Determinants of the level of involvement

To determine a counselor’s level of involvement with a specific family, two factors must be considered:

The counselor’s level of experience and comfort. Figure 4‐2 can be used to determine the knowledge base and skills that a counselor needs to implement each of the five levels of family involvement.

The family’s needs and readiness to change. Prochaska and colleagues’ stages of change model (Prochaska et al. 1992; see chapter 3 for a description of the five stages) can be used to assess a family’s readiness to change and suggests a level of counselor involvement appropriate for that change. A family in precontemplation, for instance, would do best with a lower level of intervention—Level 2 or 3—while a family in the maintenance phase might be ready for Level 5 family therapy—sorting out relationship issues that may not be directly related to substance abuse.

Both family and counselor factors must be considered when deciding a level of family involvement. Families should not be pushed rapidly toward change when they are not ready. If they are pushed too fast, their resistance increases, and they may leave treatment prematurely. Staff should not be placed unprepared in positions outside their level of development––even when no other staff is available. When therapists attempt to function in a level that is beyond their training, their interventions are typically ineffective, and they grow frustrated and demoralized. This is likely to affect the family negatively.

Figure 4‐2 can be used to determine training needs to prepare counselors to intervene at different levels. Agencies can draw on the skills that substance abuse counselors and family therapists already have and develop the additional competencies listed. Credentialing bodies can also use systematic training to develop appropriate competencies in substance abuse and family therapy counselors.

Using the family to engage the client in treatment

In some treatment models, such as the Johnson model and the Thomas and Yoshioka model, family members are used in a confrontive, unilateral intervention to engage the client in treatment. This can be a one‐time intervention and has been shown to be successful (Johnson 1986; Thomas and Yoshioka 1989).

To engage the client in treatment, Kirby and colleagues (1999) recommend using the community reinforcement training intervention. This type of intervention has been shown to significantly improve the retention of family members in treatment and to induce people who use drugs to enter treatment. This behavioral intervention “provides motivational training” for family members (Kirby et al. 1999, p. 86) by showing them how to give positive rewards to the client for not using drugs and to ignore the client who uses drugs so that he or she experiences the negative consequences of use. When the client experiences particularly difficult times as a result of drug abuse, family members are encouraged to suggest counseling (Kirby et al. 1999).

Approaches to engagement

A number of specific interventions have been developed to help clinicians use family members and other significant figures in a person’s life to engage the person in substance abuse treatment. The following descriptions of interventions are adapted from a National Institute on Drug Abuse (NIDA) research monograph (Stanton 1997, pp. 161–168). Although only Unilateral Family Therapy relies on family therapy models, the Johnson Intervention and Community Reinforcement Training emerged from the substance abuse treatment field based on a range of background influences including pastoral and family counseling, community psychology, and behavioral reinforcement theories. Following are brief descriptions of each intervention:

• Johnson Intervention. Originally developed in the 1960s (Johnson 1973, 1986) at the Johnson Institute in Minneapolis, this intervention is a method for mobilizing, coaching, and rehearsing with family members, friends, and associates to help them confront someone they believe to have a substance use disorder. At that time, they voice their concerns, strongly urge entry into treatment, and explain the consequences in the event of refusal (which could include divorce or loss of a job). Interveners usually prepare in secret to use the element of surprise. Although the approach has mostly been applied with problem drinking, it has also been adapted for other types of substance abuse (Leipman et al. 1982).
• Unilateral Family Therapy. Developed by Thomas and colleagues (Thomas and Ager 1993; Thomas and Yoshioka 1989; Thomas et al. 1987), this approach has been applied with spouses (usually wives) of uncooperative family members who are abusing substances (typically alcohol). The therapist meets with the spouse over some months, with a focus on spousal coping, reducing the individual’s substance use, ¹ and inducing the person with alcoholism to enter treatment. The method was influenced by the Johnson Intervention and the Community Reinforcement Approach (CRA), although the spouse usually carries this intervention out, which is called a “programmed confrontation.”

