family therapy as part of addiction treatment

For many family members of addicts and alcoholics, getting them into addiction and alcoholism treatment may seem like the finish line for a problem that’s been months and even years in the making.

The bad news: It’s anything but. Those who seek help for a drug and/or alcohol problem often leave behind an enormous amount of wreckage, from financial woes to legal repercussions to the general chaos and cacophony that’s part and parcel of the lifestyles they live.

On top of that, family members must then contend with their own symptoms of the disease of addiction. Recognizing that addiction is indeed a family disease is critical and far too often an afterthought by family members themselves, according to the addiction and recovery website The Fix [1]: “The people around them are affected by the deception, the failure to follow through on responsibilities, the inconsistent behavior, the crises and sometimes public embarrassment when their loves one’s behavior results in a story in the newspaper.”

The good news: Most reputable and comprehensive drug and alcohol treatment programs have long recognized the necessity for healing — not just for the addict or alcoholic, but for their loved ones as well. Involving the family in the process not only helps to mend strained and broken relationships, it can strengthen the chance for addicts and alcoholics to stay clean and sober permanently.

In other words, family therapy as part of addiction treatment is often a central component of an individual’s recovery journey, and effective family therapy serves many purposes: education, for family members about the nature and disease concept of addiction; tools that will help family members better support loved ones whose goal is long-term sobriety; and ways in which family members can deal with their own emotional damage caused by a loved one’s active addiction.

What Does It Mean That Addiction Is a Family Disease?

While many family members want to be involved in the recovery process, some are taken aback at the notion that they require some form ofamily therapy as part of addiction treatmentf treatment themselves. Family therapy as part of addiction treatment doesn’t mandate that family members check themselves into a facility, but it does ask that family members participate in the recovery of the afflicted individual — both for support and for themselves.

So how do alcoholism and addiction disrupt the family dynamic? To fully comprehend the breadth and scope of the impact, it’s important to understand the nature of that dynamic. The role each family member plays can depend on the number of individuals in the family unit, according to the publication “Impact of Substance Abuse on Families,” compiled by the U.S. Substance Abuse and Mental Health Services Administration (SAMSHA) [2]:

“For example, the parent of small children may attempt to compensate for deficiencies that his or her substance‐abusing spouse has developed as a consequence of that substance abuse. Frequently, children may act as surrogate spouses for the parent who abuses substances … alternately, the aging parents of adults with substance use disorders may maintain inappropriately dependent relationships with their grown offspring, missing the necessary ‘launching phase’ in their relationship, so vital to the maturational processes of all family members involved.”

The effects of alcoholism and addiction can extend beyond the immediate family, the publication continues: “Extended family members may experience feelings of abandonment, anxiety, fear, anger, concern, embarrassment, or guilt; they may wish to ignore or cut ties with the person abusing substances. Some family members even may feel the need for legal protection from the person abusing substances.”

In effect, addicts and alcoholics become a destructive emotional hurricane of chaos and stress, to the point that even “neighbors, friends, and coworkers also experience the effects of substance abuse because a person who abuses substances often is unreliable.” However, for those immediate family members trapped in the eye of that storm, the scope of the damage is difficult to assess, and the need for regulation by the family unit can often lead to overcompensation for abnormal emotions, interactions and activities, according to SAMSHA [3]: “To function, families often subscribe to the following: don't trust, don't feel, and don't talk. The result can be an unhealthy environment in which individuals may be isolated, engage in destructive alliances, be overly involved with other family members, or develop significant medical and stress-related problems.”

Some of those problems, according to a 2009 article in The Chicago Tribune [4], may include:

  • Jealousy — of friends, partners, family members and other people in your life, and/or their jealousy and resentment of you;
  • Conflict — from arguments to the “silent treatment” to distance caused by putting alcohol and drugs ahead of relationships;
  • Emotional trauma — erratic behavior, frequent fights, loss of temper and other outbursts can cause stress, anxiety, anger and pain;
  • Financial woes — if the addict or alcoholic loses jobs or takes too much time off or simply makes poor financial decisions such as spending too much on alcohol and drugs, it can cause resentment on the part of family members who must carry the financial burden;
  • Generational addiction — because of the examples set by addicts and alcoholics, the likelihood of their children also developing problems with drugs and alcohol is higher;
  • Health risks — pregnant women who can’t stop using or drinking can harm their unborn children; fathers who drive while intoxicated can endanger passengers; poor decision-making abilities due to impairment can lead to neglect or harm; and
  • A number of other, more severe problems, from infidelity to separation and divorce to violence.

