The Concept of Family

In the United States the concept of family has changed during the past two generations. During the latter half of the 20th century in the United States, the proportion of married couples with children shrank—such families made up only 24 percent of all households in 2000 (Fields and Casper 2001). The idea of family has come to signify many familial arrangements, including blended families, divorced single mothers or fathers with children, never‐married women with children, cohabiting heterosexual partners, and gay or lesbian families (Bianchi and Casper 2000).

Some analysts are concerned about indications of increasing stress on families, such as the increasing number of births to single mothers (from 26.6 percent in 1990 to 33 percent in 1999 [U.S. Census Bureau 2001c ]). The increase in single‐mother families, which typically have greater per‐person expenses and less earning power, may help to explain why, in the general prosperity of the last half of the 20th century, the percentage of children living in the poorest families almost doubled, rising from 15 to 28 percent (Bianchi and Casper 2000).

Bengtson (2001) asserts that relationships involving three or more generations increasingly are becoming important to individuals and families, that these relationships increasingly are diverse in structure and functions, and that for many Americans, multigenerational bonds are important ties for well‐being and support over the course of their lives.

The Family as an Ecosystem

Substance abuse impairs physical and mental health, and it strains and taxes the agencies that promote physical and mental health. In families with substance abuse, family members often are connected not just to each other but also to any of a number of government agencies, such as social services, criminal justice, or child protective services. The economic toll includes a huge drain on individuals’ employability and other elements of productivity. The social and economic costs are felt in many workplaces and homes.

The ecological perspective on substance abuse views people as nested in various systems. Individuals are nested in families; families are nested in communities. Kaufman (1999) identifies members of the ecosystem of an individual with a substance abuse problem as family, peers (those in recovery as well as those still using), treatment providers, non‐family support sources, the workplace, and the legal system.

The idea of an ecological framework within which substance abuse occurs is consistent with family therapy’s focus on understanding human behavior in terms of other systems in a person’s life. Family therapy approaches human behavior in terms of interactions within and among the subsets of a system. In this view, family members inevitably adapt to the behavior of the person with a substance use disorder. They develop patterns of accommodation and ways of coping with the substance use (e.g., keeping children extraordinarily quiet or not bringing friends home). Family members try to restore homeostasis and maintain family balance. This may be most apparent once abstinence is achieved. For example, when the person abusing substances becomes abstinent, someone else may develop complaints and/or “symptoms.” See below for an illustration.

Family members may have a stronger desire to move toward overall improved functioning in the family system, thus compelling and even providing leverage for the IP to seek and/or remain in treatment through periods of ambivalence about achieving a sober lifestyle. Alternately, clarifying boundaries between dysfunctional family members—including encouraging IPs to detach from family members who are actively using—can alleviate stress on the IP and create emotional space to focus on the tasks of recovery.

Historical Models of Family Therapy

Marriage and family therapy (MFT) had its origins in the 1950s, adding a systemic focus to previous understandings of the family. Systems theory recognizes that

• A whole system is more than the sum of its parts.
• Parts of a system are interconnected.
• Certain rules determine the functioning of a system.
• Systems are dynamic, carefully balancing continuity against change.
• Promoting or guarding against system entropy (i.e., disorder or chaos) is a powerful dynamic in the family system balancing change of the family roles and rules.

The strategic school of family therapy “introduced two of the most powerful insights in all of family therapy: that family members often perpetuate problems by their own actions; and that directives tailored to the needs of a particular family can sometimes bring about sudden and decisive change” (Nichols and Schwartz 2001, p. 97).

Based on observations of the relationship between family structure and behavior, along with work with inner‐city children and their families, Minuchin (1974) developed another approach, structural family therapy. Minuchin and Fishman (1981) believed that families use a limited repertoire of self‐perpetuating relational patterns and that family members divide into subsystems with boundaries that regulate family communication and behavior. They sought to shift family boundaries so the boundary between parents and children was clearer. Intervention is aimed at having the parents work more cooperatively together and at reducing the extent to which children assume parental responsibilities within the family.

One major model that emerged during this developmental phase was cognitive–behavioral family and couples therapy. It grew out of the early work in behavioral marital therapy and parenting training, and incorporated concepts developed by Aaron Beck. Beck reasoned that people react according to the ways they think and feel, so changing maladaptive thoughts, attitudes, and beliefs would eliminate dysfunctional patterns and the triggers that set them in motion (Beck 1976). This union of cognitive and behavioral therapies in a family setting was new and useful. The therapist considers not only how people’s thoughts, feelings, and emotions influence their behavior, but also the impact they have on spouses and other family members. Cognitive–behavioral family therapy and behavioral couples therapy are two models that have strong empirical support.

