Family Systems Therapy

   

1. Identify the central role of family and the treatment options available to treat the family to protect the system as a whole.

2. Recognize the most common and  severe types of dysfunction to protect the public.                           

 

Family Systems Therapy for Substance Abuse

This course introduces the changing definition of “family,” the concept of family in the United States, and the family as an ecosystem within the larger context of society. The chapter discusses the evolution of family therapy as a component of substance abuse treatment, outlines primary models of family therapy, and explores this approach from a systems perspective. The course also presents the stages of change and levels of recovery from substance abuse. Effectiveness and cost benefits of family therapy are briefly discussed.

Introduction

The family has a central role to play in the treatment of any health problem, including substance abuse. Family work has become a strong and continuing theme of many treatment approaches, but family therapy is not used to its greatest capacity in substance abuse treatment. A primary challenge remains the broadening of the substance abuse treatment focus from the individual to the family.

The two disciplines, family therapy and substance abuse treatment, bring different perspectives to treatment implementation. In substance abuse treatment, for instance, the client is the identified patient (IP)—the person in the family with the presenting substance abuse problem. In family therapy, the goal of treatment is to meet the needs of all family members. Family therapy addresses the interdependent nature of family relationships and how these relationships serve the IP and other family members for good or ill. The focus of family therapy treatment is to intervene in these complex relational patterns and to alter them in ways that bring about productive change for the entire family. Family therapy rests on the systems perspective. As such, changes in one part of the system can and do produce changes in other parts of the system, and these changes can contribute to either problems or solutions.

It is important to understand the complex role that families can play in substance abuse treatment. They can be a source of help to the treatment process, but they also must manage the consequences of the IP's addictive behavior. Individual family members are concerned about the IP's substance abuse, but they also have their own goals and issues. Providing services to the whole family can improve treatment effectiveness.

Meeting the challenge of working together will call for mutual understanding, flexibility, and adjustments among the substance abuse treatment provider, therapist, and family. This shift will require a stronger focus on the systemic interactions of families. Many divergent practices must be reconciled if family therapy is to be used in substance abuse treatment. For example, the substance abuse counselor typically facilitates treatment goals with the client; thus the goals are individualized, focused mainly on the client. This reduces the opportunity to include the family's perspective in goal setting, which could facilitate the healing process for the family as a whole.

Working out ways for the two disciplines to collaborate also will require a re-examination of assumptions common in the two fields. Substance abuse counselors often focus on the individual needs of people with substance use disorders, urging them to take care of themselves. This viewpoint neglects to highlight the impact these changes will have on other people in the family system. When the IP is urged to take care of himself, he often is not prepared for the reactions of other family members to the changes he experiences, and often is unprepared to cope with these reactions. On the other hand, many  therapists have hoped that bringing about positive changes in the family system concurrently might improve the substance use disorder. This view tends to minimize the persistent, sometimes overpowering process of addiction.

Both of these views are consistent with their respective fields, and each has explanatory power, but neither is complete. Addiction is a major force in people with substance abuse problems. Yet, people with substance abuse problems also reside within a powerful context that includes the family system. Therefore, in an integrated substance abuse treatment model based on family therapy, both family functioning and individual functioning play important roles in the change.

What Is a Family?

There is no single, immutable definition of family. Different cultures and belief systems influence definitions, and because cultures and beliefs change over time, definitions of family by no means are static. While the definition of family may change according to different circumstances, several broad categories encompass most families:

Traditional families, including heterosexual couples (two parents and minor children all living under the same roof), single parents, and families including blood relatives, adoptive families, foster relationships, grandparents raising grandchildren, and stepfamilies.

Extended families, which include grandparents, uncles, aunts, cousins, and other relatives.

Elected families, which are self-identified and are joined by choice and not by the usual ties of blood, marriage, and law. For many people, the elected family is more important than the biological family.

Examples would include

Emancipated youth who choose to live among peers
Godparents and other non-biologically related people who have an emotional tie (i.e., fictive kin)
Gay and lesbian couples or groups (and minor children all living under the same roof)

The idea of family implies an enduring involvement on an emotional level. Family members may disperse around the world, but still be connected emotionally and able to contribute to the dynamics of family functioning. In family therapy, geographically distant family members can play an important role in substance abuse treatment and need to be brought into the therapeutic process despite geographical distance.

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. When commencing therapy, the therapist needs to ask the client, “Who is important to you? What do you consider your family to be?” It is critical to identify people who are important in the person's life. 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. No one should be automatically included or excluded.

In some situations, establishing an individual in treatment may require a metaphoric definition of family, such as the family of one's workplace. As treatment progresses, the idea of family sometimes may be reconfigured, and the notion may change again during continuing care. In other cases, clients will not allow contact with the family, may want the counselor or therapist to see only particular family members, or may exclude some family members.

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 or her behavior, the others will also change as a consequence, which in turn causes subsequent changes in the member who changed initially. This also demonstrates that it is impossible to know what comes first: substance abuse or behaviors that are called “enabling.”

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, which portrays family systems as self-regulating with a primary need to maintain balance.

The Family as an Ecosystem

Substance abuse impairs physical and mental health, and it strains and taxes the agencies that promote physical and mental health. In families with substance abuse, family members often are connected not just to each other but also to any of a number of government agencies, such as social services, criminal justice, or child protective services. The economic toll includes a huge drain on individuals' employability and other elements of productivity. The social and economic costs are felt in many workplaces and homes.

The ecological perspective on substance abuse views people as nested in various systems. Individuals are nested in families; families are nested in communities. Kaufman (1999) identifies members of the ecosystem of an individual with a substance abuse problem as family, peers (those in recovery as well as those still using), treatment providers, non-family support sources, the workplace, and the legal system.

The idea of an ecological framework within which substance abuse occurs is consistent with family therapy's focus on understanding human behavior in terms of other systems in a person's life. Family therapy approaches human behavior in terms of interactions within and among the subsets of a system. In this view, family members inevitably adapt to the behavior of the person with a substance use disorder. They develop patterns of accommodation and ways of coping with the substance use (e.g., keeping children extraordinarily quiet or not bringing friends home). Family members try to restore homeostasis and maintain family balance. This may be most apparent once abstinence is achieved. For example, when the person abusing substances becomes abstinent, someone else may develop complaints and/or “symptoms.”

Homeostasis

A young couple married when they were both 20 years old. One spouse developed alcoholism during the first 5 years of the marriage. The couple's life increasingly became chaotic and painful for another 5 years, when finally, at age 30, the substance-abusing spouse entered treatment and, over the course of 18 months, attained a solid degree of sobriety. Suddenly, lack of communication and difficulties with intimacy came to the fore for the non–substance-abusing spouse, who now often feels sad and hopeless about the marital relationship. The non–substance-abusing spouse finds, after 18 months of the partner's sobriety, that the sober spouse is “no longer fun” or still does not want to make plans for another child.

Almost all young couples encounter communication and intimacy issues during the first decade of the relationship. In an alcoholic marriage or relationship, such issues are regularly pushed into the background as guilt, blame, and control issues are exacerbated by the nature of addictive disease and its effects on both the relationship and the family.

