Substance abuse disorders do not develop in isolation. For many individuals with substance abuse disorders, interactions with the family of origin, as well as the current family, set the patterns and dynamics for their problems with substances.

Furthermore, family member interactions with the substance abuser can either perpetuate and aggravate the problem or substantially assist in resolving it. Family therapy is suggested when the client exhibits signs that substance abuse is strongly influenced by family members' behaviors or communications with them.

Family therapy might be contraindicated if other family members are active substance abusers, violent, deny that the client's substance abuse is problematic, or remain excessively angry.

Family therapy is often used to examine factors that maintain a client's substance abuse behavior. To understand these factors, the therapist considers the family's various structural elements and how they contribute to the substance abuse.

These elements might include the power hierarchy, roles, rules, alignments, and communication patterns within the family. Through family therapy, the clinician can help the family identify dysfunctional areas, adjust its hierarchy, change various roles that members play, change dysfunctional rules, alter dysfunctional alignments between family members, and replace dysfunctional communications with clear, direct, and effective communication.

Family involvement is often critical for success in treating many substance abuse disorders--most obviously in cases where elements of the family are inadvertently reinforcing or supporting the problem. In some cases, another family member has a different agenda from the rest of the family. For example, the husband of a recovering substance abuser may have taken on additional roles in the family as a result of the vacuum left when his wife was abusing substances.

The husband may be unwilling to let her resume her place in the family or share control of the family budget, for example. Unless family therapy can shift his position, the client's recovery is likely to be impeded. When the whole family is involved in therapy, changes are faster and easier to maintain. In addition, the client gains a built-in support system.

Complex interactions between family dynamics and substance abuse have long been recognized (Lewis, 1937). Whalen suggested spousal psychopathology was a contributing factor in the onset and maintenance of substance abuse (Whalen, 1953). Jackson argued on the basis of interviews with members of Al-Anon that the depression, anxiety, and distress seen so often in family members of substance abusers stem from, rather than cause substance abuse disorders (Jackson, 1954).

Contrary to what had long been the popular opinion, most individuals with substance abuse disorders maintain close ties with their families. Research has consistently shown that people with substance abuse disorders are in closer contact with their families of origin than the members of the general population of comparable age (Bekir et al., 1993; Douglas, 1987).

A number of reviews have found strong support for the use of family therapy methods for substance abuse treatment. Recent research even suggests that family and marital treatment produces better marital and drinking outcomes than nonfamily methods (Lowinson et al., 1997).

At least one study that compared long-term and short-term family therapy (16 and 8 casework interventions over an 8- and a 4-month period, respectively) found that shorter services were often more beneficial (Garvin et al., 1976). However, comparable studies specifically on family therapy as applied to substance abuse disorders are lacking.

The Harvard Medical School Department of Psychiatry successfully used couples counseling in the context of treatment for alcohol-dependent clients. Studies of participants in the Harvard Counseling for Alcoholics' Marriages Project (Project CALM) showed that more than 50 percent of husbands with alcohol abuse disorders who participated remained alcohol free in the first year after treatment, compared with less than 30 percent of husbands treated in individual therapy.

Participants in the program also had fewer marital separations. With the addition of a relapse prevention program, the results improved even further (Rotunda and O'Farrell, 1997).

Family therapy should be conducted by a clinician with a good understanding of family systems, dysfunctional family patterns, power struggles, and communication. Alcohol and drug counselors can learn to work with families, especially if they do not hold the family responsible for the substance abuse. If possible, an appropriately trained family therapist should be available to conduct sessions involving a client's family.

Appropriateness of Brief Family Therapy

Long-term family therapy is not usually necessary within the context of treatment for substance abuse disorders. An exception is long-term residential treatment, during which the involvement of the client's family is highly recommended and often is an integral part of the therapeutic process. Making real progress with a family over a long period is challenging.

Stumbling blocks, barriers, and pathology seem to emerge. Family members drop out and reenter the therapeutic process, and it becomes increasingly difficult for the therapist to avoid making decisions. The family may try to incorporate the therapist into the family system, routinely seeking direction in a crisis. Boundary and projection issues must be addressed.

In short-term family therapy, the boundary between the therapist and the family is more clear. In general, it is easier to continue to help an individual work within the family system through subsequent individual therapy.

Some traditional approaches encourage clients to work on themselves in isolation from others, but there are very few instances in which the opportunity to work with a client's family--for at least one or a few sessions--is not beneficial. Obviously, one such exception is when the client is unwilling to pursue this approach.

Another instance best dealt with individually is when the client's situation involves issues of separation and individuation although conjoint family work often helps complete this process. Physical, emotional, or sexual abuse of the client by a family member may also rule out family therapy. Short-term family therapy is an option that could be used in the following circumstances:

  • When resolving a specific problem in the family and working toward a solution

  • When the therapeutic goals do not require in-depth, multigenerational family history, but rather a focus on present interactions

  • When the family as a whole can benefit from teaching and communication to better understand some aspect of the substance abuse disorder

Family therapy offers an opportunity to

  • Focus on the expectation of change within the family (which may involve multiple adjustments)

  • Test new patterns of behavior

  • Teach how a family system works, and how the family supports symptoms and maintains needed roles

  • Elicit the strengths of every family member

  • Explore the meaning of substance abuse within the family

An obvious prerequisite for family therapy would seem to be the existence of a family. However, some therapists, including Haley, believe it is possible to "create" a family by drawing on the client's network of significant contacts.

A more important question than whether the client is living with a family is, "Can the client's problem be seen as having a relational component (that is, involving two or more people)?"

Rather than simply trying to identify existent family members, therapists can begin by conducting an assessment of the client's social network that would include significant others, friends, employers, and coworkers. These people are significant and helpful in the client's life and can be important elements of a client's recovery program.