“This second edition is a must for any therapist wanting a broader and more

inclusive perspective on working with persons struggling with substance use. The
additions, namely, the expansion of family diversity to include sexual and gen-
der minorities, the neurobiology of addictions, motivational interviewing, ethics,
expansion of treatment models and case application, offer a comprehensive text
relevant for therapists-in-training and seasoned therapists seeking continuing
education. Dr. Reiter’s years of wisdom as a therapist and academic is evident
throughout the book and especially in the self-of-the family therapist chapter
that addresses issues crucial for growth and sustenance. Highly recommended!”
Joyce Baptist, PhD, LCMFT, Certified EMDR Therapist,
Associate Professor, Kansas State University

“Down-to-earth and comprehensive, Substance Abuse and the Family (2nd Ed.)
allows you to grasp the nuts and bolts of assessing and treating individuals and
families dealing with substance abuse issues. In this second edition, Reiter takes
us to the crossroads of neurophysiological, genetic, cultural, ethical, relational,
and risks factors of addiction. Providing hands on information for clinicians and
students, Reiter exemplifies various family therapy approaches that might con-
tribute to the process of recovery. One of the useful tools this book provides
is applying each chapter’s concepts to a standard case, which helped bring the
concepts to life.”
Jimena Castro, PhD, Assistant Professor, Our Lady of
the Lake University
SUBSTANCE ABUSE
AND THE FAMILY

In this updated edition of Substance Abuse and the Family, Michael D. Reiter
examines addiction through a family systems lens which considers a range of
interconnected contexts, such as biology and genetics, family relationships, and
larger systems.
Chapters are organized around two sections: Assessment and Treatment.
Examining how the family system organizes around substance use and abuse, the
first section includes contributions on the neurobiology and genetics of addic-
tion, as well as chapters on family diversity, issues in substance-using families,
and working in a culturally sensitive way. The second half of the book explores
various treatment options for individuals and families presenting with substance
abuse issues, providing an overview of the major family therapy theories, and
chapters on self-help groups and the process of family recovery.
The second edition has many useful additions including a revision of the
family diversity chapter to consider sexual and gender minorities, brand new
chapters on behavioral addictions such as sex and gambling, and a chapter on
ethical implications in substance abuse work with families. Additional sections
include information on Multisystemic Therapy, Behavioral Couples Therapy,
Motivational Interviewing, and Twelve-Step Facilitation. Each chapter now con-
tains a case application to help demonstrate treatment strategies in practice.
Intended for undergraduate and graduate students, as well as beginning prac-
titioners, Substance Abuse and the Family, 2nd Ed. remains one of the most
penetrating and in-depth examinations of the topic available.

Michael D. Reiter, PhD, is Professor of Family Therapy in the Department of

Family Therapy of the College of Arts, Humanities, and Social Sciences at Nova
Southeastern University. Michael is a licensed marriage and family therapist and
has authored eight previous textbooks, 18 peer-reviewed journal articles, and has
presented at national and international conferences on various aspects of family
therapy.
SUBSTANCE
ABUSE AND THE
FAMILY
Assessment and Treatment
Second Edition

Michael D. Reiter
Second edition published 2019
by Routledge
52 Vanderbilt Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
 2019 Taylor & Francis
The right of Michael D. Reiter to be identified as author of this work
has been asserted by him in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.
First edition published by Routledge 2014
Library of Congress Cataloging-in-Publication Data
A catalog record has been requested for this book

ISBN: 978-1-138-62587-7 (hbk)

ISBN: 978-1-138-62597-6 (pbk)
ISBN: 978-0-429-45957-3 (ebk)

Typeset in Sabon
by Swales & Willis Ltd, Exeter, Devon, UK
This book is dedicated to my siblings: Alyssa, Sean,
Howard, and David
Contents

ABOUT THE CONTRIBUTORS xi

PREFACE xiii

PART I Assessment 1
Chapter 1 Conceptualizing Addictions 3
Chapter 2 The Neurobiology of Addiction 25
Jaime L. Tartar, Christina M. Gobin,
and Julius Thomas

Chapter 3 The Genetics of Addiction 40

Jaime L. Tartar and Christina M. Gobin

Chapter 4 The Addicted Family 55

Chapter 5 Family Diversity and Substance Abuse 71
Chapter 6 Roles in the Addicted Family 98
Chapter 7 Family Life Cycle 117
Chapter 8 Issues in Substance-Abusing Families 136
Chapter 9 Behavioral Addictions 164
Myron Burns

ix
x Contents 

PART II Treatment 179

Chapter 10 Working with Partial Systems 181
Chapter 11 Ethics in Substance Abuse and the Family 212
Chapter 12 Systems Theory 240
Chapter 13 Family Therapy Overview I 260
Chapter 14 Family Therapy Overview II 292
Chapter 15 Family Therapy Application 320
Chapter 16 Family Recovery 345
Chapter 17 The Self of the Family Therapist 369

REFERENCES 384
INDEX 423
About the Contributors

Myron J. Burns, PhD, is an Associate Professor at Nova Southeastern University

(Fort Lauderdale, FL). He received his doctoral degree in Counseling
Psychology from Tennessee State University. Before attending Tennessee State
University, Dr. Burns graduated from Howard University. He has worked in
many roles at the University of Miami Center for Family Studies as a counse-
lor, supervisor, and project director. Dr. Burns’ research interests are in the
areas of health, drug use, and the interplay of personality and stress process
variables.
Christina M. Gobin, MS, is a PhD candidate at the University of Florida. She
received her Master’s degree at Nova Southeastern University where she inves-
tigated the effect of sleep quality on cognitive function and emotion process-
ing. Currently, she is studying the neurobiology of cocaine addiction. Her
research focuses on identifying neurobiological substrates underlying post-
cocaine cognitive function and drug seeking.
Paul J. Kiser, PhD, is an Associate Professor of Biology at Bellarmine University
(Louisville, KY). He has been involved for nearly two decades at the local
and state level studying and advocating for health policy initiatives and pre-
ventive efforts to reduce the health and economic burdens that the use of
alcohol, illicit drugs, tobacco and tobacco-related products place on our soci-
ety. He was a certified prevention specialist who served on numerous local,
regional, and state executive boards and committees, and he has consulted on
health policies for numerous private businesses and organizations as well as
at city council, fiscal court, and state legislative levels. Currently, Dr. Kiser is
researching the pervasiveness of alternative nicotine delivery systems in his
community and the implications of this on the perceptions and use rates by
college students in the region.
Joshua Leblang, Ed.S, is a Senior Lecturer in the Department of Psychiatry at the
University of Washington (Seattle, WA). He has been a clinician, supervisor,
and consultant for the past 18 years, working with teams in Washington,
New Mexico, Illinois, Connecticut, and New York, as well as with teams

xi
xii About the Contributors 

internationally in the UK and New Zealand. He has been working on the MST-
FIT (Family Integrated Transitions) adaptation for the past 13 years, transi-
tioning youth from out-of-home placement back to their natural environment.
Michael D. Reiter, PhD, is Professor of Family Therapy at Nova Southeastern
University in the Department of Family Therapy of the College of Arts,
Humanities, and Social Sciences. He is the author of eight previous books
including Systems Theories for Psychotherapists (2019), Family Therapy: An
Introduction to Process, Practice, and Theory (2018), Case Conceptualization
in Family Therapy (2014), and The Craft of Family Therapy (2014), written
with Dr. Salvador Minuchin, one of the founders of family therapy. Dr. Reiter
has authored 18 peer-reviewed articles and presented at numerous local,
state, national, and international conferences on family therapy. He served
as Coordinator of the Substance Abuse Specialty Program in the Division of
Social and Behavioral Sciences at Nova Southeastern University and was a
Certified Addictions Professional. He is a licensed marriage and family thera-
pist and approved supervisor of the American Association of Marriage and
Family Therapy.
Jaime L. Tartar, PhD, is a Professor of Behavioral Neuroscience at Nova
Southeastern University (Fort Lauderdale, FL). She earned her PhD in the
Behavioral Neuroscience program at the University of Florida where the focus
of her research involved discovering long-term changes that occur in neuro-
biological pathways involved in stress responses and developing animal mod-
els of chronic stress. Dr. Tartar completed postdoctoral training at Harvard
Medical School, where she studied neurological consequences of sleep pertur-
bations using in vitro electrophysiological recording techniques. She earned a
certificate in Sleep Medicine from Harvard Medical School Division of Sleep
Medicine. Dr. Tartar’s current research is focused on stress, sleep, and human
athletic performance.
Julius Thomas played for seven years in the NFL. He retired from football to
pursue a doctoral degree in clinical psychology to help others. He is cur-
rently pursuing post-graduate work at Nova Southeastern University (Fort
Lauderdale, FL), working in the neuroscience lab with Jaime Tartar where they
are researching the comprehensive effects of participating in contact sports.
Preface

This book was born over 20 years of teaching family therapy and substance
abuse courses. At my university, I taught a course specifically designed to explore
understanding addictions through a family systems lens. Throughout that time I
struggled to find the right textbooks that were broad enough to give the reader
an overview of the field with enough depth to allow them to use the information
effectively. While I was able to use a lot of good textbooks, none satisfactorily
accomplished my objectives for the course. Either they were based on one specific
theoretical lens or too focused on a specific perspective of addictions. Thus, I
decided to write the first edition of Substance Abuse and the Family.
That book was quite well received as many training programs utilized the
book in their Addictions and Family Therapy course. While I was very pleased
with the initial book, over the last five years I saw several areas that could be
enhanced and thus the second edition of the book developed. My intent for this
book is to provide the beginning practitioner with enough information to be able
to conceptualize substance abuse through a family systems lens. Hopefully after
reading the book, you will not be able to just see an individual, but will under-
stand that the individual acts based on interconnected contexts—which include
biology and genetics, family relationships, and larger systems.
The book is divided into two parts: Assessment and Treatment. In the first
half of the book we explore how to assess the various aspects of clients when
they present with substance abuse. Chapter 1 conceptualizes addiction, provid-
ing the basis of understanding the terms in the field as well as different models
of addiction. Chapter 2 explores the neuroscience of addiction, explaining
how substances impact brain chemistry and thus human behavior. Chapter 3
describes the genetics of addiction and how genes may predispose some people
to be more susceptible to substances. Chapter 4 explains how a family may go
through a process of becoming an addicted family. Chapter 5 presents informa-
tion on family diversity, particularly as it relates to substance abuse. Chapter 6
presents several different models of roles that members in addicted families
may adopt. Chapter 7 describes the family life cycle, focusing on children of
alcoholics and adult children of alcoholics. Chapter 8 identifies several issues
in substance-abusing families including domestic violence, dual diagnosis, and

xiii
xiv Preface 

readiness for change. Chapter 9 focuses on behavioral addictions, such as sex,

gambling, and internet addiction.
The second half of the book explores various treatment options for individu-
als and families presenting with substance abuse issues. Chapter 10 focuses on
working with partial systems, as many times the person abusing substances does
not want to enter therapy. This chapter explores various self-help groups as well
as various programs designed to work with the family to help get the substance
abuser into treatment. Chapter 11 is a brief overview of ethical issues involved
when conducting substance abuse therapy with families. Chapter 12 provides
an overview of systems theory as these ideas form the basis for most family
therapy theories. Chapter 13 presents five of the prominent family therapy theo-
ries, involving intergenerational, experiential, and communication approaches.
Chapter 14 presents five other family therapy theories involving strategic, sys-
temic, and postmodern models. Chapter 15 presents four specific treatment
approaches based on family therapy principles for working with families dealing
with substance abuse. Chapter 16 describes the process of family recovery and
how families change over time throughout their growth, as well as a brief discus-
sion of family prevention. Chapter 17 concludes the book with a focus on the
substance abuse family therapist.
The second edition has many additions including a section on the family-
disease perspective (Chapter 1), a complete revision of the family diversity and the
family chapter with the inclusion of a new section on sexual and gender minori-
ties (Chapter 5), enhancing motivation/motivational interviewing (Chapter 8),
criminality and addictions (Chapter 8), a new chapter describing the behavio-
ral addictions (Chapter 9), expansion of the CRAFT section (Chapter 10), the
addition of a section on Multisystemic Therapy (Chapter 10), the addition of a
section on Twelve-Step Facilitation (Chapter 10), a new chapter exploring some
of the ethical issues involved in substance abuse and family therapy (Chapter 11),
the addition of information pertaining to family-based substance abuse preven-
tion (Chapter 16), and a new section at the end of every chapter called Case
Application where the material from the chapter is applied to the case that was
presented in Chapter 1. The Case Application section helps solidify the learning
of the information by applying it to a case family struggling with addictions.
My hope is that after reading this book you will never view an individual the
same way again! The family systems viewpoint is just one of many, but one that
I think is very useful as it not only pertains to the individual but to the larger
spheres of influence (their family and the society they live in).
This book spans almost all of my life as I was able to work with friends
from almost all stages of my career. Paul Kiser, who has been a friend since
high school, was able to help out with his expertise in substance abuse preven-
tion. Joshua Leblang, a friend from my Masters program at the University of
Florida, contributed with his expertise as a trainer/supervisor in Multisystemic
Therapy. Christopher Burnett, one of my original family therapy teachers,
mentors, colleagues, and friends, provided the cover photo. My colleague and
good friend Jaime Tartar was my office next-door neighbor for almost ten
years—consistently yelling at me that my being in my office made her office
cold. For years Jaime would ask me when we were going to collaborate on a
project. Most of my work was in the application of family therapy theories
which did not mesh with her pursuits in neuroscience. Fortunately, this project
 Preface xv

allowed us to see how our two interests intersected. Jaime was kind enough
to write the neuroscience of addiction chapter and the genetics of addiction
chapter with Christina Gobin, a graduate student she was advising and a past
student of mine. Thanks to Christina for agreeing to help out on the project.
I also want to thank Dalis Arismendi, one of my former graduate students,
who helped me on Chapter 5 for the first edition of this book. Myron Burns,
a colleague for the last five years, had wanted to collaborate on a project and
this second edition fit nicely into his wheelhouse. Lastly, my newest friend,
Julius Thomas, who was fortunate to get connected to Jaime Tartar to help
him in his pursuit of utilizing clinical psychology to help athletes, as well as to
work with her on revision of “The Neurobiology of Addiction” chapter. April
Brown, my Graduate Assistant, aided me in a variety of ways including figure
and genogram development, updating statistics, reference procurement, as well
as a variety of other helpful acts. I also want to thank Clare Ashworth, editor
at Routledge, who helped bring this second edition to fruition.
PART I

ASSESSMENT
one

Conceptualizing Addictions

On Monday morning you enter your agency, ready for another day of providing
counseling to your clients. Mondays at your agency are always intriguing since
this is the day that you conduct new client intakes. Today you have several new
clients on your schedule. You do not know anything about them or what the
issues are that bring them to see you.
At the appointed time you walk to the waiting room and greet your first client.
As you introduce yourself, you look him over, making initial impressions based
on his age, height, weight, clothing choices, and hygiene. Walking with him back
to your office, you make small talk about the current weather, finding the office,
or something that recently happened in the news. Upon sitting down, you talk
with the client about informed consent and make sure all the proper paperwork
is signed. Then you let him know that you will need to gather a lot of information
from him, as is required from the agency, since the first meeting is designed for
you to develop a biopsychosocial assessment. You start to talk with him about
his history and current situation, all the while trying to figure out how you will
understand what is happening for him and, most importantly, what you will be
able to do to help him, regardless of what the “problem” may be.
After a few minutes of small talk and joining, you ask the client the all-important
question, “What brings you in to therapy?” (or “How can I help you,” “What
would you like different in your life,” “etc.”). The client responds that he has
been addicted to alcohol and drugs for the last two years and that he wants
to stop.
You now have a dilemma. Based on how you conceptualize problems, you will
not only ask different questions, but will pay attention to some material more
than others, leading you to develop a theory of problem formation and an associ-
ated theory of problem resolution (Reiter, 2014, 2019). When the client says that
he is abusing drugs, how do you view this? Do you see this as strictly a biologi-
cal problem? Do you believe that there is something mentally wrong with your
client—that he has a psychological disorder? Do you think that the addiction is
housed within a web of relationships and view it from a systemic perspective? Or
do you expand a systemic view to see that biology, psychology, and social factors
all contribute to the client’s experience?
Your answer to these questions is anything but insignificant. How you
answer each question informs how you conceptualize why the client developed

3
4 Assessment 

the problem, how it is currently maintained, and what you might do in therapy
to help him. Your view of why people develop addictions and how they continue
to use guides the whole of the treatment.
While there is validity to many different conceptualizations, this book attempts
to help therapists view substance abuse problems from a systemic perspective.
This includes an understanding of how the individual is impacted by the drug
compounds, their susceptibility based on their genetics, as well as how past and
current family and relational functioning impacts use of the substance. This sys-
temic orientation can help individuals to move beyond their abuse of drugs. We
will come back to our client later in this chapter, but first we should focus on
knowing some of the most prominent terms in the substance abuse arena so that
we are clear on what we are talking about.

Defining Addiction

Perhaps we should start our exploration of the field of substance abuse and the
family through defining some of the key concepts. It is important, especially
when interacting with other mental health professionals, to be on the same page
when we are discussing what is occurring for our clients. While various sub-
stance abuse professionals may have differing views on the etiology of addiction
or the most efficacious treatment, we can usually agree on the basic terms that
we use when we are explaining the situations clients find themselves in.
In the field of mental health the definitive source for criteria of mental dis-
orders is the Diagnostic and Statistical Manual of Mental Disorders (DSM),
which is currently in its fifth edition (American Psychiatric Association, 2013).
The DSM does not provide a definition of addiction but does provide criteria
for which various types of substance (and primarily mental health) issues can be
categorized. What might be viewed as addiction-related issues are housed under
the title of substance-related disorders, which encompass 10 classes of drugs:
alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnot-
ics, and anxiolytics; stimulants; tobacco; and other (or unknown) substances.
These 10 classes of drugs were chosen because they all have very similar pro-
cesses in how they impact people physiologically. The primary process focuses
on a direct activation of the brain reward system (which we will talk about more
in Chapter 2). This activation impacts the reinforcement of the drug use behav-
ior. While these drugs will show differential effects on people—for instance, it
may take more or less of the drug to produce the same effects in two different
individuals—they each demonstrate some type of impact on brain functioning.
Within the category of substance-related disorders the DSM-V makes a distinc-
tion between substance use disorders and substance-induced disorders. Substance
use disorders are a cluster of cognitive, behavioral, and physiological symptoms,
which impact the individual’s functioning, even after problems develop. What
this means is that once the person’s use of drugs begins to impair their function-
ing in a variety of areas (i.e., perhaps they are not able to maintain a job or they
find that they need much more of the drug to attain the effects) the person con-
tinues to use. Criteria include impaired control, social impairment, risky use, and
pharmacological criteria (including tolerance and withdrawal).
  Conceptualizing Addictions 5

Mild Moderate Severe

• 2 or 3 • 4 or 5 • 6 or more
symptoms symptoms symptoms

Figure 1.1  The severity classification for substance use disorders according to the
Diagnostic and Statistical Manual-V

Substance use disorders are viewed on a continuum from mild to severe. This
designation depends on how many symptoms are present. Mild substance use
disorder is based upon the presence of two or three symptoms, the moderate des-
ignation has four or five symptoms and the severe criteria is determined by six or
more symptoms (see Figure 1.1).
Substance-induced disorders are secondary disorders that occur from the use
of the drugs. Some examples of these include intoxication, sleep disorders, sex-
ual dysfunctions, and anxiety disorders. The symptoms from substance-induced
disorders are reversible, coinciding with a reduction or abstinence from the spe-
cific drug being used. A key component here is that the symptoms cannot be
associated with a medical condition or other mental disorder. As an example,
substance-induced disorders may demonstrate themselves in a relationship where
the male may not be able to get or maintain an erection—not because of physi-
ological problems, but because of the use of a specific drug. Once they stop using
the drug, they are able to have erections again.
In the substance abuse field, there are many overlapping concepts and terms.
Perhaps the most prominent one is the notion of addiction. What is addiction?
What comprises someone who is addicted? The answer to this is highly debated,
as part of the answer to this question relates to the hypothesized etiology of
drug abuse. While there may be alternative definitions to the terms/concepts that
are presented here, we will use these definitions throughout the book to help us
develop a common language.
Addiction: The American Society of Addiction Medicine (ASAM, 2014) defined
addiction as “a primary, chronic disease of brain reward, motivation, memory and
related circuitry.” The ASAM holds that it is the dysfunction of brain circuitry
which leads to problems in the biological, psychological, social, and spiritual
realms. They promote an A-B-C-D-E acronym for the characteristics of addiction:

a. Inability to consistently Abstain;

b. Impairment in Behavioral control;
c. Craving; or increased “hunger” for drugs or rewarding experiences;
d. Diminished recognition of significant problems with one’s behaviors and
interpersonal relationships; and
e. A dysfunctional Emotional response.

This definition provides a medical perspective to addiction where the action

occurs within the individual but also has external consequences.
6 Assessment 

While this is one of many definitions and criteria, overall, definitions of addic-
tion and substance-related concepts have been changing over time. As more
information about drug science and brain functioning comes forth, newer and
more accurate understandings of addiction can be developed. Given this, the defi-
nition of dependence in the DSM and International Statistical Classification of
Diseases and Related Health Problems (ICD) has changed over time (Nielsen,
Hansen, & Gotzsche, 2012).
The following are many of the primary terms in the substance abuse and
addiction field.

Abstinence: Abstinence is the complete disuse of a substance. The person

does not put in their body the drug that they were using. If someone were
addicted to alcohol and consumed 20 beers per week, but cut down to 10,
they would not be abstinent. They would need to not ingest any type of
alcohol for us to be able to utilize this term.
Craving: Craving is an intense or heightened desire for a substance.
While almost all of us have had what we might call a “craving” at some
point (for instance, on Thursday I was really craving peanut butter and
chocolate ice cream), in the substance abuse field craving refers to a desire
for the substance, which becomes a primary motivating factor to obtain
that substance.
Drugs: Drugs are usually considered to be a substance (outside of things
such as food) that impacts the physiology of the body. While foods, nutri-
ents, and vitamins do have physiological results, they are necessary for
survival. Drugs, as used in substance abuse, are not. A person can eas-
ily live a healthy life never having consumed alcohol, nicotine, cocaine,
heroin, etc.
Drug of choice: Drug of choice is the preferred drug that a person uses.
While they may use multiple drugs, such as alcohol, tobacco, and cocaine,
the drug of choice is the one the person would use if given the choice.
Dual diagnosis: Dual diagnosis is a term used when a person has more
than one recognized diagnosis (as determined by fitting the criteria of
either the DSM-V or the ICD-11). Usually this term is in reference to
having a psychological diagnosis in conjunction with a substance abuse
diagnosis. Other terms for this condition are co-occurring disorders or
co-morbid disorders.
Psychotropic drugs: Psychotropic drugs are those that are prescribed by
medical professionals usually for the purpose of treating mental disorders.
Although these are prescribed and are legal, they can be misused by the
person (i.e., taking more of the pill than prescribed) or may even become
addictive for the individual. For instance, a woman who was prescribed
Xanax for anxiety episodes begins to take a pill every day rather than as
necessitated by the occasional onslaught of a panic attack. After some time,
her behavior becomes organized around the daily taking of the Xanax
rather than being able to function without the drug.
  Conceptualizing Addictions 7

Recovery: Recovery is the process of a person reducing or abstaining from

a drug that they were dependent on. Usually, recovery is more connected
with the notion of abstinence, where the recovery process is focused on the
person not using the substance. However, recovery can also refer to a mod-
erated management of use. In this instance, instead of drinking and getting
inebriated, which was the normal pattern, the person is able to drink only
one or two drinks and not experience becoming drunk.
Relapse: Relapse is a worsening of the problem after some time of
improvement. The use of the substance does not have to go back to when
it was at its worst to be considered a relapse, but it is usually a movement
back into problematic actions and patterns. Relapses might be a one-time
occurrence or can last many years.
Slip: A slip is similar to a relapse but not as severe. It is a brief use
of the substance after a period of reduction or abstinence from the drug.
However, there is usually a quick return to a more functional state. For
instance, if someone who had smoked two packs of cigarettes per day for
three years had completely stopped smoking, but then found themselves
smoking one cigarette and then did not smoke again after that, this would
be considered a slip. The main difference between a slip and a relapse is
that a slip is just use of the substance while relapse involves a return to
negative patterns of behavior.
Substance abuse: Substance abuse occurs when a person uses a drug
beyond its normal purpose or when they develop a pattern of use that
necessitates further use and/or difficulties in various areas of their life.
Prescription medications can be abused when they are used for symptoms
for which they were not intended or in amounts not prescribed. An esti-
mated 54 million people (more than 20% of those aged 12 and older) have
used prescription medications for nonmedical reasons at least once in their
lifetime. The most misused prescription drugs are pain relievers, followed
by tranquilizers, stimulants, and then sedatives (Center for Behavioral
Health Statistics and Quality, 2016). For instance, a doctor may have pre-
scribed Vicodin for someone who was recovering from an accident. If the
person began to take more pills each day than the recommended dosage
then they would be abusing the substance. This has been a growing trend,
with opioids, central nervous system depressants, and stimulants being the
three classes of medications that are most misused.
Substance dependence: Substance dependence occurs when a person
needs an increased amount of the drug to feel the effects of that drug.
This process is known as tolerance. Further, dependence happens when the
person experiences withdrawal symptoms when they do not use that sub-
stance. We might see this in someone who uses cocaine, where each time
they use, they need just a little more of the drug to achieve their normal
high. When they do not use cocaine they may experience cravings for it,
fatigue, and tremors or chills, among other possible withdrawal symptoms.
Substance use: Substance use is when a person comes into contact
with a substance that is deemed a drug. There are many instances when

(continued)
8 Assessment 

(continued)

someone uses a substance and it is legal and not problematic for the indi-
vidual. Going to a pub with friends and having one or two beers once
a week (drinking within recommended limits) can be a physiologically
(Mukamal, 2010) and socially beneficial endeavor. It is when the use of
the substance begins to impair the person that substance use shifts to
abuse or dependence.
Tolerance: Tolerance is the diminishing physiological impact of a sub-
stance upon repeated usage. In essence, we need to use more of the drug to
obtain previous results. As an example, one year ago it might have taken
three vodka tonics for the person to feel inebriated, but, having consumed
much alcohol over the past year, today it takes five vodka tonics to have
the same feeling.
Withdrawal: Withdrawal is the physiological and psychological reac-
tions when the person reduces usage of the drug. Each drug has its own
physiological consequence when a person begins to lessen their connection
to the substance. For some drugs, such as marijuana, the obvious with-
drawal symptoms are minimal. For other drugs, such as heroin, the body’s
physiological reactions are severely debilitating to the individual. There
are even some drugs that if a person attempts to stop using by going “cold
turkey” (stopping total use rather than engaging in a controlled reduction
of use) may lead to death. These include benzodiazepines, opiates, and
even alcohol (if the person has chronically used for a long time).

Addiction

Substance use/abuse is a wide field covering a myriad of different drugs. It may

include legal substances, such as caffeine, nicotine, or alcohol, as well as com-
mon illegal drugs such as opium, cocaine, and heroin. Then there are drugs that,
in some states and in some situations, are legal but are otherwise illegal, such as
marijuana (which in some states was legal for medical purposes, but has recently
become legal for any adult to use recreationally). When discussing the substance
abuse field we are talking about some type of substance that gains entrance into
the body. This can happen through several means such as ingestion (e.g., consum-
ing psychedelic mushrooms or alcohol), inhalation (e.g., smoking cigarettes or
marijuana), injection (e.g., heroin), and absorption (e.g., LSD).
Over the last 20 years there has been a generalizing of the term addiction to
refer to non-substance-related behaviors in which the person seems to have a
compulsion to engage in that activity, such as gambling addiction, sexual addic-
tion, or internet addiction (see Chapter 9). Although in this book we will be
primarily talking about alcohol and drug addiction, any of these other ideas can
be systemically conceptualized as well since they all contribute to redistributing
how the family of the person engaging in that behavior is organized. However,
there is still debate if these non-drug addictions should be considered in the same
class as alcohol/drug addiction or even if they should be classified as a disease.
  Conceptualizing Addictions 9

Addiction as a Serious Social Problem

Before we explore the various models of addiction, let’s take a minute to focus
on the prevalence and impact that addiction has on society. According to the
National Institute on Drug Abuse (2014), the abuse of tobacco, alcohol, and
illicit drugs, in the United States alone, costs over $600 billion annually. This
includes costs related to health care, lost productivity at work, and crime. In
2016, the harmful use of alcohol resulted in some 3 million deaths (5.3% of
all deaths) worldwide and 132.6 million disability-adjusted life years (DALYs),
which accounted for 5.1% of all DALYs in that year (WHO, 2018). The World
Health Organization states that tobacco use accounts for almost 9% of all deaths
worldwide and 4% of disability-adjusted life years. These authors hold that
alcohol consumption is one of the most significant avoidable risk factors, where
reduction of alcohol use can prevent disability and/or death. The 2017 World
Drug Report, from the United Nations Office on Drugs and Crime, holds that
almost 30 million people globally suffer from drug-use disorders. Of all drugs
used, opioids were associated with the highest level of negative health outcomes.
Other potential serious health issues as a consequence of drug use include hepa-
titis C and HIV.
While the rates of substance use for middle and high school students have been
reducing slightly, they are still significant. Based on data presented by the National
Institute on Drug Abuse, in 2017 for 12th graders, 61.5% had used alcohol over
their lifespan, 50.3% illicit drugs, 45% marijuana, 26.6% cigarettes, 16.5% any
prescription drug, 11% smokeless tobacco, 9.2% amphetamines, 6.8% narcot-
ics other than heroin, 7.5% tranquilizers, 6.7% hallucinogens, 4.9% inhalants,
and 4.2% cocaine (Johnston et al., 2018). Thus, by 18 years of age, a significant
proportion of United States adolescents had engaged in some type of drug use.
This does not mean that they will develop substance abuse disorders, but it opens
the possibility for some type of negative consequences of drug use to occur (not
to mention possible involvement with the juvenile justice system).
These trends in what substance is used tend to continue into adulthood.
While 34% of adults do not use any type of alcohol or drug, 65% use alco-
hol, 6.2% use any type of drug, and 5.6% use both alcohol and drugs (Falk,
Yi, & Hiller-Sturmhofel, 2008). According to the National Institute on Drug
Abuse, in 2013, an estimated 24.6 million Americans aged 12 or older—9.4%
of the population—had used an illicit drug in the past month. This number
is up from 8.3% in 2002. The increase mostly reflects a recent rise in use of
marijuana, which is the most commonly used illicit drug. The primary drug
used was marijuana (19.8%), followed by prescription drugs, cocaine, halluci-
nogens, inhalants, and heroin. In terms of alcohol, there has been a reduction
in use by people between the ages of 12–20. Current alcohol use by this age
group declined from 28.8% to 22.7% between 2002 and 2013, while binge
drinking declined from 19.3% to 14.2% and the rate of heavy drinking went
from 6.2% to 3.7%. This decline in substance use can also be seen in smoking
cigarettes, where fewer Americans are smoking. In 2013, an estimated 55.8
million Americans aged 12 or older, or 21.3% of the population, were current
cigarette smokers. This reflects a continual but slow downward trend from
2002, when the rate was 26%.
10 Assessment 

What was just presented focused on drug and alcohol use, rather than depend-
ence. As we have talked about already, there is a distinction between the two. The
two most prominent abused substances are alcohol and marijuana. According to
the National Institute on Drug Abuse, in 2013, 17.3 million Americans (6.6%
of the population) were dependent on alcohol or had problems related to their
alcohol use (abuse). In 2013, 4.2 million Americans met clinical criteria for
dependence or abuse of marijuana in the past year. Further, in 2013, an estimated
22.7 million Americans (8.6%) needed treatment for a problem related to drugs
or alcohol, but only about 2.5 million people (0.9%) received treatment at a spe-
cialty facility. This lets us know that there is a strong need for programs to help
get people into treatment. These statistics are only focusing on the individual and
do not account for the impact that one person’s use has on those in the family.

Models of Addiction

Now that we have an understanding of what the terms in the field mean, we
can start to explore how people view the etiology of addiction. We have begun
talking about how a therapist conceptualizes what is happening for the client.
This conceptualization is based on a model of what impacts people. On a more
zoomed level, “model” in therapy refers to the theoretical orientation of the
therapist. This could be, for instance, person-centered, cognitive-behavioral, or
psychodynamic. If we expand this view, the model can be an individual lens
versus a family/systemic lens. Zooming back into the family lens we can look at
a variety of family therapy approaches such as Structural, Solution-focused, or
Bowenian (see Chapters 13, 14, & 15).
In the field of substance abuse there are many different views of how and why
people become addicted. In this section we will cover three of the primary models

Moral
Model

Addictions
Family Disease
Systems Model
Model

Figure 1.2  The three main models of addiction: The moral, disease, and family systems
models
  Conceptualizing Addictions 11

of addiction: the moral model, the disease model, and the family systems models
(see Figure 1.2). Although this book primarily focuses on a family systems model,
that does not mean that the other models are incongruent with the family systems
model. In this section we will cover each of the standard models of addiction to
provide you with a general understanding of the differences between each.

Moral Model
The moral model was perhaps the first major model of addictions, being promi-
nent in the early part of the 20th century. However, it has grown out of favor
and is perhaps currently the least championed of the three models of addiction.
This is because it had its roots in religion rather than being supported by empiri-
cal evidence. In this model people abuse alcohol (or other drugs) not because of
physiological reasons (as will be seen in the disease model) but because the person
lacks the willpower to choose otherwise. Thus, addiction is not a disease but is
rather faulty choice making. The person is most likely not choosing to become
an addict, but their choices lead them into a particular lifestyle and destructive
behavioral patterns. Having roots in religious doctrine, the moral model pro-
posed that people could easily choose to be abstinent if they were psychologically
strong enough.
Based on choice rather than disease, proponents of the moral model believed
that the user should be punished, rather than be provided with the possibility
of rehabilitation. Based upon this viewpoint, alcoholics were grouped in with
criminals, sinners, and others who were “lazy” and did not want to abide by
society’s rules. Since the decision to drink was based on a moral/characterological
defect, alcoholics were put in jails or asylums rather than provided with alterna-
tive services that might have helped them. This model can be seen in the United
States government’s “War on Drugs” where the focus is on the indictment and
incarceration of people who use and sell illegal drugs.
For the general public, the moral model makes sense. Especially in Western
societies, where personal responsibility is emphasized, there is an expectation
that people are in full control of what they do. The scientific community has
moved away from accepting the moral model as issues such as genetics, neurobi-
ology, and environmental factors gain widespread empirical support. However,
many people still believe that the individual has a choice of picking up that first
drink or smoking that first pipe. While this is the case, what happens afterward
is dynamically involved.

Disease Model
The predominant view of addictions has been through the disease model (also
known as the medical model). The disease model is perhaps the most known of
all models of addictions, having been popularized through media and twelve-
step programs. Originally developed to explain alcoholism, it has been used to
understand other types of drug addiction as well as food addiction, sexual addic-
tion, compulsive gambling and other behavioral addictions. Given that it was
developed and has been primarily utilized in viewing alcoholism, we will pri-
marily explore it through that lens. The disease model holds that alcohol is a
12 Assessment 

primary problem and should be its own focus of treatment. What this means is
that alcoholism is not a secondary symptom of some other problem (such as fam-
ily dysfunction or a psychiatric disorder). As such, treatment focuses specifically
on the addiction. Whereas the moral model views the addict as being at fault,
the disease model views them as being at risk—since they initially had a choice
whether to use the drug or not, but once they did use it to whatever extent it
overwhelmed their ability to choose (Wilbanks, 1989).
Adopting the disease model of addiction changes how the therapist views the
course of the problem. As such, there are several characteristics of the addiction
(Johnson, 1986). First, it can be described. The disease impacts many people in
very similar ways—just like chicken pox has the same symptoms, course, and
treatment for a widespread population. Second, the disease is primary—rather
than being a symptom of something else. Third, the disease follows a predictable
course, which is progressive. As will be explained in the next several paragraphs,
addiction flows through four phases. Fourth, the disease is permanent (chronic).
People will always need to be on guard to prevent the disease from taking over
(thus, they must maintain abstinence). Fifth, the disease is fatal. If people do not
get treatment, they will die. Lastly, and most importantly for this model, the
disease is treatable.
The two clinical features of substance abuse that are associated with the dis-
ease model are tolerance and withdrawal (Thombs & Osborn, 2013). Tolerance
to a drug means that over time it requires more of the substance to obtain effects
that were previously reached with lower doses. So the person progressively uses
more while receiving the same outcome. Withdrawal is a physiological effect that
occurs from reduced use of the substance. Depending on the drug, the amount
of previous use, and the person’s physiological makeup, withdrawal symptoms
could be insomnia, delirium tremens, or, in severe cases, even death.

Species of Alcoholism
The disease model was proposed by E. M. Jellinek and has been greatly expanded
since this first introduction. In this section we will discuss Jellinek’s (1983) origi-
nal classification of four species of alcoholism. These designate various levels of
severity and functioning of someone who is considered alcoholic. Jellinek used
Greek letters to provide a more neutral approach to discussing the concepts.
The first type is alpha alcoholism, which is a psychological phenomenon.
Here, instead of a physiological dependence, the person has a psychological
dependence on alcohol to help relieve stress, anxiety, or pain. At this point,
the individual is still most likely in control of the drinking and, if they decide
to quit, they may not have that many withdrawal symptoms. Yet the person
continues to drink as a way to mute psychological and emotional pain. In this
condition, there is not a progressive process. However, there is the possibility
that someone who is classified as an alpha alcoholic may shift into a different
species of alcoholism.
Beta alcoholism has many of the physiological effects of drinking (such as cir-
rhosis of the liver) but without the psychological or physical dependence. Thus,
the person has the opportunity to stop their heavy drinking, which they do quite
often—perhaps every day. The people who fall into this category might be called
  Conceptualizing Addictions 13

“social drinkers,” where they drink when they have the opportunity (such as at
parties, on New Year’s Eve, etc.) but do not feel the need to have to drink.
Gamma alcoholism contains both a physiological dependence as well as
psychological impacts. For instance, not only does a person develop a bodily
tolerance for alcohol, they also lose control of their use. Jellinek (1983) explained
that for those with this species of alcoholism there is the greatest damage. Not
only do they find that their interpersonal relationships suffer, as well as work,
economics, etc., their physical health is also at the most severe risk. This is prob-
ably the most predominating type of alcoholism in Western cultures.
The last type of alcoholism is called delta alcoholism. Delta and gamma alco-
holism are very similar yet the delta species does not include the individual losing
control. Thus, they are able to function well in their personal, business, and social
lives. This type of alcoholism would occur in countries, such as France or Italy,
where drinking (such as wine) is legal and ritualistic and forms a primary role in
social life.

Phases of Alcoholism
Jellinek (1983) delineated a four-phase progression of alcoholism. The first phase
is the pre-alcoholic phase where the person drinks mainly for social reasons. It
is at this point that a connection between drinking and stress reduction occurs.
Depending on genetics and social conditions, the pre-alcoholic phase may last a
couple of months to several years.
The second phase is the prodromal phase. Here, a person’s use of alcohol
has shifted from being a social endeavor to a primary means of stress reduc-
tion. During this period the person is usually in control of most of their actions
but begins to develop problematic patterns such as sneaking drinks and having
blackouts (where the person cannot remember what occurred during the time
they were drinking).
The third phase is the crucial phase wherein the person has little control of
their actions, especially around consumption of alcohol. At this point they have
changed their normal patterns of behavior so that they can consume alcohol more
frequently. Their tolerance has increased to where they need more alcohol to feel
the effects and they need it more often. The person has likely attempted to control
the use of alcohol with little success.
The last phase is the chronic phase where the person experiences a necessity
to drink. They may go on benders (extended periods of time being drunk), suffer
serious withdrawal symptoms if they do not drink in a given period of time, and
have experienced major difficulties in their work, social, and family relationships.