The possible complexities of the above situation illustrate both the relevance of family therapy to substance abuse treatment and why family therapy requires a complex, systems perspective. Many system-related answers are possible: Perhaps the non–substance-abusing spouse is feeling lonely, unimportant, or an outsider. With the focus of recovery on the addiction—and the IP's struggles in recovery—the spouse who previously might have been central to the other's drinking and/or maintaining abstinence, even considered the cause of the drinking, is now, 18 months later, tangential to what had been major, highly emotional upheavals and interactions. The now “outsider spouse” may not even be aware of feeling lonely and unimportant but instead “acts out” these feelings in terms of finding the now sober spouse “no fun.” Alternatively, perhaps the now sober spouse is indeed no fun, and the problems lie in how hard it is for the sober spouse to relax or feel comfortable with sobriety—in which case the resolution might involve both partners learning to develop a new lifestyle that does not involve substance use.

The joint use of both recovery and family therapy techniques will improve marital communication and both partners' capacity for intimacy. These elements of personal growth are important to the development of serenity in recovery and stability in the relationship.

Family members may have a stronger desire to move toward overall improved functioning in the family system, thus compelling and even providing leverage for the IP to seek and/or remain in treatment through periods of ambivalence about achieving a sober lifestyle. Alternately, clarifying boundaries between dysfunctional family members—including encouraging IPs to detach from family members who are actively using—can alleviate stress on the IP and create emotional space to focus on the tasks of recovery.

What Is Family Therapy?

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.

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 ameliorates the impact of chemical dependency on both the IP and the family. Frequently, in the process, marshaling the family's strengths requires the provision of basic support for the family.

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, often with the entire family group or subsets thereof, but sometimes with a single participant, who may or may not be the person with the substance use disorder.

A distinction should be made between family therapy and family-involved therapy. Family-involved therapy attempts to educate families about the relationship patterns that typically contribute to the formation and continuation of substance abuse. It differs from family therapy in that the family is not the primary therapeutic grouping, nor is there intervention in the system of family relationships. Most substance abuse treatment centers offer such a family educational approach. It typically is limited to psycho education to teach the family about substance abuse, related behaviors, and the behavioral, medical, and psychological consequences of use.

In addition, programmatic enhancements (such as classes that teach English as a second language) also are not family therapy. Although educational family activities can be therapeutic, they will not correct deeply ingrained, maladaptive relationships.

The following discussions present a brief overview of the evolution of family therapy models and the primary models of family therapy used today as the basis for treatment.

Historical Models of Family Therapy

Marriage and family therapy had its origins in the 1950s, adding a systemic focus to previous understandings of the family. Systems theory recognizes that:

A whole system is more than the sum of its parts.
Parts of a system are interconnected.
Certain rules determine the functioning of a system.
Systems are dynamic, carefully balancing continuity against change.
Promoting or guarding against system entropy (i.e., disorder or chaos) is a powerful dynamic in the family system balancing change of the family roles and rules.

The strategic school of family therapy “introduced two of the most powerful insights in all of family therapy: that family members often perpetuate problems by their own actions; and that directives tailored to the needs of a particular family can sometimes bring about sudden and decisive change”

Based on observations of the relationship between family structure and behavior, along with work with inner-city children and their families, Sal Minuchin (1974) developed another approach, structural family therapy. Minuchin and Fishman (1981) believed that families use a limited repertoire of self-perpetuating relational patterns and that family members divide into subsystems with boundaries that regulate family communication and behavior. They sought to shift family boundaries so the boundary between parents and children was clearer. Intervention is aimed at having the parents work more cooperatively together and at reducing the extent to which children assume parental responsibilities within the family.

One major model that emerged during this developmental phase was cognitive–behavioral family and couples therapy. It grew out of the early work in behavioral marital therapy and parenting training, and incorporated concepts developed by Aaron Beck. Beck reasoned that people react according to the ways they think and feel, so changing maladaptive thoughts, attitudes, and beliefs would eliminate dysfunctional patterns and the triggers that set them in motion (Beck 1976). This union of cognitive and behavioral therapies in a family setting was new and useful. The therapist considers not only how people's thoughts, feelings, and emotions influence their behavior, but also the impact they have on spouses and other family members. Cognitive–behavioral family therapy and behavioral couples therapy are two models that have strong empirical support.

Primary Family Therapy Models in Use Today

There are numerous variations on the family therapy theme. Some approaches to family therapy reach out to multiple generations or family groups. Some treat just one person, who may or may not be the IP. Usually, though, family therapy involves a therapist meeting with several family members. An expansive concept of family therapy also might spin off group programs that, for example, could treat the IP's spouse, children in groups (children do best if they first participate in groups that prepare them for family therapy), or members of a residential treatment setting. Most family therapy meetings take place in clinics or private practice settings. Home-based therapy breaks from the traditional clinical setting, reasoning that joining the family where it lives can help overcome shame, stigma, and resistance.

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 the people who abuse substances may develop codependence, which causes them to enable the IP's substance abuse. Limited controlled research evidence is available to support the disease model, but it nonetheless is influential in the treatment community as well as in the general public.

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.

Most recently, multidimensional family therapy (MDFT) has integrated several different techniques with emphasis on the relationships among cognition, affect (emotionality), behavior, and environmental input. MDFT is not the only family therapy model to adopt such an approach. Functional family therapy, multisystemic therapy, and brief strategic family therapy all adopt similar multidimensional approaches.

Family Therapy in Substance Abuse Treatment

Goals of Family Therapy

The integration of family therapy in substance abuse treatment is still relatively rare. Family therapy in substance abuse treatment helps families become aware of their own needs and provides genuine, enduring healing for people. Family therapy works to shift power to the parental figures in a family and to improve communication. Other goals will vary according to which member of the family is abusing substances. Family therapy can answer questions such as:

Why should children or adolescents be involved in the treatment of a parent who abuses substances?

What impact does a parent abusing substances have on his or her children?

How does adolescent substance abuse impact adults?

What is the impact of substance abuse on family members who do not abuse substances?
Whether a child or adult is the family member who uses substances, the entire family system needs to change, not just the IP. 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 to work together more effectively and to 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 are at increased risk of developing substance abuse problems. The single most potent risk factor of future maladaption, predisposition to substance use, and psychological difficulties is a parent's substance-abusing behavior.

Therapeutic Factors

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 them might be acceptance from the therapist; improved communication; organizing the family structure; determining accountability; and enhancing impetus for change, which increases the family's motivation to change its patterns of interaction and frees the family to make changes. 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 discussed. If the subject comes up, the tone of the exchange is likely to be accusatory and negative.

In the supportive environment of family therapy, this uneasy silence 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 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. Often family members are surprised to learn that others share their feelings, and new lines of communication open up. 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. Each of these improvements in family life and coping skills is a highly desirable outcome, whether or not the IP's drug or alcohol problems are immediately resolved. It is clearly a step forward for the family of a person abusing substances to become a stable, functional environment within which abstinence can be sustained.

