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ADDICTION AND FAMILY DYNAMICS Addiction affects families of all…
ADDICTION AND FAMILY DYNAMICS
Addiction affects families of all cultures and socio-economic backgrounds, but there are certain features that families experiencing addiction tend to share. Families in which substance misuse occurs are more likely to experience higher levels of stress and conflict and lower levels of family expressiveness and cohesion. It is not always clear whether the family dynamics led to the addiction or whether the presence of the addiction led to dysfunctional dynamics. However, it is evident they are interconnected and that family dynamics can influence the maintenance of an addiction and the recovery process.
For this Discussion, you will assess the effects of addiction on families and their members, and the interrelated impact of family dynamics on the individual with addiction. You will also examine how family structures can perpetuate addiction and how stigma can influence families to act in enabling way
learning resource Tip 39
Overall Key Messages Families affect and are affected by SUDs. In most cases, including family members in a client’s treatment or services for substance misuse is benefcial and makes achieving and sustaining long-term recovery more likely. Family-based SUD interventions are supported by empirical evidence and have been shown to be effective in promoting long-term behavior change, including recovery. A wide variety of family-based treatment models and approaches are available. You can select from these based in part on the family’s makeup, needs, readiness for change, treatment setting, and level of care required. No two families are identical, and as such, the ways in which family members function and interact with one another will vary from family to family. As a clinician, you should be prepared to adapt SUD treatments and services to each family’s unique background, structure, and situation. Each family has its own ways of behaving and relating to one another. Those dynamics infuence substance misuse and recovery and should be considered when making shared treatment decisions with clients and their family members. You should be able to identify common family structures and dynamics and understand how they infuence substance misuse. This will help you develop more targeted treatments that directly address a given family’s dysfunctions and needs. ix TIP 39 Substance Use Disorder Treatment and Family Therapy Most families are doing their best to adapt to the situation of a family member struggling with substance misuse. In general, families usually are just trying to maintain a steady state (or homeostasis). Sometimes that means engaging in behaviors that actually support the family member’s substance misuse. Avoid blaming, shaming, and using judgmental labels (e.g., referring to family members as “co-dependent” or “enablers”) when working with families. Instead, offer them education, empathy, and support. There are several ways you can integrate family-based treatments and services into care. Motivational interviewing (MI), family-focused interviews and assessments, genograms, and family based treatment goals are just a few options. Families are diverse and may need treatments and services tailored to factors such as their racial/ethnic background, level of acculturation, immigration/nativity status, and history of military service. It is not enough for clinicians to learn about and offer family-based treatments and services for substance misuse. Administrators, directors, and clinical supervisors also play a role in delivering family-based SUD treatment and ensuring programs adopt and maintain a family centered culture. This means comprehensively addressing a wide range of program development and workforce factors, like hiring and retention, training, clinician and supervisor core competencies, and licensing and credentialing. Programs that establish and foster close ties to the surrounding community can better help clients and families access resources that meet their needs. Administrators are vital to this process as well. Content Overview This TIP is divided into six chapters designed to thoroughly cover all relevant aspects of the ways in which families are touched by SUDs and how providers can offer treatment and services to help meet families’ full range of needs. Chapter 1: Substance Use Disorder Treatment: Working With Families This chapter lays the groundwork for understanding the treatment concepts and theories of family-based SUD treatment discussed in later parts of this TIP. It is for providers and administrators. Families are complex entities; no two are the same. To provide effective family-based services for SUDs, one must understand different types of families and the common characteristics families often possess (including their rules, roles, boundaries, and communication styles). Family counseling can help families facing SUDs in many different ways, including by teaching them to better understand how their interactions and behaviors are contributing to a family member’s substance misuse and learning how to adapt their behaviors to support a family member’s recovery. Family-based interventions are often centered on helping families learn how to change their behaviors toward and interactions with one another, how they can be a positive infuence on recovery, and how to prevent substance misuse in future generations. There are numerous familybased treatment models, approaches, settings, and formats for SUDs, giving providers (and their client families) a wide range of tools and options from which to choose. In Chapter 1, you will learn about: The benefts and challenges of offering family counseling for SUDs, including why you should include families in SUD treatment and services and in goal setting for those treatments