Family Therapy As Part of Addiction Treatment: How Did It Start?

While the psychotherapeutic practice of family therapy dates “from the early 1960s and is marked historically by the appearance of a special literature in the form of books and journal articles,” according to the Handbook of EMDR and Family Therapy Processes [5], family therapy as part of addiction treatment dates back even further.

Al-Anon Family Groups is a companion program to Alcoholics Anonymous and was founded in 1951, but the organization traces its origins back more than a decade before that. In the 1930s, when Annie Smith, the wife of Dr. Bob Smith — credited as one of the pioneers of A.A. alongside Bill Wilson — would tend to the wives of the alcoholics her husband and his friend attempted to help: “She said, ‘Come in my dear. You’re with friends now — friends who understand,’” according to the Al-Anon historical pamphlet “Then and Now [6]. “Perhaps Annie was the first to recognize the significance of the Twelve Steps of A.A. as a way of life for the family member as well.”

According to Al-Anon literature, family members and friends of alcoholics attended A.A. meetings with their loved ones as early as 1939, and through the application of the program’s 12 Step process, they began to see improvements in their relationships. Eventually, they began to meet separately, and “in 1950, after visiting A.A. groups throughout the United States and Canada, Bill reported that many family groups had formed. He suggested to his wife, Lois, that she open an office to provide service for these groups.” [6]

By 1951, Al-Anon was officially established, adopted a version of the 12 Steps with permission from A.A. and by 1954, Al-Anon Family Groups had opened a world headquarters. By 1957, the organization Alateen had been established for children of alcoholics, and in 1964, after Narcotics Anonymous was firmly established as a parallel-to-A.A. organization for addicts, three women (Louise, Alma and Margaret) were credited with the establishment of the Nar-Anon Family Groups [7]: “The first Nar-Anon meeting is thought to have happened in 1964 in a church in Van Nuys, California, but was eventually moved to Louise’s home in San Pedro. Louise and Margaret then travelled around the Los Angeles area starting new meetings in Torrance and Whittier.”

Nar-Anon was trademarked in 1965, the organization’s first literature was published shortly thereafter and by 1971, Nar-Anon had become incorporated and a world headquarters established. By that point, meetings had begun to slowly spread out of California and across the country. Interestingly, these grassroots family programs for the loved ones of addicts and alcoholics evolved alongside the professional therapeutic path for families.

According to the SAMSHA publication “Substance Abuse and Family Therapy” [8], marriage and family therapy dates back to the 1950s and began to look at family dynamics through the prism of systems theory, which dictates:

  • “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.”

In other words: Family systems are made up of interconnected moving parts that all play a role to maintain a balance known as homeostasis. When drugs and alcohol enter the picture, that balance is upset, forcing family members to compensate in unplanned, unexpected and sometimes unhealthy ways.

Family Therapy As Part of Addiction Treatment: How Does It Work?

family therapy as part of addiction treatmentAs family therapy evolved over the next several decades, several important milestones were achieved. In their book “The Essentials of Family Therapy” [9], Michael Nichols and Richard Schwartz detailed how 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.” In the late 1970s, the use of Cognitive Behavioral Therapy was applied to family work, resulting in Cognitive-Behavioral Family and Couples Therapy, in which “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.” [8]

Today, according to “Substance Abuse and Family Therapy,” there are four primary family therapy models used as the basis for treatment and substance abuse interventions:

  • “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 identified patient (IP)’s substance abuse;
  • “The family systems model is based on the idea that families become organized by their interactions around substance abuse;
  • “Cognitive–behavioral approaches are based on the idea that maladaptive behaviors, including substance use and abuse, are reinforced through family interactions; and
  • “Most recently, multidimensional family therapy (MDFT) has integrated several different techniques with emphasis on the relationships among cognition, affect (emotionality), behavior, and environmental input.”

The goal of them all, however, is uniform: “While individual therapy focuses on the thoughts, behaviors and emotions of one person, family therapy focuses on the relationships, and aims to understand and validate the experiences of all family members,” according to the Partnership for Drug-Free Kids [10]. “The goal of family therapy is to bring clarity to all relationships, and to foster repair and closeness if family members choose. Family therapists believe that problems exist between people, not within people.”

