Family Solutions
Families can be an incredibly powerful resource and support system for individuals with substance problems. Parents, spouses, and other family members play key roles in an individual’s recovery according to research findings. Having family support at treatment entry has been associated specifically with lower heroin and alcohol use, and is correlated with positive treatment outcomes. Family members can be highly instrumental in influencing an individual’s motivation to change, and to enter and engage in treatment –higher levels of family support are associated not only with a person’s decision to enter treatment, but also their retention in treatment and ultimately their long-term recovery. Patients who describe supportive and cohesive family relationships have fewer drug, family, and psychological problems three months after beginning treatment. In another study that looked at the family connectedness of substance using individuals who were in-treatment compared with those who were not, the in-treatment group perceived significantly greater support from family, providing further evidence that family support correlates with increased motivation to enter and remain in treatment. Additionally, individuals whose families are involved in their treatment, experience fewer and less serious episodes of relapse. (Gifford, 2016; Kelly et al, 2010; Mueser, 2012; Walters, 2000)
People with co-occurring disorders live with or have regular contact with family members, who invest time and money to provide a combination of practical and emotional support. Family involvement in the lives of people with co-occurring disorders is associated with an improved outcome of these disorders, suggesting that these supports are clinically beneficial. (Mueser, 2012)
In a 5-year follow-up study of individuals who had dropped out of treatment, less stress from social networks was the greatest predictor of remission and fewer substance use problems (McKellar, Harris and Moos, 2006). Throughout the research, family support and life stressors have been found to be critical factors in predicting remission from a substance use disorder, but in opposite ways –with high exposure to stressors associated with poor outcomes, and high social / family support associated with better outcomes and higher remission (Grella and Stein, 2013).
The research clearly shows us that the more resources a person has intact, the more likely that person is to successfully overcome an addiction. (Peele 1992)
In fact, treatment outcomes have a stronger relationship with client resources and environmental circumstances during the posttreatment period than with any specific personal characteristic(s) or the type of treatment selected. (Tucker and Vuchinich, 1992; Walters, 2000)
Al-Anon / Nar-Anon Family Groups are comprised of individuals who have a friend or family member, who is addicted to alcohol or narcotics. The purpose of these groups is to “find understanding and support by sharing common experiences with each other”. The program, according to the nar-anon.org website, “is not a religious one but a spiritual way of life”, and is based on the same Twelve Steps as Alcoholics / Narcotics Anonymous programs (see page 48), except that in the Family Groups, the first step is substituted with, “We admitted we were powerless over the addict — that our lives had become unmanageable”. The family member is advised to work on themselves by following and completing each of the 12 Steps –in much the same way that the formula instructs the individual in recovery to do, and to additionally, “release [their] addicts with love and cease trying to change them”. Family members are directed to focus more on themselves, rather than on their loved one with the substance use problem.
With the understanding that addiction is a disease and the realization that we are powerless over it, as well as over other people’s lives, we are ready to do something useful and constructive with our own. Then, and only then, can we be of any help to others. (nar-anon.org; al-anon.org)
This method stems from therapies developed in the 1960s and 70s that used confrontation to motivate behavior change. Basically, the family and friends of the individual with a substance use problem get together and form a team, and with the help of a professionally trained interventionist, they devise a plan to confront the individual in hopes of motivating him or her to seek treatment. The team then arranges a meeting and develops a strategy to lure the unsuspecting individual to the meeting on some other pretense. Following the ‘surprise’, the individual is forced to listen to unpleasant information concerning their addiction and related behaviors, which has been prepared in advance by each of the members present.
Family members are encouraged to focus on caring for and helping the individual ‘see the light’, as opposed to maligning them and complaining about past behaviors. They may provide education regarding addiction, and discuss the likely consequences of continued use. Typically, the anticipated outcome is that the individual will agree to participate in some level of treatment. Some ‘team members’ may be prepared with ultimatums designed to coerce resistant individuals to attend a treatment program, or face the imposed consequences.
While this confrontational approach helps some people realize that they have an unaddressed problem that is impacting not only themselves, but their family and friends, and motivates them to embrace the benefits of sobriety; others have found the experience to be traumatic and isolating, and to have difficulty recovering from it emotionally.
The CRAFT approach teaches family members communication and problem solving strategies, and promotes collaboration with the substance-using individual to identify ways to solve mutual problems, rather than reacting from an oppositional standpoint. It essentially teaches family members Motivational Interviewing skills (see page 46) to enable the family member to better understand the underlying causes of the substance use from their loved one’s point of view. Together they are able to devise consequences, as well as reinforcements, that make sense for accomplishing the mutual goals of the family, and that seem fair and just for all parties.
