Brief Family Therapy

Section 8: Brief Family Therapy

Substance abuse disorders are influenced by family dynamics, which can either exacerbate or alleviate the problem. Family therapy is beneficial when substance abuse is strongly linked to family behaviors, but may be contraindicated if family members are active substance abusers, violent, or in denial.

Understanding Factors Maintaining Substance Abuse

Family therapy examines structural elements like power hierarchies, roles, rules, alignments, and communication patterns to understand factors that maintain substance abuse. It helps families identify dysfunctional areas and promotes healthier communication.

Importance of Family Involvement

Family involvement is crucial, especially if family members inadvertently reinforce the problem. Changes are faster and more sustainable with whole-family involvement, creating a built-in support system.

Historical Context

Complex interactions between family dynamics and substance abuse have long been recognized, with early research suggesting spousal psychopathology as a contributing factor (Lewis, 1937; Whalen, 1953). Jackson (1954) argued that depression and anxiety in family members stem from substance abuse disorders rather than cause them.

Family Ties

Individuals with substance abuse disorders often maintain close ties with their families (Bekir et al., 1993; Douglas, 1987), and research supports the use of family therapy in substance abuse treatment.

Effectiveness of Family Therapy

Studies, including Project CALM at Harvard Medical School, show that couples counseling leads to higher rates of abstinence compared to individual therapy (Rotunda and O'Farrell, 1997). Adding a relapse prevention program further improves results.

Clinician Qualifications

Family therapy should be conducted by clinicians with expertise in family systems, dysfunctional patterns, power struggles, and communication. Alcohol and drug counselors can work with families, provided they avoid blaming them for the substance abuse.

Appropriateness of Brief Family Therapy

Long-term family therapy is not always necessary, except in long-term residential treatment. Short-term therapy maintains clearer boundaries between the therapist and family, and can be followed by individual therapy.

Exceptions to Family Therapy:

• Client unwillingness

• Issues of separation and individuation

• Physical, emotional, or sexual abuse by a family member

Circumstances Suitable for Short-Term Family Therapy:

• Resolving specific family problems

• Focusing on present interactions rather than in-depth history

• Improving family understanding of the substance abuse disorder

Opportunities Offered by Family Therapy

• Focusing on the expectation of change within the family

• Testing new behavioral patterns

• Teaching how a family system works

• Eliciting the strengths of every family member

• Exploring the meaning of substance abuse within the family

Defining "Family"

Family can be "created" through a network of significant contacts. Therapists should assess the client's social network, including friends, employers, and co-workers. The definition of "family" varies across cultures and situations. Children's perceptions can be valuable, but sensitive topics should be discussed by parents alone.

Specific Subpopulations

Family therapy approaches have been used with dually diagnosed individuals, Vietnam veterans with PTSD, older adults, cocaine abusers, and HIV-positive individuals.

Definitions of "Family" in Therapy

Family therapy may involve the whole family, a single family member, or multiple families. Network therapy includes non-family members as resources. Some family systems therapy views substance abuse as a symptom of underlying family pathology.

Types of Family Therapy

Conjoint Couple's Therapy:

Addresses couples' issues, including attraction factors, expectations, gender roles, parenting views, and communication of negative feelings.

Multifamily Groups:

Used for education and support, addressing boundaries, communication, and coping techniques. Participants realize they are not alone and learn to maintain a substance-free lifestyle. Typically involves four or five families.

Role Reversal:

Helps with boundary setting and re-establishment of the parent-child hierarchy, which is particularly important if the parent is the substance abuser.

Disadvantages of Multifamily Groups

Families may lack common experience or feel ashamed, leading to complaints without solutions. The therapist must guide the family in exploring alternatives.

Multiple Family Therapy

Addresses:

1. Inadequate internal family development

2. Family systems and role imbalance

3. Socialization variances

4. Dysfunctional family behaviors

Useful in residential settings, it allows quick assessment of deterioration in the family system and stimulates strategies to reverse this process. It works best with motivated clients, reduces dropouts, acts as a preventive measure, builds a supportive subculture, and creates structural family changes to prevent relapse (Kaufman and Kaufman, 1979, p. 84).