Life-Long Addiction
The disease model holds that addiction is not a disease that can ever be cured.
The individual is currently and will always be battling this disease. Thus, words
such as “cured” or “recovered” are not used. Instead, people who have cur-
rently stopped their drug use are seen as being “in recovery.” This is an ongoing
process where the person needs to be vigilant each and every day for the rest of
their lives.
14 Assessment 

In the disease model, one use of the drug can trigger a recapitulation of where
the person was when they were at their worst in the throes of the disease; what is
considered a relapse. To counter this, the model espouses that abstinence should
be the goal of someone dealing with addiction. When understanding an individ-
ual, the disease model holds that the person will likely develop the same symptoms
if they discontinue use of one drug and begin using another drug (Fisher, 2011).
Thus, they are encouraged to be abstinent from all psychoactive drugs.
While the disease model is currently the most widespread model, it has come
under fire. Wilbanks (1989) explained that there is not a way to determine
whether the compulsion to use the drug is uncontrollable or uncontrolled. How
we figure this out is through self-report of the addict. A second critique is that
not everyone that engages in the behavior (drug use—or sex, gambling, shop-
ping) becomes “addicted” (Fisher & Harrison, 2018; Wilbanks, 1989). Wilbanks
warns that if people do view addiction as an inevitability, once drinking/drug use
happens, they may develop a sense of learned helplessness. He encourages a shift
from viewing the addict as a helpless victim to one that is not actively trying to
control the drug use.
The disease model, in many ways, holds addiction to be a medical illness.
McLellan, Lewis, O’Brien, and Kleber (2000) supported this view as they con-
ducted an extensive literature review comparing the diagnoses, heritability,
etiology, pathophysiology, and response to treatments of drug dependence ver-
sus type 2 diabetes mellitus, hypertension, and asthma. They found that genetic
heritability, personal choice, environmental factors, medication adherence, and
relapse rates were similar for all of the disorders. They recommended viewing
drug dependence as a chronic mental illness, which necessitates long-term care.
Regardless of the challenges to the disease model of addiction, one of the
primary benefits that has come from this viewpoint is the destigmatization of
addiction. Fisher and Harrison (2018) explained, “Perhaps the greatest advan-
tage to the articulation that addiction is a disease has been to remove the moral
stigma attached to addiction and to replace it with an emphasis on treatment of
an illness” (p. 43). This has led away from attempting to punish people who are
dealing with addiction to trying to help and treat them. These viewpoints have
led to more people dealing with substance abuse seeking out treatment.
While addiction is referred to as a disease, many current researchers talk
more specifically in terms of the brain disease model of addiction (BDMA) (Bell
et al., 2014). This is because, based on genetics of addiction research as well as
neurobiological research of animals and humans, the brain is impacted through
substance use. In essence, repeated drug use leads to changes in the brain that are
difficult to reverse. This makes it difficult for the individual to refrain from the
use of the substance and remain abstinent. Besides the neurological impact that
drugs have on people, vulnerability to and recovery from substances is also tied
to social environments, developmental stages, and genetics (Volkow, Koob, &
McLellan, 2016).

Family-Disease Perspective
It wasn’t until the 1980s that people in the field began talking about addiction
as a family disease, being popularized by the work of Wegscheider-Cruse (1989).
  Conceptualizing Addictions 15

The family-disease perspective is based on the disease model of addiction

(Lemieux, 2009, 2014; Thombs & Osborn, 2013). It expands the view of just
the individual substance abuser to include the dysfunctional relationships that
maintain the substance use. This model is primarily utilized with families dealing
with alcoholism and sees these families as being inherently dysfunctional.
While the disease model focuses on how the alcoholic/substance abuser is bio-
logically, physically, emotionally, socially, and behaviorally impacted by use of
the substance, the family-disease model expands this to view how family members
are impacted as well. Perhaps the most visible member in this is the codependent.
The family-disease model views codependency as a disease (McCrady, Ladd, &
Hallgren, 2012). The codependent engages in enabling behavior, which helps
perpetuate the substance abuser’s use and continued dysfunction. However, there
has not yet been clear empirical evidence to substantiate the notion of codepend-
ency (Lemieux, 2009, 2014; McCrady et al., 2012).
The family-disease model highlights the interpersonal impact that addiction
has in the family system. This is evidenced by the family rules and family roles
(see Chapter 6). These include the enabler, hero, scapegoat, lost child, and mascot
(Wegscheider-Cruse, 1989). Along with the substance abuser, family members
function in unique ways to try to survive the pain of addiction. This family illness
can also be viewed as occurring across generations (Nowinski & Baker, 2018).
This is because interactional rules and processes are passed down and learned
from parents to children to grandchildren.
Therapists operating from the family-disease perspective usually take the
position that family members should separate themselves from the addict and
work on themselves for personal recovery (Lemieux, 2009, 2014; O’Farrell &
Fals-Stewart, 2006). This is why many therapists with a family-disease perspec-
tive utilize family support groups such as Al-Anon and Nar-Anon as well as
psychoeducation and individual therapy. O’Farrell and Fals-Stewart (2006)
explained that, based on the family-disease model, treatment for the substance
abuser’s partner and/or family members usually includes psychoeducation about
addiction as a family disease, individual and/or group therapy, and referral to a
family support group.

Family Systems Model

The family systems model of addiction views addiction as a symptom that signi-
fies a larger issue within the user’s family and relational world. This may be a
local issue, involving only the members of the nuclear family, or a multigenera-
tional process, having developed over many generations in how individuals in the
family are able to cope with the anxiety and stressors of being an individual while
also being part of a social group.
The person who is abusing the substance is considered the Identified Patient
(IP). They are the focal point of the family dysfunction, yet are not isolated
in the problem. Given that human beings are interdependent entities, the IP
is the manifestation of many factors at work within the relational web of the
family. This goes along with one of the primary tenets of a systems view in
that change in one part of the system leads to change in the whole system.
This widening of focus from the individual to the family, from part to whole,
16 Assessment 

is one of the aspects that separate the family systems model from the other
models of addiction.
A family-systems perspective is perhaps best known for the saying, “The
whole is greater than the sum of its parts.” What this means is that if we only
look at each individual in the family, we would not understand the dynamic
interaction that occurs when those members come together. Another way
of expressing this is with a mathematical formula: 1 + 1 = 3. In this equa-
tion each 1 refers to an individual. The sum is 3 rather than 2 because not
only do we need to understand each individual (their developmental stage,
intellectual–emotional–psychological capacities, previous experience, gender,
age, culture, etc.) but, and perhaps most importantly, how those two individu-
als come together—their relationship. If we substituted one of these 1s out
of the equation and put someone else in, we would see a different dynamic
between the two. For instance, think about you as a person. We would see a
different “you” when you are in relationship with one of your parents, your
significant other, your child, your boss, a police officer, or your last significant
other who broke up with you a year ago! The same would be true for the other
1 in the equation. Thus, when we put you two together, you each simultane-
ously impact and are impacted by the other.
The family systems model is a conglomerate of many ideas, and thus is dif-
ficult to specify, as there are various models of family functioning. In this book
we will present some of the basic and overarching ideas as well as some of the
specific models of family therapy. However, many of the family-centered inter-
ventions view substance abuse through a biopsychosocial perspective—where
there is a combination of biological, psychological, and social components
(Lemieux, 2014). For now, we will explore this model in terms of how these
three components connect through concentric circles. Bronfenbrenner (1979)
proposed the notion of an ecological systems theory, also known as a bio-
ecological systems theory. This theory helps to describe how an individual is
impacted by others in his relational field as well as larger systems. There are
four ecological systems in this model. The first, the microsystem, is the inner-
most system. This is where the individual is connected to those closest to him;
for instance, a spouse, relational partner, or close family members. The next
outer subsystem is the mesosystem. This includes systems that directly impact
the individuals in the microsystem. For instance, the addict’s job is part of
the mesosystem; or the spouse’s family. The third ecosystem is the exosystem.
Here, various aspects of the structure of individual/family functioning occur
such as finances or socio-economic status. The last system is the macrosystem,
which refers to the social and cultural milieu in which the individual is housed.
Housing all of these ecological systems is the chronosystem. That is, these
systems are dynamic and change over time.
If we look at this framework we can see the individual in the center, with
close friends and family around him, with larger systems such as work, school,
or church containing them, and then a larger circle that has aspects of culture
and national citizenship. All of these various systems are at play at all times.
However, usually there is greater influence from outside in rather than inside
out. For instance, the culture that a person is born and raised in inserts more
influence on how the individual functions than the individual can impose on
  Conceptualizing Addictions 17

Macrosystem
Culture, Religion,
Politics

Exosystem
Socioeconomic,
Health Care

Mesosystem
Family, Friends

Microsystem
The Individual

Figure 1.3  Representation of Bronfenbrenner’s bioecological systems approach

the overarching culture. This is just one model that helps us to understand
that an individual does not operate in isolation, but is influenced not only
by the people they are in contact with but the larger systems that define the
context for how we understand the world. Figure 1.3 represents these concen-
tric circles.
There are many different theories within the family therapy model. Throughout
this book, and especially in Part II, we will briefly present an overview of the
major theories of family therapy. Some specifically focus on family systems and
addiction while others explore how all symptoms are created by and impact the
family. When examining the specific field of substance abuse treatment, three
main models are useful to be aware of: family disease model, family systems
models, and behavioral models (McCrady et  al., 2012). As explained, family
disease models highlight the notion of addiction as a disease, codependency, and
how family members can change themselves. Family systems models hold to the
notion that addiction serves a function in the family. Therapy, from this orienta-
tion, focuses on family rules, roles, and boundaries. Behavioral models explore
the antecedents and consequences to substance use and the role the family plays
in these events. Throughout this book we will explore aspects of these three
18 Assessment 

models, as well as additional ideas that help locate addictions within the context
of relationships and families.
To end this section, I want to highlight the importance of why we should
study the family and view an issue like addictions through the lens of the family.
Gruber and Taylor (2006) explained, “substance abuse is a problem for families
because (1) It occurs in families, (2) It harms families, (3) Families both par-
ticipate in and can perpetuate active addiction, and (4) Families are a potential
treatment and recovery resource” (p. 3, italics in original). For every individ-
ual who has a substance abuse problem, the lives of four other individuals are
impacted (van Wormer & Davis, 2013). Individuals are not born as isolates;
they come into the world as part of a physiological and emotional system. Who
we are is a combination of our DNA and genetics (we are primed to display cer-
tain traits based on our genes, such as height, skin/hair/eye color, temperament,
and other such components), our past experiences, and our current choices.
These choices are based on our values and beliefs, which were primarily forged
within the iron of our family (which were mainly determined by the cultural
contexts in which that family was housed). The family is our first classroom;
learning how to be, think, and feel. Problematically, people tend to view people
as individuals—devoid of their context. This has the possibility of leading to
attributional errors. Gruber and Taylor (2006) called “for researchers and treat-
ment providers to increase their recognition of the role that family and family
functioning has for understanding the incidence and impact of substance abuse”
(p. 1). This book is an attempt to do so.
As we will discuss through the course of this book, substance abuse does not
only impact the individual; the family impacts and is impacted by addiction as
well. From parents, to spouses, to children, the family organizes differently when
addiction is involved; usually in ways that we would call “dysfunctional” where
members are negatively affected by the transactions. Thus, viewing addiction as
a “family problem” helps the clinician to include the genetic predisposition that
children have based upon their parents’ use, as well as the environmental factors
prevalent within the relationships of the family.
McCrady et al., (2012) described several advantages for utilizing a family-
based approach when working with clients dealing with substance abuse issues.
These include strong empirical support for the models, the focus on the envi-
ronmental context, and an exploration of factors that might maintain the
substance use outside of the individual. Further, these authors explained that
family-based approaches are connected to better engagement with treatment as
well as better treatment outcomes. In comparison with other treatment modali-
ties, family therapy seems to be at least equally effective (Hawkins & Hawkins,
2012).
However, there are disadvantages to using family-based approaches (McCrady
et al., 2012). These include these models’ heightened complexity of theory and
practice, the therapist’s need to focus on multiple relationships simultaneously,
the difficulty of arranging for all parties to be together in a session, and their
sometimes-discrepant views to disease-based models in which the individual is
responsible for change. These challenges lead to necessary education and train-
ing for family-based therapists to be able to successfully navigate these unique
demands of practice.
  Conceptualizing Addictions 19

Case History

Now that we have an understanding of the various terms and models of addiction,
we will come back to our client that we met at the beginning of the chapter. The
following section provides information that would have been obtained through
conducting a biopsychosocial with a new client. We will refer back to this case at
the end of each chapter of the book as a way to apply the ideas presented. Our
client, Mark Rothers, has come to a social service agency seeking help. The case
study is presented here to be used as a template for how a family systems view can
be used, even if an individual enters into the therapy room.

Presenting Problem and Past Problem History

Mark Rothers was born on March 13, 1979 in Gainesville, Florida. He is currently
remarried for 15 years to Hannah, and they have three children together: Steve,
14; Kayleigh, 12; and Pete, 11. Mark was previously married for two years to
Angelina. He has one child with Angelina, a daughter Nina, who is 17 years old.
Mark often drinks alcohol, frequently uses marijuana, and occasionally uses
cocaine. He has been very upset with life for the past six months. He is having
difficulty sleeping, has been having difficulties at work, as well as some thoughts
of death, stating, “It would be easier if I were dead.”
Mark went for couples counseling with his first wife, Angelina. They went for
four sessions, but found that things only got worse. He also went to individual
therapy to deal with his substance use. This occurred seven years ago and lasted
for seven sessions. Mark reduced his drinking and drug use at that time and main-
tained this for six months. Then he returned to his prior usage. At the time, he did
not engage in any self-help groups. Mark is taking over-the-counter aspirin and
ibuprofen when he senses a migraine attack is going to occur, which he occasion-
ally gets—perhaps five times per year. He does not take any other medications.
Mark first used substances starting at 12 years old. At that time, he would take
various hard liquors from his father’s supply. He also started to smoke cigarettes
when he was 14. At 16 he began to smoke marijuana. In his freshman year of
college, he experimented with hallucinogens; specifically LSD. During his senior
year of college he began using cocaine, having been introduced to it through
friends. Mark’s primary drug is alcohol, drinking approximately four beers per
day. He smokes marijuana approximately two times per week, usually when he is
stressed out. He infrequently uses cocaine. This is usually when he is with a cer-
tain group of friends who use that as their primary drug of choice. Mark smokes
approximately one pack of cigarettes per day.

Client’s Family History

Mark’s maternal grandmother was schizophrenic and many members on his
paternal side have issues with addiction; primarily with alcohol. His grandfather,
father, and two uncles all, in his estimation, had serious addiction issues. On his
mother’s side there is a history of depression as his grandmother and, he believes,
his mother, suffered from occasional bouts.
20 Assessment 

Mark is the second of three children of Ian and Des. The family was a lower-
class family as Ian worked as a custodial staff-person at the local university and
Des worked as a behavioral tech at a group home for developmentally disabled
adults. The oldest child, Mick, is three years older than Mark. The youngest
child, Judy, is two years younger. Currently, Judy is married, has one child—age
9—and works as an accounts administrator. Before that child was born she had a
miscarriage. Mick graduated college with a degree in engineering and moved out
of the state. He is remarried and has a 16-year-old daughter. Mark and Mick had
a falling out when they had gone out together one night and Mick had berated
Mark for being alcoholic. At that point, Mick had been in recovery from alcohol
for five years. The two came to physical blows and do not talk to one another
anymore. Mark also has conflict with his father, Ian. This is usually when either
of them has been drinking. Ian usually expresses his disappointment in how
Mark’s life turned out and Mark explains how he thinks Ian was a bad father
and is a bad grandfather.
Mark completed high school and college with a degree in business. During
both high school and college he tended to be a “B” student. He is a manager for a
national rental car agency and has been with the company for 12 years, beginning
soon after he graduated from college. In high school he worked in a fast food res-
taurant as his family was not wealthy. Throughout his college career, he worked
various jobs including fast food, restaurant server, and in the college bookstore.
Mark was involved with the legal system when he and his first wife divorced.
He was arrested for domestic violence against his first wife. The two had argued
and Mark pushed Angelina to the ground. This was the only instance of physi-
cal violence in the marriage. He was drunk at the time. He spent two days in jail
and received probation. At the time of the divorce he was made to pay alimony
and child support, which continue to be garnished from his wages.
Mark married Angelina, his college girlfriend, when he was 23 years old. The
couple were married for two years and had one child, Nina, a daughter who
was born in the first year of marriage. After Nina was born, things deteriorated
quickly between Mark and Angelina. He was arrested once for domestic violence.
When the couple divorced his ex-wife received full custody of their daughter.
Mark sees Nina infrequently; approximately three times per year. They talk on
the telephone perhaps one time per month. Nina is very close with her mother.
Mark met his current wife, Hannah, one year after his divorce. They dated for
six months and then were married. They have three children, Steve, Kayleigh,
and Pete. Hannah does not utilize any substances and is concerned with the
amount of alcohol Mark consumes. Steve is in eighth grade and is having dif-
ficulties in school, getting into fights and struggling academically. Kayleigh is in
seventh grade and is excelling. She is in the gifted program and is at the top of
her class. Pete, in sixth grade, is the closest with his mother and seems to be a
fun-loving child.

Genograms: A Family Picture

We have taken in a lot of information from our client and can display this through
the narrative of a biopsychosocial. We also have enough data to begin making a
  Conceptualizing Addictions 21

pictorial depiction of the family. In family therapy, the primary way we do this
is through the use of a genogram. There are many layers to the genogram. These
include who is in the family (usually exploring three generations), the relation-
ships between each of them, history of medical, psychiatric, and substance issues,
as well as any other particular developmental changes. One of the main purposes
of creating a genogram with the family is to start to explore potential patterns
that have been occurring within the family. A subsequent benefit of using geno-
grams in clinical work is as a summary for self or others on the status of the case
(McGoldrick, Gerson, & Petry, 2008).
When constructing a genogram there tends to be information that is sought
that may not be explored in-depth when conducting a typical intake assessment.

1951 1954

A 67 DE 64

Ian Des

………1979
1978 1976 ………………… 1979 1981 1981 1974
1980 (D)
42 39 …….. 39
A
40 37 37 44
38

Tara Mick Chelsea Angelica … Mark …… Hannah Judy Derek

… ……
… ……
2002
…
2001
……
2004 2006 2007 2009
… ….…. ?
16 17 14 .… 12 11 9

Lucy Nina Steve Kayleigh Pete Jonathan

Genogram Symbols

Family Relationships
Married
?
Divorce Male Female Unknown Death
Gender/
Miscarriage

Emotional Relationships
…… ….. Cutoff/Estranged In recovery from alcohol or drug abuse
…………. Distant/Poor
Best Friends/Very Close (D) Drug Abuse

Friendship/ Close A Alcoholism

Close-Hostile
………….
…………. Discord/ Conlict
DE Experienced Depression

Figure 1.4  A genogram of the Rothers family

22 Assessment 

This usually comes in the form of interviewing the client regarding the two or
three generations previous, which would include the client’s parents, siblings, and
grandparents, and may also involve aunts, uncles, cousins, close friends, great
grandparents and pets. Family therapists can use a genogram to provide many
varied layers of a family’s functioning. The first layer is who is in the family. This
may include the person’s gender, age, or name. A second layer is demographics—
which may include year in school, employment, relationship status, past/current
medical issues, psychiatric history, substance abuse, and other unique identifiers.
A third layer, and perhaps the most important layer, is distinguishing the rela-
tional dynamics between people. These include who is close with whom, who has
conflict with whom, who is cutoff, distant, or overly close.
While the genogram seems to be a current snapshot, it is actually a longitudi-
nal view of the family. The family therapist can explore major family transitions
such as moves, deaths, financial hardships, and the impact of one or more mem-
bers’ substance abuse. Figure 1.4 presents a genogram of the Rothers family that
we met in the previous section.
Genograms can be expanded to include not only the nuclear and extended fam-
ily, but also the larger systems the family comes into contact with. These might be
the legal, medical, educational, social, religious, cultural, and community systems.
McGoldrick et al. (2008) refer to this as a genogram within community context.

School

Employment Religion

Family
Friends

Figure 1.5  A depiction of a generic family ecomap

  Conceptualizing Addictions 23

Other therapists create a picture called a family ecomap. An ecomap usually

houses the nuclear family within a center circle, displaying that family’s connec-
tions to larger systems. An example of an ecomap can be seen in Figure 1.5.
One of the benefits of using a genogram (or ecomap) is that it is model neutral
and can be adjusted—where the therapist brings forth some information more
than others depending on their approach. Although the genogram has roots in
intergenerational approaches, such as Bowen Family Systems Theory, it has also
been used with Narrative family therapy (Chrzastowski, 2011), Solution-focused
therapy (Kuehl, 1996), Reality therapy family counseling (Duba, Graham,
Britzman, & Minatrea, 2009), and in training family therapists (Hardy &
Laszloffy, 1995). Regardless of the reason to develop the genogram, it should be
done through a process of joining with whoever is providing the information, as
it is usually constructed during the first meeting(s) with the client.

Summary
After finishing the biopsychosocial and the genogram, you now must decide
how to approach your work with Mark. Do you work with him individu-
ally? Do you try to get his family to come to treatment? If so, do you try to
get his parents and siblings into therapy? His wife? His ex-wife and child?
Everyone? How much should self-help groups be a part of the therapeutic
process? Is abstinence the goal of therapy or reduction of use? Are there
other goals that are pertinent? In the following chapters we will explore
these questions, as well as various issues of assessment when dealing with
clients and their families who are having issues with substances. The second
half of the book will focus on treatment from a family systems lens.
We will start our journey of exploring how a client coming into therapy
dealing with substance use issues can be viewed from a wide lens through
focusing first on a smaller zoomed lens. When people think about addic-
tion, they may view it from a physiological dependence issue. Drugs,
including caffeine, nicotine, alcohol, prescription medication, and harder
drugs do have a chemical and biological impact on the human body. This is
something that cannot and should not be discounted. The following chap-
ter explains the physiological impact of drugs on the brain.

Key Words
Diagnostic and Statistical drugs
Manual psychotropic drugs
substance-related disorders substance use
substance use disorders substance abuse
substance-induced disorders substance dependence
addiction craving

(continued)
24 Assessment 

(continued)

tolerance blackouts
abstinence crucial phase
withdrawal chronic phase
cold turkey benders
relapse brain disease model of addiction
slip family-disease model
recovery family systems model of
dual-diagnosis addiction
model identified patient
moral model of addiction microsystem
disease model of addiction mesosystem
alpha alcoholism exosystem
beta alcoholism macrosystem
gamma alcoholism genogram
delta alcoholism genogram within community
pre-alcoholic phase context
prodromal phase family ecomap

Reflection Questions
1. What are the distinguishing factors of addiction, according to the
DSM-V?
2. How can a mental health professional determine whether substance
use has moved into substance abuse or dependence?
3. What is the relationship between tolerance, withdrawal, and relapse?
4. How do the moral model, disease model, and family systems models
of addiction differ?
5. What benefits does creating and utilizing a genogram have in addic-
tions treatment?
two

The Neurobiology of
Addiction
Jaime L. Tartar, Christina M. Gobin, and
Julius Thomas

As presented in Chapter 1, this book is designed to help you shift your orienta-
tion from viewing addictions as an individual phenomenon to a more systemic
epistemology. However, within any system are individual parts. This chapter nar-
rows the lens of focus to the more microlevel—seeing the physiological impact
that substances have on people. We cannot deny that drugs impact people—
emotionally, behaviorally, and physiologically. Accordingly, the goal of this
chapter is to present information on how and where drugs act in the brain as
well as how they can temporarily or permanently change brain function. We will
also briefly review the particular neurobiological effects of commonly abused
substances. Here, we focus on a special classification of drugs— psychoactive
drugs, which are drugs that alter mental functioning. Because of their ability to
alter mood, psychoactive substances are developed and widely used to treat men-
tal disorders (such as depression). However, because of these same properties,
psychoactive drugs are also commonly abused and can be biologically addictive.
In neurobiological terms, addiction can be distinguished from dependence—
addiction is reserved for the process through which a drug changes the brain’s
natural reward circuitry in the mesocorticolimbic dopamine system (discussed
in detail below). Behavioral addictions, sometimes referred to as process addic-
tions, share common features with drug addictions such as impairment in
self-regulation, impulsivity, and demonstrations of relapsing behavior despite
mental and physical consequences. Examples of behavioral addictions include
compulsive buying, sex addiction, pathological gambling, binge-eating disor-
der, and internet addiction disorder (Smith, 2012). Moreover, there is a high
degree of comorbidity between drug addiction and behavioral addiction and
between drug abuse and psychological disorders; especially affective disorders.
In this view, not all drugs that result in dependency are biologically addictive.
The changes that occur with addiction require continued use of the drug in
order for an individual to feel “normal.” However, all psychoactive substances
(for medical purposes or abuse) are used for their ability to alter thoughts and
behavior. It is interesting to note that the use and abuse of psychoactive sub-
stances is not a new human phenomenon—records of psychoactive drug use by
humans date back to the chewing of the betel nut 13,000 years ago (y.a.), with
psychoactive effects on attention and well being similar to those of caffeine
or nicotine. The opium poppy (Papaver somniferum), whose seed extract can

25
26 Assessment 

produce morphine (which can be converted to heroin), is a psychoactive drug

with a particularly extensive history of human use with records dating back to
Mesopotamia 7,000 y.a. (Sullivan & Hagen, 2002).

Psychoactive Drug Action in the Brain

Routes of Administration and Entry into

the Central Nervous System
In order for a psychoactive drug to influence behavior, it must first reach the
central nervous system (CNS). There are many routes through which a drug
can reach the CNS, but the most common routes are through inhalation, oral
administration, and injection (intramuscular, IM, intravenous, IV, or subcu-
taneous, SC). In general terms, the different routes of administration offer a
trade-off between safety and efficacy. Intravenous injection offers the fastest
route to the brain; however, it is also the most dangerous route since the speed
of action offers little time to counter an overdose. The oral route is the slow-
est since the drug experiences more barriers (e.g., the stomach) before reaching
the bloodstream, but it is also the safest route in terms of overdose prevention.
For these reasons, the oral route requires the greatest concentration of drugs
and IV the least—making IV administration the fastest and cheapest, but most
dangerous, route. Whether they do it quickly or slowly, all psychoactive drugs
ultimately reach the CNS through crossing the blood–brain barrier in order to
affect thoughts and behavior.
The blood–brain barrier is made up of a very tightly knit group of cells called
endothelial cells, which serve to isolate the brain from the circulating blood
in the rest of the body. In doing this, the brain is considered to be “immu-
nologically privileged” since infectious or other dangerous compounds in the
body are not able to cross into the brain. Because psychoactive drugs are very
fat-soluble, though, they are able to cross the blood–brain barrier and the rate
of entry for any particular drug is dependent on its particular lipid solubility.
For example, heroin can cross the blood–brain barrier 100 times faster than
morphine because it is much more lipid soluble—this gives heroin its power-
ful “rush.” Of note, too, is that stress can potentiate the effect of drugs since
stress makes the blood–brain barrier more porous (Butt, Buehler, & D’Agnillo,
2011; Skultétyová, Tokarev, & Jezová, 1998). This increase in permeability
will allow psychoactive drugs to cross the blood–brain barrier more readily.
In other words, when drugs are taken during times of stress, their effect on the
brain will be greatly increased. In fact, chemicals that do not normally even
cross the blood–brain barrier can gain access to the brain during times of stress.
For example, pyridostigmine, a chemical that causes an overabundance of the
neurotransmitter acetylcholine (ACh), can only cross the blood–brain barrier
in times of stress. Beyond the direct effects on increased ACh concentrations,
increased pyridostigmine itself increases the permeability of the blood–brain
barrier to other chemicals (Amourette et al., 2009; Friedman et al., 1996). For
recreational drug use this means that during stress there is a greater risk for drug
toxicity and overdose.
  The Neurobiology of Addiction 27

Receptors: Mechanisms of Drug Action in the Brain

All psychoactive drugs affect brain function by directly or indirectly influencing
the activity of specific sites on neurons called receptors. Receptors are proteins
that span the membrane of a cell and can bind a particular molecule—this mole-
cule can be the internal (endogenous) neurotransmitter or a drug. Once activated
by a particular molecule, neuron receptors can alter brain function through
changing the voltage of a neuron, activating chemical cascades, or changing
gene transcription. An important concept here is that neurotransmitters are the
naturally occurring, endogenous chemicals in the brain that activate their spe-
cific receptors. The effect of any neurotransmitter depends on the function of
the receptor to which it binds. This means that the same neurotransmitter can
have different effects in different regions of the brain due to the properties of the
receptors in those regions. The ability of a neurotransmitter to bind to a receptor
is determined by the specific shape and size of the neurotransmitter. A good anal-
ogy here is to think of the receptor as a lock and the neurotransmitter as a key—a
dopamine key can only fit the dopamine lock. However, when psychoactive
drugs are used they usurp the process of neurotransmitter and receptor activ-
ity that influences brain processing. For example, a non-natural chemical (drug)
can “look like” a dopamine key and activate the receptor. This means that by
activating neurotransmitter systems, chemicals can directly cause people to not
function as they normally would. With drug use the brain adapts by increasing
dopamine receptors, which makes everyday activities less “rewarding.” Indeed,
the person will rely on the drug in order to feel normal—at a physiological level
interpersonal relationships no longer activate motivation and reward networks.
So here we want to take note of the fact that psychoactive drugs work through
their influence on naturally occurring neurotransmitter systems. There is not a
place in the brain that is intrinsically and uniquely sensitive to any psychoactive
drug, but rather, naturally occurring neurotransmitter systems are able to be
usurped and influenced by these drugs. There are many ways through which psy-
choactive drugs can influence receptor behavior, but the two main classification
systems to describe their activity are as either an agonist or as an antagonist. In
simple terms, an antagonistic drug behaves much as its name implies—it antag-
onizes the receptor by decreasing its activity. It can decrease (or antagonize)
receptor function by and large through two means, (1) by decreasing the amount
of the neurotransmitter that naturally binds to a receptor (there are many specific
pathways through which it can do this) or (2) by binding to and blocking the
receptor to which the neurotransmitter binds—this is essentially like putting gum
in the keyhole!
A drug agonist is effectively the opposite of a drug antagonist—it works to
increase the activity of a receptor. The same general understanding as the antago-
nist works here, but in the opposite direction. Agonists increase receptor activity
by (1) increasing the amount of the neurotransmitter that naturally binds to a
receptor (again, there are many specific pathways through which it can do this)
or (2) by binding to and activating the receptor to which the neurotransmitter
binds. As an example of how drug agonists can change behavior we can look
at how the drug nicotine, found in cigarettes, is an agonist for a type of ace-
tylcholine (Ach) receptor that is associated with physiological arousal. In fact,
28 Assessment 

these receptors bind nicotine so well that they are referred to as nicotinic acetyl-
choline receptors. Accordingly, smoking cigarettes (nicotine) mimics the effect
of acetylcholine and causes an increase in behavioral activity/arousal. Nicotine
directly affects muscle activity because all skeletal muscles function through acti-
vation of nicotinic acetylcholine receptors. Not surprisingly, then, antagonists for
the nicotinic acetylcholine receptors will decrease behavior and muscle activity.
These drugs are not used recreationally—their main function is to induce muscle
paralysis during surgery.
The classification of antidepressant psychoactive drugs known as selective
serotonin reuptake inhibitors, or SSRIs, provide another good example of a drug
agonist. The SSRIs, such as Fluoxetine (Prozac), work as agonists to increase
the amount of serotonin that will bind to its receptor by inhibiting the ability
of serotonin from being taken back into the neuron (reuptake) by the seroto-
nin transporter (SERT) once it is released. This ultimately leaves more serotonin
(5-hydroxytryptamine; 5-HT) in the synapse to bind to the receptor and the
mood changes that occur from this increase can combat major depression.
One interesting feature of SSRIs in particular, though, is that behavioral/mood
changes do not occur until weeks after the initial increase in serotonin at the syn-
apse, which may indicate a different mechanism of action through which SSRIs
like Fluoxetine exert their anti-depressant effects. In fact, research has indicated
that Fluoxetine increases levels of a certain microRNA within serotonergic raphe
nuclei which are involved in suppression of the SERT (Baudry, Mouillet-Richard,
Schneider, Launay, & Kellermann, 2010). Thus, a delay in the antidepressant
effects may be partially attributed to the time it takes for suppression of this
transporter to regulate serotonin levels in the brain.
Most drugs of addiction work as an agonist to a neurotransmitter system;
however, caffeine is one drug that has effects through working as an antagonist.
Although caffeine increases arousal through working on several neurotransmitter
system pathways, its primary behavioral effects occur through its ability to work
as an antagonist to the adenosine system. The neurotransmitter adenosine serves
as a biological signal to increase sleepiness throughout the day—adenosine levels
“build up” during the day to promote sleepiness. By working as an antagonist to
the adenosine system, caffeine can counteract sleepiness.

Mesocorticolimbic Reinforcement System

The addictive properties of any psychoactive substance stem principally from
their ability to modulate the brain’s innate reward network. This pathway, the
mesocorticolimbic dopaminergic pathway, is composed of the connection from
the ventral tegmental area (VTA) of the midbrain to the nucleus accumbens
(NAc), prefrontal cortex (PFC) and on into the limbic (emotional) system. This
system is depicted in Figure 2.1 and is thought of as “the reward pathway.” In
fact, this pathway has such a profound ability to make the organism feel good
that rats are willing to cross a painful electrified grid in order to obtain electrical
stimulation to this pathway (Carlezon & Chartoff, 2007; Olds, 1958). Before
we outline how this pathway works, it helps to appreciate that addictive sub-
stances can be so powerful because this pathway evolved and serves to “reward”
humans and other animals when they engage in behaviors that are beneficial for
  The Neurobiology of Addiction 29

survival (O’Connell & Hofmann, 2011). The hedonic responses experienced by

the organism from natural reinforcers such as food and sex are accompanied by a
release of the neurotransmitter dopamine (DA) from VTA neurons released onto
the NAc. Dopaminergic transmission within this pathway may be involved in the
subjective “feel good” experience as well as learning to “want” or seek that pleas-
urable stimulus again by ascribing incentive salience to that reward (Berridge &
Robinson, 1998; Kelley & Berridge, 2002). This dopamine modulated reward-
related learning for natural reinforcers is evolutionarily advantageous to keep us
(or our species) alive. However, drugs of abuse can result in a profoundly greater
release of dopamine along this pathway compared with these natural reinforcers,
thereby “hijacking” this reward pathway. Maladaptive reward-related learning
can occur in which valuation for these drugs is greater than for natural rein-
forcers or other pleasure-associated stimuli. Indeed, human cocaine users exhibit
greater brain activation when watching a film with cocaine-associated cues com-
pared with a non-drug evocative film, and less brain activation compared with
non-drug users in response to the evocative film (Garavan et al., 2000). Because
most psychoactive drugs are able to stimulate this pathway and cause the release
of dopamine onto the NAc, we can begin to appreciate why these drugs can
have such profound impacts on behavior and social functioning. These effects
are mediated through known brain changes that occur from addiction and give
rise to poor judgment, impaired decision making, and a loss of behavior control
(Robinson & Berridge, 2003). It is easy to see how these impairments can lead
to a massive disruption of proper day-to-day functioning. Indeed, when rats are
allowed to press a lever that will cause cocaine to stimulate this pathway, they
will lever-press to the exclusion of all other behaviors—even to the point of
starvation (Wise, 1989).
The mesocorticolimbic system is responsible for determining motivation and
drive and is necessary for the processing of natural rewards (e.g., food, sex, and
social interaction). Two of the key players involved in reward processing within

Figure 2.1  The mesocorticolimbic system

30 Assessment 

this system are the neurotransmitters dopamine and glutamate. Dopaminergic

transmission along this pathway underlies hedonic responses and reward-related
learning while glutamatergic transmission mediates learning and memory.
Dopaminergic neurons in the ventral tegmental area (VTA) send axonal pro-
jections to the nucleus accumbens (NAc), the prefrontal cortex (PFC), and the
amygdala, and release dopamine. Additionally, glutamatergic projections from
the PFC, amygdala, and hippocampus project to the NAc. The NAc is implicated
in reward and motivation. The PFC is the main region involved in higher order
cognitive function such as inhibition of inappropriate responses, planning, and
mediating goal-directed behavior. The mesocorticolimbic amygdala is implicated
in emotion processing of a stimulus as well as establishing conditioned asso-
ciations between cues and rewarding or aversive experiences. The hippocampus
underlies context-specific memory under which a rewarding or aversive stimulus
was experienced.
The mesocorticolimbic system involves a series of feedback loops with parts of
the brain to control internal balance, or homeostasis. Physiological homeostasis
involves maintaining biological “balance” within the body by ongoing com-
pensation for perturbations or chemical fluctuations (e.g., hormone changes).
It is important not to confuse physiological homeostasis with the idea of family
homeostasis, which concerns how family members come together and regulate
their functioning. In this book, we will primarily be focusing on family homeo-
stasis. Physiological homeostasis helps us respond when a basic need is detected.
In response to a need, the mesocorticolimbic dopamine system will feed forward
into motor control areas and memory systems in order to respond to the body’s
need. These other areas include the learning and memory systems (the PFC, hip-
pocampus and amygdala) as well as sensory and motor input (i.e., the basal
ganglia, thalamus) (Söderpalm & Ericson, 2013). These areas, combined with
cortical integration, serve as the “motivation control system” of the body to
ensure that we engage in behaviors that keep us (or our species) alive. For exam-
ple, homeostatic signals which communicate hunger to the brain will activate the
mesocorticolimbic and ancillary systems to motivate humans and other animals
to start searching for food, remember where food was found, and recognize areas
where food was previously found (Söderpalm & Ericson, 2013). Essentially, the
mesocorticolimbic system drives us to get motivated and get moving in a goal-
directed manner. Psychoactive drugs that activate the mesocorticolimbic system
will be treated as intrinsically rewarding (just like food, sex, or other naturally
pleasurable stimuli). Indeed, this pathway appears to serve as a common neu-
robiological vulnerability that underlies behavioral as well as psychoactive
addictions. With repeated use of chemical substances, the body learns to treat
the drug as part of the homeostatic drive—in the absence of the drug the sys-
tem activates to seek out the drug (Wise, 1989). All psychoactive drugs that are
addictive either directly or indirectly activate the mesocorticolimbic system. The
pharmacological properties of these drugs allow their activation of this system
to be quite powerful—even usurping the strength of other natural reinforcers to
activate this system.
To provide an example of the impact that these processes have on human
functioning, we can look at one reason why addicts may not engage in normal
processes like eating and sex. They may find that activities that they used to find
  The Neurobiology of Addiction 31

pleasurable, such as having sexual intercourse with their partner, are no longer as
physiologically gratifying as they used to be. They may even need to get “high” to
enjoy sex with their partner. While this physiological process is in play, there are
also relational impacts that the reduction of pleasure has, which we will discuss
throughout the remainder of this book.

