Transcript Family therapy approaches to problem alcohol use: using

Family Therapy & Problem Alcohol Use:
Opportunities and Cautions when
working systemically
A Presentation to the The Association of Family and
Conciliation Courts, Ontario Chapter
Brenda Spitzer, MSc, RMFT
Problem alcohol use is a family problem
Problem alcohol use is a family problem
Problem alcohol use is a family problem
Problem Alcohol Use.....
Transforms family relationships, roles, rules, and rituals.
Isolates the family from potential sources of extended family,
social, and community support.
Usually has far reaching, long-lasting effects on the physical and
emotional health of the family and children.
How do family therapists and other
therapists who work with a wide range of
clinical issues encounter problem alcohol
use?
As the primary presenting issue of a self-referred individual
client.
As a major presenting issue in couple therapy.
As an identified goal for the therapy by a referral source or
collateral system (CAS, criminal court).
As a secondary issue arising after individual, couple or family
therapy has started and goals have been established not directly
related to alcohol use.
What is the rationale for working with
the family in therapy?
Shouldn’t the client be referred for specialized addiction service
before couple or family sessions are considered?
Doesn’t family therapy assign responsibility for problem
drinking to family members inappropriately?
Including families in treatment of problem
alcohol use is important to address the
effects of problem drinking on the family and
the effects of family dynamics on problem
drinking
It is important to bring the whole picture into focus to explore
and address the not-so-visible symptoms as well as the easily
visible ones, with concern for how they manifest themselves in
each individual in the family.
Dysfunctional family dynamics often result from problem
alcohol use and problem alcohol use can be reinforced by family
dynamics or be one manifestation of family dysfunction.
Areas to Explore when Assessing Problem
Alcohol Use:
1. Level and pattern of alcohol use (of “the drinker”)
2. Consequences of alcohol use
3. How the family system organizes around the problem drinking
Level of alcohol use of “the drinker”
Continuum of Problem Alcohol Use
No/Low Risk
At Risk
Mild
Moderate
Triangle represents North American adult population
Severe
Areas to Explore when Assessing for
Problem Alcohol Use:
Level and pattern of alcohol use of “the drinker”:
Level of use can range from no/low risk to severe on a continuum that
described Alcohol Dependence.
Low Risk/Mild Risk Drinking can include experiencing some adverse reactions
from drinking such as disagreements with family members about what
constitutes too much drinking.
Severe Drinking/Alcohol Dependence reflects a physical/psychological
dependence on alcohol with several negative physical, psychological and social
effects.
A referral to specialized services for acute problem drinking is important if
drinking is causing serious medical, psychological or interpersonal problems.
Level of alcohol use of “the drinker”
No/Low Risk
At Risk
Mild
Moderate
Brief treatment interventions that include family interventions
are well-suited to mild or moderate alcohol problems
Severe
Areas to Explore when Assessing for Problem
Alcohol Use:
Consequences of alcohol use:
Is alcohol use a regular issue that a couple has disagreements about?
Is alcohol use something that is hidden or a “secret” in the family?
Who is most upset about the alcohol use?
What activities does alcohol use interfere with or negatively impact?
How did alcohol get introduced into the therapy?
Is the alcohol use impacting the client and family’s ability to attain
identified therapy goals?
When drinking is identified as a problem for
a family: questions to consider next:
How is the family system organized around the problem drinking?
Family members may be extremely cautious in their behavior in
order to avoid exacerbating existing problems (that may not be
directly related to alcohol use).
Family members often adapt their behaviour in order to
minimize or survive an unhealthy situation.
Adaptation can have harmful effects on those who are adjusting
and also may inadvertently reinforce the problem alcohol use.
Three typical family characteristics emerge: family denial,
avoidance of social and emotional engagement
When drinking is identified as a problem for
a family: questions to consider next:
How is the family system organized around the problem drinking?
How is the family system organized around
the problem drinking?
Family denial is common and often occurs in at least three ways:
Systemic denial: the entire family system denies or minimized
the existence of a problem. This usually occurs when the family
members do not want to admit that one of them is a problem
drinker or because they perceive the problem alcohol use as a
reflection upon themselves. This may lead to “negative
anonymity;” where the family seeks anonymity which, in turn
has a negative impact on the family.
Denial prevents others from knowing or judging the family but
keeps the family from getting support and help.
How is the family system organized around
the problem drinking?
Family denial of alcoholism occurs in at least three ways:
Protection against Exposure : A second form of family denial is
protection against exposure which is accomplished by not
talking about the problem or pretending it does not exist.
Conversely, exposure means not only experiencing the problem,
but recognizing it, discussing it, and overcoming any effects.
How is the family system organized around
the problem drinking?
Family denial of alcoholism occurs in at least three ways:
Blaming all family dysfunction on alcohol use: Traditionally
when problem alcohol use was identified in a family, it was
assumed that the problem drinker was the primary concern to
be treated before any family work could be done.
