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Substance Use Disorder Treatment and Family Therapy: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 39.)
Consider the family from the client's point of view—that is, whom the client would describe as a family member or a significant other.
Many families or family members may be hesitant to participate in treatment at first. However, some family members are willing to attend at least an initial session.
Integrating family-based counseling techniques into substance use disorder (SUD) treatment is possible along a continuum of care, from assessment through the various stages of family counseling.
Chapter 4 discusses common issues you may face as an SUD treatment provider using an integrated family counseling approach. It also presents family-centered counseling strategies you can use to overcome these challenges. This chapter will help you determine when to use family-based interventions across the continuum of care, whom to involve in those interventions, and what to consider when providing screening and assessment in a family context. It also summarizes the goals of family involvement in a client's SUD treatment and identifies your role in providing integrated family counseling, along with the stages of family counseling.
Family involvement can positively affect SUD treatment engagement and retention. Whether you provide individual or group treatment, family member psychoeducation, or counseling for couples or families as part of your organization's treatment program, it is important to keep a family-centered focus. Because most SUD treatment services and reimbursement are geared toward individuals who initially present for treatment, the first step in providing integrated family counseling for SUD treatment is to ask the individual client whom he or she considers to be family. Who are the significant people in the client's life who can support the client's recovery and also benefit from family-based interventions?
The size, norms, and values of a person's social network and the quality of social and family support affect the recovery of the individual with an SUD. Positive social/family support (especially support for recovery) is related to long-term abstinence and recovery, and negative social/family support (e.g., interpersonal conflict, social pressure to use) is related to increased risk for returning to substance misuse (Brown, Tracy, Jun, Park, & Min, 2015; Cavaiola, Fulmer, & Stout, 2015; Moos & Moos, 2007; Worley et al., 2014). These associations occur in diverse populations with people who use various substances. Social support, bonding with family members, goal direction, and monitoring by families help clients’ recovery efforts (Moos, 2011; Moos & Moos, 2007).
Engaging family members in treatment is the key to decreasing interpersonal conflict among family members and increasing family bonding and other elements of recovery support for the client.
It is your responsibility to provide a safe, supportive environment for all participants in family counseling. Generally, you can use integrated family counseling to treat SUDs when there are no health or legal constraints and no current risk of intimate partner violence in the family or couple with whom you are working. However, engaging clients and their families in family-based interventions without first carefully assessing for such constraints, and particularly for violence in the family, can result in less effective treatment and increased risk of physical or other forms of abuse.
Only in rare situations are family-based interventions and counseling inadvisable, inappropriate, or counterproductive. Integrated family counseling is often an excellent way to approach the treatment of SUDs, but you may sometimes need to rule it out because of safety, health, or legal constraints. Several factors, including the presence of violence in the family, can influence your decisions about involving family members in treatment. The following sections discuss these factors.
Domestic violence is a serious issue among people with SUDs. Before considering couples or family counseling, evaluate the client's history of violence, particularly in family contexts. Ask about current violence and criminal justice involvement and adjust your counseling approach accordingly. For example, if a restraining or protection from abuse order prohibits spouses from seeing each other, make sure that the spouse who has been violent does not have direct contact in your treatment program with the protected partner. To the extent possible, arrange for separate treatment for the client who is violent, such as in a Batterer's Intervention Program, and individual counseling focused on safety planning for the partner who has been a victim of violence.
Experts in the field of domestic violence generally do not recommend joint counseling for couples in which intimate partner violence has occurred (National Domestic Violence Hotline, 2014) because:
It is not effective.
It is unsound practice if based on the assumption that both people are responsible for the violence.
It is unsound practice if sessions focus on improving communication instead of the abusive behavior.
It can be dangerous; the nonabusing partner may be punished after being honest during sessions.
Violence is often a behavioral expression of anger, but anger does not always result in violence. Family members can learn how to express anger appropriately and safely via structured family counseling. Extreme anger or threats of violence, however, rule out family counseling.
When screening and treating families in which violence occurs, do not practice outside the scope of your training. Consult your clinical supervisor to determine the appropriate course of action if you believe that any family member is in danger of domestic violence.
Child abuse and neglect are serious considerations in the delivery of SUD treatment. Children in violent households have more physical, mental, and emotional problems than do those in nonviolent homes. Substance misuse and child maltreatment must be addressed at the same time to ensure children's safety—but do not include children in family sessions if there is current risk of child abuse by family members.
