workplace, schools, healthcare clinics, the criminal justice system, foster care and child welfare agencies, mental health facilities, and faith-based organizations. People with SUDs can receive family case management services in a variety of settings, including specialty SUD treatment programs, mental health service programs, adult drug courts, family courts, and child welfare agencies.
If your clients need intensive case management, your role as an SUD treatment provider is to link them and their families to specialized services. These services can range from less intensive (e.g., general case management support services) to more intensive (e.g., wraparound services, assertive community treatment programs) (Rapp et al., 2014). If clients and their families need less intensive case management services, act as a community liaison by initiating contact with other agencies that can provide services to them. You can inform clients about resources in the community, collaborate with other service providers, and advocate for clients and their families when needed.
Peer recovery support services for people with SUDs have demonstrated efficacy in helping people initiate and sustain recovery (Bassuk, Hanson, Greene, Richard, & Laudet, 2016). Peer recovery support services for family members are also available. A family-focused peer recovery support specialist is a nonclinical provider who is trained and supervised in providing education, support, and resources to family members who have a family member with an SUD. Family peer recovery support specialists have lived experience of having a family member with an SUD, mental disorder, or co-occurring disorder.
Family peer recovery support specialists understand the perspective of family members living with the effects of substance use behaviors and the challenges and successes of recovery. They provide education and emotional support to family members and actively link them to family-based resources in the addiction treatment, mental health, criminal justice, and child welfare service systems. Family peer recovery specialists also introduce and actively link family members to community-based recovery support services like Al-Anon.
“Meeting complex family needs requires coordination across systems. Most families with substance use disorders are involved in multiple service delivery systems (e.g., child welfare, health, criminal justice, education). Coordination and collaboration prevents conflicting objectives and provides optimal support for family members.”
You should become familiar with family peer recovery support services in your community so that you can actively link family members to a peer recovery support specialist who can help family members follow through on their own recovery goals in concert with the family's treatment plan.
RESOURCE ALERT: FAMILY-FOCUSED RECOVERY SUPPORT GROUP ONLINE RESOURCES.
CLINICAL SCENARIO: DEBBIE'S CASE MANAGEMENT.
Just as people with SUDs are at risk for a return to substance misuse after initiating recovery, family members can also experience a “relapse” or return to old behaviors and strategies for trying to manage the stress of living with a relative's active substance use. Family members are often acutely aware of the signs that a relative is using again. Seeing such signs may activate family members’ anxiety, anger, and feelings of helplessness; it can trigger old behaviors like blaming, shaming, ineffective communication, neglecting self-care, and becoming overly responsible for family functioning. Family members may reengage in risk behaviors like smoking, drinking, and overeating to manage their stress.
A seemingly small cue that the relative has returned to substance use can set off a family member. These cues can be linked to previous traumatic events. For example, Bev's husband (Harry) is a police officer. When Harry is not drinking, he leaves the car in the driveway. When he is drinking, he puts the car in the garage so that neighbors will not notice that he is drunk. When Bev sees the car in the garage, she remembers the many times that Harry came home drunk. Bev goes into a panic and starts screaming at him when she sees the car in the garage, even though Harry has not been drinking.
The same principles of relapse prevention counseling apply to both family members and the individual with the SUD. Family members can create their own relapse prevention plans if you help them:
Identify their own triggers or cues that signal a return to old behaviors.
Identify cognitive distortions (e.g., all-or-nothing thinking) that may precede a behavioral relapse.
Learn or reengage effective coping skills to manage the stress of the individual's return to misuse.
Create a written plan for family members, including specific self-care activities they can do, support people they can contact, and crisis numbers to call if the situation warrants.
See the updated TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment (Substance Abuse and Mental Health Services Administration, 2019a; https://store.samhsa.gov/product/TIP-35-Enhancing-Motivation-for-Change-in-Substance-Use-Disorder-Treatment/PEP19-02-01-003), for more information about relapse prevention plans.
Family counseling approaches in SUD treatment refect the principles of systems theory. Such approaches view the client as an integral part of the larger family system. In SUD treatment, family counseling focuses on how the family influences one member's substance use behaviors and how the family can learn to respond differently to substance misuse. When family members change their behavioral responses to substance misuse, the entire family system changes, leading to improved health and well-being for everyone. Chapter 4 advances the systems theory approach and provides counseling strategies to apply during intakes, initial sessions, and other stages of treatment.
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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