Family Therapy in Substance Use Disorder (SUD) Treatment

By Lori Ryland, Ph.D., LP, CAADC, CCS, BCBA-D, Chief Clinical Officer, Pinnacle Treatment Centers

There’s an old saying you may have heard before:

“Addiction is a disease of loneliness.”

While we no longer use the term addiction in clinical practice – we now use the phrase substance use disorder – there’s an element of truth in that old saying we should not ignore. When a person develops a substance use disorder, they often keep it to themselves. That may lead to feelings of isolation, which can lead to increased substance use. This increased use can then, in turn, lead to problem behaviors that drive friends, family, and loved ones away, which compounds feelings of isolation, and perpetuates this cycle – which can continue for years, if left unaddressed.

In this way, it’s possible to see loneliness as both an outcome and partial cause of the misuse of substances. That may seem contradictory, but the more we learn about substance use disorder, the more we understand the need to resolve contradictions.

Like family, for instance.

Yes, it’s true: the role of the family in substance use disorder is often contradictory and resolving the role of family is often an important step in the treatment process. As you read this, you may scratch your head and wonder what we mean:

How is family contradictory?

What we mean is that with regards to substance use disorder/addiction, the family, or family members, often play two roles that appear to be in conflict:

1. They can contribute to the development of a substance use disorder
2. They can contribute to successful recovery from a substance use disorder

We make these assertions within the context of personal responsibility, of course. No one can blame anyone else for their substance use, and no one can give full credit for recovery from substance use to another person.

Blame is not productive, but understanding is. It’s important to understand both how the family can contribute to the development of SUD, and how the family can contribute to a successful recovery: that’s the goal of this article.

We’ll start with a brief overview of Family Systems Theory, which is the basis for almost the use of family therapy in SUD treatment.

What is Family Systems Theory?

Here’s a simplified way to think about family systems theory:

1. Every person grows up as part of a complex web of human relationships, which we call a family
2. The dynamics of those family relationships contribute to the development of the individual
3. Therefore, the behaviors an individual develops are directly impacted by the idiosyncrasies of the family

Another way to think of family systems theory is to remember that no one lives in a vacuum. We all grow up surrounded by other people, who, in some way or another, directly or indirectly, influence who we become and what we do. In this context, the traditional concept of the biological family does not apply. Families come in almost infinite configurations, which depend on a variety of factors unique to each group of people who consider themselves a family.

Families may consist of:

• Single parents
• Two parents
• Grandparents serving as parents
• Blended families may include children from previous relationships
• Intergenerational families may include:
  • Grandparents
  • Uncles
  • Aunts
  • Cousins
  • Other relatives
  • Close friends
• Adoptive/foster families may include members who are not biologically related
• Non-traditional families may include members who are not biologically related but come together by choice or circumstance

That means that families can include any and all possible combinations of parents, spouses or partners, in-laws, siblings, children, chosen family members, stepparents, stepchildren, foster parents, foster children, godparents, godchildren, blended family members, extended family members, friends, fellow veterans, colleagues, mentors, mutual-help group peers, sponsors, and concerned significant others.

In the SUD treatment context, the person in treatment – often in collaboration with their therapist – decides who they want to participate in family therapy the rule of thumb is that if they matter to the person in treatment, then they matter to the treatment:

Anyone with an interest in the successful recovery of the person in treatment can participate and should participate if requested.

Substance Use Disorder: Family Risk Factors

We assert, above, that families can play a role in the development of a substance use disorder. To explain that further, we’ll offer three sets of family risk factors related to substance use disorder. The first set includes factors that may lead to the initiation of substance use and the development of a SUD, the second set includes factors that can contribute to ongoing substance use, and the third includes factors that may prevent, delay, or impede the SUD treatment and recovery process.

We retrieved this information on family risk factors – as well as all the information that follows – from the Substance Abuse and Mental Health Services Administration (SAMHSA) publication “Treatment Improvement Protocol 39: Substance Use Disorder Treatment and Family Therapy.”