Psychoactive Drug Classifications and Brain Actions

Inhalation Drugs: Marijuana and Cigarettes

Marijuana is a widely used psychotropic drug whose active psychoactive sub-
stance is the tetrahydrocannabinol (THC) chemical that is produced by the
cannabis plant. As we reviewed above, psychotropic drugs have their effect in the
CNS by serving as agonists or antagonists for naturally occurring neurotransmit-
ters. Tetrahydrocannabinol is an agonist for the receptors that naturally bind the
neurotransmitter anandamide. Interestingly, though, in this case the effects of
THC were well known before the endogenous neurotransmitter was discovered.
For that reason, anandamide took its name from the Sanskrit word for “bliss.”
There are two known receptors to which THC binds in the brain—cannabinoid
receptors 1 and 2 (CB1 and CB2). Anandamide activation of the cannabinoid
receptors can impair working memory (Kunos & Bátkai, 2001) and increase
feeding behavior.1 Unsurprisingly, then, marijuana (i.e., THC) use is also associ-
ated with decreases in working memory and increases in appetite (a reason why
people seem to get the “munchies” after smoking or ingesting marijuana). The
potential effect of THC on psychotic behavior is less clear. Although there is a
well-described association between psychotic disorders (such as schizophrenia)
with ongoing cannabis use (Chadwick, Miller, & Hurd, 2013), it is not certain
if marijuana use precedes the behavior changes or is a response to it (e.g., in an
effort to “self-medicate”). As reviewed at the beginning of this chapter, the meso-
corticolimbic system is the final common pathway whose activation mediates the
addictive properties of all psychotropic drugs. Tetrahydrocannabinol activates
this system, and, accordingly, can also have addictive effects. In fact, THC can
activate dopamine release in the NAc even at relatively low doses (Chen, Paredes,
Lowinson, & Gardner, 1990). There is also a probable role for THC in poten-
tiating alcohol use since a drug that antagonizes the CB1 receptor also reduces
ethanol intake in rats (Colombo et al., 1998). This means that marijuana is bio-
logically addictive and, in fact, 9% of marijuana users become dependent on it
(Danovitch & Gorelick, 2012). However, this rate is much lower compared with
all other addictive substances (Lopez-Quintero et  al., 2011). Like other drugs,
when the person stops using marijuana, there may be physiological and psy-
chological withdrawal issues. The most common withdrawal symptoms include
marijuana cravings, mood-swings, and sleep disruption.
The use of cannabidiol (CBD) alone is becoming increasingly popular.
Although marijuana contains THC and cannabinoid, CBD alone is not psycho-
active. Cannabidiol has a low affinity for the CB1 receptors and CB2 receptors,
but can increase the production of endogenous cannabinoids (Hayakawa et al.,
2008). Recent evidence points to the use of CBD as an anti-inflammatory agent
32 Assessment 

and as a possible therapeutic agent in the treatment of anxiety, depression, and

addiction (Zlebnik & Cheer, 2016).
Cigarettes, like marijuana, are a common inhalation drug; however, cigarette
use is legal and regulated across the U.S. Cigarette smoking is the most common
use of the tobacco plant whose chemical, nicotine, gives tobacco its reinforc-
ing and addictive properties. Nicotine influences behavior through binding to
the previously described nicotinic acetylcholine receptors (nAChRs) on neurons
in the mesocorticolimbic pathway. When nicotine binds to the nAChRs on the
VTA neurons it causes them to release more dopamine onto the NAc neurons.
Nicotinic acetylcholine receptors are also located on neurons in the VTA that
indirectly modulate dopamine activity (Koob & Volkow, 2010). Compared with
marijuana, and even other psychotropic drugs, nicotine is extremely addictive
(Kandel, Chen, Warner, Kessler, & Grant, 1997). Although there is not a clear
consensus on what constitutes “addiction” to nicotine, it can be clearly charac-
terized by persistence of use and withdrawal symptoms. There is also a larger
degree of individual variability on the likelihood to become addicted to nicotine
and the ability to quit nicotine use. Clear genetic factors have emerged that point
to individual risk for nicotine use and are discussed in the next chapter.

Antianxiety and Sedative Hypnotics: Barbiturates,

Benzodiazepines, and Alcohol
The general classification of antianxiety and sedative hypnotics refers to drugs
that have anxiolytic (anxiety-reducing) and sedative (sleep-inducing) proper-
ties. Here we will focus on the sedative hypnotics alcohol and barbiturates
(derivatives of barbituric acid) and the antianxiety benzodiazepines. All of
these drugs affect behavior by essentially decreasing brain function (which is
one reason why, when prescribed, individuals are warned not to operate heavy
machinery or drive motor vehicles while taking the drug). Importantly, these
drugs decrease brain function in a dose-dependent manner, meaning that as
the drug dose increases, brain activity decreases. This dose-dependent property
translates into reduced feelings of anxiety at low doses, loss of inhibition fol-
lowed by sleepiness at medium doses, and, at the highest doses, coma and even
death can occur.
A critical feature of all of these drugs is that they have cross-tolerance for each
other; tolerance for one of these drugs will increase tolerance for another. For
example, if a person develops a tolerance to alcohol, they will also develop a tol-
erance for antianxiety medication. Cross-tolerance is possible because antianxiety
and sedative hypnotic drugs all work as agonists at the same brain receptor—the
GABAA receptor. The GABAA receptors are widely distributed throughout the
brain and function as one of the “workhorses” of the brain to inhibit neuron
activity. When activated, the GABAA receptor will open up and allow chloride
(Cl-), a negatively charged ion, into the neuron, thus reducing the excitability
of that neuron (Olsen & DeLorey, 1999). The GABAA receptor has a binding
site for the endogenous neurotransmitter, GABA. There are two additional bind-
ing sites on this receptor to which other endogenous chemicals bind in order to
modulate the effects of GABA on the receptor. It is these other binding sites that
can also bind benzodiazepines, alcohol, or barbiturates.
  The Neurobiology of Addiction 33

Activation of the benzodiazepine binding site modulates the receptor so that

GABA binds to it much more easily (increases the affinity for GABA). In other
words, benzodiazepines reduce anxiety by allowing GABA to more easily bind
to its receptor, which decreases neuron excitability. Barbiturates, on the other
hand, do not function by changing the ability of GABA to bind to its receptor,
but rather, increase the amount of time the channel is open so that more Cl- ions
can pass into the neuron and reduce the excitability of the neuron. Although
these benzodiazepines and barbiturates seem to have similar enough effects on
the GABAA receptor, barbiturates are much more dangerous since prolonged
increases of Cl- into the cell can cause the brain to rapidly shut down through
a decrease in neuron activity. In addition, they can further decrease brain activ-
ity by binding to sodium (Na+) channels on neurons and preventing the flow of
sodium ions (which also decreases neuron excitability). The combined effect of
barbiturates on prolonged Cl- influx and decreased Na+ influx into cells causes
neurons to essentially “shut down.” While this can aid in increasing sleepiness
at normal doses, this effect can result in a loss of consciousness or even death
minutes after a barbiturate overdose.
Alcohol is lipid (fat) soluble and, as such, can easily cross the blood–brain
barrier inducing widespread effects on the CNS. Alcohol has two major binding
sites in the brain—one is the GABAA receptor and the other is the N-methyl-D-
aspartate receptor (NMDA) receptor. Alcohol enhances the inhibitory effects of
GABA at the GABAA receptor, which accounts for the sedative effects of alco-
hol. The NMDA receptor naturally binds the neurotransmitter glutamate and
acts as a coincidence detector (the binding of glutamate along with post-synaptic
depolarization) to allow for memory formation in the brain (through a process
called long-term potentiation, or LTP). Since alcohol decreases glutamate’s abil-
ity to bind to the NMDA receptor it can decrease memory formation (possibly
related to the “black out” effects of alcohol) in addition to a decrease in overall
brain excitation (since NMDA receptors have an excitatory effect of neurons).
Behavioral consequences to this reduced excitation include a loss of higher cor-
tical (especially frontal lobe) functions and loss of motor control. Examples of
frontal lobe impairments can include an inability to think clearly, a change in per-
sonality, difficulty with emotional control, and difficulty with rational thought.
This is one reason that there are so many motor vehicle accidents when the per-
son who is driving has alcohol in their system since the individual has a loss of
cerebellar control. Damage to the cerebellum with alcohol use or injury results in
difficulty with the timing and coordination of intended movements. This means
the intentional mouth and tongue movements (which can cause slurring), stand-
ing up from a sitting position, walking, or even swerving in time to avoid a
collision when driving, are hampered.
These physiological impacts of alcohol use are also a major factor in the change
of a person’s functioning in interpersonal relationships—especially when they are
drunk. Given that their ability to think and emotional control are depressed, they
have a tendency to act in ways that are not “normal” for them. This may come in
the form of someone who is usually quiet and non-violent becoming boisterous
and physically abusive.
Long-term alcohol use causes NMDA receptors to increase in number in
response to the ongoing antagonistic effects of alcohol on these receptors. As a
34 Assessment 

consequence, the abrupt cessation of alcohol intake in chronic users can cause
NMDA-receptor-mediated seizure activity 6–48 hours later (Hughes, 2009).
The up-regulation of NMDA receptors that occurs with chronic alcohol use is
also associated with delirium tremens (DTs), which include tremors, increased
blood pressure/racing heart, and hallucinations (Hughes, 2009). It is uncertain in
humans how long it takes for these consequences to occur—the prevailing view
is that these effects begin after at least a few years of heavy drinking. However,
other findings show that heavy use for a short period can bring about seizures
and DTs (Ng, Hauser, Brust, & Susser, 1988).
Alcohol is a very addictive substance. In the next chapter we will review vari-
ous biological factors that contribute to individual differences in the sensitivity
to alcohol’s addictive properties. In general, though, the addictive properties
of alcohol are mediated through the mesocorticolimbic dopamine system. Like
other addictive drugs, alcohol increases the release of dopamine in the NAc.
Experiments in rats support the idea that it is alcohol’s activation of the mes-
ocorticolimbic dopamine system that gives alcohol its addictive properties. In
particular, the intake of alcohol can be reduced by injecting a dopamine antago-
nist directly into the NAc (Samson, Hodge, Tolliver, & Haraguchi, 1993). The
reinforcing effects of alcohol are also mediated through its ability to release
endogenous opioids (Davidson, Swift, & Fitz, 1996). Endogenous opioids, bind-
ing to opioid receptors, cause feelings of pleasure and euphoria in humans and
other animals. Thus, a person may seek out alcohol, outside of the taste, to attain
the physiological effects.

Stimulants: Caffeine, Amphetamine, and Cocaine

In general, the classification “stimulants” are a class of drugs that increase energy
and alertness and also create a sense of well-being. These drugs increase
energy through an increase in sympathetic nervous system (SNS) activity.
This causes the same types of physiological and behavioral effects to stimu-
lants that the body naturally produces during a “fight or flight response.” The
physiological changes include an increase in heart rate, increased respiration,
pupil dilation, increased sweating, and elevated blood pressure. Behaviorally,
activation of the SNS causes an increase in alertness and attention. However,
continued stimulant use can result in paranoia and hostility. Due to the role of
stimulants in increasing energy, alertness, focus, and concentration this classi-
fication of drugs is used therapeutically in different forms for the management
of attention disorders (e.g., ADD/ADHD) and severe daytime sleepiness (e.g.,
narcolepsy). Of note, though, is that these prescription stimulants are also
commonly used to increase academic or professional performance. Attention-
enhancing drugs such as Modafinil, Adderal, and Ritalin are also referred to as
“smart drugs” for their ability to boost academic performance.
By far, the most widely used general stimulant is caffeine (in fact I wager
that many reading this chapter are doing so with the help of this drug!). Above,
we discussed the role of caffeine as an antagonist for the adenosine system and
here we clarify how caffeine can directly increase energy production in the
body. Caffeine readily crosses the blood–brain barrier and inhibits an enzyme
called phosphodiesterase (PDE), which breaks down a chemical called cyclic
  The Neurobiology of Addiction 35

adenosine monophosphate (cAMP). Without PDE putting on the brakes, cAMP

levels increase, which results in an increase in glucose production in the cell
(which results in more energy). The rise in cAMP also prolongs the effects
of epinephrine (adrenaline) or drugs that have adrenaline-like activities such
as amphetamines.
Caffeine use is not considered biologically addictive. While caffeine use can
cause physical withdrawal symptoms (such as headaches), withdrawal symp-
toms do not always mean that there is physical dependence. The main reason
that caffeine is not considered biologically addictive is that (at doses that reflect
human use) it does not alter the mesocorticolimbic pathway (Nehlig, Armspach,
& Namer, 2010). However, there are possible withdrawal symptoms, such as
jitteriness and mood instability.
Like caffeine use, amphetamine and cocaine use cause an increase in SNS activ-
ity, but, unlike caffeine, they are both highly addictive. Amphetamine and cocaine
have similar behavioral effects to each other, but they have distinct modes of
action in the brain. Behaviorally, both of these drugs can produce an increased
sense of euphoria, increased focus and concentration, an increase in energy, and
decreased appetite. In the mesocorticolimbic system amphetamine and cocaine
are both “extreme” dopamine agonists.
Amphetamine2 use causes the direct release of dopamine from neurons and
blocks dopamine reuptake (going back into the neuron after it is released), while
cocaine mainly works by blocking the reuptake of dopamine. Another difference
is that amphetamine is also an agonist for the neurotransmitter noradrenaline
(A.K.A norepinephrine). The neurobiological differences between the two also
cause amphetamines to have longer-lasting effects compared with cocaine (Barr
et  al., 2006). These longer-lasting effects, however, are also the reason why
amphetamines are also more likely to result in behavioral psychosis. Importantly,
both of these stimulants result in profound and irreparable brain damage by
causing lesions in the neurotransmitter systems (at axon terminals) that they
activate (Gouzoulis-Mayfrank & Daumann, 2009; Yamamoto, Moszczynska, &
Gudelsky, 2010).

Psychedelic Drugs: LSD and MDMA

Hallucinogenic drugs have their effects through actions on the serotonin (5-HT)
neurotransmitter system. These drugs are not biologically addictive and their
reinforcing effects are derived from their ability to alter perceptual experi-
ences. The drug lysergic acid diethylamide (LSD) works as an agonist for the
serotonin receptor 5-HT2A. The activation of this receptor by LSD produces
visual hallucinations and perceptual distortions. While some people find these
experiences to be rewarding and exciting, others find the hallucinations and
perceptual distortions to be frightening. LSD was originally created as a blood
stimulant in Switzerland in 1938. The hallucinogenic properties of LSD were
discovered when its discoverer, Albert Hoffman, accidently spilled some of it
on himself. After this, Sandoz Pharmaceuticals distributed the drug for psychi-
atric research (Dyck, 2005). Recently, a Phase 2 pilot study conducted by the
Multidisciplinary Association for Psychedelic Studies (MAPS) has demonstrated
that LSD-assisted psychotherapy for anxiety associated with a life-threatening
36 Assessment 

illness can be safely administered to patients. A positive trend in the reduction

of anxiety was noted and warrants further research.
Another commonly abused hallucinogenic is the drug MDMA (3,4-methyl-
enedioxy-N-methylamphetamine)—commonly known as “Ecstasy.” MDMA
works as an agonist of serotonin and norepinephrine systems. MDMA was orig-
inally manufactured by the German drug company, Merk. MDMA was used
clinically to help patients “open up” during psychotherapy (Bernschneider-
Reif, Oxler, & Freudenmann, 2006). Indeed, the behavioral effects of MDMA
create an increased sense of euphoria and empathy and also produce halluci-
nations. While MDMA is not biologically addictive, its neurobiological effects
are nevertheless devastating to its users through selective lesions on the same
serotonin neurons that are activated by its use; this results in memory problems
and declines in cognitive processing (Gouzoulis-Mayfrank & Daumann, 2009;
Yamamoto, Moszczynska, & Gudelsky, 2010). MDMA is currently being used
again during psychotherapy and especially for posttraumatic stress disorder
(PTSD) due to the ability of MDMA to assist with reprocessing of traumatic
memories (Feduccia & Mithoefer, 2018).
Psilocybin is another frequently used hallucinogenic drug. Psilocybin is pro-
duced by over 100 species of psilocybin mushrooms and has low addictive
risk and toxicity. The behavioral effects of Psilocybin are similar to the other
psychedelics and are mediated (at least partly) through the 5-hydroxytryptamine
(HT)2A receptor. Psilocybin is also sometimes used as an adjunct in psycho-
therapy and has shown some benefits for the treatment of anxiety, depression,
and drug addiction (Johnson & Griffiths, 2017).

Case Application

Addiction adds a significant amount of strain on the Rothers’ family environ-

ment. A family therapist would benefit from understanding and exploring the
neurobiological basis of Mark’s addiction in treating Mark and the Rothers
family. Understanding the biological basis of the addiction can allow the fam-
ily to form a basis for appreciating the future intrapersonal and interpersonal
difficulties as Mark works through reducing or abstaining in substance use. In
particular, Mark and his family will need to understand that his brain is currently
biologically addicted to alcohol. Recognizing the biological changes in the brain
that occur with addiction can assist in the recovery process.
Like all chemical addictions, the natural motivation and reward centers of
Mark’s brain have experienced “hard-wired” changes. The pathway through
which Mark, or any addict, progresses from casual drinking to dependence
involves a complex interplay between psychological, biological (including
genetic, see Chapter 3), and environmental variables. It is possible that Mark
had a natural vulnerability for alcohol addiction since individuals who natu-
rally have decreased DA signaling (through decreased DA D2 receptor density
and function) in the mesolimbic pathways appear to be at an increased risk for
dependence (Tupala & Tiihonen, 2004). In the brain of any addict, increased use
of alcohol will result in a reduction in the release of DA in the NAc and in limbic
pathways, which will create withdrawal symptoms and craving (e.g., restlessness,
  The Neurobiology of Addiction 37

irritability, anxiety, and insomnia). For Mark, alcohol use during withdrawal is
reinforcing since it will restore DA levels (Hui & Gang, 2014).
Many areas of the brain that are important for emotion and memory pro-
cessing have been altered as a result of the addiction to alcohol and possibly
through the comorbid use of other substances. Critically, environmental experi-
ences and exposures can create a state of neurological vulnerability for relapse. In
particular, even a single drink after Mark quits can prime his brain for continued
use through the role of dopamine in “priming” the brain for drinking behavior.
Mark’s brain will also be in a vulnerable state for relapse when he is around
cues that were part of his routine alcohol use. These cues can be people, places,
or even objects. This is because drug abuse can sensitize the mesolimbic system
(see the “Mesocorticolimbic Reinforcement System” section in this chapter) so
that the experience of the drug is intertwined with the environment in which it
is taken. Of note is that there is a significant amount of strain on Mark’s family
environment. One useful possibility will be for Mark to obtain stress manage-
ment techniques as part of the therapeutic process. Stress commonly works as an
antecedent for addiction relapse. In particular, the stress hormone cortisol crosses
the blood–brain barrier and can bind directly to receptors in the VTA, ultimately
increasing the drive for substance use (Adinoff, 2004).
The family therapist can consider incorporating education about the neural
circuits of addiction in order to help Mark and his family understand that chemi-
cal addiction presents unique challenges relative to other behaviors. One avenue
of approach would be to explain that, at a neurological level, we are all motivated
to engage in particular behaviors based on the natural reward the brain receives
from successfully completing motivated behavior. At birth, we are hard-wired to
engage in certain activities necessary for sustaining our survival (the canonical
“4 Fs” of motivation: fight, flight, food, and sex). This basic reward circuitry
has been significantly altered in Mark—the motivation to engage in adaptive and
healthy human behavior is decreased in the addicted individual. With consistent
exposure of brain receptors to an addictive substance, the substance can eas-
ily become the most desirable thing in life to the addict. In Mark’s case, he has
decreased motivation to pursue the healthy behaviors in which we expect non-
addict adults to engage. His body is now motivating him to seek out alcohol for
pleasure and punishes him for not using alcohol. When he does not use alcohol,
he will experience physiological withdrawal symptoms. Summarily, Mark’s body
may now be receiving signals from his brain that alcohol is more important to the
system than food, sex, or relationships. As an addict, his role and interactions in
his family environment are severely altered. His desire to maintain and engage
in his interpersonal relationships is no longer as imperative as it once may have
been. It is difficult to accurately predict the complete behavioral consequences of
his alcohol use. There are many biological and social factors that will contrib-
ute to the withdrawal symptoms experienced by each individual. As the reward
network has been altered we can expect varied levels of motivation based on the
re-wiring of neural networks.
The family should also understand how alcohol has, and will continue to,
affect his life. The most common behavioral consequences of alcohol’s long-
term effects on the brain are the loss of frontal lobe function and motor control.
This creates an inability to think clearly, personality changes, and difficulty
38 Assessment 

with emotion control, and these effects can take place slowly over time. With
continued chronic use of alcohol the individual tends to slowly suffer more
severe decreased function. The rate and extent of impairment that someone
experiences is individual and has many contributing factors. This is important
for Mark’s family to understand since this information may allow the family to
interact with him better knowing the limitations in his cognitive ability. Due to
the effects that the substance abuse has had on his brain, he is now hard-wired
to value alcohol over other aspects of life. His dopaminergic pathway has been
hijacked by his dependency on alcohol and is now, in essence, taking over his
thinking. Motivation on a neurological level is the sequential events that lead
from our brain to our body in order to complete a desired action. Because of
his dependence on alcohol, and its effects of reducing psychological pain and
providing pleasure, Mark is now no longer functioning in a cognitively nor-
mal way. It will be challenging for him to be motivated to enjoy or engage in
healthy behaviors.
Perhaps most importantly, it is critical for the client or therapist to know
that not all hope is lost for an addicted brain and that meaningful changes in
brain plasticity can come about with strenuous and consistent therapy. With
addiction recovery the brain shows increased pre-frontal cortex (PFC) activ-
ity and some recovery of executive control and general cognitive functioning.
Notably, if the inhibitory control networks of the client can be strengthened,
the ability to withstand the drive to use will be concomitantly strengthened.
Mindfulness training techniques have also been associated with overcoming
strong drug cravings through increasing inhibitory control (Adinoff, 2004). In
addition, over time, changes in the DA pathways in the mesolimbic pathway
can become at least partially restored (Charlet, Rosenthal, Lohoff, Heinz, &
Beck, 2018).

Summary
In this chapter we have presented some of the basics of the neuroscience
of how addiction happens. The processes that we have discussed impact
people differentially. For instance, it may take four alcoholic drinks for
the person to begin to experience some of the effects while others may
need only one or two drinks. Regardless of how much, or how little, of the
drug is needed to activate the various receptors in the brain, the individual
effects affect the person’s relational world.
The physiological brain changes that occur for people who use and
abuse substances may be the frustrating aspect for family and friends, and
probably also for the individual, as to why they cannot just stop, cold
turkey, in using. While drug use is a choice, there are more factors in play,
such as dependence and withdrawal mechanisms. Thus, having an under-
standing of how drugs impact the body should help in conceptualizing
what is happening for the individual while the individual is engaged in the
relational networks of their life.
  The Neurobiology of Addiction 39

Key Words
psychoactive drugs antianxiety and sedative
behavioral addiction hypnotics
process addiction anxiolytic
blood–brain barrier sedative
receptors dose-dependent
neurotransmitters cross-tolerance
antagonistic drug delirium tremens
agonist drug stimulants
mesocorticolimbic pathway hallucinogenic drugs
mesocorticolimbic system lysergic acid diethylamide (LSD)
marijuana MDMA
tetrahydrocannabinol (THC) Psilocybin

Discussion Questions
1. Explain the relationship between psychoactive drugs and their impact
on the brain.
2. What are the differences between antagonistic and agonist drugs?
3. How do stimulants and sedatives differ in their impact on the body?
4. Why are some drugs cross-tolerant?
5. How might the physiological impact of different drugs impact a per-
son’s familial relationships?

Notes
1 An interesting aside here is that chocolate contains anandamide-like substances—this
might explain why so many people find chocolate so scrumptious and difficult to deny!
2 Methamphetamine is a common variant of amphetamine. The only difference between
them is that methamphetamine is double methylated. The process of double methylation
causes methamphetamine to have faster, stronger, and more dangerous effects in the body.
Methamphetamine breaks down into amphetamine once metabolized in the body.
three

The Genetics of Addiction

Jaime L. Tartar and Christina M. Gobin

In the last chapter, we reviewed the basic concepts surrounding how psychotropic
drugs can be biologically addictive through their ability to activate and modulate
the mesocorticolimbic dopaminergic system. In this chapter, we will focus on
how specific natural variations in genes can make individuals more susceptible to
the effects of drugs and biological addiction. In reviewing the effects of genes on
any behavior, including addiction, the most important concept to understand is
that genes do not code for any behavior. In other words, it is a common miscon-
ception to think that genes control behavior.
In recent years, we have seen headline-grabbing reports of behavior-
controlling genes. These include the so-called smart gene, the happiness gene, the
aggression gene, the athletic gene, and the addiction gene. This is a misunder-
standing of what genes actually do. While genes contribute to different aspects
of behavior, no individual gene is responsible for a single behavior. In other
words, when we describe a particular gene as one that contributes to the devel-
opment of a behavioral characteristic, such as alcoholism, we are not saying that
the trait is “genetically-determined.” There are certainly genes that contribute
to drug sensitivity and to drug addiction, but there can never be an “addiction-
gene.” This is a very important distinction and one that is commonly confused
in the media and in everyday conversation. It is likely that individuals seeking
therapy will be equally confused about this. In order to better understand why
this can never be the case, let’s first review what it is that genes actually do.

Genes: The Basic Units of Heredity

Genes are the basic units of heredity and are located within strands of deoxyribo-
nucleic acid (DNA). DNA is made up of two strands of four repeating nucleotides:
adenine (A), thymine (T), cytosine (C), and guanine (G). The two strands of DNA
fit perfectly together in such a way that an A on one strand always pairs with a
T on the other strand, and a C on one strand always pairs with a G on the other
strand. For example, if one strand contained the base sequence C-A-T-G, the
corresponding strand would be G-T-A-C. The chain of these matching nucleotide
bases are held in place by a backbone of sugar and phosphate running along each
side of the paired nucleotides. These two side backbones are strong and flexible

40
  The Genetics of Addiction 41

structures that coil around each other giving DNA its famous double-helix shape.
Humans have 23 pairs of very long strands of DNA—these are the chromosomes
and they are stored in the nucleus of each cell. Each parent contributes 23 chro-
mosomes to their offspring, and, altogether on these chromosomes, the human
genome contains about 3.2 billion base pairs (matching pairs of nucleotides).
Interestingly, most of the nucleotide sequence in the DNA does not code for
genes—these sections occur within and between genes and are collectively called
non-coding DNA (sometimes referred to as “junk” DNA).
The relevant or coding DNA consists of a series of nucleotides that code for a
specific amino acid. When the DNA sequence is set to be “read,” it is unwound
and a molecule very similar to DNA called ribonucleic acid (RNA) is copied from
one of the DNA strands (one strand is specifically designated for this purpose).
When RNA is produced, it carries its own matching nucleotide sequence (except
here Thymine is substituted for Uracil so, in RNA, A pairs with U, in place of T).
The production of RNA from the DNA strand is called transcription. This is just
like when you transcribe a recorded lecture—you copy exactly what was said in
the same language. Transcription does exactly this—it transcribes, or copies, the
information from the language of nucleotides (DNA) into a matching language of
nucleotides (RNA). This RNA will then carry the matching nucleotide code out of
the nucleus—by doing this it serves as a messenger and is appropriately called mes-
senger RNA (mRNA). The mRNA then reaches protein-making factories called
ribosomes in the cell. The ribosomes read the mRNA as part of translation—the
process of making proteins from the mRNA code. Here, the mRNA is translated
from the language of nucleotides (RNA) into the new language of proteins. In par-
ticular, every 3 nucleotides that are read by the ribosomes represents one codon.
From the 4 aforementioned nucleotides, 64 combinations of these nucleotide tri-
plets or codons can be generated. Each codon will tell the ribosome to make one
of 20 possible amino acids. These chains of amino acids will then combine to
make a protein with a unique 3-D structure and specific function such as execut-
ing enzymatic reactions, providing structure, or signaling communication within
and between cells. Some of these proteins may include receptor proteins, which
are involved in the neurochemical cascades that result in certain physiological
or behavioral responses. This whole process through which DNA makes RNA,
which then makes proteins, is a fundamental principle in understanding how genes
work. It is so fundamental, in fact, that “DNA makes RNA makes protein” is
known as the central dogma of biology. Altogether, the human genome contains
20,000–25,000 distinct protein-coding genes.
So now that we have an appreciation that a gene is only a strand of DNA that
codes for a specific protein, we can better appreciate why it is inappropriate to
think of genes as controlling behavior. It would never make sense to think that
one protein determines your cheerful disposition! In sum, genes code for proteins
and proteins can contribute to behavior, but they do not determine behavior.

Polymorphisms
Within a population, there can be differences in the genes that lead to differences
in the expressed proteins. These differences are known as polymorphisms and
42 Assessment 

are described by how many times a number of the nucleotides repeat. Variable
number tandem repeats (VNTRs) have a core repeat sequence that ranges from
500–30,000 nucleotides. Short tandem repeats (STRs), on the other hand, have
a much shorter core repeat sequence that ranges from 50–300 nucleotides.
Single nucleotide polymorphisms (SNPs, pronounced “snips”) consist of only
a single nucleotide difference in the sequence of the DNA. These types of poly-
morphisms are inherited and lead to differences in protein or enzyme activity
between individuals. Later in the chapter we will confront specific polymor-
phisms that are associated with addiction. Since each person has two copies of
a gene (alleles), they can be heterozygous or homozygous for polymorphism—
they could have inherited two different alleles (heterozygous) or two of the same
alleles (homozygous).

Genetic Vulnerability to Addiction

Susceptibility vs Inevitability
Like other behaviors, the genetic vulnerability to addiction is complex. Having
a genetic susceptibility for addiction does not determine someone’s fate—it only
affects the way the body responds to drugs. For example, one set of genetic poly-
morphisms can make it harder to quit using and increase withdrawal symptoms.
Conversely, other polymorphisms can make it harder for someone to become an
addict (for example, if unpleasant symptoms are experienced from using a drug
that typically induces pleasant feelings). Later in this chapter we will review
some of the genetic factors that are shown to increase addiction susceptibil-
ity. For therapists, it is important to appreciate that some individuals can be
biologically predisposed to drug sensitivity. These biological differences in how
the body processes and responds to drugs can help to explain why addiction
is much harder to control in some individuals compared with others. In other
words, two people can “try” just as hard and be equally motivated to overcome
addiction, but a biological predisposition can make it physiologically more dif-
ficult for one of them to get better. With advances in “personalized medicine,” it
might soon become practical to genotype addicted populations in order to better
treat them. Genotyping is a technique of identifying an individual’s genetic code
(genotype). In other words, it is the process of determining the genetic make up
(genotype) and identifying the specific alleles that an individual has inherited
from his/her parents. Finding differences in drug sensitivity at a physiologi-
cal level means that addiction treatment can be aided by customized therapy
and treatment strategies. In the field of psychopharmacogenetics, research is
currently underway to customize addiction treatment based on individual geno-
types (reviewed in Heilig, Goldman, Berrettini, & O’Brien, 2011). The idea of
customized treatment has already shown promise in addiction treatment. For
example, in the finding that naltrexone hydrochloride is significantly more effec-
tive in alcoholics with a specific opioid receptor gene polymorphism (Asp40),
compared with alcoholics without the polymorphism (48% vs 26%, respec-
tively; Anton et al., 2008).
  The Genetics of Addiction 43

Patterns of Inheritance: Pedigree Studies

Gene polymorphisms are passed down from parents to children through spe-
cific patterns of inheritance. However, the pattern of inheritance in families
does not follow the classic “Mendelien” transmission pattern where one allele is
dominant or recessive and only one trait is expressed. Drug abuse and addiction
involves multiple genes and is susceptible to environmental influences (Enoch
& Goldman, 1999). Investigations in the genetics of addiction and substance
abuse are thought to follow a gene–environment interaction (G x E) model. The
GxE model assumes that both genetics and environment play a role in addiction
susceptibility (Hesselbrock & Hesselbrock, 1990). For this reason, analyses of
families with substance-use disorders are helpful in uncovering the inheritance
pattern and environmental influences on addiction development. Figure 3.1 por-
trays the complex gene x environment interaction.
An important note to make here is that heritability estimates are sometimes
misinterpreted as estimates of genetic contribution to a particular trait in an
individual. Heritability estimates do not refer to individuals, but rather, to vari-
ation within groups of people (i.e., a population). Heritability is the proportion
of the total variation of a certain trait in a population that is due to genetic
variation. With this in mind, pedigree studies on addiction provide overwhelm-
ing evidence that addiction to alcohol and other psychoactive substances have

Gene–Environment Interaction

High
100 environmental
influence

80
Alcoholic ProbabiIity (%)

Moderate
environmental
60
influence

40
Low
environmental
20 influence

0
Genetic Influence

Figure 3.1  Environmental and genetic factors play a combined role in addiction. In this
figure alcoholism susceptibility is shown as a function of a G x E model.
Addiction probabilities are low when there is little genetic susceptibility and
little environmental influence towards alcohol use. The highest probabilities
of alcoholism arise with a high genetic influence and strong environmental
influence towards alcohol use. Figure adapted from Dick and Kendler (2012)
44 Assessment 

strong heritability estimates. For example, first-degree relatives (mother, father,

sibling) of people who use opiates are significantly more likely to have drug or
alcohol addiction (Rounsaville et  al., 1991). Of note here is that there is also
a family-linked association between alcoholism, opiate use, and depression—
suggesting a common genetic link between these conditions (Kosten, Rounsaville,
Kosten, & Merikangas, 1991). In addition, pedigree studies find that, compared
with the general population, the potential for alcoholism is increased in people
who are biologically-related to someone with alcoholism. Moreover, this risk is
increased up to seven-fold for first-degree relatives of an alcoholic (Cotton, 1979;
Merikangas, 1990). The specificity of inheritance for specific substances is not
clear. The reason for this uncertainty is that drug users tend to use more than
one substance and the availability and popularity of specific substances changes
with time. In other words, it is difficult to pinpoint the inheritance for one drug
in particular since many drug users also use other common substances (e.g., alco-
hol), and the availability of any particular drug may wax and wane over the years
while other substances become more readily available.

Genome-Wide Association Studies (GWAS):

Polymorphism Identification in Addiction
In addition to looking at inheritance patterns in families, there is also a goal
of genotyping individuals in order to better understand addiction and improve
treatment. Findings in this area stem largely from genome-wide association
studies (GWAS). GWAS identify genetic markers of disease, mental illness, or
behavioral differences by comparing the variation in DNA between people.
Family-based GWAS on addiction and substance use behavior have shown
many genes involved in these behaviors. These studies typically look at the entire
genome (all of the DNA) in a group of people with substance addiction and
compare their genome to a group of people who do not have substance addic-
tion. Gene sequencing machines can “read” the entire nucleotide sequence for
each person. Polymorphisms (VTTRs, STRs, and SNPs) in genes that are found
to be more common in the addicted compared with the non-addicted group are
further investigated as genes that are associated with addiction. These identi-
fied polymorphisms require further investigation since genes are often inherited
in linkage groups. Therefore, a polymorphism that is shown to be commonly
found in addicted individuals might just be “tagging along” with another gene
or group of genes that is actually affecting drug or alcohol sensitivity. Results
from GWAS have found various genetic markers that are associated with sub-
stance use and abuse.

From Mice to Men: Animal Studies

Once a gene is identified as playing a role in the vulnerability to substance-abuse
disorders, animal models are widely employed to test the function of the gene at
a level of analysis that isn’t possible in humans. Specifically, the mouse and rat
are particularly useful in showing the role of genes in addiction since humans and
rodents share many of the same genes and their reward pathways function similarly.
  The Genetics of Addiction 45

Researchers commonly use knockout (KO) mice to model the genes involved in
substance abuse. Knockout mice are laboratory mice in which an existing gene is
inactivated and replaced with an artificial piece of DNA. By doing this, the gene
will no longer express certain proteins. To construct knockout mice, embryonic
stem cells are first collected from mouse embryos four days after fertilization.
Embryonic stem cells are used because they have the ability to differentiate into
almost any type of adult cell. Thus, the effects of inactivating a gene in an embry-
onic stem cell can be detected in any tissue of an adult mouse. Next, researchers
insert artificial DNA into the chromosomes within the nuclei of embryonic stem
cells by utilizing either gene targeting or gene trapping.
Gene targeting, also known as homologous recombination, involves manipu-
lating a gene contained in an embryonic stem cell’s nucleus. An artificial piece
of DNA that shares a homologous (identical) sequence of the genes is added.
The homologous sequence borders the existing DNA sequences for a particular
gene both upstream and downstream of the gene’s location on the chromosome.
The identical patterns of DNA sequence are readily recognized by the cell’s spe-
cific mechanisms; subsequently, the existing gene is exchanged with the artificial
piece of DNA, which eliminates the function of the existing gene since the artifi-
cial DNA piece is inactive. This artificial piece of DNA contains a reporter gene
which serves as a genetic tag used for tracking.
Gene trapping is similar to gene targeting in the sense that researchers once
again manipulate a gene in an embryonic cell. Rather than direct targeting of a
particular gene, however, a random process is utilized instead in which an arti-
ficial DNA piece with a reporter gene is organized to attach itself randomly into
any gene. With this method, the cell’s RNA splicing mechanisms are inhibited
from functioning properly. As a result, the existing gene’s function is inactivated
and the existing gene is precluded from producing its specific protein.
Employing these methods to produce knockout mice can help researchers
determine the function of genes within the context of drug addiction. Particularly,
researchers may inactivate a gene that codes for a specific receptor protein and
then test the animal’s physiological and behavioral responses to a particular drug
of abuse. For example, the conditioned place preference test (CPP) may be used
to measure how rewarding or aversive the drug is to the animal. This test uses an
apparatus containing three chambers to test an animal’s preference for a drug-
conditioned chamber versus a vehicle-conditioned chamber. On alternating days,
the animals receive injections of a drug in one chamber, or injections of a vehi-
cle solution in the other chamber. These chambers are designed to have distinct
visual, olfactory, and/or tactile sensations. On testing day, the animal is placed
in the neutral center camber which contains gates that are opened to access each
chamber. If the animal spends significantly more time in the drug-paired chamber
versus the vehicle-paired chamber, a conditioned place preference is found, sug-
gesting the drug is rewarding to the animal. On the other hand, significantly more
time spent in the vehicle-paired chamber versus the drug-paired chamber sug-
gests a conditioned place aversion. Using this test, a gene targeting study found
that KO mice lacking the mu-opioid receptor gene (MOR) (which codes for the
mu-opioid receptor) no longer demonstrated a conditioned place preference after
being injected with morphine. This implicated the mu-opioid receptor as playing
a role in the rewarding properties of morphine (Matthes et al., 1996).
46 Assessment 

Other behavioral models such as self-administration were designed to answer

different questions about the rewarding properties of a drug by considering an
animal’s voluntary choice to take the drug. In a classical version of this model,
an animal is implanted with a jugular catheter, which exits through a subcutane-
ous excision on the back and connects to a tether within an operant chamber.
The rat is presented with two levers throughout a two-hour session. Pressing the
“active” lever results in an infusion of the drug through the jugular vein paired
with light and tone cues, while pressing the other “inactive” lever provides no
programmed consequences. With drugs that are rewarding to the animal, the
animal will choose to continuously press the active lever over the inactive lever.
This paradigm combined with targeting a particular gene has elucidated the role
of some key receptors that may underlie the behavioral responses of voluntary
drug taking and persistent drug seeking. As mentioned in the previous chap-
ter, releases of dopamine following administration of drugs of abuse subserve
some of the rewarding effects of the drug. So too have increases in the neuro-
transmitter glutamate been noted within areas implicated in reward following
administration of psychostimulants such as cocaine. One particular receptor that
modulates glutamate release, the metabotropic glutamate receptor 5 (mGlu5), is
highly expressed within the nucleus accumbens (the region implicated in reward)
(Tallaksen-Greene, Kaatz, Romano & Albin, 1998), and repeated cocaine
administration has been shown to result in increases in mGlu5 mRNA within
this region (Ghasemzadeh, Nelson, Lu, & Kalivas, 1999). How this related to the
behavioral aspects of cocaine addiction were unknown. Using KO mice lacking
the GRM5 gene that codes for mGlu5, the functional role of this receptor was
able to be investigated within the context of cocaine addiction. It was found that
mGlu5 KO mutant mice, when compared with the wild-type (WT, typical form)
mice, do not self-administer cocaine, despite both the mutant and WT mice show-
ing similar cocaine-induced increases in dopamine (Chiamulera et al., 2001). This
shifted research to investigate a more complex neurocircuitry of addiction impli-
cating alterations in dopaminergic and glutamatergic transmission within the
mesocorticolimbic pathway. Understanding how these genes function and how
their respective receptor proteins are expressed within specific brain regions of
non-human animals, modeled throughout the addiction cycle (repeated voluntary
use, withdrawal, and relapse), pharmacotherapies to target those same receptors
in humans can be utilized to help treat addiction.