Once you have addressed safety issues, you may still be able to engage parents in couples counseling that focuses on parenting issues. Refer all family members for appropriate counseling, including children. If you suspect a parental figure in the family is abusing a child, consult your supervisor immediately and follow agency policy and mandated reporting laws in your state to report the abuse.
COUNSELOR NOTE: INTERVENING WITH A DOMINEERING FAMILY MEMBER.
Given the intensity of physical and emotional instability people in withdrawal experience, it is not practical to attempt integrated family counseling during this process. Until the person stabilizes after withdrawal, provide the family with psychoeducation about SUDs and the effects of substance misuse on the family system. Continue to assess the physical and emotional stability of the client with the SUD over time; protracted withdrawal symptoms can affect the ability to participate in family counseling.
In addition, a parent in withdrawal may experience intense feelings, which can increase the risk of child maltreatment. During this time, provide additional support to the family and make sure that children know how to find safe adults to help and protect them when needed.
Clients with SUDs often have co-occurring mental disorders. Family counseling is generally appropriate for clients with SUDs and mental disorders—and in fact, some family-based interventions are particularly effective for specific co-occurring mental disorders, including severe adult anxiety disorders (Gehart, 2018). A review of the evidence found that any kind of brief psychoeducation, including family-based interventions, reduces relapse, increases medication adherence, and improves social functioning of people with serious mental illness (SMI; Zhao, Sampson, Xia, & Jayaram, 2015).
“SMI is a diagnosable mental, behavioral, or emotional disorder that an adult has experienced in the past year that causes … serious functional impairment that substantially interferes with or limits at least one major life activity. Examples include schizophrenia, bipolar disorder, and major depression.” (www.samhsa.gov/dbhis-collections/smi)
Family counseling may not be helpful for clients who are actively suicidal or psychotic. Families of clients in these states may have other goals they would like to address in family counseling. However, your primary goal in cases of active suicidality or psychosis is to provide treatment to stabilize clients. Family-based interventions with clients who have co-occurring disorders should focus on education about the mental disorder, the effects of SUDs and co-occurring mental disorders on families, and development of coping skills to manage those effects. For example, address medication nonadherence as a risk behavior, like substance misuse, and help the family engage in positive reinforcement strategies. (See Chapter 3 for more information about positive reinforcement strategies).
Cognitive impairment can include short- and long-term memory problems as well as difficulties in learning, concentration, and decision making (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011). It may be linked to extensive substance misuse or head trauma and may cause disruptive behavior.
Family counseling is not as effective with clients who have significant cognitive impairment. However, you can still consider integrated family counseling and family-based SUD interventions for clients with such impairments. Family counseling can be helpful if the client is not overly disruptive, is also involved in individual counseling or other rehabilitation treatment, and is stabilized on appropriate medications as needed. Your goals in this situation are to help all family members understand how to cope with behavioral disruptions and support the client to remain abstinent from alcohol and drugs.
Another factor that can complicate any counseling process is external coercion. One or more family members, particularly those with SUDs, can be mandated to treatment by the criminal justice system, Child Protective Services, or an employer. In these circumstances, the person who has been mandated is likely to be angry and to try to get you, as well as family members, to focus on how unfair the situation is.
Your first priority should be to form an alliance with the mandated client without “taking sides” with the client regarding the need for treatment. Motivational interviewing (MI) strategies can help you build a therapeutic alliance and help the client and family members resolve their ambivalence about participating in family counseling (Lloyd-Hazlett, Honderich, & Heyward, 2016).
MI is an evidence-based counseling approach that has demonstrated effectiveness with clients who are mandated to treatment and has been used as an intervention to help enhance client motivation to participate in formal treatment (Miller & Rollnick, 2013). Although MI is used primarily in individual and group counseling, you can adapt MI principles and counseling strategies in family sessions with a focus on changing substance use that negatively affects family functioning (Lloyd-Hazlett et al., 2016). See TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019a; https://store.samhsa.gov/product/TIP-35-Enhancing-Motivation-for-Change-in-Substance-Use-Disorder-Treatment/PEP19-02-01-003) for more information about MI.
Address the issue of communicating with the referring organization. Clarify that your primary concern is the family's well-being, and share with them any requirements you must follow regarding release of information or progress to the referring organization. Inform all family members about agency policies, their rights and responsibilities as clients, and your legal/ethical responsibilities as a counselor. Have family members sign all pertinent releases as part of this informed consent process.
COUNSELOR NOTE: THINK OUTSIDE THE BOX.
From individual to multiple family counseling formats, family-based interventions can include a combination of family members (e.g., couples or siblings), the entire family, an individual family member, or several family groups at one time. In family counseling, the units of treatment are the family and the individual within the context of the family system.