Through the 1980s and 1990s, newer models of MFT were articulated. In response to the problem‐focused strategic and structural family therapies, authors such as de Shazer, Berg, O’Hanlon, and Selkman promulgated solution‐focused family therapy (e.g., Berg and Miller 1992; de Shazer 1988). They asserted that pinpointing the cause of poor functioning is unnecessary and that therapy focused on solutions is sufficient to help families change.

Soon after the introduction of solution‐focused therapy to the MFT landscape, White and Epston’s Narrative Means to Therapeutic Ends 1990 heralded the narrative movement in MFT. This family therapy development has focused on the way people construct meaning and how the construction of meaning affects psychological functioning.

In the early part of the 21st century, MFT seems poised to undergo another change, focused on empirically demonstrating the effectiveness of different approaches to therapy. The few models that have been tested empirically have shown promising results. For example, functional family therapy, multisystemic therapy, multidimensional family therapy, and brief strategic family therapy all have been shown to be highly effective in reducing acting‐out behavior among adolescents and/or in reducing the risk for problem behavior among their younger siblings. Among the couples therapy models known to have reduced marital distress and psychological problems are emotionally focused couples therapy, cognitive–behavioral couples therapy, behavioral couples therapy, integrative couples therapy, and systemic couples therapy. (See chapter 3 for further information.)

Primary Family Therapy Models in Use Today

There are numerous variations on the family therapy theme. Some approaches to family therapy reach out to multiple generations or family groups. Some treat just one person, who may or may not be the IP. Usually, though, family therapy involves a therapist meeting with several family members. An expansive concept of family therapy also might spin off group programs that, for example, could treat the IP’s spouse, children in groups (children do best if they first participate in groups that prepare them for family therapy), or members of a residential treatment setting.

Most family therapy meetings take place in clinics or private practice settings. Home‐based therapy breaks from the traditional clinical setting, reasoning that joining the family where it lives can help overcome shame, stigma, and resistance. It is a return to the practices of social workers who, in the early 20th century, did their work in clients’ homes (Beels 2002). Meeting the family where it lives also provides valuable information about how the family really functions.

Four predominant family therapy models are used as the bases for treatment and specific interventions for substance abuse:

1. The family disease model looks at substance abuse as a disease that affects the entire family. Family members of the people who abuse substances may develop codependence, which causes them to enable the IP’s substance abuse. Limited controlled research evidence is available to support the disease model, but it nonetheless is influential in the treatment community as well as in the general public (McCrady and Epstein 1996).
2. The family systems model is based on the idea that families become organized by their interactions around substance abuse. In adapting to the substance abuse, it is possible for the family to maintain balance, or homeostasis. For example, a man with a substance use disorder may be antagonistic or unable to express feelings unless he is intoxicated. Using the systems approach, a therapist would look for and attempt to change the maladaptive patterns of communication or family role structures that require substance abuse for stability (Steinglass et al. 1987).
3. Cognitive–behavioral approaches are based on the idea that maladaptive behaviors, including substance use and abuse, are reinforced through family interactions. Behaviorally oriented treatment tries to change interactions and target behaviors that trigger substance abuse, to improve communication and problemsolving, and to strengthen coping skills (O’Farrell and Fals‐Stewart 1999).
4. Most recently, multidimensional family therapy (MDFT) has integrated several different techniques with emphasis on the relationships among cognition, affect (emotionality), behavior, and environmental input (Liddle et al. 1992). MDFT is not the only family therapy model to adopt such an approach. Functional family therapy (Alexander and Parsons 1982), multisystemic therapy (Henggeler et al. 1998), and brief strategic family therapy (Szapocznik et al. in press) all adopt similar multidimensional approaches.

Goals of Family Therapy

The integration of family therapy in substance abuse treatment is still relatively rare. Family therapy in substance abuse treatment helps families become aware of their own needs and provides genuine, enduring healing for people. Family therapy works to shift power to the parental figures in a family and to improve communication. Other goals will vary according to which member of the family is abusing substances. Family therapy can answer questions such as

• Why should children or adolescents be involved in the treatment of a parent who abuses substances?
• What impact does a parent abusing substances have on his or her children?
• How does adolescent substance abuse impact adults?
• What is the impact of substance abuse on family members who do not abuse substances?