Genes and the Environment

While GWAS and animal models offer objective evidence for the heritability
of addiction, it is also commonly accepted that addiction sensitivity “runs in
families.” However, the extent to which these traits are expressed also
depends largely on the environment. It is very difficult to untangle the distinct
contribution of genes from the distinct contribution of the environment to behavior—
especially given that most families share a similar environment. Researchers have
tried to better pinpoint the genetic contribution to behavior through adoption
studies in order to compare “genetic” siblings with “environmental” siblings. In
addition, twin studies are used to quantify behavior in twins (identical and fra-
ternal) who are reared apart vs reared together. Findings from these methods
  The Genetics of Addiction 47

provide heritability factors for many behaviors and these numbers are often
reported (and accepted) as percentages (e.g., the heritability of religiosity is ~27%;
Button, Stallings, Rhee, Corley, & Hewitt, 2011). However, an important factor
to consider here is that within each study, there is not a large amount of envi-
ronmental variation in the test subjects; people who adopt children tend to be a
pretty homogenous group. This underscores an important point in heritability fac-
tors in general, and one that is particularly critical for addiction therapy: Greater
environmental differences lead to less genetic contributions to behavior, and, con-
versely, greater environmental similarities lead to greater genetic contributions to
behavior. We can use a thought experiment to solidify this idea. Imagine that
there were 100 genetic clones of Einstein. Now imagine 50 of the cloned baby
Einsteins were raised in families in extreme poverty with limited access to edu-
cational, social, and nutritional resources (the “impoverished” group), and 50
baby Einsteins were raised in affluent families with easy access to many intel-
lectual, social, and nutritional resources (the “enriched” group). Even though our
Einsteins are all genetic clones, there is little doubt that when these Einsteins are
grown, we will see marked differences in intelligence between the impoverished
and enriched group but only marginal differences in intelligence when we com-
pare the Einsteins within the groups. In other words, the genetic contribution to
intelligence would be overwhelmed by the vast environmental differences between
the enriched and impoverished group, while the slight differences in environment
within each group barely impacts intelligence when comparing members of each
group with each other.
With addiction counseling and research these ideas are pronounced because
the genetic contribution to addiction is quite high compared with other factors:
40–50% of a person’s susceptibility to drug addiction can be linked to genetic
factors (Uhl, 2004). The effect of home environment on addictive behaviors
shows that parents have much less of an influence on substance use and abuse
than do peers and same-sex siblings (Grant et  al., 2007). During adolescence
the heritability of substance abuse is thought to be 40%; however, this likeli-
hood of addiction increases when there is an association with delinquent peers or
same-sex siblings who use addictive substances (Button, Stallings, Rhee, Corley,
Boardman, & Hewitt, 2009). Thus, someone whose genes may predispose a pre-
dilection for substance abuse may not become addicted if they are around people
who do not use (or only use occasionally), while another person whose genes do
not predispose a predilection for substance abuse may become addicted if they
spend a lot of time with their friends who are using.
However, as with all behaviors, genes and environment combine to influence
substance use and the likelihood of addiction. In particular, several environmen-
tal factors have been identified which appear to decrease heritability estimates of
substance use and addiction. These include factors that indicate a less “permissive”
environment such as: late-age of first substance use (Agrawal et al., 2009), being
married (Heath, Jardine, & Martin, 1989), being raised in a religious household
(Koopmans et al., 1999), being raised in a family that is strict or cohesive (Miles,
Silberg, Pickens, & Eaves, 2005), and having non-deviant peer-groups (Kendler,
Gardner, & Dick, 2011). Combined, these findings underscore the idea that the
heritability of substance use and abuse is not static, but, rather, is moved by
the environment. An individual with the strongest genetic risk imaginable for
48 Assessment 

alcohol addiction will not become an addict if they never drink. In this extreme
case the environmental contribution to alcoholism has become 100%! That same
individual, though, who is raised in an environment that is very permissive with
alcoholic family members and peers, will be at extreme risk for alcoholism.
What we are talking about here is the move away from the nature-or-nurture
debate. We have reviewed how the GxE model can show gene–environment
probabilities; however, perhaps this is not the most productive way of viewing
this problem. Perhaps, instead, we can explore it as nature-via-nurture. We have
already made note of the fact that life events and environmental factors work in
concert with genetic predispositions to shape the likelihood of substance abuse
and addiction. However, not all environmental effects have the same impact on
addiction. One way to overcome this is to calculate how environmental “weights”
combine with genetic predisposition to explain the percentage of the variance
each factor holds and the overall likelihood of addiction in any one individual.
This idea—that gene polymorphisms and environmental factors each have small
individual effects, but can combine to have profound effects on the likelihood of
addiction, is the next stage of addiction research. One way that researchers are
beginning to look at this is through Genetic Risk Scores (GRS). Unlike GWAS,
where you look gene by gene for polymorphic effects, with GRS you can compare
one total score against a factor of interest (genetic or biological). Strategies for
mathematically incorporating environmental or biological factors into genetic
polymorphism studies provide a valuable tool for therapists. For example, these
findings can shed light on when therapists should focus on stress reduction
intervention vs impulse control training. Before genetically-tailored addiction
counseling can be fully realized, however, several hurdles in testing efficiency,
understanding, and interpretation need to be overcome. The mutagenic nature
of addiction (involving the expression of several hundred genes) will also require
more basic research in order to develop a genetic profile for patients in therapy.

Epigenetics: How the Environment Changes

the Genome
There are some heritable genetic factors that are strongly influenced by the envi-
ronment, but do not cause modification to the DNA sequence. These changes, and
the study of them, are known as epigenetics. Unlike polymorphisms in the nucle-
otide sequence, these changes involve DNA methylation and the modification of
histones; changing either of these will alter how genes are expressed. Heritable
epigenetic changes are probably more related to methylation, since histone modi-
fication is not thought to be heritable. DNA methylation is a tool that cells use
to prevent genes from being expressed; it essentially locks genes in the “off”
position. Unlike methylation changes, histone modification doesn’t directly “turn
off” genes. Since the DNA is wrapped around histone cores, their modification
can indirectly influence which genes are expressed. In general, epigenetic changes
or the “epigenetic landscape” explains the effect of the environment on gene
expression—it explains how identical genotypes (i.e., identical twins) can show
variation based on individual environmental experiences. Perhaps unsurprisingly,
epigenetic modifications have been shown to play a crucial role in substance
abuse and addiction behaviors. Since epigenetic changes can affect long-term and
  The Genetics of Addiction 49

heritable changes in gene expression, it serves as an attractive mechanism for

the heritable and persistent factors that characterize drug addiction. Research
into the epigenetics of addiction shows that stress during childhood and ado-
lescence increases the risk of addiction, independent of one’s genotype (Zhang
et al., 2013). These changes in drug sensitivity and addiction probability are now
thought to come about through epigenetic changes in gene transcription that can
make the brain more sensitive or vulnerable to addictive substances (Robison &
Nestler, 2011). In addition, the behavioral changes seen with substance abuse are
also thought to be a product of epigenetic changes. For example, the “hyperactiv-
ity” changes that are commonly seen with cocaine use are associated with histone
modification in the NAc (Kennedy et al., 2013).
In addition to the canonical epigenetic pathways of methylation and his-
tone modification, MicroRNAs (miRNAs) are also shown to play an important
role in addiction susceptibility. These miRNAs are small RNA molecules (~22
nucleotides long) that are non-protein coding RNAs whose main function is to
downregulate or “turn-off” gene expression. There is an emerging role for the
miRNAs in addiction. In particular, there is strong evidence to support a criti-
cal role of miRNAs in alcohol (Pietrzykowski, 2010), cocaine (Eipper-Mains,
Kiraly, Palakodeti, Mains, Eipper, & Graveley, 2011), and nicotine (Lippi et al.,
2011) addiction. In general, miRNAs are emerging as crucial regulators in addic-
tion behavior, and, as such, hold the promise of serving as potential targets for
adjuvant medical treatment during addiction therapy (Dreyer, 2010; Jonkman &
Kenny, 2013).

“Risky” Genes
In this section we review some of the prominent polymorphisms that have been
linked to drug addiction; this list is not meant to be exhaustive, but rather, to
provide a general idea of how genetic differences can increase addiction suscep-
tibility. Most of the polymorphisms are not drug-specific—meaning that they
are associated with addiction to more than one substance. For that reason, we
will talk about the genes themselves and how addiction works through different
pathways to influence drug sensitivity. As shown in Figure 3.2, we will see that
one common final pathway in addiction appears to be a left-shift in the dose-
effect curve.

Polymorphisms in the Alcohol Metabolic Pathway

The heritability for alcoholism is shown to be strongly associated with genes that
affect the enzyme family of alcohol dehydrogenases (ADHs). ADHs are enzymes
that convert ethanol to acetate and the genes that produce these enzymes are
clustered together on the short arm of chromosome 4 (Foroud et al., 2000). In
particular, ADH converts alcohol to acetaldehyde, which is then converted to
acetate by aldehyde dehydrogenase. A genetic change that slows the rate at which
acetaldehyde is converted to acetate causes unpleasant effects of alcohol such as
facial and neck flushing, increased heart rate, headache, and nausea. Perhaps
unsurprisingly, individuals who experience these effects with alcohol tend not to
50 Assessment 

100

80

60
Effect

Left-shifted
dose-effect
40 curve

20

0
0 20 40 60 80 100
Drug Dose

Figure 3.2  The left shift in drug effects means that for those individuals who have a
genetic predisposition for drug abuse, feelings of reward from a drug occur at
lower doses. For substitution therapy (e.g., methadone) this also implies that
the dose should match those that are most sensitive in the primary substance
of abuse (see Li et al., 2008)

consume alcohol often. The genetic basis for this change in alcohol metabolism
has been found in the ADH gene. This gene is located in a cluster in a linkage
region, meaning that these genes are inherited together. Polymorphisms in the
ADH gene and the aldehyde dehydrogenase (ALDH2) gene are associated with
alcohol abuse. In particular, a SNP in the ALDH2 allele renders one copy of the
ALDH2 gene useless (thus leaving only one functional copy). This SNP is referred
to as rs671 and ALDH∗2. This results in a smaller production of a key enzyme
needed for alcohol metabolism. Individuals with this polymorphism are much
more sensitive to the above-mentioned unpleasant effects of alcohol, and, as a
consequence, have extremely low risk for alcohol abuse (Higuchi et al., 2004).
Approximately 18% of individuals are heterozygous for this SNP and approxi-
mately another 2% are homozygotes (HapMap data release #28). These are the
biological principles on which the drug disulfiram (Antabuse) are based to assist
with alcohol therapy.

Polymorphisms in the Opioid Pathway

The endogenous opioids are important for reward perceptions and pain reduction
(Vaccarino & Kastin, 2000). Endogenous chemicals are those that are naturally
produced by the body. The endogenous opioids such as endorphin, enkephalin,
and dynorphin are produced and released to aid in decreased pain and/or increased
pleasure. A polymorphism in one of the receptors for the opioid system, the
μ-opioid receptor (MOPR), is associated with increased addiction susceptibility.
  The Genetics of Addiction 51

This polymorphism is a SNP where one nucleotide change causes the amino
acid adenine to be substituted for guanine (the SNP is referred to as rs1799971
or A118G). When the endogenous opioid, β-endorphin, or an exogenous drug
(e.g., morphine) binds to the MOPR on interneurons in the mesocorticolimbic
dopaminergic pathway, there will be an increase in dopamine in the nucleus
accumbens (NAc). The MOPR adenine to guanine (A118G) SNP results in an
increase in MOPR binding and activity which is thought to make individuals
have stronger cravings for alcohol and become more physically dependent on the
exogenous drugs (Bond et al., 1998).
Exogenous chemicals are those that are produced outside of the body, but
have physiological effects on the system. As reviewed in the last chapter, drugs
of addiction trigger an increase in dopamine activity in the mesocorticolimbic
dopaminergic pathway. Activation of this pathway appears to be the mecha-
nism through which stimulants and other psychoactive drugs result in addiction.
Increased risk for addiction (especially alcohol addiction) occurs if an individual
carries at least one copy of the MOPR A118G SNP (van den Wildenburg et al.,
2007). Approximately 25% of individuals are heterozygous for this SNP and
approximately another 5% are homozygous (HapMap data release #28).

Polymorphisms in the Dopamine System

Whereas a SNP polymorphism in the MOPR indirectly affects dopamine activity,
another polymorphism in a dopamine receptor is also associated with increased
risk for addiction. Specifically, one allele type (the TaqI A minor, A1 allele,
rs2283265) of the dopamine 2 receptor gene (DRD2) is associated with alcohol-
ism and addiction to cocaine, opioids, and nicotine (Le Foll et al., 2009). There is
also a smaller, but still significant, role for this polymorphism in alcoholism risk
(Munafò, Matheson, and Flint, 2007). The dopamine receptor D2 (DRD2) TaqI
A polymorphism is associated with a decreased amount of available receptors,
which decreases the receptor density in the synapse (Noble et al., 1991). In the
NAc, the DRD2 A1 polymorphism can lead to 40% fewer dopamine receptors
(Ritchie & Noble, 2003). Approximately 40% of individuals are heterozygous
for this SNP and another 10% are homozygous (HapMap data release #27).
Functionally, this change is thought to lead to a “reward deficiency syndrome,”
which is thought to increase thrill-seeking behavior and drug use in order to
increase feelings of pleasure (Blum et al., 2010).

Racial Frequencies in Addiction Sensitivity

There are well-documented genetic differences in race for substance abuse risk.
Overall, people of European descent (i.e., “Whites”) have higher rates of sub-
stance use and abuse compared with other racial groups (McCabe et al., 2007).
In young adults, 38.2% of illicit substance users self-report as White, with
self-reported Blacks and Hispanics following, at 30.6% and 27.5%, respec-
tively (Substance Abuse and Mental Health Services Administration, 2005).
Differences in racial frequencies, beyond cultural mores, are likely related to the
racial frequency differences found among specific polymorphisms’ associations
52 Assessment 

with substance use and addiction. For example, there is a racial difference in
the ALDH2 polymorphism frequencies with approximately 50% of Northeast
Asians carrying the mutant ALDH2 SNP. In addition, the MOPR A118G SNP is
most common in people with European (15–30%) or Asian (40–50%) ancestry
and less common in people of African American and Hispanic ancestry (1–3%)
(Tan, Tan, Karupathivan & Yap, 2003). The Dopamine D2 A1 allele polymor-
phism is associated with severe substance dependence in Whites and non-White
groups, but the A1 allele polymorphism is far more frequent in Whites (18%)
compared with Blacks (7%) (Moyer et al., 2011).
Specific polymorphisms tend to be carried within races only because, his-
torically, people of certain geographic regions in the world would mate with
each other and, accordingly, share common polymorphism or mutations.
Polymorphism frequency differences among races, however, do not imply a
genetic basis for race. In fact at a genetic level race does not exist—it is a sociocul-
tural construct. In human DNA 85% of the genetic variation is due to individual
variation, while only 15% can be identified as racial variation. In other words,
the overwhelming majority of genetic variation among humans is individual, not
racial, variation. Underscoring this point is the finding that Europeans and sub-
Saharan Africans are more genetically similar than sub-Saharan Africans are to
Melanesians (Pacific Islanders). This is in spite of the fact that both sub-Saharan
Africans and Melanesians share “African” features such as dark skin, curly
hair texture, and similar cranial-facial features. Racial traits that are readily
observable and easily classify people into groups only account for the minority
of genetic variation (Templeton, 1998). Accordingly, racial frequency differ-
ences in addiction biology exist primarily due to “in-group” mating. These
differences can be useful in understanding and treating addicted populations.
For example, the strong genetic link to problems with alcohol metabolism can
explain why this group is much less likely to show alcoholism even in risky
environmental circumstances.

Case Application

In Mark’s case it can assist the family therapist to be familiar with the idea
that genetic differences between individuals can contribute to the way someone
responds to drugs and how easily that person can become addicted to drugs.
Genetic differences between people can also change how easily treatment might
be for that person. In Mark’s case, his environment contributed to his alcohol use
and we can surmise that there was a likely gene-by-environment interaction in his
pathway to addiction—nature-via-nurture.
Earlier in this chapter we introduced the concept that it might become practi-
cal to genotype addicted populations in order to develop customized therapy
and treatment strategies. While the genetic contribution to his addiction can’t be
known through interviewing Mark and his family, there has been a recent surge
in personalized treatment options in order to apply genetic information to better
treat patients. While it is helpful for the family therapist to be aware of potential
genetic contributions to addiction, it is not expected that the therapist will offer
genetic counseling or carry out complex genotyping of patients. This type of
  The Genetics of Addiction 53

personalized treatment might occur within a treatment center or hospital. For

example, if Mark entered a treatment center, it might be discovered that, based
on his genotype, naltrexone hydrochloride will not be very effective for him. In
this case, extra emphasis on behavioral strategies might be critical to his recovery.
As the field of behavioral genetics grows, continued gene mapping of “risky
genes” can also shed light on gene polymorphisms that are associated with co-
morbid disorders such as depression and addiction. These findings can help the
family therapist consider possible co-occurring disorders or risks that the client
might be experiencing.
Finally, a critical consideration for the family therapist is to consider the likeli-
hood for addiction risk in other family members. Mark’s brother Mick struggled
with alcoholism and Mark and his father do not have a healthy relationship when
alcohol is involved. As we reviewed in this chapter, there is a genetic contribution
to addiction risk and first-degree relatives of addicts are at risk for addiction with
a seven-fold increase in risk for first-degree relatives of an alcoholic.

Summary
Whether or not a person will become an addict—and how fast and
strongly—depends on many things, including his or her surroundings
and personal history, what types of drugs are involved, and the way that
person’s body and brain respond to drugs. Individuals are impacted by
their genetic makeup, having predispositions to react to certain chemicals.
However, this is not a one-to-one relationship. Rather, there is a connec-
tion between genes and environment. People behave and react based on
the interplay between predisposition and experience—which can best be
viewed through the notion of nature-via-nurture. Thus, whether someone
becomes addicted to drugs or alcohol is partially explained by their genetic
predisposition and partly by their environmental history.

Key Words
genes polymorphisms
Deoxyribonucleic Acid (DNA) Variable Number Tandem
nucleotides Repeats (VNTRs)
non-coding DNA Short Tandem Repeats (STRs)
coding DNA alleles
transcription genotyping
ribosomes gene–environment interaction
translation model
codon heritability
amino acids Genome-Wide Association
protein Studies (GWAS)

(continued)
54 Assessment 

(continued)

knockout mice Alcohol Dehydrogenases

gene targeting (ADHs)
gene trapping linkage region
Genetic Risk Scores (GRS) endogenous chemicals
epigenetics exogenous chemicals
microRNAs (miRNAs)

Discussion Questions
1. Explain why we do not refer to genes controlling behavior.
2. Describe the relationship between polymorphisms and addiction.
3. How is addiction best viewed as susceptibility rather than inevitability?
4. Describe the gene–environment interaction model.
5. Discuss the genetic implications for racial differences in addiction.
four

The Addicted Family

In this chapter we will be talking about families—and more specifically about

those that have one or more members addicted to alcohol or drugs. However,
there is debate about what constitutes a family. Some people view it as a tradi-
tional nuclear family, with a husband and wife and their children. Others view
it as either married or non-married partners. Some view it to include three gen-
erations; children, parents, and grandparents. Others may hold a wider lens to
include the extended family, which will include aunts, uncles, cousins, and great-
grandparents. Some may include close friends who are viewed by family members
as kin (i.e., a parent’s good friend is called “Aunt Debbie” or “Uncle Brian” by
the child).
In this book we will be using a wide definition of family, which includes people
who are in committed relationships, either by choice or circumstance, who come
to function as an organized unit. This may include partners who do not have
children, step-families (which also includes the non-residential parent/siblings),
same-sex couples, or a variety of other family configurations. While we discussed
in Chapter 3 the impact that genetics has on substance abuse, what we will be
talking about from this point forward in the book is how the transactional pat-
terns that develop in a family (as well as whatever genetic and biological processes
are in play) not only impact one or more member’s use of substances, but their
psychological and emotional well-being as well.
While all families are idiosyncratic, they also are universal. Universally, they
all function based on family rules and roles, with various types of boundaries,
which lead them to develop a level of homeostasis—a stable state—at which they
function (see Chapter 12 for a more in-depth explanation of these concepts). All
families experience this. These components are what make the family a system
and allow it to function (however, we would then label that unique way of being
as “functional” or “dysfunctional”). What is idiosyncratic is what the level of
homeostasis is; the specific family process.
Because people and families operate based on patterned behavior, it is these pat-
terns that lead us to understand how that specific family functions. For instance,
we would classify a family as being paternal if we see that the male is the head of
the household. This would not come from a one-time observation but from many
observations over an extended period. That the family has rules to maintain the
male as the head of the household (such as wife deferring to husband and children

55
56 Assessment 

needing to ask father rather than mother for privileges), and consequences when
this does not occur (the children getting in trouble for going to mother after father
has said “no” to a request), keeps it functioning as it is. This is what we would
call their homeostasis—a steady state.
Once established, families then engage in behaviors that maintain the homeo-
stasis. However, these rules and patterns change over time, usually at family
life cycle transitions (such as having a baby, a child becoming an adolescent, or
when a family is launching a child—see Chapter 7 for a more in-depth descrip-
tion of the family life cycle). When substance abuse is involved in a family, there
are usually disruptions to the family’s normal routines and rituals. For instance,
in families in which the father is abusing alcohol, there are daily disruptions
(such as waking, food, and bedtime rituals) but also to annual celebrations and
holidays. The father’s engagement usually becomes reduced during these events,
which forces the family system to change how it might normally function at
these times. Extended family members may not invite this nuclear family, or
perhaps just not the alcoholic, to family events, or the spouse may have to take
over most of the caretaking duties because the other person is incapable (physi-
cally or emotionally).
While the physiological impact of using substances is primarily an individual
occurrence (besides second-hand smoke of cigarettes or marijuana), the abuse of
the substance permeates the individual, family, and social system. As such we can
view addiction as a family issue—some would say a family disease. We know that
addiction runs in families (see Chapter 3). Each individual in a family is predis-
posed, to certain levels, to engage in substance use themselves. In families where
past generations had issues with substances, the next generation is more likely
to use than in those families with no overuse issues. Also, given what we know
from systems theory, all components of a whole are interconnected to develop
and maintain a symptom. In the case of the families we are talking about in this
book, this means that the symptom is addiction. This symptom demonstrates that
there is some type of dysfunction within the interactions of the family members.
Addiction can also be viewed as a family disease in that the addict’s behaviors
have deleterious consequences on the other family members. Not only does the
partner have to, at times, physically care-take for the addicted individual (i.e.,
when they are drunk, under the influence, or dealing with the consequences of
a recent use), but they have to also keep the family afloat. Grandparents may be
needed to lend a hand or children may be recruited to take on more adult roles.
These are just a few of the possible ways that family members have to change to
accommodate the addiction. We will cover more of these changes throughout the
course of this book.
For addicted families, several patterns and processes may be in place (Ruiz,
Strain & Langrod, 2007). First, if the adults in the house abuse substances, they
may inadvertently model problematic drug use. This is in contrast to socially
sanctioned use, especially with moderate levels of alcohol consumption. Given
the recent rise in legalized recreational use of marijuana, children and teens are
more likely to be exposed to its use. The question comes as to the difference
between use and abuse. Second, the family’s homeostasis may be maintained and
centered on drug use. Third, family members may have adapted to the substance
  The Addicted Family 57

use and inadvertently function in ways that enable the current level of drug use as
well as the progression of use and familial dysfunction.
Families in which drug use/addiction plays a key factor tend to have rigid
boundaries between the family system and other larger systems (Lawson &
Lawson, 1998). Rigid boundaries, as will be talked about further in Chapter 12,
do not allow much information to flow from one system or subsystem to another.
Thus, people become closed off from letting others know what is happening
within the system. These families tend to engage in keeping many secrets. As
Lawson and Lawson explained: “The rules in these families are: (1) do not talk
about the alcoholism, (2) do not confront the drinking behavior, and (3) protect
and shelter the alcoholic so that things don’t become worse” (p. 58).
For addicted families, much effort is spent in not allowing the outside world
know what is occurring within the family system. The rules to prevent talking
about the family’s situation can be overt or covert. Overt rules are those that are
easily known, where there was a direct statement that someone is to do or not
to do something. For instance, a family may develop “Mommy’s ‘Relaxation
Time’” where she cannot be disturbed, which allows her to take a bottle of wine
into the den and drink without having to engage the other members of the fam-
ily. Covert rules have to be assumed based on people’s actions surrounding that
issue. We might view covert rules in an addicted family by seeing how children
back off from engaging their father when he comes home from the bar in fear of
him having a blow-up, which has happened in the past when he has come home
drunk. No one in the family has ever said anything about this (such as, “Mom, I
am scared when Dad comes home drunk because I don’t want him to yell at me”),
but they operate in ways to keep this rule maintained.
Addicted families, particularly those operating from rigid boundaries, will usu-
ally not let the school, work, or friend systems know that there is discord in the
house; discord due to excessive drug use. This is why sometimes it is a shock
to those who know the family when the system becomes overwhelmed and the
secret can no longer be hidden. This might be when there was an explosion and
some type of domestic violence occurred or perhaps the person abusing drugs
was fired from his or her job.
Further, the consequences of substance abuse tend to be progressive, where
over time the use and the negative consequences from it get worse. McCrady,
Ladd, and Hallgren (2012) explained, “Reciprocal interactions between the
drinker [substance abuser] and his or her social environment typically tend to
worsen drinking and drinking-related consequences over time, and dysfunctional
patterns of individual and family interactions become overlearned and ‘auto-
matic’ through repetition” (p. 235). That is, the family’s homeostasis changes
over time to where dysfunction and distressing interactions become the family’s
primary way of engaging one another.
This may make it seem strange that the family can hide the chaos for as long
as they do. However, if we look below the surface we can understand better as
to why they may be able to keep the addiction—and the consequences of the
addiction—a secret. As a whole, the family tends to adopt certain beliefs that help
to maintain their problematic interactions. Wegscheider-Cruse (1989) provided
several of these alcoholic family rules, which include:
58 Assessment 

• The alcoholic/drug user’s intake of the substance becomes the central focus
of the family.
• The family’s problems are not because of the alcohol/drug use.
• The addict is not responsible for the family problems.
• Everyone must maintain stability of the family.
• Family members do not talk about the family problems with people outside
of the family.
• People are not allowed, even within the family, to talk about their feelings.
• If people stop doing what they are doing to maintain the system, things will
get worse.

As family members engage in these rules, they maintain the functioning level
of the family. Hoping that they do not rock the boat to make things worse,
family members paradoxically allow things to get incrementally worse. Because
members are not allowed to talk to each other or the outside world about the
problems happening in the family, this becomes the homeostasis, with an incre-
mental deterioration in how people engage one another. It is like the family is a
ship that has scraped an iceberg. There has been a breach in the hull that every
crewmember is ignoring. However, to keep the ship afloat, each member starts to
bail water. But by not acknowledging the breach, more water enters the ship and
requires more time to try to deal with. Eventually, everyone drowns.

Characteristics of Addicted Families

While all families are idiosyncratic, there are characteristics that tend to occur
in families that are experiencing one or more members dealing with substance
abuse. However, I want to be clear that not all families will fit into these; yet,
some semblance of them will be pertinent for most families dealing with addic-
tions. How many and to what degree these characteristics fit a particular family
is based upon a multitude of factors which include how many members are in
the family, the family’s culture, how severe the addiction is, the type of substance
that is abused, and the amount of time the family has been organized around
addiction, as well as many other factors.
Reilly (1985) provided three primary characteristics of addicted families:
negativism, parental inconsistency, and parental denial (see Figure 4.1). Addicted
families tend to experience negativism. While most families have an ideal of har-
mony and happiness, addicted families are usually not content with love and
excitement flowing throughout their days. People tend not to be supportive of
one another; usually seeing the negative in themselves and others. In many ways
the “life” of the family has been sucked out. To offset this, family members may
unconsciously help to promote various types of crises as ways to imbue some
type of excitement into the family. This is not done on a conscious level, but
has become an expected and habitual way of living. Although this life is painful,
it may be viewed as more favorable than the bland and dull life they are other-
wise experiencing.
A second major characteristic of substance-abusing families is that of parental
inconsistency (Reilly, 1985). If there are two parents in the household, they tend
  The Addicted Family 59

Negativism

Addicted
Family

Parental Parental
Denial Inconsistency

Figure 4.1  Addicted families tend to engage in negativism, parental inconsistency, and
parental denial

not to be aligned with one another. Thus, children receive mixed messages which
one parent promotes while the other negates. The rules in these families tend to
become blurry, where one day they are arbitrarily enforced while on another
day they are ignored. Children are unsure of what they are or are not allowed to
do in the family. This confusion leads children to try to seek some type of clar-
ity and consistency; even sometimes through acting out as an attempt to get the
parents to engage in a more consistent form of parenting. For instance, a child
may be allowed freedom by one parent, such as being able to have a friend over,
but not by the other parent. This can become extremely confusing to the child
when they are following the directives of one parent yet the other parent tells
them they cannot—such as mother agreeing to allow a friend come over for a
play date and then have the father, who is alcoholic, tell the daughter once the
friend comes over that the friend has to leave.
Addicted families also tend to engage in parental denial (Reilly, 1985). Usually
in these families, one or more children tend to have symptoms—these might be
emotional, such as depression or anxiety, or they might be behavioral, such as
getting into fights, not listening to directions, or even using substances them-
selves. As the child’s problematic behavior escalates, the parent attempts to deny
that there is a problem. Perhaps they try to justify the misbehaviors as “a phase”
or “a reaction to a crisis.” This denial is family-wide. The parents may use this
strategy in regards to their child’s substance use or to their partner’s. While they
look away and fail to recognize the signs of distress in the person and the family
system, the problematic behavior and interactions increase.
60 Assessment 

As we have seen, one person’s behavior not only impacts that individual but
others within their relational web (and are conversely impacted by others’ behav-
iors). In an alcoholic family, there are problems that impact the individual (i.e.,
the physical consequence of drug use) but more importantly impact multiple
people. These can be seen in the marital, parental, and parent–child subsystems
(Lawson, 2011). In the marital subsystem, these relational problems include
the partners having conflict, abuse, instability, and separation or divorce. The
two partners usually do not have the same view on the use of the substance.
For the parental subsystem, relational problems include difficulties parenting,
where one or both parents may not fulfill their parental duties, the parents may
not agree on what or how to care-take, leading to a potential chaos in terms of
the structure of the family. In the parent–child relationship, problems may come
in the form of physical or sexual abuse, an influx of secrets, communicational
problems, role reversal—including parentification—and issues of trust and con-
flict in the family.
In addicted families, it may be one or more adults or one or more children—
or both an adult and a minor—who is addicted. For substance-abusing families
where the adolescent or adult child is addicted, they typically have one parent
who becomes overinvolved while the other is more punitive toward the abuser
(Stanton, 1985). The one who is more punitive tends to be the parent of the
opposite sex.
So far we have been talking about how addicted families tend to organize and
some of the rules that develop that maintain the dysfunctional family system.
If we look specifically at the use of alcohol, we can see some repetitive ways of
being for these families. Middleton-Moz and Dwinell (2010) provided the com-
mon characteristics of alcoholic families (p. 3). These include:

• Focus on alcohol by all family members.

• All family members operate based on shame.
• Inconsistency and insecurity: Parental responses, discipline, and rules change
depending on the stage of alcohol intoxication and/or the codependent’s
response.
• Denial of feelings and/or addictions.
• Looped, indirect communication and double messages.
• Repetitive emotional cycles of family members.
• Chaotic interaction or no interaction.
• Hypervigilance and hypersensitivity.
• Unspoken rules.
• Doubting own perceptions.
• Fear of normal conflict.
• Broken promises.
• Family members develop survival roles and coping mechanisms.

Not all families will engage in these characteristics; however, many families
will have many of these traits. The more of these characteristics that are present,
the more the family will likely spiral out of control and lead to multiple members
displaying symptoms.
  The Addicted Family 61

Alcoholic Family Types

As presented in Chapter 1, there are varying categories of alcoholism (e.g., alpha,

beta, gamma, and delta alcoholism). Conversely, there are also varying categories
of families in which alcohol plays an organizational function. This is because
there is an interaction between family dynamics and the dynamics of alcoholism
(Kaufman, 1984, 1985). These categories are played out through the patterns of
relating that family members engage in over time.
Edward Kaufman (1984, 1985) is one of the primary theorists of how families
develop various constellations around abuse. He illuminated four different types
of families that are dealing with addiction (he was specifically talking about alco-
hol, but these conceptualizations may be appropriate for families where one or
more members are having serious issues with other drugs). These are the func-
tional, neurotic enmeshed, disintegrated, and absent family systems.
The functional family system is one in which all of the various family members,
for the most part, are able to successfully navigate the challenges of intrafamilial
and external relationships. Families will usually be in this stage during the very
early part of the addictions process. In these families, one member may drink,
but it is usually controlled and in specific contexts (such as just on a “boy’s night
out” or at dinner). Members tend to be able to get along well with one another
and can function at school, work, and other social systems.
Over time, stressors may increase and biological functions may kick in, such as
tolerance for the drug, so that the individual who is using develops a psychologi-
cal and physiological dependence on the substance. As the person’s need for the
drug changes over time, so do the rules of the family system. When this happens,
the functional family system may eventually shift into the neurotic enmeshed
family system. This is when the system can be considered an alcoholic family.
In the neurotic enmeshed family system the behavior of the person who is
using will interrupt normal family processes. Based on this, conflict tends to arise
and family members have to shift previous functional roles to help to maintain
homeostasis in the family. For the person dependent on the substance, their
physiological, psychological, behavioral, and emotional functioning is usually
hampered (for instance, they develop physical illness or sexual dysfunction).
Because of this underfunctioning in various areas of personal and family life,
other members must take up the cause and overfunction.
The ambiguity and confusion surrounding the loss of stability leads the various
members to attempt to gain some type of control. This may come in the non-
dependent spouse trying to control the alcoholic’s drinking (i.e., “Honey, don’t
you think you’ve had enough drinks tonight”) or children may attempt to hide
the liquor so their parent does not drink. The alcoholic’s behavior may start to
become disorganized, where they may engage in yelling and screaming or even
physical abuse toward their spouse or children. Within the family, shifts start to
happen within the subsystems and between individuals. The adults may close off
their ranks and become more rigid in how they handle the children. Most likely,
the alcoholic is beginning to feel isolated from other members—perhaps experi-
encing the family members ganging up on them (usually in an attempt to get them
to stop drinking, which they take as a personal assault).
62 Assessment 

Toward the end of this phase of the alcoholic family’s development, the system
will change into the disintegrated family system. At this point, the actions of the
addicted individual have gotten so severe and negatively impacted the family to
such a degree that the family has separated. Some of the possible problems that
might have arisen in the family include physical or sexual abuse, economic loss,
or the loss of close connections with larger systems such as religious organiza-
tions, work, or extended family members. In the disintegrated family system, the
situation has spiraled out of control and led to such chaos that the addicted indi-
vidual has usually been made to leave the house, but still probably has contact
with family members. Perhaps they have supervised visits with children or may be
invited for a family event, such as a graduation or Thanksgiving dinner.
The final type of family is the absent family system. If the addiction has become
so severe and endemic that others have lost hope of change, after time they will
give up on the individual. Family members most likely have tried for years to help
the addicted individual only to be let down over and over with the person perhaps
saying they would get treatment and not following through, hurting members
in the family (physically or emotionally), and overall being a major burden on
the family. The addiction, whether to alcohol or other substances, may have led
to the addicted individual making many poor economic choices (i.e., gambling,
poor business decisions, or not using money to pay for needs such as mortgages).
Family members have probably given second, third, and fourth chances—more
realistically countless chances—and have been continuously let down. They have
been told that the person was going to change, and perhaps they did for a very
short time, only to quickly enter back into drug use and chaotic behavior. In the
absent family system, members have come to disown the addicted individual.
Kaufman (1985) states that for many in this type of family stage, even after
sobriety is gained, a reconnection to their family of origin is unlikely, and they
may need to develop a new nuclear family. Figure 4.2 presents Kaufman’s four
categories of addicted families.
Kaufman (1984, 1985) provided suggestions for working therapeutically with
each family system, as families in each structure are in a different functional state
and thus will need different approaches to work with them effectively. When
working with the functional family system, which is doing fairly well, they may
be able to better utilize family educative approaches. This may cover concepts
such as drug interactions and recovery processes, which may help them to be able
to make changes. Therapists might also explore family rules and roles in order
to determine dysfunctional role behavior and develop new, more effective, rules
and roles.

Functional Neurotic Enmeshed Disintegrated Absent

Members can manage User underfunctions Family separation Loss of hope

Use is controlled and Interruption of normal

Loss of control No contact with abuser
speciic family process

Figure 4.2  Kaufman’s four categories of addicted families

  The Addicted Family 63

For the neurotic enmeshed family system, the psychoeducational techniques

will probably be useful but not sufficiently effective. They will most likely need
more formal psychotherapy. Therapy for families in this category is difficult as
members will likely try to stay in the past rather than focus on and deal with the
present (Kaufman, 1984). Since these families usually have significant levels of
enmeshment, therapists might focus on engaging in boundary-making to help
people and subsystems to define their roles. Helping the alcoholic to engage a
support group is useful as well as helping family members to connect with their
own support groups, such as Al-Anon or Alateen.
In the disintegrated family system, trying to engage in family therapy from
the get-go may be difficult as members are very hesitant to engage the alcoholic.
Thus, Kaufman suggests that in these cases, individual work with the alcoholic to
help them to stabilize and become sober will most likely need to happen before a
reconnection to the larger family system occurs. However, therapists may explore
what role family members might play in treatment for the possibility that a new
foundation for familial relationships can take shape. Kaufman (1984) suggests
that after prolonged abstinence of several months, if family members are willing
to support themselves and the alcoholic, family definitional sessions might be
used to help people develop new roles and identities in relation to one another.
Therapy with the absent family system tends to be quite different than with
the other three types of family systems. With each of the previous three family
systems, the goal is a reconstitution of the family system. With the absent fam-
ily member those connections have been severed. What is most likely required
here in therapy is a focus on developing a new nuclear family.

