Family therapy is a collection of therapeutic approaches that share a belief in family‐level assessment and intervention. A family is a system, and in any system each part is related to all other parts. Consequently, a change in any part of the system will bring about changes in all other parts. Therapy based on this point of view uses the strengths of families to bring about change in a range of diverse problem areas, including substance abuse.
Most all family-based approaches address a wide array of problems in addition to the substance abuse, including: family communication and conflict; other co-occurring behavioral, mental health, and learning disorders; problems with school or work attendance; and peer networks.1
As with Individuals, Families Are Complex and Evolving
The idea of family implies an enduring involvement on an emotional level. Families must be distinguished from social support groups such as 12‐Step programs—although for some clients these distinctions may be fuzzy. One distinction is the level of commitment that people have for each other and the duration of that commitment.
Another distinction is the source of connection. Families are connected by alliance, but also by blood (usually) and powerful emotional ties (almost always). Support groups, by contrast, are held together by a common goal; for example, 12‐Step programs are purpose‐driven and context‐dependent. The same is true of church communities, which may function in some ways like a family; but similar to self‐help programs, churches have a specific purpose.
For practical purposes, family can be defined according to the individual’s closest emotional connections. In family therapy, clients identify who they think should be included in therapy. The therapist cannot determine which individuals make up another person’s family. The therapist needs to ask the patient, “Who is important to you? Who are those closest to you?” Anyone who is instrumental in providing support, maintaining the household, providing financial resources, and with whom there is a strong and enduring emotional bond may be considered family for the purposes of therapy. In some situations, family may be defined as peers/co-workers.
As treatment progresses, the idea of family sometimes may be reconfigured, and the notion may change again during continuing care. In other cases, the patient will not allow contact with the family or may only want contact with particular family members and not others.
One definition of family is “a group of people with common ties of affection and responsibility who live in proximity to one another.” That definition may be expanded, though, in identifying four characteristics of families central to family therapy:2
- Families possess nonsummativity, which means that the family as a whole is greater than – and different from – the sum of its individual members.
- The behavior of individual members is interrelated through the process of circular causality, which holds that if one family member changes his behavior, the others will also change as a consequence; this, in turn, causes subsequent changes in the member who initially introduced change. This also demonstrates that it is impossible to know what comes first: substance abuse or behaviors that are called “enabling” (in essence, supporting unwanted behavior).
- Each family has a pattern of communication traits, which can be verbal or nonverbal – overt or subtle means of expressing emotion, conflict, affection, etc.
- Families strive to achieve homeostasis – self‐regulating with a primary need to maintain balance.
What Is Family Therapy?
In family therapy, the unit of treatment is the family and/or the individual within the context of the family system. The person abusing substances is regarded as a subsystem within the family unit – the person whose symptoms have severe repercussions throughout the family system. The familial relationships within this subsystem are the points of therapeutic interest and intervention. The therapist facilitates discussions and problem-solving sessions – ideally with the entire family group, but sometimes with a single participant, who may or may not be the person with the substance use disorder.
Family therapy in substance abuse treatment has two main purposes. First, it seeks to use the family’s strengths and resources to help find or develop ways to live without substances of abuse. Second, it mends the impact of chemical dependency on both the dependent individual and her family.
In treating substance use disorders, family therapy helps families become aware of their own needs and provides genuine, enduring healing for people. It works to shift power to the parental figures in a family and to improve overall communication. Other goals will vary according to which member of the family is abusing substances.
A distinction should be made between family therapy and family‐involved therapy. Family‐involved therapy attempts to simply educate families about the relationship patterns that typically contribute to the formation and continuation of substance abuse.2
How Does Family Therapy Work?
A major goal of family therapy in substance abuse treatment is prevention – especially keeping substance abuse from moving from one generation to another.
Whether a child or adult is the family member who uses substances, the entire family system needs to change – not just the user. Family therapy, therefore, helps the family make interpersonal, intrapersonal, and environmental changes affecting the person using alcohol or drugs. It helps the non-using members work together more effectively and define personal goals for therapy beyond a vague notion of improved family functioning. As change takes place, family therapy helps all family members understand what is occurring. This out‐in‐the‐open understanding removes any suspicion that the family is “ganging up” on the person abusing substances.
