TIP 39

Family Therapy

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What is a Family?
Types
Traditional families
Single parents.
Foster relationships.
Grandparents raising grandchildren.
Stepfamilies.
Extended families
Elected families
In general: Family can be defined according
to the individual’s closest emotional
connections.
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Impact of Substance Abuse on Families
Financial: Money spent for drug use;
Psychological denial or protection of the
addict, chronic anger, stress, anxiety,
hopelessness, inappropriate sexual behavior,
neglected health, shame, stigma, and
isolation.
Environmental (homelessness, safety)
FASD in children of women who abuse alcohol
during pregnancy
Older adults cared for by their children.

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Parent’s substance use can have cognitive,
behavioral, psychosocial, and emotional
consequences for children, including:
Impaired learning capacity
A propensity to develop a substance use disorder
Adjustment problems, including increased rates
of divorce, violence, and the need for control in
relationships
Depression, anxiety, and low self-esteem
Children forced prematurely to accept adult
responsibilities

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Family Therapy vs. Family
Involved
Family therapy
a collection of therapeutic approaches that share
a belief in the effectiveness of family -level
assessment and intervention.
In family therapy the unit of treatment is the
family and the individual within the family
system
Family-involved therapy
uses a individual-level assessment and
intervention, while educating the family

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Family therapy in substance abuse treatment
has two main purposes
use family’s strengths and resources to help find
or develop ways to live without substances of
abuse
to ameliorate the impact of chemical
dependency on both the identified patient and
family.

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Assessment
assess for the potential for domestic
violence or abuse
Do not accept the family's version of the
problem
not interested in the content of family's
stories, but more in the process of the
family’s interaction
Resonance defines the emotional and
psychological accessibility or distance
between family members and needs to be
assessed in the context of culture
The counselor should announce at the
beginning
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secrets
Initial Treatment
Denial and Resistance are essential to both
family and substance abuse treatment
A therapeutic alliance is built around
individual goals that family members can
reach in therapy
One of the most useful strategies a
counselor can use is to support the
existing family power structure

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Family Therapy
The unit of treatment is the family, and/or the
individual within the context of the family
system.
The person abusing substances is regarded
as a subsystem within the family,
The familial relationships within this
subsystem are the points of therapeutic
interest and intervention.
In family therapy, content is what the family
talks about and process is how the family
interacts
Family therapy
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are present
By observing process the counselor learns
the unwritten rules that guide the family's
communication
For every action there is a corresponding
reaction from the rest of the family is the
definition of the principle of
complementarity

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Goals of family therapy in
substance abuse treatment
Helping families become aware of their own
needs
Providing genuine, enduring healing for family
members
 Working to shift power to the parental figures
in a family
Improving communication
Helping the family make interpersonal,
intrapersonal, and environmental changes
affecting the person using alcohol or drugs
Keeping substance abuse from moving from
one generation
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Systems & Contexts
Systems
Individual
Family
Culture
Society
5 Contexts
Family
Peers
Culture
Neighborhood
Counseling

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Life Context
Includes those in the immediate household
and those systems outside the family in
which the family members participate

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Techniques
Effective strategies (3 Ps)
Practical
Problem Focused
Planned

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Complementarity
Members behave in ways that fulfill
unconscious needs and demands of the other
Each member's recovery needs must be
explored in relationship to the others
The Addict.
The Hero.
The Mascot.
The Lost Child.
The Scapegoat.
The Caretaker (Enabler).

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Boundaries
Types
Enmeshment
Disengagement
Healthy
Function
Regulate flow of information
Maintain structure to permit function
Setting clear rules and consequences is one of
the best ways to start setting the boundaries
between parent and child

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Homeostasis and Resistance
Current behavior patterns preserve order and
stability
The system will resist change
It is appropriate to work with a family if one
or more members attends the session under
the influence of alcohol or other drugs
The most frequently observed type of family
resistance is an identified patient withtoo
much power or control

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Triangulation
A third member is drawn into a problem
between two others
In detraingulation, the counselor changes a
way of interacting by coaching one member
to do or say the opposite of what he or she
would normally do