The role of the family therapist is a crucial one, but it’s not a dominant one. Therapists often allow patients to steer the course of the therapy, according to the SAMSHA publication “Family Therapy Can Help” [11]: “’Family’ means a group of two or more people with close and enduring emotional ties. Using this definition, each person in treatment for a behavioral health disorder has a unique set of family members. Therapists don’t decide who should be in family therapy. Instead they ask, ‘Who is most important to you?’ Sometimes members of a family live together, but sometimes they live apart. Either way, if they are considered family by the person in treatment, they can be included in family therapy.”

It’s important to note that while the core issue that has precipitated a need for family therapy as part of addiction treatment is the patient’s use of alcohol and drugs, these sessions aren’t limited solely to that use. After all, the drugs and alcohol are but a symptom of a larger problem, and as patients work on addressing and changing the internal factors that drive their substance abuse, they’re also encouraged to look at the part family dynamics and relationships may have played, according to the SAMSHA publication “Impact of Substance Abuse on Families” [2]:

“In any form of family therapy for substance abuse treatment, consideration should be given to the range of social problems connected to substance abuse. Problems such as criminal activity, joblessness, domestic violence, and child abuse or neglect may also be present in families experiencing substance abuse. To address these issues, treatment providers need to collaborate with professionals in other fields.”

Family Therapy As Part of Addiction Treatment: What Happens?

The publication “Family Therapy Can Help” [11] lays out a basic framework for the process of family therapy as part of addiction treatment:

  • “Family therapy is typically introduced after the individual in treatment for mental illness or addiction has made progress in recovery … timing is important because people new to recovery have a lot to do.”
  • “There are two main goals in family therapy. One goal is to help everyone give the right kind of support to the family member in behavioral health treatment, so that recovery sticks and relapse is avoided. The other goal is to strengthen the whole family’s emotional health, so that everyone can thrive.”
  • “Specific objectives for family therapy are unique to each family, and these objectives may change over time. The family decides for itself what to focus on, and when.”
  • “Sessions usually last about an hour and take place at a clinic, at the therapist’s office, or — less often — in a family member’s home. The focus of the session may be on the person in treatment, on another family member, or on the family as a whole.”
  • “In the session, the family therapist may ask questions or listen and observe while the others talk. The therapist does this to learn such things as how family members behave and communicate with each other and what the family’s strengths and needs are. The particular techniques used by the therapist will depend on the phase of treatment for the member in treatment and the family’s readiness for change.”
  • “A session can be devoted to talking about family concerns and how people are feeling. Family members might use the session to talk about a particular crisis or problem that needs solving. Or, they might want to focus on the changes that have been happening.”

Ideally, family therapy sessions serve a three-pronged role: preparation for conversations and sessions that may be awkward, uncomfortable or difficult; the sessions themselves; and processing of what transpired during those sessions. All three components of family therapy as part of addiction treatment are critical, because preparation without the follow-through only builds anxiety and worry on the parts of both the patients and the families; and the sessions without the processing can leave a lot of painful emotions and unresolved issues on the table that neither party is quite sure what to do with.

It’s important to understand that family therapy as part of addiction treatment is just the beginning. Most therapists will encourage all parties to continue therapeutic sessions once a patient leaves residential treatment, and reputable treatment center therapists will facilitate appointments with outside professionals so that the process is uninterrupted. In addition, family members are usually encouraged to safeguard their own mental health and pursue recovery for their own issues, either through individual counseling or via family support groups like Al-Anon, Nar-Anon or Celebrate Recovery for those who prefer a religious foundation to the process.

It’s also important to note that the damage wrought by addicts and alcoholics in the grips of their disease may have caused deep fractures in the family dynamic, and some family members may be unwilling to participate in family therapy. In other cases, there may be unwillingness by some family members to engage in therapy because family dysfunction has contributed to a loved one’s addiction. In such cases, “it may be important to work with the client and family to restructure this resistance in order to bring the family into treatment and correct the maladaptive interactional patterns that are related to the substance abuse problem.” [12]

Regardless, both patients and their families members should keep in mind that the therapeutic goals of substance abuse treatment and family therapy are different but compatible, according to the SAMSHA publication “Substance Abuse Treatment and Family Therapy” [12]: “Substance abuse treatment providers typically focus on a system consisting of a person with a substance use disorder and the nature of addiction. Family therapists see the system as a person in relation to the family. Clearly, the reaction of the family to the client, the reaction of the client to the family, and the nature of addiction can be mutually reinforcing dynamics.”

Does Family Therapy As Part of Addiction Treatment Work?

It’s difficult to determine the success of family therapy as part of addiction treatment because of a number of factors — primarily that the family dynamic is made up of so many independent variables, i.e. loved ones and relatives who are each responsible for their own actions, thoughts, feelings and responses. It stands to reason that at the very least, therapy can open the door to the healing process, but the definition of whether that process is successful can mean different things.