Whether a child or adult is the family member who uses substances, the entire family system needs to change, not just the IP. Family therapy, therefore, helps the family make interpersonal, intrapersonal, and environmental changes affecting the person using alcohol or drugs. It helps the nonusing members to work together more effectively and to define personal goals for therapy beyond a vague notion of improved family functioning. As change takes place, family therapy helps all family members understand what is occurring. This out‐in‐the‐open understanding removes any suspicion that the family is “ganging up” on the person abusing substances.

A major goal of family therapy in substance abuse treatment is prevention––especially keeping substance abuse from moving from one generation to another. Study after study shows that if one person in a family abuses alcohol or drugs, the remaining family members are at increased risk of developing substance abuse problems. The single most potent risk factor of future maladaption, predisposition to substance use, and psychological difficulties is a parent’s substance‐abusing behavior (Johnson and Leff 1999). A “healthy family structure can prevent adolescent substance abuse even in the face of heavy peer pressure to use and abuse drugs” (Kaufman 1990a , p. 51). Further, if the person abusing substances is an adolescent, successful treatment diminishes the likelihood that siblings will abuse substances or commit related offenses (Alexander et al. 2000). Treating adolescent drug abuse also can decrease the likelihood of harmful consequences in adulthood, such as chronic unemployment, continued drug abuse, and criminal behavior.

Therapeutic Factors

Because of the variety of family therapy models, the diverse schools of thought in the field, and the different degrees to which family therapy is implemented, multiple therapeutic factors probably account for the effectiveness of family therapy. Among them might be acceptance from the therapist; improved communication; organizing the family structure; determining accountability; and enhancing impetus for change, which increases the family’s motivation to change its patterns of interaction and frees the family to make changes. Family therapy also views substance abuse in its context, not as an isolated problem, and shares some characteristics with 12‐Step programs, which evoke solidarity, self‐confession, support, self‐esteem, awareness, and smooth re‐entry into the community.

Still another reason that family therapy is effective in substance abuse treatment is that it provides a neutral forum in which family members meet to solve problems. Such a rational venue for expression and negotiation often is missing from the family lives of people with a substance problem. Though their lives are unpredictable and chaotic the substance abuse—the cause of the upheaval and a focal organizing element of family life—is not discussed. If the subject comes up, the tone of the exchange is likely to be accusatory and negative.

In the supportive environment of family therapy, this uneasy silence can be broken in ways that feel emotionally safe. As the therapist brokers, mediates, and restructures conflicts among family members, emotionally charged topics are allowed to come into the open. The therapist helps ensure that every family member is accorded a voice. In the safe environment of therapy, pent‐up feelings such as fear and concern can be expressed, identified, and validated. Often family members are surprised to learn that others share their feelings, and new lines of communication open up. Family members gain a broader and more accurate perspective of what they are experiencing, which can be empowering and may provide enough energy to create positive change. Each of these improvements in family life and coping skills is a highly desirable outcome, whether or not the IP’s drug or alcohol problems are immediately resolved. It is clearly a step forward for the family of a person abusing substances to become a stable, functional environment within which abstinence can be sustained.

To achieve this goal, family therapy facilitates changes in maladaptive interactions within the family system. The therapist looks for unhealthy relational structures (such as parent‐child role reversals) and faulty patterns of communication (such as a limited capacity for negotiation). In contrast to the peripheral role that families usually play in other therapeutic approaches, families are deeply involved in whatever changes are effected. In fact, the majority of changes will take place within the family system, subsequently producing change in the individual abusing substances.

Family therapy is highly applicable across many cultures and religions, and is compatible with their bases of connection and identification, belonging and acceptance. Most cultures value families and view them as important. This preeminence suggests how important it is to include families in treatment. It should be acknowledged, however, that a culture’s high regard for families does not always promote improved family functioning. In cultures that revere families, people may conceal substance abuse within the family because disclosure would lead to stigma and shame.

Additionally, the definition, or lack of definition, of the concept of “rehabilitation” varies greatly across cultural lines. Cultures differ in their views of what people need in order to heal. The identities of individuals who have the moral authority to help (for example, an elder or a minister) can differ from culture to culture. Therapists need to engage aspects of the culture or religion that promote healing and to consider the role that drugs and alcohol play in the culture. (Issues of culture and ethnicity are discussed in detail in chapter 5.)

