Chapter 30. Family Therapy

 

 

Chapter 30. Family Therapy

FAMILY THERAPY: INTRODUCTION

Any review of the development and applications of the family treatment model for addictions over the last half-century reveals a rapid progression in the acceptance of family-involved therapy as an

important component of treatment for alcoholism and drug abuse. For example, the treatment literature from the 1950s and early 1960s primarily conceptualized substance abuse as an individual

problem that was best treated on an individual basis (e.g., Jellinek 1960). However, throughout the 1960s, this view was gradually supplanted by what would now be the prevailing clinical wisdom that

family members can play a central role in the treatment for alcoholism and drug abuse (Stanton and Heath 1997). In the early 1970s, couples and family therapies were described by the National

Institute on Alcohol Abuse and Alcoholism as “one of the most outstanding current advances in the area of psychotherapy of alcoholism” (Keller 1974, p. 161). By the late 1970s, family therapy for

substance abuse was embraced by the majority of substance abuse treatment programs and community mental health settings (e.g., Coleman and Davis 1978; Kaufman and Kaufman 1992), and since

the late 1980s, family-based assessment and intervention have become widely viewed as part of standard care for alcoholism and drug abuse. In fact, many have argued that the only reason not to

include family members in the treatment of a substance-abusing patient is refusal by the patient or members of the family to be involved (e.g., O’Farrell 1993b).

In addition, the popular literature on families and substance abuse has grown into its own cottage industry of sorts, with a wide range of books appearing on bookstore shelves describing codependency,

enabling, and adult children of alcoholic individuals. Thus, the role of family factors in the etiology and maintenance of addictive disorders and the application of family therapy in substance abuse

treatment has indeed come a long way.

Historically, family interventions used to treat alcoholism grew out of couples therapy approaches and focused primarily on the spousal system. In contrast, family treatments for drug abuse evolved

from systemic family therapy, focusing on the entire family. More recently, this distinction has blurred, with both alcoholism and drug abuse treatment programs often providing a wide array of family

therapy services for the patients and their family members.

This chapter describes different types of family therapy commonly used in the treatment of alcoholism and drug abuse. It also summarizes the evidence base for each type of family therapy described.

We will focus on the use of family-involved treatments to 1) help the family, 2) initiate change when the substance-abusing individual refuses to seek help, and 3) aid recovery once the substance abuser

has sought help.

Preparation of this chapter was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (K02 AA00234) and by the Department of Veterans Affairs.

HELPING THE FAMILY WHEN THE SUBSTANCE ABUSER REFUSES TO GET HELP

Spouses and other family members often experience many stressors and heightened emotional distress caused by the negative consequences of the substance abuser’s drinking and drug use. Stress is

highest for the family when the substance abuser refuses to get help. Two approaches try to help family members cope with their emotional distress and concentrate on their own motivations for change

rather than trying to motivate the substance abuser to change. These approaches 1) help the family member use the concepts and resources of Al-Anon and 2) teach specific coping skills to deal with

alcohol- and drug-related situations involving the substance abuser.

Al-Anon Facilitation and Referral

Al-Anon is a 12-step program that is by far the most widely used source of support for family members troubled by a loved one’s substance abuse. Al-Anon advocates that family members detach

themselves from the substance abuser’s drinking and drug use in a loving way, accept that they are powerless to control the substance abuser, and seek support from other members of the Al-Anon

program (Al-Anon Family Groups 1985).

There are two ways in which a psychiatrist or other addiction professionals might use Al-Anon to help family members. The first is referral to the Al-Anon program. This includes providing information

about times and locations of nearby Al-Anon meetings and discussing any concerns the family member may have about the program. Arranging for the family member to go to his or her first few

meetings with an established Al-Anon member can be particularly effective. Like any other referral, checking back to see if the person has followed through is important. The second is Al-Anon

facilitation therapy (AFT), which is a therapist-delivered counseling method designed to encourage involvement in Al-Anon. Nowinski (1999) developed and tested a therapist manual for this approach.

It consists of 10–12 sessions designed to engage the family member in the program and concepts of Al-Anon. Each session explores one of the Al-Anon 12 steps (e.g., admitting one is powerless over

another person’s addiction) or a closely related Al-Anon concept (e.g., detaching with love). AFT also has recovery tasks that the family member is asked to pursue between sessions, including attending

Al-Anon meetings and reading Al-Anon literature.