Many problem drinkers do not quit drinking – families may
deteriorate while waiting for a change in the drinker’s
behaviour.
Viewing the “drinker” as the primary concern may lead to lost
opportunities to intervene to support family members, to
identify and name unspoken family concerns and address family
dysfunction.
How is the family system organized around
the problem drinking?
How is the family system organizing around the problem
drinking?
Social disengagement: Social disengagement is the withdrawing
of family members from interaction with others.
This often comes from the family’s fear of the consequences of
encounters that include the drinker and a wish to protect itself
from exposure, embarrassment, discomfort and fear.
The family often becomes isolated making it harder to access
support.
How is the family system organized around
the problem drinking?
How is the family system organizing around the problem
drinking?
Emotional withdrawal: Emotional disengagement is a response
to anticipation of negative emotions, such as anger and tension.
A common reaction is to become “non-feeling,” that is, to deny
and minimize negative feelings to prevent further pain.
Avoidance becomes the norm for handling negative emotions,
but may end up cutting off the benefits of positive relationships.
When drinking is a problem for a family:
questions to consider next:
How and when should the family therapist address the drinking
problem?
It’s important to introduce drinking earlier in the sessions if it
appears to underpin the presenting problems or if it appears to
interfere with achieving treatment goals.
The issue of problem drinking can wait until later in the sessions
if it seems to be more marginally related to presenting
problems and therapy is progressing well.
When drinking is a problem for a family:
questions to consider next:
Should the therapist work with the family or just the “identified
problem drinker”?
Working with the family allows for support for family members
even if the problem drinking is ongoing.
Working with the family may facilitate disruption of unhelpful
family patterns that have inadvertently reinforced drinking
behavior or hidden problem drinking.
When drinking is a problem for a family:
questions to consider next:
Should the therapist work with the family or just the “identified
problem drinker”?
Seeing the entire family may reduce isolation and create greater
opportunities for family members to receive support and for
new family patterns of relating to emerge.
Separate sessions for the problem drinker may be important if
drinking is more severe and if the drinker is motivated to make
behavioural changes.
When drinking is a problem for a family:
questions to consider next:
Should the children be included in the family therapy?
Opportunities: Addressing drinking with children present allows
for identification and exploration of a subject that may have
been secret or taboo.
This may lead to relief, create opportunities to share in an
honest way about drinking and other family dynamics and may
make it safer for kids to discuss the issue going forward.
The presence of kids for a discussion of alcohol use may make it
more difficult for all family members to avoid, minimize or hide
difficult family issues including drinking.
When drinking is a problem for a family:
questions to consider next:
Should the children be included in the family therapy?
Risks: a discussion of the problem drinking in front of children
may be inappropriate if it is linked to intimate couple issues that
would be too “adult” for children to explore.
Discussion of problem drinking in front of children may not be
appropriate in families where there are power and control
dynamics that lead children to feel unsafe in discussing
challenging issues. In these families, prioritizing safety should
take precedence over challenging family denial.
Features of family therapy with problem
drinking:
What are some helpful ways to raise the issue of the problem
drinking?
1. Empathic responses to client and family members
2. Circular and interventive questions to explore and create
change opportunities for the family system
3. Focussing on Goals identified by the Client(s)
4. Tolerance of Client(s) Ambivalence about Change
5. Providing the Client with Choices
Family therapy with problem drinking:
What are some helpful ways to raise the issue of the problem
drinking?
Empathic responses to client and family members: Research
indicates that it is more effective for therapists to work to
understand the complex emotions and communicate
understanding the emotion to clients as a facilitator of change
compared to a traditional confrontational style that attempt to
“break through” client denial
Family therapy with problem drinking:
What are some helpful ways to raise the issue of the problem
drinking?
Circular and interventive questions: These are questions
designed to explore the relational aspects of the family system
allowing the therapist and the family to better understand and
be aware of their cyclical sequences of interactions which
interconnect with family beliefs.
Circular questions may reveal the family’s patterns of relating
and believing that perpetuate dysfunctional behaviors and
cognitions.
Family therapy with problem drinking:
What are some helpful ways to raise the issue of the problem
drinking?
Circular and interventive questions:
Examples: “How does dad’s behaviour bother you differently
than it bothers mom?”
“Who would be most relieved if dad cut down on his drinking?”
“Who is most likely to agree with dad that drinking is not a big
problem for the family? Who is least likely to agree with dad?”
Family therapy with problem drinking:
What are some helpful ways to raise the issue of the problem
drinking?
Focussing on Goals identified by the Client(s): It is typically more
effective to focus the therapy on what the client(s) identify as
most important to change even if it does not directly involve
problem alcohol use.
The therapist can explore how problem drinking contributes to
the gap between the client’s presenting situation and their
preferred situation creating opportunities for the client to create
linkages between drinking and non-preferred outcomes.