Effectiveness of Family Therapy

While there are limited studies of the effectiveness of family therapy in the treatment of substance abuse, important trends suggest that family therapy approaches should be considered more frequently in substance abuse treatment. Much of the federally funded research into substance abuse treatment has focused on criminal justice issues, co‐occurring disorders, and individual‐specific treatments. One reason is that research with families is difficult and costly. Ambiguities in definitions of family and family therapy also have made research in these areas difficult. As a result, family therapy has not been the focus of much substance abuse research. However, evidence from the research that has been conducted, including that described below, indicates that substance abuse treatment that includes family therapy works better than substance abuse treatments that do not (Stanton et al. 1982). It increases engagement and retention in treatment, reduces the IP’s drug and alcohol use, improves both family and social functioning, and discourages relapse.

Although the effectiveness of family therapy is documented in a growing body of evidence, integrating family therapy into substance abuse treatment does pose some specific challenges:

• Family therapy is more complex than nonfamily approaches because more people are involved.
• Family therapy takes special training and skills beyond those typically required in many substance abuse treatment programs.
• Relatively little research‐based information is available concerning effectiveness with subsets of the general population, such as women, minority groups, or people with serious psychiatric problems (O’Farrell and Fals‐Stewart 1999).

The balance, however, certainly tips in favor of a family therapy in treating substance abuse. Based on effectiveness data and the consensus panel’s collective experience, the consensus panel recommends that substance abuse treatment agencies and providers consider how they might incorporate family approaches, including age‐appropriate educational support services for their clients’ children, into their programs.

Cost Benefits

Only a few studies have assessed the cost benefits of family therapy or have compared the cost of family therapy to other approaches such as group therapy, individual therapy, or 12‐Step programs. A small but growing body of data, however, has demonstrated the cost benefits of family therapy specifically for substance abuse problems. Family therapy also has appeared to be superior in situations that might in some key respect be similar to substance abuse contexts.

For example, Sexton and Alexander’s work with functional family therapy (so called because it focuses its interventions on family relationships that influence and are influenced by, and thus are functions of, positive and negative behaviors) for youth offenders found that family therapy nearly halved the rate of re‐offending—19.8 percent in the treatment group compared to 36 percent in a control group (Sexton and Alexander 2002). The cost of the family therapy ranged from $700 to $1,000 per family for the 2‐year study period. The average cost of detention for that period was at least $6,000 per youth; the cost of a residential treatment program was at least $13,500. In this instance, the cost benefits of family therapy were clear and compelling (Sexton and Alexander 2002).

Other studies look at the offset factor; that is, the relationship between family therapy and the use of medical care or social costs. Fals‐Stewart et al. (1997) examined social costs incurred by clients (for example, the cost of substance abuse treatment or public assistance) and found that behavioral couples therapy was considerably more cost effective than individual therapy for substance abuse, with a reduction of costs of $6,628 for clients in couples therapy, compared to a $1,904 reduction for clients in individual therapy.

Similar results were noted in a study by the National Working Group on Family‐Based Interventions in Chronic Disease, which found that 6 months after a family‐focused intervention, reimbursement for health services was 50 percent less for the treatment group, compared to a control group. While this study looked at chronic diseases such as heart disease, cancer, Alzheimer’s disease, and diabetes, substance abuse also is a chronic disease that is in many ways analogous to these physical conditions (Fisher and Weihs 2000). Both chronic diseases and substance abuse

• Are long‐standing and progressive
• Often result from behavioral choices
• Are treatable, but not curable
• Have clients inclined to resist treatment
• Have high probability of relapse

Chronic diseases are costly and emotionally draining. Substance abuse is similar to a chronic disease, with potential for recovery; it even can lead to improvement in family functioning. Other cost benefits result from preventive aspects of treatment. While therapy usually is not considered a primary prevention intervention, family‐based treatment that is oriented toward addressing risk factors may have a significant preventive effect on other family members (Alexander et al. 2000). For example, it may help prevent substance abuse in other family members by correcting maladaptive family dynamics.

Other Considerations

Family therapy for substance abuse treatment demands the management of complicated treatment situations. Obviously, treating a family is more complex than treating an individual, especially when an unwilling IP has been mandated to treatment. Specialized strategies may be necessary to engage the IP into treatment. In addition, the substance abuse almost always is associated with other difficult life problems, which can include mental health issues, cognitive impairment, and socioeconomic constraints, such as lack of a job or home. It can be difficult, too, to work across diverse cultural contexts or discern individual family members’ readiness for change and treatment needs.

These circumstances make meaningful family therapy for substance abuse problems a complex and challenging task for both family therapists and substance abuse treatment providers. Modifications in the treatment approach may be necessary, and the success of treatment will depend, to a large degree, on the creativity, judgment, and cooperation in and between programs in each field.

