1. Family Based Views of Alcoholism & Drug Abuse

In the 1950s and 1960s, substance abuse was viewed and treated as an individual problem. However, over the last several decades, there has been an increase in family-involved treatment for those individuals battling alcoholism and/or drug addictions. 

With the support of research, we have gained a greater understanding of family members’ influence on substance-using behaviors, as well as the supportive role that families can have on abstinence.

Let’s spend some time learning about the treatment models that are available to help achieve abstinence, improve overall family functioning, and increase positive couple relations. These approaches lay the foundation for family and couple participation in substance use treatment.

Although there are numerous treatment models, there are three that dominate family-based treatment: the family disease model, the family systems model, and the behavioral model.  The level of family involvement in treatment will be determined by which model is used.  Family involvement may be as little as providing assessment information only, or as much as being an equal partner in the treatment process.

a. Family Disease Model: The best-known and most widely used treatment model is the family disease model. This model views alcoholism and drug abuse as an illness of the family; it not only effects the substance abuser, but also members of the family.

There are two key concepts in this model: codependency and enabling. From this outlook, family members, including the substance abuser, suffer from “codependency,” which can involve control issues, dishonesty, frozen feelings, fear, denial, anxiety, depression, stress-related illnesses, care-taking, and self-centeredness. 

This is not to say that all of these characteristics are present or that they are ‘bad,’ but can result from living with a substance abuse problem. Family members may develop these characteristics as a reaction to the substance abuse.

At the core of codependency is enabling, which is defined as a set of behaviors that support substance- using behaviors. Some enabling behaviors include calling in to work for the substance abuser because he or she is hung-over, giving the substance abuser money knowing he or she will buy alcohol or drugs, or making excuses to extended family members when the substance abuser does not attend a family function.

b. Family Systems Model: Another popular viewpoint is the family systems model. This model views substance use as a major organizing principle of behavioral relationships between family members. The substance abuse represents an unhealthy attempt to cope with difficulties or problems and also serves as a tool to regulate family transactions. 

For example, substance abuse may distract family members from focusing on deeper family concerns, like a major illness or financial troubles. Family members support continued substance use through care-taking behaviors (i.e., cleaning up after a binge, making excuses) and behaviors that do not support abstinence (i.e., buying beer for the household, ignoring the substance use).

The substance abuse also serves to maintain homeostasis, which refers to the balance and stability of family patterns of functioning.  Over a period of time, the family has adapted to the patterns of behavior (accepted behaviors as well as those that are not desired) and they have found a way to make the system work.  Therefore, change can be difficult and uncomfortable for all family members.

c. Behavioral Model: The third model is the behavioral model, which we will discuss as family- based or couples-based. Behavioral models view substance use as a behavior learned through social relations and reinforced by experience. Thus, substance use can be maintained by triggering cues and post-use consequences in the family environment.

Why should family and substance use issues be examined at the same time? Why would family-based treatment play a role in the behavioral improvement of the substance-using partner? What are some of the positive characteristics that the family unit can offer in maintaining abstinence?

These are tough questions that most couples seeking family-based treatment would want to know the answers to before engaging in this type of treatment.  Family members arguably provide the most effective means for disrupting substance-using behaviors by providing an environment that is favorable to maintaining abstinence.

Family-based models view the family as a source of triggers, as well as a provider of consequences, both positive and negative. Triggers are cues that can make a person act, think, or feel a certain way.

Triggers that may be present within a relationship and effect substance-using behavior include, but are not limited to, marital problems, financial trouble, harsh communication, or controlling behaviors that cause stress. Family functions where substances, mainly alcohol, are used for bonding or celebrating can indirectly lead to recurring abusive behavior.

Even though the family may remain critical of the behavior, their own actions might indicate to the substance user that they do not necessarily “practice what they preach.” For example, while at a family function the non-substance-abusing partner will drink alcohol while repeatedly questioning the substance-abusing partner about his or her drinking.

We can safely assume that both partners may engage in behaviors that either positively or negatively support drinking. Positive consequences may include family members cleaning up after a drinking binge, covering for the substance abuser at his or her job, or making excuses for him or her to avoid family functions.

At the same time, remaining silent about such behaviors can also lead to an undesired result. Non-substance-abusing partners who help to “cover” or care for the substance abuser might be harming behavioral change and thus, can be viewed by the substance abuser as condoning the behavior.