It is up to clients to identify whom they would like to include in family counseling. Make your best efforts to include anyone the client thinks is significant—anyone who provides emotional or financial support, maintains the household, or has a strong, enduring social or emotional bond with the client. The term “family” can mean people living in the client's household, immediate family members (e.g., a parent, spouse, intimate partner, siblings, children), and extended family members (e.g., grandparents). Some clients want no family involved in treatment or may include or exclude some family members.
Explore the client's ambivalence and reasons for excluding family members. You can offer your ideas about why you think it might be important or helpful to include specific family members, but honor the client's autonomy and right to give or not give permission to include family members in treatment.
Once the client gives permission, there are several factors you should consider in determining whether and how to involve family members in family sessions. These considerations include:
Geographic constraints: Some clients have no significant family members close enough to attend family sessions in person. Using secure teleconferencing and videoconferencing technology is one strategy for including family members in important conversations with the client. Another strategy might be to hold longer family sessions (e.g., 2 hours) or multiple sessions over consecutive days with family members who are able to travel and attend family counseling.
Work and scheduling conflicts: Work or other scheduling conflicts of family members can be obstacles to their attendance at family sessions. Sometimes these are legitimate concerns and sometimes they are expressions of ambivalence about participating in family counseling. Strategies for overcoming these obstacles include providing multiple session times outside of normal work hours and exploring family members’ reluctance to participate in family counseling via an individual session or phone consultation.
Disruptive behavior: You may need to exclude from family sessions a family member who is continually angry, blaming, or disruptive. Address this issue with the family and the individual separately, explore options for addressing that family member's needs (e.g., individual counseling, referral to other support services), and then reinvolve the individual in family sessions when his or her needs have been addressed.
Family subsystems: One helpful strategy for managing the family counseling process is to do individual or subsystem work with different constellations of family members, when needed. For example, if parents have overly rigid or loose boundaries, help them reestablish appropriate boundaries and authority in the parental subsystem before including children in family sessions. Do not include children in family sessions if the focus of the work is solely the couple's relationship.
Refusal to attend counseling: Strategies to include relatives who refuse to attend sessions include:
Arranging an empty chair in the room to represent that family member and addressing the absent family member metaphorically.
Calling the family member who is not present during the family session to enlist his or her help in answering a question that has come up in the session.
Decisions about which and how family members participate in family counseling depend on the client's wishes, family members’ willingness, and your judgment of what is most helpful for the entire family.
Assessment is one of the most important components of any SUD treatment program.
Individual assessment should be family focused. Gathering information about the client's family:
Yields a more thorough, and perhaps more accurate, family history.
Presents an opportunity to confirm and clarify information on the client.
Provides insight into the context where substance misuse most often occurs and where it may have started or accelerated.
Sets the tone for a continuing focus on the family.
Identifies family resources to help plan long-term care.
Documents specific information that can determine treatment goals.
Conduct a comprehensive psychosocial assessment with the individual who is identified as the primary client with the SUD as part of your standard assessment procedures. Assessments in SUD treatment programs focus on the individual's current and history of substance use. Other information gathered during an individual assessment that is helpful to understanding current family functioning includes the client's:
History of mental disorders.
History of family-of-origin SUDs or mental disorders.
History of domestic violence.
History of trauma.
History of physical, emotional, verbal, or sexual abuse.
History of criminal justice involvement, including arrests for driving under the influence and periods of incarceration.
Occupational and work history, including periods of unemployment or underemployment.
Sexual and reproductive health history, including HIV status, safe sex practices, sexual or gender identity, and sexual practices.
During individual assessment, emphasize the importance of including family members in treatment, encourage discussion about who might be involved in family treatment, and explore the current family situation from the client's perspective. Including family members at the start of SUD treatment gives you an opportunity to provide education about the biological and psychosocial aspects of SUDs. It also helps uncover client and family strengths and begins the process of preparing family members for changes to the family system that will happen as the client initiates recovery (van Wormer & Davis, 2018).
Here are some questions that can start the conversation:
Who can support you while you are in treatment?
Who in the past has been the most helpful to you?
Who is taking care of your children while you are in treatment?
Does anyone in your family use substances?
Is anyone in your family recovering from a substance use disorder?
How would your family react to your recovery from the substance use disorder?
What does your family think about your being here? Did you tell them? Why or why not?
How is substance use an important part of your family life?
Who in your family or support system would you like to be involved in your treatment?
Is it okay if we talk about the ways that your family can be involved in treatment?