Coping Skills Therapy

Coping skills therapy (CST) teaches family members of substance abusers how to deal with alcohol- and drug-related situations involving the substance abuser. Rychtarik and McGillicuddy (2005)

developed and tested a therapist manual for an eight-session CST group for spouses and family members of substance abusers. Based on a family stress and coping perspective, CST helps group

members apply a problem-solving approach to substance-related problem situations commonly experienced by families of substance abusers (e.g., dealing with intoxicated behavior, partner violence,

failure to maintain household responsibilities). In each CST session, the group leader presents a stressful situation drawn from a master list of possible situations, leads the group in problem solving, and

provides situation-specific skill hints. For example, the group leader may present a situation involving the substance abuser asking for money when in the past he has used these occasions to go out and

drink. Responses discussed by participants might range from passive acquiescence to assertively declining the request. The therapist then models the recommended response, group members role-play

the situation, and the therapist and group provide feedback. Participants keep a diary of personal problematic situations encountered and these are discussed and role-played in the group as well.

Evidence for Family Therapy

Research reviewed in detail elsewhere (O’Farrell and Fals-Stewart 2001, 2003) shows that Al-Anon referral, AFT, and CST all produce improvements in family members’ emotional distress and coping

that are greater than in a waitlist control group. Evidence that Al-Anon facilitation and referral help family members as intended and believed by its many adherents comes from controlled studies that

support this widely used approach (e.g., Barber and Gilbertson 1996; Miller et al. 1999).

Although they produce similar improvements in emotional distress, CST leads to less drinking and less violence by the alcoholic individual than does AFT. Specifically, spouses of alcoholic persons who

received CST experienced less violence from their male partners and their male partners drank less in the year after treatment than did women who received AFT (Rychtarik and McGillicuddy 2005).

These advantages of CST over AFT are important because one-half to two-thirds of substance abusers have been violent toward a female partner in the past year (O’Farrell et al. 2003, 2004). In addition,

reduced drinking by the alcoholic individual who was not in treatment is an important indirect effect of CST. Although CST is not widely used, these findings suggest it should receive more attention from

clinicians and program administrators.

Table 30–1 summarizes key points about family-based methods to help the family when the substance abuser refuses to get help.

TABLE 30–1. Family-based methods to help the family when the substance abuser refuses to get help

Major approaches to help the family

Al-Anon facilitation and referral—Engages family member in program and concepts of Al-Anon.

Coping skills therapy—Teaches family member how to deal with common alcohol- and drug-related situations involving the substance abuser.

Evidence for these approaches

Both Al-Anon and coping skills therapy reduce emotional distress and improve coping of family member.

Coping skills therapy leads to less drinking and less violence by substance abuser than does Al-Anon.

INITIATING CHANGE WHEN THE SUBSTANCE ABUSER REFUSES TO GET HELP

Many, if not most, substance abusers seek treatment in response to external pressure. With the possible exception of legal system coercion, pressure by a family member is the most powerful

inducement for substance abusers to enter treatment (Stanton 1997). Several family-based methods have been developed to motivate resistant substance abusers to enter treatment. These include the

Johnson Institute intervention, a relational intervention sequence for engagement (ARISE), pressure to change (PTC), and community reinforcement and family training (CRAFT).

Johnson Institute Intervention

The best known of these family-involved motivational techniques is the Johnson Institute intervention (Johnson 1986; Liepman 1993). The intervention, as it is most commonly called, involves three to

four educational and rehearsal sessions to prepare family members and others (e.g., neighbors, friends) for a confrontation meeting. After these preparation sessions, the confrontation meeting is

scheduled and the substance user is brought to this meeting, typically not knowing the agenda of the group. Once the substance user is in their midst, family members then share their concerns and

feelings; these are to be presented in a sincere, nonjudgmental fashion. The intervention team members also express their hope that the substance user will enter treatment, and they outline the

consequences if the substance user refuses and openly discuss the desired outcome of both the intervention itself and the recommended treatment. A referral to treatment is then made. Often, thePrint: Chapter 30. Family Therapy

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members of the intervention team meet with the therapist at a later date to go through a debriefing and discuss a plan for change for the family members and others in the substance user’s social

network to follow.

A Relational Intervention Sequence for Engagement

ARISE (Landau and Garrett 2006) was developed as a less coercive alternative than the traditional Johnson intervention. ARISE is a three-stage approach, with each successive stage involving greater

family involvement, therapist involvement, and coercion. The ARISE model advocates use of less coercive steps early in the process and gradually proceeds to the use of greater counselor and family

involvement if the lower-intensity steps are not successful in motivating the substance abuser to engage in treatment.

