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Chapter 1 Substance Abuse Treatment and Family Therapy
This chapter introduces the changing definition of “family,” the concept of family in the United States, and the family as an ecosystem within the larger context of society. The chapter discusses the evolution of family therapy as a component of substance abuse treatment, outlines primary models of family therapy, and explores this approach from a systems perspective. The chapter also presents the stages of change and levels of recovery from substance abuse. Effectiveness and cost benefits of family therapy are briefly discussed.
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Introduction
The family has a central role to play in the treatment of any health problem, including substance abuse. Family work has become a strong and continuing theme of many treatment approaches (Kaufmann and Kaufman 1992a ; McCrady and Epstein 1996), but family therapy is not used to its greatest capacity in substance abuse treatment. A primary challenge remains the broadening of the substance abuse treatment focus from the individual to the family.
The two disciplines, family therapy and substance abuse treatment, bring different perspectives to treatment implementation. In substance abuse treatment, for instance, the client is the identified patient (IP)—the person in the family with the presenting substance abuse problem. In family therapy, the goal of treatment is to meet the needs of all family members. Family therapy addresses the interdependent nature of family relationships and how these relationships serve the IP and other family members for good or ill. The focus of family therapy treatment is to intervene in these complex relational patterns and to alter them in ways that bring about productive change for the entire family. Family therapy rests on the systems perspective. As such, changes in one part of the system can and do produce changes in other parts of the system, and these changes can contribute to either problems or solutions.
It is important to understand the complex role that families can play in substance abuse treatment. They can be a source of help to the treatment process, but they also must manage the consequences of the IP’s addictive behavior. Individual family members are concerned about the IP’s substance abuse, but they also have their own goals and issues. Providing services to the whole family can improve treatment effectiveness.
Meeting the challenge of working together will call for mutual understanding, flexibility, and adjustments among the substance abuse treatment provider, family therapist, and family. This shift will require a stronger focus on the systemic interactions of families. Many divergent practices must be reconciled if family therapy is to be used in substance abuse treatment. For example, the substance abuse counselor typically facilitates treatment goals with the client; thus the goals are individualized, focused mainly on the client. This reduces the opportunity to include the family’s perspective in goal setting, which could facilitate the healing process for the family as a whole.
Working out ways for the two disciplines to collaborate also will require a re‐examination of assumptions common in the two fields. Substance abuse counselors often focus on the individual needs of people with substance use disorders, urging them to take care of themselves. This viewpoint neglects to highlight the impact these changes will have on other people in the family system. When the IP is urged to take care of himself, he often is not prepared for the reactions of other family members to the changes he experiences, and often is unprepared to cope with these reactions. On the other hand, many family therapists have hoped that bringing about positive changes in the family system concurrently might improve the substance use disorder. This view tends to minimize the persistent, sometimes overpowering process of addiction.
Both of these views are consistent with their respective fields, and each has explanatory power, but neither is complete. Addiction is a major force in people with substance abuse problems. Yet, people with substance abuse problems also reside within a powerful context that includes the family system. Therefore, in an integrated substance abuse treatment model based on family therapy, both family functioning and individual functioning play important roles in the change process (Liddle and Hogue 2001).
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What Is a Family?Chapter 1 Substance Abuse Treatment and Family Therapy
This chapter introduces the changing definition of “family,” the concept of family in the United States, and the family as an ecosystem within the larger context of society. The chapter discusses the evolution of family therapy as a component of substance abuse treatment, outlines primary models of family therapy, and explores this approach from a systems perspective. The chapter also presents the stages of change and levels of recovery from substance abuse. Effectiveness and cost benefits of family therapy are briefly discussed.
Go to:
Introduction
The family has a central role to play in the treatment of any health problem, including substance abuse. Family work has become a strong and continuing theme of many treatment approaches (Kaufmann and Kaufman 1992a ; McCrady and Epstein 1996), but family therapy is not used to its greatest capacity in substance abuse treatment. A primary challenge remains the broadening of the substance abuse treatment focus from the individual to the family.
The two disciplines, family therapy and substance abuse treatment, bring different perspectives to treatment implementation. In substance abuse treatment, for instance, the client is the identified patient (IP)—the person in the family with the presenting substance abuse problem. In family therapy, the goal of treatment is to meet the needs of all family members. Family therapy addresses the interdependent nature of family relationships and how these relationships serve the IP and other family members for good or ill. The focus of family therapy treatment is to intervene in these complex relational patterns and to alter them in ways that bring about productive change for the entire family. Family therapy rests on the systems perspective. As such, changes in one part of the system can and do produce changes in other parts of the system, and these changes can contribute to either problems or solutions.
It is important to understand the complex role that families can play in substance abuse treatment. They can be a source of help to the treatment process, but they also must manage the consequences of the IP’s addictive behavior. Individual family members are concerned about the IP’s substance abuse, but they also have their own goals and issues. Providing services to the whole family can improve treatment effectiveness.
Meeting the challenge of working together will call for mutual understanding, flexibility, and adjustments among the substance abuse treatment provider, family therapist, and family. This shift will require a stronger focus on the systemic interactions of families. Many divergent practices must be reconciled if family therapy is to be used in substance abuse treatment. For example, the substance abuse counselor typically facilitates treatment goals with the client; thus the goals are individualized, focused mainly on the client. This reduces the opportunity to include the family’s perspective in goal setting, which could facilitate the healing process for the family as a whole.
