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Center for Substance Abuse Treatment. Treatment of Adolescents with Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 32.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Treatment of Adolescents with Substance Use Disorders

Treatment of Adolescents with Substance Use Disorders.

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Chapter 6—Family Therapy

The interconnected relationships within a family are widely recognized as crucial elements of substance use disorders and their treatment. Clinicians and researchers agree that interactions among family members can affect the emotional health of individual members and thus fail to prevent the development of substance use disorders. Although family factors have been implicated in the etiology of adolescent substance use, it is important to recognize that individual, environmental, and contextual factors also contribute to adolescent substance use behaviors. With that in mind, adolescent substance use disorders are commonly referred to as multidimensional disorders.

Through the years, many substance use disorder treatment programs have worked with family members in a component called family-based therapy, family-centered therapy, or simply family therapy. Just as these names differ, so have the services differed from one treatment program to another. They reflect that family-based interventions work at the level of family change (e.g., parenting practices, family environment, problem solving) and also aim to take into account the psychosocial environments in which the adolescent lives. In one situation, family therapy might refer to an educational session or a discussion of family problems with a substance abuse counselor. In others, it might consist of a few family conferences with members of the treatment team present to explore what family members can do to help the patient. Some programs may have very effective family counseling sessions, referred to as family therapy.

The distinctions among family-based therapy, family-centered therapy, and family therapy are not unimportant. They reflect different versions of family-based intervention. Some family-focused interventions assume that information about the 12-Step philosophy, delivered in the context of family treatment, is sufficient to affect the substance-using behaviors of the adolescent. Other approaches, as well as most family-based therapies, assume that the interaction within the family and between important family members and other extrafamilial individuals is critical to making change. Data support the link between changes in central aspects of family functioning and changes in the substance-using and problem behaviors of the adolescent (Schmidt et al., 1996).

Too often, however, the phrase "family therapy" is a "catch-all" name for any activity that brings family members together for discussion. Unfortunately, much of what has passed for family therapy throughout the development and history of substance use disorder treatment has not been the provision of services using a carefully learned and disciplined therapeutic approach. Nor has it been designed with a solid understanding of family dynamics or led by well-trained and experienced family therapists.

Fortunately, these old approaches have all but disappeared from treatment programs. It is now recognized throughout the substance use disorder treatment field that working with families is a huge responsibility that requires a clinical understanding of family interactions and pathologies. It is notable that one of today's leading texts on family therapy has concluded that much of the cutting edge research in the field at large is done in the context of a substance use disorders (Nichols and Schwartz, 1998).

Over the past two decades, much has been learned in carefully constructed and controlled research studies to indicate how a family therapist, working in conjunction with other members of the treatment staff or alone, can intervene constructively to help a family change behaviors (Stanton and Todd, 1979; Stanton and Shadish, 1997; Gurman et al., 1986; Liddle, 1992). These studies have been conducted in research-based settings, not within existing community-based programs. However, sufficient outcome data and experience now exist to transfer the research models to naturalized treatment settings. Family therapy programs may also be suitable sites of effective research on adolescents who have substance use disorders.

Family Therapy as a Recent Approach

Integrating Family Therapy

Substance use disorder treatment programs can use family therapists to apply therapeutic approaches that have been proven effective with adolescents and their families. Preparing for and integrating a therapist who will provide family therapy in a treatment program requires a considerable amount of time. Furthermore, a therapist who practices a family-based approach should have formal, professional training in this method. Family therapy fits well into the regimen of treatment in which case management is used; it has also been shown effective in home-based treatment (Comfort and Shirley, 1990; Thompson et al., 1984).

What Is Family Therapy?

Three approaches of family therapy are being applied in treatment settings today:

  1. The old-style paradigm believes that something wrong in the family produced the substance use disorder. In other words, the family caused it. This view has been recently revised to reflect an increased understanding of family dynamics.
  2. The second paradigm focuses on risk and protective factors by working with families to reduce the risk factors and increase the protective factors. It is commonly used in adolescent substance use prevention programs as well as treatment.
  3. The third paradigm of family therapy, which is the concern of this chapter, takes a multisystemic or multidimensional perspective in the therapeutic process. Therapy includes all family members, and in some cases, peers (although their involvement would be limited to when the therapist believes their participation would be helpful). In effect, the family or the group is the patient. The justification for the multidimensional approach is that the two most important influences on the adolescent are his family and members of his peer group.