This conversation sets the stage for the initial family interview. If the client agrees to family involvement in treatment, get signed privacy/confidentiality releases and then schedule an initial family interview.
Before determining whether to use family-based interventions, you should conduct a family interview. The family interview is part of the assessment process. Although family members may feel ambivalent about getting involved in treatment, they are often willing to attend at least an initial interview.
The primary focus is to engage the family and begin to develop an alliance with each family member. You can also use the initial interview to determine how the family functions, identify major family problems, and identify the family's perception of how the SUD has affected their family and each member (Schumm & O'Farrell, 2013b). You should also make a preliminary determination of any current or history of family violence and physical or sexual abuse because safety is paramount.
Other tasks for the family interview include:
Determining the need for further screenings and assessments of SUDs and mental disorders for individual family members.
Determining whether an immediate intervention or referral is needed or whether the family can return for a more thorough assessment later.
Telling the family what will be involved in a more extensive assessment.
Evaluating the appropriateness of including children in family sessions and when it would be most effective to include them.
Providing information about the treatment process including schedules, treatment activities, staff involvement, and program expectations.
Suggesting an out-of-session assignment for each relative present (if he or she agrees to further counseling) as a way for them to take a small step toward change (van Wormer & Davis, 2018).
Scheduling an initial family counseling session for a more comprehensive family-based assessment.
A family-based assessment differs from an individual assessment. The focus of a family assessment is not the history of substance misuse of the identified client, but an evaluation of current family functioning, the history of substance misuse over time and across generations, and the role of substance misuse in the development of family problems (Schumm & O'Farrell, 2013b). You can also explore the history of the individual's SUD over time, but always link this history to the development of family system dynamics and functioning over time (Schumm & O'Farrell, 2013b). Family counseling assessments focus on family interactions and family strengths.
The primary assessment task is to observe family interactions during sessions to determine alliances, conflicts, interpersonal boundaries, and communication and meaning. In a family systems approach to assessment, the counselor identifies the interactional behavior sequences that contribute to the problem (i.e., substance misuse), including the actions and reactions of everyone in the system and the associated meanings (Gehart, 2018; see the “Family Behavior Loop Mapping” section of Chapter 3).
Ask each family member to describe his or her theory about the client's substance use behavior.
Their input will help you understand how the family system is organized around and reacts to the behavior (Gehart, 2018). The next task is to explore the family's strengths and positive ways they have managed the disruptions to family life caused by substance misuse. Exhibit 4.1 offers an alternative approach.
Exhibit 4.1. A Narrative Approach to Family Assessment.
Conduct a strengths assessment with the client and all family members involved in treatment. The goal of this assessment is to identify their current coping skills and abilities; family, social, and recovery supports; motivation and commitments to change; self-efficacy; and other sources of recovery capital. This will give you a baseline of family coping skills and client-centered knowledge, values, and resources to build on in helping the family develop a treatment and recovery plan. Recognizing different strengths available to clients is an important element of conducting an effective strengths assessment.
The term “recovery capital” refers to the internal and external resources that a person draws on to begin and sustain recovery. Internal resources include client values, knowledge, skills, self-efficacy, and hope. External resources include employment; safe housing; financial resources; access to health care; as well as social, family, spiritual, cultural, and community supports (White & Cloud, 2008).
A strengths-based assessment is more than simply asking clients to name their strengths at initial intake (White & Cloud, 2008). Some clients will have difficulty identifying their strengths or say that they don't have any. As part of the family history, conduct a careful and thorough exploration of family members’ internal and external resources, how they have overcome adversity in the past, and how they have previously managed problems like SUDs, physical illness, or mental illness.
Uncovering exceptions or unique outcomes when SUDs and mental disorders have overwhelmed family functioning is key to helping the family expand awareness of their values, strengths, competencies, and abilities. View strengths broadly to include family members’ values, interpersonal skills, talents, and knowledge gained from previous efforts to overcome SUDs or adversity (including trauma). Also consider the family members’:
Spirituality and faith.
Personal hopes, dreams, and goals.
Family, friend, and community connections.
Cultural and family narratives of resilience.
Ability to heal.
General skills in daily living.
There are four broad categories of strengths to explore in this assessment (Rapp & Goscha, 2012):
Personal attributes are personal qualities associated with identity, such as honesty, assertiveness, warmth, compassion, and caring.
Talents and skills are abilities and competencies a person has developed, such as being good
at managing money, fixing cars, or using a computer.