Working out ways for the two disciplines to collaborate also will require a re‐examination of assumptions common in the two fields. Substance abuse counselors often focus on the individual needs of people with substance use disorders, urging them to take care of themselves. This viewpoint neglects to highlight the impact these changes will have on other people in the family system. When the IP is urged to take care of himself, he often is not prepared for the reactions of other family members to the changes he experiences, and often is unprepared to cope with these reactions. On the other hand, many family therapists have hoped that bringing about positive changes in the family system concurrently might improve the substance use disorder. This view tends to minimize the persistent, sometimes overpowering process of addiction.
Both of these views are consistent with their respective fields, and each has explanatory power, but neither is complete. Addiction is a major force in people with substance abuse problems. Yet, people with substance abuse problems also reside within a powerful context that includes the family system. Therefore, in an integrated substance abuse treatment model based on family therapy, both family functioning and individual functioning play important roles in the change process (Liddle and Hogue 2001).
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There is no single, immutable definition of family. Different cultures and belief systems influence definitions, and because cultures and beliefs change over time, definitions of family by no means are static. While the definition of family may change according to different circumstances, several broad categories encompass most families:
- Traditional families, including heterosexual couples (two parents and minor children all living under the same roof), single parents, and families including blood relatives, adoptive families, foster relationships, grandparents raising grandchildren, and stepfamilies.
- Extended families, which include grandparents, uncles, aunts, cousins, and other relatives.
- Elected families, which are self‐identified and are joined by choice and not by the usual ties of blood, marriage, and law. For many people, the elected family is more important than the biological family. Examples would include
- Emancipated youth who choose to live among peers
- Godparents and other non‐biologically related people who have an emotional tie (i.e., fictive kin)
- Gay and lesbian couples or groups (and minor children all living under the same roof)
The idea of family implies an enduring involvement on an emotional level. Family members may disperse around the world, but still be connected emotionally and able to contribute to the dynamics of family functioning. In family therapy, geographically distant family members can play an important role in substance abuse treatment and need to be brought into the therapeutic process despite geographical distance.
Families must be distinguished from social support groups such as 12‐Step programs—although for some clients these distinctions may be fuzzy. One distinction is the level of commitment that people have for each other and the duration of that commitment. Another distinction is the source of connection. Families are connected by alliance, but also by blood (usually) and powerful emotional ties (almost always). Support groups, by contrast, are held together by a common goal; for example, 12‐Step programs are purpose‐driven and context‐dependent. The same is true of church communities, which may function in some ways like a family; but similar to self‐help programs, churches have a specific purpose.
For practical purposes, family can be defined according to the individual’s closest emotional connections. In family therapy, clients identify who they think should be included in therapy. The counselor or therapist cannot determine which individuals make up another person’s family. When commencing therapy, the counselor or therapist needs to ask the client, “Who is important to you? What do you consider your family to be?” It is critical to identify people who are important in the person’s life. Anyone who is instrumental in providing support, maintaining the household, providing financial resources, and with whom there is a strong and enduring emotional bond may be considered family for the purposes of therapy (see, for example, Pequegnat et al. 2001). No one should be automatically included or excluded.
In some situations, establishing an individual in treatment may require a ****phoric definition of family, such as the family of one’s workplace. As treatment progresses, the idea of family sometimes may be reconfigured, and the notion may change again during continuing care. In other cases, clients will not allow contact with the family, may want the counselor or therapist to see only particular family members, or may exclude some family members.
Brooks and Rice (1997, p. 57) adopt Sargent’s (1983) definition of family as a “group of people with common ties of affection and responsibility who live in proximity to one another.” They expand that definition, though, by pointing out four characteristics of families central to family therapy:
Families must be distinguished from social support groups such as 12‐Step programs—although for some clients these distinctions may be fuzzy. One distinction is the level of commitment that people have for each other and the duration of that commitment. Another distinction is the source of connection. Families are connected by alliance, but also by blood (usually) and powerful emotional ties (almost always). Support groups, by contrast, are held together by a common goal; for example, 12‐Step programs are purpose‐driven and context‐dependent. The same is true of church communities, which may function in some ways like a family; but similar to self‐help programs, churches have a specific purpose.
For practical purposes, family can be defined according to the individual’s closest emotional connections. In family therapy, clients identify who they think should be included in therapy. The counselor or therapist cannot determine which individuals make up another person’s family. When commencing therapy, the counselor or therapist needs to ask the client, “Who is important to you? What do you consider your family to be?” It is critical to identify people who are important in the person’s life. Anyone who is instrumental in providing support, maintaining the household, providing financial resources, and with whom there is a strong and enduring emotional bond may be considered family for the purposes of therapy (see, for example, Pequegnat et al. 2001). No one should be automatically included or excluded.
In some situations, establishing an individual in treatment may require a ****phoric definition of family, such as the family of one’s workplace. As treatment progresses, the idea of family sometimes may be reconfigured, and the notion may change again during continuing care. In other cases, clients will not allow contact with the family, may want the counselor or therapist to see only particular family members, or may exclude some family members.
Brooks and Rice (1997, p. 57) adopt Sargent’s (1983) definition of family as a “group of people with common ties of affection and responsibility who live in proximity to one another.” They expand that definition, though, by pointing out four characteristics of families central to family therapy:
- Families possess nonsummativity, which means that the family as a whole is greater than—and different from—the sum of its individual members.
- The behavior of individual members is interrelated through the process of circular causality, which holds that if one family member changes his or her behavior, the others will also change as a consequence, which in turn causes subsequent changes in the member who changed initially. This also demonstrates that it is impossible to know what comes first: substance abuse or behaviors that are called “enabling.”
- Each family has a pattern of communication traits, which can be verbal or nonverbal, overt or subtle means of expressing emotion, conflict, affection, etc.
- Families strive to achieve homeostasis, which portrays family systems as self‐regulating with a primary need to maintain balance.
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 EcosystemIn 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.
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.
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.