By the fifth month, some open attempt (or a series of attempts) is made to get the person who is abusing alcohol into treatment. When other cases were added in which the potential clients had not entered treatment but had achieved and maintained clinically meaningful reductions in their drinking levels, ¹ 37 percent of the people who abused alcohol and whose spouse was treated immediately had entered a program, compared with 11 percent for a group for which treatment was delayed (Thomas et al. 1990).

• Community Reinforcement Training (CRT). This method was adapted from the original CRA to alcoholism treatment developed by Azrin and colleagues (Azrin 1976; Azrin et al. 1982; Hunt and Azrin 1973; Meyers and Smith 1995) and has been applied to cocaine dependence by Higgins and others (Higgins and Budney 1993; Higgins et al. 1993, 1994). CRT involves seeing a distressed family member (usually the spouse) the day that she telephones to get help for a family member with alcoholism. It also requires being available during nonworking hours in case the family member reaches a crisis point when the person who is abusing alcohol requests help. The approach attempts to take advantage of a moment when the person is motivated to get treatment by immediately calling a meeting at the clinic with the counselor, even in the middle of the night (Sisson and Azrin 1993).

This generally nonconfrontational program includes a number of sessions with the spouse in which checklists are completed and the spouse is taught how to implement a safety plan if the risk of physical abuse is high, encourage abstinence, encourage treatment seeking, and assist in treatment. Sisson and Azrin (1986) examined the effectiveness of this approach with 12 cases—seven in which a family member received CRT and five in which the person received traditional (e.g., Al‐Anon) counseling. In six of the seven CRT cases, the individual who abused alcohol entered treatment, whereas none of the traditional cases entered treatment.

Selecting an integrated model for substance abuse treatment

Care must be taken in the choice of an integrated therapeutic model. The model must accommodate the needs of the family, the style and preferences of the therapist, and the realities of the treatment context (e.g., in a residential treatment setting one would not select an approach that demanded frequent contact with family members when clients come from a wide geographical area and family members would not be able to visit often).

The model also must be congruent with the culture of the people that it intends to serve. For example, some parents from Asian cultures may be perplexed by the assumption that children have a “voice” in the family (e.g., children who take on adult‐like responsibilities by interpreting for parents, but do not hold adult‐like responsibilities in the family). The model selected must accommodate differences in family structure, hierarchies, and beliefs about what is appropriate and expected behavior.

When choosing and applying a family systems model, certain basic questions must be considered:

• Does the model fit what is observed in the family? For instance, a general lack of predictable structure may call for structural family therapy, which would be inappropriate for a distant and conflicted couple who instead may need emotion‐focused couples therapy. Further, does the model provide direction as to where to go with the family? Is the direction simple enough to address a chaotic family system, yet encompassing enough to address multiple presenting problems and family structures?
• Can the model be used when not all family members attend all sessions? Can it be used with only one family member, if only that one person is ready for treatment?
• Will the model work with the family of origin and address intergenerational issues, such as how the family got where it is, and how does that history influence the family now?
• Will the model help the counselor manage the amount of change in the family system? Will the counselor be able to manage the competing homeostatic and change needs of the family? If not, the result may be too much resistance or too little change to satisfy the family.
• If the model uses a directive technique, will it increase the family’s resistance? Further, will that model’s directive nature fit the counselor’s style? Would the counselor, for example, be comfortable saying, “Say this to him now”? Or does the counselor need a model with a less directive style?
• How much time is required to implement the model? Is it applicable in the short term, such as 8 to 12 sessions? Do the model’s time requirements match the time available for therapeutic intervention?
• Is the model compatible with a particular family’s cultural characteristics? If the counselor were to use the model, would family members be inclined to view the counselor as a good match for their cultural practices and values? Some models suggest, directly or implicitly, that one and only one family organization or structure is healthy, and all others are inferior. Such views may be inappropriate for families whose cultural or ethnic belief system conflicts with a particular model’s assumptions and standards.

Theoretical basis

Structural/strategic family therapy assumes that (1) family structure––meaning repeated, predictable patterns of interaction––determines individual behavior to a great extent, and (2) the power of the system is greater than the ability of the individual to resist. The system can often override any family member’s attempt at nonengagement (Stanton 1981a ; Stanton et al. 1978).

