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Counseling Family Members of Addicts/Alcoholics:The Stages of Change Model

Counseling Family Members of Addicts/Alcoholics:The Stages of Change Model



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counseling families of alcoholics and addicts
Journal of Family Social Work, 11 (2), 202-221
counseling families of alcoholics and addicts
Journal of Family Social Work, 11 (2), 202-221

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Published by: katherine stuart van wormer on Jul 31, 2008
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Counseling Family Membersof Addicts=Alcoholics: The Stagesof Change ModelKatherine van Wormer, Ph.D., MSSWABSTRACT. This article adapts the stages of change model, a modelin which specific interventions of harm reduction are directed towardthe client’s readiness for treatment, as a guiding framework for counselingfamily members of alcoholics=addicts. Interventions at each stageof the family’s readiness for change, from precontemplation to action,are described.KEYWORDS. Alcoholism, families, stages of change, transtheoreticalapproachThe family is a system composed of members in constant anddynamic interaction with each other. Patterns of interaction getestablished: who interacts with whom, who talks and who listens,who has the authority and who is the controlling force behind thescenes. The family has a pattern, a rhythm that is more than thesum of its parts. Any change in the behavior of one of its membersaffects not only each of the others but the system as a whole.Addiction, accordingly, is often defined as an illness not just of theKatherine vanWormer, Ph.D., MSSW, is Professor of Social Work, Universityof Northern Iowa.Address correspondence to: Katherine van Wormer, University of NorthernIowa, 30 Sabin Hall, Cedar Falls, IA 50614.Journal of Family Social Work, Vol. 11(2) 2008Available online at http://jfsw.haworthpress.com# 2008 by The Haworth Press. All rights reserved.202 doi: 10.1080/10522150802174319individual but of the whole family. Sometimes the misery is so intensethat the system barely functions.Families are important in both the etiology of addiction and its recovery(Gruber & Taylor, 2006). In relapse prevention, success in establishinga social support network raises the chances of long-term treatmentsuccess. Family therapy, even in only a few sessions, can be invaluablein reducing the feelings of guilt or confusion in significant others. Familycounseling, moreover, can be invaluable in preparing the family forchanges that are needed to enhance and maintain the addicted person’srecovery. That is what this paper is about—the change process itselfand motivation for change at every level of the treatment process.Paralleling the individual substance user’s pathway from experimentationto addiction is the family’s progression along a continuumfrom stability to a loss of control over events relevant to the family,employment, child care, and general family functioning. Changes inthe addictive behavior—for example, gambling—are met by changesin family roles and relationships. The changes may not be direct. Onetruth about relationships is that there tends to be a lag between the timewhen a condition, such as addiction (etc.), surfaces and when the realitybecomes truly accepted. The situation can become even more complexas individual family members are at different places along the continuumof recognition of the need to take action against a serious problem.To reflect this developmental process and the need to shape treatmentinterventions accordingly, I have chosen as the most appropriatemodel, the stages of change model. This model initially was developedby Prochaska and DiClemente (1986) to describe the process ofsmoking cessation and further developed and modified by Miller(1999) and Miller and Rollnick (2002). Patricia Dunn (2000) findsthe stages of change model appropriate for social work because it iscompatible with the mission and concepts of the profession, is an
integrative model, and is grounded in empirical research. Throughbuilding a close therapeutic relationship, the counselor can help theclient develop a commitment to change and proceed at his or herown pace. In working with families with substance abuse issues, suchpatience and empathy are paramount. Yet there is much work to doin families of this sort; the anger and denial can be palpable.Sometimes, the anger and resentment by significant others need tobe addressed before a recovering family member is returned to thefamily setting. Sometimes, of course, the family environment itselfis toxic, several of the participants having serious problems withKatherine van Wormer 203boundary issues or drugs, for example. Here, too, interventions mustbe directed toward the whole family. To treat the individual in isolationis to ignore the context in which much of that behavior takesplace. To know the context, an understanding of the systemic intergenerationalnature of addiction is essential.Even more than ordinary illness, addiction is a source of major stressthat reverberates through the family system and affects the family’sinteractions with every other system in the community. The emotionaland financial resources of the family may be almost entirely depletedby the stress of the addict’s illness. The havoc wreaked on the familyby alcohol misuse is even more dramatic and progresses more rapidlywhen a drug such as methamphetamine (meth) enters the picture.Qualitative data based on interviews with former meth addicts revealthat communication and caregiving duties break down to the extentthat the well-being of the children and the family as a whole are in direjeopardy (see Brown & Hohman, 