Theoretical Approaches

Traditional "Family Disease" Model:

Views family members as co-dependent enablers needing to detach. Treatment often involves referral to Al-Anon (Al-Anon, 1979; Bepko, 1985).

Family Systems Models:

Regard substance abuse as a symptom of dysfunctional interpersonal dynamics (Bowen, 1974; Gorad et al., 1971). Substance abuse meets a need for the family and inadvertently reinforces the behavior (Davis et al., 1974; Stanton, 1977).

Family Treatment Goals:

Identify the specific role or family-level "adaptive function" served by substance abuse, with the goal of bolstering interpersonal functioning to reduce secondary gains (Bepko, 1985; Stanton and Todd, 1982; Steinglass et al., 1977).

Strategic Family Therapy

Targets the positive interpersonal aspects of substance abuse and its benefits to the family. Paradoxical interventions may provoke spontaneous growth (Weeks and L'Abate, 1979; Winn, 1995).

Structural Family Therapy

Addresses imbalances in family relationships, such as disengagements and inappropriate coalitions (Minuchin, 1974). It explores healthy and dysfunctional roles, alignments, collusions, and communication patterns.

Bowenian Family Therapy

Focuses on family-of-origin emotional attachment patterns to address substance abuse disorders (Bowen, 1978). Adults and adolescents are helped to differentiate and define themselves by curtailing emotional entanglements.

Contextual Family Therapy

Emphasizes ethical legacies and unconscious loyalties passed down through generations (Boszormenyi-Nagy and Spark, 1973). Treatment clarifies unconscious "ledgers" and encourages parents to address their childhood issues directly.

Other Family Therapy Models

Focus on utilizing family strengths, enlisting family members as agents of change, and providing support for recovery (Liddle et al., 1992; Meyers et al., 1998; Noel and McCrady, 1993; Sisson and Azrin, 1993).

Behavioral Marital Therapy (BMT)

Teaches clear communication, conflict resolution, marital enhancement, and substance abuse-specific coping skills. It has demonstrated empirical support in controlled trials (McCrady, 1989).

Study on BMT

Couples were assigned to:

1. Minimal Spouse Involvement (MSI)

2. Alcohol-Focused Spouse Involvement (AFSI)

3. BMT

BMT included relationship enrichment, communication skills, problem-solving, and relapse prevention. Follow-up assessments showed better marital satisfaction and slower relapse rates in the BMT group (McCrady et al., 1986, 1991; O'Farrell and Cowles, 1989).

BMT and Long-Term Effectiveness

Marital therapy may prevent relapse by stabilizing the substance user's interpersonal context (Noel and McCrady, 1993). BMT approaches have been successfully employed with male and female substance abusers (Fals-Stewart et al., 1996; Wetchler et al., 1993).

Network Therapy Approaches

Recognize the potential support from those outside the immediate family (Favazza and Thompson, 1984; Galanter, 1993). Involve friends, extended family members, and Alcoholics Anonymous (AA) (Galanter, 1993).

Community Reinforcement Approach (CRA)

Trains significant others to encourage sobriety by reinforcing abstinence and allowing the drinker to experience negative consequences from intoxication (Hunt and Azrin, 1973; Sisson and Azrin, 1986, 1989).

CRA and Domestic Violence

Address domestic violence risks by de-escalating conflict and ensuring safety. Significant others attend all sessions, participate in communication-skills training, and monitor disulfiram use (Sisson and Azrin, 1993).

CRA Study

Significant others were divided into a CRA group and a control group referred to Al-Anon. The CRA group showed better outcomes, with more resistant spouses entering treatment (Sisson and Azrin, 1986).

Community Reinforcement and Family Training (CRAFT)

Analyses behavior patterns surrounding substance abuse, identifies triggers and consequences, and develops a safety plan (Meyers et al., 1996, 1998).

The basic rules taught are to be brief, be positive, be specific and clear, label feelings, express understanding for the other's perspective, accept partial responsibility when indicated, and offer to help (Meyers et al., 1998).

CRAFT Study

Significant others were assigned to CRAFT, Al-Anon-only, or a Johnson Institute intervention group. The CRAFT group had a higher percentage of substance abusers entering treatment (Meyers et al., 1998).