But how, you may ask? By helping the substance abuser wade through the waters of his or her actions, non-substance abusers may not be fully aware that some of these behaviors reflect unspoken support for the use of alcohol or drugs.

This is crucial to understanding the relationship between family and substance abuse. This is not to say that family members engage in these behaviors consciously or out of any intent to cause harm, but often these actions come from a genuine desire to help.

Negative consequences may include family members avoiding the substance abuser, negative verbal comments that are directed at the substance abuser, or the occurrence of physical violence.

Partners in relationships where substance use is common often believe they are being effective by being critical of the behavior, but the opposite effect often takes place; these criticisms can drive the substance abuser farther away from the family (which is counter-productive to the goals of most commonly used treatment models). 

Families who are curious about the link between substance abuse and relationships should know that these criticisms could add to current stress levels and cause a chain reaction that leads to a relapse.

Couples-based models examine couple relationships and the substance use together, as a give-and-take system. This view also acknowledges that substance use decreases the amount of time that couples spend together, the couple’s amount of time for fun activities, and the level of shared daily caring activities.

While the family structure is a crucial part of this behavioral model, the most important piece remains the relationship partner.

There are a number of reasons for this, but three can be pointed to as most important:

1. First, the quality of the intimate relationship where substance use is a factor is inherently poor. Alcohol and drug use negatively influence daily caring rituals that otherwise provide the support necessary to maintain a healthy relationship.

2. Next, when a couple learns new methods of dealing with disagreements, they can stop behaviors that could cause a relapse. Arguments may arise from the non-substance-abusing partners’ fears of past or future drug use, which can isolate the substance abuser and send him or her back into the use cycle. Couples learn that these discussions can remain positive, even while attempting to tackle fears that obviously still exist.

3. Finally, happiness and feelings of fulfillment within a committed relationship will only help to motivate the substance abuser to maintain abstinence. When both partners are satisfied in their relationship, there is more open communication between them. As a result, couples communicate more effectively and fewer disagreements tend to occur. These improvements help to establish a supportive relationship, as well as aid in the growth of coping strategies, which, in turn, help control substance-using behaviors.

Family members serve as ‘change agents’ when they engage in behaviors that are supportive of achieving and maintaining abstinence.

Examples of change behaviors include learning how to deal with substance use by not:

• Threatening, nagging, or bringing up the past.

• Encouraging treatment involvement and attendance at self-help meetings.

• Ending behaviors that support use (i.e., care-taking).

• Learning and using skills that promote healthy communication and family interactions.

The “Vicious Cycle”: Substance use and relationship functioning can be described as a vicious cycle because without change, substance use continues and relationship distress increases. There are a number of factors that contribute to the start and maintenance of substance-using behaviors.

Figure 1 depicts substance use as a behavior that can be triggered by and can continue as a result of both partners arguing about past use, nagging, and accepting positive consequences that result from family care-taking.

Substance use, and the behaviors that promote it, then influence relationship functioning negatively, resulting in lack of caring behaviors, unresolved arguments, and decreased satisfaction. Moving through the cycle, arguments, decreased satisfaction, and poor communication can lead to continued substance use. Without initiating change and promoting behaviors that support relationship improvement, this cycle will continue.

Figure 1: Substance Use & Relationship Functioning

2. Treatment Implications

a. Family Disease Model: Typically, the treatment provider sees family members without the substance abuser present, while the substance abuser participates in individual treatment and/or attends self-help meetings. The focus of treatment for the family is educational in nature, emphasizing the disease and codependency concepts. 

Family members learn to stop enabling behaviors and to focus on decreasing their own distress and increasing their coping skills.  Also, family members may be referred to self-help support groups such as Al-Anon, Al-Ateen, or Adult Children of Alcoholics (ACOA).

b. Family Systems Model: The underlying principle in the family systems treatment approach is that change in the family system can help to change the role that substance use has in the family. In addition, a family systems approach can help redefine the role of the substance-abusing family member in the family. 

It is important to note that these changes can create a period of instability while the family system experiences changes in functioning, as well as changes in the roles that family members have within that system. Treatment is aimed at restructuring behavior patterns so that the substance use is no longer necessary for family functioning. 

The goals of treatment are for the family to work together to: clarify roles, identify and adhere to more effective family rules, and define and reinforce appropriate boundaries between family members.  Restructuring and joining are two types of techniques that can be used to achieve these goals.

• Restructuring techniques challenge the family’s typical behavior patterns.