Families and SUD: Risk Factors

1. Factors that may affect substance use initiation:

• Introduction to substance use by family member
• Parenting style:
  • Rigid, authoritarian parenting styles are associated with increased SUD
  • Relaxed, overly permissive parenting styles are associated with increased SUD
• Absence of supportive connections within family
• Socioeconomic factors that result in lack of parental monitoring

2. Factors that may affect ongoing substance use:

• Frequent, regular, high level of substance use (including alcohol) at family events
• Absence of strong bonds between family members
  • Absence of strong parent-child bond increase risk of ongoing use
• Poor communication:
  • Ineffective, inconsistent communication within family increase risk of ongoing use
• Parenting techniques that include harsh punishment or verbal abuse increase risk of ongoing use
• Parenting style:
  • Rigid, authoritarian parenting styles are associated with ongoing use
  • Relaxed, overly permissive parenting styles are associated with ongoing use

3. Factors that may prevent or attenuate successful recovery from SUDs include:

• Dysfunctional family dynamics:
  • Problems with family boundaries
  • Lack of family cohesion
  • Unclear family roles
• Lack of open and consistent communication
• Underdeveloped parenting skills
• Lack of parental warmth and involvement
• Divorce
• Death of parent

When we mention parenting styles above, it’s important to understand that those factors apply to adults as well as adolescents. Our parents are our parents, and how they talk to us and behave towards us impacts us when we’re fully grown adults as well as when we’re children or adolescents. The words and actions of parents have a disproportionate impact during childhood and adolescence, but the influence of parents does not automatically disappear when we turn eighteen. In most cases, the words and actions of our parents can have a powerful effect on us for our entire lives.

So far, we’ve shared information about the role family plays in the disordered use of substances. We’ve explained the theoretical basis for including the family in SUD treatment and the familyrisk factors related substance use disorder.

Now we’re finally ready to explain exactly what we mean when we say family therapy.

What is Family Therapy?

Here’s how the Substance Abuse and Mental Health Services Administration (SAMHSA) defines family counseling/therapy:

“Family counseling or therapy is a collection of treatment approaches and techniques founded on the understanding that if change occurs with one person, it affects everyone else in the family and creates a change reaction.”

That’s a solid, working definition to keep in mind as you read the rest of this article. The real takeaway is that the goal of family therapy is behavioral change: not only for the person in treatment, but for their family members, too.

The following list includes the most common and widely recognized benefits of family therapy in the SUD treatment and recovery process.

The Benefits of Family Participation in SUD Treatment

Family participation in the context of SUD treatment is associated with:

• Increased treatment engagement
• Increased treatment retention rates
• Improved prevention of substance misuse
• Enhanced outcomes for individuals:
  • Substance use decreases
  • Relapse rates decrease
  • Symptoms of co-occurring disorders decrease
  • Work, school, and social function improves
• Enhanced outcomes for families:
  • Conflict decreases
  • Relationships stabilize
  • Communication
  • Family members negatively impacted by addiction can heal
  • Risk of adverse experiences for children decreases

It may be too obvious, or an oversimplification, to say that families can have a significant impact on the treatment and recovery process for any illness or injury. From chronic diseases like diabetes to acute injuries related to accidents, a supportive family network improves outcome. We recognize this for most medical conditions, but we often forget – or never realize – that family is every bit as important in recovery from SUD.

Now let’s take a look at the types of family therapy evidence shows are effective in for SUD treatment.

Types of Family Therapy for SUD

There are several different approaches to family therapy for SUD. Most are based on two types of psychotherapy: cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). However, while those approaches help people with SUD connect patterns of emotion and thought with patterns of behavior and focus on replacing treatment-interfering behaviors with treatment-promoting behaviors, family therapy can go beyond psychotherapy to address social and structural factors that may contribute to SUD.

