Family Therapy for Substance Abuse

1. Family Therapy for Substance Abuse • Studies have supported its efficacy in treating substance abuse (e.g., Stanton & Shadish, 1997) • Important to keep in mind that “family therapy” can encompass many different approaches (e.g., structural, behavioral, etc.)

2. Substance abuse often develops and/or is maintained within a family context • May reflect other family difficulties • May be maintained or exacerbated by family interactions • Individuals struggling with addiction often have close contacts with family members • Adolescents, obviously • Adults with addictive disorders five times as likely to live with parents or be in touch on a weekly basis (Stanton & Heath, 2004)

3. Some characteristics that distinguish drug abusing families (Stanton et al., 1982): • High frequency of multigenerational chemical dependency • Genetic or environmental? • Poorer expressions of conflict • Overt alliances between addict and over-involved parent • Drug oriented peer group that individual retreats to from family • Symbiotic child rearing practices (i.e., parents as dependent upon child as child on parent) • Pseudoindividuation of the addict

4. Why engage in family therapy? • Substance abusers often do not seek services themselves • Oftentimes family denies problem as well • Sometimes families sabotage (consciously or unconsciously) addictive behaviors treatment • Why? • Sobriety can result in significant family changes • When can family therapy be helpful? • Basically, at any “stage” of addictive behaviors treatment • Convincing individual to enter treatment • During the active “substance abuse treatment” stage • During recovery and relapse prevention

5. One Model of Family Therapy for Substance Abuse • Chapter authors label it “Transitional Family Therapy” • First Stage: Define Problem and Contract • Therapist convenes enough family members to convince the family of the need to make changes • Therapist explicitly defines the substance abuse problem • May be more complicated in families because of multiple abusers or perspectives • For example, kids may see use as a problem; spouse or partner doesn’t

6. Once problem is defined, treatment goals are defined • Primary goal involves eliminating (or reducing) substance use • Other treatment goals are initially subordinate to this one • Important early on to establish alliances with senior sober family members (usually parent or spouse/partner) • Important to keep these members focused on the same goal • For example, in working with family with adolescent abuser, it’s important to not let parents get distracted by other issues • Allows the therapist to “use” parental or other family influences • Generally more powerful than therapist influence • Important to adapt a “nonblaming” stance toward family • For example, can’t blame parents for kids’ problems (even though you might want to)

7. Ideally, by the second session therapists create three graphic constructions • List of goals • List of tasks • Three-generation genogram • Useful for exploring family history of substance use • Issue of genetics versus environment • Can be tricky in family therapy • Genetics can be used to help reduce blame, but it can be interpreted in a way that removes responsibility or provokes fear

8. Second Stage: Establish Family Context for Sobriety • Increase positive family behaviors • Important to chart and document • Ties in, again, with behavioral economics • Sometimes refer family members and/or abusing individual to support groups • Third Stage: Halting Substance Abuse • Goals have been set and agreed upon; family context has improved-substance abusers need to take final step

9. At this stage detoxification is often in order, medical or otherwise • Stage Four: Family Stabilization • Sobriety often disrupts the family system • What might this look like???

10. Couples interact hesitantly in the efforts of continuing sobriety • Parents see behaviors in children that they did not see before (too impaired to notice) • Challenge in this stage is to simply keep the family together • Minimize stress, deescalate conflict, etc. • Stage Five: Reorganization and Recovery • Therapy focuses on improving family functioning, which will also prevent relapse • Improve marriage, overall relationships, address long-standing family conflicts

11. Important for substance abuser to develop a new role in the family • For example, a cocaine dependent father was probably not serving a responsible parental role • All family members have to accept and understand these roles • Overcome the “baggage,” so to speak

12. Other Considerations in Family Therapy • The issue of the “family intervention” • In general, difficult to get families to engage in this process • Too confrontational and secretive • Some approaches may be better than others • Challenges in getting the family in • Sometimes a family member will be reluctant • Important for the therapist to make direct requests

13. Psychodynamic Treatment for Substance Abuse • Important to differentiate “psychoanalysis” from “psychodynamic” • What is the difference?

14. Psychodynamic approaches (e.g., Khantzian) resulted in the self-medication hypothesis • Remember, though, the research on lack of specificity • Important to keep in mind psychodynamic principles • Insight is key • The issue of “objects” • Simplistically, they are “things” that we are attached to, often with unconscious representations • Substance abuse can be interpreted as a replacement for a human object • Collapse of “idealized object” can trigger substance abuse • Can also be used to deal with deficient “internalized self-object”

15. Defective self-care functions • Addict does not have ability to care for oneself, so places him/herself in dangerous situations • Inability to manage one’s own affective states (i.e., cannot “self-soothe”) • External agent required to soothe oneself • Substance use compensates for perceived helplessness • Substance use as a result of “narcissistic range” • Frustrated by feeling of powerlessness, leads to compulsive, immediate actions • Importance of early experiences • If not resolved and understood, could result in later problems • For example, unresolved abandonment issues as an adult could result in substance use

16. Technical aspects of psychodynamic therapy with adults • Again, remember that in these approaches insight is key • Also important to remember that psychodynamic approaches are often very deterministic • Understanding the role of alcohol or drugs is key • Is it an important other-object? • Is it a result of deficient affective regulation? • Often one explores positive and negative role of alcohol • Similar to a decisional balance exercise, but focus is different • In psychodynamic therapy the “role” of the therapist is very important • Transference-feeling that the patient projects onto the therpaist

17. Therapist cannot maintain a harsh, punitive stance (superego), but also cannot be too permissive (id) • Appropriate care and concern from the therapist will result in a desire to change behaviors as a result of transference • Interpreted as a message of care from an object • Often interpreted in terms of something missing from childhood • Countertransference issues (feelings of the therapist toward the patient) • Issues of frustration often occur • Why more so in addictive behaviors than other disorders?

18. In psychodynamic therapy one is often dealing with issues other than the substance abuse directly • Remember what are thought to be the causal factors for substance abuse • Develop insight and resolve these conflicts, abuse will alleviate