The first stage involves one or more telephone sessions with the family member who contacted the treatment agency, followed by an in-person meeting of the family and other network members with

the therapist to mobilize them in support of treatment for the substance abuser. The second stage involves an informal “invitational intervention” with a therapist present. This meeting is not a surprise

to the substance abuser and does not involve consequences for refusing treatment. Family and relevant others and the substance abuser are invited to attend this meeting, although the meeting can still

be conducted without the substance abuser present. In the meeting, the members collectively consider possible approaches that might be used to motivate the substance abuser to enter treatment. If,

after repeated attempts, the substance user remains unwilling to seek help, the process moves to the third and final stage, which involves a formal intervention similar to the Johnson approach.

The Pressure to Change Approach

James G. Barber (e.g., Barber and Crisp 1995) developed the PTC approach for partners living with heavy drinkers who deny their alcohol problem and refuse treatment. PTC makes use of learning theory

to train partners in coping responses that are designed to empower the non-substance-abusing partner and provide incentive for the alcoholic partner to change.

PTC involves five to six structured counseling sessions to instruct the non-substance-abusing partner how to use five gradually increasing levels of pressure on the drinker to seek help or moderate his or

her drinking. During the course of these five levels, the partner 1) receives feedback from the therapist about the seriousness of the drinker’s problem and receives education on PTC; 2) plans activities

for the drinker that are incompatible with drinking for times when he or she usually drinks (e.g., taking children to an amusement park, going to dinner with friends or relatives who do not drink); 3)

responds to drinking by withdrawing reinforcers, and responds to drinking-related crises by suggesting treatment; 4) establishes a contract in which the partner agrees to exchange some reinforcer for

sobriety; and 5) confronts the drinker, when prior steps have been unsuccessful, with the negative effects of the drinking and a simple, direct request to seek change or seek help.

Community Reinforcement and Family Training

The CRAFT approach (Smith and Meyers 2004) involves six to eight sessions that draw heavily on learning theory. CRAFT teaches a family member how to use positive reinforcement and negative

consequences to discourage drug use or drinking by the substance abuser. Positive reinforcement might include the family member engaging in pleasant activities (e.g., discussing enjoyable topics,

giving gifts) when the substance abuser is not drinking or using drugs. In addition, the family member would expressly state that reinforcement is being given because the substance user is not drinking

or using drugs. Negative consequences for intoxication might include withholding reinforcements, explaining why, and ignoring the substance abuser during periods of intoxication. Emphasis is also

placed on the family member decreasing stress in general and increasing positive aspects of his or her own life. This might include establishing new friendships, engaging in positively rewarding

activities outside of the relationship with the substance abuser, or joining a therapy group.

A unique aspect of CRAFT is its emphasis on identifying dangerous situations as behavioral changes are introduced at home. The family member is taught how to identify potentially violent situations so

that he or she can take immediate action before getting hurt. The therapist helps the family member identify the sequence of events that lead to violence and teaches him or her to identify significant

cues before physical violence begins. The family member develops a specific plan for leaving these situations until it is safe to return.

Finally, CRAFT teaches the family member effective ways to suggest treatment to the substance abuser. Often this involves picking a time and situation when the substance abuser may be highly

motivated to enter treatment because substance use has caused unacceptable behavior. Such situations may occur after the substance abuser has engaged in embarrassing behavior when drinking,

disappointed his or her children, or been arrested for drunk driving.

Evidence for Family Therapy

Research reviewed in detail elsewhere (O’Farrell and Fals-Stewart 2001, 2003) shows that, of these family-based methods to promote change and treatment entry by the resistant substance abuser,

CRAFT has the strongest evidence base. Across four randomized trials (two for alcoholics and two for drug abusers), the average treatment engagement rate for CRAFT was 68% (range from 59% to

85%), which was significantly and substantially higher than comparison groups of AFT or Al-Anon referral (20%) or the Johnson intervention (30%). Thus, CRAFT is a more effective alternative to

engage substance abusers in treatment than popular confrontational or detachment approaches.

The Johnson Institute intervention showed a disappointing treatment engagement rate of 30% in the first randomized, controlled study of this popular method. This was similar to the 25% rate in an

uncontrolled study, and it is not much higher than for Al-Anon, which does not try to change the substance abuser’s behavior. The reason for these disappointing findings is that 70% of families in these

two studies who started the intervention process did not go through with the family confrontation meeting. When family members completed the confrontation in these two studies, most succeeded in

getting their substance abuser into treatment. Adherents of the Johnson intervention have cited “a 90% success rate,” which we now know does not apply for an intent-to-treat basis (which has a

25%–30% success rate) but only for the minority of families willing and able to use the method.

ARISE has a less coercive multistep process that is conceptually appealing and may lead to better engagement rates than the Johnson intervention. However, although ARISE has shown promise in

uncontrolled studies, controlled studies have not been reported.