and services. The history of family-based SUD treatment and how the incorporation of families into traditional treatment approaches and settings has changed over time. The core objectives of current family-based treatment for SUDs, such as helping the family become a source of strength in their family member’s recovery and helping them understand how they infuence their family member’s substance-related behaviors. x TIP 39 Common characteristics present in nearly all families (e.g., roles, rules, communication patterns, degree of loyalty, culture) and how those characteristics varyand subsequently affect a family member’s recovery. The various pathways by which family-based SUD treatment and services are delivered, such as parallel, sequential, and integrated approaches. Different pathways may be more appropriate for certain families depending on their particular structure, way of functioning, and dynamics. The different degrees of family involvement that can occur in SUD treatment across different levels of care and settings (e.g., residential treatment, outpatient care). Chapter 2: Infuence of Substance Misuse on Families This chapter summarizes the ways in which substance misuse affects family dynamics (the ways in which families behave toward and relate to one another) and family systems and the ways in which those in turn infuence substance misuse. This chapter is for providers. Families operate in their own unique ways. Family dynamics play a large role in both sustaining and reducing/preventing substance misuse. Although all families are different, certain families affect and are affected by SUDs in similar ways. You should be aware of how the dynamics among specifc family typessuch as families with young or adolescent children, families with adult children, childless couples, and blended familiesare affected by and contribute to the risk of substance misuse in the family. This will help you better determine which treatment/services are best suited to the family and their dynamics. This chapter also presents the latest empirical evidence about common traits of families touched by drug and alcohol addiction. Again, although each family is different, this discussion will help you understand and identify possible targets of intervention, such as poor communication style, high levels of family confict, ineffective parenting approaches, and lack of family connectedness. In Chapter 2, you will learn the following: Families with SUDs tend to share certain characteristics, which are often the focus of treatment and services. These include problems with communication, confict, parenting skills, family cohesion, and family attitudes about substance use. Most families engage in behaviors to try to maintain homeostasis, or balance. Family members often try to keep things as “normal” and consistent as possible, and in doing so may behave in ways that actually make substance misuse more likely. Sometimes this is called enabling. Rather than criticize or shame families for such behaviors (which are completely normal and, in a way, adaptive), instead work with families to help them learn how to develop healthier behaviors and dynamics. There may be gender-specifc differences in how family dynamics affect and are affected by SUDs. These gender differences may need to be taken into consideration when offering treatment and services. For instance, women are often socialized to be caretakers and to not be confrontational. A mother or daughter may feel that it is not her place to criticize a family member’s substance misuse and may instead engage in caretaking or “enabling” behaviors. These gender beliefs may need to be addressed in treatment if they are contributing to family dysfunction and preventing recovery. In couples in which one partner has an SUD, research suggests there is a high risk of interpersonal violence and mistreatment. Be sure to screen for all forms of abuse. Parents struggling with SUDs may not be able to properly care for their young or adolescent children, possibly leading to negative physical, emotional, economic, and social outcomes for offspring. Neglect and other forms of abuse also may be present. This raises professional and legal issues related to safety, and means loss of child custody may become a factor at some point during treatment/services. xi TIP 39 Children of parents with SUDs may be forced to take on roles inappropriate for their developmental stage. For instance, a teenager may feel that he has to become the “father” of the household because his father has alcohol use disorder and cannot reliably earn a living and help support the family. This can be a signifcant source of stress for the child. It is easy to sympathize with young children living with parents with drug and alcohol addiction, but do not overlook the effects of SUDs on adult children. Even when grown, children can be negatively affected by their parents’ substance misuse, including being at risk for substance misuse themselves as well as other unhealthy outcomes (e.g., suicide attempts, higher mortality). Just by nature of their structure, blended families often struggle with certain diffcult dynamics and situations (like loss of a biological parent or stepparents/stepchildren feeling like “outsiders”). When SUDs are thrown into the mix, this can raise the family stress level even higher. Be particularly sensitive to the diffculties facing blended families with SUDs, and understand how helping them strengthen their bonds with one another can be a powerful factor in supporting recovery and preventing substance misuse. Adolescent substance misuse can negatively affect parents and siblings and also place the youth at risk for dangerous or unhealthy outcomes (like car accidents, dropping out of school, or continued substance misuse into adulthood). A family may need help identifying dynamics and functions that