To achieve this goal, family therapy facilitates changes in maladaptive interactions within the family system. The therapist looks for unhealthy relational structures (such as parent-child role reversals) and faulty patterns of communication (such as a limited capacity for negotiation). In contrast to the peripheral role that families usually play in other therapeutic approaches, families are deeply involved in whatever changes are affected. In fact, the majority of changes will take place within the family system, subsequently producing change in the individual abusing substances.

Family therapy is highly applicable across many cultures and religions, and is compatible with their bases of connection and identification, belonging and acceptance. Most cultures value families and view them as important. This preeminence suggests how important it is to include families in treatment. It should be acknowledged, however, that a culture's high regard for families does not always promote improved family functioning. In cultures that revere families, people may conceal substance abuse within the family because disclosure would lead to stigma and shame.

Additionally, the definition, or lack of definition, of the concept of “rehabilitation” varies greatly across cultural lines. Cultures differ in their views of what people need in order to heal. The identities of individuals who have the moral authority to help (for example, an elder or a minister) can differ from culture to culture. Therapists need to engage aspects of the culture or religion that promote healing and to consider the role that drugs and alcohol play in the culture.

Effectiveness of Family Therapy

While there are limited studies of the effectiveness of family therapy in the treatment of substance abuse, important trends suggest that family therapy approaches should be considered more frequently in substance abuse treatment. Much of the federally funded research into substance abuse treatment has focused on criminal justice issues, co-occurring disorders, and individual-specific treatments. One reason is that research with families is difficult and costly. Ambiguities in definitions of family and family therapy also have made research in these areas difficult.

Although the effectiveness of family therapy is documented in a growing body of evidence, integrating family therapy into substance abuse treatment does pose some specific challenges:

Family therapy is more complex than nonfamily approaches because more people are involved.

Family therapy takes special training and skills beyond those typically required in many substance abuse treatment programs.

Relatively little research-based information is available concerning effectiveness with subsets of the general population, such as women, minority groups, or people with serious psychiatric problems.

Co-occurring problems

Even though an individual with a substance use disorder generally brings a family into treatment, it is possible that more than one person in the family has substance abuse problems, mental illness, problems with domestic violence, or some other major difficulty. Substance abuse, in fact, may be a secondary reason for referral for therapy. Changing the family's maladaptive patterns of interaction may help to correct psychosocial problems among all family members.

Biological aspects of addiction

Other important considerations involve the biological and physiological aspects of addiction and recovery. The recovery process varies according to the type of drug, the extent of drug use, and the extent of acute and chronic effects. Recovery also may depend, at least partly, on the extent to which the drugs are intertwined with antisocial behavior and co-occurring conditions. For the IP, post-acute withdrawal symptoms also will commonly present and interfere with family therapy for a significant period before gradually subsiding.

The biological aspects of addiction also may affect the type of therapy that can be effective. For example, family therapy may not be as effective for someone whose drug use has caused significant organic brain damage or for a person addicted to cocaine who has become extremely paranoid. Severe psychopathology, however, should not automatically exclude a client from family therapy. Even in these cases, with appropriate individual and psychopharmacological treatment, family therapy may be helpful since other members of the family might need and benefit from family therapy services.

Safety and Appropriateness of Family Therapy

Only in rare situations is family therapy inadvisable. Occasionally, it will be inappropriate or counterproductive because of reasons such those as mentioned above. Sometimes, though, family therapy is ruled out due to safety issues or legal constraints. Family or couples therapy should not take place unless all participants have a voice and everyone can raise pertinent issues, even if a domineering family member does not want them discussed. Family therapy can be used when there is no evidence of serious domestic or intimate partner violence. Engaging in family therapy without first assessing carefully for violence can lead not only to poor treatment, but also to a risk for increased abuse.

A systems approach presumes that all family members have roughly equal contributions to the process and have equity in terms of power and control. This belief is not substantiated in the research on family violence. Hence, family therapy only should be used when one family member is not being terrorized by another. Resistance from a domineering family member can be addressed and restructured by first allying with this family member and then gradually and gently questioning this person (and the whole family) about the appropriateness of the domineering behavior.

Only the most extreme anger contraindicates family therapy. Kaufman and Pattison (1981) developed the concept of the need for a period of abstinence before sufficient trust can be built to counteract the anger. Including all family members in treatment and providing them a forum for releasing their anger may help to work toward that threshold. Redefining the problem as residing within the family as a whole can help transform the anger into motivation for change. In turn, this motivation can be used to restructure the family's interactions so that the substance abuse is no longer supported. The therapist's ability to reframe proposed obstructions by family members is often the key to creating a positive therapeutic direction.

If, during the screening interview, it becomes clear that a batterer is endangering a client or a child, the treatment provider should respond to this situation before any other issue and, if necessary, suspend the rest of the screening interview until the safety of the client can be ensured. The provider should refer the client or child to a domestic violence program and possibly to a shelter and legal services, and should take necessary steps to ensure the safety of affected children. Any outcry of anticipated danger needs to be regarded with the utmost seriousness and immediate precautions taken.

Genograms

One technique used by family therapists to help them understand family relations is the genogram—a pictorial chart of the people involved in a three generational relationship system, marking marriages, divorces, births, geographical location, deaths, and illness. This is typically explained to the client during an initial session and developed as sessions progress, is used for discussion points, and is especially helpful when client and therapist reach a point of being “stuck” in the therapeutic process. Genograms can be used to help identify root causes of behaviors, loyalties, and issues of shame within a family. Working on a genogram can create bonding and increased trust between the therapist and client.

The genogram has become a basic tool in many family therapy approaches. Significant physical, social, and psychological dysfunction may be added to it. Though the preparation of a genogram is not standardized, most of them begin with the legal and biological relationships of family members. They may also note family members' significant events (such as births, deaths, and illnesses), attributes (religious affiliation, for instance), and the character of relationships (such as alliances and conflicts). Different genogram styles search out different information and use different symbols to depict relationships. In addition, a genogram can show “key facts about individuals and the relationships of family members. For example, in the most sophisticated genogram one can note the highest school grade completed, a serious childhood illness, or an overly close or distant relationship. The facts symbolized on the genogram offer clues to the family's secrets and mythology since families tend to obscure what is painful or embarrassing in their history”. A family map is a variation of the genogram that arranges family members in relation to a specific problem (such as substance abuse).

Genograms enable clinicians to ascertain the complicated relationships, problems, and attitudes of multigenerational families. Genograms can also be used to help family members see themselves and their relationships in a new way.

Traditional Models of Family Therapy

The family therapy field is diverse, but certain models have been more influential than others, and models that share certain characteristics can be grouped together. Family therapy theories can be roughly divided into two major groups. One includes those that focus primarily on problem solving, where therapy is generally brief, more concerned with the present situation, and more pragmatic. The second major group includes those that are oriented toward intergenerational, dynamic issues; these are longer-term, more exploratory, and concerned with family growth over time. Within these larger divisions, other categories can be developed based on the assumptions each model makes about the source of family problems, the specific goals of therapy, and the interventions used to induce change.

