Substance Abuse Treatment and Family Therapy
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Substance Abuse Treatment and Family Therapy
Substance Abuse Treatment and Family Therapy
Source: SAMHSA/CSAT Treatment Improvement Protocols
TIP 39. Substance Abuse Treatment and Family Therapy
Culturally competent practices and attitudes can be implemented at all levels of a treatment program to ensure appropriate treatment for families with substance abuse issues.
The effectiveness of substance abuse treatment is undermined if treatment does not include community and cultural aspects - the broadest components of an ecological approach.
Concerted efforts are instituted to identify and change preconceived notions or biases that people may have about other people's cultural beliefs and customs.
This chapter provides information about several specific populations: children, adolescents, and older adults; women; cultural, racial, and ethnic groups; gays and lesbians; people with physical and cognitive disabilities; people in rural locations; and people with co -occurring substance use and mental disorders.
In addition, information is provided regarding people who are HIV positive, people who are homeless, and veterans. Each section discusses relevant background issues and applications to family therapy.
Introduction
This TIP uses the term specific populations to examine features of families based on specific, common groupings that influence the process of therapy.
Whenever people are categorized or classified in this way, it is important to remember that individuals belong to multiple groups, possess multiple identities, and live their lives within multiple contexts.
Different statuses may be more or less prominent at different times. The most important general guideline for the therapist is to be flexible and meet the family "where it is."
It is vital that counselors be continuously aware of and sensitive to the differences between themselves and the members of the group they are counseling.
Therapists bring their own cultural issues to therapy, and the therapist's age, gender, ethnicity, and other characteristics may figure in the therapeutic process in some way.
Differences within the family also should be explored. Is the family a homogeneous group or one that represents several different backgrounds?
What is the significance that family members assign to their own identities and to the identity of the therapist?
These considerations and sensitivity to the specific cultural norms of the family in treatment must be respected from the start of therapy. If these factors are not apparent or explicit, the therapist should ask.
Age
Age is an important factor in the therapeutic process. Substance use may have different causes and different profiles based on an individual's age and developmental stage.
For example, a teenager may drink for different reasons than does a middle -aged father. The age of the person abusing substances is also likely to have different effects on the family. This TIP discusses three age groups: children, adolescents, and older adults.
Children
Background issues
While actual numbers of children who abuse substances are small compared to other age groups, children who use drugs are an underserved populationone as poorly identified as it is poorly understood. Nonetheless, substance abuse among children is of grave importance. Drug or alcohol use can have a severe effect on the developing brain and can set a potential pattern of lifelong behavior (Oxford et al. 2001).
The use of inhalants is especially prevalent among children. The National Institute on Drug Abuse (NIDA) -funded 2001 Monitoring the Future survey found that more than 17 percent of eighth graders said they had abused inhalants at least once in their lives (Johnston et al. 2002).
In a recent policy statement, the American Academy of Pediatrics (AAP) described inhalant abuse as "an under -recognized form of substance abuse with a significant morbidity and mortality" (AAP 1996, n.p.). For more information, see also TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (cCenter for Substance Abuse Treatment [CSAT] 1999c ).
Application to family therapy
When a child is abusing substances, single family therapy is probably the most useful approach. Regardless of the approach, the therapist will need to make accommodations and adjustments for children in therapy.
For instance, children should not be left too long in the waiting room and should not be expected to sit still for an hour while adult conversation takes place around them.
Stith et al. (1996) interviewed 16 children between the ages of 5 and 13 who were involved in family therapy with their parents and siblings and found these children wanted to be involved in therapy, even when they weren't the identified patient (IP).
They were aware that important things were happening in therapy and wanted to be part of them. They did, however, indicate that being part of family sessions often had been an unsatisfying experience dominated by adult conversation and time spent out of the session in the waiting room.
The personal qualities of the therapist were important to the children. Finally, they said that if they were to be part of therapy, they needed to participate in ways that fit their styles of communicationactivity and play.
Approaches to incorporate children in therapy via playsuch as family puppet shows, family art projects, and board games with a therapeutic focuscan be modified to fit family therapy, and play therapy can be a valuable component of family sessions.
The Association for Play Therapy defines play therapy as "the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development" (Bratton et al. n.d., p. 1).