Outcomes for PTC were better in three controlled studies than a waitlist control on initiating change defined as treatment entry or reduced drinking for the rather brief period of 2 weeks. Treatment entry

rate (31%) is less than half of that found for CRAFT. PTC has been used with spouses of heavy drinkers, not drug abusers or other family members. Nonetheless, PTC may be a promising approach. It is

brief, and well specified in a manual for therapists and a self-help manual for spouses. If it can be shown that PTC produces durable reductions in the drinker’s alcohol use, it may be of particular use in

countries without extensive alcohol treatment systems.

Table 30–2 summarizes key points about family-based methods to initiate change when the substance abuser refuses treatment.

AIDING RECOVERY WHEN THE SUBSTANCE ABUSER HAS SOUGHT HELP

Preceding sections have examined interventions to help the family and support the substance abuser’s entry into treatment. Regardless of the impetus for seeking help, once the substance abuser has

entered treatment, family therapy interventions are often used as part of the treatment to aid the substance abuser’s recovery and help the family. Network therapy, family systems therapy (FST), and

behavioral couples therapy (BCT) are three influential approaches. We will now examine the hallmark therapy techniques and the evidence base for these approaches.

TABLE 30–2. Family-based methods to initiate change when the substance abuser refuses to get help

Major approaches to initiate change

Johnson Institute intervention—Therapist helps family plan and conduct surprise family confrontation meeting called an intervention.

A relational intervention sequence for engagement (ARISE)—A three-step model starting with low pressure methods and ending with Johnson intervention if earlier steps are unsuccessful.

Pressure to change (PTC)—Teaches coping responses to empower family member and provide incentives for alcohol abuser to change.

Community reinforcement and family training (CRAFT)—Teaches family member to use positive reinforcement and negative consequences to discourage substance use and encourage treatment.

Evidence for these approaches

CRAFT is most effective, averaging 68% treatment engagement across four randomized trials.

Although popular, the Johnson intervention has only 25%–30% engagement rate because many families do not follow through with the confrontation.

PTC reduces drinking for brief period but durability of changes are unknown.

ARISE is promising, but lacks controlled studies.

Network Therapy

Network therapy (Galanter 1999) involves key members of the patient’s social network at the outset and at regular intervals during treatment to support the patient’s recovery. Network therapy will not

be considered further here because Chapter 28 of this volume, “Network Therapy,” is devoted to a detailed consideration of this approach.

Family Systems Therapy

FST has incorporated many core concepts of family systems theory as applied to substance abuse (Stanton et al. 1982; Steinglass et al. 1987). Therapy focuses on the interactional rather than the

individual level, using a variety of techniques to affect interactions within the family. Greatest emphasis is put on identifying and altering family interaction patterns that are associated with problematic

substance use.

The family systems approach views substance abuse as a major organizing principle for patterns of interactional behavior within the family system. A reciprocal relationship exists between family

functioning and substance abuse, with an individual’s drug and alcohol use being best understood in the context of the entire family’s functioning. According to family systems theory, substance abuse

often evolves during periods in which the individual family member is having difficulty addressing an important developmental issue (e.g., leaving the home) or when the family is facing a significantPrint: Chapter 30. Family Therapy

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crisis (e.g., marital discord). During these periods, substance abuse can serve to 1) distract family members from their central problem or 2) slow down or stop a transition to a different developmental

stage that is being resisted by the family as a whole or by one of its members.

From a family systems perspective, substance abuse represents a maladaptive attempt to deal with difficulties that develop a homeostatic life of their own and regulate family transactions. The

substance abuse itself serves an important role in the family and once the therapist understands the function of the substance abuse for the family, he or she can then explain how the behavior has come

about and the function it serves. In turn, treatment is aimed at restructuring the interaction patterns associated with the substance abuse, thereby making the drinking or drug use unnecessary in the

maintenance of the family system functioning. To accomplish this aim, family systems therapists use a variety of therapy techniques. These techniques fall into two broad categories,

restructuring.

Joining with the family

Joining consists of techniques designed to promote therapeutic alliance and increase the therapist’s leverage within the family. The therapist alternates between joining that supports the family system

and its members and joining that challenges the system. This involves making a connection with each family member engaged in treatment and instilling a sense of confidence that the therapist has a

firm commitment to working together with the family members on identified problems. In the joining process, the therapist typically solicits from each family member his or her perception of the

problems in the family and his or her feelings about the issues raised. By attending to each person’s views, the therapist conveys that each family member’s viewpoint is important and that differences in

perception about the identity, nature, and severity of problems are acceptable. The therapist attempts to communicate to each family member that he or she understands the family member’s

perceptions of the problems and has a clear idea about how to address the issues raised by the family member.