Phases of the Alcoholic Family

As we have seen in the previous section, we can classify addicted families based
on the severity of the substance abuse and the impact it has had on the family.
The movement from one type of family to another is a gradual rather than
instantaneous process. As such, we can look at how the addicted family changes
through a sequence of stages. The developmental phase of alcoholism is based
upon the user’s mode, which is either wet (in active use) or dry (in abstinence).
This is connected to the status of the phase, which can be stable or unstable.
Steinglass (1985) and Steinglass, Bennett, Wolin, and Reiss (1987) delineated
three phases in the development of the alcoholic family; the early phase, the mid-
dle phase, and the late phase (see Figure 4.3).
In the early phase of alcoholism the family begins to develop an alcoholic
identity. What this means is that when alcohol is introduced into the family it
becomes a major organizing principle, overriding the normal family develop-
ment. The focus in the family shifts from normal family processes such as values,
rules, and boundaries to a lens of values, rules, and boundaries (internal and
external of the family system) around alcohol.
One of the determining factors in how the family addresses the introduction
of alcohol as a major factor in the system is each of the adults’ families-of-origin.
For those that came from an alcoholic family, they might fall into the patterns
that they know so well. Part of what happens at this stage is the negotiation,
64 Assessment 

Early • Alcohol starting to organize the

family
Phase • Family rules begin to change

Middle • Rigidity in regulatory behaviors

• Growth becomes stiled
Phase
Late • Movement to understand options
• Shift from peace to turmoil
Phase
Figure 4.3  Three phases of development for the alcoholic family

usually unconsciously between partners, of whose family of origin will be used

as the guide for the current nuclear family.
The early phase of the alcoholic family might not have anyone using alcohol to
the degree that might be considered addicted or dependent. However, it is at this
point that the rules of the system are laid down as a foundation for how people
are going to be in various areas of their lives; one of these areas being the use of
alcohol. For those who came from alcoholic families, an acceptance of alcohol
with family rules about not talking about use or abuse could become the ground-
work for later alcoholism.
The middle-phase alcoholic family occurs when the regulatory behaviors of the
family enable whatever use of alcohol is occurring (whether it be daily, weekly, or
monthly abuses). Family members alter their behavior to try to maintain a calm
in the family. However, there is usually some type of developmental hindrance
as family members tend to become more rigid in their regulatory behaviors. For
instance, having more expectations of members not to talk about the abuser’s
behaviors; especially to anyone outside of the family system.
In this phase the focus of growth becomes stifled as members work toward just
trying to maintain the status quo. It is at this point that both individual and fam-
ily development does not move as it should. Instead of having a solid foundation
for people to grow in healthy ways, people are restricted in how they can act and
how they view themselves.
During the middle phase, family members have come to adopt certain roles that
help to maintain the family’s homeostasis around substance use (see Chapter 6
for a more in-depth explanation of family roles). The family usually goes through
the sobriety-intoxication cycle (Steinglass et al., 1987). Here, there are periods of
use and non-use; each having constraints and pressures on the family. And dur-
ing these two ends—sobriety and intoxication—the family will display different
  The Addicted Family 65

patterns of interactional behavior. This can make it difficult for the family thera-
pist to have a wide view of the family as they may only be seeing a very limited
behavioral repertoire of the family—depending on which cycle the family is cur-
rently exhibiting.
When the family is in the intoxicated interactional state, they may be able to
engage in strategies of short-term problem-solving that they weren’t able to in
the sobriety state. The family adopts a perception that they can perform some
behaviors during use and others during non-use. In each part of the cycle, there
are interactional sequences that are predictable. And although alcohol is seen as
the primary problem of the family, there are certain constructive—at least in the
immediate context—aspects of being in the intoxicated state. This may be that
the family more readily cooperates with one another during this period rather
than being more autonomous when in the sobriety state.
The middle phase of the alcoholic family is characterized by stability and reg-
ularity. This is not the case in the early or late phases, which find the family
engaging in significant systemic reorganization. In many ways, these two phases
are mirror images of one another, in which the family experiences shifts in their
functioning. Issues to be addressed include delineating family boundaries, deter-
mining who is inside and outside the family system, identifying life themes, and
protecting the family from implosion, and these tend to dominate the family’s life.
In the late phase of development of the alcoholic family, the family tries
to defend the family themes that have been developed, primarily in the pro-
ductive moments of the middle phase. While, for the most part, the alcoholic
family had difficulty in finding a purpose and identity, there is now a movement
toward understanding the options available to them. However, this can be felt
by the family as a shift from a more peaceful position to that of turmoil. This
is because in the late phase there is a shifting of the family rules—which is usu-
ally experienced as anxiety-provoking since most families attempt to maintain
stability (homeostasis).
In the early phase of the alcoholic family there was an attempt by the adult
partners to separate from their families-of-origin. The middle phase found the
family focusing within, figuring out how to stay together. Now, during the late
phase, the children in the family will begin to launch and potentially develop
families of their own. Thus, the family begins to develop a future orientation to
explore issues of family values and family heritage.
To summarize the exploration of phases of the alcoholic family, we can look at
the developmental tasks of the family at each phase of the family’s development.
While these tasks play a role during each phase, they become more prominent at
specific phases in the family’s life. In the early phase, perhaps the key task is to
determine family member configurations. This is figuring out who is in and who
is out of the family. To complete this task, the family will develop boundaries to
demarcate itself from larger systems, such as extended family. At times, the early
phase alcoholic family will procure rigid boundaries to ensure that what hap-
pens in their family stays there and other people do not get involved. During the
middle phase, the family’s developmental task is to focus on major life themes.
Here, the family is determining where to place their focus and construct a way of
organizing itself—usually around alcohol. In the late phase, the family shifts to
an exploration of family values and heritage.
66 Assessment 

Family Typology of Addiction

In this chapter we have looked at some of the general characteristics of addicted

families, alcoholic family types, as well as the developmental phases an alcoholic
family may go through. Now, we switch our focus to exploring addicted families
based on the use of a family typology.
Haugland (2005) delineated a four-tier family typology based on paternal
drinking: protective families, emotional disruptive families, exposing families,
and chaotic families. Protective families are perhaps the most functional. These
families have the lowest level of drinking by the adults, with fewer comorbid
symptoms (such as depression or anxiety). The protective aspect of the families is
that the parents are able to shield the children from the alcohol use and whatever
consequences are present. This happens by the drinking partner being able to still
engage in being a parent. As such, these families have only minor disruptions in
their rituals and routines; perhaps only happening during the drinking phase. We
might look at the substance abuser as a functional user, where they can maintain
control of their actions. The use of the substance is not widely known and people
outside of the family—and perhaps even the children—would be very surprised
to learn the extent of the use.
In the emotional disruptive family, the non-drinking partner actively main-
tains the rituals and routines of the family when the other spouse is involved in a
drinking phase. When the substance-abusing spouse does drink, the family ritu-
als and routines are fraught with conflict and negative emotions. This plays out
in the abusing spouse having less of a parenting role and the non-abusing spouse
having a more difficult time taking on the brunt of the parenting responsibili-
ties. Whereas in the protective family the children were shielded by any conflict
between the parents and the consequences of the drinking, this is no longer the
case. They may witness the alcoholic when drunk, experiencing hangovers, and
when the parents are arguing with one another. Members of the family may
experience other difficulties such as anxiety, depression, or other types of disrup-
tive behaviors.
The third typology of family is the exposing family, which finds itself having
more severe disruptions in its normal rituals and routines. When the person is
drinking the family atmosphere changes substantially, usually with a height-
ened tension and increased conflict. The children tend to be exposed to a lot
of the drinking behavior and consequences, viewing their parent underfunction
and decompensate. Arguments, heated exchanges, and perhaps even violence
occur between the adult partners. This leads to the children interfering in the
conflict between the parents or trying to get the alcoholic to stop their drinking.
At this point in the family’s life, most likely every member will be displaying
some type of emotional or psychological problem.
The last type of family is the chaotic family, which displays the most severe
type of dysfunction in family process. The normal family routines and ritu-
als have been severely disrupted. The alcoholic parent has most likely given
up parental responsibility and the non-abusing spouse is not able to compen-
sate for this abdication. There is a high level of stress and conflict between the
adults, leading to perhaps emotional and physical abuse. In these families, there
is a high likelihood that one child will become parentified; which has negative
  The Addicted Family 67

Emotional
Protective Exposing Chaotic
Disruptive
Non-using
Most
partner More severe
Most functional dysfunctional
maintains disruptions
processes
stability

Children aware Heightened Substance abuser

Lowest levels of
of the substance tension and defaults in
substance use
use conlict parenting

Members begin
Children Children attempt Children in
to experience
unaware of to mediate turmoil; usually
their own
problems conlict one parentiied
symptoms

Figure 4.4  Haugland’s (2005) four-tier family typology based upon paternal drinking

consequences on all members. The drinking of the alcoholic is at its height and
members’ emotional and psychological functioning is quite negatively impacted.

Case Application

The Rothers family is finding itself in a difficult place where alcohol is becom-
ing more of an organizing principle in family life. While Mark is the identified
patient, the ripples of discord are emanating to all reaches of the family. They
have become an addicted family. Rigid boundaries have become the primary
demarcation between subsystems. Rigid boundaries usually lead to disengage-
ment. This can be seen in the cutoff between Mark and his brother Mick as well
as between Mark and his ex-wife Angelina and daughter Nina. The rules in the
Rothers family have allowed drinking to organize family life, where Mark is
allowed to keep his “stash” in the refrigerator in the garage. Overt rules were
developed between Mark and Hannah where Mark is allowed two beers before
dinner and one after. This is why Hannah is quite upset as Mark goes over the
allotted amount of beers just about every day. Other overt rules of the family
include everyone having dinner together without being on any electronic device.
Covert rules include the children going to Hannah for all of their emotional and
psychological needs as Mark is usually in a bad mood if he is disturbed when in
his man cave, which is where he does most of his drinking.
While there has been conflict and discord within the family, the Rothers
have not fully articulated their concerns to one another. Mark and Steve have
had several verbal altercations where they have cursed at each other, especially
surrounding Mark trying to discipline Steve when the school lets them know
of Steve’s misbehaviors. Mark and Hannah rationalized that Steve was just
a teenager and was in a phase. This demonstrates one aspect of them being
an addicted family; that they are engaged in parental denial. They have not
68 Assessment 

asked Steve yet whether he has tried alcohol or marijuana, but both Mark and
Hannah are concerned that this is a possibility, especially given Mark’s family
history of substance use and abuse. The Rothers also engage in parental incon-
sistency, where rules are transitory, usually depending on Mark’s mood. He
tends to be in a better mood early on the weekends but can be quite angry later
in the afternoon, after who knows how many beers and if his favorite sports
teams have lost. There is also rampant negativism in the family, with mem-
bers not fully trusting other members. Mark, Hannah, and Steve are currently
displaying the most overt negativism, mainly toward each other, but Steve is
also negatively viewing his sister (as a goody-two-shoes) and his brother (as a
momma’s boy).
The Rothers family has most likely moved into the category of the neurotic
enmeshed family system. Mark’s need for alcohol has increased over the last sev-
eral months and the rules of the family have shifted to allow this continued use.
Mark is beginning to underfunction, having called in to work several times when
he was not feeling well, and Hannah has had to do even more around the house
and with the children, although she was already the primary care taker for the
children. The animosity between husband and wife has increased and is begin-
ning to shroud many of the interactions occurring in the home. At this point,
Mark feels an outsider, both within his nuclear family as well as in his family-of-
origin. While they are still a ways away from moving into the disintegrated family
system, the seeds have been sown. We can look at Mark’s first marriage and
family as having moved into that category, where there was physical, emotional,
and psychological separation. While that family never became an absent fam-
ily system, there is a lack of trust and respect between Mark and Angelina and
Nina, who are very close. For the therapist working with the current iteration
of the Rothers family, it will be important to talk about the intra-familial pat-
terns where Mark is feeling ever-increasingly the outsider. Ways to incorporate
him back into the family may help to increase his sense of desire for change. The
therapist will likely suggest a self-help group, such as Alcoholics Anonymous, for
Mark. Groups such as Al-Anon and Alateen might be useful for Hannah as well
as the children.
The Rothers are also most likely in the middle phase of development for an
alcoholic family. Mark has likely fallen into the patterns that he experienced
growing up in his own family, where addiction was a common presence, espe-
cially with his father Ian as well as his brother Mick and sister Chelsea. It used to
be a bit charming when Mark would go into his den and have a drink after work
and watch television or play video games. However, the family discovered that
these times became more frequent and longer in duration, to the point where they
are currently spending very little time with him. No one yet has really confronted
him as to his drinking behaviors as well as his disengagement from the family.
The Rothers family does not seem to be currently growing. Rather, they are in a
survival mode, trying not to let the undercurrents of hostility and resentment seep
to the surface. However, this is not always the case as Steve seems to be expe-
riencing his pain in negative ways both at home and at school. The family does
engage in the sobriety-intoxication cycle, but the sobriety periods are become
more infrequent and of lesser duration. These usually happen when there is a
family event that everyone must attend.
  The Addicted Family 69

The Rothers may be classified as an emotional disruptive family. Hannah is

actively engaged in keeping the family on its normal routines, such as eating din-
ner together every night as well as Sunday Fun Day. Previously, the children just
thought their father enjoyed a beer or two while watching sports. However, they
pretty much now consistently see him with a beer in his hand. This is when he
is watching television, playing video games, and at the dinner table. They have
also seen more tension and disagreement between their parents. Family members
are finding that they are experiencing their own symptoms, with Mark thinking
that life would be better for all if he wasn’t on this Earth, Hannah angry and
confused, Steve acting out at home and school, and Pete becoming more clinging
to Hannah. On the surface it seems as if Kayleigh is doing quite well. However,
she is feeling a lot of pain without showing it.

Summary
Families function as a unit, developing patterns of interaction that deter-
mine how people are supposed to be with one another. In families dealing
with substance abuse, these interactions tend to become restricted as the
family organizes around the use of the substance. This usually comes in
the form of protecting the family from outside systems—by having rules
about not talking to others, or even themselves, about the drug use. Over
time, the family adapts and changes by the severity of the drug use and its
impact on various family members. As this is happening, the family recon-
figures the rules of the system to develop a new homeostasis so that it can
function—however well or poorly that might be.

Key Terms
homeostasis absent family system
covert rules early phase of alcoholism
overt rules middle phase of alcoholism
negativism the sobriety-intoxication cycle
parental inconsistency late phase of alcoholism
parental denial protective families
functional family system emotional disruptive families
neurotic enmeshed family exposing family
system chaotic family
disintegrated family system

Discussion Questions
1. Describe some of the overt and covert rules of addicted families.
2. What are some of the common characteristics of addicted families?

(continued)
70 Assessment 

(continued)

3. What are the differences between the functional, neurotic-enmeshed,

disintegrated, and absent family systems?
4. How does a family move through the early, middle, and late phases of
alcoholism?
5. What are the developmental tasks at each phase of the alcoholic family’s
development?
6. Describe the distinctions between protective, emotional disruptive,
exposing, and chaotic families.
five

Family Diversity and

Substance Abuse

For the last quarter century, the notion of diversity has been an ever-increasing
topic in the field of counseling and therapy. There is not enough space in this
book to do a thorough review of the importance of understanding diversity when
working with clients. However, this chapter provides an overview of some of the
main topics specifically exploring the intersection of ethnicity and substance use.
Diversity is a very wide term referring to difference. People are diverse enti-
ties; we are not all the same. However, based on various factors such as age,
gender, sexual orientation, race, and culture we learn how to be who we are (how
to think, feel, and behave). These classifications of people can in some ways be
arbitrary, but they help inform the therapist about possible factors impacting
the client. Yet even within a cultural group there can be significant variations
based on age, gender, economics, sexual orientation, etc. As it relates to substance
abuse, one’s country of origin, culture, and religion play a significant role in the
individual’s beliefs and values as well as their views on the use of substances.
When exploring diversity and substance abuse, we need to explore what has
been the “normal” way of viewing addiction and recovery. This has been from
a White European-American culture (Cable, 2000). For instance, the founders
of Alcoholics Anonymous (Bill W. and Dr. Bob) were both White heterosexual
males, one of which worked on Wall Street while the other was a physician, who
developed a view of power in addiction based on a Western view (Krestan, 2000).
This view is a “power over” rather than a “power to.” Based on this Western
view, the first principle of AA was developed—we admitted we were powerless
over alcohol—that our lives had become unmanageable. However, people from
non-Western societies may not adhere to this basic premise of AA.
This chapter explores the intersection of diversity issues, most notably ethnic-
ity, culture, and addiction. It is important for the therapist to understand the role
that substance use and abuse has in various cultural groups and its impact on
therapy. This is especially so since the United States is projected to soon become
a “minority White” country in that Whites are projected to comprise only 49.9%
of the population in 2045, whereas Hispanics are projected to comprise 24.6%,
African Americans 13.1%, Asians 7.8%, and multiracial groups 3.8% (Frey,
2018). The K–12 enrollment is also changing where, by 2025, it is predicted that
Whites will comprise 46%, Hispanics 29%, Blacks 15%, Asian/Pacific Islanders
6%, American Indian/Alaska Natives 1%, and those of two or more races 4%.

71
72 Assessment 

According to the U.S. Census Bureau, the percentage of foreign-born individuals

in the U.S. is projected to rise from 13.3% in 2014 to 14.3% in 2020, 15.8% in
2030, 17.1% in 2040, 18.2% in 2050, and 18.8% in 2060.

Culture and Ethnic Diversity

Elements of culture primarily involve beliefs and traditions that families teach
over generations in explicit and implicit ways. Some traditions, such as the way
women should dress and holiday celebrations, are taught directly by family or
community members to their children. However, elements of culture are also
expressed through family roles, family dynamics, communication patterns, affec-
tive behaviors, and levels of support, attachment, and connectedness (Szapocznik
et  al., 2007). Cultural transmission occurs through enculturation, a process of
social learning by which there is exposure of new generations to particular and
different social contexts depending on their place of origin.
While individual and familial factors are important, many patterns of behavior
within a given culture are collective in nature. The group establishes norms of
acceptable behavior and most of the individuals tend to follow them; sometimes
even without noticing. Cultural patterns work in the same way. While individuals
and families live in a specific location, they follow behaviors, thoughts, attitudes,
and trends that come from those geographical and cultural locations. In that way,
conflicts may emerge when individuals and families from other countries migrate
to the U.S. and adapt to new cultural patterns while trying to maintain elements
from their original culture.
This is the battle between ethnic identity and acculturation issues. Ethnic iden-
tity refers to the identification of the individual with his or her ethnic group
based on shared social experience or ancestry. It is a sense of collective identity
based on the perception that the individual shares a common heritage with his or
her ethnic group. This can be observed in the way people dress, eat, and behave
according to their culture of origin. Acculturation refers to the process of psycho-
logical, interpersonal, and behavioral changes that result following interaction
between different cultures. Acculturation includes changes in food, clothing, lan-
guage, and the rules of interaction. However, changes in psychosocial patterns
occur as well. For instance, a parent moving from a Caribbean country to the
U.S. may change the way she disciplines her children as a natural process in the
way to adapt to the new culture.
The ethnic groups presented in this chapter are Hispanic Americans, African
Americans, American Indians, Asian Americans, and Caucasians. This is not
exhaustive of the variety of ethnic groups that can be explored, but they are the
most prominent in the United States. Sexual and gender minority individuals
and families will also be presented. This chapter presents generalities and not
all families that come from these ethnic groups will be reflected in the expla-
nations. Further, what is presented is about homogamous ethnic families. This
does not take into consideration the increase in the United States of interethnic
couples and families. According to the Pew Research Center, in 2015, 29% of
Asian, 27% of Hispanic, 18% of Black, and 11% of White newlyweds were
intermarried. These numbers are higher for U.S.-born individuals (i.e., 46% of
  Family Diversity and Substance Abuse 73

U.S.-born Asians and 39% of U.S.-born Hispanics). This is leading to a change

in the demographic of the youth of the United States, where 14% of U.S. infants
are multiracial or multiethnic.
We will explore some of the risk and protective factors for each cultural group.
These include risk and protective factors in the individual, peer, school, commu-
nity, and family domains. However, while these are general patterns for people
from certain cultural groups, an individual assessment for that person/family is
needed to ensure you understand the uniqueness of each client. Risk relates to
the factors that may lead people to engage in problematic substance use and/
or drinking. Regardless of culture, family risk factors for substance use include
family conflict, parental attitudes that allow substance use and antisocial behav-
ior, family history of substance abuse, lack of parental supervision, and poor
family management and supervision (Montgomery & Springer, 2012). Protective
factors lead the person or family to either not use or be able to recover from prob-
lematic use. In many ways, protective factors are related to the resiliencies that
people and families utilize to make it through difficult times. Family protective
factors against substance use include close family attachment and family engage-
ment in pro-social activities (Montgomery & Springer, 2012). Each section ends
with ideas about treatment for that specific group, since there are treatment
implications for each group. As Fisher and Harrison (2018) explained, “Without
sensitivity to cultural differences and cultural competency, providers will likely
be ineffective from the outset because attempts to assess alcohol and other drug
involvement will be met with both cultural and therapeutic resistance” (p. 48).
Treatment considerations when working with clients dealing with substance
abuse have traditionally focused on majority populations. However, there have
been many recent advances when working with underserved populations in the
area of substance abuse therapy (Blume, 2016). Also, therapists should adapt
their engagement and strategies for clients depending on the setting, presenting
problem, and intersectionality of the client. Figure 5.1 presents some of the pri-
mary factors that impact intersectionality. Keep in mind that this is quite limited
and there are many other factors of intersectionality including weight, ability,
intelligence, etc.

Hispanics/Latin American Families

Hispanics and/or Latinos, which include Mexican American, Central and South
American, Puerto Rican, Cuban, Dominican, and “other Hispanics,” represent
the largest and fastest growing minority group in the U.S. Census, comprising
just over 18% of the population in the United States (56.7 million people). This
accounts for the second largest group behind Whites (non-Hispanic). According
to Frey (2018), it is estimated that by 2045 Hispanics will comprise 24.6% of the
U.S. population.
According to data from the 2016 U.S. Census, Hispanic families have a house-
hold median income on the lower end of the continuum, earning $47,675 in 2016.
As a comparison, White non-Hispanics had a median income of $65,041. About
19.4% of Hispanic families lived below the poverty line. Although Hispanics
have the highest dropout rate of high schoolers of any race, they have also had
74 Assessment 

Class Gender

Ethnicity Race

Sexuality
Personal Age
Identity

Figure 5.1  Personal identity is based upon an intersectional perspective where people
form a sense of self due to the variety of domains of their lives

the highest reduction in dropouts. In 1996, 34% of Hispanic high schoolers

dropped out, while, just 20 years later in 2016, 10% did so. Hispanic Americans
had the highest percentage increase of any ethnic group of enrollment in K–12
schools and colleges. This was an 80% increase from 9.9 million to 17.9 million.
Approximately 47% of Hispanic high school graduates were enrolled in college,
which was tied with White Americans, just above Black, and significantly under
Asian enrollments. Around 67.8% of Hispanic households contain a married
couple while 22.6% are female households with no husband present.
Issues of migration play a significant role for many Hispanic families. Some
individuals and families migrate willingly while others do so involuntarily, per-
haps to escape serious economic and dangerous unrest in their home country.
For those forced to leave their country because of these reasons, they may expe-
rience various levels of trauma (Falicov, 2014). Latino immigrants may differ
based on the circumstances of immigration, reasons for coming to the U.S., the
relationship between the U.S. and their home country when they immigrated,
and cultural aspects of where they settled in the U.S. (Marano & Roman, 2017).
Hispanic families tend to operate based on familismo, an attitudinal and
behavioral set of values and expectations that underpin a strong family network
of support, connection between nuclear and extended family, and living in close
proximity, where loyalty across the lifespan is valued (Hernandez & Moreno,
2018). Familismo reflects cultural values of collectivism and interdependence
(Falicov, 2014). Hispanic families have strong nuclear family units. Children play
a central role as they tend to connect husband and wife in marriage (Fisher &
Harrison, 2018). Filial love, that is, the love of a parent for a child, tends to be
viewed as more important than romantic love. Children, especially females, tend
to live at home until they get married.
  Family Diversity and Substance Abuse 75

Hispanic families also tend to engage in patriarchy and marianism (Eshleman

& Bulcroft, 2010). Patriarchy is when the authority members in the family are
men, who tend to have dominance over the women and children. This is seen
in many Hispanic families through males operating from a place of machismo;
where the male tries to be strong, aggressive, and authoritarian. Marianism is a
focus on the mother as being cherished and the focal point of the family. This
leads to an interesting dynamic in Hispanic families where the mother tends to
keep everything in order yet the father has ultimate say-so.

Hispanic American Families and Substance Abuse

Hispanics have reported the highest lifetime prevalence rates of alcohol, cigarette,
licit, and illicit drug use (except for amphetamines) of any racial group (Delva
et al., 2005; Johnston et al., 2018). Hispanics initiate their drug use earlier than
other racial groups. The annual prevalence rate of any illicit drug use is 14.6
for African Americans, 14.9 for Caucasian, and 20.9 for Hispanics (Szapocznik
et al., 2007). The National Household Surveys on Substance Abuse revealed that
Latino drug use has increased progressively since 2002 (SAMHSA, 2009).
Cuban Americans had the highest rates of marijuana, cocaine, and alcohol use
compared with Mexican American, Puerto Rican, and other Latin American ado-
lescents living in the U.S. (Delva et al., 2005; Turner et al., 2006). American-born
Hispanic adolescents reported higher drug use rates than foreign-born Hispanics
(Szapocznik et al., 2007). Among Hispanic groups, Mexican Americans tend to
show the highest levels of alcohol abuse (Carvajal & Young, 2009). At the same
time, another vulnerability for substance abuse as a risk factor for Hispanics is
the higher level of other factors such as low socioeconomic status, lower levels of
education, poor access to healthcare, and language barriers (Ramirez & De La
Cruz, 2002; Stevenson et al., 2004). Along with African Americans, the Hispanic
population, as compared with other cultural groups, experiences more negative
consequences, such as homelessness, HIV, partner and family violence, and incar-
ceration (Amaro et al., 2006).
As previously explained, familismo is an important aspect of Hispanic families
and plays a role in substance use. Some authors have found that familismo is
a protective factor against substance use (Ma et al., 2017), while others found
that it actually is a risk factor for addiction (Applewhite et al., 2017; Escobedo,
Allem, Baezconde-Garbanati, & Unger, 2018). As a protective factor, familismo
may connect the Hispanic youth with family support that provides self-efficacy to
be able to avoid negative peer group influence (Ma et al., 2017). As a risk factor,
familismo and the push for interdependence may lead Hispanic emerging adults
to stay at home, which may lead them to continue to associate with peers who
engage in substance misuse (Escobedo et al., 2018).

Hispanic Youth
Hispanic adolescents tend to use drugs at higher rates than White and African
American adolescents (Cardoso, Goldback, Cervantes, & Swank, 2016). This
is especially so for marijuana use, leading to a rise in Hispanic youths being
76 Assessment 

admitted to substance abuse treatment programs (Marzell, Sahker, Pro, & Arndt,
2017). This increase is likely for those aged 15–17 living in dependent situations
and who were most likely referred through the school system. However, Latino
youth may be quite vulnerable to moving from general use to abuse or depend-
ence on substances (Hernandez & Moreno, 2018). This is especially important
since Latinos tend to underutilize mental health services. One reason for this is a
potential language barrier, given the youth’s acculturation status and the avail-
ability of Spanish-speaking therapists in that locale.
There is a relationship between Hispanic youth’s cultural orientation and that
of their perceived parents’ cultural expectations (Unger et al., 2009). Those who
experienced higher levels of parental expectations to adhere to a Hispanic life-
style had higher risk of cigarette, marijuana, and alcohol use. Youth with higher
levels of Hispanicism (i.e., those who held more closely to Hispanic cultural val-
ues and beliefs) had lower levels of recent substance use and peer drug use as
well as higher levels of family functioning and school bonding (Martinez et al.,
2017). However, the protective effects of Hispanicism were reduced as levels of
Americanism were increased.
Hispanic youth and emerging adults had increased substance use when experi-
encing several role transitions (Allem et al., 2016). More specifically, when they
entered a new relationship, they had increased use of cigarettes, marijuana, and
binge drinking. When they experienced a breakup of a relationship, they had
increases in binge drinking, marijuana, and hard drug use. For those starting a
new job, they had increases in binge drinking and marijuana use. Thus, Hispanic
youth may experience use and/or abuse of a variety of substances depending on
their levels of acculturation, family cohesiveness, and specific transition they are
experiencing at that point in their lives.

Risk and Protective Factors

For Hispanics, family network is a source of emotional social support and
familismo is an integral part of the culture. Familismo has been shown to be a
protective factor among Latinos against negative behaviors including drug use
and abuse. At the same time, lack of family, family dysfunction, and family dis-
organization have been shown to be related to more drug and alcohol use (Griffin
et al., 2000). This connection to family, in the form of high parental presence and
high parent–family connectedness, is also a protective factor against the initia-
tion of the youth engaging in smoking (Mahabee-Gittens et al., 2011). This leads
to the consideration of the family as being the ideal realm of intervention for
Latinos (Hernandez & Moreno, 2018).
Identification with and pride in the individual’s culture is also beneficial
and related to lower substance and alcohol use (Vega et al., 2002). Latino self-
identification is a protective factor for Latin American substance use (De La Rosa
et al., 2005). Adolescents with high levels of acculturation, represented by pref-
erence for English language use and endorsement of interests and values of the
U.S., show higher rates of substance use (Gil et al., 2000; Turner et al., 2006).
Discrepancies in acculturation between adolescents and their parents in the way
that adolescents from immigrant families born in the U.S. master English and
adopt host country behaviors more than their parents, have been found to be
  Family Diversity and Substance Abuse 77

related to drug use in adolescents. This is because differential acculturation cre-

ates an additional familial conflict that affects adolescent bonding to the family
and parental authority (De la Rosa et al., 2005; Szapocznik et al., 2007).
Substance abuse tends to increase as Hispanics acculturate to the U.S. (Alegría
et al., 2006). One of the key cultural Hispanic values is that of respect, which
is sometimes referred to as respeto or simpati’a. Ma et  al. (2017) found that
higher levels of simpati’a were associated with reduced levels of drug use. They
explained, “Simpati’a, a construct that encourages respectful, smooth, and pleas-
ant interpersonal relationships, is inconsistent with deviant behaviors” (p. 329).
Hispanic adolescents who experience family economic stress, acculturative gap
stress, community and gang exposure, and family and drug stress were at higher
risk of substance use than those without these stressors (Cardoso et al., 2016).
King, Vidourek, Merianos, and Bartsch (2017) found that Hispanic youth at
highest risk for alcohol use had authoritarian parents, poor school experiences,
legal problems, and perceived alcohol use by peers. Perceived discrimination
also plays a role as a risk factor in increased substance use. For instance, Unger,
Soto, and Baezconde-Garbanati (2016) found that Hispanics who experienced
higher levels of discrimination were at greater risk for cigarette, alcohol, mari-
juana, and hard drug use. However, respeto is a protective factor against binge
drinking, marijuana, and hard drug use (Escobedo et  al., 2018). Moreover,
being male, unmarried, young, and under/unemployed are risk factors for alco-
hol and substance abuse for Latin Americans. Concomitantly, being female
and employed can be protective factors against drug consumption (Carvajal &
Young, 2009).

Treatment Implications
Barriers for Hispanic Americans to receiving mental health care include language
issues, lack of insurance, cultural beliefs against psychotherapy, tendencies to
keep things within families, and a reluctance to take medications (Falicov, 2014).
Sparks, Tisch, and Gardner (2013) held that there are not many treatment pro-
grams that gear themselves toward the Hispanic culture. This can be problematic
as there are several issues that seem to be unique to this population and adherence
to Hispanic culture may be a protective factor to reduce the risk of substance use.
For instance, therapists should consider acculturation issues when working with
Hispanic clients as there is a relationship between Hispanicism, Americanism,
and substance use and abuse (Martinez et al., 2017).
Ma et  al. (2017) suggested that substance abuse treatment for Hispanic
adolescents include components that strengthen the sense of familismo and
simpati’a. Escobedo et  al. (2018) concurred, promoting treatment programs
that addressed familismo and respeto, which are core Hispanic cultural values.
This leads to the recommendation of the inclusion and/or integration of parents,
school, and peers in substance abuse treatment for Hispanic adolescents (King
et al., 2017). Further, treatment that targets and reduces stress from a variety of
contexts (i.e., family, work, and school) is encouraged (Cardoso et al., 2016).
For instance, therapists can be aware of the relationship between particular role
transitions (such as dating, employment, or moving) and specific substance use
(Allem et al., 2016).
78 Assessment 

Given the relationship between perceived discrimination and increased sub-

stance use, therapists might consider helping Hispanic clients to find ways other
than substance use to cope with discrimination (Unger et al., 2009; Unger et al.,
2016). Not only might Hispanic Americans experience discrimination in their
lives outside of therapy, they may experience it within the mental health system
as well. Latinos were twice as likely as other groups to experience perceived dis-
crimination in health care/mental health substance abuse treatment (Mays et al.,
2017). This leads to a greater likelihood of premature termination of treatment.
Falicov (2014) suggested that treatment for Hispanic Americans include thera-
pists who are culturally aware, have cultural competence, maintain flexibility
in the therapeutic process to accommodate to more specific cultural practices
(i.e., temporality, gift giving, kisses as greetings, or advice giving), are focused on
trust-building practices (successive engagement over time of a meaningful rela-
tionship), are strength-based, and are able to decrease system barriers and stigma
(i.e., finding culturally appropriate services or using a translator). Marano and
Roman (2017) concurred, stating that therapists working with Latino families
should follow cultural expectations, cultural variables, and be flexible and adapt-
able in their interventions.
Therapeutic intervention should focus on both substance-use factors as well
as fit culturally for Latino families. Hernandez and Moreno (2018, p. 276) pro-
vided several suggestions for effective interventions when working with Latino
substance-using youth:

1. Assessing acculturation, potential acculturation gaps between parents and

adolescents, and cultural orientation to capture the heterogeneity among
Latino subgroups and generate information that may offer guidance on what
therapeutic approaches may offer the best “fit” for any given family.
2. Working with parents and adolescents to restore the protective factors of
familismo and respeto by improving communication, particularly in situa-
tions where acculturation gaps exist.
3. Strengthening parenting practices (increasing monitoring and supervi-
sion) and parenting self-efficacy among Latino parents, who may feel they
have lost control over the lives of their adolescents since arriving in the
United States.
4. Educating parents on the various cultural perspectives their adolescents may
be identifying with so that they understand and offer their adolescents culture-
specific guidance.
5. Increasing access for Latino families by taking linguistically competent inter-
ventions out into the communities in which they live or socialize.
6. Including explicit protocols for addressing culturally based attitudinal stig-
mas and misconceptions regarding the therapy and the treatment process.
7. Stressing the importance of interpersonal connections with families, not
only during the treatment process but also during recruitment and follow-up
methods.

While these are general ideas for working with Latino families, therapists are
encouraged to be flexible and make sure their assessment is idiosyncratic for that
particular family.
  Family Diversity and Substance Abuse 79

African American Families

African Americans are a distinct cultural group, but one that has tremendous
cultural diversity (Boyd-Franklin, 2003; Williams, 2016). African Americans
constitute a wide array of national origins, including Africa, the Caribbean, and
South and North America. African Americans—those who in the U.S. Census
identified as Black alone or as a combination—comprise approximately 14% of
the U.S. population (42 million people). This accounts for the third largest group
behind Whites and Hispanics.
African Americans are unique as an ethnic group in three main areas: the
African legacy, the history of slavery, and racism and discrimination (Boyd-
Franklin, 2003). African Americans have a long connection to Africa, the
continent from which they or their ancestors come and for which there are asso-
ciations with customs and ideas that are not mainstream in the United States.
One of the primary lasting vestiges of this African legacy is the importance of
kinship ties. Additionally, African culture is associated with the importance of
religious and spiritual beliefs. The period of slavery in the U.S. led to a strained
relationship between the African American community and that of mainstream
U.S. culture. The racism and discrimination that occurred during and after slav-
ery, through segregation, and up until the present day, has had a severe impact on
African Americans in a multitude of areas including education, employment, and
economics. Boyd-Franklin stated, “Both [racism and discrimination] affect an
African American from birth until death and have an impact on every aspect of
family life, from childrearing practices, courtship, and marriage, to male-female
roles, self-esteem, and cultural and racial identity” (2003, p. 9).
African American families tend to have one of the lowest median incomes,
averaging about $39,490 in 2016. Around 22% live below the poverty line,
which is the highest rate among the four largest ethnic groups. Approximately
7% of African American youth drop out of high school; this is the second highest
rate of the four major ethnic groups. In 2016, 43% of Black high school gradu-
ates enrolled in college and 18.5% graduate college. One of the distinguishing
characteristics of African American families is the prominence of motherhood,
whether it is the child’s biological mother, grandparent, or community mothering
(Pellebon, 2012).
While a typical two-parent family is part of the African American community
(46.6%), there is a high number of single-parent families; specifically female-led
(44.8%). This pattern is known as the matricentric female-headed family pattern,
leading to a possibility of African American families being “multi-problemed” as
they tend to fall below the poverty line, have young mothers, and have members
with low levels of education (Eshleman & Bulcroft, 2010). There is also a high
proportion of cohabitation and nonmarital births for African Americans, partly
due to economic barriers (Kelly & Hudson, 2017). These factors lead to the pos-
sibility of eventual relationship dissolution. While African American families tend
to be matricentric, they also tend to give high value to extended family (Kelly &
Hudson, 2017). Households may have multiple generations living together, with
grandparents helping to raise grandchildren. African Americans also espouse
both individualistic and collectivistic values and have very strong religious and
spiritual beliefs.
80 Assessment 

African American Families and Substance Abuse

Wright (2001) provided several explanations for substance abuse patterns in
African American families:

• Using and abusing substances on the weekend which may be reminiscent

of the times immediately following slavery when ex-slaves were given their
paycheck on Friday and would use the money to drink on the weekend.
• The proliferation of liquor stores and drug availability in predominantly
Black neighborhoods.
• Economic instability and frustrations of not being able to fully provide for
the economic welfare of the families.
• Attempts to deal with social environments ripe with racism and discrimination.

Compared with Caucasian and Hispanic populations, African Americans have

reported the lowest rates for use of alcohol, cigarettes, and illicit drugs (Nasim
et al., 2011). However, the biggest social, economic, and public health problem
for this group is drug addiction (Dei, 2002). Mortality rates for alcohol-related
diseases are 10% higher in African Americans than in other populations in the
U.S. Wright (2001) explained that many African Americans use drugs and alco-
hol as a way to cope with the stress of living in an oppressive environment. Blacks
who experienced racial discrimination were more likely to engage in weekend
and problematic alcohol use (Thompson, Goodman, & Kwate, 2016).
African Americans tend to view substance abuse as a secondary problem to the
social context of racism and poverty. Drug use may be a method of trying to cope
with racism for some African Americans, using drugs for relief from oppressive
social problems over which they have no control (Nasim et al., 2011). Substance
use and abuse for African Americans may be related to the inability to cope with
social exclusion, rather than directly related with drug and alcohol consumption.
African Americans experience racism in all aspects of their lives, including drug
treatment and incarceration, as Blacks experience higher rates of incarceration
for drug offences (Nicosia, MacDonald, & Pacula, 2017).
A second factor influencing African American drug and alcohol use is peer
influence. There is solid evidence demonstrating the negative effect of peer influ-
ence on African American youth alcohol behaviors (Epstein, Williams & Botvin,
2002). As a consequence of racism and social exclusion, African Americans tend
to interact more with other individuals from the same racial group and are more
vulnerable to being influenced by social pressure from other African Americans.
Nasim et  al. (2007) found that peer group affiliation, defined as the sense of
belonging to a particular social group, influences early alcohol initiation, which
is related to current use, heavy use, and lifetime use.
The national differences for African Americans have implications for cultural
beliefs, values, and practices. For instance, substance abuse is higher for Blacks
from the United States as compared with those from the Caribbean (Lacey et al.,
2016). This may be due to acculturative stress, where the longer time in a country
being exposed to negative social conditions (i.e., economic stress and discrimina-
tion) may lead to increased substance use. However, there are also likely differing
views of what is drug or substance use/abuse based on culture and religious views.
  Family Diversity and Substance Abuse 81

African American Youth

Overall, African American adolescents use alcohol less than their counter-
parts from other ethnicities while using marijuana at approximately the same
amount (Clark, Nguyen, & Belgrave, 2011). African American teens use alcohol
more than any other drug (Scott et al., 2011). Annual drug use among African
American youth is lower than that of Hispanic youth and slightly higher than
that of Caucasian youth. However, the consequences of drug use in African
American youth are more severe than for Caucasians and Hispanics in terms of
HIV/AIDS contraction (especially for women) and criminal justice involvement
(especially for men) (Szapocznik et al., 2007). Black females tend to engage in
earlier sexual onset and, when using alcohol, have increased rates of sexually
risky behavior (Chung et al., 2017). At the same time, alcohol is the primary con-
tributor to accidents and suicides for African American adolescents (Centers for
Disease Control, 2003). There are also psychological consequences, such as low
self-esteem and depression, due to alcohol use among African American youth
(Maag & Irvin, 2005).
African American college students, when compared with their White peers,
are less likely to engage in heavy alcohol use and more likely to abstain from
alcohol consumption (Wade & Peralta, 2017). One reason for this is perceived
race-based police bias, where African American students experience unsolicited
policing more than their White counterparts. This may lead them to be more cau-
tious when the possibility of drinking presents itself. While Blacks, Whites, and
Hispanics had similar risks for adolescent and early adulthood drinking issues,
Blacks were at greater risk of developing alcohol problems after young adulthood
(Lui & Mulia, 2018).