Environmental strengths are external resources that can help a person achieve his or her recovery goals. External resources can include
a safe living environment, supportive family and friends, affiliation with a spiritual or faith-based community, and participation in recovery support groups.
Interests and aspirations are activities that enrich a person's life (e.g., hiking, dancing, traveling), along with goals and dreams that motivate forward movement in life (e.g., wanting to get a high school equivalency degree, learn to play the guitar, or get a job helping others).
In addition to doing an initial strengths assessment, maintain a strengths-focused lens throughout counseling to set a positive tone for family sessions and enhance family members’ motivation to address challenging problems (Tuerk, McCart, & Henggeler, 2012).
Initially conceptualized by Murray Bowen (1978) as part of an intergenerational family model, a genogram is a comprehensive pictorial map of a family's health, communication, relationship, vocational, and other psychosocial patterns within and across three or more generations of the family. It provides information about marriages, divorces, births, geographical locations, deaths, and illness over the generations. It also depicts family patterns, events, and relationships, including emotional closeness, enmeshment, conflict, and emotional cutoffs (Platt & Skowron, 2013). Genograms are useful to discuss in psychoeducational sessions, family interviews, and assessments (Platt & Skowron, 2013). The genogram is both an assessment instrument and a counseling intervention (Gehart, 2018). As an assessment tool, it can help identify intergenerational dynamics. As an intervention, it can help family members see how they are living out dysfunctional family patterns, roles, and rules (Gehart, 2018).
A genogram can also help family members see their current problems from a wider perspective and identify strengths and resources. You can also use a genogram as a project the family works on together to enhance communication and bonding. A genogram can help you identify intergenerational relationship patterns and generate hypotheses about counseling interventions (Shellenberger, 2007).
The genogram is flexible. Tailor it to the needs and current challenges of the family. Some of the themes you can highlight in a genogram include:
Substance misuse across generations.
Mental illness and trauma across generations.
Individual and family strengths across generations.
The roles of culture and spirituality across generations.
The impact of substance misuse, mental illness, trauma, and family strengths on relationship patterns (e.g., enmeshment, conflict, emotional cutoffs, or emotional support and closeness).
Strategies for creating a genogram with a family include the following:
Beginning the process at the initial family interview. Ask family members about their understanding of SUDs and how their family member's substance misuse has affected family relationships. Then trace the history of the problem and family dynamics to prior generations. Also ask about important events like births, graduations, marriages, and deaths and how those events may be linked to the current substance misuse (Shellenberger, 2007).
Asking about family members with SUDs who are or were in recovery and any information family members have about their recovery efforts.
Filling in as much genogram information as possible about current and extended family members. Start with the identified client and his or her current spouse or intimate partner. Work up to include parents, stepparents, and siblings. Then work down to the children.
Spending time gathering information about the child's relationships with parents and siblings— if the identified client is one of the children (e.g., a teenage son)—before moving on to extended family.
Giving family members between-session assignments to gather more family history to bring back to the next family session. This can help family members gain further insight into how intergenerational family dynamics affect current family functioning.
Asking young children to draw themselves and other relatives, including extended family (e.g., aunt, uncle, grandparent) during the session or at home and to bring the drawing to a family meeting.
Continually adding to the genogram for a fuller, richer understanding of family history, relationship dynamics, and the role of substance misuse and recovery efforts in family life across generations.
Genograms are not intended for an initial assessment only. Work on the genogram at different points in the treatment process to see how counseling may have affected family relationships. For example, a couple's relationship might be represented as conflicted initially, but after some couples work, the genogram might include the symbol for a closer, less conflicted relationship. Genogram are a tool to assess family progress throughout treatment. Exhibit 4.2 shows common symbols used in genograms.
Exhibit 4.2. Genogram Symbols.
The genogram in Exhibit 4.3 shows five generations in American playwright Eugene O'Neill's family, depicted by Monica McGoldrick (1995). The key to symbols depicts a slightly different version of how to identify family members with SUDs, mental disorders, physical illnesses, emotional closeness, conflict, and cutoffs than shown in the key in Exhibit 4.2. It is a good example of how a genogram can uncover a family history of substance misuse. The Counselor Note on how to have meaningful conversations about genograms also gives important guidance on what clients and their families need to know about this helpful tool, including how it relates to SUD treatment and recovery. For more information about the heritability of addictions and the role of genetics and family history in SUD treatment and recovery, also see Chapter 2 (pp. 24-25).
Exhibit 4.3. O'Neill Genogram.
COUNSELOR NOTE: TALKING TO CLIENTS ABOUT GENOGRAMS IN A MEANINGFUL WAY.