are supporting the teen’s SUD and making recovery more diffcult. Chapter 3: Family Counseling Approaches This chapter reviews research-based family counseling approaches specifcally developed for treating couples and families in which the primary issue facing the family system is an SUD. It describes the underlying concepts, goals, techniques, and research support for each approach. This chapter is for providers. The numerous family-based SUD treatments that exist differ in the strategies and techniques used to address substance misuse. However, Substance Use Disorder Treatment and Family Therapy these treatments share certain features, such as an emphasis on treating the family as a whole rather than focusing only on the individual with an SUD; using a nonblaming, collaborative approach to care; and adapting to the culture and values embraced by each family. Specifc familybased treatments that can be used effectively to help families improve their functioning and enhance recovery include psychoeducation, multidimensional family therapy (MDFT), behavioral couples and family therapy, brief strategic family therapy (BSFT), functional family therapy, and solution-focused brief therapy. This chapter discusses each in detail. In Chapter 3, you will learn the following: Family-based treatment guides families in enhancing their thoughts about and reactions to substance misuse. This in turn typically leads to major changes within the family as a whole. Regardless of approach, all family-based treatment shares certain core aspects. Aspects include improving the health and well-being of the whole family, not just the person with substance misuse; respecting the value of family and other social relationships as a key part of recovery; and meeting harm-reduction goals other than abstinence, which can still beneft the family and the individual. Psychoeducation is a widely used approach to family-based SUD treatment, and many families can improve their functioning and dynamics simply by learning about drug and alcohol addiction and recovery. Do not underestimate the power of this seemingly simple intervention. MDFT has good empirical support for reducing SUDs, especially among adolescents. It addresses individual behaviors and family processes. It has improved functioning among adolescents, parents, families as a whole, and families’ relationships within their communities. Behavioral couples and family counseling approaches help support recovery by teaching clients to improve the quality of their relationships, engage in healthier communication, and build positive relationships with one another. xii TIP 39 BSFT uses a problem-focused, practical approach to reduce or eliminate youth substance misuse and enhance family functioning. Functional family therapy also takes a problemsolving approach to engaging, motivating, and creating behavior change among clients. Families are also taught how to apply their newfound skills to future situations. Solution-focused brief therapy invites families to build a positive vision of their future and identify interpersonal changes and improvements in target behaviors needed to make that vision a reality. Network Therapy uses a combination of individual and group therapy approaches and involves members of the client’s network of supportive family members and friends in sessions. The main goal is for members of the supportive network to learn how they can reinforce the client’s efforts to achieve and maintain abstinence. In addition to understanding specifc treatment approaches, consider offering other family-based skills and services that can support recovery across the continuum of care. These could include engaging the family in treatment, linking members to community and mutual-aid recovery supports, facilitating behavioral contracts between the person in recovery and his or her family members, and teaching relapse prevention techniques (e.g., family-based problem-solving). Case management services can help families address problems within larger systems of care, like healthcare-, education-, legal-, and childcare-related issues. These commonly occur in individuals and families with SUDs and thus should be a standard part of family-based SUD treatment. Family peer recovery support services offer families the valuable opportunity to learn from others who have walked in their shoes. This can be incredibly powerful and healing, as families touched by drug and alcohol addiction often feel isolated and struggle with stigma, shame, and confusion. Chapter 4: Integrated Family Counseling To Address Substance Use Disorders This chapter discusses the advantages and limitations of integrated treatment models and the degree of providers’ involvement with families. It offers guidelines on how to deliver family counseling in combination with specifc SUD treatment and to match counseling approaches to each family’s specifc level of recovery. The intended audience is providers. As a general rule, families should be incorporated into SUD treatment and services to give individuals the best chances at lasting recovery. Be sure to let the individual in recovery decide who in the family should be invited to participate in treatment. Barriers to participation may need to be problem solved, such as family members who live far away, have scheduling conficts, or simply refuse to be a part of treatment. As in individual counseling, screening and assessment are critical components to information gathering, but in this context, both processes should be family based. For instance, discuss not only the individual’s history of substance misuse but also how substance misuse has occurred historically, throughout the family. Rather than focusing entirely on problems within the family, be sure to also explore family members’ strengths, including supportive qualities (e.g., warmth, compassion), talents, and goals. This