Risk and Protective Factors

Cho and Kogan (2016) viewed the risk and protective factors for African
American males from a developmental perspective, where there is a possible
cascading effect for young African American men who have had harsh, unre-
sponsive parenting while they were growing up. This environment influences
precocious transitions in adolescence (having to engage in adult roles prema-
turely), which was related to economic instability in young adulthood. Further,
economic instability was related to a poor sense of future orientation, which
was associated with increased substance abuse. A risk factor in this process was
when the individual grew up in a disadvantaged community as this increased
the risk of substance abuse. However, a protective factor for these African
American men was being in a supportive romantic relationship. Zemore et al.
(2016) found similar results in that risk factors for heavy drinking for African
Americans included being poor, experiencing prejudice, being young, and
being unmarried.
While harsh, unresponsive parenting is a risk factor associated with increased
substance use, positive parenting behaviors, such as authoritative parenting,
helping with schoolwork, limiting television time, and giving of praise, have been
found to be protective factors against substance use (Vidourek, King, Burbage, &
Okuley, 2018). African American youth whose parents did not engage in positive
82 Assessment 

parenting behaviors were one-and-a-half to three times more likely to recently

use alcohol than those whose parents engaged in positive parenting behaviors.
Religious involvement and spirituality may also be protective factors for
African Americans. Higher levels of spirituality and a sense of purpose in life,
for African-American substance abuse clients, were related to higher physical
and psychological well-being (Blakey, 2016; Stewart, Koeske, & Pringle, 2017).
Further, engaging in religious services and experiencing self as religious and spir-
itual were associated with lower levels of alcohol-use disorders, especially so for
African American females (Ransome & Gilman, 2016).
Ethnic identity can be a protective factor as it is associated with better out-
comes in drug use for African American adolescents (Chavous et  al., 2003).
African American adolescents who had positive attitudes towards being African
American had lower tendencies of drug use (Belgrave, 2002; Caldwell et  al.,
2006). Adolescents expressing a strong ethnic group affiliation have low sus-
ceptibility to heavy drinking, even as peer risk behaviors increased (Nasim et al.,
2007). Africentrism, which refers to the values, beliefs, and behaviors deriving
from an African cultural heritage and religiosity, has also been found to be a
protective factor from drug use in the African American community. Nasim et al.
(2007) concluded that youth with higher Africentric beliefs started consuming
alcohol at a later age than other racial groups. At the same time, Africentrism
promotes a concern for significant others, which reduces the rate of alcohol con-
sumption. Additionally, susceptibility for alcohol use is low for highly religious
adolescents where moral and social judgment plays an important role when
engaging in activities out of church.
Social support has been shown to be another protective factor for substance
abuse behaviors for African Americans. However, Nasim et al. (2011) found that
social support is significantly different for Caucasians and African Americans in
that Caucasians reported more family support and African Americans reported
social support from church members and other religious-related networks.
Conversely, those individuals with less family support were most at risk because
they had fewer resources to cope with adversity.

Treatment Implications
Given the importance of protective factors as well as the understanding of the
familial and cultural impact for African Americans, counselors and therapists
who work in the area of substance abuse should be promoting and incorporat-
ing the identified protective factors during prevention and treatment processes.
One means to do this is to enhance the client’s racial identity by including family
members and important role models such as teachers, relatives, friends, and the
community in the treatment plans.
Since spirituality is extremely important to the African American community,
as well as its association to positive gains in psychological well-being, incor-
porating spirituality into treatment should be a possible avenue, depending on
the particular client’s beliefs (Nasim et al., 2011; Stewart et al., 2017). Cheney,
Booth, Borders, and Curran (2016) encouraged treatment providers for African
American substance abusers to help connect them to social capital. This included
connecting clients to religious and spiritual activities, non-drug-using friends and
  Family Diversity and Substance Abuse 83

family, abstinence-supporting networks, and engagement in conventional activi-

ties (i.e., “normal” activities, such as leisure, church, and play). Kelly and Hudson
(2017) recommended that therapists working with African American clients
address the following five areas: joining (being warm and authentic); stressors,
traumas, socioeconomic concerns, and a lack of role models; racial stigma and
shame; identifying and supporting cultural values; and therapist self-awareness.
African Americans tend to exhibit unique treatment barriers, including treat-
ment location, perceptions for treatment necessity, and treatment stigma (Fisher
& Harrison, 2018). Scott et al. (2011) explained that African Americans tend to
lack access to treatment, usually because of socioeconomic factors. Compared
with other racial groups, African Americans are less likely to enter and complete
outpatient substance abuse treatment (Mennis & Stahler, 2016; Montgomery,
Burlew, & Korte, 2017). Another reason for this, besides economics, may be
people’s readiness for change (see Chapter 8). To help substance abuse treatment
retention, therapists should consider focusing on increasing client motivation and
improving their readiness for change.
African Americans may also engage in early treatment termination because of
perceived experiences of discrimination when receiving health care (Mays et al.,
2017). Patient discrimination may increase for those individuals who are unin-
sured and/or racial/ethnic minority patients. With these potentials, as well as
cultural suspicion and mistrust of the mental health field as a backdrop, it is
especially important for therapists to be able to join with and develop a positive
therapeutic relationship with African American families (Boyd-Franklin, 2003).

Asian American Families

Asian Americans were the fastest growing ethnic group in the United States
between 2000 and 2010, increasing by 43% (U.S. Census, 2012). They now
account for approximately 5% of the total population (18.2 million people). This
is the fourth largest group behind Whites, Hispanics, and African Americans.
Asian American families tend to earn more than any other ethnic group. In
2016, their annual median income was $81,431. However, approximately 10%
live below the poverty line. They also have the highest percentage of comple-
tion of high school (approximately 97%) and college (52%). Only 3% of Asian
Americans drop out of high school, which is the lowest amount of any of the
primary ethnic groups. Out of all the ethnic groups presented in this chapter,
Asian Americans have the highest rate of married couples (80.4%). Only 11.8%
of families are female only with no husband.
Asian American families tend to operate from a patriarchal perspective, with
children showing a lot of respect for their elders. Asian American parents have
many expectations for success and high achievement of their children, which
may lead to children feeling self-blame or feelings of isolation if they do not meet
those expectations (Fisher & Harrison, 2018). Asian American families have a
strong respect for elders, filial history, and authority, leading them to function
more collectivistically than individually. Yet, the family structure is geared more
toward the nuclear rather than the extended family (Suzuki et al., 2017). Thus,
family pride tends to be more important than individual pride and individual
84 Assessment 

feelings tend to be kept in and not discussed. One means of social control in
Asian American families and communities is through shame and “saving face”
to avoid embarrassment. However, the more acculturated the child, the less the
sense of family obligation, which would lead to not engaging in as many family
face-saving behaviors.
Asian culture tends to favor perfectionism, which is associated with values such
as filial loyalty, collectivism, and adhering to social norms (Fisher & Harrison,
2018). This leads to clarity in role functions so that families are strongly struc-
tured, with children deferring to parents, and wives usually deferring to husbands.
Asian American males tend to be the breadwinners while females are in charge of
the home and disciplining the children. Acculturation has serious implications for
Asian American families, especially since they are, more than other ethnic groups,
likely to intermarry (Suzuki et al., 2017).

Asian American Families and Substance Abuse

Asian Americans are considered a low-risk group in the substance abuse
literature (Iwamoto, Grivel, Cheng, & Zamboanga, 2016a) and have been under-
researched (Iwamoto, Kaya, Grivel, & Clinton, 2016b; Sahker et  al., 2017).
Substance use rates are generally lower for Asian Americans than for other U.S.
ethnic groups, although there are variations among Asian subgroups. They tend
to avoid activities that could be potentially embarrassing to themselves or their
family members. Asian American women, compared with men, start drug use
later, have less education, and have lower employment rates (Han et al., 2016).
Lo and Cheng (2012) found that racial discrimination towards Asian Americans
increases the individual’s likelihood of having a substance abuse disorder. They
also found that income moderates the relationship between discrimination and
substance use disorders in that low income was related to more discrimination
and more substance abuse. Yoo, Gee, and Lowthrop (2010) found that many
Asian Americans reported racial discrimination in various aspects of their lives,
including being passed over for a promotion, treated like “not an American,”
and viewed with suspicion, which led to them using substances when trying to
cope with racial stressors, especially discrimination. However, Asian Americans
perceive less discrimination than African Americans. Since Asian Americans tend
to be high achievers, increased education inhibits the levels of discrimination
compared with African Americans (Lo & Cheng, 2012).
Asian American and Caucasian families tend to have differences in parent-
ing styles, with Caucasian families displaying more parental warmth, which
tends to be a protective factor for those families (Luk, Patock-Peckham, & King,
2015). However, lack of maternal warmth was not associated with substance
use for Asian Americans, which may be because this is seen as more normative.
Further, Caucasian families tend to operate more from a position of individuality
while Asian Americans do so from a more collectivistic orientation. This leads
Caucasians to tend to engage in increased substance use if their individuality is
violated whereas Asian Americans may be exposed more to parental denial of
their individuality.
Asian American parents are likely to maintain the traditional values and prac-
tices of their home country; however, the children, much more quickly than
  Family Diversity and Substance Abuse 85

the parents, are able to connect to the new dominant culture (Fang & Schinke,
2011). This leads to a potential increased generation gap between parents and
children. As such, those adolescents who have acculturated to the U.S. culture
are at higher risk of alcohol use than peers with more traditional beliefs (Hahm,
Lahiff, & Guterman, 2003). However, a protective factor is the strong sense of
familial connection as the more attached the adolescents are to their parents, the
lower their risk of alcohol use. Parental attachment is such an important mediat-
ing factor that those Asian American adolescents who were highly acculturated
and had low parental attachment were 11 times more likely to use alcohol than
those low in acculturation.

Asian American Youths

Rates of substance use among Asian American youth have been increasing dur-
ing the past decades, putting Asian American adolescents as likely as youth of
other racial groups to be at risk of substance abuse (Hong, Huang, Sabri, & Kim,
2011). As Asian Americans become more acculturated, problems in behavior
such as substance abuse increase (Ryabov, 2015). As immigrants, especially ado-
lescents, become more acculturated they are more likely to relate with American
peers who may influence their behavior towards substance use. Asian American
adolescents who spend more time with non-Asian peers are more likely to drink
than Asians who socialized with other Asian Americans (Thai, Connell, & Tebes,
2010). This pattern of increased substance use by successive immigrant genera-
tions is called second generation decline and may be due to initial immigrants
not engaging in substance use as much because of a protective culture, lack of
inter-generational conflict, and resiliency (Ryabov, 2015). That is, first-generation
immigrants are more acculturated into Asian culture, have more respect for gen-
erational roles, and come to the U.S. with resiliencies. Each of these protective
factors may decrease for each subsequent generation that is born in the U.S.
Although family is the first of the social influences that has primary impact
on Asian Americans’ behavior, peer use is one of the most robust predictive
factors of substance use and abuse among Asian American youth (Le, Goebert
& Wallen, 2009; Liu & Iwamoto, 2007). In Liu and Iwamoto’s (2007) study,
Asian Americans who had peers using substances were twice as likely to drink
and use illicit drugs and four times more likely to use marijuana. Further, mas-
culine norms are related to more substance use in Asian American men than
women. Males tend to drink to have power over women and to display risk-
taking behaviors.
For Asian American emerging adults, heavy episode drinking and associated
alcohol-related problems are increasing (Iwamoto et al., 2016a, 2016b). These
researchers found that, for college students, the rates of alcohol-related problems
are similar for Asian American and White males. Asian Americans have tradi-
tionally been viewed as a model minority, especially regarding substance use and
risky sexual behavior (Sabato, 2016; Sahker et al., 2017). However, this may not
necessarily be the case. While past 30-day drug use was lower for Asian American
youth than for other groups, they are more likely to use cigarettes, pipes, and
cigars (Sabato, 2016). Further, there is a high level of association between sub-
stance use and risky sexual behavior.
86 Assessment 

Risk and Protective Factors

Family relationships are a primary protective factor for Asian Americans (Fang
& Schinke, 2011). Family represents an integral socialization source, which can
influence or inhibit risky and negative behaviors (Hahm et al., 2003). Asians that
perceived higher negativity from parents and/or friends toward drinking are less
likely to relate with peers that use substances or alcohol and therefore are less likely
to engage in drinking behaviors (Thai et al., 2010; Luk et al., 2013).
Higher levels of acculturation, family conflict, and discrimination are risk fac-
tors for alcohol and drug use disorders for Asian Americans (Savage & Mezuk,
2014). Wang, Kviz, and Miller (2012) explained that “while the cultural con-
text unique among Asian American adolescents may multiply their vulnerability
to alcohol use and abuse, parent-child bonding may be sufficiently protective
to mediate this risk” (p. 833). Asians with high levels of attachment and cohe-
sion with their parents are less likely to use drugs (Savage & Mezuk, 2014).
Additional protective factors against substance use for Asian Americans include
neighborhood safety (Savage & Mezuk, 2014) and high academic achievement
(Luk et al., 2013). Religiosity is another protective factor for Asian Americans
against alcohol and marijuana abuse among acculturated Asian Americans.
Religiosity in Asian Americans is related to perceiving alcohol and substance use/
abuse as a negative behavior that goes against the family. The higher the level of
acculturation, the more religiosity serves as a protective factor (Luk et al. 2013).
Asian parenting styles are predominantly authoritarian (Chuang & Su, 2009).
In that way, acculturation gaps start to develop between parents and children
leading to parent–child separation through intergenerational conflict or intergen-
erational cultural dissonance. As a good relationship with parents is a protective
factor, parenting style could influence children’s behaviors in positive or negative
ways. Asians’ collectivistic values, which include the notion that children should
think of their family first and obey their parents, can be in conflict with the indi-
vidualism that Asian American children born and raised in the U.S. are likely to
espouse. This potentially leads to conflict with their parents who have the expec-
tation of teaching Asian values to the new generations.
While Asian Americans are more likely than their White counterparts to binge
drink when they experience psychological distress (Woo, Wang, & Tran, 2017),
they may be at risk the more they take on U.S. beliefs, values, and behaviors since
acculturation to the United States may be a risk factor for substance abuse for
Asian Americans. For instance, those who were born in the U.S. reported higher
levels of drug use in the past year than those born outside the U.S. (Bersamira,
Lin, Park, & Marsh, 2017). These authors found that predictors of past-year
drug use for Asian Americans included acculturation (those being born in the
U.S. and better English proficiency with higher rates), gender (men higher than
women), ethnic subgroup, age, lifetime prevalence of a major depressive episode,
and drinking behavior.

Treatment Implications
Asian Americans (and Pacific Islanders) have had a higher trend of substance
abuse treatment admissions than other ethnic groups (Sahker et  al., 2017).
  Family Diversity and Substance Abuse 87

More Asian Americans are seeking out treatment, possibly as a result of Asian
American families having an increased acceptance of psychotherapy than they
traditionally had. Those seeking services tended to have much lower levels of
income or were at that time homeless. Those that did go to treatment were pri-
marily forced by their family, legal, or work systems to go. This may relate to the
stigma for substance abuse among Asian Americans, not only for the individual,
but for the entire family (Han, Lin, Wu, & Hser, 2016).
As described, all Asian Americans are not the same, depending on country
of origin and history of immigration. Therapists should be aware of the vari-
ous subgroups to ensure they are utilizing appropriate interventions that address
culturally appropriate stress coping strategies (Woo et  al., 2017). Barriers for
treatment for Asian Americans tend to include peer pressure, family influences,
and face-loss concerns (Masson et  al., 2013). Han et  al. (2016) recommended
providing culturally competent treatment for Asian Americans, focusing on men-
tal health issues and communication between therapist and client. These authors
found that Asian American women had lower levels of treatment satisfaction,
especially concerning their perceptions of therapist empathy and the agreement
about treatment goals.
Since Asian Americans are likely to come from families where going to ther-
apy is associated with stigma, therapists are encouraged to provide clients with
information as to the therapeutic process and the collaborative nature of the
therapeutic relationship (Suzuki et al., 2017). Luk et al. (2015) explained, “Given
the collectivistic nature of Asian cultures, it is reasonable to assume family factors
are critical points of intervention” (p. 1367). Fisher and Harrison (2018) recom-
mended that the therapist keep in mind that the father or elder of the family may
be the gatekeeper for treatment.
Wang, Kviz, and Miller (2012) recommended that when working with Asian
American families, prevention programs need to be designed to deal with accul-
turation effects and should incorporate culture-specific strategies. These strategies
can shorten the divide between generations, especially for newly immigrated fam-
ilies where the children are being raised in the United States but with parents who
are maintaining values and practices from their home country.

American Indian Families

The U.S. Census Bureau combines data for American Indians and Alaska Natives
(AI/ANs). There are approximately 5.2 million American Indian and Alaska
Natives, which comprise between 1–2% of the population in the United States.
In the United States, there are 567 federally recognized tribes, with 100 state-
recognized tribes. While many AIs belong to tribes, not all do. Based on the
National Survey on Drug Use and Health (NSDUH) data collected from 2005 to
2014, approximately 22% of American Indians/Alaska Natives live on reserva-
tions or trust lands (Center for Behavioral Health Statistics and Quality, 2016).
Those AI/ANs living on tribal lands have the same or less mental and behavio-
ral health issues as AI/ANs that don’t live on tribal lands. Sixty percent of AI/
ANs live in metropolitan areas, which accounts for the lowest percentage for the
major ethnic groups. American Indians are one of the fastest growing and one of
88 Assessment 

the youngest ethnic groups in the U.S. (John, 2012). This growth rate may be four
times that of the national average (Eshleman & Bulcroft, 2010).
While the iconic view of American Indians is living on reservations, only about
22% do (U.S. Census, 2012). Approximately 58% of households are run by mar-
ried partners, which is a higher level than African American families but lower
than Caucasian, Asian, and Hispanic families. However, the configuration of these
couples is changing, as American Indians tend to have a high rate of intermarriage—
marrying outside of their ethnic group, usually to a White partner.
There tends to be a wide economic disparity between American Indians and
their White counterparts. In 2015, the median family income for American
Indians was $38,530 while for the nation as a whole it was $55,775. Part of the
reason for this disparity is that American Indians tend to live in rural environ-
ments, as well as their ethic for sharing (John, 2012). The poverty rate for AIs
is over 30% (Robbins et al., 2017). Further, they tend to not achieve high levels
of education, with a dropout rate that is twice that of African Americans and
Hispanics and three times as much as Whites (Schaefer, 2010).
One of the distinguishing features of American Indian families is the impor-
tance placed on kinship as they tend to be collectivistic, where self identity
happens in relation to family, clan, and tribe (Robbins et al., 2017). Elders play
a special role in the family, with children learning from an early age to respect
the older generation (Eshleman & Bulcroft, 2010). Given that American Indian
women tend to start having children at an earlier age than other ethnic groups,
the disparity in age between a grandparent and grandchild tends to be smaller
than in other ethnic groups (John, 2012).

American Indian Families and Substance Abuse

American Indians and Alaska Natives have higher rates of substance abuse
compared with the larger population (Fish, Osberg, & Syed, 2017). There are
several possible reasons for this disparity as AI/ANs have experienced the effects
of colonialism and serious historical trauma, such as massacres, removal from
tribal land, and family separations (Myhra & Wieling, 2014). Ehlers et  al.
(2013) found that a majority of AIs occasionally think about historical losses,
which is associated with substance dependence. Other negative outcomes of
the historical trauma AIs have experienced are economic difficulties and over-
crowded housing.
While American Indians are impacted by abuse of many substances, alcohol
has been the most dominant and detrimental (Greene, Eitle, & Eitle, 2014).
About 10.5% of U.S.-born AI/AN adults, in the past year, exhibited an alcohol
use disorder while 13% had a substance use disorder (NSDUH). Lifetime preva-
lence rates for alcohol use showed that American Indians had 5% to 15% more
alcohol consumption than non-American Indians. One potential reason for this is
that American Indians start drinking earlier than other ethnic groups.
Drinking represents a double-edged sword for American Indians, with both
socially reinforced and socially destructive behaviors (Fish et al., 2017). Problem
drinking is associated with reduced transmission of traditional values and prac-
tices through generations. But at the same time alcohol use is viewed as a part of
native life and identity. Because Indians were colonized by White men who used
  Family Diversity and Substance Abuse 89

alcohol to control and destroy Indian communities, some American Indians per-
ceive drinking as a way of not letting non-American Indians or “Whites” control
them. American Indians also may view drinking as a social shared activity. On
the other hand, most see alcohol as an enemy that separates people from their
family members. In this way, alcohol has been perceived in ambiguous ways;
weakening or strengthening American Indian life and promoting social connect-
edness or fragmenting Native communities (Yuan et al., 2010).
Elders play a significant role in AI/AN families. For those families where a
grandparent is raising the grandchildren, 36% had either a child, parent, or
grandparent experiencing an alcohol or drug problem (Mignon & Holmes,
2013). In these families, grandparents typically face financial issues as well as
lack of support from extended family and various human service organizations.
Besides the cultural aspects that may predispose AI/AN individuals to engage
in substance use, there is also a genetic component (Ehlers & Gizer, 2013). These
authors explained that high levels of substance dependence in AI tribes may be
based on lack of genetic protective factors, genetically mediated risk factors (drug
sensitivity, externalizing traits, and consumption drive), as well as environmental
factors. According to the NSDUH survey data, approximately 36% of AI/AN
adults used tobacco products in the past month, with 63% smoking cigarettes
daily. Almost 50% used alcohol in the past month while 26% binge drank and
8% drank heavily. Those living on tribal lands drank significantly less (39.7% vs
53%) than those living off tribal lands. In the past year, 10.5% of AI/AN adults
were diagnosed with an alcohol use disorder, 13.1% with a substance use dis-
order, and 4.5% with an illicit drug use disorder. Almost 14% of AI/AN adults
needed substance abuse treatment in the past year.

American Indian Youth

American Indian and Alaska Native youth have many similarities to youth from
any cultural group while also having some distinct challenges. American Indian
and Alaska Native youth may have different experiences with substance use, cul-
ture, and trauma that other ethnic groups do not (Paul, Lusk, Becton, & Glade,
2017). Patterns of increases in drug use over time have proven to be very similar
in American Indian adolescents to those seen among youth from other cultural
groups (Beauvais, Jumper-Thurman & Burnside, 2008). However, research has
also found that American Indian adolescents tend to engage in the use of alcohol
and tobacco more than youth from other ethnic groups (Lowe, Liang, Riggs, &
Henson, 2012). King, Vidourek, and Hill (2014) found that one in three AI youth
reported recent alcohol use. This was significantly lower than their White or
Hispanic counterparts who reported recent alcohol use at approximately one in
two. Compared with adolescents of other ethnic groups, American Indians suffer
more social consequences from alcohol consumption such as sexually transmitted
diseases and health problems such as chronic liver disease and cirrhosis.
For AI/AN youth, increased drinking is related to lower engagement in school,
lower community norms against drinking and drugs, lower perceived police
enforcement and higher neighborhood disorganization (Friese, Grube, & Seninger,
2015). Tingey et al. (2017) also found that AI adolescents who used alcohol were
likely not bonded to school or engaged in structured extracurricular activities.
90 Assessment 

The more acculturated American Indians are with non-American Indian values,
the higher the rates of alcohol use (Fish et al., 2017).
One of the most serious issues for AI/AN adolescents is suicide. Leavitt et al.
(2018) provided evidence that AI/ANs, of all ages, are 3.5 times more likely to
die by suicide than those from racial and ethnic groups that had the lowest rates
of suicide. Seventy percent of AI/ANs who died by suicide lived in rural areas and
were likely to have used alcohol and marijuana in the hours before death. They
were almost two times more likely to have had a reported alcohol problem. Gray
and McCullagh (2014) found alcohol/substance abuse, bullying, poverty, friends
and family who attempted and completed suicide, and mental health problems to
be risk factors for American Indian suicide.

Risk and Protective Factors

Risk factors for American Indian alcohol consumption are primarily related to
demographic variables such as low income, gender, family history, and geographic
location. Poverty, being male, and a family history of alcohol are associated with
higher levels of alcohol and drug consumption among American Indians (Lieb
et al., 2002). American Indians and Alaska Natives tend to have early exposure
to drinking and drug use by their parents and grandparents, which leads to early
onset of drinking and drugging, usually in early adulthood (Myhra & Wieling,
2014). One of the messages they may receive is that substance use is acceptable
and maybe even desirable. This is important since early onset of drinking is a
significant predictor of the person developing an alcohol use disorder (Stanley
et al., 2014).
Morrell, Hilton, and Rugless (2018) found that peer and family substance
use, favorable attitudes toward substance use, easier access to substances, higher
levels of sensation-seeking, and poor school performance were potential risk
factors for AI/AN youth substance use. Whitesell et  al. (2014) explained that
risk factors for AI youth substance misuse included exposure to stress, early
puberty, and deviant peer relationships. For AIs living in urban settings, exter-
nalizing behaviors, family conflict, and not liking school were all predictors of
later alcohol use disorder (Stanley et al., 2014). These results have serious con-
sequences as AI youth who have a substance use disorder or conduct disorder
have higher arrest rates, with over 50% of AI youth arrested having one or both
of these disorders (Hartshorn, Whitbeck, & Prentice, 2015).
Peer attitudes may be a risk or protective factor for this population. Peer
groups tend to include more relatives (i.e., cousins, siblings) than unrelated
friends, because American Indians tend to have bigger families and relate more to
family members than with individuals from other racial groups. American Indian
youth with prosocial peer relationships tend to have low or no substance use
(Whitesell et al., 2014). Concomitantly, positive engagement in extracurricular
activities is associated with lower levels of substance use (Moilanen, Markstrom,
& Jones, 2014).
American Indian youth who have a strong sense of spirituality and reli-
gious involvement engage in lower levels of substance use (Kulis et  al., 2012).
Connection to the American Indian church or Christianity is associated with
lower substance use while connection to AI beliefs is associated with antidrug
  Family Diversity and Substance Abuse 91

attitudes, norms, and expectancies. Tribal beliefs encourage togetherness and

prohibit violence and related behaviors. Those individuals who identify with
tribal values have less orientation towards alcohol use (Kulis et al., 2012). Pride
in being American Indian and religious affiliation is associated with lower levels
of alcohol use. American Indians with a low orientation toward traditional cul-
ture are more than 4.4 times as likely to use alcohol compared with those who
are more traditionally oriented (Yu & Stiffman, 2007). While American Indians
tend to have the highest rates of abstinence among all racial groups, when they do
engage in substance use they experience more related health disparities (Spillane
& Venner, 2018).

Treatment Implications
For AI youth, early substance use intervention is extremely important since expo-
sure to stress and problematic peer and family relationships are associated with
high substance use (Whitesell et  al., 2014). These prevention programs should
be aimed at decreasing the youth’s exposure to stress, enhancing prosocial peer
relationships, and increasing positive parental influence and relationships.
Myhra, Wieling, and Grant (2015) found that AI families have several
resources that can be accessed by therapists. These include grandparents as a
source of stability, intergenerational communication regarding substance use,
forgiveness and healing, and healing through cultural means. For many, grand-
parents help to raise the grandchildren, being both parent and teachers of the
culture. Grandparent injunctive norms against substance use can be significant
protective factors (Martinez, Ayers, Kulis, & Brown, 2015). American Indian
families are encouraged to talk about alcohol’s individual and intergenerational
use in an attempt to break negative intergenerational patterns of substance use
and abuse. One way that AI individuals have healed in their own sobriety is
through forgiveness and/or making amends. For many AI/AN individuals who
have abused substances, healing can come through cultural means. Various cul-
tural, spiritual, and language practices bring strength and help connect them to
important values.
When working therapeutically with American Indian adolescents, Spillane and
Venner (2018) provided some general cultural considerations for therapists. These
include the client’s cultural identity and acculturation, religiosity and spirituality,
collectivism and conceptions of family, history of discrimination, experienced
microaggressions, and negative stereotypes of American Indians. Therapists are
recommended to be culturally sensitive to these aspects, which have impact on
the risk and protective factors of the person and family. In order to engage in
culturally sensitive interventions, therapists and agencies need to be flexible while
incorporating evidence-based treatments, as well as developing original means of
working that take into consideration the client’s traditional and cultural world-
view (Croff, Rieckmann, & Spence, 2014). Incorporating Alcoholics Anonymous
may be useful as AA’s focus on a higher power in many ways relates to the spirit-
ualism that many AI/ANs espouse (Myhra & Wieling, 2014) and has been shown
to assist in increased abstinence for this population (Muñoz & Tonigan, 2017).
Interventions that incorporate culturally relevant health beliefs tend to have
the best outcomes (Lewis & Myhra, 2017). Thus, interventions should connect
92 Assessment 

the AI/AN client with cultural activities and positive cultural constructs (Brown,
Dickerson, & D’Amico, 2016). One way of doing this is to bring in cultural
experts when conceptualizing intervention and treatment programs. Chen, Balan,
and Price (2012) suggested that therapists include tribe leaders and elders when
developing treatment programs for American Indians. Legha, Raleigh-Cohn,
Fickenscher, and Novins (2014) recommended that substance abuse treatment
for AI/ANs should be integrated, individualized, comprehensive, and long term.
The use of peer recovery support is an effective means of reducing substance use
as members of the culture work together for sobriety (Kelley, Bingham, Brown,
& Pepion, 2017).

Sexual and Gender Minority Individuals

This chapter has primarily presented brief overviews on how families function
differently based on their primary culture. However, the notion of diversity has
expanded beyond concepts such as ethnicity to that of intersectionality. This
includes notions of sexual orientation, ability, education, social class, attractive-
ness, weight, age, etc. All of these aspects of privilege and oppression lead to
individuals developing a sense of identity. In this section we will explore two
aspects of self that may impact substance use and family functioning, sexual and
gender identities.
Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ) aware-
ness has significantly increased during the 21st century. We will use the phrase
sexual and gender minority (SGM) communities to refer to those individuals
who experience either same-sex attractions or behaviors (sexual minority) and
those whose gender identity does not match with their sex assigned at birth
(Mereish, Gamarel, & Operario, 2018). Anderson (2009) explained, “Gender
identity is a person’s internal sense of being male or female, regardless of his or
her genitals” (p. 9).

SGM Families
While there are many similar processes between SGM and non-SGM families,
there are some issues that are specific to SGM families. One of these is the family-
of-origin issue, which usually centers around issues of sexuality and gender iden-
tity (Shelton, 2017). Sexual and gender minority individuals and couples may not
be out to their family and must hide their sexual orientation or gender identity.
Or, if they are out, there may be tension or even emotional and physical cut-off
from the family.
For those who do come out, there may be community implications (Shelton,
2017). These can include homophobic reactions, prejudice, discrimination, and
the possibility of hate crimes. Physical safety and emotional abuse, such as online
bullying for SGM teens, become significant daily concerns. These are dependent
on the locale of the individual/family as some communities are more open for
diverse individuals, as well as having better resources.
  Family Diversity and Substance Abuse 93

Sexual and gender minority families, when the person is out, go through devel-
opmental stages of coming out (Anderson, 2009). This is an internal and external
process where family members adjust to the notion of having an LGBTQ family
member, disclosing internally to family members as well as those outside of the
family, and accepting a new family identity.

SGM Individuals and Substance Use

Similar to heterosexual and cisgender youth, SGM youth might use substances
to deal with stress, conform to peer pressure, deal with family difficulties, and
for experimentation (Mereish et  al., 2018). However, SGM youth may have
additional factors that could contribute to substance use. They tend to have an
experience of social oppression (Anderson, 2009). Additionally, they may have
difficulty in dealing with the process of sexual or gender identity development.
This is significant since there is a higher rate of suicidality for SGM individu-
als. Substance use and misuse may be a means of trying to cope with potential
victimization (Anderson, 2009; Mereish, O’Cleirigh, & Bradford, 2014). Sexual
and gender minority individuals have unique health concerns such as perceived or
overt stigma, increased emotional problems, and increased substance use problems
(Davila & Safren, 2017).
There are varying findings on the differences in substance use between SGM
and heterosexual individuals. Marshal et al. (2008) found that SGM youth were,
on average, 190% more likely to engage in substance use. This finding was even
higher for those who were bisexual (340% higher) and female (400% higher).
However, Senreich and Vairo (2014) noted that the difference in substance use
between SGM and heterosexual youth is not as much as originally believed.
Yet, SGM youth have higher reported use of emerging drugs than their het-
erosexual counterparts (Goldbach, Mereish, & Burgess, 2017). These emerging
drugs include cigarettes, smokeless tobacco, e-cigarettes, alcohol, marijuana,
synesthetic marijuana, and prescription drugs. Hatzenbuehler, McLaughlin, and
Xuan (2015) also found that SGM adolescents were more likely to smoke, drink,
and misuse alcohol. Compared with their heterosexual counterparts, sexual-
minority women have a larger difference in their reported levels of alcohol and
drug use than sexual-minority males (Hughes, Wilsnack, & Kantor, 2016).

Risk and Protective Factors

The coming out process can be related to the person’s substance use (Senreich &
Vairo, 2014). First, SGM individuals might self-medicate due to feelings of shame
and guilt. Second, the person might be using substances to deal with the fear of
how family, friends, and community will react once they come out. Third, the
person may be increasing their substance use based upon their peer network and
social environment. That is, coming out may lead to a sense of liberation, which
might encourage increased substance use.
One of the primary stressors for SGM youth is acceptance by family mem-
bers. When family members reject the SGM youth, health problems increase.
94 Assessment 

Ryan, Huebner, Diaz, and Sanchez (2009) found that SGM individuals who
experienced higher levels of family rejection during adolescence were 8.4 times
more likely to have attempted suicide, 5.9 times more likely to report depres-
sion, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to have
engaged in unprotected sex.
Because there is a higher likelihood that SGM individuals may be rejected by
family members after coming out, they may not experience a traditional family
configuration. Thus, they tend to place more import on what are called “families of
choice” or elected families. These elected families might include family members,
supportive friends, and romantic partners who support the SGM individual in
their identity. Elected families may be more important for the SGM individual
than biological families (Anderson, 2009; Shelton, 2017).
Peer networks also play a significant role in the risk factors for SGM adoles-
cent use. For SGM adolescents, substances tend to play a significant role in their
social environments (Senreich & Vairo, 2014). For instance, Hatzenbuehler et al.
(2015) found that SGM youth have increased rates of tobacco use in their peer
networks. Further, gay bars and clubs tend to play a significant role in peer rela-
tions for SGM young adults, where club drugs are popular (Adam & Gutierrez,
2011; Anderson, 2009). Some of the primary club drugs are ecstasy, Ketamine
(Special K), Gamma Hydroxybutyrate (GBH), and LSD.
The socioeconomic status (SES) that youth come from also plays a role in
their risk or resiliency. Sexual and gender minority youth that come from higher
SES are more likely to have the support of family, peers, and significant others
(McConnell, Birkett, & Mustanski, 2015). This is important since more family
support is related to higher levels of mental health. Conversely, lower levels of
family support is related to lower levels of mental health. However, even if family
support is low, SGM youth may have better outcomes when their peer and social
supports are in place. Yet, when family, peer, and social supports are all lacking,
SGM youth tend to have the worst outcomes. Sexual and gender minority youth
of color may be even more at risk of substance abuse as well as suicidal ideation
and attempts, homelessness, sexually transmitted diseases, sexual victimization,
and trauma (Murphy & Hardaway, 2017). This could be due to these individu-
als being at risk for discrimination because of their sexual orientation as well as
their race.

Treatment Implications
Sexual and gender minority substance abuse clients will likely find themselves
in heterosexual-dominated treatment (van Wormer & Davis, 2013). Thus, it is
important that therapists working with SGM clients utilize a gay affirmative
practice (Crisp & DiNitto, 2012; Senreich & Vairo, 2014; van Wormer & Davis,
2013). This includes the therapist’s knowledge, attitudes, and behaviors when
working with the SGM population. Therapists should have knowledge about
SGM terminology, the impact of oppression, social policies impacting SGM
individuals, the coming out process, and community resources. Attitudinally,
therapists should have positive attitudes in working with the SGM population.
This takes self-reflection to assess for any internalized homophobia or denial of
people’s gender identities. Behaviorally, therapists working with SGM individuals
  Family Diversity and Substance Abuse 95

should be able to create a safe environment, focus on the substance abuse as the
problem rather than the client’s sexual orientation or gender identity, explore the
substance abuse within the person’s interpersonal and social contexts, support
clients in their perspectives of self, include significant others in treatment (i.e.,
family members or friends), and obtain supervision when necessary.
Because SGM individuals are impacted by a variety of individual, familial, and
social factors, Mereish et  al. (2018) encouraged interventions to focus on the
individual, familial, and structural levels. Senreich and Vairo (2014) explained,
“The impact of the client’s sexual orientation on the relationship with his or her
family and how it will affect recovery, particularly if it is a source of tension and
secrecy, needs to be explored” (p. 475). On the macro-level, therapists and others
working with SGM individuals can help to change norms, policies, and societal
discourses to reduce potential stigma and victimization.
Therapy of SGM families may involve aspects of psychoeducation of both
LGBTQ issues and substance abuse (Senreich & Vairo, 2014). This is impor-
tant since issues of acceptance are a prevalent risk factor for SGM adolescents
and young adults. Hicks (2000) recommended that when working with LGBTQ
substance abusers, the therapist might consider connecting the client to special-
ized addiction treatment programs. These specialized programs allow a space
for inclusivity and acceptance and can focus on SGM considerations, such as
coming out, homophobia, discrimination, self-acceptance, socialization, family
issues, and spirituality. Murphy and Hardaway (2017) expressed a need for
community-based outreach programs that would assist LGBTQ youth of color.
These programs would focus on the interpersonal, social, and community inter-
sections that would enhance racial, ethnic, and LGBTQ pride.

Case Application

Regardless of culture and ethnicity, the Rothers family has both risk and protec-
tive factors in relation to various members’ usage of drugs and alcohol. Family
members are at risk for alcohol use and abuse. This is especially so based on the
paternal intergenerational alcoholism. Mark grew up being exposed to frequent
alcohol use in his home. Further, he was exposed to and involved in a family that
had organized around alcohol. These same experiences and patterns are occur-
ring in the present family, where Steve, Kayleigh, and Pete are each living in a
house where frequent alcohol use, and now dependence and abuse, is happening
on a daily basis. Other risk factors include the increase in family conflict and
discord between the parents where family rules may be inconsistent.
The therapist working with Mark, and potentially his family, should assess
what culture each member identifies with. While someone may be raised in one
cultural group, they might identify more closely with another group’s beliefs and
values. Further, not all members of a family may identify with the same cultural
group. Even if they do, they might have differences in beliefs, values, and behav-
ioral processes based on other factors such as socioeconomic status, immigration,
or geographic location.
Working with the Rothers, the therapist should not just assume their ethnicity
based upon family name, looks, or color of their skin. Instead, the therapist can
96 Assessment 

ask them about their ethnic and cultural history and how that currently informs
their actions and viewpoints. Further, the therapist should be aware of potential
ethnic and cultural differences between themself and the Rothers family mem-
bers as these may play a role in the therapeutic process. This is enhanced by the
therapist being aware of his or her own social location—the various contexts that
influence the person’s identity, such as race, social class, ethnicity, sexual orien-
tation, gender identity, age, ability status, etc. The therapist can then engage in
the process of location of self where the therapist has a dialogue with the clients
about the intersection of their identities and how these may facilitate or limit
what occurs in therapy (Watts-Jones, 2010). This dialogue is enhanced when the
therapist is able to engage in self-reflection, empathically connect with the client
as two human beings, as well as to the client’s social location and community
context (Aponte & Nelson, 2018).