Unlike Nar/Al-Anon, the goal of the family member is to seek behavioral change –they are non-apologetically attempting to reduce or stop the substance use of their loved one, as well as increase their willingness to get help. ‘Detachment’ from their loved one is not encouraged or promoted.
In one study, CRAFT trained family members encouraged approximately two‐thirds of treatment‐resistant patients to attend treatment, typically after four to six CRAFT training sessions. The family members also showed marked psychosocial and physical improvements (Roozen et al, 2010). In another study comparing CRAFT trained “concerned significant others (CSOs)” with CSOs attending Al/Nar-Anon in motivating “treatment-refusing illicit drug users” to enter treatment, CRAFT alone engaged 58.6% of users, CRAFT plus on-going support engaged 76.7% of users, and Nar/Al-Anon CSO’s engaged 29% of users (Meyers et al, 2002).
CRAFT is the leading research-supported way for families to help their substance user enter treatment and maintain recovery. They are three times more likely to motivate their loved one to engage in treatment than family members who attend Al/Nar-Anon, and twice as likely as family members who hire an interventionist. (Foote et al, 2014; Meyers et al, 2002; Roozen et al, 2010)
Communication and problem-solving skills for parents, spouses, and other key caregivers of those with substance use and co-occurring disorders is provided through training based on an evidence-based curriculum and delivered by a family-peer coach, or via a self-help workbook – entitled The Parent’s 20-Minute Guide: How to Help Your Child Change Their Substance Use or a similar version for spouses. (Foote et al, 2014; Partnership for Drug-Free Kids, 2015)
SMART Recovery Family & Friends helps those who are affected by the substance use or addictions of a loved one, and is the complement to SMART (Self-Management and Recovery Training) for those in recovery (see page 47). It is a science-based, secular alternative to Al/Nar- Anon and Intervention, and is based on CRAFT principles and techniques. Like Nar/Al-Anon, volunteers offer support to Concerned Significant Others (CSOs) through group meetings, either online or in person, to “address specific issues encountered when a friend or family member tries to reach out and help a loved one affected by addiction. The meetings share SMART Recovery tools that can be implemented by CSOs to help with emotional upsets, effective communication methods when dealing with loved ones, and more.” (smartrecovery.org).
Previous research has established that effective drug treatment may depend on the quality of an individual’s interpersonal relationships… A key component of substance-abuse treatment should involve strengthening the individual’s place in the community as a productive worker, family member, and community member. (Kelly et al, 2010)
Unfortunately, the majority of treatment programs put little emphasis on building and/or strengthening the patient’s critical support system –one that could potentially encourage and sustain the process of recovery long after the patient has been discharged. (Kelly et al, 2010; Mueser, 2012)
The result of the high stress of coping with a relative with a co-occurring disorder is often the loss of family support and ensuing negative outcomes such as housing instability and homelessness. Increasing family coping skills and decreasing the stress related to having a close relationship with someone with a co-occurring disorder could enable families to continue to provide critical supports that contribute to improving the outcome of the disorders. (Mueser, 2012)
When the family members of patients with co-occurring disorders were provided with psycho-education about substance use and mental health disorders, in addition to communication skills training to reduce family stress, and problem-solving training to resolve conflicts and enhance their loved one’s motivation to address substance use problems, those patients exhibited improved psychiatric, substance use, and functional outcomes, and their family member demonstrated increased knowledge of co-occurring disorders, diminished perception of burden, and improved mental health benefits –overall family functioning improved significantly. These findings support the utility of family intervention for substance-use and co-occurring disorders, and the added benefit of communication and problem-solving training, in order to provide family
members with the information and skills they need to help their loved one overcome the effects of these disorders. Addressing unhealthy communication patterns is often seen as the first step in moving a loved one toward addiction therapy. (Foote et al, 2014; Gifford, 2016; Mueser, 2012)
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. (Center for Substance Abuse Treatment, SAMHSA, 2004).
Many treatment programs do have a ‘family education’ program, designed to create an awareness of substance use disorder, its associated behaviors, and the consequences of continued drug use, but rarely does a program focus on the family system, the interdependent relationships of its members, and the various dynamics at play –that could be contributing to or exacerbating substance use and/or mental health problems. Without a deeper understanding into these complexities, barriers to enduring healing may be difficult to breach.
Evidence from the research indicates that substance abuse treatment that includes family therapy works better than substance abuse treatments that do not. It increases engagement and retention in treatment, reduces the patient’s drug and alcohol use, improves both family and social functioning, and discourages relapse. (Center for Substance Abuse Treatment, SAMHSA, 2004)