Family Therapy and the Treatment of Substance Use Disorders

The Family Matters Model

Melody Bacon

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351754521
• Edition: 1
• Topic: Psychologie
• Subtopic: Sucht in der Psychologie

This accessible guide offers a much-needed integration of family therapy into the treatment of substance use disorders. By proposing a means by which family therapy can be moved to the forefront of addiction treatment, it places the family perspective at the center of its approach and provides a multifaceted alternative to the prevalent individual-focused model.

Drawing from Bowen Family SystemsTheory and the principles of the 12 step program, the book presents a model of integration that addresses the needs of families struggling with addiction. Illustrated with discussion questions and case narratives of former addicts, the text guides both practitioners and families towards a goal of creating an environment that supports recovery. Offering an overview of the history and current models of addiction treatment, chapters also outline a 6 week Family Matters Program, with accompanying treatment interventions and case studies. The book concludes with an examination of how this program can be implemented by practitioners in a variety of clinical settings.

Family Therapy and the Treatment of Substance Use Disorders is essential reading for anyone with an interest in understanding the diverse ways in which addiction affects families. It will be particularly relevant to students of family therapy, but clinicians who work across the fields of substance abuse treatment or family counseling will also benefit from reading this book.

1

The Entwined History of Human Culture and Mood-Altering Substances

First you take a drink, then the drink takes a drink, then the drink takes you.

F. Scott Fitzgerald

The mouth of a perfectly contented man is filled with beer.

Ancient Egyptian proverb

When it comes to understanding, context makes a big difference. Imagine looking at a close-up photograph of a young woman, standing in front of the Eiffel Tower. You might assume she was in Paris, France. Now imagine viewing this same photograph shot from further away; you might see that she is actually in Las Vegas, Nevada, standing in front of the Paris Las Vegas hotel. Without being able to view the full context of the scene, you might have drawn the wrong conclusion. The same can be said for understanding the phenomenon of addiction; you need the full context in order to draw accurate conclusions. This chapter will review the history of alcohol and other mood-altering substances as a context for the treatment of substance use disorders.

History provides the context for much of human experience and what history clearly reveals is that human culture has been intricately entwined with alcohol and other mood-altering substances. This trajectory follows three parallel and sometimes overlapping pathways: use for necessity and pleasure; use as a medicinal substance; and use as part of a religious ritual. Some substances, such as alcohol, fit in all three of these categories while others, such as peyote, are primarily used within a religious or spiritual context. Others, such as tobacco, were introduced as medicinal substances but quickly moved into the first category involving pleasure and conviviality.

Necessity and Pleasure

The earliest evidence that exists concerning the production of alcoholic beverages is found in the form of clay pots dated from around 8000 BC (Standage, 2005). The inference can be drawn that the brewing of beer emerged as humans began to live in permanent settlements, thus creating the environment for fermentation. Later, beer is referenced in documents found in both ancient Mesopotamian and Egyptian civilizations that reveal the significance of beer as vital both for its antibacterial properties, making water suitable for drinking, and for its ability to make people feel better. In fact, beer was so valuable that for a time it served as a type of currency. There is ample evidence, for instance, that the workers who built the pyramids in Egypt were paid in beer (Standage, 2005, p. 27). The prominent role that beer played in Egyptian culture is exemplified in an ancient Egyptian proverb from around 2200 BC, “The mouth of a perfectly contented man is filled with beer” (Standage, 2005, p. 14; Gately, 2008, p. 5).

In addition, beer served as a distinguishing characteristic of civilization. As Standage (2005) elaborates, “the Mesopotamians regarded the consumption of beer and bread as one of the things that distinguished them from savages and made them fully human” (p. 27). The Mesopotamian epic of Gilgamesh is an example of this idea. Gilgamesh, a Sumerian king, was a man of civilization. In the course of events, he met Enkidu, a wild man of the forest, and they joined together to slay a demon in the forest. Enkidu’s first encounter with civilization included being introduced to alcohol. “Enkidu ate the food until he was sated; he drank the beer – seven jugs! and became expansive and sang with joy!” (as quoted in Gately, 2008, p. 5). Thus began Enikidu’s development from a wild to a civilized man.

