Family Solutions for Substance Abuse

Clinical and Counseling Approaches

Eric E. Mccollum, Terry S Trepper

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780789006226
• eBook ISBN: 9781317789949
• Edition: 1
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

Use goal-oriented techniques for successful family therapy with substance abusers!Family therapy is an essential core competency for substance-abuse counselors, according to the Substance Abuse and Mental Health Services Administration. Family Solutions for Substance Abuse: Clinical and Counseling Approaches delivers the information and techniques you need to effectively treat addicts and their families. By understanding and changing the dynamics of the family system, you will be better able to guide your clients to adopt strategies and behaviors that sustain recovery and maintain healthy relationships.Family Solutions for Substance Abuse provides clear models of diagnosis and intervention for families, whether that means couples, teenagers and their parents, or Mom, Dad, and the kids. The theoretical background on family systems will help you understand the context of the client's addiction and the way it affects and is affected by other family members. Numerous case studies and figures bring the expert advice and theory into the practical realm so you can choose the best strategies for helping the shattered family heal.Family Solutions for Substance Abuse will teach you useful therapeutic skills and strategies, including:

• understanding interdependence
• joining with different family members
• negotiating goals and contracts
• dealing with family violence
• assessing motivation
• handling relapses
• ending treatment

Treating addictions is notoriously difficult for even the most skilled therapist working with the most motivated client. Using the techniques in Family Solutions for Substance Abuse offers you and your clients a better chance at success, because addicts whose families share their treatment are much more likely to stay in counseling and remain clean and sober.

Chapter 1

Why Work with Families in Substance Abuse Treatment?

Sixteen-year-old Dylan has had two stays in a residential drug treatment program as well as trips through several outpatient programs in the past three years. He began smoking marijuana when he was eleven and currently uses any drug he can get, although he prefers crack. He is in trouble with the law for a variety of things—possession, dealing, and breaking and entering. Despite his problems, Dylan has a pleasant smile and a winning personality. Lots of people are rooting for him to stay out of trouble. At their last meeting, his probation officer [PO] told him, “Dylan, if you keep going like you are, you're going to end up at the detention center, and the judge is going to make you serve out all your suspended time. If it gets to that point, there won't be anything I can do about it. You've got to get your act together.” When he reads his weekend arrest report this morning, Dylan's PO spots Dylan's name right off. “Damn,” the PO says to himself. Dylan has been arrested on another breaking-and-entering charge.

Maria is thirty-two. She is the mother of twin daughters who have been placed in foster care because of her alcohol use. Most afternoons find Maria in front of her television set, drinking vodka until she passes out. She has tried all the treatment programs she could find in her county. She has not been sober for more than three weeks since she was twenty-three. Her social worker tells Maria over and over again that she has to stop drinking if she ever wants to get her daughters back. But every time she comes for a home visit, it is clear to the social worker that Maria has not even decreased her rate of drinking.

To see Tyrone on the street, you would never guess that he has two years of community college under his belt, or that he used to work as the night manager at a fast-food place to save money for the rest of his college courses. He wears a knit stocking cap pulled down over his forehead against the autumn chill and a tattered flannel shirt. He no longer makes much effort to cover the needle marks on his arm.

Traditionally, substance abuse treatment, similar to most other forms of mental health and medical treatment, viewed the individual with a drug or alcohol problem as the focus for intervention. The causes of drug abuse and addiction were sought in qualities of the individual and historically have included such things as moral failure, psychological distress, and genetic predisposition. Even the disease model of addiction encourages a focus on individuals; diseases are something that individuals get, after all.

The individual focus in substance abuse treatment seems sensible. Clearly, Dylan, Maria, and Tyrone are making daily choices that keep them mired in addiction. No one is holding a gun to Maria's head and making her drink, for instance. So, it is only logical to try to understand why people use drugs, and what they can do to stop, by closely examining the users themselves. Our experience, however, as well as the research literature, tells us that the individual view alone is only half the story and omits important resources that can help drug abusers in treatment. For that reason, we have spent more than ten years working with people who abuse substances and their families in treatment.

As family therapists, we knew that working with whole families was effective with any number of problems that we usually think of as individually based.* We believed that the same would be true in substance abuse treatment. Our experiences include two large research projects—one focused on drug-abusing adolescents and the other on women and their partners. In addition, we have been involved in a series of smaller projects for which we taught substance abuse counselors the principles of working with families from a family systems perspective. Based on all these experiences, we are convinced that including families in substance abuse treatment is essential if we want to provide the best service to our clients. However, to do so, substance abuse counselors or others who work in substance abuse treatment need to learn some special skills and ways of thinking about drug and alcohol problems. The purpose of this book is to present those skills and ways of thinking.

“LIKE A ZOOM LENS…”

Moving from an individual focus to a family focus is much like zooming a camera lens from a close-up to a wide-angle view. In wide-angle mode, things come into the frame that are not visible in the close-up. To illustrate this change in perspective, we will look at Dylan, Maria, and Tyrone's situations in turn to see what a wide-angle view might add to our understanding of why they use drugs and what a family approach might add to their treatment.