Family therapy with problem drinking:
What are some helpful ways to raise the issue of the problem
drinking?
Tolerance of Client Ambivalence: Traditional treatments have
often emphasized the bottom line where goals and behavioural
plans are set.
Intentionally focussing on clients ambivalence can be very
effective and decentralizes the change in drinking behaviour as
a goal for therapy. Therapists work with clients to take up both
sides of the ambivalent conflict with the goal of inviting the
drinker to stay present to considering both sides.
Family therapy with problem drinking:
Tolerance of Client Ambivalence cont’d
By focussing on ambivalence the therapist is able to give the
message that the client has a choice as opposed to
communicating that the therapist “knows best”
Giving permission for ambivalence provides the psychological
space necessary for making difficult decisions. It is important for
the therapist not to declare a position with regard to the
outcome and to respect the autonomy of their clients by being
clear about all their potential options while also being clear
about the dangers.
Family therapy with problem drinking:
How can the therapist work with the family if the problem
drinker is not present?
Family sessions without the problem drinker can be helpful in
addressing family coping, family safety, family reactions and
interactions.
Changing family coping: these are interventions that aim to
reduce family behaviours that protect the problem drinker.
Feedback to the drinker: factual, objective, caring, provided
when there is no drinking and with specific requests, providing
family support for drinker’s efforts to change.
Family member self care: socializing, creating supportive
networks, resuming some “normal” and positive family
routines.
Pitfalls and cautions: Triangulation
“Triangulation” can undermine progress in family therapy:
Triangles form when two parts of a system (family/therapist
system) are allied against another part.
Triangles form to reduce tension or pressure in one part of a
system by creating an alliance against a third part of a system.
Pitfalls and cautions: Triangulation
“Triangulation” can undermine progress in family therapy when two parts of a system
form an alliance against a third part of a system:
Problem
drinker
Family
members
Problem
drinker
Therapist
Therapist and family
members allied against the
problem drinker
Therapist
Family
members
Family members and
problem drinker allied
against the therapist
Pitfalls and cautions: Triangulation
“Triangulation” can undermine progress in family therapy:
Triangles form when two parts of a system (family/therapist system/collaterals) are
allied against another part
CAS
Family
CAS
Family
Therapist
Therapist and CAS allied against
the family (including the drinker)
Therapist
Therapist and family (including
the drinker) allied against CAS
How can conflicts and pitfalls be avoided
when working systemically?
Ethical Principles to consider when attempting to avoid pitfalls in
systemic work:
Autonomy (the promotion of personal choice)
Fidelity (make honest promises)
Beneficence (work to promote good for the client(s)
Nonmaleficence (do no harm)
Justice (all individuals to be treated fairly; equals as equals,
unequals to be treated in a way most beneficial to their specific
circumstances)
Pitfalls and cautions:
Triangulation can easily be triggered when there are multiple
systems working with a family where there is problem drinking
when:
The differing mandates of the “helpers” are not made clear and
explicit and the potential for conflicts in mandates is not
considered.
Narrow goals are defined by a 3rd party not directly involved in
the therapy and with considerable power.
Pitfalls and cautions:
Triangulation can easily be triggered when there are multiple systems
working with a family where there is problem drinking when:
Alliance between family and therapist against 3rd party with evaluative
mandate – may lead to the family avoiding taking responsibility for
problematic behaviour that led to 3rd party involvement.
Therapeutic work becomes fractured and uncoordinated or there is “too
much therapy” because the service providers of the family systems are
not coordinated or parts of the family system are treated in an
uncoordinated way.
What is helpful for the family system may not be identified as preferred
outcomes for individual family members.
How can conflicts and pitfalls be avoided
when working systemically?
Therapists need to be aware of the potential for boundary violations
that occur as a result of triangulations, especially if there are
imbalances of power in the system.
Therapists should be mindful when information-sharing, even when
there are releases permitting this when this is not be in the best
interests of the clients or undermines the family’s trust in the
therapy.
Agencies with high degrees of “legitimate power” or institutional
power such as child welfare, schools, courts should avoid relying on
information attained through family therapy which can lead clients
to become guarded and secretive which undermines the therapy.
How can conflicts and pitfalls be avoided
when working systemically?
Therapists should seek supervision or consultation if they are
becoming aware of unhelpful alliances that appear to be
preventing progress in the therapy.
Therapists should be aware of the potential for an alliances with
another helping professional whom often are more similar in
social location relative to clients and families seeking assistance
for problem alcohol use.
How can conflicts and pitfalls be avoided
when working systemically?
Therapists should consult with clients and be transparent about
information shared with 3rd parties, ideally in advance to obtain
informed consent (even when releases have been signed)
except in cases when doing so creates a safety risk.
Therapists should consult with other systems working with the
family to coordinate service, avoid duplication of service, to
avoid working at cross-purposes with other services and do so
in a way that includes the family in the process.
Questions & Comments
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