While beer played a central role in ancient Egyptian and Mesopotamian civilizations, wine was also being produced, though it was reserved for the wealthy elite. By the time of Ancient Greece, however, wine played a central role in all strata of society and was used for offerings to the gods, as a currency, in rituals and convivial gatherings, and to assuage thirst (Gately, 2008, p. 11). Like beer, wine was used to make water potable, but its central role was that of communal connection. In fact, as Gately (2008) points out, in some Greek states, the consumption of wine was considered a civic duty (p. 11). Wine was generally mixed with water in various degrees of concentration, and it was considered barbaric to drink wine that was not mixed with water. The Ancient Greeks exported wine as far as southern France, the Crimean Peninsula and the Danube (p. 67). The Romans, who wholeheartedly adopted many aspects of Greek culture, extended the exportation of wine, seeing it not only as a sign of civilization but also as a means for better conquering indigenous tribes who were less formidable when they were intoxicated (p. 67).

The use of fermentation is evidenced in cultures throughout the world. In Mexico, tribes would travel great distances to find cacti whose fruit could be made into alcohol (Gately, 2008, p. 2). In China, evidence has been found dating back to 7000–6600 BC for a fermented drink that was made with rice, honey, grapes, and hawthorn berries (p. 2). And in the area now known as Iran, jars have been discovered that once held wine as well as other indications that mead, made from honey and beer, was also a mainstay.

Other substances also have served to provide social conviviality. Jay (2010) notes that kava, a substance that is imbibed in various forms to induce a sense of tranquility and ease of mind, is a central aspect of Polynesian culture. The use of kava is a means for maintaining culture values of generosity, sensitivity and conversation (p. 25).

Medicinal

Part of the challenge in defining addiction is that many drugs are used instrumentally for a medicinal benefit. For example, the Ebers Papyrus, an ancient Egyptian medical text dating from around 1600 BC, describes the parts of the poppy plant and suggests it was recognized as an analgesic. Later texts from ancient Greece describe plants in terms of either cure or poison (Jay, 2010, p. 51). Likewise, tobacco, a New World import, took hold of European culture for its abilities to treat a variety of ailments. As Jay (2010) describes, “It could be chewed to treat stomach ailments, and the leaves applied topically for headaches” (p. 114).

The medicinal purposes of plants and their derivatives resulted in the development of a classification of substances for medicinal purposes in the 16th century by the Swiss alchemist and physician, Paracelsus. His intention was to transform Western medicine by basing the practice of medicine on chemical therapies. One such drug, “laudanum,” which was probably a tincture of opium to help in pain relief, became so entrenched in common culture that it could be found on drug store shelves until it was removed in the 1930s by government edict (Jay, 2010, pp. 63–67).

During the mid-18th century, the classification of drugs was refined by Linnaeus, who had developed a renowned classification system of botany. Linnaeus’s work on inebriants is the first modern classification of mind-altering drugs which included alcohol, poppy, and nightshade (Jay, 2010, p. 68). It is interesting to note that during his travels around Europe, Linnaeus was appalled at the excessive use of alcohol, particularly distilled liquor, he witnessed in the remote villages. He believed alcohol was by far the most destructive of the drugs in his classification. (p. 69).

At the beginning of the 19th century, a young German pharmacist’s apprentice, Friedrich Sertürner, began to experiment with tarry opium, derived from the opium poppy, until he eventually isolated a compound that formed clear crystals. He named the compound morphine, after the god Morpheus, the Roman god of sleep (Jay, 2010, p. 77). This was the first plant to have given up a pure chemical substance. Like all drugs, morphine was a double-edged sword – it made modern surgery possible, but it also carried with it the potential for severe addiction. This breakthrough eventually resulted in the isolation of caffeine, nicotine, and codeine, which is found in the juice of the poppy head; and in 1860 the coca leaf would yield the stimulant cocaine (p. 78).