The process of joining may involve the therapist promoting areas of strength in the family, supporting a threatened member of the family, and using the family member’s methods of communicating

(e.g., humor, touching) to introduce new ideas and concepts (Minuchin 1974). Of course, joining is an ongoing process that is ultimately supported and reinforced as the therapist demonstrates his or her

understanding and helpfulness throughout the course of treatment.

Restructuring family alliances and interactions

Unlike joining, the second category of intervention techniques, restructuring, involves challenging the family’s homeostasis. Restructuring takes place through modifications in the family’s bonding and

power alignments among individuals and subsystems in the family (e.g., Haley 1976; Minuchin 1974). Several different techniques are used in the process of restructuring, including contracting,

enactment, reframing, restructuring, and marking boundaries. Contracting is an agreement to work on agreed-upon issues, with an emphasis on helping the substance abuser with his or her problems

prior to expanding to and probing other issues. The contract is developed at the end of the first interview and is maintained throughout treatment. As part of the contract, the family must choose to

develop a family system that is conducive to abstinence by the substance abuser and agree to pursue the contract after it has been agreed upon as part of the initial evaluation.

Enactment involves the therapist eliciting, observing, and interrupting recurring problematic behavioral sequences in family interaction patterns. To do this, the therapist requires family members to talk

to each other about problems in sessions rather than direct their communications to the therapist. The therapist carefully observes these enactments. Once the therapist has observed problematic

interactions, he or she can interrupt and destabilize these customary behavioral exchanges among family members.

Reframing requires the therapist to help family members understand the interrelatedness of their behaviors and to see and understand how the substance abuse serves an important function in the

family. Restructuring is composed of shifting family interaction patterns and establishing new, healthier behaviors. For example, this might include changing seating arrangements to strengthen the role

of parents in the family, restating problems in solvable form, and teaching methods of communication and problem solving that preclude triangulation or conflict avoidance.

Marking boundaries is accomplished by clearly delineating individual and subsystem boundaries. For example, the parental subsystem should be protected from intrusion by children and other adults who

may be inside or outside the family. To strengthen the parental subsystem, sessions with parents that exclude other family members may be held.

FST is more than a set of techniques. It involves a conceptual framework that explains common puzzling clinical phenomena (e.g., a family member seeming to sabotage a patient’s newfound sobriety)

and guides interventions. From this perspective, substance abuse by a family member serves an important function for the family, helping to maintain the homeostasis of the family system. Thus, if a

family has functioned as a stable unit with a substance-abusing member, subsequent sobriety would likely threaten homeostasis and may be resisted on some level.

Behavioral Couples Therapy

BCT (O’Farrell and Fals-Stewart 2006) works directly to increase relationship factors conducive to abstinence. A behavioral approach assumes that family members can reward abstinence—and that

alcoholic and drug-abusing individuals from happier, more cohesive relationships with better communication have a lower risk of relapse.

BCT is designed for married or cohabiting couples seeking help for alcoholism or drug abuse. The purposes of BCT are to build support for abstinence and to improve relationship functioning. BCT

promotes abstinence with a “recovery contract” that includes a daily ritual to reward abstinence. BCT improves the relationship with techniques for increasing positive activities and improving

communication. Finally, BCT helps the couple plan for continuing recovery to prevent or minimize relapse.

The BCT therapist sees the substance-abusing patient together with the spouse or live-in partner typically for 12–20 weekly outpatient couples sessions over a 3–6 month period, followed by periodic

maintenance contacts. BCT usually is an adjunct to individual or group counseling for the substance abuser. Generally, couples are married or cohabiting for at least a year, without current psychosis, and

one member of the couple has a current problem with alcoholism and/or drug abuse. The couple starts BCT soon after the substance abuser seeks help.

The BCT recovery contract

Before the substance abuser seeks help, the problems from substance abuse lead the couple into an intense, hostile struggle in which the spouse tries desperately to control the substance abuse. In

turn, the substance abuser, although at times promising to reform or staying abstinent for short periods, continues to drink or use drugs. Such repeated unkept promises to change and problems caused

by the substance abuser’s continued use lead to a high level of distrust and conflict in the relationship.