In recent years, calls for the use of evidence-based treatment models have increased. It may be necessary to use evidence-based approaches, especially for adolescents, to get managed care organizations to pay for services. A declaration that a provider is using an evidence-based model, however, may become complicated because the majority of family therapists are eclectic in their use of techniques, and few adhere strictly and exclusively to one approach. Furthermore, evidenced-based approaches may not be appropriate for all cultures or adaptable to practice in all settings. It is important that the research-to-practice issues should be addressed and that research, conducted under conditions that may be artificial to the practice of therapy, be carefully critiqued.

Family Therapy Concepts

The field of family therapy has developed a number of theoretical concepts that can help substance abuse treatment providers better understand clients' relationships with their families. In addition, a number of therapeutic practices can assist in the treatment of substance use disorders in the context of family systems. This section provides information about some of these concepts and practices. For more information, refer to citations in the previous section. In addition, Nichols and Schwartz's The Essentials of Family Therapy 2001 provides an overview of the background, theory, and practices of family therapy. Also, see appendix D, which lists further sources of information.

There are a number of theoretical approaches to family therapy, but most of them share many concepts and assumptions. Perhaps foremost among these is the acceptance of the principles of systems theory that views the client as a system of parts embedded within multiple systems—a community, a culture, a nation. The family system has unique properties that make it an ideal site for assessment and intervention to correct a range of problems, including substance abuse.

Individual, Family, and Environmental Systems

Elements of the family as a system

Complementarity. Complementarity refers to an interactional pattern in which members of an intimate relationship establish roles and take on behavioral patterns that fulfill the unconscious needs and demands of the other. An implication when treating substance abuse is that the results of one family member's recovery need to be explored in relation to the rest of the family's behavior.

Boundaries. Structural and strategic models of family therapy stress the importance of paying attention to boundaries within the family system, which delineate one family member from another; generational boundaries within families; or boundaries between the family and other systems, and regulate the flow of information in the family and between systems outside the family. Ideally, boundaries should be clear, flexible, and permeable, allowing movement and communication (Brooks and Rice 1997). However, dysfunctional patterns can arise in boundaries ranging from extremes of enmeshment (smotheringly close) to disengagement (unreachably aloof). When boundaries are too strong, family members can become disengaged and the family will lack the cohesion needed to hold itself together. When boundaries are too weak, family members can become psychologically and emotionally enmeshed and lose their ability to act as individuals. Appropriate boundaries vary from culture to culture, and the clinician needs to consider whether a pattern of disengagement or enmeshment is a function of culture or pathology.

Subsystems. Within a family system, subsystems are separated by clearly defined boundaries that fulfill particular functions. These subsystems have their own roles and rules within the family system. For example, in a healthy family, a parental subsystem (which can be made up of one or more individual members) maintains a degree of privacy, assumes responsibility for providing for the family, and has power to make decisions for the family (Richardson 1991). These subsystem rules and expectations can have a strong impact on client behavior and can be used to motivate or influence a client in a positive direction.

Enduring family ties. Another important principle of family therapy is that families are connected through more than physical proximity and daily interactions. Strong emotional ties connect family members, even when they are separated. Counselors need to address issues, such as family loyalty, that continue to shape behavior even if clients have detached in other ways from their families of origin. With regard to treatment, it is possible to involve a client in a form of family therapy even if family members are not physically present (see below), and the focus of the therapy is on the family system and not the individual client.

Family Therapy With an Individual Client

Szapocznik and colleagues studied a one-person family approach for treating adolescents who abused substances. They compared one-person family therapy with a family group; in both treatments therapists used structural and strategic therapy techniques. (There was, however, no nontherapy control group, nor was there a control that used a different therapeutic approach.) After a 6-month follow-up that included 61 percent of original participants, adolescent clients in both groups were found to have decreased their substance use, and the families improved their ability to function. The authors note, however, that one-person family therapy was most effective when carried out by an experienced therapist proficient in strategic family therapy.

Change and balance. Family rules and scripts are not unchangeable, but families exhibit different degrees of adaptability when faced with the need to change patterns of behavior. A tendency in all families, though, is homeostasis—a state of equilibrium that balances strong, competing forces in families as they tend to resist change so as to maintain the family's balance—that must be overcome if change is to occur. In order to function well, families need to be able to preserve order and stability without becoming too rigid to adapt. Flexibility therefore is an important quality for a high-functioning family, although too much flexibility can lead to a chaotic family environment.

Capacity for change

Families that have members who abuse substances are more likely to show a lack of flexibility, rather than an excess. In a family organized around substance abuse, the tendency toward homeostasis means that other family members, in a misguided attempt to prevent disruption in the family, may enable continued abuse and keep the person using substances from attaining abstinence. Families that are adjusted to substance use—called an alcoholic family by Steinglass and colleagues (1987)—have found ways to accommodate a person's substance abuse and perhaps gain something from the abuse. Steinglass and colleagues (1987) found that alcoholic families generally have limited ideas of acceptable behavior and are particularly wary of change. In many cases, the presence of alcohol (or other substances of abuse) is necessary for family members to express emotion, communicate with one another, have a short-term resolution of conflicts, or express intimacy. It is important to note that the client maintains a consistent “set point” for a level of success in his role within the family.

Adjusting to abstinence

Mostly because of policy and funding, family interventions in substance abuse treatment often target a client's family for a limited period of time. Family therapists, however, can present a good case for long-term family therapy. In a systems model, a problem such as substance abuse can have both beneficial and harmful effects, and a family will adapt its behavior to the substance abuse. In addition to explaining the phenomenon of enabling, this model also explains why the family of a client who has a substance use disorder can be expected to act differently (and not always positively) when the individual with a substance use disorder enters recovery. A family may react negatively to an individual member's cessation of substance use (e.g., children may behave more aggressively or lie and steal to restabilize the family dynamics), or there may be a period of relative harmony that is disrupted when other problems that have been suppressed begin to surface. For example, family members may express resentment and anger more directly to the recovering person. If these other problems are not dealt with, the family's reactions may trigger relapse. Family therapy techniques can resolve problems formerly masked by substance abuse to ensure that the family helps, rather than hinders, a client's long-term abstinence (Kaufman 1999).

Triangles

Murray Bowen developed the concept of triangulation, which occurs when two family members dealing with a problem come to a place where they need to discuss a sensitive issue. Instead of facing the issue, they divert their energy to a third member who acts as a go-between, scapegoat, object of concern, or ally. By involving this other person, they reduce their emotional tension, but prevent their conflict from being resolved and miss opportunities to increase the intimacy in their relationship (Nichols and Schwartz 2001). In families organized around substance abuse, a common pattern is for one parent to be closely allied with a child while the other parent remains distant. In such a triangle, one person, often the child, will actively abuse substances. Triangulation is especially common in families that have low levels of differentiation (that is, high levels of enmeshment), but it does occur to some extent in all families.

The third party in a triangle need not be a family member. As Nichols and Schwartz note, “Whenever two people are struggling with conflict they can't resolve, there is an automatic tendency to draw in a third party”. Counselors should be aware of the possibility of becoming involved in a triangle with clients by competing with the client's family over the client. This process is especially common in programs that treat only the client without involving the family. Triangulation involving the counselor leaves a client feeling torn between the family and the treatment program, and for this reason, the client often terminates treatment. A substance of abuse can also be considered an entity with which the client triangulates to avoid deeper levels of intimacy.