This standardization was the first step toward the emergence of modern drugs. From standardization emerged commoditization, the first of which was Dover’s powder, created by Thomas Dover in 1732, a standardization of laudanum that was packaged to be easily displayed on the shelves of local grocers. Its removal in the 1930s signaled the beginnings of a more concerted effort on the part of the United States government to regulate powerful substances and make them less accessible to the general public.

Many of these drugs were used by individuals who wanted to experiment on themselves to better determine their effects. One such person was Sigmund Freud who hoped that cocaine would be an antidote to depression. During the 19th century, drugs were not yet stigmatized, and cocaine was sold as a remedy for almost any condition. The coca plant was used in the recipe for Coca-Cola which was advertised as a nerve tonic, and a cure for “hysteria, headaches and melancholia” (Jay, 2010, p. 92).

Eventually problems began to become apparent, though the line between medicinal and recreational use was still difficult to draw. However, by the beginning of the 20th century drug addiction was becoming a greater cause for concern. Jay (2010) notes that “In New York, addicts who sold scrap to feed their habits were known as ‘junkies’” (p. 95). And eventually cocaine and morphine became illicit drugs sold by street-corner hustlers. He writes, “The public image of the drug user was changing from medical patient to dangerous thrill-seeker” (p. 95).

In 1914 the Harrison Narcotics Tax Act solidified the efforts to remove opiates and cocaine from the store shelves and limited them to medical use. This, in turn, stimulated efforts to create substitutes. In 1898, Bayer created a morphine substitute under the brand name of Heroin. This was soon withdrawn and eventually they launched Aspirin which took the share of headache pill market that opiates used to occupy.

In the 1880s chemists were investigating the alkaloids of ephedra and by 1927 the British pharmacologist, Gordon Alles, had synthesized a derivative he named amphetamine (Jay, 2010, p. 100). Amphetamines found their first major application during WWI when they were used to boost the endurance of soldiers and pilots in combat (p. 100). They were a popular over-the-counter pharmaceutical, but it did not take long for amphetamines to become recognized as a source of addiction and they, too, were placed in the category of controlled substances.

Almost all drugs that fall under the medicinal category have eventually revealed themselves to be highly addictive. Morphine made modern surgery possible, and its derivatives have been used to alleviate severe pain and thus diminish tremendous suffering. Amphetamines have been used most recently to treat attention deficit disorders. Similarly, cocaine did indeed lift the mood of a depressed individual but soon revealed itself to be so addictive that the cure was worse than the disease. But, unlike cocaine, which is primarily used as a topical anesthetic for eye surgery, morphine and other narcotics are a necessary part of modern medicine. Moreover, most people who use these medications do not become addicted to them.

Use in Religious Ceremonies

In addition to conviviality, pleasure, and medicinal purposes, humans have also used psychoactive substances as part of religious ritual. Jay (2010) reports that among the earliest artifacts of hallucinogenic drug use are two chillum-style pipes excavated from the Andes and dating to before 2000 BC. These were found to contain residue of seeds that contain dimethyltryptamine (DMT) – a powerful, naturally occurring hallucinogen (p. 14). DMT is used to this day in shamanic rituals among the Amazonian indigenous cultures to induce immersion into a spiritual world. As Jay (2010) explains, the Amazon cultures that continue to use DMT typically describe the experience as terrifying (p. 16). Under the influence of hallucinogenic snuff, the shamans experience a state of hyper-consciousness and report being able to see, hear, smell, and understand aspects of reality that are normally not apparent (p. 20). This frequently consists of the use of hallucinogenic substances, such as peyote or DMT, with the intention of enabling allowing the individual to experience some form of transcendence or merging with the divine. In this case, most often the individual is accompanied by a guide who can interpret these experiences and also act as a stabilizing influence and a form of protection.