Roles, boundaries, and power establish the order of a family and determine whether the family system works. For example, a child may assume a parental role because a parent is too impaired to fulfill that role. In this situation, the boundary that ought to exist between children and parents is violated. Structural/strategic family therapy would attempt to decrease the impaired parent’s substance abuse and return that person to a parenting role.

Whenever family structure is improperly balanced with respect to hierarchy, power, boundaries, and family rules and roles, structural/strategic family therapy can be used to realign the family’s structural relationships. This type of treatment is often used to reduce or eliminate substance abuse problems. As McCrady and Epstein (1996) explain, the family systems model can be used to (1) identify the function that substance abuse serves in maintaining family stability and (2) guide appropriate changes in family structure.

Techniques and strategies

In this treatment model, the counselor uses structural/strategic family therapy to help families change behavior patterns that support substance abuse and other family problems. Because these patterns in dysfunctional families are typically rigid, the counselor must take a directive role and have family members develop, then practice, different patterns of interaction. Counselors using this treatment model require extensive training and supervision to direct families effectively.

One modification that flows from structural/strategic family therapy is strategic/structural systems engagement (SSSE). In SSSE, the family is helped to exchange one set of interactions that maintains drug use for another set of interactions that reduces it. In particular, SSSE targets the interactions linked to specific behaviors that, if changed, will no longer support the presenting problem behavior. Once the family, including the person with a substance use disorder, agrees to participate in therapy, the counselor can refocus the intervention on removing problem behaviors and substance abuse.

Another modification, brief strategic family therapy (BSFT), also flows from structural/strategic family therapy. In BSFT, structural family therapy “has evolved into a time‐limited, family‐based approach that combines both structural and strategic [problem‐focused and pragmatic] interventions” (Robbins and Szapocznik 2000). BSFT is known to be effective among youth with behavioral problems and is commonly used for that purpose among Hispanic families (Robbins and Szapocznik 2000).

BSFT is used to help counselors attract families that are difficult to engage in substance abuse treatment (Szapocznik and Williams 2000). In Hispanic families with adolescents using drugs, Szapocznik and colleagues reported that 93 percent of families were brought into treatment using standard BSFT, versus 42 percent in a control group. Treatment completion rates were higher among those receiving BSFT (Szapocznik et al. 1988). To achieve this improvement, BSFT was modified to a one‐person family technique. The technique is based on the idea of complementarity (Minuchin and Fishman 1981), that is, when one family member changes, the rest of the family system will respond. Szapocznik and Williams (2000) used the one‐person family technique with the first person in the family to request help. Once the whole family was engaged, they refocused attention on problem behavior and drug abuse.

One of the specific techniques used in structural/strategic family therapy is illustrated below.

While structural/strategic family therapy has been shown to be effective for substance abuse treatment, counselors must carefully consider using this approach with multiproblem families and families from particular cultures. Some points to consider are

• Culture. Counselors should become familiar with the roles, boundaries, and power of families from cultures different from their own. These will influence the techniques and strategies that will be most effective in therapy.
• Age and gender. Cultural attitudes toward younger people and women can affect how the counselor can best assume the directive role that structural/strategic family therapy requires.
• Hierarchies. Certain cultures are very attuned to relative positions in the family hierarchy. Sometimes, children may not ask questions of the parent. Other children will remove themselves from the situation until the parent notices they are not there. The professional needs to be attentive to who is who in the family. Who is revered? Who are friends? What is its history? Place of origin? All these are clues to understanding a family’s hierarchy.

Counselors who use structural/strategic family therapy need to appreciate how a particular intervention might be experienced by family members. If family members experience the intervention as duplicitous, manipulative, or deceitful, the counselor may have broached a possible ethical line. As discussed in the section on informed consent in chapter 6, family therapists or substance abuse counselors might wish to explain in advance that such interventions could be part of the therapeutic process and obtain the client’s informed consent for their possible inclusion. If clients have questions about the use of such interventions, they should be answered ahead of time and included as part of the informed consent.