Family therapists have developed a range of techniques that can be useful to substance abuse treatment providers working with individual clients and families.

Behavioral techniques

Behavioral Marital Therapy (BMT) is a behavioral family approach for the treatment of substance use disorders. BMT attempts to increase commitment and positive feelings within a marriage and improve communication and conflict resolution skills. This is important because marital relationships where one partner abuses substances are typically marked by conflict and dissatisfaction. Improvements in the quality of marital interactions can increase motivation to seek treatment and decrease the likelihood of marital dissolution after abstinence is achieved. In situations where one or both partners are unable to participate sincerely because they are too angry or where there is violence, these techniques may not be suitable. BMT and related approaches have been shown to improve both a client's participation in substance abuse treatment and treatment outcomes, as well as improving relations between partners.

BMT Exercises To Increase Commitment and Goodwill

Catch Your Partner Doing Something Nice: Clients are initially asked to notice and record at least one act each day that shows love or caring from their partners. After the next session, clients are instructed to notice and then tell their partner what they have observed. Each client is then asked to pick a favorite caring behavior from the list and act it out in a role-playing exercise. The therapist gives positive feedback and constructive suggestions based on the role-playing exercise. The person acting out the activity can repeat it, incorporating the therapist's suggestions. This exercise is designed to improve spouses' care-taking and communication skills as well as build appreciation for one another.

Caring Days: Each partner is told to select 1 day of the week when he or she will shower the other with acts of kindness and caring. At the next session, the other partner is asked to guess which day was selected. This exercise helps partners notice and understand what each does for the other, while increasing positive actions within the relationship.

Shared Rewarding Activities: Conflict or dysfunction resulting from substance abuse can lead to a significant decline in the amount of time couples spend together in recreational activities. To change this pattern, this exercise first requires couples to list activities they enjoy doing with their partner (either with or without children, inside or outside the home).

At their next session the couple shares their lists, and the therapist points out areas of agreement on both lists. Co-therapists then role-play how they would go about agreeing on and planning a shared activity. The therapist models ways to present activities in a positive manner, plan for potential problems, and learn to agree on activities. Couples subsequently plan and carry out a mutually enjoyable activity.

Structural techniques

In structural family therapy, family problems are viewed as the result of an imbalanced or malfunctioning hierarchical relationship with indistinct or enmeshed, too rigid, or flexible interpersonal boundaries. The complexities of these approaches defy any brief, simple review. Though it well oversimplifies the complexities, one could say that the primary goal is to strengthen or rearrange the structural foundation so the family can function smoothly. After an assessment stage, the therapist generally begins by preparing, with the family, a written contract that clearly describes the goals of treatment and explains the steps necessary to reach them. This contract increases the likelihood that the family will return after the first session because they have a clear idea of how they will resolve their problems.

The structural family therapist generally tries to be warm and empathic while at the same time remaining firm and objective in therapeutic relationships with clients. The therapist motivates clients to change through a process of joining with the family. During this process, the therapist

Identifies and adjusts to the family's way of relating to each other, which will make resistance less likely.

Conveys understanding and acceptance to each person in the family so that everyone will trust the therapist enough to take his or her advice.

Shows respect to each person by virtue of their family role, which could mean, for example, asking parents first for their views on the problem at hand.

Listens as each person expresses feelings, because most people in therapy think that no one understands or cares how they feel.

Makes a special effort to form linkages with family members who are angry, powerful, or doubtful about therapy so that they are engaged.

According to Minuchin and Fishman (1981) joining is “more an attitude than a technique”, and Kaufmann and Kaufman indicate that the process is very deliberate at first, becoming more natural as therapy progresses. While joining typically confirms the family's positive traits and supports the family so that members have the confidence and strength to change, it can also mean challenging the family to provide an impetus to change.

One of the basic techniques of structural family therapy is to mark boundaries so that each member of the family can be responsible for him- or herself while respecting the individuality of others. One of the ways to make respectful individuation possible is to make the family aware when a family member:

Speaks about, rather than to, another person who is present

Speaks for others, instead of letting them speak for themselves

Sends nonverbal cues to influence or stop another person from speaking

When appropriate, the therapist will take action necessary to stop behaviors that contribute to enmeshment in the family.

The therapist needs to observe the family closely by tracking family interactions or by having the family enact a dysfunctional behavior pattern within the therapy session. The therapist then acts accordingly either to restructure boundaries that are too rigid or strengthen boundaries that have become enmeshed or fused. For example, in families where substance abuse is present, one parent often becomes over-involved with a child. In such cases, the therapist needs to strengthen boundaries that support the parents as a unit (or subsystem) capable of maintaining a hierarchical relation with their children and able to resist interference from older generations of the family or people outside the family.

Structural therapists motivate and teach a family new ways of behaving using structuralization. Using this process, the therapist sets an example for how family members should behave toward one another. After observing a problem behavior, such as the family's ignoring one family member's thoughts and needs, the therapist acts in a contrary way (paying special attention to what the usually ignored person thinks, feels, or desires). By setting an example in this manner, the therapist provides a model for how the family can behave and applies gentle pressure on family members to change their behavior.

Other important techniques for restructuring family relations include system recomposition, structural modification, and system focusing (Aponte and Van Dusen 1981). System recomposition helps family members build new systems (perhaps outside the family) or remove themselves from existing systems (which can imply physical separation or changing existing patterns of interaction and communication). Structural modification is the process of constructing or reorganizing patterns of interaction (for instance, by shifting triangles to develop better functioning alliances). System focusing, also called reframing or relabeling, is the process of presenting another perspective on an apparent problem so that it appears solvable or as having positive effects for those who look at it as a problem. Relabeling can help family members see their own complicity in one member's relapse by showing them what they might lose if the recovery were to succeed. For example, the therapist might show children that they gain greater freedom if their parents abuse substances. Relabeling also makes new options for solving problems more apparent and can act to provoke family members to change their behavior. Overall, structural intervention techniques may be difficult to use without some further training. However, they can be employed easily in assessment to understand the ways by which the organization of the family may be structured to support the substance use.

Strategic techniques

Strategic family therapy shares many techniques and concepts with structural family therapy, which are often used together. For example, reframing or relabeling is a process common to both approaches. The structural therapist seeks to alter the basic structure of family relations working on the theory that this will improve the presenting problem. The strategic therapist, however, focuses on solving one specific problem that the family has identified and is concerned only with basic family interactions and behavior that perpetuate the presenting problem. To the strategic therapist, interactions are not the result of underlying structural problems.

Different approaches fit into the strategic approach. All of them have in common relabeling/reframing and a focus on sequence of interactions. They differ in the scope (length) of the interaction they observe; however they all look for the sequence of interaction and then develop a directive to modify the sequence.

Directives are part of strategic therapy's emphasis on change taking place outside of therapy sessions. Indirect techniques are specific types of directives that may seem unrelated or contradictory to the task at hand but that actually help the family move toward its goal. Reframing is an indirect technique.