Multidimensional family therapy started sometime in the 1930s when social scientists began to understand that family members are interconnected and interdependent parts of a system. They constantly interact with and affect each other. When there is a change in any individual member of the family, others in the family system are affected. From a systems perspective, families are seen as organisms that continuously change and reconstitute themselves (Gladding, 1995). One study summarized family systems as a powerful and influential series of interconnected relationships among family members that provide for human behavior, emotion, values, and attitudes (Figley and Nelson, 1990).

Contemporary family therapy approaches understand the importance of treating individuals as subsystems within the family system and as units of assessment and intervention; in other words, each member of the family is capable of being assessed and can act as a unit of intervention--for example, by changing her interactional patterns. The critical point is that family-based treatments work with multiple units, including individual parents, adolescents, parent-adolescent combinations, and whole families, as well as family members vis-_-vis other systems. It is the multiple systems approach that distinguishes current family-based therapies from older family therapy approaches (Liddle, 1995).

Applied appropriately, family therapy often can quickly cut through to the reality of a situation. This makes it an effective tool in treatment. When used with all of the members of the family, it can open and improve communications, often eliminating the family secrets that have enabled the client to continue practicing his addiction. It is important to note that some families with an adolescent with a substance use disorder do not need family therapy. These families function well and should not change in any substantive way. If the family system is effective overall, individual or group therapy for the member with the substance use disorder may be the focus of the therapy, with occasional family meetings to convey information, to help the family provide support to the substance-using member, and to integrate the family into the long-term goal of relapse prevention.

Elaborations of the Family Systems Perspective

Within the systems approach, several types of family therapy strategies have been applied and studied with adolescents who have substance use disorders. These include

  • Functional family therapy
  • Structural ecosystems therapy
  • Multisystemic family therapy
  • Multidimensional family therapy
  • Problem-based therapy

All of these are considered integrative family therapies, meaning that they draw from and build on a number of structural, strategic, and behavioral models of family therapy that have emphasized families as systems.

Engagement in Treatment

Engaging adolescent substance users in treatment is notoriously difficult (Szapocznik et al., 1988). Youths in these circumstances typically do not believe their substance use is a problem and rarely seek treatment. Instead they are brought into treatment by their parents or coerced into treatment by the criminal justice system. Thus, family therapy models specializing in engagement interventions were developed. Such specialized engagement interventions allow therapists to diagnose, join, and restructure a family from the first contact to the first family therapy session (Szapocznik et al., 1988).

Using the principles of family therapy to work with the family to engage them in treatment is a well-established component of family treatment of substance use disorders. The therapist uses the usual therapeutic tools of family therapy but uses them to deal first with the problem of engagement until resistance to participation is overcome. Henggeler further developed these ideas by emphasizing that therapists, along with the treatment team, must strive to engage the family in treatment and to reach treatment goals; if obstacles develop, the therapist should devise alternative strategies to attain desired outcomes (Henggeler et al., 1986).

Changing Interactions Among Family Members

The therapist's intervention aims to bring about change in the way family members relate to each other by examining the underlying causes of dysfunctional interactions and by encouraging new (and presumably healthier) ones. By creating a context in which families focus on revitalizing interpersonal bonds and acting in more adaptive ways within the family, the process helps members of the family change negative emotional and attributional components (especially blaming) of their interaction.

In doing so, the therapist helps family members appreciate how the values and perspectives of each family member may differ from their own, but that differences do not have to be a source of conflict. Helping family members solve problems together in the therapeutic setting enables them to learn strategies that can be applied with the adolescent in the home. Such maneuvers in therapy decrease family conflicts and improve the effectiveness of communication. Family members, both parents and youth, learn how to listen to one another and solve problems through negotiation and compromise.

For example, in family therapy sessions, the therapist may help the adolescent understand the origins of expressions of hostility toward him by family members. Take the situation in which the parents are upset about the teenage son playing the stereo in the family's apartment late at night and keeping other family members from sleeping. The therapist might ask the parents if they ever played their radio too loudly when they were teenagers, thus helping them to identify with their son. This softening on the part of the parents may help the adolescent accept the fact that he will still be able to hear his favorite music even if he lowers the volume of the stereo. Then, an agreement may be negotiated in which the adolescent agrees to decrease the volume or use headphones after 9:30 p.m. or when others are watching television. This is a more productive resolution of the problem than having the teenager leave the family's apartment at night so he can play his stereo the way he really likes to.

Another method of improving communication between family members is to introduce the concept of "I" statements. "I" statements focus on the effect of an action on the speaker rather than on the action itself. Instead of saying "you always do (blank)_" a family member would say, "I feel (blank) when you (blank) because (blank)." These statements are often effective because people can disagree about what they "always" do, but it is more difficult for them to dispute what someone says she feels. Further expansion on this technique would involve a listening skills exercise. One member would paraphrase what she heard the other person say until the first speaker states that she got it exactly right.

