Family Involvement and Treatment Strategies in Addiction Recovery

Why Include Loved Ones?

Including significant others improves recovery, increases abstinence, and reduces relationship conflict.

Temporary Increase in Conflict After Treatment

Relationships often improve after treatment, but conflict may rise as roles shift.

Traditional Approach: Wait Until Ready

Very low follow-through: less than 10% call back.

Traditional Approach: Refer to Al-Anon

Helps family cope but rarely gets the identified patient (IP) into treatment; only 1 in 8 enter within a year.

Johnson-Style Intervention

Mixed success; depends heavily on family follow-through.

CRAFT (Community Reinforcement and Family Training)

Most effective modern method; 64% of IPs enter treatment.

CRAFT Teaches CSOs To...

Reinforce sobriety, avoid reinforcing use, step back during use, and prepare for windows of readiness.

CRAFT Key Principle: Don't Supply Substances

Loved ones should not provide any addictive substances.

CRAFT Key Principle: Don't Protect from Natural Consequences

Do not shield the IP from the real results of their use.

CRAFT Key Principle: Reinforce Non-Use

Increase rewards for sober behavior.

CRAFT Key Principle: Competing Activities

Engage in activities that reduce time/opportunity for use.

CRAFT Key Principle: Withdraw Attention During Use

Step back when the IP is actively using.

Disturbed Spouse Hypothesis

Claims wives have pathology that 'needs' alcoholic husbands — no evidence.

Disturbed Family Hypothesis

Claims family system maintains addiction to preserve equilibrium — no evidence.

Codependence Hypothesis

Proposes family develops a disease alongside addiction — not empirically supported.

Stress-Coping Hypothesis

Supported theory; family reactions are normal responses to chronic stress.

Al-Anon Principles: Loving Detachment

Family focuses on their wellbeing, not controlling the IP.

Al-Anon Principles: Powerlessness

Members accept they cannot control the IP's drinking.

Purpose of Al-Anon

Improves family mental health; not designed to get IP into treatment.

BCT Overview

Evidence-based treatment for couples where one partner has SUD.

Goals of BCT

Engage couple, support abstinence, improve communication, maintain recovery.

Eligibility for BCT

Together ≥1 year; only one partner with SUD; no severe violence or desire to separate.

Four Promises in Engagement

No threats of separation, no violence, focus on present/future, full participation.

Recovery Contract

Daily trust discussion, support from SO, logs of progress.

Communication Skills Taught in BCT

I-statements, active listening, conflict resolution, scheduled positive activities.

Ethics in Addiction Treatment: Autonomy

Client chooses goals and changes.

Beneficence

Use effective, wellbeing-promoting treatments.

Justice

Fair, culturally competent care.

Nonmaleficence

Avoid harm; protect confidentiality.

Three Elements of Informed Consent

Competence, comprehension, freedom of choice.

What Informed Consent Includes

Treatment description, risks/benefits, alternatives, confidentiality limits, finances, qualifications.

42 CFR Part 2

Extra protection for substance-use treatment records; written consent required.

Tarasoff Rule

Duty to protect potential victims, not just warn them.

When Confidentiality Can Be Broken

Imminent harm, child/elder abuse, medical emergencies.

Boundary Violations

Avoid dual relationships, gifts, favoritism, and any sexual relationships.

Professional Conduct Requirements

Practice within competence, maintain records, seek supervision, monitor impairment.

Addiction as Chronic Disease

Relapse is normal; do not discharge clients for resumed use.

DSM-IV: Remission

No symptoms for ≥1 month.

Outcomes: Abstinence Rates

24% fully abstinent at 1 year; others reduce drinking substantially.

Common Timing of Resumed Use

3-6 months post-treatment.

Maintenance Principles

Do not predict relapse; encourage autonomy; follow up regularly.

Mutual Help Groups

≥2 meetings/week during treatment predicts long-term involvement.

Medication-Assisted Treatment

Methadone, buprenorphine, naltrexone, disulfiram.

Responding to Resumed Use

Not punitive — explore What's up? What's new? What's needed?

Prevention Paradox

Most harm comes from non-dependent drinkers.

Universal Prevention

Programs for all (schools, communities).

Selective Prevention

Targets people with risk factors.

Indicated Prevention

Targets early symptoms without diagnosis.

DARE Program

Ineffective or harmful.

Effective Universal Methods

Social skills training, delaying onset, reducing environmental risks.

Supply-Side Strategies

Taxes, age limits, limiting alcohol outlets — strong evidence.

Demand-Side Strategies

Education, media literacy; advertising increases youth use risk.

Selective Prevention - Risk Factors

Family history, male gender, antisocial behavior, low sensitivity, positive expectancies, psychiatric issues.

Concerns with Selective Programs

Stigma, normalization, self-fulfilling prophecy.

Indicated Prevention Successes

Drinker's Checkup & Behavioral Self-Control Training reduce use by ~50%.

Moderation Works Best For...

Low severity, few dependence symptoms, strong social stability.

Harm Reduction Examples

Needle exchange, substitution therapies, safer-use education.

Chapter 24 - Ethics

Addiction treatment requires heightened ethical protections; informed consent requires competence, comprehension, freedom; confidentiality and boundaries are essential; supervision improves practice; professionals must stay current.

Chapter 15 - Families

Don't wait for 'hitting bottom'; families see problems first; CRAFT is most effective for engaging IP; involving SOs benefits everyone.

Chapter 21 - Resumed Use

Resumed use is common and not necessarily relapse; drinking usually decreases greatly after treatment; recurrence requires more care, not withdrawal; maintain follow-up contact.