Solution-focused techniques

Solution-focused approaches to family therapy build on many of the ideas and techniques used in strategic therapy. This approach is less concerned with the origins of problems and more oriented toward future changes in family interactions. The solution-focused therapist fosters confidence and optimism, so solution-focused approaches do not focus on problems and deficiencies, but rather on solutions and clients' competencies. A variety of solution-focused therapies have been developed specifically for the treatment of substance abuse. Because of its narrow focus on the presenting problem, solution-focused family therapy works well with many existing substance abuse treatment approaches

Although solution-focused therapy appears to be somewhat at odds with traditional substance abuse treatment approaches, Osborn (1997) found that many alcoholism counselors endorse the fundamental assumptions and approach of solution-focused therapy. Even if one does not completely adopt the solution-focused therapy approach, some of this model's techniques can be used with a variety of other approaches, including a focus on the past. One such technique is to ask the client to remember a time when problem behaviors were not present and then to examine what behaviors occurred during these times. “Can you think of a time when the problem was not happening or happening less? What was happening? What were things like at that point? How can that behavior be repeated now?” The focus on past exceptions, whether deliberate (cases where the clients controlled the problem) or random (cases where the problem disappeared temporarily because of factors beyond the client's control), helps clients to see that change is possible and that at times, the apparent problems abated.

Another technique is to use the “miracle question,” which is, “If a miracle occurred, and the presenting problem disappeared, how would you know that the problem had disappeared?” The miracle question is useful because it helps clients see how their lives can be different. This technique is described in greater detail in chapter.

Value of Integrated Models for Clients

Treatment outcomes. Family involvement in substance abuse treatment is positively associated with increased engagement rates for entry into treatment, decreased dropout rates during treatment, and better long-term outcomes.

Client recovery. When family members understand how they have participated in the client's substance abuse and are willing to actively support the client's recovery, the likelihood of successful, long-term recovery improves.

Family recovery. When families are involved in treatment, the focus can be on the larger family issues, not just the substance abuse. Both the individual with the substance use disorder and the family members get the help they need to achieve and maintain abstinence (Collins 1990).

Intergenerational impact. Integrated models can help reduce the impact and recurrence of substance use disorders in different generations.

Integrated Models for Substance Abuse Treatment

Several models have demonstrated effectiveness in treating substance use disorders: structural/strategic family therapy, multidimensional family therapy, multisystemic therapy, and behavioral and cognitive–behavioral family therapy. The others have not demonstrated research-based outcomes for substance abuse treatment at this point, but appear to have made inroads into the substance abuse treatment field.

Structural/Strategic Family Therapy

Theoretical basis

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

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

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

Integrated Structural/Strategic Family Therapy for Substance Abuse

Therapy begins with an assessment of substance abuse, individual psychopathology, and family systems. If chemical dependence or serious substance abuse is discovered, therapy begins by working with the family to achieve abstinence. In the next phase, abstinence is consolidated by resolving dysfunctional rules, roles, and alliances. Then developmental issues and personal psychopathology are treated as part of the family contract. For example, an adolescent client's trouble accepting responsibility and a parent's depression can be part of what the family contracts to change. With that in place, a family plan for relapse prevention is incorporated. Finally, in the abstinence phase, intimacy deepens as families learn to appropriately express feelings, including hostility and mourning of losses.

Techniques and strategies

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

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

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

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

Structural/Strategic Family Therapy's Technique of Joining and Establishing Boundaries

Family: The client is a 22-year-old Caucasian female who abuses prescribed medication and has problems with depression and a thought disorder. She is the younger of two children whose parents divorced when she was 3. She stayed with her mother, while her brother (age 7 at the time) went with their father. Both parents remarried within a few years. Initially, the families lived near each other, and both parents were actively involved with both children, despite ill feelings between the parents. When the client was 7, her stepfather was transferred to a location 4 hours away, and the client's interactions with her father and stepmother were curtailed. Animosity between the parents escalated. When the client was 8, she chose to live with her father, brother, and stepmother, and the mother agreed. The arrangement almost completely severed ties between the parents.

At the time the client entered a psychiatric unit for detoxification, the parents had no communication at all. The initial family contact was with the father and stepmother. As the story unfolded, it became clear that the client had constructed different stories for the two family subsystems of parents. She had artfully played one against the other. This was possible because the birth parents did not communicate.

Treatment: The first task was to persuade the father to contact the mother and request that she attend a family meeting. He, along with the stepmother, agreed, though it took great courage to make the request because the father believed his daughter's negative stories about her relationship with the mother. In the next session, the older brother (the intermediary for the past 4 years) and his wife also attended.

Because the relationship between the counselor and the paternal subsystem had already been established, it was critical to also join with the maternal subsystem before attempting any family system work. The counselor knew that nothing could be accomplished until the mother and stepfather felt an equal parental status in the group. This goal was reached, granting the mother free rein to tell the story as she saw it and express her beliefs about what was happening.

A second task was to establish appropriate boundaries in the family system.

Specifically, the counselor sought to join the separate parental subsystems into a single system of adult parents and to remove the client's brother and sister-in-law as a part of that subsystem. This exclusion was accomplished by leaving them and the client out of the first part of the meeting. This procedural action realigned the family boundaries, placing the client and her brother in a subsystem different from that of the parents.

This activity proved to be positive and productive. By the end of the first hour of a 3-hour session, the parents were comparing information, routing incorrect assumptions about each other's beliefs and behaviors, and forming a healthy, reliable, and cooperative support system that would work for the good of their daughter.

This outcome would have been impossible without taking the time to join with the mother and father in a way that allowed them to feel equal as parents. Removing the brother from the parental subsystem required the client to deal directly with the parents, who had committed themselves to communicating with each other and to speaking to their daughter in a single voice.

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

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

Structural/Strategic Family Therapy in the Criminal Justice System

Darius, a 21-year-old male from the San Juan pueblo in New Mexico, was referred to a clinic for court-mandated substance abuse counseling. He had just received his third violation for driving under the influence (DUI). Darius had been on probation since age 13 for various charges, including burglary and domestic violence, and he had a long history of alcohol and drug abuse. He had been on his own for 8 years and had no family involvement in his life. Darius had participated in several residential treatment programs, but he had been unable to maintain abstinence on his own.

When Darius entered outpatient treatment, he was extremely angry at “the system” and refused initially to cooperate with the therapist or his treatment plan. The therapist was pleasantly surprised that he did show up for his weekly sessions. The following interventions seemed to help Darius:

The counselor suggested that one treatment goal might be for Darius to finally get off probation. At the time, he still had 18 months of probation remaining.
The counselor helped Darius see the relationship of alcohol and drugs to his involvement with the criminal justice system.

The counselor constructed a genogram depicting three generations of Darius' family of origin. This portrayal illustrated a great deal of family disintegration linked to poverty, substance abuse, and his parents' and grandparents' boarding school experience. The counselor initiated couples therapy to help Darius stabilize a significant relationship. After conferring with the probation officer, the counselor decided that Darius would benefit from a 6-month trial of Antabuse treatment. The probation officer required that Darius find regular employment.