For more detailed information about structural/strategic family therapy, refer to Charles Fishman’s manual Intensive Structural Therapy: Treating Families in Their Social Context 1993 and Szapocznik and colleagues’ Brief Strategic Family Therapy (in press).

The following case study demonstrates how structural/strategic family therapy might work with a client from the criminal justice system.

Theoretical basis

The multidimensional family therapy (MDFT) approach was developed as a stand alone, outpatient therapy to treat adolescent substance abuse and associated behavioral problems of clinically referred teenagers. MDFT has been applied in several geographically distinct settings with a range of populations, targeting ethnically diverse adolescents at risk for abuse and/or abusing substances and their families. The majority of families treated have been from disadvantaged inner‐city communities. Adolescents in MDFT trials have ranged from high‐risk early adolescents to multiproblem, juvenile justice‐involved, dually diagnosed female and male adolescents with substance use problems.

As a developmentally and ecologically oriented treatment, MDFT takes into account the interlocking environmental and individual systems in which clinically referred teenagers reside (Liddle 1999). The clinical outcomes achieved in the four completed controlled trials include adolescent and family change in functional areas that have been found to be causative in creating dysfunction, including drug use, peer deviance factors, and externalizing and internalizing variables. The cost of this treatment relative to contemporary estimates of similar outpatient treatment favors MDFT. The clinical trials have not included any treatment as usual or weak control conditions. They have all tested MDFT against other manualized, commonly used interventions. The approach is manualized (Liddle 2002), training materials and adherence scales have been developed, and have demonstrated that the treatment can be taught to clinic therapists with a high degree of fidelity to the model (Hogue et al. 1998).

Research basis

MDFT has been developed and refined over the past 17 years (Liddle and Hogue 2001). MDFT has been recognized as one of the most promising interventions for adolescent drug abuse in a new generation of comprehensive, multicomponent, theoretically‐derived and empirically‐supported treatments (c Center for Substance Abuse Treatment [CSAT] 1999c ; NIDA 1999a ; Waldron 1997). MDFT has demonstrated efficacy in four randomized clinical trials, including three treatment studies (one of which was a multisite trial) and one prevention study. Investigators have also conducted a series of treatment development and process studies illuminating core mechanisms of change.

Techniques and strategies

Targeted outcomes in MDFT include reducing the impact of negative factors as well as promoting protective processes in as many areas of the teen’s life as possible. Some of these risk and protective factors include improved overall family functioning and a healthy interdependence among family members, as well as a reduction in substance abuse, drastically reduced delinquency and involvement with antisocial peers, and improved school performance. Objectives for the adolescent include transformation of a drug using lifestyle into a developmentally normative lifestyle and improved functioning in several developmental domains, including positive peer relations, healthy identity formation, bonding to school and other prosocial institutions, and autonomy within the parent–adolescent relationship. For the parent(s), objectives include increasing parental commitment and preventing parental abdication, improved relationship and communication between parent and adolescent, and increased knowledge about parenting practices (e.g., limit‐setting, monitoring, appropriate autonomy granting).

Core components

MDFT is an outpatient family‐based drug abuse treatment for teenagers who abuse substances (Liddle 2002). From the perspective of MDFT, adolescent drug use is understood in terms of a network of influences (i.e., individual, family, peer, community). This multidimensional approach suggests that reductions in target symptoms and increases in prosocial target behaviors occur via multiple pathways, in differing contexts, and through different mechanisms. The therapeutic process is thought of as retracking the adolescent’s development in the multiple ecologies of his or her life. The therapy is organized according to stage of treatment, and it relies on success in one phase of the therapy before moving on to the next. Knowledge of normal development and developmental psychopathology guides the overall therapeutic strategy and specific interventions.

The MDFT treatment format includes individual and family sessions, sessions with various family members, and extrafamilial sessions. Sessions are held in the clinic, in the home, or with family members at the court, school, or other relevant community locations. Change for the adolescents and parents is intrapersonal and interpersonal, with neither more important than the other. The therapist helps to organize treatment by introducing several generic themes. These are different for the parents (e.g., feeling abused and without ways to influence their child) and adolescents (e.g., feeling disconnected and angry with their parents). The therapist uses these themes of parent–child conflict as assessment tools and as a way to identify workable content in the sessions.