In person-centered SUD treatment, the clients’ desire, ability, reasons, and need to change drive counseling goals. The same is true for integrated family counseling to address SUDs. Yet each family member may have different ideas about what he or she can gain from participating in family counseling. For example, parents may want their son to stop drinking with friends. The son may participate in family sessions to get his parents to stop fighting. The goal of each family member may differ, but the overarching goal is to engage the family in changing communication patterns that support the son's substance use.
Your overall focus in family counseling is on the roles, relationships, and communication patterns of the family system (van Wormer & Davis, 2018). Be aware of the core objectives of family-based interventions as you work with family systems to identify their specific treatment goals.
There are several core objectives of family-based interventions in SUD treatment:
Leverage the family to influence change— Encourage family members to support and enhance each other's desire, abilities, reasons, and need to make important lifestyle changes, including shifts away from substance misuse. Your goal is to help families develop effective coping and communication skills that promote recovery and prevent returns to substance use.
Involve families in SUD treatment—Get family members involved in treatment in some way. This might include family members attending a family psychoeducational activity or participating in a structured family-based counseling intervention, as described in Chapter 3. Your goal is to help families recognize their strengths, address family dynamics, and build effective relationship skills.
Change family behaviors that support substance misuse—Help the family recognize behavioral, cognitive, and emotional responses that
unintentionally support the client's continued substance misuse. Address negative effects of substance misuse on family systems to improve functioning.
Prevent SUDs across generations—Help families recognize the intergenerational transmission of family patterns that promote substance misuse. Your goal is to help families prevent SUDs in current and future generations by encouraging parenting practices that help prevent SUDs in children, improve SUD treatment outcomes in adolescents, and enhance the family recovery process.
The following sections describe ways to meet these objectives by focusing on certain goals in your provision of integrated family counseling for SUDs.
Your role in family-based interventions depends, to some extent, on your level of training, education, licensing, and scope of practice. For example, if you are leading a family psychoeducation group, your primary role is as a guide or educator. In couples counseling, your role is to facilitate the couple's interactions. Whatever family-based intervention you provide, your role also includes:
Approaching the family on their own terms.
Working together with the family.
Facilitating communication among all family members.
Facilitating family member interactions (avoid being an arbiter of right and wrong).
Educating family members about how families work.
Educating family members about the effects of substance misuse on the family.
Educating family members about the recovery process.
Facilitating the development of a relapse prevention plan.
Actively linking family members to community-based recovery support and other services.
The key to successful family work is to maintain a focus on engagement and collaboration with the family throughout treatment.
After the family interview and assessment process, initial family counseling sessions should focus on building a relationship with the entire family. The identified client should always be part of family sessions. The only times to exclude someone are if he or she is intoxicated or under the influence of drugs (“high”), has severe psychiatric symptoms (e.g., hallucinations, delusions, severe mania), has threatened violence, or a combination of these.
To engage family members’ support for a client with SUD as he or she initiates and sustains recovery, you can:
Welcome and thank family members for coming.
Use reflective listening to understand family members’ frustrations and concerns.
Use externalizing language (e.g., “the drinking,” not “her drinking”) to help the client and family members disengage substance use from negative identity conclusions. Making the SUD an external focus of attention allows everyone to work as a team to defeat it.
Explore how family members have been helpful in the past.
Explain ways that family members can support the client's recovery.
Ask the client whether he or she is willing to have family members help in this way.
Ask whether family members have any questions.
Ask whether the client has any questions about family members’ participation.
Summarize the important points of the session and recovery commitments anyone has made.
Actively link family members to community-based family recovery supports (e.g., Al-Anon) and additional behavioral health or social services, when appropriate.
Assess the willingness of family members to participate in ongoing family counseling if appropriate.
Initial sessions should focus on:
Working together with the family.
Orienting them to the family counseling process.
Continuing the assessment of how substance misuse has affected each family member.
Reframing substance misuse from a character flaw to a biochemical and behavioral problem they can work together to remove from their lives.
Continuing the assessment of family strengths and strategies they have already used to lessen the impact of substance misuse on the family.
Exploring family hopes for the future and each family member's ideas on how counseling can help.
Key opening strategies include building relationships and giving each family member time to share his or her frustrations and hopes for the future. Avoid jumping too quickly into goal consensus.
The process of recovery from SUDs is complex and multifaceted. A useful framework for understanding this process involves the stages of change (SOC) model, a transtheoretical approach to behavior change, originally developed by Prochaska and DiClemente (1984). The SOC model was developed for use with individuals, but it can be a helpful approach to assessing family members’ readiness to discuss a problem that they often view as something so shameful they can't talk about it. The SOC approach can help you guide families through the process of change.