In the Western world, specifically in Ancient Greece, the rituals associated with the god Dionysus involved the use of wine for intoxication. No one knows what these rituals, called the Eleusinian mysteries, involved, as the details were a closely guarded secret, but it is said that those who went through the initiation lost their fear of death. The cult of Dionysus celebrated death and resurrection and offered a way for celebrants to counterbalance the cultural emphasis on the rational and logical. Similarly, in Ancient Egypt, Hathor, the goddess of fertility, was celebrated each year to coincide with the flooding of the Nile River during which time celebrants were encouraged to become intoxicated (Gately, 2008, p. 7).

Later on, Christianity would adopt the use of wine during its central ritual of the mass. From its inception, wine has been intimately associated with Christianity. Jesus’s first miracle was turning water into wine at a wedding feast. In addition, wine was used at the Last Supper by Jesus as a symbol for the blood he would spill for the redemption of humanity. Thus the central ritual of Christianity, called the Eucharist, was established as a remembrance of this act and a sign of affiliation with the Church (Gately, 2008). But, unlike other rituals involving intoxicants, adherents were not seeking an ecstatic or mind-altering experience, but rather partaking, symbolically, in the suffering of Christ.

Shifting Views on Intoxication

Even though mood- and mind-altering substances have been used instrumentally in various forms since the beginning of human civilization, the line separating use and abuse has also been a topic of debate and controversy. During the time of the Ancient Greeks, men who were habitual drunks, called apeles, meaning careless and/or carefree, were not disgraced, and in fact were honored with that title (Gately, 2008, p. 15). Those who drank too much were considered weak, though conversely, those who abstained from drinking alcohol were looked upon with suspicion (p. 15). The Greeks believed such people to be coldhearted and dangerous, lacking passion. Still, the Greeks recognized that drinking too much came with a high degree of risk, including death.

The Romans, venerating all things Greek, adopted a similar attitude toward drunkenness. Gately (2008) explains that the vast majority of Ancient Romans, and those they later conquered, saw relatively few reasons for not drinking regularly and in fact looked upon abstinence with suspicions. Some Germanic tribes, for example, refused to negotiate treaties unless all parties involved had gotten drunk together.

The first comprehensive attempt to institute moderation in drinking can be found in the writings of St. Paul who exhorted followers to avoid drinking alcohol “unworthily” (Gately, 2008, p. 43). Later, St. Clement of Alexandria (AD 150–215) wrote a detailed account concerning the consumption of wine wherein he argues that it was a sacred duty to drink wine as a sign of one’s participation in the mystery of Christ’s redemptive act. He emphasized that wine should be kept away from the youth, given its propensity to loosen inhibitions, and that adults should avoid drinking wine during meals and while at work. However, the elderly were advised to view it as an everyday drink as “the milk of old age” (p. 45). Clement painted a picture of those who disregarded his guidelines and became intoxicated as ugly, staggering, and vomiting (p. 45). In addition, he determined that women should not be allowed to drink wine, except as part of the Eucharist. This was in keeping with a long-standing proscription dating back to the time of Ancient Greece, that women were to be kept from drinking alcohol. During the Roman era there were very severe repercussions for those who did, including death. As Gately (2008) explains, “The wife of Egnatius Maetennus was clubbed to death by her husband for drinking from a large jar and he … was acquitted of murder by Romulus” (p. 29). This same historian reported, with approval, that a woman had been starved to death by her family for having “broken open the box containing the keys to the wine store” (p. 29). As we shall see, this particular antipathy toward women who drink alcohol continued well into the modern era, and it could be argued exists in some forms to this day.

Beer and wine continued to be mainstays of human civilization throughout the Middle Ages, during which time distillation of wine became more common. Brandy and later on rum became connected with the colonization of the Americas. In fact, rum was such an important part of daily life in the Colonial United States that its taxation was one of the precursors to the Revolutionary War.

A notable shif...