Summary
This chapter presented issues of family diversity; especially in regard to eth-
nicity of families. It presented general characteristics, adolescent drug use,
risk and protective factors, and various aspects of treatment for Hispanic
American, African American, Asian American, American Indian, and SGM
families. I encourage you to engage in further exploration of the various
ethnic groups that you work with in therapy. What was presented were
some of the common risk and protective factors in relation to substance
abuse. However, these are generics. You can use them as a foundation for
what might possibly be in play for the individual and family in front of you.
Yet, keep in mind the idiosyncratic way that that family fits—and does not
fit—in relation to what is commonly known about that ethnic group.

Key Terms
diversity peer group affiliation
culture Africentrism
enculturation second generation decline
ethnic identity intermarriage
acculturation intersectionality
risk factors sexual and gender minority
protective factors sexual minority
familismo gender identity
patriarchy emerging drugs
machismo elected families
marianism club drugs
simpati’a gay affirmative practice
matricentric female-headed social location
family pattern location of self
  Family Diversity and Substance Abuse 97

Discussion Questions
1. Discuss why it is important to understand the culture of the family
when working with them in therapy.
2. What are some of the unique risk and protective factors for the vari-
ous ethnic groups?
3. How do the various ethnic groups differ in their relationship to sub-
stance abuse?
4. What is the relationship between ethnic youth, peers, and family?
5. Describe how family ethnicity and culture play a role in substance use
and abuse.
six

Roles in the Addicted

Family

When substance abuse is present, perhaps the most visible person in the family—
because they tend to be the one having the most difficulties—is the person abus-
ing drugs or alcohol. We would call this person the dependent. However, the
dependent is not alone in the sea of troubles the family is experiencing. Others
in the family impact and are impacted by the effects of the substance use. For
those most central to the substance abuser, they have been labeled enabler, co-
alcoholic, or codependent.
Whether it was as a child growing up in a house where one or both parents
utilized drugs or alcohol, or in their current family, people’s behavior is inte-
grally linked to that of their parents, spouse, siblings, and children. For instance,
adolescents with substance-using parents use substances three times as often as
adolescents who come from non-drug-using parents (Horigian et al., 2015).
Each person comes together, accommodating to others, influencing others, and
being a participant, in a unique dance of the family. While each family dances
in their own unique way, family members tend to adopt one or more roles to
ensure that the dance continues—even if the music is a bit discordant—as that
dance is more familiar and safe than the myriad of possibilities they have not
yet explored. Gruber and Taylor (2006) explained, “Family role structures and
role assignments can be barriers to facing substance use and abuse issues” (p. 5).
We know that families are a system—a unit—and that systems are comprised of
many differing parts. These parts all come together to lead the family to function
in its current manner. For families where substance abuse is involved, relationships
are usually inundated with resentments, fears, frustration, anger, hopelessness,
and helplessness (Wallace, 2012). The family’s specific functioning will change
over time depending on the life cycle stage of the family, as well as current stress-
ors such as job loss, addiction, or divorce. Families are organized to maintain
the status quo—the family homeostasis—where the current functioning level is
maintained by family members taking on one or more primary roles in the family.
Family members usually do not consciously try to fulfill a role, but tend to do
so as a way to accommodate the current situation in the family. Some people,
depending on family configuration, will need to take on multiple roles. These
roles are based on the rules of the family. In this chapter we will explore several
conceptualizations of the various roles that family members adopt and what indi-
vidual members, as well as the family as a whole, gain or lose through taking on
these roles.

98
  Roles in the Addicted Family 99

Rules in Substance-Abusing Families

While all families function based on a myriad of overt and covert family rules,
alcoholic families tend to have distinct rules which they abide by (Wegscheider-
Cruse, 1989). The first rule is that the dependent’s alcohol use becomes the
primary organizing principle and focus of the family. The family believes that
alcohol is not at the core of whatever problems they are having. There is some-
thing else, perhaps unruly bosses, bad teachers, over-demanding extended family,
or a bad economic situation, which is leading to the tumult in the family.
The alcoholic family tends to absolve the dependent of blame on having
become addicted, putting that responsibility on someone or something else. For
these families, they believe that they need to maintain consistency; even at the
cost of the pain they are currently feeling. And what is interesting is that it is
not just one member doing this, but the recruitment, to some degree, of each
member. Everyone in these families is expected to help; in essence, to become
an “enabler.” For instance, the Rothers family may say that Mark’s drinking is
because of his family-of-origin; him having been born into a family of drinkers
and that is just how it is with “Rothers men.”
Another rule of alcoholic families is in the realm of communication. Members
are not allowed to talk about what is occurring in the house to people outside
of the family. This prevents others from knowing about the family pain and dis-
connects family members from possible support systems. People from the larger
system may suspect that something is not quite right in the family, but are not
given enough of an opening to understand or to help. For instance, a child who
has one or both parents abusing substances, with the family having significant
tension, may begin to do poorly in school—academically and behaviorally. The
teacher might inquire of the student as to what is going on, wherein the child
says, “Nothing. Everything is fine.” But said in a tone that clearly says that every­
thing is definitely not fine. The teacher, hearing the metamessage—the message
within the message—explores a little more with the student as to whether there is
anything going on at home. The child, knowing that they should not talk about
what is happening in the house, holds to their position and loses a potential
resource for individual and perhaps systemic change.
One of the other primary rules in the alcoholic family deals with honesty.
Members cannot be open and honest with one another; they must provide a
false face of strength. When a child approaches the non-addicted parent and asks
how come their father is acting differently, the parent may chastise the child,
saying that there is nothing wrong or it is none of their business. Each person
now pretends that there is not a problem in the family and all is as it should be.
Yet what is happening is that people begin to restrict themselves. They do not
allow themselves, or each other, to “be”—to say and do what they think and
feel. Dishonesty and lying begins to become an operating principle, where the
individual becomes closed off from others while the family system closes itself off
from the outside world. People learn how to be incongruent and lose the connec-
tion between their thoughts, feelings, and behaviors.
This next section describes some of the primary roles that are seen in alcoholic
and other drug-using families. While substance-abusing and non-substance-
abusing family members adopt roles within the family, these roles have an added
100 Assessment 

dimension in addicted families (Hawkins & Hawkins, 2012). Family roles are
multiple, that is, someone is not only in one role. We are all son or daughter,
partner, parents, friend, etc. Further, the roles that are given to people, and that
people take on, change and adapt over time. This coincides with how the fam-
ily’s homeostasis changes as the family moves through the family life cycle. In
addicted families, it also coincides with the progressive changes that substance
abuse has on the individuals, interpersonal processes, and family identity.
The family roles presented here for those in addicted families are the most
popular constructions in the United States regarding family roles (Vernig, 2011).
Keep in mind that an individual may, depending on the structure of the family,
occupy one or more roles. This usually happens in smaller families. In larger fam-
ilies, one or more individuals may demonstrate the same role. Whenever a person
takes on one of these roles—what are called survival roles—they are not able to
access their full self (Satir, Banmen, Gerber, & Gomori, 1991). This prevents
them from engaging in a positive growth process. The more they rely on their
survival role, the less they are able to experience their own thoughts and feelings.

Wegscheider-Cruse’s Family Roles

Sharon Wegscheider-Cruse was one of the first substance abuse therapists to talk
about the various ways that family members adapt and conform to living life
in an alcoholic family. Originally a student of Virginia Satir (see Chapter 13),
Wegscheider-Cruse opened people’s eyes to the notion that the family is one entity
but is comprised of many individuals who are impacted differentially to what is
happening in the family—but that they all work in conjunction with one another
(see Figure 6.1).

Enabler Dependent

Hero Scapegoat

Mascot
Addicted Lost Child
Family

Figure 6.1  Wegscheider-Cruse’s roles in an addicted family

  Roles in the Addicted Family 101

Dependent
The dependent individual is the person who uses the substance. From a fam-
ily system’s perspective, their behavior is a symptom of underlying issues in the
family—usually centering on unresolved conflict between people based on how
the family has organized. This conflict may be between spouses or intergenera-
tionally between children and parents (even if the children are now adult). The
dependent person tends to move away from responsibilities in various contexts
(i.e., career, parenting, emotional). The dependent incrementally shifts from the
family being the central organizing feature of their life to the drug of choice being
their main focus.
The dependent’s primary motivating feeling is that of shame. They feel bad
about themselves but do not know how to change. We can tell the dependent’s
symptoms through their use of whatever substance(s) they overuse. While we
might think that there are no benefits for their actions, people who use sub-
stances overwhelmingly talk about how it reduces or numbs their pain. Although
this might only be in the short run, there at least is a temporary barrier between
the pain of their life, their shame, and experiencing that pain. For the family
there is really no payoff, yet the dependent is so caught up in their own experi-
ence that they have difficulty connecting their actions with those of their loved
ones. If they stay in this role too long (depending on what substance they are
overusing) there is a possibility that they can become addicted. Severe addiction
may lead to many physical problems (such as cirrhosis of the liver, brain mal-
function or even death).

Enabler
In a family there may be one or more enablers—people who inadvertently help
to maintain the family function that supports the dependent’s usage. While there
may be several enablers in a family, there is usually one person who is the chief
enabler—the person who tries to help the dependent, but in a way that maintains
the problem cycle. The chief enabler is usually the spouse of the addicted person.
The enabler tries to protect the dependent from having to face the full con-
sequences of their actions. This protection, in the short run, diverts social and
financial consequences, yet does not protect the dependent from the emotional
pain they are experiencing. Just as addiction is a process that usually begins with-
out awareness, enabling follows the same course. Without conscious awareness,
the enabler does not realize the depth of the addiction and attempts to save the
person, a little at first and then greater over time.
The primary motivating feeling for the enabler is that of anger. We can tell the
enabler has been caught in the web of the family process through their sense of
powerlessness. Regardless of all of their attempts to try and help, things do not
get better. Slowly, the family’s situation becomes even worse. So why do they
stay in this role? The enabler gains a sense of importance and self-righteousness.
Further, since they are trying to keep things together for the family, they take on
most of the responsibility and make sure that things keep on running. However,
having the weight of the world on your shoulders is back-breaking. Eventually,
the enabler may develop physical illness and a sense of martyrdom.
102 Assessment 

The enabler tends to be the person closest to the dependent and the person
who takes their mental, emotional, and physical abuse. Instead of focusing on
themself, the dependent tends to criticize the enabler. This leads into a downward
spiral where the enabler tries to help because if the substance abuser could just
get past this point they would be able to show love again. The enabler then takes
on more of the dependent’s responsibilities, but also more of the criticism.
Many people use the terms enabler and codependent interchangeably. However,
the two are not quite the same. While the codependent does enable, they do it
differently than many other people in the dependent’s circle (Curtis, 1999). A lot
of people in the dependent’s relational field tend to enable their behavior (i.e., a
boss not inquiring about them being late for work, a coworker covering for the
absent dependent who left work early to go to the bar, or a friend who does not
tell the dependent’s wife how drunk the person got). Yet it is usually only one
person, the person closest to the dependent, whose identity becomes intertwined
with their connection and role in trying to help the substance abuser—this would
be the codependent.

Hero
The hero is usually the oldest child, who tries to help the family in its pursuit of
success. They may do really well at school, sports, music, or other such endeav-
ors. Their primary motivation is from inadequacy and guilt. They feel bad about
themselves as well as their family. In order to try to show themself, their family,
and the community that the family is not problematic, they try to pull everyone
up through their own success. Although others may see it in a positive vein, their
identifying symptom is that of overachievement.
As we’ve discussed, the roles of the family are intertwined. While the depend-
ent individual shifts their focus from the family to the drug and begins to abdicate
their parental power, the enabler makes excuses for this behavior and tends to
overcompensate for the dependent’s inactions. The family hero also steps into
some of the responsibilities that were given up by the addict. For instance, since
the hero is likely to be the oldest child, they are likely to take on some of the
parental duties that the dependent is no longer doing. Thus, they are very likely
to become parentified.
The hero takes this role for several reasons. First they gain positive attention
from those within and outside of the family. Second, they bring some sense of
self-worth to the family in a time when they are beginning to fall apart. The
hero’s behavior gives the family a sense of pride and something to focus on dur-
ing the chaos they are experiencing. However, if they take on this role too much
they can develop a compulsive drive that will eventually catch up with them.
The hero tends to be the overachiever in the family. They try to control their
own behavior by doing “well” while also attempting to control those around
them and the situation. For some, they may exhibit signs of perfectionism.
Glover (1994) recommended that therapists help the hero shift from an external
locus of evaluation and acceptance to an internal locus. This will allow the indi-
vidual to increase their own sense of self-worth. In this process, the therapists
can work to increase the person’s self-esteem and development of their self-
concept from internal conceptualizations of who they are.
  Roles in the Addicted Family 103

Scapegoat
In family systems terms, the scapegoat is the identified patient. This is the person
who will most likely be presented as the problem in the family; the person who
needs therapy. They are most likely to be engaged in some type of delinquency,
be it stealing, lying, behavior problems, or their own potential drug use. Their
motivating feeling is that of hurt. The scapegoat is likely to be the second oldest
child (Thombs, 1999).
We might look at people and wonder why they continue to engage in behav-
iors that others deem inappropriate and suffer the consequences for those
actions. While the hero is getting attention through praise, the scapegoat also
receives attention, just negative. However, attention is attention. And this atten-
tion focuses the drama away from the dependent person. So the misbehaving
actions can be seen as a way to protect the family by the individual becoming the
lightening rod of the family. But staying in this role too long can lead to severe
consequences as the person may engage in self-destructive activities that might
lead to their own addiction, incarceration, or even death.
There is a dialectic happening with the scapegoat. They seem weak as they cannot
keep things together and succeed. Part of this is based on seeing all of the attempts
by the codependent and the hero to try to save the family—only to see each attempt
fail. In some ways they may develop a sense of learned helplessness; where they do
not try to make things better—and why would they if others couldn’t?
On the other side of the coin is that the scapegoat—the identified patient—
has power in that the system must organize around them (Reiter, 2016). Their
actions get results. Part of this power comes in the form of defiance. They are able
to stand up to others, showing strength, but these actions hide their weakness.
The scapegoat feels inadequate and tends to feel self-pity and hostility.

Lost Child
In families that are having some type of crisis, some children such as the hero or
the scapegoat tend to draw the attention away from the crisis and the depend-
ent and onto themselves. Other children try to deflect any attention away from
themselves. They do not want to be involved in any type of conflict. This is the
plight of the lost child, who tends to demonstrate a heightened sense of shyness
and engages in solitariness. They operate from a primary feeling of loneliness.
Whereas the hero escapes into success, the scapegoat into destruction, the lost
child escapes into themself. This provides a sense of relief for the family as they
do not need to put much energy into them as they do not take up much of their
resources. Yet if the lost child takes this escape too far they may become socially
isolated. Their engagements with other people are severely limited, even extending
into adulthood. They might also think that if they were no longer in the family,
things would be better for everyone—and thus they may have suicidal ideation.

Mascot
The ambience of families dealing with substance abuse is one of caution, fear, pain,
and restraint. If these were the only possibilities, the family would quickly sink.
104 Assessment 

However, the mascot helps bring some type of amusement into the family through
their clowning around. They tend to be hyperactive and try to joke as much as they
can. This is problematic because it is coming from a motivating feeling of fear. The
mascot tends to be the youngest child in the family (Thombs, 1999).
The mascot gets attention through smiles from others and brings a sense of fun
to the family. Yet this is done to try to cover up the distress of everyone in the
family. When they take this to extremes they maintain an immaturity that does
not allow them to grow. They might also develop some type of emotional illness.
Family members tend to view the mascot as the most fragile person in the family
and may try to protect them (Thombs, 1999).
Some have suggested that the mascot is the last role to be developed in an alco-
holic family (Veronie & Fruehstorfer, 2001). These authors believed that when
both parents were alcoholic there was a lower likelihood that one of the children
would grow into the mascot role. Further, families that do not have a functioning
adult would most likely not develop a mascot as this role would take too much
energy from the family system.
These roles—the dependent, enabler, hero, scapegoat, lost child, and mascot—
all work together to try to keep the family ship afloat throughout a storm of pain
and distress (see Figure 6.2). Each member has their own way of trying to make
things better; by taking focus off the addiction and the pain and onto something
else—be it achievement, misconduct, humor, or invisibility.

Black’s Survival Roles

Claudia Black (2001), along with Wegscheider-Cruse, is one of the most influential
proponents in working with families dealing with substance abuse. She proposed

• The person using substances

Dependent • Tends to focus on self

• Usually the sober partner of the dependent

Enabler • Overfunctions

• Usually the oldest child

Hero • High achieving and seeks approval

• Usually second born

Scapegoat • Tends to garner negative attention

• Tends to isolate self

Lost Child • Escapes through loneliness

• Tends to be the youngest child

Mascot • Uses humor to bring relief to the family

Figure 6.2  The various family roles that work together to maintain an addicted family’s
problematic homeostasis
  Roles in the Addicted Family 105

similar roles that family members tend to take on in addicted families. While there
are many overlapping ideas between her conceptualization and Wegscheider-
Cruse’s, an understanding of Black’s roles may help to broaden the notion that
individuals in a family tend to become restricted in certain ways of being in
the family.

Codependent
As we have seen, the dependent does not use in isolation. Although the actual
consumption of the drug might occur when the individual is alone, the emotional
field surrounding the drug use happens in a relational field. The person who is
closest to the dependent, usually their spouse/partner, tends to unconsciously
enter into a dance of destruction with the dependent where their own identity
becomes obscured—a process known as codependency (see Figure 6.3). Black
(2001) describes how this happens, “It now encompasses the dynamics of giving
up a sense of self, or experiencing a diminished sense of self in reaction to an
addictive system” (p. 3).
The codependent’s experience is one of giving up focus on the self to focus
on the other—in this case the person whose drug use has become out of control.
Black (2001) explained some of these processes: They tend to lose a sense of
self; of what they want and what they need. They become so focused on another
person whose needs are ever increasing that they do not focus on their own life.
They tend to be reactive to someone else rather than thoughtful of what and why
they are behaving as they are. Codependents focus more on the dependent’s needs
rather than on their own priorities. While doing this they take responsibility for
the other person; doing for them instead of letting the addicted individual do
for themselves. Problematically, the codependent tends to utilize denial as a key
theme in their lives.

The Responsible Child

At least one child in the family tends to become more responsible than the other
children. Usually this is the oldest or only child (Black, 2001). Their behavior is
designed to help calm the storms that are present in the family. Black explained,
“This child takes responsibility for the environmental structure in the home
and provides consistency for others” (p. 17). The responsible child helps to
provide a semblance of normalcy in an otherwise potentially chaotic family.

Loss of
Identity
Family
Dependent Codependent
Member
Reactive
to Other

Figure 6.3  The codependent loses a sense of identity and becomes reactive to the
dependent’s emotions and behaviors
106 Assessment 

They exhibit good organization skills, responsibility, and are able to set and
achieve goals. When they engage in these types of behaviors, they are rewarded.
This occurs at both home and school. For those who come into contact with a
family only through the responsible child, they might think that the family is
functioning quite well.
On the surface the family seems to be functioning, as the individual is suc-
ceeding. However, while they are being responsible they are also learning about
distrust. The responsible child has learned that his or her parents cannot be relied
upon; thus, the responsible child has to become very independent and learn how
to fend for themselves if they want to ensure that things get accomplished. This
can have serious consequences for their future relationships with adults.
Because the responsible child is so focused on acting more mature than they
really are, they tend to lose out on their childhood. Instead of being able to be a
child/adolescent they have to be an adult. This leads to them being more serious
in social situations and not being able to let go and have fun.

The Adjuster
The adults in the family (usually the dependent and codependent), as well as
the responsible child, tend to be the main players to organize and structure the
family. This structure is chaotic but manageable, especially by the responsible
child who learns to forge their own path. Not all children develop this type of
navigation. Black (2001) described this alternative role, “The child called the
adjuster finds it much easier to exist in this increasingly chaotic family situation
by simply adjusting to whatever happens” (p. 20). The adjuster tends to be a
younger child who does not try to impose their will on the situation. Rather,
they roll with the flow, going along with what is happening. One of the reasons
for this is that they have developed a belief system that, regardless of what they
might try, they wouldn’t make a difference. In essence, they have developed a
sense of learned helplessness.
In looking in from the outside of this family, the adjuster would seem to be the
loner of the family. They are more detached, physically and emotionally. During
conflicts in the home, the adjuster might sneak away to their room and not put
themself into the center of attention. The parents in the family may provide more
attention to other children, as they seem more present in the family.
One of the difficulties of adopting the adjuster position is not coming in con-
tact with one’s true thoughts and feelings. The person may just behave rather
than have a sense of what or why they are acting in the way they are. As adults
they continue to not take control of their situation and just go with the flow.
While they may be more flexible and spontaneous than the responsible child, they
have a reduced sense of control, lacking a sense of power or direction.

The Placater
Whereas the adjuster has a fairly flat affect and does not become emotionally
reactive, there is usually one child in the house who does; this is the most sensi-
tive child. Black (2001) explained, “In the addicted family the placating child
  Roles in the Addicted Family 107

is not necessarily the only sensitive child in the home, but is the one perceived
as the ‘most sensitive’” (p. 22). The placater experiences a lot of pain due to
their heightened sensitivity. Whereas the responsible child overcomes their pain
through achievement and order, and the adjuster blunts their pain, the placater
attempts to lessen their own and others’ pain. They tend to try to be the “fixer”
in the family. When they grow up, this child might go into the mental health field
as they are attuned to knowing people’s pain and trying to reduce it.
While it may seem that this attunedness to another’s pain and being empathic
is a positive trait, it can become problematic. The placater has a tendency to not
disagree with others. In this case, the person may lose a sense of self, not being
able to stand up for his own rights. In the family, the parents tend to like the pla-
cater because the child does not put up an argument. They get along with others
and do not bring more drama to a play that is full of discord. Further, if there is
conflict, they are usually the first to apologize.
As adults, the placater still attempts to care-take for others. They will tend
to find jobs where they can help others. However, they may have a tendency to
develop symptoms such as depression (Black, 2001), as internally their experience
is one of loneliness. Although they are in connection to others, the relationship is
usually lopsided where they are giving and the other person is taking. Placaters
tend to not receive the gifts of due concern that others may be able to give.

The Acting-Out Child

The roles of the various children in drug-using families that Black has proposed
have so far all been ways for the members to deal with the chaos of the family
without making things any worse. Members either try to provide stability, fade
into the woodwork, or make others feel better. However, there is usually one
member who deals with the pain and chaos of the family by taking the focus
off of the dependent person and onto himself. This is the acting-out child. Black
(2001) explained this role, “They will cause disruption in their own lives and in
the lives of other family members. In doing so, they will often provide distraction
from the real issues” (p. 25).
The acting-out child tends to produce conflict through confrontation within
and outside of the family. The more that the parents can focus on this child’s
negative behavior the less they have to focus on what is happening in other areas
of the home—especially as it relates to drug use. Although not done intention-
ally, the child attempts to save the family by offering themself up as a scapegoat.
This tends to have deleterious effects on the child’s self-esteem. They may think
of themselves as worthless and troublesome.
This low level of self-esteem follows the acting-out child into adulthood. They
have most likely entered into peer systems where they can cause trouble with oth-
ers. Out of all of the children in the house, the acting-out child has the highest
probability of developing their own addiction. However, alcohol and/or drugs
can serve a purpose for a person displaying any of these roles. For instance, alco-
hol may loosen up the rigidity of the responsible child. The adjuster may develop
a heightened sense of power when under the influence. For the placater, alcohol
might give them the courage to stand up for themselves and become more asser-
tive. Figure 6.4 presents Black’s roles for people in an addicted family.
108 Assessment 

Dependent

Adjuster Codependent

Addicted
Family

Placater Responsible

Acting-out

Figure 6.4  Claudia Black’s classification of roles in an addicted family

Overlap of Wegscheider-Cruse’s and

Black’s Family Roles

As can be seen, there are many similarities between the family roles proposed by
Wegscheider-Cruse and Black (see Figure 6.5). The responsible child is similar to
the hero. The scapegoat is similar to the acting-out child. The adjuster is similar
to the lost child. The placater is similar to the mascot. Whatever term is used, if
treatment is not sought at some point in the individual’s life, the person will most
likely develop future symptoms in school, work, relationships, and health and
emotions; usually based on which family role they had adopted (Middleton-Moz
& Dwinell, 2010).
The hero/responsible child seems to be doing very well during their childhood
as they tend to succeed in various areas of their life, providing a positive focus
for the family. However, without intervention, they may try too hard to succeed,
perhaps becoming a workaholic. They have learned that it is their responsibility
to do, as they could not rely on others in their families. As adults, they may tend
to not trust others and not be a team player. They could also develop symptoms
of perfectionism, where they punish themselves for making mistakes. In their
relationships, they may try to take over and control the other person, operating
from a need to be right. They tend to have difficulty forming very intimate rela-
tionships and may find a partner who needs them to continue to be responsible.
In the areas of health and emotions, these individuals may not be able to express
  Roles in the Addicted Family 109

Wegscheider-Cruse Black

Dependent Dependent

Enabler Codependent

Hero Responsible Child

Scapegoat Acting-Out Child

Lost Child Adjuster

Mascot Placater

Figure 6.5  Comparison of Wegscheider-Cruse and Black’s roles in an addicted family

their emotions well, keeping things inside. This pain may come out in the form of
physical illnesses. The hero/responsible child tends to deny their pain and anger,
and is not happy when they complete projects.
The acting-out child/scapegoat helps to channel the family’s energy away from
the addicted individual by sacrificing themself as being the family’s problem. In
school and work this person tends to get into trouble, perhaps getting detentions
and suspensions, or often getting fired. They tend to go against authority and the
rules of the system they are operating in at the moment. In relationships, they
create conflict. During adolescence this may manifest itself in running away from
home. As an adult, they may find a partner who is codependent, takes care of
them, and allows them to continue to act out. They tend to find ways to hurt their
partner and create chaos in their lives, perhaps by having unplanned pregnan-
cies or getting into frequent verbal and physical altercations. In terms of health
and emotions, they are likely to engage in their own substance use and possibly
abuse. Instead of being able to talk with others about what is going on for them,
they display their emotions behaviorally—usually focusing on pain and anger.
Because they have adopted this role of the “tough guy” they are not able to show
their softer and more loving side.
The adjuster/lost child tends to meld into the background where they do not
bring focus on themselves—either good or bad. This person will tend to iso-
late from not only their family members, but from people at school or later at
work. They tend not to be able to take much initiative in their lives—instead
finding themselves not engaging others. Because they are trying to stay in the
110 Assessment 

background, they stifle their abilities so they do not shine. In relationships, when
they do engage with someone, they take the backseat in the relationship—finding
a partner who can take the focus off them. As regards their health and emotions,
they tend to have low self-esteem and low self-worth. Others would view them
as shy and may try to control them. These individuals feel helpless and may use
substances as a way to control a very small aspect of their lives.
The placater/mascot tries to engage others to make them feel good about them-
selves and take focus off the family pain. This individual would most likely be
the “class clown,” where others may laugh when around them but may not take
them seriously. Even when they do well in something, they may allow someone
else to take credit for it. In relationships they may lose their identity and do for
others rather than standing up for themselves. When conflict happens they will
either try to avoid it through joking about it or giving in to the other. When in an
authority position, they may not follow through on discipline or consequences.
Instead of standing up for their needs and wants they may become dependent on
the other person. When it comes to their health and emotions, they do not do well
handling stress. Substance use may help them to dissipate some of their feelings,
as they tend to internalize their emotions.
There may also be role reversal where someone who adopted one of the family
roles later gives up that role and adopts a different role. For instance, the family hero,
who has been succeeding in various areas of life (i.e., school) may eventually become
the scapegoat (i.e., they begin abusing substances and develop an addiction). This
reversal is not something that happens quickly, but over time as the person gives
up one role for another. However, I want to make it clear that a person does not
develop a family role on their own. It is only when other family members allow
them to take it on and all family members engage one another in ways that maintain
everyone’s roles that people are able to function as they do.
The problems the people have based on the family roles they have adopted
may (or may not) develop if intervention does not occur. However, with therapy
and/or self-exploration, this does not need to be the case. People who adopt
any of these roles can change their lives so that they are able to function well in
school, work, relationships, and with their physical and emotional health.

Support for the Family Roles

There has been considerable debate regarding the various family roles put forth
by Wegscheider-Cruse and Black. While empirical attempts have been made
to validate these proposed family roles, there has not been enough testing and
support to validate them (Vernig, 2011). Potter and Williams (1991) developed
the Children’s Roles Inventory (CRI) as a means of measuring the various roles
that children may play in alcoholic families. This measure was based on Black’s
construction of family roles and was found to have good internal consistency.
However, these authors believe that alcoholic as well as non-alcoholic families all
have these same roles. Using the CRI, Alford (1998) found that people from dys-
functional families showed greater agreement with the lost child and scapegoat
roles, but less strong agreement with the hero role. Factoring out adult children
of alcoholic participants, people from dysfunctional families were three times
  Roles in the Addicted Family 111

more likely to be in the lost child role and less likely in the mascot role. Alford
concluded that, irrespective of parents’ substance use, family dysfunction had
the greatest impact on which role a member identified with. Fischer et al. (2005)
found that in families with high parental drinking and family dysfunction, oldest
children tended to take on the hero role, especially in relation to their younger
siblings, who tended to adopt the lost child role. Yet, those older siblings in the
hero role were buffered from the family of origin whereas siblings in the lost
child and scapegoat roles had higher levels of vulnerability to the family of origin
(Fischer & Wampler, 1994). These researchers held that males in the mascot role
were buffered from family dysfunction much more than those in the lost child
or scapegoat roles. Thus, there are differential impacts on children in substance-
abusing families based on gender and which role they take on.
There has been a lot of controversy surrounding whether Wegscheider-
Cruse’s or Black’s family roles can be empirically substantiated. Rhodes and
Blackham (1987) developed scales to determine Black’s roles of placater, acting-
out child, adjuster, and responsible child. In their study they compared children
from alcoholic and non-alcoholic families to determine whether there were any
differences on these scales. They found that there were not any significant differ-
ences except for the acting out scale. Devine and Braithwaite (1993) developed
alternative scales that represented the placater, acting out, lost child, and mas-
cot. These researchers found that their scales helped support the various family
roles developed by Wegscheider-Cruse and Black. Although there was support,
their scales did not endorse all of the various behaviors hypothesized with these
roles. As added evidence of the usefulness of using the family role typologies,
these scales were effective in differentiating children from alcoholic and non-
alcoholic homes.
While Wegscheider-Cruse and Black’s family roles tend to be the predominate
models proposed about how family members cope with what is occurring in
the addicted family, other therapists and theorists have also proposed their own
typologies. We will end this chapter by discussing one more model of family
roles—that of Vernon Johnson.

Johnson’s Family Roles

Johnson (1986) explained that in families dealing with alcohol, family members
take on one or multiple roles, depending on the family configuration and what
is occurring in the family. These roles include the protector, the controller, the
blamer, the loner, the co-dependent, and the intervener (see Figure 6.6). Many
of these roles overlap with the roles that Wegscheider-Cruse and Black endorsed.

The Protector
The protector role will usually demonstrate itself during the beginning of the
family’s encounter with addiction. At this point, the drinking/drug use is only
infrequently impacting the family functioning. The protector tends to become
defensive of the addict and the family. This comes in the form of apologizing for
112 Assessment 

Protector

Intervener Blamer

Addicted
Family
Loner Controller

Co-
Enabler
Dependent

Figure 6.6  Vernon Johnson’s typology of family roles in an addicted family

the addict’s behavior (i.e., not showing up, anger outbursts, disregard), contact-
ing the addict’s employer to provide excuses for being late or missing work, and
agreeing with the addict’s rationalization for the drug use.
As the protector begins to engage in each of these actions, their sense of self
diminishes. They do not feel as good about themselves and find that they are
using rationalizations for their own actions like the addict uses for theirs. The
addict will tend to project their anger and frustration onto the protector who
takes this on and feels increasingly inadequate. The commonality between the
protector and addict is that they are both deceiving themselves and others as to
what is happening.

The Controller
As the addiction process progresses, family members’ sense of self wears away to
where they feel out of control. They may believe that they are at fault for what
is happening in the family. To gain some type of continuity and equilibrium, a
person may adopt the role of the controller. Here, the person tries to be active in
trying to change the addict’s behaviors.
The controller engages in many different behaviors to reduce the drug use and
its consequences. They might take over the buying and procurement of the sub-
stances so that they have control over what type and how much is present. As a
  Roles in the Addicted Family 113

more extreme aspect of this, the controller may engage in drinking/drug use with
the addict in the hopes that if they do it together the addict will not use as much
as they do on their own or with their substance-use cohorts. Some more subtle
behaviors they might engage in include pouring out alcohol or disposing of drugs,
not agreeing to go to events where the person may use, and pleading with the
addict to stop (for self, spouse, and/or children). However, there is a paradoxical
process that happens where the more the person tries to control the addict’s use,
the more the addict uses.

The Blamer
When feelings of low self-worth grow, the individual’s self-deception takes over
and they project their feelings of anger, hurt, and failure on others; most likely the
addict. Active conflict becomes more prominent in these families as the blamer
begins to covertly and overtly go after others. Covertly they may give the silent
treatment to the other person when they do not like what the other person did.
Overtly, they may bring up, in an aggressive manner, actions the other person
just did (or did in the past) that they did not like, such as not getting along with
their parents or being late for an event.
One of the interesting aspects of the blamer is their fluctuations, where at some
points they seem to be quite depressed and at other points they are demonstrating
outbursts. These seem to be related to quite trivial events. However it might be,
the person is so focused on blaming the other that they are not in touch with their
own feelings of uncontrollability, unrest, and self-delusions.

The Loner
As the ability to control one’s surroundings slips away, the individual may shift
from an external focus to an individual focus. The person’s self-worth and self-
esteem are most likely extremely low. Their interactions with others have become
strained and they tend to isolate themselves; eventually adopting the loner role.
Here, the person has become increasingly defensive, leaving friends and family
members to feel uncomfortable in their presence and likely to disengage from
them. The loner feels alone in their misery, floating on a raft in an ocean with the
current flowing away from land.

The Enabler
Over time, the addicted person progressively underfunctions, and one or more
family members tries to compensate for this and overfunction. They become
responsible for the addict. At this point they may take on the enabler role. This is
perhaps one of the most famous roles, as the enabler’s behavior allows the addict
to not have to face the consequences of his actions. As the enabler tries to control
the chaos, the addict is able to continue to use, and the family continues to spiral
into dysfunction.
114 Assessment 

The Co-Dependent
The co-dependent is, in essence, the next stage of the addiction process from
the enabler. The person is clearly not able to see how their own behavior is
deteriorating and is tied to the addict’s behavior. The person increasingly has
aspects of each of the roles presented here; they become more protective, more
controlling, and more blaming. Their sense of reality is distorted and they are not
able to see how they are falling into a morass of progressive and chronic pain.
Co-dependents tend to exhibit poor self-esteem, a need to be needed, a strong
urge to control and change others, a willingness to suffer, a resistance to change,
as well as a fear of change (Thombs, 1999).

The Intervener
The roles that were previously described present a dysfunctional way of trying to
deal with the chaos occurring in a family dealing with addiction. Johnson (1986)
provides a role that is more productive; that of the intervener. This happens
when the person understands addiction and the process that happens for not
only the user but those in his relational field. The intervener will have engaged in
a self-exploration to understand how he or she may have adopted the role(s) of
protector, blamer, controller, enabler, and/or co-dependent. The person is able
to make a distinction between self and addict and not take the responsibility for
change totally onto themselves.

Case Application

Mark is the dependent in the Rothers family. He is drinking enough that he is

considered an alcoholic, where there is both abuse and dependence. If he stopped
drinking there would be withdrawal. On initial assessment of the family, Mark
would be the first concern, as he is isolating himself, increasing the amount of
his alcohol consumption, and has made statements about wanting to be dead.
However, there are concerns throughout the family as individuals have developed
survival strategies of various roles to help them cope with being an addicted family.
The Rothers family find themselves organized by alcohol, but don’t quite
know it. They have come under the spell of the first rule of addicted families;
that substance use is the primary organizing principle of the family. They realize
that they are having problems, but have not put the focus on substance use and
abuse. Rather, they are looking at Mark as being depressed and Steve as acting
out. While they might think that alcohol does not help Mark’s discontent, they
view it as an accomplice rather than as the mastermind of the disharmony. Since
they do not know whether Steve is using any drugs or alcohol, the family views
his acting out at home and school through a developmental lens, as a rebel-
lious teenager rather than as symptomatic of being raised in an alcoholic family.
People may be seen in isolation rather than connected in a web of intergenera-
tional patterns and relationships.
The Rothers family also find themselves abiding by the rule of not talking
about how alcohol is now running their lives. There may be times when Hannah
  Roles in the Addicted Family 115

suggests to Mark that he not take another beer, but after being rebuked several
times for this intrusion in his drinking, she keeps it to herself. The children also
do not talk about Mark going off into his den to watch television and drink by
himself and have accepted this as just how their family is. Steve may be the first
to bring the drinking to the forefront, but it would likely occur during a huge
confrontation where all parties involved are angry. This would devalue his con-
cern for the amount of Mark’s drinking. Hannah has not yet said anything to
her family about her concerns for Mark’s drinking and how the family seems to
be slowly unraveling. There are rigid boundaries between the Rothers and other
systems, such as extended family, religious, and school systems.
While Mark is the dependent in the family, he is not the only member to take
on a role that maintains the family’s current homeostasis. Hannah is the chief
enabler. While she does not like Mark drinking, and his associated foul mood
and disconnection from the family, her actions inadvertently keep the family
functioning in their current state, which allows Mark to continue his pattern of
usage. She serves as a buffer between the children and Mark, ensuring that no
one upsets him. She can feel the tension underneath the surface of the family’s
interactions and does what she can to keep that at bay. She may have explored
possibilities for Mark, such as therapists, self-help groups, or treatment pro-
grams, but hasn’t approached him about it in fear of rocking the boat too much.
She at first covered for Mark in terms of calling in sick for him at his work, or
taking care of their children when he was drunk. However, she is also one of the
most vocal about him changing, not realizing how some of her past actions had
contributed to maintain the substance abuse.
The hero in an addicted family is usually the oldest child, but not so in the
Rothers family. Kayleigh is the hero as she is overachieving at school. While on
the surface it would seem that she is the most “healthy” person in the family, her
striving to do well is likely in reaction to the tension and discord in the family.
She may believe that if she does everything right, everything will be fixed in the
family. However, she is likely to learn about her own inadequacy as the harder
she tries to take the weight of the family on her shoulders, the more the family
negatively spirals. This could eventually lead to a sense of guilt that she could not
help the family.
Steve has taken on the role of scapegoat in the family. He is acting out in
school and at home. In all likelihood, the Rothers family will come to ther-
apy with Steve as the identified patient, most likely through a referral from
the school system. Steve’s negative behaviors bring him attention both inside
and outside the house. Whenever he argues at home, his parents interact with
him. While that may be through yelling and argument, it shows that he is
important and has some type of power. His feelings of weakness, fear, and
inadequacy become hidden when he defies authority and attempts to show
strength and power.
Pete likely fills both the role of lost child and mascot. There are times when he
will be alone in his room to get away from the cloud of misery that has been hov-
ering over the family. In these moments, he is the lost child as no one in the family
has to worry about him. They have a reprieve for wondering, “What next?” At
other times, Pete may act in the role of the mascot as he can be the most playful
person in the family.
116 Assessment 

Summary
As can be seen from each of the models presented in this chapter, families
in which there is addiction tend to have members who engage in various
coping strategies to survive what is currently happening in the family. It
is important to remember that the adoption of these roles is relational,
expressing both individual and familial coping responses. When people
adopt a role in the family, they and the other members restrict the behav-
ioral, psychological, and emotional experience of that person. If the role
becomes their identity, there is a greater likelihood that some type of symp-
tom (physical, emotional, or psychological) will be present. However, it is
important to keep in mind that people adopt these roles, and allow others
to take on their role, as a way to survive the chaos and pain that is living
in the addicted family.