Another goal in the family treatment of substance use disorders is to equip parents with the skills and resources needed to address the inevitable difficulties that arise in raising adolescents. Parents of youths who use substances typically aggravate small conflicts because their parenting practices are too extreme (e.g., too permissive, authoritarian, or inconsistent). Moreover, by the time parents seek therapy for their child they have "tried everything" and feel quite hopeless about being able to improve the situation. It is the family therapist's job to help parents regain their optimism and motivate them to continue to help their child. Family therapists, then, bolster the parents' self-confidence as parents and at the same time help them improve their parenting skills. Parents are taught how to provide age-appropriate monitoring of their child (e.g., to know their friends, to know how they spend their time), set limits (e.g., negotiate with the youth about reasonable curfews, schedules, and family obligations), establish a system of positive and negative consequences, rebuild emotional attachments, and take part in activities with the child outside the home.

The special case of multidimensional family therapy includes several core targets of assessment and change: the individual adolescent, the parent(s), the family interaction (parent-adolescent interactional patterns), and family members vis-_-vis extrafamilial persons and systems. Interventions within each of these core targets occur in a particular sequence. The theoretical framework underpinning the sequence of the interventions within each subsystem includes developmental theory and research, including attachment relations, family systems, and family therapy. Process studies on multidimensional family therapy indicate that certain aspects of behavior (proximal targets) must be changed before other target behaviors can change (more distal behaviors). In a sense, it is a moderator approach to change. For example, some aspects of a parent's behavior change before others (attachment increases before parenting practices can change) (Schmidt et al., 1996). In the therapeutic alliance with the adolescent, focusing on the client's life experiences and the capacity to tell his story in a therapeutic context to a therapist who will help him tell it to others (including his family, in the context of other parallel work with the parent and extrafamilial others), often facilitates improvements in initially poor therapist-adolescent alliances (Diamond and Liddle, 1996). Furthermore, interactional impasses within the context of family therapy sessions can be resolved if the interaction can be facilitated through certain stages (i.e., resist problem solving in enactments too early, focus on slowing down the pace of the communication, help the parent and adolescent share their experience of their situation) (Diamond and Liddle, 1996).

Beyond the Family

Contemporary family systems approaches have evolved to the point at which numerous systems, in addition to the youth and family, are targets of the intervention. These extended systems--most notably peers, school, and neighborhood--are believed to help maintain dysfunctional interactions in families and thus are important targets. For example, the therapist might focus on the system composed of interactions between the adolescent and her peers who engage in delinquent acts, or focus on the system consisting of interactions between the adolescent and an institution, such as school, that keep her from becoming engaged in schoolwork. The aim of family treatment, then, is to change the dysfunctional systems within the core systems--the family--and between the family and social systems such as the peer group or the school.

These approaches may direct family members to join groups such as a church or civic group. In the area of peer relationships, therapists may discourage association with deviant peers and help establish parental sanctions for contact with these bad influences. In the forms of family therapy known as multisystemic therapy and structural ecosystems therapy, for example, the parents are supported by the counselor to implement effective parenting to address the problem of associations with deviant peers. The counselor also helps the parents develop strategies for monitoring and supporting the youth's school performance or vocational functioning.

As another example, the therapist within the multidimensional family therapy approach would identify and assess the negative consequences associated with taking part in these extrafamilial systems--such as skipping an appointment with a probation officer or hanging out with peers late at night on unsafe street corners where illicit drugs are bought and sold. The therapist might meet with the probation officer or ask the adolescent to bring a peer to a session to review the problem from the youth's perspective.

The therapist then helps the adolescent and his family become aware of these consequences by identifying their long-term significance, such as the potential legal problems of missing appointments with the probation officer or being blamed for participating in drug deals. Conducting this type of session requires great skill to ensure that the participants in the discussion do not feel blamed for the problem or become defensive about their actions. When sessions are led skillfully by a therapist who has established a therapeutic alliance with the adolescent, the adolescent will ideally reach rational alternatives to his behavior.

Like other systemic therapies, these therapies are based on knowledge of the developmental aspects of families, primarily of adolescents, and the ecological environment in which they live. The therapist draws from this base of knowledge to assess and intervene with the adolescent, the family, or the community institutions with which the adolescent is involved, including such institutions as the juvenile justice system, a gang, a youth organization, or a public health clinic, as well as the school. These systems are assessed in terms of their past and present actions that contribute to family dysfunction.