For instance, if the family dynamic is so broken because of the actions and behaviors of the addict or alcoholic, but treatment leads to long-term sobriety by that individual despite the family’s unwillingness to repair relationships, would that not be a measurement of success? What if the addict or alcoholic, in evaluating the dysfunction of a family dynamic that may encourage substance abuse, chooses to cut ties to family members who contribute to the problem but remains clean and sober after treatment — would that not be considered success?

Needless to say, family therapy as part of addiction treatment can have a number of different outcomes, some of which may be unexpected and unplanned at the commencement of that therapy. There are, however, a number of studies that look at some of the markers of recovery success because of family therapy: “In those studies comparing family/marital therapies to nonfamily approaches, almost without exception the nonfamily conditions had higher (treatment program) dropout rates,” according to M. Duncan Stanton in a paper for the National Institute on Drug Abuse (NIDA) [13]. “Put another way, significantly more family therapy cases stayed in treatment compared to nonfamily cases.”

Works by others in the field concur: A 2012 paper in the Journal of Marital and Family Therapy [14] concludes that “Reviews of both adolescent and adult drug abuse now consistently include family-based models among the most highly regarded and most strongly supported approaches, particularly multiple systems-oriented treatments for adolescents and behaviorally based treatments for adults.” A 2006 article in the journal Addiction Research and Theory [15] states that “therapeutic work aimed at improving family functioning leads to improved drinking outcomes.”

In other words, according to “Family Therapy Can Help” [11], “For people with addiction, family therapy can help them decide to enter or stay in treatment. It can reduce their risk of dropping out of treatment. It also can reduce their continued use of alcohol or drugs, discourage relapse, and promote long-term recovery.”

But more importantly, that publication points out, “Family therapy benefits other family members besides the person in treatment. By making positive changes in family dynamics, the therapy can reduce the burden of stress that other family members feel. It can prevent additional family members from moving into drug or alcohol use. Research also shows that family therapy can improve how couples treat each other, how children behave, how the whole family gets along, and how the family connects with its neighbors.”

Ultimately, time and effort are both required to repair the damage that addiction does to families. But family therapy as part of addiction treatment is a vital component of the process — for the addict, and for those who love and care for that individual. Any reputable treatment program that includes a component of family therapy as part of addiction treatment gives its patients a better chance at long-term sobriety through the mending of fractured relationships, the encouragement for family members to work on their own recovery and the nurturing of a supportive environment to which to return after treatment.

SOURCES

[1]: https://www.thefix.com/living-sober/addiction-family-disease

[2]: https://www.ncbi.nlm.nih.gov/books/NBK64258/

[3]: https://www.ncbi.nlm.nih.gov/books/NBK64085/

[4]: https://www.chicagotribune.com/sns-health-addiction-families-story.html

[5]: https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781118269985.app4

[6]: https://al-anon.org/pdf/AR2.pdf

[7]: https://static1.squarespace.com/static/5432b68ce4b0c6e32c53d626/t/590e491b725e25240d2a8487/1494108443939/SUMMARY_OF_NAR-ANON_FOR_PANELS.pdf

[8]: https://www.ncbi.nlm.nih.gov/books/NBK64269/

[9]: https://books.google.com/books/about/The_Essentials_of_Family_Therapy.html?id=hoRHAAAAMAAJ

[10]: https://drugfree.org/parent-blog/what-is-family-therapy-for-addiction-how-can-it-help-my-family/

[11]: https://store.samhsa.gov/system/files/sma13-4784.pdf

[12]: https://www.ncbi.nlm.nih.gov/books/NBK64259/

[13]: https://s3.amazonaws.com/academia.edu.documents/41002517/monograph165.pdf?response-content-disposition=inline%3B%20filename%3DBeyond_the_Therapeutic_Alliance_Keeping.pdf&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWOWYYGZ2Y53UL3A%2F20200116%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20200116T160240Z&X-Amz-Expires=3600&X-Amz-SignedHeaders=host&X-Amz-Signature=618ef92b6398b3fac77d3dafdb08eb3d8536469c43e5e1120d2e05990f546916#page=161

[14]: http://www.med.miami.edu/CTRADA/documents/Rowe_2012_Family_therapy_for_drug_abuse_Review_and_updates_2003_2010.pdf

[15]: https://www.tandfonline.com/doi/abs/10.1080/16066350500489311