Evidence shows the following therapeutic approaches improve outcomes for people with SUD:

Multi-Dimensional Family Therapy (MDFT)

• • The idea behind MDFT is that change can occur across multiple domains in life:
    • At home
    • In the community
    • At school
  • MDFT therapists adapt to the specific needs of the client and family
  • Treatment happens in three stages:
    • Build a foundation of trust and understanding
    • Create change
    • Solidify the change
  • MDFT is appropriate for diverse cultural populations, high risk adolescents, and adults with co-occurring mental health disorders

Behavioral Family Therapy (BFT)

• • BFT is based on the idea that substance use is a learned behavior
  • Peers, parents, and role models may reinforce this behavior
  • Therapy focuses on reinforcing:
    • Abstinence/reduced substance use
    • Positive behaviors
    • Positive social connections
  • BFT is appropriate for all families participating in SUD treatment

Solution Focused Brief Therapy (SFBT)

• • SBFT takes a slightly different approach than the other approaches. Rather than identifying family factors that cause substance use, counselors focus on immediate solutions to specific problems.
  • The idea is that solving a problem creates a template for solving other problems
  • Counselors work to identify situations when the individual in SUD treatment does not or did not use substances, and use those situations as a “behavioral repertoire” to create a practical, behavioral solution to an immediate problem they can implement right away
  • SBFT is appropriate for families with adults with SUDs and co-occurring disorders, as well as people with SUD with a history of trauma

Community Reinforcement and Family Training (CRAFT)

• • CRAFT is designed for family members of a person with SUD who is extremely treatment resistant, and unlikely to enter treatment on their own
  • A CRAFT therapist teaches family members to reinforce positive, non-substance using behaviors
  • A CRAFT teaches family members not to interfere with natural consequences of substance use, i.e. how not to enable substance use
  • CRAFT leverages various positive reinforcement strategies to guide the person with SUD to make behavioral change and commit to treatment
  • CRAFT is appropriate for any family dealing with SUD, but is particularly effective in helping treatment-resistant individuals commit to behavioral change

Psychoeducation Workshops

• • Psychoeducation is the process of teaching an individual in treatment and their family members everything they need to know about addiction, treatment, and recovery.
  • Family workshops often include classes on the following topics:
    • Positive, healthy communication
    • Setting boundaries
    • Conflict resolution
    • SUD treatment techniques and approaches
    • Codependent family dynamics
    • Benefits of 12-step programs
  • Psychoeducation is appropriate for any family dealing with SUDs

The educational component of family therapy is designed to keep everyone in the family current about what’s happening in the recovery process and help them understand how they can help support their loved one or family member in the recovery process moving forward. Psychoeducation is not therapy per se, but it’s an essential part of the family therapy process. The more families understand what their loved one experiences during treatment, the better they can offer the compassionate support that promotes recovery.

Summing it All Up: The Principles of Family Therapy

We outline the theoretical basis for family participation in SUD treatment above, in the introduction, when we describe what we mean by family systems. We’ll close this article by expanding and further articulating that theoretical basis. Below, we offer the seven foundational principles of family therapy in SUD treatment, as defined by SAMSHA in the Treatment Improvement Protocol (Tip 39) we cite throughout this article.

The Seven Principles of Family Participation in SUD Treatment

1. Recognize the therapeutic value of including the family in SUD treatment
2. Utilize a collaborative approach to the therapeutic relationship
3. Prioritize harm reduction in addition to abstinence
4. Expand the concept of treatment success to include the wellbeing of the entire family
5. Acknowledge the value of family and social relationships as vital sources of support
6. Adapt family therapy to align with the values and cultural beliefs practiced by the family and their home community
7. Understand the complexity of SUDs and the importance of working with families to manage the treatment and recovery process

We mention this above, but it bears repeating. Any chronic medical condition affects family functioning – including a chronic condition such as substance use disorder. When a family member has a chronic medical condition, the family rallies to help. That’s what we encourage families to do when a loved one or family member enters treatment for SUD: rally behind them and help them in any way they can.

Evidence shows that family participation improves outcomes.

Therefore, that’s the first step. If you have a family member in treatment for SUD and they ask you to come to family therapy, do it. You’ll help them, you’ll help yourself, and you’ll increase the likelihood that your family member or loved one achieves lifelong recovery.

About The Author

Chris Powell

See author's posts