2006). In Iowa, as revealed in mediareports, hundreds of parents are losing custody of their children, a trendseen only in recent years as meth has secured its grip statewide (Reiter,2003; Rood, 1999; van Wormer & Davis, 2008).Perhaps because of the difficulty of working with such chaoticfamilies and the stigma of addiction in general, the family therapy fieldhas devoted little effort to addictions-focused treatment and hastended to refer drug-afflicted members to specialized services or selfhelpgroups. And because of the difficulty that substance abuse treatmentcenters face in working with the whole family, combined withthird-party reimbursement disincentives to do so, often little morethan lip service is given to family members’ needs by these treatmentcenters. The recent emphasis on the importance of engaging membersof social networks in treatment appears to be focused on retention ofthe alcoholic or addict in treatment or in getting the family to see thatthe individual take recommended medications rather than to beactively involved in the treatment process as a family (Loughran,2006). Too often, any family that does not match the traditional moldtends to be invisible, while the importance of the extended family as avital resource goes unrecognized. Yet, for children and partners in thefamily system, the need to sort out their feelings and to learn moreabout the nature of the problem that has so consumed them over theyears is crucial for long-term recovery of everyone involved.In contrast to traditional family therapy, the family treatmentinterventions described in this paper are designed to elicit resilience204 JOURNAL OF FAMILY SOCIAL WORKand healing in family members rather than to uncover the family’spresumed role in causing and perpetuating the addiction. I haveadapted interventions to parallel the readiness of the family forchange, a phase approach. The phase approach views treatmentneeds in terms of the five basic intervals stretching from precontemplationthrough the maintenance period. Keep in mind that, in
reality, there is no clear-cut division among the stages and that thesequence of the progression is oversimplified here for the sake ofexplanation. The stages of family needs, moreover, may or may notdirectly correspond to the alcoholic or addict’s stage of recovery.Family members, for example, may be far more ready for changein the direction of sober lifestyle than is the person with the severeproblems.THEORETICAL FRAMEWORKSometimes called a transtheoretical approach because it relies onseveral theories of social psychology, the stages of change modelwas first proposed by Prochaska and DiClemente (1986) to describehow smokers who were able to break their nicotine habit successfullydid so. Their concern was with the movement of people from denialof the need to change (called precontemplation) to the reaching of adecision to adopt a healthier lifestyle (preparation) and then the takingof steps to do so (action). The focus of this model was on the individual’smotivation to change. This framework has played an integralrole in the development of motivational interviewing.Miller and Rollnick (1991) set forth an empirically based formulationof motivational interviewing (MI) in their groundbreakingtext Motivational Interviewing: Preparing People to Change AddictiveBehavior. The goal of MI is basically harm reduction. The method isto elicit statements in the individual with substance use or otherdestructive behaviors that are in a positive, health-seeking directionand to reinforce those statements. Miller and Rollnick incorporatedin their model Prochaska and DiClemente’s notion that changeinvolves a psychological progression, that therapist interventionsmust be carefully tailored to the client’s readiness to change(Prochaska & Norcross, 2007).Europeans, immersed in the harm reduction perspective, had earlierin the 1980 s adopted this theoretical approach and incorporatedKatherine van Wormer 205it in treatment programs (van Wormer & Davis, 2008). The UnitedStates, reticent at first and steeped in a tradition of harsh confrontationalstrategies directed toward clients who had ‘‘hit their bottom,’’has begun now to move in this direction. The dual influence of favorableempirical research proving the effectiveness of short-term, motivationaltreatment and of decisions by insurance companies toreimburse such evidence-based practices has reshaped the treatmentindustry in the United States (van Wormer & Davis, 2008). The conceptof stage-based treatment is central to integrated treatment foraddicted clients with mental disorders as well, in that it provides aframework for assessing clients’ motivational states and gearing interventionscorresponding to the client’s degree of readiness (Mueser,Noordsy, Drake, & Fox, 2003).In every stage of the Prochaska and DiClemente model, extendingfrom precontemplation through maintenance or relapse, resolvingambivalence is a central theme of focus (DiClemente, 2006). Thisapproach has been found to be helpful in work with partners with substanceabuse problems in regard to resolving ambivalence about change(O’Farrell & Fals-Stewart, 2006). Helping people make decisions thatwill benefit their lives, similarly, is the overriding goal of motivationalenhancement therapy. An important point enunciated by Prochaskaand Norcross (2007) is that if one tries to use strategies appropriate toa stage other than the one the client is at, the intervention will be ineffective.If the client is only barely motivated to contemplate giving upa favorite habit and needing some guidance in weighing the pros andcons of change and the counselor pushes for 12 Step involvement, the

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