Cooklin (2001) points out that play therapy does not mean playful interactions in therapy, but refers to more structured and often nonverbal processes such as the use of toys, games, puppets, models, or role playing. Its goal is to reduce the child's anxiety and to facilitate emotional processing. He also emphasizes, though, that when the client is a child, a level of playfulness is helpful in the therapistclient relationship.
Adolescents
Background issues
Youthful substance use is usually transitory, episodic, or experimental, but for some, it may be a serious, long -lasting indicator of other life problems (Furstenberg 2000).
A growing body of research, primarily using animals, addresses the sensitivity of adolescents' brains to alcohol (see, e.g., Spear 2000). Substance use in the teen years is associated with disruptive behaviors such as conduct disorders, oppositional disorders, eating disorders, and attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD).
The United States has the highest rate of adolescent drug abuse of all industrialized nations (Liddle et al. 2001). The Overview of Findings From the 2002 National Survey on Drug Use and Health found that 17.6 percent of 12 - to 17 -year -olds reported drinking in the month preceding the survey, and 11.6 percent of 12 - to 17 -year -olds said they had used an illicit drug (Office of Applied Studies [OAS] 2003a).
More than 65 percent of young people who were classified as heavy drinkers were also using illicit drugs (OAS 2002b ).
Alcohol is the substance most often used and abused by adolescents, and its usage reflects troubling patterns (AAP 2001). In 2001, of people age 12 to 17, 10.7 percent reported binge alcohol use in the past month and 2.5 percent reported heavy alcohol use in the past month (binge drinking is defined as five or more drinks on the same occasion; heavy use is five or more drinks on the same occasion at least 5 days in the past month) (OAS 2003a).
Substance use among adolescents is associated with poor school performance, problems with authority, and high -risk behaviors, including driving while intoxicated and unprotected sexual activity. Fifteen -year -olds who drink have been found to be seven times as likely to have sexual intercourse as their nondrinking contemporaries (AAP 2001). Sexually active teenagers who use alcohol or drugs are at greater risk of acquiring sexually transmitted diseases, including HIV/AIDS (AAP 2001).
Some specific risk factors for adolescent substance abuse include:
Antisocial behavior at a young age, especially aggression
Poor self -esteem
School failure
ADD and AD/HD
Learning disabilities
Peers who use drugs
Alienation from peers or family
Depression and other mood disorders (e.g., bipolar disorder)
Physical or sexual abuse (AAP 2001)
Application to family therapy
A growing body of evidence supports family therapy's capacity to engage and retain clients in therapy and its efficacy in ameliorating adolescent drug use, as compared to other approaches (Liddle and Dakof 1995a ).
Specific family therapy approaches such as Brief Strategic Family Therapy (Szapocznik and Williams 2000) and Multidimensional Family Therapy (Liddle et al. 2001) have shown great promise in terms of usage reduction in adolescents and improvements in family functioning.
Part of the treatment process involves teaching adolescents to make choices and encouraging them to find alternatives to substance use. Parents can be instrumental in this process and the importance of modeling behavior should be emphasized. Siblings also should be drawn into therapysometimes the problems of an adolescent IP will overwhelm the needs of a quieter sibling.
In general, family therapists can support families by providing opportunities for them to work on negotiation skills with their adolescent child. Therapists can teach parents techniques to decrease reactivity and ways to provide real and acceptable choices for their children. Children should be encouraged to handle developmentally appropriate tasks and to understand that outcomes are tied to behavior.
Moving therapy from the clinic to settings with which the adolescent is familiar and comfortable can be a helpful strategy. Conducting sessions at an adolescent's home may promote a more open and sharing tone than sessions in a therapist's office.
Scheduling of sessions must be sensitive not only to school obligations, but to extracurricular and social activities as well. Such flexibility is an important attribute for any therapist working with adolescents.
When teens are not willing to engage in therapy/treatment, parents may be encouraged to attend therapy to examine ways of working with their troubled teen.
Gender also may have implications in family groupings for therapy sessions, particularly in families where abuse has occurred. There may be cases where father/son or mother/daughter sessions will be helpful.