The five stages of change and the counseling focus for each stage adapted for family work (DiClemente, 2018; van Wormer & Davis, 2018) are:
Precontemplation: Client or family doesn't perceive a problem or need for behavior change. Counseling focus: Engage the family. Establish a working alliance with each family member. Help family members identify their core values, hopes, and dreams and how substance misuse or other disruptive behaviors are blocking them from achieving their goals. Remember, each family member might be in a different stage of change around specific behavioral change goals.
Contemplation: Client or family is ambivalent about behavior change and begins to identify reasons for change. Counseling focus: Elicit from each family member his or her own reasons for wanting or needing to change certain behaviors, including substance misuse, to help the family reach their goals. Reinforce family members’ strengths and their capacity to take action toward desired solutions to family problems.
Preparation: Client or family is motivated to change behavior and starts taking steps toward change. Counseling focus: Help family members clarify their own goals and strategies for change, offer some options and advice, if asked for, and encourage them to engage in recovery and social support resources outside of family counseling.
Action: Client or family is actively engaged in behavior change. Counseling focus: Help the family develop a change plan that includes tasks for each family member. Invite one family member to write out the plan. Then make a copy for each family member. At the next family session, review the plan and how each family member did with achieving change goals. Tweak the plan if needed and continue to evaluate the plan's effectiveness.
Maintenance: Client or family has changed behavior and is actively engaged in sustaining change. Counseling focus: Help the family anticipate potential stressors that could destabilize family functioning again. As behavioral changes are made, substance misuse decreases or the client becomes abstinent, and family function shifts to supporting the family to maintain those behavioral changes outside of treatment.
Apply the SOC approach to a behavior each family member can change to support recovery and enhance family functioning. For example, when one partner's drinking is interfering with a couple's relationship, the drinking partner needs to change the drinking behavior. At the same time, the nondrinking partner may need to change his or her negative communication pattern of blaming and judging the drinking partner and shift to a positive communication pattern that reinforces nondrinking behavior. Please note that each family member may be at a different stage of change or level of motivation regarding the behavior change that he or she needs to make to improve family functioning.
Educating families about the SOC framework can help them identify where they each are in the stages and support each other to move toward positive change. The SOC approach provides an overarching model for behavior change from an SUD treatment perspective. See TIP 35, Enhancing Motivation for Change in Substance Use Disorder Treatment (SAMHSA, 2019a; https://store.samhsa.gov/product/TIP-35-Enhancing-Motivation-for-Change-in-Substance-Use-Disorder-Treatment/PEP19-02-01-003), for more information about the SOC model.
COUNSELOR NOTE: THE ROLE OF FAMILY IN RELAPSE PREVENTION.
Another useful framework for understanding the stages of change that the family system undergoes in family counseling comes from Virginia Satir (Satir, Banmen, Gerber, & Gomori, 1991). These six stages (Gehart, 2018) are:
Status quo: This is a state of family homeostasis in which at least one family member has symptoms of a mental disorder or SUD; the family organizes interactions and functioning around the symptom.
Foreign element: A foreign element moves the system off balance. The foreign element could be a life crisis like substance misuse or a counseling intervention like offering the family a new perspective on or information about substance misuse.
Chaos: The counseling intervention throws the family system into a temporary state of chaos. The family most often experiences discomfort and tries to get back to the stage 1 status quo.
Integration: Eventually, the family system interprets the new information in a meaningful way, which opens up new possibilities for change.
Practice: The family system develops new ways to interact/communicate based on new information.
New status quo: This is a new state of homeostasis that supports all family members to grow and contribute to enhanced family functioning.
Families often undergo the stages several times until the system gets used to change (Gehart, 2018). This framework is based on the idea that the family system is resilient and will find its way to a new and healthier level of functioning. Your task is to be respectful of how the family uses and responds to your introduction of a “foreign element” and honor the family system's autonomy (Gehart, 2018).
You will encounter challenges, myths, and obstacles that hinder engagement and treatment of families dealing with SUDs. Some challenges are related to attitudes and myths about offering family counseling in SUD treatment settings. Others may be related to integrating family work into SUD treatment settings. Still others are related to family issues such as low motivation to change and power dynamics within the family. The next sections describe some challenges and strategies to overcome them.