The format of MDFT has been modified to suit the clinical needs of different clinical populations. A full course of MDFT ranges between 16 and 25 sessions over 4 to 6 months, depending on the target population and individual needs of the adolescent and family. Sessions may occur multiple times during the week in a variety of contexts including in‐home, in‐clinic, or by phone. The MDFT approach is organized according to five assessment and intervention modules, and the content and foci of sessions vary by the stage of treatment.

Theoretical basis

Multiple family therapy (MFT) is an eclectic variety of family therapy that is psychoeducational in nature, with roots in social network intervention, multiple impact therapy, and group meeting approaches. It is often used in residential settings and involves family members from groups of clients in treatment at the same time coming together (Kaufman and Kaufmann 1992b).

Techniques and strategies

In general, families are personally invited to attend the MFT meeting and are oriented before the first session. Family members who are currently abusing drugs or alcohol are excluded. Families sit together in a circle, with several therapists interspersed among the group. The session starts with self‐introductions. After the purpose of the meeting is described and the need for open communication is stressed, one family’s situation is discussed for about an hour. Three or four families are the subject for each session, although all the families participate in the discussion (Kaufman and Kaufmann 1992).

In early treatment, families “support each other by expressing the pain they have experienced” (Kaufman and Kaufmann 1992, p. 76). Later, the ways the family has contributed to and enabled the client’s substance abuse are identified. Homework is often assigned that gives family members new tasks, shifts their roles, and works to restructure the family. Techniques to improve communication that Kaufman finds useful are psychodrama, the “empty chair,” and family sculpture (Kaufman and Kaufmann 1992).

The MFT group can be used as a means to identify when a couple would benefit from couples therapy (Kaufmann and Kaufman 1992b ). To make use of group interactions in this way and to ensure that the counselor feels comfortable in the role of coleading this type of large group, the counselor should receive adequate supervision.

Theoretical basis

This model originated in the simple observation of high treatment dropout rates among adolescents in family therapy for their substance abuse. Programmatic features that seemed to lower dropout rates were identified and implemented to maximize accessibility of services and make treatment providers more accountable for outcomes (Henggeler et al. 1996).

Techniques and strategies

Multisystemic therapy has proven useful as a method for increasing engagement in treatment in a study in which adolescents randomly assigned to this treatment were compared to a group receiving treatment as usual (Henggeler et al. 1996). Features of this therapy that are designed to make it successful include the following:

• Multisystemic therapy is provided in the home.
• Low caseloads allow counselors to be available on an as‐needed basis around the clock.
• Family members are full collaborators with the therapist.
• It has a strengths‐based orientation in which the family determines the treatment goals.
• It is responsive to a wide range of barriers to achieving treatment goals.
• Services are designed to meet individual needs of clients, with the flexibility to change as needs change.
• The counselor and other members of the treatment team assume responsibility for engaging the client and using creative approaches to achieve treatment goals (Henggeler et al. 1996).

Multisystemic therapy has influenced the development of other therapies, including functional family therapy, a brief prevention and treatment intervention used with delinquent youth and those with substance abuse problems (Sexton and Alexander 2000).

Theoretical basis of behavioral family therapy

Behavioral family therapy (BFT) combines individual interventions within a family problemsolving framework (Falloon 1991). BFT helps each family member set individual goals since the approach assumes that

• Families of people abusing substances may have problemsolving skill deficits.
• The reactions of other family members influence behavior.
• Distorted beliefs lead to dysfunctional and distorted behaviors (Walitzer 1999).
• Therapy helps family members develop behaviors that support nonusing and nondrinking. Over time, these new behaviors become more and more rewarding, leading to abstinence.

Theoretical basis of cognitive–behavioral family therapy

This approach integrates traditional family systems therapy with principles and techniques of BFT. The cognitive–behavioral combination views substance abuse as a conditioned behavioral response, one which family cues and contingencies reinforce (Azrin et al. 1994). The approach is also based on a conviction that distorted and dysfunctional beliefs about oneself or others can lead people to substance abuse and interfere with recovery. Cognitive–behavioral therapy is useful in treating adolescents for substance abuse (Azrin et al. 1994; Waldron et al. 2000).