A major goal of family therapy in substance abuse treatment is prevention – especially keeping substance abuse from moving from one generation to another. Study after study shows that if one person in a family abuses alcohol or drugs, the remaining family members will have an increased risk of using substances themselves. The single most potent risk factor of future mal-adaption, predisposition to substance use, and psychological difficulties is a parent’s substance‐abusing behavior. A healthy family structure can prevent adolescent substance abuse, even in the face of heavy peer pressure to drink or use.2
How Is Family Therapy Typically Used Today?
Four predominant family therapy models are used as the bases for treatment and specific interventions for substance abuse:
- The family disease model looks at substance abuse as a disease that affects the entire family. Family members of those who abuse substances may develop codependence, which leads them to enabling (or, essentially, supporting) continued substance abuse. Awareness of such destructive behaviors within the family is learned and appropriate corrections are practiced.
- The family systems model is based on the idea that families become organized by their interactions around substance abuse. In adapting to the substance abuse, it is possible for the family to maintain balance (or homeostasis). For example, a man with a substance use disorder may be antagonistic or unable to express feelings unless he is intoxicated. Using the systems approach, a therapist would look for and attempt to change the maladaptive patterns of communication or family role structures that require substance abuse for stability.
- Cognitive–behavioral approaches are based on the idea that maladaptive behaviors, including substance use and abuse, are reinforced through family interactions. Behaviorally oriented treatment tries to change interactions and target behaviors that trigger substance abuse, to improve communication and problem solving, and to strengthen coping skills.2
Brief strategic family therapy (BSFT) is a variant therapeutic strategy that targets family interactions thought to maintain or exacerbate drug abuse and other co-occurring behaviors, such as conduct issues at home and at school, oppositional behavior, delinquency, befriending antisocial peers, aggressive or violent behavior, and risky sexual behavior.3
In BSFT, the therapist establishes a relationship with each family member, observes how the members behave with one another, and assists the family in changing negative interaction patterns.1
- Multidimensional family therapy (MDFT) has integrated several different techniques with emphasis on the relationships among cognition, affect (emotionality), behavior, and environmental input.
Developed for adolescents with drug abuse problems and their families, this approach addresses a range of influences concerning drug abuse patterns and is designed to improve overall family functioning.4
Sessions with parents include such topics as family management, the parent-adolescent relationship and parenting skills, including monitoring and setting limits. These sessions also provide opportunities to provide emotional support. “We connect with parents in a way that recognizes their stress and the anger, hopelessness and even despair they may feel about their child,” notes Dr. Howard Liddle of the University of Miami, who led two studies involving MDFT. “Then we help parents reconnect emotionally to their child. This renewed caring is instrumental in changing parenting practices.”
In addition to experiencing longer lasting abstinence gains, MDFT recipients:
- Improved their academic performance, while the grades of youths who experienced cognitive-behavioral therapy (CBT) worsened.
- Had fewer arrests and placements on probation.
- Suffered fewer psychiatric symptoms, such as those related to depression and anxiety.
- Reduced self-reported delinquency and associations with delinquent peers, while youths receiving the group CBT increased delinquent peer involvement.
“Outcomes of MDFT appear to improve even after therapists complete their work with teens and families,” continues Dr. Liddle. “MDFT outcomes are among the best there are for adolescents,” adds Dr. Lisa Onken of the National Institute on Drug Abuse. Sustainability of treatment effects – as indicated by 12-month outcomes – was “the most important finding” of the studies. “This is important particularly for younger adolescents, who would be on a very negative developmental trajectory without effective treatment.”
Young teens also demonstrated another MDFT benefit: Participants were more likely to remain in treatment – an important challenge in substance use interventions.5
Whichever approach you take, it is important to understand that the family dynamic in drug and alcohol addiction is incredibly powerful, and that addressing an unhealthy imbalance in communication is your first step in moving your loved one toward addiction therapy. It can be a journey of recovery and self-discovery for everyone involved.6
Even in the best of circumstances, families can find it difficult to change; some family members may be resistant. As each family member starts to adjust, deal with past conflicts, and establish new routines, recovery can permeate the family. Family therapy can help each member of the family make specific, positive changes that can help the whole family heal from the effects of substance use disorders and any co-occurring mental health conditions.7
Why Is Family Therapy So Effective?