Dylan—An Adolescent Drug User

As we pull back from an individual focus to a family focus, we come to understand more about the circumstances that surround Dylan's drug use. Dylan's mother and father have never gotten along. Although they no longer have the violent physical fights they used to have, the constant tension in the house regularly erupts into screaming matches. Much of the time, the fights are about Dylan. Dylan's dad thinks Dylan is lazy and no good.

“I was working nights to support my family when I was your age,” he often tells Dylan, “plus going to high school. I never thought a son of mine would grow up to be such a bum.”

Dylan's mother, on the other hand, tends to be softer with her son and defends him when his father criticizes him.

“Leave him alone, Frank,” she says. “Can you blame the boy for being in trouble when he's got a father like you?”

As their fight escalates, Dylan usually slips out the back door and heads downtown, hoping to score and hook up with some of his friends. If he is lucky, his parents will be asleep by the time he comes home.

What does the wide-angle view tell us about Dylan's drug use? Does his parents' conflict make him take drugs? Of course not. Many kids grow up in unhappy homes and never resort to drug use, while other kids with severe drug problems live in homes that are relatively untroubled. What this view does tell us is that Dylan's drug use occurs in a unique context—a context in which he is the focus of his parents' corrosive and bitter conflict—and that for Dylan to stay clean and sober, that context must change. Although changing how Dylan and his parents get along will not automatically change Dylan's drug use, it will free him from having to shoulder the burden of his parents' troubles, thereby creating some calmer space for Dylan to think about his addiction and what he wants to do about it.

Including parents and other family members in the treatment of adolescents with drug and alcohol problems makes perfect sense in many ways. Adolescents usually live with their parents, and it is often at the parents' behest that the adolescent comes to treatment in the first place. Further, despite growing independence, adolescents are both emotionally and financially dependent on their parents. Thus, parents play a key role in adolescents' lives and have much to offer as part of substance abuse treatment. However, in a number of the adolescent treatment agencies where we have consulted, parents were not involved at all in their children's treatment. This was surprising to us in light of the research that shows how useful family involvement in adolescents' drug treatment can be. **Szapocznik and his associates (1988) found that including an adolescent's family members increases the adolescent's involvement in treatment. Obviously, if parents or other family members support treatment and attend with the adolescent, there is a greater chance the adolescent will attend and become involved. Not only does family involvement help get adolescents involved in treatment, it also keeps them there. Diamond and colleagues (1996) report, based on a review of the family therapy outcome and process literature, that family members' involvement in adolescent drug treatment lowers the adolescents' rates of attrition. In other words, an adolescent is less likely to drop out of treatment if family members are involved. Finally, various studies suggest that family treatment approaches for adolescents are more effective than individual or group-only approaches (Friedman, 1989; Henggeler et al., 1991; Joanning et al., 1992; Lewis et al., 1990). And one study (Schmidt, Liddle, and Dakof, 1996) found that parents who were involved in family therapy with their drug-abusing adolescents changed their parenting practices in ways that appear to be associated with their children's decreases in substance use. So, not only does it make intuitive sense to include an adolescent's family members in treatment, it is also effective. One of the missing pieces in Dylan's many attempts at treatment may have been the participation of his parents.

Maria—An Adult Alcoholic

At first glance, it is more difficult to see how family counseling might help Maria. She is an adult, after all, and not dependent on her husband the way Dylan is dependent on his parents. However, spouses of adult substance abusers and addicts often contribute significantly to the problems of their partners. This certainly seems to be the case for Maria. According to her, Paul, her husband, is “always on my case about something. The house isn't clean enough for him, or he doesn't like what I cook, or he thinks I should get a job. If he'd just leave me alone, life wouldn't stink so much. Who can blame me for drinking?”

As you might guess, Paul has a different view. He feels caught between having to work to support the family and wondering if he and Maria will ever be able to get their daughters back.

“I'm doing my best to help,” he explains. “If Maria would just stop drinking, I could relax, and we could focus on getting our kids back. My boss is hassling me at work because all I can think about is Maria and whether or not she's doing anything to stop drinking. I've been calling her all the time, and that's starting to interfere with my job. Every day that I can't see our girls is like torture for me. I just don't know what we're going to do.”

The wide-angle view gives us a different picture of Maria's drinking. Although Paul's worry does not cause Maria to drink, both of them are caught in an escalating pattern of nagging and withdrawing that centers on alcohol. The more Paul nags at Maria to stop drinking, the more she withdraws through continued drinking. This pattern makes change difficult for both of them.

An extensive body of research literature describes the benefits of including the family members of adult substance abusers such as Maria in treatment. For one thing, the onset of drug abuse and the occurrence of drug overdoses are often precipitated by family events (Duncan, 1978; Krueger, 1981; Noone, 1980). This connection is especially strong for women. Anglin and colleagues (1987) reviewed the literature on the couple relationships of female opiate addicts and concluded that “women are commonly introduced to narcotics and maintained in their addiction by men, especially when the women are involved in an intimate interpersonal relationship with male addicts” (p. 500). Williams and Klerman (1984), in a similar review of the literature concerning the couple relationships of alcoholic women, note that “[w]omen are… more likely than men to cite marital instabilityand family problems as reasons both for problem drinking and for seeking treatment” (p. 291). Gomberg (1993) and Wilsnack, Wilsnack, and Klassen (1984) both report similar findings.