During the course of treatment, Darius was able to stop drinking and reevaluate his belief system against the backdrop of his family and the larger judicial system in which he had been so chronically involved. He came to be able to express anger more appropriately and to recognize and process his many losses from family dysfunction. Although many of his family members continued to abuse alcohol, Darius reconnected with an uncle who was in recovery and who had taken a strong interest in Darius' future. Eventually, Darius formed a plan to complete his GED and to begin a course of study at the local community college. The counselor helped Darius to examine how the behaviors and responsibilities he took on in his family shaped his substance use.

Multidimensional Family Therapy

Theoretical basis

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

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

Research basis

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

Techniques and strategies

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

Core components

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

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

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

Multiple Family Therapy

Theoretical basis

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

Techniques and strategies

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

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

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

Multisystemic Family Therapy

Theoretical basis

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

Techniques and strategies

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

Multisystemic therapy is provided in the home.

Low caseloads allow counselors to be available on an as-needed basis around the clock.

Family members are full collaborators with the therapist.

It has a strengths-based orientation in which the family determines the treatment goals.

It is responsive to a wide range of barriers to achieving treatment goals.
Services are designed to meet individual needs of clients, with the flexibility to change as needs change.

The therapist and other members of the treatment team assume responsibility for engaging the client and using creative approaches to achieve treatment goals (Henggeler et al. 1996).

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

Behavioral Family Therapy and Cognitive–Behavioral Family Therapy

Theoretical basis of behavioral family therapy

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

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

Theoretical basis of cognitive–behavioral family therapy

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

Techniques and strategies of behavioral family therapy. To facilitate behavioral change within a family to support abstinence from substance use, the counselor can use the following techniques:

Contingency contracting. These agreements stipulate what each member will do in exchange for rewarding behavior from other family members. For example, a teenager may agree to call home regularly while attending a concert in exchange for her parents' permission to attend it.

Skills training. The counselor may start with general education about communication or conflict resolution skills, then move to skills practice during therapy, and end with the family's agreement to use the skills at home.

Cognitive restructuring. The counselor helps family members voice unrealistic or self-limiting beliefs that contribute to substance abuse or other family problems. Family members are encouraged to see how such beliefs threaten ongoing recovery and family tranquility. Finally, the family is helped to replace these self-defeating beliefs with those that facilitate recovery and individual and family strengths.

Techniques and strategies of cognitive–behavioral family therapy

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

Example of Behavioral and Cognitive–Behavioral Family Therapy

Family: Peter, a 17-year-old white male, was referred for substance abuse treatment. He acknowledged that he drank and smoked marijuana, but minimized his substance use. Peter's parents reported he had come home 1 week earlier with a strong smell of alcohol on his breath. The following morning, when the parents confronted Peter about drinking and drug use he denied using marijuana steadily, declaring, “It's not a big deal. I just tried marijuana once.”

Despite Peter's denial, his parents found three marijuana cigarettes in his bedroom. For at least a year, they had suspected Peter was abusing drugs. Their concern was based on Peter's falling grades (from a B to a C student), his appearance (from meticulous grooming to poor hygiene), and unprecedented borrowing (he had borrowed a lot of money from relatives and friends, most of the time without repaying it).

For the first two family sessions, Peter, his older sister Nancy, 18, and their parents attended. During the sessions, Peter revealed that he resented his father's overt favoritism toward Nancy, who was an honor student and popular athlete in her school, and the related conflict between the parents about the unequal treatment of Peter and Nancy. In fact, the father often was sarcastic and sometimes hostile toward Peter, disparaging his attitude and problems. Peter viewed himself as a failure and experienced depression, frustration, anger, and low self-esteem. Furthermore, Peter wanted to retaliate against his father by causing problems in the family. In this respect, Peter was succeeding. His substance abuse and falling grades had created a hostile environment at home.

Treatment: The counselor used cognitive–behavioral therapy to focus on Peter's irrational thoughts (such as viewing himself as a total failure) and to teach Peter and other family members communication and problemsolving skills. The counselor also used behavioral family therapy to strengthen the marital relationship between Peter's parents and to resolve conflicts between family members. Although the family terminated treatment prematurely after eight sessions, some positive treatment outcomes were realized. They included an improved relationship between Peter and his father, improved academic performance, and an apparent cessation of drug use (a belief based on negative urine test results).

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

Behavioral Family Therapy: Improving Communication

Family: Delbert, a 49-year-old man with alcohol dependence, had stopped drinking during a 28-day inpatient treatment program, which he entered after a DUI arrest. He attended Alcoholics Anonymous (AA), worked every day, and saw his probation officer regularly. In many ways, Delbert was progressing well in his recovery. However, he and his wife, Renee, continued to have daily arguments that upset their children and left both Delbert and Renee thinking that divorce might be their only option. Delbert had even begun to wonder whether his efforts toward abstinence were worthwhile.

Treatment: Delbert and Renee finally sought help from the continuing care program at the substance abuse treatment facility where Delbert was a client. Their counselor, using a behavioral family therapy approach, met with them and began to assess their difficulty.

What became obvious was that their prerecovery communication style was still in place, despite the fact that Delbert was no longer drinking. Their communication style had developed over the many years of Delbert's drinking––and years of Renee's threatening and criticizing to get his attention. Whenever Renee tried to raise any concern of hers, Delbert reacted first by getting angry with her for “nagging all the time” and then by withdrawing. The counselor, realizing the couple lacked the skills to communicate differently, began to teach them new communication skills. Each partner learned to listen and summarize what their partner had said to make sure the point was understood prior to response.

To eliminate the overuse of blaming, the couple instead learned to report how their partner's actions affected them. For example, they learned to say, “I feel anxious when you don't come home on time,” rather than to impugn their partner's character or motivation with invectives such as, “You are still as irresponsible as ever; that's why I can't trust you.”

In addition, since both Delbert and Renee were focused on the negative aspects of their interactions, the therapist suggested they try a technique known as “Catch Your Partner Doing Something Nice.” Each day, both Delbert and Renee were asked to notice one pleasing thing that their partner did. As they were able to do so, their views of each other slowly changed. After 15 sessions of marital therapy, their arguing had decreased, and both saw enough positive aspects of their relationship to merit trying to save it.

Bowen Family Systems Therapy

Theoretical basis

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

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

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

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

Techniques and strategies

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

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

Creating distance. Alcohol and drugs are used to manage anxiety by creating distance in the family.

Triangulation. An emotional pattern that can involve either three people or two people and an issue (such as the substance abuse). In the latter situation, the substance is used to displace anxiety that exists between the two people.

Coping. Substance abuse is used to mute emotional responses to family members and to create a false sense of family equilibrium.

Use of Bowen Family Systems Therapy With Immigrant Populations

Although no demonstrated outcomes substantiate Bowenian therapy to address substance abuse, counselors have often used it to treat clients with substance use disorders who have immigrated to this country. It is believed that this therapeutic approach is a good match for such clients because it emphasizes the intergenerational transmission of anxiety and the effects of trauma that are passed down through generations.

The perspective that the “past is the present” provides a mechanism to understand the lowered self-esteem of a person who has lost everything of importance: language, homeland, culture, possessions, and often, a sense of cultural identity. For many the circumstances of migration are traumatic. Such losses are not only carried from the past, but continue to occur in the present as family members are subject to the indirect consequences of migration, such as unemployment or underemployment, marginal or overcrowded housing, untreated health problems, and poverty. In this situation, alcohol and drugs can provide an expedient way to blot out pain and hopelessness. Healing cannot begin until both the counselor and the client understand the significance of the loss of past cultural identification in light of a current substance use disorder.