For more information on substance abuse treatment with adolescents, see TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (CSAT 1999c ) and TIP 32, Treatment of Adolescents With Substance Use Disorders (CSAT 1999e).
Older Adults
Background issues
Although definitions of "older adults" vary, they typically refer to individuals age 60 and older. Up to 17 percent of older adults are estimated to have problems with alcohol or prescription drugs. Older men are much more likely than older women to abuse alcohol (Atkinson et al. 1990; Bucholz et al. 1995; Myers et al. 1984); women typically experience later onset of problem drinking than do men (Gomberg 1995; Hurt et al. 1988; Moos et al. 1991).
For both men and women, substance abuse can lead to social isolation and loneliness, reduced self -esteem, family conflict, sensory losses, cognitive impairment, reduced coping skills, decreased economic status, and the necessity to move out of one's home and into a more supervised setting (CSAT 1998d ).
There are two patterns of substance abuse among older adults. The first includes those for whom drug or alcohol abuse has been a chronic, lifelong pattern leading to significant impairment by the time they are older.
The second includes older adults who have recently begun misusing alcohol or drugs in response to life transition issues, such as the death of a spouse. Through reduced tolerance and the decrease in the amount of body water (associated with aging) in which to dilute alcohol (Dufour and Fuller 1995; Kalant 1998), alcohol use considered moderate and nonproblematic through a person's middle years can cause intoxication and dysfunction in an older person.
In general, treatment is more effective and the prognosis more optimistic for people with later -onset substance disorders.
Source: SAMHSA/CSAT Treatment Improvement Protocols
TIP 39. Substance Abuse Treatment and Family Therapy
Culturally competent practices and attitudes can be implemented at all levels of a treatment program to ensure appropriate treatment for families with substance abuse issues.
The effectiveness of substance abuse treatment is undermined if treatment does not include community and cultural aspects - the broadest components of an ecological approach.
Concerted efforts are instituted to identify and change preconceived notions or biases that people may have about other people's cultural beliefs and customs.
This chapter provides information about several specific populations: children, adolescents, and older adults; women; cultural, racial, and ethnic groups; gays and lesbians; people with physical and cognitive disabilities; people in rural locations; and people with co -occurring substance use and mental disorders.
In addition, information is provided regarding people who are HIV positive, people who are homeless, and veterans. Each section discusses relevant background issues and applications to family therapy.
Introduction
This TIP uses the term specific populations to examine features of families based on specific, common groupings that influence the process of therapy.
Whenever people are categorized or classified in this way, it is important to remember that individuals belong to multiple groups, possess multiple identities, and live their lives within multiple contexts.
Different statuses may be more or less prominent at different times. The most important general guideline for the therapist is to be flexible and meet the family "where it is."
It is vital that counselors be continuously aware of and sensitive to the differences between themselves and the members of the group they are counseling.
Therapists bring their own cultural issues to therapy, and the therapist's age, gender, ethnicity, and other characteristics may figure in the therapeutic process in some way.
Differences within the family also should be explored. Is the family a homogeneous group or one that represents several different backgrounds?
What is the significance that family members assign to their own identities and to the identity of the therapist?
These considerations and sensitivity to the specific cultural norms of the family in treatment must be respected from the start of therapy. If these factors are not apparent or explicit, the therapist should ask.
Age
Age is an important factor in the therapeutic process. Substance use may have different causes and different profiles based on an individual's age and developmental stage.
For example, a teenager may drink for different reasons than does a middle -aged father. The age of the person abusing substances is also likely to have different effects on the family. This TIP discusses three age groups: children, adolescents, and older adults.
Children
Background issues
While actual numbers of children who abuse substances are small compared to other age groups, children who use drugs are an underserved populationone as poorly identified as it is poorly understood. Nonetheless, substance abuse among children is of grave importance. Drug or alcohol use can have a severe effect on the developing brain and can set a potential pattern of lifelong behavior (Oxford et al. 2001).
The use of inhalants is especially prevalent among children. The National Institute on Drug Abuse (NIDA) -funded 2001 Monitoring the Future survey found that more than 17 percent of eighth graders said they had abused inhalants at least once in their lives (Johnston et al. 2002).