The Therapeutic Alliance

Even with a systems perspective, family therapy models consider the therapeutic alliance between therapist and adolescent as the crucial component. It is important for the therapist to work hard to establish a therapeutic relationship with the adolescent. This relationship supports the adolescent in developing a personal agenda, such as ensuring that the family system of discipline does not deny the adolescent the opportunity to participate in social activities or impede personal growth. This qualifies the sense in which therapy is conducted with the whole family. It is also a chief task for the therapist to clarify to the client and other family members that the purpose of the whole exercise is to help the client. This often conflicts with the family's tendency to scapegoat the member who has been in trouble or to ignore the personal needs of the client.

What Should the Program Staff Know?

At a practical level, the duration of family-based treatment typically ranges from 2 to 6 months, decreasing in intensity toward the end of the period of treatment. This may translate into approximately 5 to 20 therapy sessions. Naturally, more difficult cases take longer. Henggeler and colleagues, using a family preservation model, reported a caseload size per counselor of 4 to 6 families (Henggeler et al., 1992). Other approaches have caseloads of 4 to 10 cases per counselor. Different groups of family members may attend different therapy sessions; for example, if the therapist is discussing poor parenting, the youth will not be included because the youth's presence might serve to undermine parental authority. Treatment can be relatively intense, with multiple sessions during a single week. It also can be intense in terms of explicit goal setting and extensive homework assignments. Also, the setting does not have to be conventional and can occur in either home or community settings.

Family therapists should be acutely aware of the complex of behaviors and systemic interactions associated with recovering from a substance use disorder. They also should be aware of cultural differences in family patterns and typical attitudes toward therapy (McGoldrick et al., 1982). Adolescent substance involvement should be considered within the context of other problem behaviors such as delinquency and school problems, necessitating new frameworks of diagnosis and assessment, as well as treatment. Liddle and Dakof wrote that familial attitudes and behavior, family emotional environment, and parenting practices are dimensions consistently targeted by family-based interventions (e.g., parental substance use, parent-adolescent conflict, emotional disengagement) (Liddle and Dakof, 1995a).

Adolescent clients will benefit when the treatment team, including counselors, nurses, and doctors, working in conjunction with family therapists, has a general understanding of family therapy within the substance use disorder treatment setting. When they have this understanding, the treatment team can best support the efforts of the therapist and coordinate their components of treatment with family therapy. For example, when substance use disorder counselors know that the adolescent is going through an intense time in family therapy, they can reduce the intensity of substance use education with the adolescent. Likewise, the physician can include the provision of family therapy as a factor in her decisions about medication.

Research Studies

Increasing numbers of research-based trials are clearly defining and studying the use of family-based therapy among adolescents in treatment for substance use disorders. In 1980, the National Institute on Drug Abuse (NIDA) began to address adolescent substance use disorders systematically to find out if effective family-based therapy models could be applied to adolescents (Liddle et al., 1992). The role of family relationships in the creation and maintenance of substance use disorders has been understood for some time. The pioneering study on family therapy with adults with substance use disorders was a NIDA project (Stanton and Todd, 1979). Szapocznik and colleagues were the first to establish the effectiveness of family therapy in treating adolescent substance use disorders (Szapocznik et al., 1983, 1990). In subsequent research funded primarily by NIDA, and to a lesser degree by the National Institute on Alcohol Abuse and Alcoholism and other sources, great strides have been made in understanding and defining the types of family therapy that work best with adolescents with substance use disorders.

The great importance of these models to the substance use disorder treatment field is that as they have been carefully tested and documented over time in many different settings, including the home and outpatient programs, revisions have been incorporated as needed, thereby improving the effectiveness of the models. Thus, a program that applies one of the documented family therapy models can implement family therapy with some certainty that successful treatment of adolescents will result. In the public arena, State directors of alcohol and drug treatment agencies, as well as individual program directors, can be assured that funds invested in family therapy are wisely spent.

Driven largely by current efforts to reduce the costs of health care and provide documented evidence of the effectiveness of the care, the primary setting for adolescent substance use disorder treatment today is the outpatient program. For the first time, conclusions can now be drawn about some particular forms of family therapy that work effectively in this setting.

The documentation of family therapies in adolescent programs is particularly interesting because they have been used successfully among adolescents who are difficult to treat (Liddle and Dakof, 1995b; Stanton and Shadish, 1997; Henggeler et al., 1986). One of the most exciting aspects of this accumulating research and treatment evaluation is that the family therapies applied in these research settings have been shown to be especially effective with adolescent clients from the most disadvantaged backgrounds and with very severe substance use disorders.


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