These techniques include:

1. Contracting: an agreement to work together to overcome family issues.

2. Reframing: involves helping family members to understand their behavioral relationships and the role substance use has in the family.

3. Enactment: drawing out persistent behavioral patterns and providing family members with positive alternatives to deal with these patterns.

4. Restructuring: emphasizes changing family interaction patterns to establish new and healthier patterns.

5. Marking boundaries: establishing clear roles and boundaries for the individual and family.

• Joining techniques are designed to promote a relationship between the treatment provider and the family.  Joining involves the treatment provider acknowledging family strengths, supporting threatened family members, and using family members’ styles of communication to introduce new concepts and ideas.

c. Behavioral Model: In essence, behavior-oriented family treatment challenges substance abusers to address several key issues.

The goals of treatment are to:

●  help family members identify troublesome behaviors and modify them in order to reduce negative reinforcement of substance use,

●  promote healthy relationships,
●  reinforce abstinence, and
●  increase socially acceptable behaviors.

Effective behavioral techniques include identification and reduction of relapse triggers, as well as elimination of abusive behaviors exhibited by both partners. Family and couples treatment aims to improve and build relationship factors that are supportive of abstinence. 

The substance abuser and family members receive education and skill development to increase positive activities, enhance communication skills, strengthen the relationship, and prevent relapse.  Increasing positive activities can be done through Catch Your Partner Doing Something Nice, Caring Day assignments, and Shared Rewarding Activities.

Listening skills, expressing feelings directly, and negotiating for requests are positive communication skills. Developing a Continuing Recovery Plan can assist the substance abuser and his or her partner in identifying triggers and coping strategies that can aid in preventing relapses and addressing relapses should they occur.

This approach also helps the couple to identify specific activities, in the form of Action Plans, the substance abuser and the couple implement to promote continued abstinence, relationship enhancement, and the maintenance of gains resulting from implementing positive change.

A number of these activities and exercises are described throughout this workbook, including the sections titled: Building Support for Abstinence, Increasing Positive Interactions: Couple & Family Activities, He Said – She Said: A Discussion on Communication Barriers and Skills for Successful Communication, and Continuing Recovery: Helpful Guidelines.

“Breaking The Vicious Cycle”: Engaging in change-driven behaviors, such as those described in this workbook, can help to break the “vicious cycle” that maintains substance use and gets in the way of healthy relationships. Figure 2 highlights some of the skills that can help in “Breaking the Vicious Cycle.”

Figure 2: “Breaking the Vicious Cycle”

3. Integration of Views

Depending on the needs of the substance abuser and his or her family, each of these viewpoints can be used successfully in full or in part. All efforts aimed at family and relationship improvement are beneficial for substance-using couples and families. 

These efforts can build support for abstinence, enhance commitment to the relationship, increase the strength of the relationship, increase positive activities, improve communication skills, promote positive feelings, maintain abstinence, and prevent relapse.

In addition, research with couples where there is alcohol/drug use has reported that participation in couples-based treatment results in higher marital satisfaction, better overall family functioning, lower divorce and separation rates, higher child functioning, decreased levels of domestic violence, fewer relapse occurrences, and fewer drug related arrests and hospitalizations1,2 .

Examples of combining the different techniques include “medication contracts,” attending AA and family-focused treatment, and any activity or behavioral change that supports abstinence and enhances family functioning.

A medication contract refers to the substance abuser taking a substance-related medication, such as antabuse, in front of his or her partner while participating in an Abstinence Trust Discussion (as described in the section: Building Support for Abstinence).

The substance abuser and family members may choose to attend self-help meetings and treatment, either together or individually. Family members and the substance abuser can engage in a number of activities and behavior-change exercises that promote and support abstinence, as well as family and couple satisfaction and happiness.

For more information:

1 Fals-Stewart, W. Birchler, G.R. & O’Farrell,  T.J. (1996). Behavioral couples therapy for male substance-abusing patients: Effects on relationship adjustment and drug-using behavior. Journal of Consulting and Clinical Psychology, 64, 959-972.

2 Fals-Stewart, W., Birchler, G.R. & O’Farrell, T.J. (1999). Drug-abusing patients and their partners: Dyadic adjustment, relationship stability and substance use. Journal of Abnormal Psychology, 108, 11-23.

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See more of this publication at Sobriety: A Couple’s Workbook

Learning Sobriety Together: A Couple’s Workbook is also available as a pdf download – see list of manuals on the addiction and Family Research Group site
http://addictionandfamily.org/