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Benefits
Improved treatment outcomes
Family support of client recovery
Family recovery
Intergenerational Impact
Reduced resistance
Increased flexibility

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Limitations
Lack of structure
Additional training
Mindset shift: individual to family

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Levels of Involvement
Levels
Level 1: Minimal
Level 2: Psychoeducation
Level 3: Address feelings/support
Level 4: Systematic assessment and
interventions
Level 5: Family Therapy
Determined by:
The counselor's level of experience and comfort
The family's needs and readiness to change

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Level 3 Specialized Skills
Elicit family member's concerns
Empathically listen
Form preliminary assessment
Encourage efforts to cope
Tailor education to the family
Identify dysfuctions, make referrals

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Level 4 Specialized Skills
Engagement
Facilitate expression from all members
Assess family's level of functioning
Support individuals and avoid coalitions
Reframe the problem(s)
Encourage viewing solutions through
collaborative lense
Help generate alternative coping methods
Calibrate roles

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Level 5: Specialized Skills
Engage difficult members
Generate and test hypotheses about
interactional patterns
Escalate conflict to break impasse
Temporarily side with one member
Deal with resistance to change
Negotiate collaborative relationships

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Integrated Models
Structural Strategic
Family structure is repeated patterns of
interaction
Family structure determines individual behavior
Power of the system is greater than that of the
individual
Goals
Identify the function of substance abuse in
maintaining family stability
Guide changes in family structure

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Multidimensional Family Therapy
(Adolescents)
Goals-Adolescent
 Positive Peer Relations
 Healthy Identity Formation
 Bonding to Prosocial Activities
 Autonomy within the Parent-Child relationship
Goals-Parent
 Increase parental commitment
 Improve communication
 Increase parenting skills

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Behavioral Family Therapy
Assumptions
 Addicted Families have skill deficits'
 Family member reactions influence the behavior
 Distorted beliefs lead to dysfunctional behavior
Goals
 Contingency contracting to change reward paradigms
 Skills training to provide alternative behaviors to reward
 Cognitive Restructuring to replace irrational thoughts
with positive ones

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BFST
Patterns of interaction in the family influence
the behavior of each family member
BFST it is important that the counselor joins
into the "system“
 Interventions change maladaptive patterns
of interaction
Elements of the family's interactions
examined
Organization
Resonance
Developmental Stages
Identified Patient
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Solution Focused Brief

Focuses on what life will be like when the
problem is solved

Miracle question

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3 Stages of Recovery
Attainment of Sobriety
Adjustment to Sobriety
Maintenance of Sobriety

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Stage 1: Attainment
Motivate family to engage client in detox
Contract with the family for abstinence and
treatment compliance
Define problems
Employ support groups
Use the “network” to motivate treatment
Interview family in relation to the larger
system
Introduce the difference between facts and
reactions
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Stage 2: Attainment
Restructure family roles
Realign subsystem and generational
boundaries
Reestablish family and the larger system
boundaries
Teach relapse prevention
Identify communication dysfunction
Use contingency contracting
Ask scaling and relational questions
Identify exceptions to behavior
Identify problem and solution sequences
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Stage 3: Maintenance
Renegotiate relationships with larger systems
Employ support groups

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Special Populations
Domestic Violence
Racial/Ethnic Minorities
GLBT
People with Disabilities
Children/Adolescents
Older Adults (elder abuse, culture norms)
Rural Populations
Homeless clients
Veterans

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Adolescents
Adolescents needing substance abuse
treatment
Truancy
Violent or aggressive
Risky sexual behavior
Both under and overinvolvement of parents
have been linked to adolescent problem
behaviors
In families of addictedadolescents, parents
have a difficult time determining what is
age-appropriate
In the event of a powerful identified patient
(adolescent) the counselor should align with
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Violence
Screen for partner violence, child abuse and
elder abuse
Screen for personality disorders which may
indicate a propensity for violence toward self
or others
Develop a safety plan as necessary
Report abuse as required

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Summary
Family therapy considers the problem to be
instigated and maintained by the whole
family, not the identified patient
There are multiple approaches to family
therapy
It is important to be aware of cultural
implications for family therapy

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