Techniques and strategies of behavioral family therapy

To facilitate behavioral change within a family to support abstinence from substance use, the counselor can use the following techniques:

• Contingency contracting. These agreements stipulate what each member will do in exchange for rewarding behavior from other family members. For example, a teenager may agree to call home regularly while attending a concert in exchange for her parents’ permission to attend it.
• Skills training. The counselor may start with general education about communication or conflict resolution skills, then move to skills practice during therapy, and end with the family’s agreement to use the skills at home.
• Cognitive restructuring. The counselor helps family members voice unrealistic or self‐limiting beliefs that contribute to substance abuse or other family problems. Family members are encouraged to see how such beliefs threaten ongoing recovery and family tranquility. Finally, the family is helped to replace these self‐defeating beliefs with those that facilitate recovery and individual and family strengths.

Techniques and strategies of cognitive–behavioral family therapy

In addition to the behavioral techniques mentioned above, one effective cognitive technique is to find and correct the client’s or the family’s distorted thoughts or beliefs. Distorted personal beliefs may be an idea such as “In order to fit in (or to cope), I have to use drugs.” Distorted messages from the family might be, “He uses drugs because he doesn’t care about us,” or, “He’s irresponsible. He’ll never change.” Such messages can be exposed as incorrect and more accurate statements substituted.

Below is an example of a technique used in behavioral family therapy to improve communication.

Theoretical basis

Family/larger system/case management therapy is for families who are or should be involved intensely with larger systems, which include the workplace, schools, health care, courts, foster care, child welfare, mental health, and religious organizations. The therapy also helps families interact with the larger systems in their lives.

For many families, dealing with larger systems is not a problem. Their dealings with the larger systems are routine and positive; when they have occasional difficulties they can navigate within larger systems. Other families, however, have recurrent problems and more frequent dealings with larger systems. Often, interaction with large systems is intense and extensive throughout the family’s life cycle, in many cases because of issues such as poverty, chronic illness, legal problems, and cultural and language barriers.

The goal of family/larger systems therapy is to empower the family in its dealings with larger systems. The empowerment begins when the counselor designates “the family as the major expert on the family” (Imber‐Black 1991, p. 601). Imber‐Black further suggests that counselors determine

• What larger systems affect the family?
• What agencies and agency subsystems regularly interact with family members?
• How is the family moved from one larger system to another?
• Is there a history of significant involvement with larger systems, and if so, regarding what issues? (Imber‐Black 1991)

For example, families with substance abuse problems interact more regularly with the judicial system, because of arrests (e.g., for driving under the influence, loss of parental rights, and domestic violence). This connection can have an adverse effect on the family. It may limit finances, time together, and unity; stress family relationships; and result in loss of child custody. It can also complicate the therapeutic process, especially if the family is ordered to come to treatment. However, even though a family may resist and feel coerced, the judicial system can be the stimulus that gets the family treated and reconnected with social services. Family/larger system/case management therapy can be used effectively by probation and parole officers and by drug court officials. (See TIP 27,a Comprehensive Case Management for Substance Abuse Treatment [CSAT 1998a].)

Techniques and strategies

In family/larger system/case management therapy the counselor assumes a role similar to that of a case manager. The counselor helps initiate contact with other systems, including agencies that can provide services to the client and his or her family members. The counselor can help the client navigate the maze of systems that he is involved with, including courts, law enforcement, social service agencies, and child welfare. To some extent, the counselor is a community liaison, who can provide information to clients about the resources in the community and advocate in the community for more funding and other support for substance abuse treatment.

Theoretical basis

Network therapy harnesses the potential of therapeutic support from people outside of the immediate family, especially when conducting effective substance abuse interventions. By gathering those who genuinely care about the individual with a substance use disorder––especially friends and extended family members––the counselor helps encourage the individual who uses drugs to stop using and remain abstinent. Galanter (1993) also points to the importance of AA in network therapy.