The BCT recovery contract specifies behaviors that each member of the couple can enact to reduce distrust and conflict about substance abuse and to reward abstinence and actions leading toward

abstinence. The recovery contract starts with the trust discussion, in which the patient states his or her intent not to drink or use drugs that day (in the tradition of “one day at a time,” from Alcoholics

Anonymous [AA]). Then the spouse expresses support for the patient’s efforts to stay abstinent, and the patient thanks the spouse for the encouragement and support. For patients taking a

recovery-related medication (e.g., disulfiram, naltrexone), daily medication ingestion witnessed and verbally reinforced by the spouse also takes place during the trust discussion. The couple performs

the trust discussion in each BCT session to highlight its importance and to let the therapist observe the couple’s performance of this important ritual.

Self-help meetings and drug urine screens are part of the contract for most patients. Performance of the trust discussion and other recovery activities (self-help meetings, drug screens, medication) are

marked on a calendar that is provided. At the start of each BCT session, the therapist reviews the recovery contract calendar to see how well each spouse has done his or her part. The calendar provides

an ongoing record of progress that is rewarded verbally at each session. The couple also agrees not to discuss substance-related conflicts that can trigger relapse, reserving these discussions for the

counseling sessions. The following two case examples illustrate the use of the BCT recovery contract. The second case illustrates that when both members of a couple have a current substance problem

and both want abstinence, BCT often is workable.

Recovery contract for Mary and Jack

Mary was an addicted daily drinker and marijuana smoker who came to treatment after being suspended from her job for drinking. Her husband, Jack, was a light drinker with no drug involvement. As shown in Figure

30–1, their recovery contract had 1) a daily trust discussion, 2) at least two AA meetings per week, and 3) drug urine screens at each BCT session. They were very compliant, as shown by their calendar.

FIGURE 30–1. Recovery contract and calendar for Mary and Jack.Print: Chapter 30. Family Therapy

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Source. Reprinted from O’Farrell TJ, Fals-Stewart W: Behavioral Couples Therapy for Alcoholism and Drug Abuse. New York, Guilford, 2006, p. 48. Used with permission.

Jack was upset about the positive urine screens for marijuana in the first few weeks. The counselor explained that marijuana could stay in the system for some time and suggested Jack go to Al Anon to help with his

distress over Mary’s suspected drug use. Soon thereafter, Mary’s drug screen results were negative for marijuana and stayed that way. Jack found Al Anon helpful, so they added to the contract 1 night a week going

together to a local church where Mary attended AA and Jack went to Al Anon.

Recovery contract for Sue and Gene—a dual problem couple

Sue came to BCT after detoxification for heavy daily drinking plus cocaine and marijuana use three to four times per week. Gene had similar problems but did not need detoxification. Sue’s parents had been given

temporary custody when Gene was arrested for drunk driving while Sue (also intoxicated) and the kids were in the car. Both Sue and Gene wanted to “quit for good” to get their three school-age children back. Sue and

Gene had 6 months weekly BCT. Their “dual recovery contract,” shown in Figure 30–2, committed them to 1) a daily trust discussion, 2) taking disulfiram (Antabuse) daily together, 3) attending three AA meetings per

week, and 4) undergoing weekly urine screens.

FIGURE 30–2. Contract and calendar for Sue and Gene, a dual problem couple.Print: Chapter 30. Family Therapy

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Source. Reprinted from O’Farrell TJ, Fals-Stewart W: Behavioral Couples Therapy for Alcoholism and Drug Abuse. New York, Guilford, 2006, p. 48. Used with permission.

About 5 weeks after starting BCT, Sue used cocaine on Friday night when she went to the local bar with a girlfriend. At the next BCT session her urine screen was positive for cocaine. The following Friday found them both

in the bar. They had planned to just socialize, but when cocaine was offered they did not refuse and did one line each. The next night they went to the bar again and each used multiple lines of cocaine. This relapse was a

turning point. They got more committed to their recovery. They planned things to do Friday and Saturday nights, starting with an AA meeting together on Friday night. Each got a sponsor and some sober friends.

After weekly BCT, they had quarterly checkups for 2 more years. They regained custody of their children and stayed abstinent except for a few isolated days for Gene and a 5-day relapse for Sue, which led to a few crisis

sessions with the BCT counselor to help them get back on track.

Other support for abstinence

BCT also supports abstinence by 1) reviewing substance use or urges to use since the last session; 2) decreasing exposure to alcohol and drugs (e.g., deciding whether to have alcohol in the house); 3)

addressing stressful life problems to reduce relapse risk and make abstinence more rewarding; and 4) decreasing partner behaviors that trigger or reward substance use. These aspects are part of many

types of substance abuse counseling. In BCT they are carried out with the participation of the spouse.