Because of the variety of family therapy models, the diverse schools of thought in the field, and the different degrees to which family therapy is implemented, multiple therapeutic factors probably account for the effectiveness of family therapy. Among these factors might be: acceptance from the therapist; improved communication; organizing the family structure; determining accountability; and enhancing impetus for change.
Family therapy also views substance abuse in its context – not as an isolated problem – and shares some characteristics with 12‐Step programs, which evoke solidarity, self‐confession, support, self‐esteem, awareness and smooth re‐entry into the community.
Still another reason that family therapy is effective in substance abuse treatment is that it provides a neutral forum in which family members meet to solve problems. Such a rational venue for expression and negotiation often is missing from the family lives of people with a substance problem. Though their lives are unpredictable and chaotic, the substance abuse – the cause of the upheaval and a focal organizing element of family life – is not likely discussed. If the subject comes up, the tone of the exchange could very well be accusatory and negative.
In the supportive environment of family therapy, the uneasy silence on the subject of substance abuse can be broken in ways that feel emotionally safe. As the therapist brokers, mediates and restructures conflicts among family members, emotionally charged topics are allowed to come out into the open. The therapist helps ensure that every family member is accorded a voice. In the safe environment of therapy, pent‐up feelings such as fear and concern can be expressed, identified, and validated.
Family members gain a broader and more accurate perspective of what they are experiencing, which can be empowering and may provide enough energy to create positive change. Unhealthy relational structures (such as parent‐child role reversals) and faulty patterns of communication (such as a limited capacity for negotiation) are exposed and addressed by the therapist. Whether or not the user’s drug or alcohol problems are immediately resolved, that person’s family can make constructive strides in becoming a stable, functional environment within which abstinence can be sustained.
Naturally, the recovery process pertaining to the substance use disorder varies according to the type of drug, the extent of drug use, and the extent of acute and chronic effects. Recovery also may depend on the extent to which the drugs are intertwined with antisocial behavior and any co‐occurring conditions. For the addicted individual, post‐acute withdrawal symptoms will likely present themselves and interfere with family therapy for a significant period before gradually subsiding.2
What Are the Key Takeaways on Family Therapy and the Family’s Role?
Overall, studies have shown that family therapy increases engagement and retention in treatment, reduces drug and alcohol use, improves both family and social functioning, and prevents substance abuse relapse.2
Demonstrating positive results in both adults and adolescents, family therapy has been effective at addressing not only substance use problems, but other co-occurring problems, including conduct disorders, child mistreatment, depression, family conflict and unemployment.8
At Skywood Recovery, not only is the whole person treated, but the whole family as well – whatever course of action is needed in our broad and flexible array of treatment capabilities. While more than ten federally funded studies tout our approach as highly effective, we remain humble and honored to have the privilege to care for each and every individual – and family – who steps through our door.
1 “Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide”, National Institute on Drug Abuse, https://teens.drugabuse.gov/sites/default/files/podata_1_17_14_0.pdf .
2 “Substance Abuse Treatment and Family Therapy”, National Center for Biotechnology Information, http://www.ncbi.nlm.nih.gov/books/NBK64269/ .
3 “Comorbidity: Addiction and Other Mental Illnesses”, Research Report Series, National Institute on Drug Abuse, https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf , (September 2010).
4 “DrugFacts: Treatment Approaches for Drug Addiction”, National Institute on Drug Abuse, https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction , (January 2016).
5 “Multidimensional Family Therapy for Adolescent Drug Abuse Offers Broad, Lasting Benefits”, National Institute on Drug Abuse, https://www.drugabuse.gov/news-events/nida-notes/2010/12/multidimensional-family-therapy-adolescent-drug-abuse-offers-broad-lasting-benefits , (December 1, 2010).
6 Gifford, Steven, LICDC, LPC, “Family Involvement Is Important in Substance Abuse Treatment”, PsychCentral, http://psychcentral.com/lib/family-involvement-is-important-in-substance-abuse-treatment/
7 “Family Involvement”, Retention Toolkit, UW Alcohol and Drug Abuse Institute and Washington State DSHS Division of Behavioral Health & Recovery, http://adai.uw.edu/retentiontoolkit/family.htm .
8 “Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition)”, National Institute on Drug Abuse, https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment/behavioral-5 , (December 2012).