Transcript Family Therapies in Addictions

Family Therapies in
Addictions Treatment
Louise Martin
Lambeth Addictions
January 2014
Tom





Tom is 22 and lives at home with his mother Pattie and father Doug. Pattie is prone
to depression and has been out of work for many years following a traumatic
miscarriage. Doug drinks a few glasses of wine most nights to relax after a hard
days’ work. Both come from families with a ‘stiff upper lip’.
Tom started using heroin when he was 15. His parents were initially terrified when
they found out and didn’t know what to do for the best. They took him to the GP to
get help but were told that as an adult, he needed to make his own decisions. As
they would rather he be safe than out on the streets, they started letting him use
heroin in his bedroom at home. They hoped heroin was a phase that would pass,
and wanted to keep him safe until this happened. He was their little boy and they
would do anything to keep him safe.
Pattie and Doug increasingly found it hard to talk without arguing. Pattie’s
depression got worse, Doug drank more and their relationship started to suffer with
the worry and disagreement over how to manage Tom. Seeing his parents in distress
and feeling guilty but not feeling able to make things better, Tom used more heroin.
As time has passed, the family have become more and more used to Tom’s drug use
and the problems that go with it – occasional he steals from them, he doesn’t get up
til midday, he hasn’t managed to keep a job, he sometimes has dealers coming to
the house to get money he owes. They all feel hopeless to change anything.
Despite their problems, they do share happier moments together and are close to
their extended family.
Rationale







Systems theory and circular causality
Embeddedness of substance users
Impact of substance use
Reciprocal relationships
Good for clients
Good for families
Improves treatment outcomes and well-being
Evidence







Involving family members improves rates of entry, retention
and outcome in addictions treatment (Copello et al 2010)
FT> individual treatment, peer therapy, psychoeducation for
families (Stanton and Shadish meta-analysis)
NICE for SM: involve the family, offer Family Support,
Behavioural Couples Therapy (BCT)
Lyotard – different kinds of evidence
EBP as a dominant discourses that silence others (Mirza and
Corless 2009)
Much good evidence that doesn’t meet NICE gold standard
Where is the evidence for co/multi-morbid problems?
3 types of intervention:
3 different aims



Engaging with family as a way of getting using
person into treatment eg CRAFT (Miller,
Meyers and Tonigan 1999)
Support to family member in their own right–
eg Copello’s Family Support, Al-Anon
Involving the family member in the person’s
treatment – eg BCT, Steinglass’ systemic
motivational interviewing, family therapy
Copello’s 5 step Family Support







Stress-strain-coping model
Having a close relative with a substance misuse problem is
stressful
‘Stress’ is moderated by social support and ways of coping
Engaged, withdrawn, tolerant
These factors determine how much ‘strain’ someone
experiences
Family members historically pathologised – ‘codependent’,
‘enmeshed’, ‘enabling’
People don’t know how to respond to drug-taking behaviour,
and do the best they can
The stress-strain-coping-support
model
Relative’s substance problem
Stress on family member
Social support
Ways of coping
Family member ‘strain’
5 steps
1 – Listen non-judgementally and explore concerns
2 - Give relevant targeted information (eg about
substances and treatment)
3 - Explore coping – ‘engaged’, ‘tolerant’, ‘withdrawn’
4 – Discuss social support – map
5 – Discuss further support needs
-
Useful model
Can be hard to identify these people - rely on service
Often more complex problems
Organisational issues of data/recording
Behavioural Couples Therapy
(BCT)




-
Manualised therapy that supports couples (or close family who
live together) who are aiming to maintain abstinence.
1 using/drinking partner, 1 non-using/drinking
Focuses on making the relationship more satisfying and
supporting abstinence
Behavioural contracting, daily trust discussion, communication
and problem-solving skills training, improving positive couple
activities.
Some useful components
limited applicability
does not account for other problems
does not adequately deal with domestic violence
Peter Steinglass
Systemic Motivational Interviewing