Solution-Focused Brief Therapy

Theoretical basis

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

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

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

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

Techniques and strategies

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

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

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

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

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

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

Asking the Miracle Question

If the answer to the miracle question is “I don't know,” as it often is, the client should be encouraged to take all the time needed before answering. The client can also be prompted, if necessary, with questions such as, “As you were lying in bed, what would you notice that would tell you a miracle had occurred? What would you notice during breakfast? What would you notice when you got to work?” Then the therapist should expand on each change noticed.

For example, the therapist might ask, “How would that make a difference in your life?” If the client answered that he would not wake up thinking about drinking, ask, “What would you think about? How would that make a difference?”

Accept the client's answer without narrowing it. Some clients say their miracle would be to win the lottery. The counselor should not narrow the response by saying, “Think of a different miracle.” Instead expand the response by asking questions such as, “What would be different in your life if you won the lottery?” “What would be different if you paid all your bills on time?”

Make the vision interpersonal. Ask, “As your miracle starts to come true, what would other people notice about you?”

Help the client see that elements of the miracle are already part of life. Even if those elements are small, ask, “How can you expand the influence of those small parts of the miracle?”

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

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

Relational questions. Helping clients set goals that take the views of important others into account can extend the benefits of change into the client's environment. A good relational question is, What will other people notice about you as you move closer and closer to your goal? For instance, an adolescent client might declare that he is completely confident that he will not relapse. In reply, he might be asked,

“Do you think your father is that confident?” Being urged to look at his situation from the perspective of the parent, who might only be somewhat confident that the client will not relapse, motivates the client to think about how he must behave to instill more confidence in this important other figure.

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

Case Study of Exceptions to Problem

Family: Darcy had been diagnosed with an alcohol use disorder. In family therapy, she and her husband Steve came to recognize a problem sequence known as a pursuer–distancer pattern. When Steve sensed Darcy distancing from him emotionally, he would begin to worry that she was in danger of going on another drinking binge. His response to this fear was to suggest that Darcy call her sponsor or go to extra AA meetings.

Steve's concern made Darcy feel her independence was threatened. She would get angry, refuse to take Steve's advice, and distance herself even more. Steve would then insist that she call her sponsor, and the tension between them would escalate into an argument. The quarrel often ended when Darcy stormed out of the house to spend the night with her sister, who was not a healthful influence. She would suggest a drink to calm Darcy's nerves––and then join her in a binge.

Treatment: After Darcy and Steve defined this sequence, the therapist helped them look for exceptions to it––times when the sequence started, but did not end in a binge. Both Darcy and Steve were able to identify a solution sequence. Darcy remembered a time when Steve was pestering her. Instead of going to her sister's house, she spent an hour online reading passages and trading messages and suggestions with the online recovery community. Then she called and had lunch with her sponsor before going to an AA meeting where her sponsor was the speaker that day. When she came home, she was able to reassure Steve that she was not tempted to drink at that point and suggested they go to a movie together. Steve recalled an occasion when he was getting anxious about Darcy, but instead of pestering Darcy, he mowed the lawn. The physical activity dissipated his anxiety, and he was then able to talk to Darcy calmly about his concerns without pressuring her to take any specific action. The therapist helped Darcy and Steve to build on these successful times, identifying ways to more positive sequences of behavior.

Matching Therapeutic Techniques to Levels of Recovery

Both individuals and families go through a process of change during substance abuse treatment.

Attainment of sobriety. The family system is unbalanced but healthy change is possible.

Adjustment to sobriety. The family works on developing and stabilizing a new system.

Long-term maintenance of sobriety. The family must rebalance and stabilize a new and healthier lifestyle.

Once change is in motion, the individual and family recovery processes generally parallel each other, although they may not be perfectly synchronized (Imber-Black 1990). For instance, family members may be aware of a drinking problem sooner than the person who is doing the drinking. When a person who drinks excessively comes to treatment, both the client and the family need education about alcohol abuse, and both need to think about seeking help to stop the drinking. Similarly, once the person who drinks decides to stop drinking and makes plans to do so, the family must learn to stop supporting the drinking. Familiar ways of interacting must change if the family is to maintain a healthy emotional balance and support abstinence. In short, as both the individual and the family change, both have to adjust to a change in lifestyle that supports sobriety or abstinence, the changes needed to maintain sobriety or abstinence, and a stable family system.

Different models of integrated treatment suggest different techniques that can be used at different levels of recovery. As the family addresses its challenges and the client addresses a substance use disorder, they will progress from attainment of sobriety to maintenance.

Techniques useful during the stage when the client and the family are preparing to make changes in their lives include the following:

Multidimensional family therapy
  (Liddle 1999)

Motivate family to engage client in detoxification.
Contract with the family for abstinence.
Contract with the family regarding its own treatment.
Define problems and contract with family members to curtail the problems.
Employ Al-Anon, spousal support groups, and multifamily support groups.

Behavioral family therapy

(Kirby et al. 1999)

Conduct community reinforcement training interviews such as interviews with area clergy to help them develop ways to impact the community.

Bowen family system therapy (Bowen 1978)

Reduce levels of anxiety.

Create a genogram showing multigenerational substance abuse; explore family disruption from system events, such as immigration or holocaust.

Orient the nuclear family toward facts versus reactions by using factual questioning.

Alter triangulation by coaching families to take different interactional positions.
Ask individual family members more questions, so the whole family learns more about itself.

During the time that the client and the family are getting used to the changes in their lives, the following techniques are suggested by different models of family therapy:

Structural/strategic systems (Stanton et al. 1982)

Restructure family roles (the main work of this model).
Realign subsystem and generational boundaries.
Reestablish boundaries between the family and the outside world.

Multidimensional family therapy (Liddle 1999; Liddle et al. 1992)

Stabilize the family.
Reorganize the family.
Teach relapse prevention.
Identify communication dysfunction.
Teach communication and conflict resolution skills.
Assess developmental stages of each person in the family.
Consider family system interactions based on personality disorders, and consider whether to medicate for depression, anxiety, or posttraumatic stress disorder.
Consider whether to address loss and mourning, along with sexual or physical abuse.

Cognitive–behavioral family therapy (Azrin et al. 2001; Kirby et al. 1999; Waldron et al. 2000)

Conduct community reinforcement training interviews.
Establish a problem definition.
Employ structure and strategy.
Use communication skills and negotiation skills training.
Employ conflict resolution techniques.
Use contingency contracting.

Solution-focused family

Employ the miracle question.
Ask scaling and relational questions.
Identify exceptions to problem behavior.
Identify problem and solution sequences.
The following techniques are suitable during the period when the gains made by the client and the family during treatment are being solidified and safeguards against relapse or returning to old habits are being implemented:

References: Center for Substance Abuse Treatment. Substance abuse treatment and family therapy. Rockville (MD): Substance Abuse and Mental Health Services Administration; 2004. 232 p. (Treatment Improvement Protocol; no. TIP 39).