will help you maintain a positive tone throughout treatment and can help keep families motivated and engaged in care. In Chapter 4, you will learn that: In some instances, certain family members should not be included in SUD treatment and services. Such situations include when intimate partner violence has occurred, when child abuse or neglect has occurred, when individuals are currently withdrawing from substances, when clients with SUDs are also are struggling with psychosis or are suicidal, and when clients have signifcant cognitive problems (like severe learning or memory problems). xiii TIP 39 Substance Use Disorder Treatment and Family Therapy Mandated family treatment can be diffcult because family members are not seeking care willingly. In such cases, MI can help you build rapport with clients and enhance their willingness and desire to participate in treatment. As with individual treatment, screening and assessments should be conducted to identify current and past problems in need of intervention. Use a family-based focus that explores the family history of SUDs, mental disorders, abuse, legal problems, work and school issues, and overall health. Family interviews can help you gather this information and also serve as an opportunity for you to build rapport with families, educate them about treatments and services, and get their “buy-in” to enter and stay engaged in treatment. Family-based assessments help you determine the history of the family’s functioning and substance misuse. Do not forget to also explore the family’s strengths and supports. A genogram can help you and your client families visualize their current and history of substance-related problems. It is also a way to depict their strengths and resources. Family members may each have different goals for treatment, and that’s okay. Your job is to help them identify changes they would like to make, teach them how to make those changes, and guide them in becoming sources of support for one another. You can do this by educating families about SUDs and recovery, facilitating communication between family members, and linking them to community-based resources and support networks. It is common to encounter certain challenges in working with families with SUDs, but these can be overcome by helping families build healthier coping skills, educating them to correct myths and misconceptions about SUDs and recovery, offering case management services to help coordinate schedules and service needs, and addressing each family member’s particular stage of change. Chapter 5: Race/Ethnicity, Sexual Orientation, and Military Status This chapter discusses family counseling for SUDs among families of diverse racial and ethnic backgrounds; lesbian, gay, bisexual, or transgender (LGBT) families; and military families (including active duty personnel and veterans). Each section discusses the latest empirical evidence for familybased SUD treatment with that population as well as suggestions for how you can tailor family-based interventions to improve outcomes. This chapter is for providers. Family-based counseling is supported by empirical evidence as a safe and effective option for overcoming drug and alcohol addiction. However, no SUD treatment is “one size fts all” for all families. Certain families may beneft more from particular treatment approaches, formats, and settings than from others, based in part on their attitudes, beliefs, and dynamics. These attitudes, beliefs, and dynamics often differ based on a given family’s culture or background. As such, it is critical that you as a clinician understand how diverse families may affect and are affected by substance misuse and tailor your treatments and services as needed. For instance, in families of certain racial or ethnic backgrounds, there may be language barriers or cultural beliefs that make treatment seeking less likely. In military families, there may be attitudes that normalize substance misuse and make recovery seem unnecessary. This chapter will guide you through some specifc types of families and how their dynamics, functions, attitudes, and values could affect treatment. In Chapter 5, you will learn that: Diversity among families is an important factor to consider when trying to understand how substance misuse fts into a particular family and which treatments and services may be best for them.
Thombs, D. L., & Osborn, C. J. (2019). Introduction to addictive behaviors (5th ed.). Guilford Press.
Chapter 8: The Family System
Substance Abuse and Mental Health Services Administration. (2020). Chapter 2 – Influence of substance misuse on familiesLinks to an external site., In TIP 39: Substance use disorder treatment and family therapy. https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-02-02-012-508%20PDF.pdf
Read only Chapter 2, pages 23-42.
Review Chapter 8 of the course text, focusing on pages 204-213 on family roles.
Review pages 32-34 in TIP 39 focusing on codependence.
Review the interactive media, Hart City – Family Services Case Study.
Reflect on the complicated relationship among family dynamics, family roles, and addiction.
Post a response to the following:
Explain at least two potential impacts that addiction could have on the family as a whole, its individual members, and their relationships. How can family structures perpetuate addiction? What are some of the reasons why family members act in enabling ways, and what are the implications of these enabling behaviors? Finally, explain how the public stigma of addiction might influence families to act in enabling ways. Be sure to provide examples to support your response.
Support your initial post with evidence from at least one Learning Resource. You may state your opinion and/or provide personal examples; however, you must also back up your assertions with evidence, including in-text citation(s) and reference(s) in APA style.