CRAFT and Well-being

CRAFT improves the social and emotional welfare of significant others, reducing anger, anxiety, and depression. It emphasizes communication skills training and marital reciprocity counselling (Meyers et al., 1998; Sisson and Azrin, 1986).

Multidimensional Family Therapy (MDFT)

A brief family therapy model for adolescent substance abuse and conduct disorders (Liddle et al., 1992). It integrates structural/strategic family therapy with adolescent development research (Schmidt et al., 1996). MDFT enhances a family's ability to buffer adolescents against destructive peer and social influences by nurturing healthy teen development through supportive rather than strictly authoritarian parent-child relationships.

MDFT Model Components

Individual sessions with the adolescent are interspersed with family sessions to allow the therapist an opportunity to form a supportive relationship with the teen and act as an intermediary between parent(s) and child.

Therapy sometimes includes representatives of extra familial systems such as school and probationary personnel as well as peers.

MDFT and Conflict Resolution

MDFT works to find common ground and create a trusting relationship. Adolescents are challenged to articulate their issues, and parents are challenged to listen and evolve the relationship into mutual respect (Liddle et al., 1992).

MDFT Outcomes

Reduced alcohol and marijuana use, improved school performance, and positive outcomes remained at follow-up 1 year later (Liddle and Dakof, 1995; Schmidt et al., 1996).

Recommendations for Family Therapy

The Institute of Medicine (IOM) recommends brief couples therapy for all alcohol-abusing clients (IOM, 1990). Edwards and Steinglass (1995) support the routine inclusion of non-alcoholic family members in the assessment phase.

Benefits of Family Therapy

Family members can participate in positive treatment and recovery experiences.

Duration and Frequency of Sessions

Most family therapy is short-term, with sessions lasting 1 1/2 to 2 hours. Therapy typically involves no more than two sessions per week over 6 to 10 weeks.

Residential Treatment Programs

May include "family weeks" or require significant others to attend sessions regularly.

Multiple Impact Model

Brings together groups of sober individuals and their families for an extended weekend of work, recasting family roles and creating new agreements (Wegscheider-Cruse, 1989).

Opening Session

• Clarify the problem and identify family goals.

• Ask each family member open-ended questions.

• Educate the family on effective participation and biosocial issues.

• Provide feedback on similar or different goals.

• Prioritize directions for change and establish a contract.

Theoretical Approaches in Opening Session

• Solution-focused therapy: Gather information, affirm family members, and assign tasks.

• Eriksonian therapy: Ask how they will know when they get there and test for resistance.

• MRI strategic model: Examine previously attempted solutions.

Follow-Up

Plan for follow-up and support, such as alumni support groups or follow-up conversations.

Native Americans in Brief Family Therapy

Example of a Native American man seeking treatment for alcohol abuse, where cultural beliefs and family dynamics played a significant role. The therapist encouraged the client and father to express their resentment and appreciation of each other in letters read aloud to each other.

Cultural Issues

Understanding the family's ethnic and cultural background is crucial to promote change. (Soo-Hoo, 1999) Therapists need the family's permission to share closely held secrets,

Examples of Cultural Considerations

• Requesting a letter from the family elder in the Philippines to allow members to reveal family matters to an outsider.

• Working with a client who belonged to the Southern Baptist fundamentalist movement and getting the family's minister to help frame the situation.

Cultural Meaning

The language used to describe dynamics within the family system is charged with specific cultural meaning.

Culturally Specific Models

Many substance abuse treatment programs have developed culturally specific family therapy models for various populations (Ablon, 1980; Kaufman and Borders, 1988; Aktan et al., 1996; Flores-Ortiz and Bernal, 1989; Hill, 1989; Laureano and Poliandro, 1991; Panitz et al., 1983; Szapocznik et al., 1991; Ziter, 1987).

Treatment for Hispanic Adolescents

A family therapy approach that has been successful with substance-using Hispanic adolescents combines elements from structural, strategic, and Milan therapies (Santisteban and Szapocznik, 1994; Szapocznik and Kurtines, 1989; Szapocznik et al., 1988, 1991). This approach focuses considerable effort on overcoming initial resistance to treatment because the process embodies the family's issues around the adolescent's substance use.