Once adults get to treatment, involvement of their partners improves engagement in treatment as well as retention and outcome (see, for example, Atkinson, Toison, and Turner, 1993; Fals-Stewart, Birchler, and O'Farrell, 1996, 1999; McCrady et al., 1986; O'Farrell, 1989, 1991; O'Farrell and Feehan, 1999). Not only does the inclusion of spouses or other adult partners in treatment improve substance abuse outcomes, it also results in higher levels of relationship satisfaction (Fals-Stewart, Birchler, and O'Farrell, 1996; McCrady et al., 1986) and lower levels of spouse abuse (O'Farrell, Van Hutton, and Murphy, 1999). Finally, a significant connection exists between family relationships and relapse (McCrady et al., 1986; O'Farrell et al., 1998), another argument in favor of including partners in the treatment of substance-abusing adults.

Including partners in treatment results in better outcomes, but the benefit does not stop there. The social costs of alcohol and drug abuse are reduced when family members are involved. Such costs include, for example, further substance abuse treatment, involvement with the criminal justice system, lost work days, public support payments, and so forth. Fals-Stewart, O'Farrell, and Birchler (1997), for instance, found that the cost of providing couples treatment to male alcoholics was not significantly different from the cost of providing individual treatment, but the subsequent savings in social costs between the two modalities was dramatic. Couples treatment provided a net yearly savings of $6,628 versus a net savings of $1,904 for individually based treatment in the year following treatment. O'Farrell and associates (1996) found a similar reduction in social costs when couples therapy was included as a part of treatment. Overall, then, not only will a client such as Maria have the best chance for a good treatment outcome in a program that also involves her husband, but society's interest is well served by this approach as well.

Tyrone—A “Loner” Addict

People such as Tyrone pose the greatest challenge to the wide-angle view. Who seems more cut off from family than a heroin addict who is focused almost constantly on finding the next dose? Most of us see “street people” and assume that they must be isolated from everyone and everything in their past. While this is an easy assumption to make, it does not reflect reality. Tyrone, for example, sees his sister a couple of times a week when he goes by her house to take a shower, get a hot meal, and sometimes borrow money. Although Tyrone's sister worries about him and wonders if helping him is somehow enabling him not to face his addiction, she also feels that she is the only real support he has, and that if she does not help him he might engage in even more high-risk behavior, such as burglary or mugging, to support his habit. Tyrone sees his mother every couple of weeks, but when he does, they simply fight with each other. She tells him she is disgusted with him and his life and that she cannot imagine what Tyrone's deceased father would say if he knew his son was an addict. However, she, too, often gives him money and food when he comes by her house.

Tyrone's situation is not unusual. Although young-adult drug addicts (age thirty-five or younger) often appear to be cut off from their families, 60 to 80 percent of them either live with their parents or are in daily contact with them, while up to 95 percent have weekly contact with at least one parent (Cervantes et al., 1988; Stanton, 1997). Family members can be influential in involving these young adults in treatment (Garrett et al., 1997, 1998, 1999) and helping them complete it. Stanton and Shadish (1997) report that opiate-addicted adults in individual treatment drop out at a rate of 64 to 95 percent, while adding a family component reduces the dropout rate to 33 percent. Finally, as in the cases of Dylan and Maria, research does indicate that Tyrone will have a more successful treatment outcome if his sister or mother is also involved in his treatment (Stanton, Todd, and Associates, 1982).

We have examined the cases of Dylan, Maria, and Tyrone both to illustrate the differences between a close-up (individual) and a wide-angle (family system) view and to summarize the research literature on the advantages of including family members in substance abuse treatment. For each case, the research suggests that family involvement would help get the substance abuser involved in treatment, help keep the person in treatment, and result in better outcomes than an individually focused program alone.

WHAT THIS BOOK IS ABOUT

While we are convinced that it is important to involve families in treatment, we also know that many substance abuse counselors do not believe that they have the skills or training they need to do so. The need for family counseling training for substance abuse counselors was highlighted by the Substance Abuse and Mental Health Services Administration's 1998 publication of...

Table of contents

• Cover
• Half Title
• Haworth Marriage and the Family
• Title Page
• Copyright Page
• Table of Contents
• Chapter 1. Why Work with Families in Substance Abuse Treatment?
• Chapter 2. Understanding the Family in Context: Family Systems Theory and Practice
• Chapter 3. What Makes a Difference in Treatment?
• Chapter 4. Working with Families: Basic Skills
• Chapter 5. Assessing Motivation
• Chapter 6. Negotiating a Contract for Therapy
• Chapter 7. Problem and Solution Sequences
• Chapter 8. The Ups and Downs of Change
• Chapter 9. Ending Treatment
• References
• Index