-
Substance use becomes central organising factor of family
Comes to serve a function eg distance regulation
Family level ambivalence about giving it up
Family has developed homeostasis and it will be a challenge to
change.
Family level treatment – assessment (beliefs, pros and cons)
detox (contracting, predicting obstacles) , RP, rehab
useful framework
families often don’t see it this way prior to detox
doesn’t account for other family problems
no evidence
Reality






Useful but simplistic models for multi-problem
families
Mental and physical health (eating disorder, PD,
depression, trauma, HIV, hepatitis, cancer), legal,
financial.
Secrets, abuse, conflict, different expectations from
relationship, attachment, trust
Relational distress in the room is often high
These models foreground the addiction as primary
where the families may not.
Recovery presented as linear process
Examples




mother, father and 2 teenage sons; he discovered she’s
having an affair, relationship crisis, it gradually emerges
he has relapsed to alcohol. Trust, conflict.
couple with 5 year old daughter. He finds out she’s been
using crack daily for one year, relationship crisis, need
to rebuild trust. Miscarriage that they’ve not spoken
about.
gay couple both drink++, one uses heroin also. Both
physically v unwell. Asked by the system to help them
separate as relationship is dysfunctional.
couple – she has ED, he has ASPD and depression. Both
history of c/h abuse. She drinks, he smokes cannabis.
Conflict, control, distress.
Eg of 2 useful FT/systemic models


Transgenerational (eg McGoldrick, Byng-Hall)–
identify patterns and scripts across generations. How
emotions are shown, how people ‘do’ being in a
couple, parenting, substance use, closeness and
distance – what do you want to do the same
(replicative script)? Differently (corrective
/improvised script)? Family life cycle
Attachment (eg Dallos and Vetere) – styles, beliefs
and expectations about relationships. Attachment
styles as communication patterns. Seeing broken trust
as an ‘attachment injury’. Therapeutic relationship as
secure base.
Dilemmas



Who is the client? (The service, the client, the
family, the relationship?)
Child protection and influence on how honest
people can be
Domestic violence – work with it v don’t work
with it
Important systemic concepts




Self-reflexivity: How does my ‘self’ influence my
therapy – what I choose to ask/not ask? As a white,
middle-class, professional, woman, and mother….
What will I privilege? What will I miss? What stories
do I have about relationships? Therapy? Recovery?
How do these affect how I will work and relate to
clients? Eg MI and contexts of oppression
Power
Discourses: drug users are __ , treatment= abstinence
vs methadone
Reflecting team
References (bold=essential reading)











Copello, A., Templeton, L, Orford, J. and Velleman, R. (2010) 5-Step Method: Principles
and practice. Drugs: education, prevention and policy, December 2010; 17(S1): 86–99
Corless, J. and Mirza, K.A.H. and Steinglass, P. (2009) Editorial: Family therapy for
substance misuse: the maturation of a field. Journal of Family Therapy 31: 109–114.
Dallos, R. and Draper, R. (2000) An Introduction to Family Therapy. Open University Press
Dallos R and Vetere, A (2008) Systemic therapy and attachment narratives. Journal of Family
Therapy 30: 374–385
Lyotard, J. (1984) The post-modern condition. Minneapolis; University of Minnesota Press
McGoldrick, M. (1980). Problems with family genograms. American Journal of Family
Therapy, 7, 74-76.
Miller, W.R., Meyers, R.J., & Tonigan J.S. (1999). Engaging the unmotivated in
treatment for alcohol problems: A comparison of three intervention strategies. Journal
of Consulting and Clinical Psychology, 67, 688-697.
Mirza, K. A. H. and Corless, J. (2009) Life beyond empirical science and evidence-based
practice. Journal of Family Therapy 31: 206–210
O’Farrell, T. J. and Fals-Stewart, W. (2006) Behavioural Couples Therapy for Alcoholism and
Drug Abuse. Guilford Press
Stanton, M. D. & Shadish, W. R. (1997) Outcome, attrition and family-couples treatment for
drug abuse: a meta-analysis and review of controlled, comparative studies. Psychological
Bulletin 122; 170-191
Steinglass, P (2009) Systemic-motivational therapy for substance abuse disorders: an
integrative model. Journal of Family Therapy 31: 155–174