Safety and Appropriateness of Family Therapy

Only in rare situations is family therapy inadvisable. Occasionally, it will be inappropriate or counterproductive because of reasons such those as mentioned above. Sometimes, though, family therapy is ruled out due to safety issues or legal constraints. Family or couples therapy should not take place unless all participants have a voice and everyone can raise pertinent issues, even if a domineering family member does not want them discussed. Family therapy can be used when there is no evidence of serious domestic or intimate partner violence. Engaging in family therapy without first assessing carefully for violence can lead not only to poor treatment, but also to a risk for increased abuse.

A systems approach presumes that all family members have roughly equal contributions to the process and have equity in terms of power and control. This belief is not substantiated in the research on family violence. Hence, family therapy only should be used when one family member is not being terrorized by another. Resistance from a domineering family member can be addressed and restructured by first allying with this family member and then gradually and gently questioning this person (and the whole family) about the appropriateness of the domineering behavior (Szapocznik et al. 1988). (See also appendix C, Guidelines for Assessing Violence.)

It is the treatment provider’s responsibility to provide a safe, supportive environment for all participants in family therapy. Children benefit by attending support groups specifically for them; it is important to create a safe environment in which they can discuss family violence, abuse, and neglect. Usually, a way can be found to include even the family member who has turned to violence as a way of dealing with problems. That person is a vital part of the family and will be pivotal in understanding the nature of the family violence. For example, Johnson (1995) distinguishes between common couple violence and patriarchal terrorism. The former is characterized by occasional violent outbursts by either spouse and is not likely to escalate. It is usually an intermittent response to conflict, and in therapy can be examined and channeled into more positive expression. Patriarchal terrorism, however, is systematic male violence with the goal of control. It may not be possible or advisable to include a chronically violent partner in the family therapy process.

Child abuse or neglect is another serious consideration. Children in violent homes have more physical, mental, and emotional health problems than do children in nonviolent homes. Children of people with alcohol abuse disorders suffer more injuries and poisonings than do children in the general population. Research has shown that when families exhibit both of these behaviors—substance abuse and child maltreatment—the problems must be treated simultaneously to ensure a child’s safety. It should be noted that the withdrawal experienced by parents who cease using alcohol or drugs presents specific risks. The effects of withdrawal often cause a parent to experience intense emotions, which may increase the likelihood of child maltreatment. During this time, it is especially important that family support resources be made available to the family (Bavolek 1995), and that children know how to find safe adults to help. Any time a counselor suspects child abuse or neglect, laws require immediate reporting to local authorities. For further information, see TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000b ).

Domestic violence is a serious issue among people with substance use disorders, and it must be factored into therapeutic considerations. If, for example, a restraining order prohibits spouses from seeing each other, the treatment provider must work within this limitation, using therapeutic configurations that make sure that a client who is abusive is not in a session with the person he or she has been barred from seeing. Often when there is concomitant family violence, the offender is mandated to complete a Batterer’s Intervention Program before participating in any couple’s work. At the same time, the victim/spouse is engaged in safety planning and sometimes treatment for his or her own issues.

Only the most extreme anger contraindicates family therapy. Kaufman and Pattison (1981) developed the concept of the need for a period of abstinence before sufficient trust can be built to counteract the anger. Including all family members in treatment and providing them a forum for releasing their anger may help to work toward that threshold. Redefining the problem as residing within the family as a whole can help transform the anger into motivation for change. In turn, this motivation can be used to restructure the family’s interactions so that the substance abuse is no longer supported. The therapist’s ability to reframe proposed obstructions by family members is often the key to creating a positive therapeutic direction.

It is up to counselors and therapists to assess the potential for anger and violence and to construct therapy so it can be conducted without endangering any family members. Because of the life‐and‐death nature of this responsibility, the consensus panel includes guidelines for the screening and treatment of people caught up in the cycle of family violence. These recommendations, adapted from TIP 25, Substance Abuse Treatment and Domestic Violence (CSAT 1997b ), are presented in appendix C. However, these guidelines are not a substitute for training; counselors and therapists should have training and supervision in handling family violence cases.

If, during the screening interview, it becomes clear that a batterer is endangering a client or a child, the treatment provider should respond to this situation before any other issue and, if necessary, suspend the rest of the screening interview until the safety of the client can be ensured. The provider should refer the client or child to a domestic violence program and possibly to a shelter and legal services, and should take necessary steps to ensure the safety of affected children. Any outcry of anticipated danger needs to be regarded with the utmost seriousness and immediate precautions taken.

General Goals

Goals for Specific Groups