Network therapy also attempts to connect people to the larger community. Network therapy is compatible with traditional healing practices, alternative medicine, AA attendance, and participation in community events such as pueblo feast days and arts and crafts fairs. Network therapy is especially useful for reconnecting urban American Indians with the larger community.

Techniques and strategies

A counselor using network therapy is responsible for mobilizing the client’s network. The counselor keeps people in the network informed and involved and encourages the client to accept help from the network and to accept the rewards that the network can offer.

Theoretical basis

Bowen family systems therapists believe that all family dysfunctions, including substance abuse, come from ineffective management of the anxiety in a family system. More specifically, substance abuse is viewed as one way for both individuals and the family as a group to manage anxiety. The person who abuses alcohol or drugs does so in part to reduce anxiety temporarily, and when the entire family can justifiably focus on the individual who uses drugs as the problem, it can deflect attention from other sources of anxiety.

A major source of anxiety can be a family’s reactivity, or the intensity with which the family reacts emotionally to relationship issues instead of carefully thinking them through. Ideally, family members are able to strike a balance between emotional reactivity and reason and are aware of which is which. This is called differentiation. Further, family members are autonomous, that is, neither fused with nor detached from others in the family.

Bowen family systems therapy is also based on the premise that a change on the part of just one family member will affect the family system. To reduce the family’s reactivity, for example, counselors coach the most motivated family members in ways to curb their reactivity and behave differently in their relationships. Such changes can decrease or even eliminate the problem that brought the family into treatment.

In Bowenian therapy, it is assumed that the past influences the present. In fact, it is still “alive.” It is present in the form of emotional responses that can be passed down from one generation to another (Friedman 1991).

Techniques and strategies

The Bowenian approach to substance abuse often works through one person, and its scope is highly systemic. For instance, Bowen attempts to reduce anxiety throughout the family by encouraging people to become more differentiated, more autonomous, and less enmeshed in the family emotional system.

In Bowen’s view, specific and problematic anxiety and relationship patterns are handed down from generation to generation. Some intergenerational patterns that may require therapeutic focus are

• Creating distance. Alcohol and drugs are used to manage anxiety by creating distance in the family.
• Triangulation. An emotional pattern that can involve either three people or two people and an issue (such as the substance abuse). In the latter situation, the substance is used to displace anxiety that exists between the two people.
• Coping. Substance abuse is used to mute emotional responses to family members and to create a false sense of family equilibrium.

Theoretical basis

Solution‐focused brief therapy (SFBT) replaces the traditional expert‐directed approach aimed at correcting pathology with a collaborative, solution‐seeking relationship between the counselor and client. Rather than focusing on an extensive description of the problem, SFBT encourages client and therapist to focus instead on what life will be like when the problem is solved. The emphasis is on the development of a solution in the future, rather than on understanding the development of the problem in the past or its maintenance in the present. Exceptions to the problem—that is, times when the problem does not happen and a piece of the future solution is present—are elicited and built on. This counters the client’s view that the problem is always present at the same intensity and helps build a sense of hope about the future.

Rooted in the strategic therapy model, de Shazer and Berg, along with colleagues at the Brief Family Therapy Center in Milwaukee, shifted solution‐focused brief therapy away from its original focus, which was how problems are maintained (Watzlawick et al. 1974; Zeig 1985), to its current emphasis on how solutions develop (de Shazer 1988, 1991 1997). SFBT has been increasingly used to treat substance use disorders since the publication of Working with the Problem Drinker: A Solution‐Focused Approach (Berg and Miller 1992). Berg and Miller challenged the assumptions that problem drinkers want to keep drinking, are unaware of the damage drinking causes, and require an expert’s help and information if they are to recover. Quite the contrary, SFBT counselors insist, people who abuse substances can direct their own treatment, provided they participate in the process of developing goals for therapy that have meaning for them and that they believe will make significant change in their lives.