SUD treatment has historically been viewed through the lens of an individual approach. Integrated family-based interventions should be as much of a priority in your treatment program as any other treatment activity. When family counseling is viewed as an adjunct to individual or group counseling, it sends the message to clients and family members that family counseling is simply not that important. Evaluate your attitudes about family involvement in treatment and be a champion for integrating family-based interventions as an important and primary part of SUD treatment.
The SUD treatment field has promoted the myth that family counseling that includes the client with SUD may bring up painful feelings for the client that will somehow lead to a return to use or jeopardize the client's recovery. Although family counseling may temporarily shake up the family system and activate intense feelings, these feelings are a normal part of any counseling experience. Your task is to help the client and family members discover new ways of coping with intense emotions instead of reverting to old behaviors like substance misuse or blaming and shaming the family member with the SUD.
It is challenging to provide family-oriented case management or referral and coordination of services while doing family counseling. You are working with a family system made up potentially of many family members, who may each require other treatment or social services. This requires an appreciation for each family member's needs and a concerted effort to coordinate other agencies’ services to satisfy multiple needs. Actively link individual family members to case management services or peer providers who can work collaboratively with you to coordinate the multiple service needs of the family.
Secretiveness is often a hallmark of family behavior where there is an SUD. When family members become involved in counseling, they may want to tell you secrets outside a family session. Different family counseling models approach this differently. However, in the context of SUD treatment, it is important to avoid being the holder of family secrets. Holding a secret puts you in an ethically untenable position and will interfere with the family counseling process. Let everyone know during the initial family interview that you will bring up information a family member brings to you outside of family sessions, and you will do so during the next family session. The only exception to this boundary is if a family member tells you privately of violence or abusive behavior that needs to be addressed separately.
Historically, the term “denial” has described clients or family members who do not see substance misuse as a problem. This label is judgmental, so avoid using it and let family members know that using labels to confront each other leads to conflict or an emotional cutoff. As with name calling, using labels like “denial” is often an attempt to establish power in a relationship, which is damaging to that relationship. Set boundaries in early family sessions by establishing some rules for interactions, including no “labels” or name calling. You can also reframe “denial” as precontemplation, one of the stages of the SOC model and simply an indication that the family member is ambivalent and not quite ready to change.
Just as the family system organizes itself around the client's substance misuse to maintain a level of homeostasis, you can expect family members to act differently (and not always positively) when the client with the SUD enters recovery. For example, family members may express resentment and anger more directly to the recovering person because of the disruption of the family's homeostasis. Children and adolescents may engage in more externalizing behaviors like aggression, violence, lying, or stealing. An adolescent or intimate partner who has taken on major responsibilities for family functioning given up by the adult client with the SUD may resent and unintendedly sabotage the client's efforts to resume a position of responsibility and authority in the family system. Or the family may experience a period of relative harmony that is disrupted if other family issues begin to surface. Your task is to help family members adjust to these changes in lifestyle, find ways to support the client's recovery, learn new relationship and coping skills, and find healthier levels of functioning and family homeostasis.
Clients with co-occurring mental disorders or those who are prescribed medications for alcohol use disorder or opioid use disorder often are uncertain about adhering to medication routines. Some of the reasons clients stop taking medications include cost, negative side effects, the belief that they are not in recovery because they are substituting one drug for another, or systemic barriers (e.g., having to go to a clinic every day to receive a methadone dose). When clients stop taking medications, symptoms of mental disorders or old substance use behaviors reemerge, and families return to previous patterns of dysfunction. The issue of medication adherence is a common theme in the families you serve. Your task is to raise this issue, when applicable, in family sessions.
Before jumping to educating family members about medications and how important medication adherence is for individual and family stability, explore both the client's and the family's perspective about medication and its role in family functioning. As you explore multiple perspectives, use some motivational counseling tools like elicit-provide-elicit; that is, eliciting what family members already know about medication, asking permission to offer information, providing brief chunks of information, and then eliciting the family members’ reactions to the information (Miller & Rollnick, 2013). Once the topic is raised and all family members have accurate information about the medication and the importance of medication adherence in family stability, the conversation can shift to the family working as a team to support the client to adhere to medication as prescribed or safely taper off medication under medical supervision if and when it is no longer needed for the client to maintain stable recovery.
Integrating family-based counseling techniques into SUD treatment is possible along a continuum of care, from initial assessment through the various stages of family counseling. This chapter examined some of the common issues you may face and family-centered strategies you can use along that continuum of care, including when to use family counseling, who can be involved, the goals of family-based interventions, and your role as a counselor. Chapter 5 examines your role in delivering culturally responsive family-based SUD treatment. It also explores the diversity of family cultures you will encounter in your work.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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