Improving relationship functioning

Using a series of behavioral assignments, BCT increases positive feelings and activities and teaches constructive communication because these relationship factors are conducive to abstinence. Three

methods focus on increasing positives. First, “catch your partner doing something nice” asks each person to notice and acknowledge one nice thing each day that his or her partner did. Second, “caring

day” involves each person planning ahead to surprise his or her partner with a day when the person does some special things to show his or her caring. Third, “shared rewarding activities” for fun

together, either by themselves or with their children or other couples, can bring the couple closer together. Such shared activities are associated with positive recovery outcomes (Moos et al. 1990).

Teaching communication skills can help the substance abuser and spouse deal with stressors in their relationship and in their lives, and this may reduce the risk of relapse. BCT includes basic

communication skills of effective listening and speaking, and use of planned communication sessions. Couples also learn more advanced skills of conflict resolution, skills in negotiating agreements for

desired changes, and problem-solving skills.

Continuing recovery

Most couples who attend BCT sessions faithfully show substantial improvement. However, when the structure of the weekly BCT sessions ends, there is a natural tendency for backsliding. Therefore, it is

critical to help couples maintain the gains they made in BCT and prevent or minimize relapse. Near the end of weekly sessions, the BCT counselor helps the couple make a continuing recovery plan that

specifies what aspects of BCT (e.g., trust discussion) they wish to continue and an action plan of steps to prevent or minimize relapse. Couple checkup visits every few months for an extended period can

encourage continued progress. Finally, those with more severe problems may benefit from periodic couple relapse prevention sessions in the year after weekly BCT ends (O’Farrell 1993a).

Evidence for Family Therapy

Research reviewed in detail elsewhere (Epstein and McCrady 1998; O’Farrell and Fals-Stewart 2001, 2003, 2006) shows that of these family-based methods to aid recovery when the substance abuser

has sought help, BCT has the strongest evidence base. Over 15 randomized trials have compared substance abuse and relationship outcomes for alcohol- and drug-abusing patients treated with BCT or

individual counseling. Many of the studies compared equally intensive treatments of BCT plus individual counseling with individual counseling alone. The studies show a fairly consistent pattern of

results. Substance-abusing patients who received BCT more often achieved abstinence and had fewer substance-related problems, happier relationships, and lower risk of couple separation and divorce

than those who received only individual treatment (e.g., Fals-Stewart et al. 1996, 2006; O’Farrell et al. 1992; Winters et al. 2002). Although earlier studies of BCT were done with white male alcohol- and

drug-abusing patients and their female partners, more recent studies have shown the same pattern of superior results for African American and Hispanic patients, heterosexual female patients, and both

male and female same-sex couples with a substance-abusing member. Finally, BCT produces greater improvements than individual-based treatment in compliance with recovery-related medication (e.g.,Print: Chapter 30. Family Therapy

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disulfiram for alcoholic patients, naltrexone for opioid patients), intimate partner violence, and emotional problems of the couple’s children (e.g., Fals-Stewart and O’Farrell 2003; Fals-Stewart et al.

2002; Kelley et al. 2002).

TABLE 30–3. Family-based methods to aid recovery when the substance abuser has sought help

Major approaches to aid recovery

Network therapy (see Chapter 28)

Family systems therapy (FST)—Joining with the family and restructuring family alliances and interactions.

Behavioral couples therapy (BCT)—Recovery contract with daily trust discussion supports abstinence; positive activities and communication skills improve relationship.

Evidence for these approaches

BCT has the strongest evidence base of over 15 randomized trials.

BCT produces more abstinence, happier relationships, better compliance with recovery-related medication, and greater reductions in partner violence and emotional problems of the couple’s children than individual-based

treatment.

Evidence supports FST for adolescent substance abusers and young adult heroin-dependent patients.

Evidence that supports FST with adult alcoholism is not very extensive.

There is also evidence supporting the clinical utility of FST. Evidence for the effectiveness of FST is strongest for adolescent substance abusers (e.g., Szapocznik et al. 1988) and young adult

heroin-dependent patients (Stanton et al. 1982). Although family systems concepts have influenced clinicians’ working with adult alcoholic patients and their families (e.g., Steinglass et al. 1987), the

evidence base supporting this practice is not very extensive. There have been only a small number of studies, generally with small sample sizes, and without a consistent pattern of favorable results.

Interestingly, however, one study (Shoham et al. 1998) found FST to be superior to BCT at retaining in treatment couples with more seriously disturbed communication patterns. If replicated, these

findings might implicate a patient–treatment matching effect.

Table 30–3 summarizes key points about family-based methods to aid recovery when the substance abuser has sought help.