SFBT is consistent with research that stresses the importance of collaborative, nonconfrontational therapeutic relationships in substance abuse treatment (Miller et al. 1993) and treatment matching as a means of increasing motivation for change (Prochaska et al. 1992). In fact, even substance abuse counselors who firmly believe in the disease model also accept and use SFBT as one component of substance abuse treatment (Osborn 1997). Further, McCollum and Trepper (2001) have put forth a system‐based variation of the therapy specifically for use with families of people with substance use disorders.

As yet, however, little definitive research has confirmed the effectiveness of SFBT for substance abuse. Gingerich and Eisengart (2000) found and evaluated 15 studies on the outcome of SFBT in treating various problems. They concluded that “the 15 studies provide preliminary support for the efficacy of SFBT, but do not permit a definitive conclusion” (Gingerich and Eisengart 2000, p. 477), especially for substance abuse. Of the 15 studies, only two poorly controlled ones looked at the substance abuse population. One of them described a man with a 10‐year drinking history. He achieved more days abstinent and more days at work per week during treatment as compared to before treatment (Polk 1996). The other study involved a therapist who used SFBT with 27 clients in treatment for substance use disorders. A larger percentage of the SFBT clients recovered (by study definitions) after two sessions and after seven sessions than did the comparison clients, but no details were given about the severity of the cases or specific client outcomes (Lambert et al. 1998).

Techniques and strategies

In SFBT, the counselor helps the client develop a detailed, carefully articulated vision of what the world would be like if the presenting problem were solved. The counselor then helps the client take the necessary steps to realize that vision.

In addition, the counselor encourages clients to recall exceptions to problems, that is, times when the problem did not occur, and to examine and increase those exceptions. In this way, the client moves closer to the problem‐free vision.

The techniques of solution‐focused brief therapy are designed to be quite simple. They include the miracle question, exception questions, scaling questions, relational questions, and problem definition questions.

The miracle question. Perhaps the most representative of the SFBT techniques, the miracle question elicits clients’ vision of life without the problems that brought them to therapy. The miracle question traditionally takes this form:

• I want to ask you a strange question. Suppose that while you are sleeping tonight and the entire house is quiet, a miracle happens. The miracle is that the problem that brought you here is solved. Because you are sleeping, however, you don’t know that the miracle has happened. When you wake up tomorrow morning, what will be different that will tell you a miracle has happened, and the problem that brought you here has been solved? (De Jong and Berg 1997).

The miracle question serves several purposes. It helps the client imagine what life would be like if his problems were solved, gives hope of change, and previews the benefits of that change. Its most important feature, however, is its transfer of power to clients. It permits them to create their own vision of the change they want. It does not require them to accept a vision composed or suggested by an expert (Berg 1995).

Exception questions. Sometimes a continual problem is less severe or even absent. Hence, the substance abuse counselor might inquire, “Tell me about the times when you decided not to use, even though your cravings were strong.” The answer will set the stage for examining how the client’s own actions have helped lead to that different outcome.

Scaling questions. As a clear vision of change emerges, techniques begin to focus on helping the client make change happen. At this point, one especially useful technique is the scaling question. It might ask, On a scale of 1 to 10, where 1 means one of your goals is met and 10 means all your goals are completely met, where would you rate yourself today? A good follow‐up question is, What would it take for you to move from a 4 to a 5 on our 10‐point scale? Such questions help clients gauge their own progress toward their goals and see change as a process rather than an event.

Relational questions. Helping clients set goals that take the views of important others into account can extend the benefits of change into the client’s environment. A good relational question is, What will other people notice about you as you move closer and closer to your goal? For instance, an adolescent client might declare that he is completely confident that he will not relapse. In reply, he might be asked, “Do you think your father is that confident?” Being urged to look at his situation from the perspective of the parent, who might only be somewhat confident that the client will not relapse, motivates the client to think about how he must behave to instill more confidence in this important other figure.

Problem definition questions. This technique, used with the families of people with substance use disorders, defines the steps that each person takes to produce an outcome that is not a problem (McCollum and Trepper 2001). The therapist helps the family define a problem it would like to solve, and then constructs the part each member plays in the sequence of behaviors leading up to that problem. Next, the therapist helps the family examine exceptions to the problem sequence and uses the exceptions to construct a solution sequence.