In a recent policy statement, the American Academy of Pediatrics (AAP) described inhalant abuse as "an under -recognized form of substance abuse with a significant morbidity and mortality" (AAP 1996, n.p.). For more information, see also TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (cCenter for Substance Abuse Treatment [CSAT] 1999c ).
Application to family therapy
When a child is abusing substances, single family therapy is probably the most useful approach. Regardless of the approach, the therapist will need to make accommodations and adjustments for children in therapy.
For instance, children should not be left too long in the waiting room and should not be expected to sit still for an hour while adult conversation takes place around them.
Stith et al. (1996) interviewed 16 children between the ages of 5 and 13 who were involved in family therapy with their parents and siblings and found these children wanted to be involved in therapy, even when they weren't the identified patient (IP).
They were aware that important things were happening in therapy and wanted to be part of them. They did, however, indicate that being part of family sessions often had been an unsatisfying experience dominated by adult conversation and time spent out of the session in the waiting room.
The personal qualities of the therapist were important to the children. Finally, they said that if they were to be part of therapy, they needed to participate in ways that fit their styles of communicationactivity and play.
Approaches to incorporate children in therapy via playsuch as family puppet shows, family art projects, and board games with a therapeutic focuscan be modified to fit family therapy, and play therapy can be a valuable component of family sessions.
The Association for Play Therapy defines play therapy as "the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development" (Bratton et al. n.d., p. 1).
Cooklin (2001) points out that play therapy does not mean playful interactions in therapy, but refers to more structured and often nonverbal processes such as the use of toys, games, puppets, models, or role playing. Its goal is to reduce the child's anxiety and to facilitate emotional processing. He also emphasizes, though, that when the client is a child, a level of playfulness is helpful in the therapistclient relationship.
Adolescents
Background issues
Youthful substance use is usually transitory, episodic, or experimental, but for some, it may be a serious, long -lasting indicator of other life problems (Furstenberg 2000).
A growing body of research, primarily using animals, addresses the sensitivity of adolescents' brains to alcohol (see, e.g., Spear 2000). Substance use in the teen years is associated with disruptive behaviors such as conduct disorders, oppositional disorders, eating disorders, and attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD).
The United States has the highest rate of adolescent drug abuse of all industrialized nations (Liddle et al. 2001). The Overview of Findings From the 2002 National Survey on Drug Use and Health found that 17.6 percent of 12 - to 17 -year -olds reported drinking in the month preceding the survey, and 11.6 percent of 12 - to 17 -year -olds said they had used an illicit drug (Office of Applied Studies [OAS] 2003a).
More than 65 percent of young people who were classified as heavy drinkers were also using illicit drugs (OAS 2002b ).
Alcohol is the substance most often used and abused by adolescents, and its usage reflects troubling patterns (AAP 2001). In 2001, of people age 12 to 17, 10.7 percent reported binge alcohol use in the past month and 2.5 percent reported heavy alcohol use in the past month (binge drinking is defined as five or more drinks on the same occasion; heavy use is five or more drinks on the same occasion at least 5 days in the past month) (OAS 2003a).
Substance use among adolescents is associated with poor school performance, problems with authority, and high -risk behaviors, including driving while intoxicated and unprotected sexual activity. Fifteen -year -olds who drink have been found to be seven times as likely to have sexual intercourse as their nondrinking contemporaries (AAP 2001). Sexually active teenagers who use alcohol or drugs are at greater risk of acquiring sexually transmitted diseases, including HIV/AIDS (AAP 2001).
Some specific risk factors for adolescent substance abuse include:
Antisocial behavior at a young age, especially aggression
Poor self -esteem
School failure
ADD and AD/HD
Learning disabilities
Peers who use drugs
Alienation from peers or family
Depression and other mood disorders (e.g., bipolar disorder)
Physical or sexual abuse (AAP 2001)
Application to family therapy
A growing body of evidence supports family therapy's capacity to engage and retain clients in therapy and its efficacy in ameliorating adolescent drug use, as compared to other approaches (Liddle and Dakof 1995a ).
Specific family therapy approaches such as Brief Strategic Family Therapy (Szapocznik and Williams 2000) and Multidimensional Family Therapy (Liddle et al. 2001) have shown great promise in terms of usage reduction in adolescents and improvements in family functioning.