CONCLUSION

This chapter described a variety of family interventions to help the family and initiate change when the substance abuser resists treatment and to aid recovery once treatment has begun. It also showed

that popular approaches may or may not have a strong evidence base. In helping the family, Al-Anon facilitation and referral helps family members as intended and believed by its many adherents.

However, coping skills training, which not only helps the family but also reduces violence and drinking better than Al-Anon, is virtually unknown. For initiating change, the Johnson Institute intervention

is very popular and proponents often state that the approach is very effective, but research has demonstrated that methods such as CRAFT are far more effective. For aiding recovery, BCT appears to be a

very effective treatment for married or cohabiting substance-abusing patients, but it is rarely used by substance abuse treatment providers in non-research settings (Fals-Stewart and Birchler 2001).

Dissemination of effective family-based treatment methods is a shared responsibility between researchers and treatment providers. Investigators need to examine family treatment techniques that

providers can adopt, given the economic and system constraints faced by community programs. For example, the involvement of managed care in substance abuse treatment has resulted in the more

routine use of brief interventions. Thus, family-based treatment methods that require multiple therapy sessions over the course of several months may not be adopted, regardless of effectiveness.

Conversely, it is the responsibility of providers and treatment programs to consider using family-based treatment methods that may be less familiar (e.g., behavioral interventions), but nonetheless

more effective, than traditional approaches. This would require challenging preconceived notions about what long-standing clinical wisdom may dictate as effective. Although these changes may be

difficult to implement, the beneficiaries are likely to be substance-abusing patients and their families.

KEY POINTS

Family therapy interventions have been designed for three main purposes: 1) to help the family when the substance abuser refuses help, 2) to initiate change when the substance abuser resists treatment, and 3) to aid

recovery once treatment has begun.

Major approaches to help the family when the substance abuser refuses help are 1) Al-Anon facilitation and referral and 2) coping skills therapy (CST).

Studies show that both Al-Anon and CST reduce emotional distress and improve coping by the family member. However, CST leads to less drinking and less violence by the substance abuser than does Al-Anon.

Major approaches to initiate change when the substance abuser resists treatment are 1) the Johnson Institute intervention, 2) a relational intervention sequence for engagement (ARISE), 3) pressure to change (PTC), and 4)

community reinforcement and family training (CRAFT).

Studies show that CRAFT is most effective in initiating change, averaging a 68% treatment engagement rate across four randomized trials. Although popular, the Johnson intervention has only a 25%–30% engagement rate

because many families do not follow through with the confrontation meeting that is the hallmark of this approach.

Major approaches to aid recovery once treatment has begun are 1) network therapy, 2) family systems therapy (FST), and 3) behavioral couples therapy (BCT).

Studies show that BCT is effective with alcoholism and drug abuse. BCT produces more abstinence, happier relationships, better compliance with recovery-related medication, and greater reductions in partner violence and in

emotional problems of the couple’s children than does individual-based treatment.

Studies support FST for adolescent and young adult drug abusers, but evidence supporting FST with adult alcoholism is not very extensive.

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Moos RH, Finney JW, Cronkite RC: Alcoholism Treatment: Context, Process, and Outcome. New York, Oxford University Press, 1990

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Steinglass P, Bennett L, Wolin S, et al: The Alcoholic Family. New York, Basic Books, 1987

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SUGGESTED READING

Al-Anon Family Groups: Al-Anon Faces Alcoholism. New York, Al-Anon Family Groups, 1985

Johnson VE: Intervention: How to Help Someone Who Doesn’t Want Help. Minneapolis, MN, Johnson Institute Books, 1986

Landau J, Garrett J: Invitational Intervention: A Step by Step Guide for Clinicians Helping Families Engage Resistant Substance Abuses in Treatment. New York, Haworth, 2006

Nowinski JK: Family Recovery and Substance Abuse: A Twelve-Step Guide for Treatment. Thousand Oaks, CA, Sage, 1999

O’Farrell TJ, Fals-Stewart W: Behavioral Couples Therapy for Alcoholism and Drug Abuse. New York, Guilford, 2006

Rychtarik RG, McGillicuddy NB, Duquette JA: Coping skills training program for women with alcoholic partners: therapist manual. Unpublished manuscript, University at Buffalo, The State University of New York, 1995. Available

from Robert Rychtarik, Ph.D., Research Institute on Addictions, 1021 Main St, Buffalo, NY 14203

Smith JE, Meyers RJ: Motivating Substance Abusers to Enter Treatment: Working With Family Members. New York, Guilford, 2004

Steinglass P, Bennett L, Wolin, S, et al: The Alcoholic Family. New York, Basic Books, 1987

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