Part of the treatment process involves teaching adolescents to make choices and encouraging them to find alternatives to substance use. Parents can be instrumental in this process and the importance of modeling behavior should be emphasized. Siblings also should be drawn into therapysometimes the problems of an adolescent IP will overwhelm the needs of a quieter sibling.
In general, family therapists can support families by providing opportunities for them to work on negotiation skills with their adolescent child. Therapists can teach parents techniques to decrease reactivity and ways to provide real and acceptable choices for their children. Children should be encouraged to handle developmentally appropriate tasks and to understand that outcomes are tied to behavior.
Moving therapy from the clinic to settings with which the adolescent is familiar and comfortable can be a helpful strategy. Conducting sessions at an adolescent's home may promote a more open and sharing tone than sessions in a therapist's office.
Scheduling of sessions must be sensitive not only to school obligations, but to extracurricular and social activities as well. Such flexibility is an important attribute for any therapist working with adolescents.
When teens are not willing to engage in therapy/treatment, parents may be encouraged to attend therapy to examine ways of working with their troubled teen.
Gender also may have implications in family groupings for therapy sessions, particularly in families where abuse has occurred. There may be cases where father/son or mother/daughter sessions will be helpful.
For more information on substance abuse treatment with adolescents, see TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (CSAT 1999c ) and TIP 32, Treatment of Adolescents With Substance Use Disorders (CSAT 1999e).
Older Adults
Background issues
Although definitions of "older adults" vary, they typically refer to individuals age 60 and older. Up to 17 percent of older adults are estimated to have problems with alcohol or prescription drugs. Older men are much more likely than older women to abuse alcohol (Atkinson et al. 1990; Bucholz et al. 1995; Myers et al. 1984); women typically experience later onset of problem drinking than do men (Gomberg 1995; Hurt et al. 1988; Moos et al. 1991).
For both men and women, substance abuse can lead to social isolation and loneliness, reduced self -esteem, family conflict, sensory losses, cognitive impairment, reduced coping skills, decreased economic status, and the necessity to move out of one's home and into a more supervised setting (CSAT 1998d ).
There are two patterns of substance abuse among older adults. The first includes those for whom drug or alcohol abuse has been a chronic, lifelong pattern leading to significant impairment by the time they are older.
The second includes older adults who have recently begun misusing alcohol or drugs in response to life transition issues, such as the death of a spouse. Through reduced tolerance and the decrease in the amount of body water (associated with aging) in which to dilute alcohol (Dufour and Fuller 1995; Kalant 1998), alcohol use considered moderate and nonproblematic through a person's middle years can cause intoxication and dysfunction in an older person.
In general, treatment is more effective and the prognosis more optimistic for people with later -onset substance disorders.
Member
Join Date: Oct 2014
Posts: 430
Thanks for this thorough review, Allfor.
Any advice for finding a therapist versed in cognitive behavioral therapy to deal with substance (alcohol) abuse? I've tried the CRAFT and SMART web pages for recommended practitioners, but haven't found anyone in my city. My health insurance has a long list of providers, but it's unclear from the credentials they list what kind of therapy they offer. Ideas?
Any advice for finding a therapist versed in cognitive behavioral therapy to deal with substance (alcohol) abuse? I've tried the CRAFT and SMART web pages for recommended practitioners, but haven't found anyone in my city. My health insurance has a long list of providers, but it's unclear from the credentials they list what kind of therapy they offer. Ideas?
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Join Date: May 2012
Posts: 1,927
Originally Posted by sauerkraut 
Thanks for this thorough review, Allfor.
Any advice for finding a therapist versed in cognitive behavioral therapy to deal with substance (alcohol) abuse? I've tried the CRAFT and SMART web pages for recommended practitioners, but haven't found anyone in my city. My health insurance has a long list of providers, but it's unclear from the credentials they list what kind of therapy they offer. Ideas?
Any advice for finding a therapist versed in cognitive behavioral therapy to deal with substance (alcohol) abuse? I've tried the CRAFT and SMART web pages for recommended practitioners, but haven't found anyone in my city. My health insurance has a long list of providers, but it's unclear from the credentials they list what kind of therapy they offer. Ideas?
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