Key Words
metamessage codependency
survival roles the responsible child
dependent the adjuster
enabler the placater
chief enabler the acting-out child
hero the protector
parentified the controller
scapegoat the blamer
lost child the intervener
mascot

Discussion Questions
1. Explain the differences between each of Wegscheider-Cruse’s family
roles. How do they all interweave with one another?
2. Describe each of the survival roles that Claudia Black proposes.
3. Discuss Johnson’s family roles.
4. How are Wegscheider-Cruse’s, Black’s, and Johnson’s family roles
similar?
5. In what ways are the development of family roles both individual and
relational?
seven

Family Life Cycle

This chapter discusses how a family changes over time. Families are not static
entities. Not only do the individuals in them follow normative developmental
patterns (i.e., Erik Erikson’s stages of individual development), but the family as
a whole does as well. The chapter starts by exploring the typical stages a family
goes through and then will narrow in on the individuals in the family by first
talking about children growing up in alcoholic families and then exploring adult
children of alcoholics. The chapter ends by focusing on the concept of resil-
iency and how children growing up in addicted families might gain and utilize
strengths and resources to help them through the chaos.

Normal Family Development

We have described the family as a system; a group of interacting parts that come
together to function as a whole. As an organized unit the family develops rules to
help it navigate various transitions of living. While not all families go through the
same transitions, they all change over time. This section focuses on the “typical”
North American family life cycle, which entails a heterosexual couple that has
one or more children. These stages may change based on various factors such as
not having children, premature death of a member, divorce, or other such issues.
To be clear, these are the generic transitions for what has become the “standard”
North American family. However, the configuration of families has changed to
some degree as two-income families, stepfamilies, same-sex couples, and having
children out of wedlock alters the timing and fluidity of the stages. But having this
knowledge as a foundational understanding of family development can assist in
understanding these other family configurations.
A family’s life cycle can be seen as being comprised of six stages (Carter &
McGoldrick, 1999). These include: leaving home—single young adults; the
new couple; families with young children; families with adolescents; launching
children; and families in later life. At each of these stages there are emotional
processes based on the transitions from one stage to another as the family has to
accommodate the introduction or departure of one or more members. Further,
the family system needs to change—shifting various boundaries and rules—at the
end of each stage to be able to function well when moving into the next stage.

117
118 Assessment 

We can look at the beginning of a family life cycle as starting with a single
young adult. In previous years this may have been when the adolescent became
an adult—around 18 years of age. Due to various circumstances including eco-
nomics and culture, the age of launching may be being pushed back. For the
individual who is starting their adult life, there are many challenges that must be
faced. Perhaps foremost in this is taking on the responsibility for one’s own life.
This comes in the form of economic, social, and emotional ownership of one’s
self. The individual must differentiate from their family, developing their own
life while also still being connected to the family. At this stage in the life span, a
shift tends to happen from the importance of nuclear family relationships to peer
relationships. The young adult will also need to establish themselves financially,
usually through the beginning of their career. At this stage the person is also look-
ing for a potential romantic partner, which leads into the next stage of the family
life cycle. However, the single young adult stage has been increasing in length
as more men and women have been gaining a post-secondary education as well
as beginning their work career before marrying. According to the U.S. Census
Bureau, median age at first marriage has increased from around 20 years old for
women and 23 years old for men in 1950 to 27 years old for women and 29 years
old for men in 2017.
At some point two individuals who are in the young adult stage meet one
another and decide to enter into some type of committed relationship (i.e., mar-
riage). The new couple isn’t only the joining of two individuals, but two family
systems. Although some of these connections of in-laws are very close, others
are more distant. Yet the projections of these family systems—the two people in
the new couple—interact with one another based on patterns and understand-
ings from each of their family of origins. At this point, each individual needs to
commit to the new family system requiring a readjustment of how they operate
to include more time, energy, and loyalty to their new partner and a reduction of
energy in relationships with peers and other family members. This can be a very
discordant time, especially if one or both members of the couple were extremely
close to their family of origin. If so, the person may feel split loyalties, where they
are caught in a tug of war between wanting to do for their original family and
doing for their partner (Boszormenyi-Nagy & Krasner, 1986).
The third stage of most families occurs when they have their first child. In
families with young children, the two individuals who have adapted to become
a couple now must adapt again to allow the entry of another member into the
family. This requires a change in the rules of the family system. Many families
experience difficulties at this stage as they are unsure of how to negotiate time and
energy into the couple and as well as their parental responsibilities. In traditional
sex role families, the wife exerts much of her focus on the new child while the hus-
band feels excluded to some degree. Besides the parents having to negotiate with
one another around financial and child-caring issues, they also must open the
boundaries of their new family to include the role of grandparents and extended
family. For some families where there are more diffuse boundaries between the
couple system and the grandparent system, there may be role confusion as the
grandparents try to take over the executive functioning of parenting. Depending
on how many children the couple has, there may be multiple adjustments of new
members into the family, which would lead to this stage lasting longer.
  Family Life Cycle 119

The next stage is that of the family with adolescents. The major systems
change that needs to occur is the parents’ increasing flexibility to allow more
independence for the adolescent in the preparation of the adolescent developing
into a young adult. The adolescent tests boundaries to try to begin the differ-
entiation process from the family. Also at this stage, the parents’ parents may
begin to need more assistance in their own lives due to illness. For those adults
who must take care of their own children while taking care of their aging par-
ents a new term has recently been put forth—the sandwich generation—as they
are sandwiched between having to care-take for those generationally above and
below them (their children and their parents). While the adolescent is beginning
to move away from the family, husband and wife now must put focus back on
the marital relationship.
Once the adolescent becomes a young adult, the family moves into the fifth
stage; launching children and moving on. Here the family allows the departure
of the young adult and must renegotiate from three or more people to now only
two. Parents have the difficulty of letting go their primary parenting responsi-
bilities to allow their child, who is now an adult, to make their own choices.
This requires a shift from parenting to more of a consulting or even a friend-
ship role with the child as they now are having an adult–adult relationship with
their children. At some point after the launching, the young adult will have
found their partner and the parents will have to allow for the entrance of new
family members (son-in-laws or daughter-in-laws) as well as the possibility of
grandchildren. The parents’ parents are likely to be ailing at this point and the
possibility of their deaths play a major role in the family. The launching stage is
also a significant time for marital discord as the empty nest syndrome happens.
If the couple has not kept engaged with one another as a romantic dyad, they
may find at this point, with no one in the house besides themselves to focus on,
that they have grown apart.
The last stage of the family life cycle is families in later life. The two adults
must deal with each of their own frailties. A generational role shift occurs where
instead of being caretakers for others, the elderly individuals find that others
are beginning to take care of them. Retirement has occurred, which can be a
significant loss of identity to those who had seen a close connection between
themselves and their careers. Spouses must adjust to the loss of their partner by
death and shifting their role from primary to secondary in their children and
grandchildren’s lives.
As has been hinted at in this explanation of the family life cycle, there are
usually four family subsystems operating at the same time in this developmen-
tal process. The launching stage is a fork in the family’s life where the parents
take one road—moving closer to later life—and the child, who is now a young
adult, taking the other road. When a new couple forms, we can see three fami-
lies in play: (1) the couple; (2) one partner’s parents, who are in the launching
or recently launched stage; and (3) the other partner’s parents, who are also in
the launching or recently launched stage. As the new couple has a child and that
child matures into an adolescent, each of the original families-of-origin begins to
move into the families at later life stage. When the adolescent matures enough
to enter into the single adult stage (and enters the fork of single adulthood—
launching), their two sets of grandparents may be at the latter end of their lives.
120 Assessment 

Single/Couple/Child/Launching/Later Life
Single/Couple/Child/Launching/Later Life
Grandparents
Single Adult/Couple
Parents
Children

Figure 7.1  The generational overlapping of family systems during each family’s
developmental life stage progress

Thus, at one time we may see three or more different generations operating
separately, yet intertwined. Figure 7.1 presents a visualization of these overlap-
ping family systems.
What was just presented is based on a family life cycle where there is not a
major change in the family, such as divorce, early death of a partner and/or
remarriage. However, approximately 50% of couples do divorce and the divorce
rate is even higher for second marriages. When remarriage happens, there is now
a joining of multiple family systems where the integration of three or more fam-
ily systems needs to occur. Also, the parental subsystem attempts to negotiate
parenting duties; determining whether the step-parent will play a primary role in
disciplining non-biological children.
The family system is impacted when substance abuse is involved. As discussed
in Chapter 4, families dealing with addiction tend to have boundaries that are
either too rigid or too diffuse. Since clearer boundaries usually help the system
function more effectively, families that hold onto rigid or diffuse boundaries will
tend to not be able to adapt when they transition into new life stages. These tran-
sitions between family developmental stages are a likely time for the development
of symptoms if the family cannot adjust to deal with the current situation. For
instance, families in the launching stage may have an adult engage in increased
substance use as a way to negotiate the loneliness and disengagement they feel
from their partner and the family.
The understanding of life stage needs to be housed within a multicontextual
perspective where individual, family, and larger systems all influence and are
influenced by each other (Carter & McGoldrick, 1999). The family therapist
should be able to assess the individual in terms of their own developmental pro-
cess (perhaps through an understanding of Piaget’s perspective or Erikson’s life
tasks). The therapist must then understand how the various individuals come
together to form the family system. This nuclear family is housed within the con-
text of the extended family. The extended family is housed within the community
  Family Life Cycle 121

Individual

Family/Extended
Family

Community

Time
Figure 7.2  The embedded connections between the individual and larger systems
over time

and the social connections the family has with others. Lastly, the community can
be viewed within larger frames of social structure that include issues of hierarchy
and power inequality. Figure 7.2 provides a visualization of these embedded con-
nections and that they change over time.

Addiction and the Family Life Stages

In families dealing with addiction, members have difficulty in being able to differ-
entiate from one another (Hudak, Krestan, & Bepko, 1999). One of the reasons
for this is that the more ingrained and organized around the addiction the system
becomes, the more isolated it becomes from extended family and larger systems.
Family members have probably developed rigid boundaries with outside systems
and either rigid and/or diffuse boundaries within. Further, they are most likely
engaging in the use of secrets; not letting others outside the family, or even within
the family, know about the addiction, violence, abuse, and discord.
Family therapists must be able to see the interacting process of individual and
family development to help put into perspective the development and mainte-
nance of the symptoms (i.e., the substance abuse or acting out) that one or more
members display. Hudak et  al. (1999) explained, “Two interacting sequences
occur simultaneously: the progression of the alcoholism within the individual and
122 Assessment 

the developmental progression within the family itself. Alcoholism both influ-
ences and is influenced by the movement through the family life cycle” (p. 459).
During the single young adult stage, the individual—whether abusing substances
themselves or coming from a family dealing with addiction—may not be able to
separate from the family system. Alternatively, if the young adult is the addict, the
family may emotionally cutoff, leaving the individual with a reduced support sys-
tem. These and other factors may hamper the substance abuser’s ability to engage
with others in the future. There may also be conflict where the addicted young
adult tries to delay the launching stage, as they are not financially or emotionally
stable. At the same time, the parents try to separate from their child, wanting
to decrease their already exhausted attempts to help. Ruiz, Strain, and Langrod
(2007) reported that 60–80% of adult substance abusers live with their parents
or have regular contact with them, and 75–95% of adult substance abusers have
weekly contact with at least one parent. Thus, adult substance abusers tend to
come into frequent contact with their parents, where dysfunctional patterns of
interaction will likely increase as the severity of the substance use increases.
For the new couple, if addiction is present at the beginning of the relationship,
many of the key patterns will be forged around the maintenance of the addic-
tion. This can negatively impact the development of a solid foundation upon
which to grow the relationship. These may come in the form of inability to han-
dle differences between the partners, dynamics of power, and issues of intimacy
(Hudak et  al., 1999). Couples where addiction plays a key role tend to have
intense conflict and experience one member overfunctioning while the other part-
ner underfunctions. This puts strain on an already stressed system where some
partners may not be willing to continue to invest the amount of energy needed to
maintain the relationship. There is also the possibility that having addiction pre-
sent in the relationship between the couple will lead to them disconnecting from
their own families-of-origin to maintain the secrets that are developing around
the substance use.
Once the parents have children, addiction plays a significant role in how the
family members interact with one another. There is an increased risk of physi-
ological problems if the mother was using during pregnancy (see Chapter 8 for a
discussion of fetal alcohol syndrome) as well as emotional and behavioral diffi-
culties for children of alcoholics (see the section below). The more that addiction
impacts one or both adults, the greater the chance that their parenting will be
distorted. This may come through in one or both parents neglecting or even abus-
ing the children. Depending on the severity of the addiction, the family has most
likely isolated itself from extended family and larger systems, thus losing poten-
tial support.
When launching children, addiction can have a serious negative effect in that
the couple must reengage one another, as much of their time has been spent cen-
tered on the children. If addiction is present, it may not allow the two adults to
reconnect to one another, increasing the possibility that conflict and divorce may
occur at this stage. There may also be issues surrounding economics if money was
diverted to pay for the substances or the addicted person was not able to main-
tain employment. The launched children, now single young adults, may use this
opportunity to leave home and emotionally disengage from their addicted parent.
  Family Life Cycle 123

For families in later life, addiction may change from illegal drugs such as
cocaine and heroin to prescribed drugs. One of the problems of drug use in later
life is the difficulty in assessment (Hudak et al., 1999). Symptoms such as mem-
ory loss, disorientation, and impaired body functioning may be viewed as a result
of old age rather than because of drug use. This stage can be especially difficult if
there was divorce and the individual did not remarry or enter into another com-
mitted relationship. They can feel very isolated, which may increase the cycle of
substance use.
While we have explored the family life cycle and some of the risk factors for
substance abuse at each stage, we can also look at a smaller process specific for
substance-abusing families called the family addiction cycle (Ruiz et al., 2007).
These authors explained this process, “A cyclical, homeostatic pattern has been
described in families of addicts in which, when the addict improves in some way,
the parents begin to fight and to separate emotionally from each other” (p. 275).
This separation occurs until the substance-abusing individual relapses or has seri-
ous difficulties in other areas of his or her life (i.e., getting fired from a job, failing
at school, or having a relationship end). Once this happens the parents focus
their attention on the substance abuser rather than on each other. That is, the
substance abuse serves a function in the family for togetherness. This cycle con-
tinues once the substance abuser improves, leading to increased couple conflict
(see Figure 7.3).

Substance abuse
Increased couple (usually by
con
lict
conlict adolescent/young
adult

Improvement of Parental focus on

the substance the substance
abuser abuser

Figure 7.3  The family addiction cycle happens when the substance abuser improves.
Conflict happens in other relations until increased substance use diffuses
that conflict
124 Assessment 

Children of Alcoholics (COAs)

Once adults enter into the families with young children stage, they must negoti-
ate their own individual growth as well as caring for the well-being of another
person; one who cannot take care of themself (at least for several years). This
task is hard enough on its own, but becomes even more complex when the adults
are dealing with addiction in the system. In the previous chapter, we discussed
the various roles that members tend to adopt in addicted families. In this section,
we will spotlight specifically on the children, as growing up in a family where
addiction is present can have serious consequences for the child, even when they
mature into adulthood.
Children of alcoholics (COAs) are any people under 18 living in a house with
one or more alcoholic parent(s). Based on data from the combined 2009 to 2014
National Survey on Drug Use and Health, about 1 in 8 children, or 8.7 million
children aged 17 or younger, lived in households with at least one parent who
had a substance use disorder in the last year. That represents about 12.3% of
children aged 17 or younger in the U.S. Most of the children lived in families
where the parent abused alcohol while others had a parent abusing illicit drugs.
Perhaps a disturbing finding that the NSDUH survey uncovered was that
younger children were more likely to have a parent abusing substances. An
annual average of 1.5 million children aged 0 to 2 (12.8% of this age group), 1.4
million children aged 3 to 5 (12.1% of this age group), 2.8 million children aged
6 to 11 (11.8% of this age group), and 3 million children aged 12 to 17 (12.5%
of this age group) lived with at least one parent who had an SUD.
There was a clear difference by gender in terms of which parent abused sub-
stances. Of children living in a family with a substance-abusing parent, a much
larger portion of the substance-abusing adults were the fathers rather than the
mothers (5.4 million for the former and 3.4 million for the latter). Approximately
7 million children aged 17 or younger resided in a two-parent household where
at least one parent had a SUD in the past year. Among the 1.7 million children
residing in single-parent households with a parent who had a past year SUD,
about 344,000 lived with their fathers and 1.4 million lived with their mothers.
In this section, I present many of the adverse impacts of growing up in a family
where one or more adults are abusing substances. However, this is not the case
for all COAs. Hawkins and Hawkins (2012) explained, “Children of alcoholics
often show remarkable resiliency in the face of potentially detrimental effects of
parental alcoholism and grow into well-functioning adults” (p. 265). While many
COAs can foster their resiliencies to live healthy lives, living in a family with a
substance-abusing parent can have serious consequences.
One of the potential problems for children growing up in a family with one or
more drug-abusing parents is that they may become parentified. Parentification
is when a child is placed into a parental role in the family. This is usually due to
the adults in the family being unable, for various durations, to fulfill that role.
This may be because the adult is a single parent and must work one or more jobs,
leaves the house in search of the substance, or that they are intoxicated and are
not psychologically present. In two-parent families, parentification usually hap-
pens when one or both parents are impaired, such as having a chronic illness (i.e.,
Parkinson’s, cancer) or is battling drug use.
  Family Life Cycle 125

Children may become parentified not only when there is parental alcoholism,
but also when there is unpredictability in the family (Burnett, Jones, Bliwise,
& Ross, 2006). In drug-using families, there tends to be a higher prevalence
of unpredictability. As such, some children may find the need to try to control
the situation; in this case, attempting to take over for the underfunctioning
parent. The child can feel the anxiety in the system and see that there are jobs
and functions that are being neglected; such as bathing, feeding, and overseeing
young children.
The parentified child will usually be the oldest child. This would most likely
be the responsible child or the hero. They will try to raise the younger children,
providing rules and punishments in an attempt to get the family to function bet-
ter. The parentified child will also tend to be female, adapting more quickly to
a care-taking function in the family (Burnett et al., 2006). In the short run the
parentified child helps the family as the other children are taken care of, having
their immediate needs met. This is important so that larger systems, such as child
welfare agencies, do not get involved with the family. However, the parentified
child enables the addicted adult to continue to abdicate their responsibilities.
Through this abdication, there is a greater chance of attachment difficulties.
In family therapy, attachment can be conceived as the child’s connection to one
or more adult caregivers. The better the attachment to one’s caregivers, the more
the child’s emotional and psychological well-being develops. One of the issues
that happens in addicted families is that positive attachments can be hampered
when one or both parents is addicted. Buelow and Buelow (1998) explained that
COAs might exhibit two ends of a continuum; being overly dependent or severely
independent. These issues of too much dependency or too much self-reliance will
last into later life. For instance, children may grow up to enter relationships
where they find themselves engaging in co-dependent behaviors; needing some-
one else so much that their own identity becomes obscured. Or alternatively, they
might quickly end relationships at the first sign of conflict, not being able to stay
engaged during times of distress.
The problems that children in alcoholic families experience can be classified
into four realms (Lawson, 2011). The first is physical neglect or abuse. When
abuse happens, the child is physically harmed. This may result in bruises, cuts,
and marks. More severe abuse can lead to broken bones, damage to internal
organs, or, in severe cases, to death. Physical neglect leads to the possibilities
of isolation, potential illness, and accidents. The second classification of prob-
lems is acting-out behaviors. These include the child engaging in problematic
behaviors such as fighting and aggression or even their own substance use,
which may be severe enough to bring in the police and legal system. The third
realm of problems in alcoholic families is emotional reactions, which include
a variety of fears, low self-esteem and confidence, a repression of emotions,
depression, or even suicidal desires. The last realm of problems living in alco-
holic families includes social and interpersonal difficulties. These include peer
and family interactional problems. Children of alcoholics tend to feel different
from other children, leading to a sense of embarrassment, not being loved or
connected, and adjustment problems.
Children of alcoholics tend to exhibit behavioral problems as they get older,
where the type of problem varies based on age. Younger children tend to engage
126 Assessment 

in more externalizing problem behaviors while older children engage in more

internalizing problem behaviors (Puttler et  al., 1998). Externalizing behavior
problems are symptoms the child displays to the external world in a negative
manner. These tend to be in the areas of aggression, delinquency, and hyperac-
tivity. Internalizing behavior problems impact the internal world of the child.
These may include being withdrawn, anxious, or depressed. Some of the coping
strategies that COAs use, such as suppressing their feelings, may seem adaptive
in the present, but can become maladaptive at some point in the future (Hawkins
& Hawkins, 2012). There is also a difference in problem manifestation based
on gender, where boys display more behavior problems than girls. Externalizing
behaviors increase when one or both parents is experiencing alcohol-related
symptoms (Hussong et  al., 2010). So, while any child who is growing up in a
house where there has been alcohol abuse is more likely to have higher levels of
externalizing behavior problems than those from non-alcoholic families, these
behavior problems are heightened when the parent is actively experiencing nega-
tive effects of problem drinking.
Depending on the substance of choice, there are differential impacts upon
the children. For instance, children who come from families where their fathers
abused illicit drugs rather than alcohol had significantly more negative child
behaviors, such as irritability, fighting, anger, fear of new situations, and wor-
rying (Cooke, Kelley, Fals-Stewart, & Golden, 2004). Whether a child displays
symptoms, and which type of symptoms, is related to the organization of the
family, the severity of the addiction, how open the family is in talking about their
experience—with each other and outside systems—as well as the various resilien-
cies the child may have available.
Children of alcoholics grow up in an environment that in many ways is very
different than their non-COA peers. The chaos that they tend to live in impacts
them emotionally and psychologically. This is most likely based on them hav-
ing a less healthy lifestyle and more mental health difficulties than non-COAs
(Serec et al., 2012). While the child may not demonstrate symptoms right away,
living in an addicted family can take a toll in various ways. When children grow
up in a house where at least one parent has a long-standing alcohol disorder,
they are more prone as adolescents to engage in alcohol, marijuana, and illicit
drug use (Hussong, Huang, Serrano, Curran, & Chassin, 2012). This may be
based on the interplay of their genetic predispositions as well as the environ-
ment they are living in (see Chapter 2 for the gene–environment hypothesis).
Further, COAs who came from chaotic families, especially during preschool
and middle school, had increased risk for dating violence in late adolescence
(Livingston et al., 2018).
The problems of COAs can start from when the child is very young. In attach-
ment theory, young children may not develop positive attachments to their
parents (or whoever is their primary caregiver) when addiction is present. This
can have very deleterious effects on the child. Fitzgerald, Puttler, Refior, and
Zucker (2007) explained that preschool children growing up in families where
there is an alcoholic “have organized a system of dysfunctional behaviors, cogni-
tions, and self-concepts that are symptomatic of psychopathology and that are
embedded within the maintenance structures of poor parenting, poor family rela-
tionships and poor socioeconomic resources” (p. 19).
  Family Life Cycle 127

It is extremely important to keep in mind the impact that substance use in a

family has on the children throughout the course of the addiction. Even after the
adult(s) in the family have ceased substance use, the balance of the family is still
usually out of kilter (Lawson, 2011). This can be seen in the children maintain-
ing the roles that they developed to cope with the chaotic family functioning. As
the family’s homeostasis had organized around the addiction, it takes time and
energy for the rules of the system to change so that a more functional arrange-
ment is developed. Even then, there has already been psychological ramifications
for each member of the family.
We have presented many issues that COAs may face; however, these are
dependent based on several factors (Middleton-Moz & Dwinell, 2010), which
include:

• the degree to which the parent or parents focus on the developmental needs
of their children rather than on the addiction or the effects of addiction;
• delayed grief and/or trauma that has not been resolved in the parent(s);
• which parent is alcoholic and the other parent’s response to the addiction;
• the stage of alcoholism the parent is experiencing, and how the alcoholism
or addiction is manifested;
• the amount of energy that is available to the child rather than expended
on repression and denial of unfinished business left over from the parent’s
childhood;
• the presence or absence of a caring adult caregiver who is not in denial;
• the birth order and personality of the child (p. 58).

The family therapist will need to assess each of these areas, as well as other
aspects of family functioning, to gain a more comprehensive perspective of the
coping of children in addicted families.
It would seem that it is imperative to locate and provide intervention for COAs
since there are so many possible negative consequences of growing up in a family
where there is significant drug use. However, addicted families tend to develop
rigid boundaries with outside systems, keeping what is happening in the family
a secret. Although they may know that something is not right within the fam-
ily, COAs tend to be very hesitant when it comes to disclosing to non-parental
adults about the family situation, usually engaging in an internal risk assessment
to try to determine what might happen after the disclosure (Tinnfalt, Eriksson,
& Brunnberg, 2011). Children of alcoholics are more likely to disclose the sub-
stance abuse happening in the family to outside parties when the parent has
self-identified as being alcoholic and is receiving treatment, as well as when they
believe they can trust the adult to whom they would potentially disclose. One of
the primary reasons for not telling adults about the substance abuse is the fear of
what may happen to the family; for instance, would child welfare try to take the
COA and his or her siblings out of the family, or would the drug-abusing adult
be arrested.
For younger COAs, the therapist might consider helping them enter into group
therapy as a way to increase peer support and reduce isolation, as many substance-
abusing families have rules that isolate people and diminish their voices
(Markowitz, 2014). One aspect of treatment for younger COAs is to help them
128 Assessment 

deal with the denial of their parent(s)’ difficulties. This prevents the COA’s anger
from seeping out and boiling over. Given that COAs tend to receive messages from
their parents that deny and invalidate their feelings, therapists should actively vali-
date the COA’s beliefs and feelings.

Adult Children of Alcoholics (ACOAs)

We have seen that while children are growing up in a house where one or both
parents engages in drug and alcohol abuse they might experience internal and
external problems. They may act out in school or develop issues such as anxiety
and depression. But what happens when these individuals grow up?
When children who grew up in alcoholic families become adults we refer to
them as adult children of alcoholics (ACOAs). While some are able to engage in
healthy and meaningful relationships with their family of origin, as well as being
able to establish their own families, many are not. There are many factors that go
into how well an ACOA copes as they develop. For instance, ACOAs who had
a mother who was alcoholic showed less positive relationship with their parents
and peers as opposed to non-ACOAs (Kelley et al., 2010).
While it seems to go against logic that someone who was negatively impacted
by parental alcoholism would use alcohol and become addicted themselves,
this is a common pattern. Adult children of alcoholics tend to start using alco-
hol earlier than children who did not grow up in alcoholic families (Braitman
et al., 2009). When they get into college, they drink as much and as often as
non-ACOAs. However, they have a tendency to engage in more drug use than
their counterparts.
As they get older, ACOAs tend to have more relational difficulties than
non-ACOAs. For instance, ACOAs have a higher need for control (Beesley &
Stoltenberg, 2002). Given that when they were children there was a lot of unpre-
dictability in their addicted family, as adults they may try to ensure not only that
they are stable and behaving appropriately, but that their partner, children, and
business associates are as well. This leads the individual to have difficulty form-
ing trusting relationships, which impacts their relationships, as ACOAs tend to
report lower relationship satisfaction than non-ACOAs.
Adult children of alcoholics have a higher likelihood of developing depressive
symptoms as they enter young adulthood (Kelley et al., 2010). This may come
from internalizing behavior problems where they were not able to openly express
their pain and now find it bottled up. By having no outlet for their distress, and
having a low sense of efficacy in control, they may find their sadness escalating
into depression.
Adult children of alcoholics tend to experience some type of stigma associ-
ated with their parent’s substance abuse, dependent on the child’s gender. Female
ACOAs tend to experience stigma when their parent had high levels of alco-
holism and the family avoided talk about it (Haverfield & Theiss, 2016). Male
ACOAs usually feel stigma when the family avoided talk of alcoholism. For both
groups, experiencing stigma was associated with increased symptoms of depres-
sion and decreased self-esteem and resilience. Thus, work with ACOAs might
focus on helping to increase self-esteem and decrease various issues of shame.
  Family Life Cycle 129

Wegscheider-Cruse and Cruse (2012) suggest that many ACOAs become

“addicted” to trying to seek relief from their pain. Not only do the substances
one uses impact brain chemistry, but the actions that we engage in also impact
our brain’s functioning. Individuals who do not use substances, but who attempt
to deal with the pain of living in or having grown up in a dependent house, tend
to engage in medicating behaviors. These behaviors become addictive for the
person because, when they engage in them, their brain releases chemicals that
temporarily medicates and reduces their emotional pain. The person, unknow-
ingly, may become addicted to this sensation.
In this process, there are some medicating behaviors that occur more often
than others (Wegscheider-Cruse & Cruse, 2012). These include, “workaholism;
compulsive eating; which is different from sugar addiction; compulsive con-
trolling of eating, such as anorexia, a highly medicating behavior; compulsive
caretaking and controlling others; seduction; sexual acting out; spending and
gambling; excessive exercise; and ‘guru chasing’” (p. 28). Guru chasing is when
the individual continuously seeks the latest fad of help (such as a new group,
therapist, or method of treatment).
Adult children of alcoholics tend to have several common characteristics
(Middleton-Moz & Dwinell, 2010), which include: fear of trusting, debilitating
guilt, loyalty to a fault, hyperresponsibility or chronic irresponsibility, a need
to be perfect, counterdependency/fear of dependency, a need to be in control
as well as a difficulty with spontaneity, a guess at what is normal, difficulty
hearing positives and difficulty with criticism, a desire to please or defy others,
overachievement or underachievement, poor self-worth or shame, compulsive
behaviors, continual trigger responses, addictions, living in anxiety and fear, a
need to be right, denial, fear of conflict and normal anger, being chaos junkies,
a fear of feeling, frequent periods of depression, fear of intimacy, repetitive rela-
tionship patterns (usually negative), fears of incompetence, hypersensitivity to the
needs of others, a fatalistic outlook, difficulty relaxing or having fun, discounting
and minimizing pain, as well as resiliency strengths. Not all of these characteris-
tics are present; however, they tend to be more prominent in adults who grew up
in families where one or both parents were alcoholic.
Adult children of alcoholics may narrate their lives differently than non-ACOAs
(McCoy & Dunlop, 2017). The ACOAs story their lives with less agency, mean-
ing that they did not view themselves as able to influence their lives in positive
ways. While having the same amount of redemptive imagery in their life stories,
they experienced them differently than non-ACOAs. The redemptive and agentic
stories of ACOAs were related to poorer emotional functioning.
Growing up in an alcoholic family may also impact later occupational choice.
This is because ACOAs tended to have expectations placed on them as children/
adolescents to assume adult roles and have responsibilities to be caregivers either
to the underfunctioning parents or their younger siblings (Vaught & Wittman,
2011). Because of these early responsibilities, ACOAs may not have engaged in
normal child play like non-ACOAs, which can have a role in how they interact
with peers and employers.
Perhaps one of the most lasting and negative consequences of growing up
in an addicted family is the residue of unstable relationships. Adult children of
alcoholics tend to be attracted to people who espouse the emotional qualities
130 Assessment 

they were not able to demonstrate in their family of origin (Middleton-Moz &
Dwinell, 2010). These qualities may later become points of contention when the
ACOA, based on their desire to control the situation, tries to change them in the
other person.
Adult children of alcoholics that present for treatment are likely to experience
one or more of the following issues: guilt, shame, poor sense of self, fear of anger,
denial, and likely use of substances and/or compulsive behavior (Markowitz,
2014). Therapists might assess for each of these to ensure a wide lens in which
to understand the potential difficulties for a COA. One way of helping ACOAs
is for them to develop a cognitive life raft. Middleton-Moz and Dwinell (2010)
defined this as “an intellectual understanding of the emotional impact of growing
up in an alcoholic and/or addicted family” (p. 99). In many ways, understand-
ing the patterns and legacy of the past allows people to come to terms with their
previous experience and to prevent it from taking such an unconscious hold on
their current functioning. In the following section we will discuss another concept
that enables ACOAs to survive and overcome their situation.

Resiliency

So far, we have talked about how children can be negatively impacted while
growing up in an addicted family as well as in their life away from the family as
adults. However, I want to end the chapter on a more positive note. While chil-
dren growing up in families dealing with substance abuse are at risk for a variety
of emotional and behavioral difficulties, not all experience these. Many children
(and later when they become adults) come out of these families and succeed.
Perhaps the distinguishing feature of this is having resilience. Resilience can be
defined as “being able to overcome adverse situations and develop a positive self-
image despite a difficult situation” (Mignon, Faiia, Myers, & Rubington, 2009,
p. 194). As we have seen, children growing up in addicted families face the chal-
lenges that all children face, and they also deal with the excesses of stress, anger,
disappointment, fear, and chaos that others who were raised in non-addicted
families may not. Developing various means of resiliency is a key strategy for
survival for many of these children.
In exploring a variety of studies focused on resiliencies for children who
grew up in families where one or both parents had a substance use disorder,
Wlodarczyk et al. (2017) categorized them into child-related, family and paren-
tal, and environmental factors. Child-related resiliencies and protective factors
included both psychological and biological factors. Those who could positively
engage adults, use coping strategies, and had certain biological responses had
better mental health outcomes than those who did not have these conditions.
Family and parental factors included strong family cohesion and adaptability,
secure parent–child attachment, low parenting stress, and high parental support.
Environmental factors that functioned as protective factors against later mental
health negative outcomes included positive social support.
Wolin and Wolin (1993) listed seven resiliencies that can help children liv-
ing in troubled families: insight, independence, relationships, initiative, creativity,
  Family Life Cycle 131

Insight

Morality Independence

Humor
Resiliencies
Relationships

Creativity Initiative

Figure 7.4  The seven resiliencies proposed by Wolin and Wolin (1993)

humor, and morality (see Figure 7.4). Insight is the ability of the person to explore
and be honest with themselves. It includes sensing, knowing, and understanding.
The child can sense danger in the family based on people straying from the safe
norm. Sensing then shifts into knowing, where the child takes in the larger picture
of what is happening in the family and how that is impacting them. As the child
becomes an adult they develop understanding—of who they are and their rela-
tionships with others.
The resiliency of independence includes straying, disengaging, and separating.
In troubled families there is a pull for togetherness that can be overwhelming.
Children who are able to engage in some type of independence have the potential
for more successful functioning. This happens first in terms of the child straying from
the family conflict, where they remove themselves from the center of chaos. The
further they stray, the more the child feels comfortable and can begin to disen-
gage emotionally from the family. As adults they are able to separate themselves
from the family—by being able to choose their own path rather than getting
swept away in the family’s troubles.
Relationships—positive relationships—connect us to other people in meaning-
ful ways. They allow people to be affirmed as a unique individual; one who can
love and is worthy of love. The resiliency of relationships grows over time from
connecting, to recruiting, and then to attaching. As children, resiliency is aided
by the child finding and connecting to meaningful adults. These early connections
tend to be somewhat sporadic, but help to establish a foundation of inner worthi-
ness. This foundation allows the child to actively seek out and recruit people to
132 Assessment 

engage in a relationship, many times as a parent substitute. This adult may be

a neighbor, teacher, or extended family member. As the child moves into adult-
hood, recruitment changes into attaching, where the individual is able to hold
and maintain long-term meaningful relationships where there is a balanced give
and take of due concern.
Resilient individuals are also skilled at initiative; the ability to take control
of their environment. This happens through exploring, working, and generat-
ing. Growing up in addicted families is chaotic. The resilient child will engage
in exploring, finding very small ways to have some control in the environment.
This may be through keeping items hidden from others, going through parents’
drawers, or other small experiments of initiative. During this time they start
developing self-efficacy. Once they enter school, this exploring changes into
working; perhaps in trying to achieve in school. As adults, these individuals tend
to be able to engage in generating, where they are developing projects of personal
satisfaction and self-growth.
The resiliencies of creativity and humor are related to each other. They each
start with the child playing and then shaping. The development of creativity then
moves through composing while that of humor goes through laughing. These
resiliencies are located internally, where the person uses her imagination as a
safe place to move away from the chaos and conflict in the family. Creativity
and humor begin with playing, where the child imagines themself to be someone
else; perhaps a superhero, princess, doctor, or firefighter. In adolescence, playing
becomes shaping, where the individual engages in some form of art. This may
be painting, music, poetry, or dance. In adulthood, the resiliency of creativity
is developed through a shift from shaping to composing, producing an active
product, where their art has become a skill. For the resilience of humor, shaping
becomes laughing, where the person is able to take misery and absurdity and find
a way to laugh at what happened.
The last resilience we will talk about is morality, which occurs through the per-
son’s life through judging, valuing, and serving. Morality is the process of trying
to be good—to one’s self and to others. As children, individuals may feel wronged
and try to figure out and judge the rights and wrongs of what occurred. When the
child grows into an adolescent, they then engage in valuing various principles to
live by; such as honesty, caring, and helping. This leads them to focus on helping
other people; especially those who have been wronged. In adulthood, this resil-
iency comes out via serving, where the person devotes time and energy to others,
such as volunteering—perhaps working in a soup kitchen, homeless shelter, or
other such community-based organizations.
People who survive troubled families may have one, several, or all of these
resiliencies working for them. Depending on how chaotic the family is, the same
level of resilience in one person may not help to prevent trouble as it might in
someone else whose family situation was a little more stable. These resiliencies
can be enhanced, with parents or adult mentors helping to build them throughout
the child’s development. Further, those children who receive professional inter-
ventions (i.e., parenting skills training, individual and group interventions) are
more likely to connect to the various resiliencies available to them (VanDeMark
et al., 2005).
  Family Life Cycle 133

Case Application

The Rothers family is a remarried family that is somewhat unique in that all of
the children who live in the home are the biological children of the two adults.
While technically the family is a step-family, they do not function as one since
there is extremely minimal interaction between Nina, Mark’s biological child
from his first marriage, and Mark and the other children. So, in many ways, the
Rothers family life cycle conforms to that of the typical North American family.
Although this is a second marriage for Mark, and a first marriage for Hannah,
they still married earlier than the median age of men and women for first mar-
riage in the United States.
The family currently finds themselves in the stage of families with adolescents.
This is the point in the family life cycle where parents usually begin to allow
more autonomy for the adolescent, preparing him or her for being able to func-
tion independently in the single young adult stage. However, this process may be
hampered in the Rothers family as addicted families usually maintain more rigid
boundaries both within the family and between the family and larger systems. In
order to provide more autonomy, boundaries need to become clearer, allowing
more flexibility and negotiation between subsystems. Further, Mark and Hannah
may not be as likely to allow Steve, the oldest of the children, increasing levels of
freedom since he is frequently acting out and getting into trouble at both home
and school. Steve’s acting out would likely lead the parents to try to develop more
rigid boundaries, where they are better able to assert their parental authority
rather than allowing him more say in his development. Thus, we might expect
that there will be quite a delay in the Rothers family in their transition from a
family with young children to a family with adolescents where boundary flex-
ibility might be stunted. This may lead to later difficulties for one or more of the
children when they move into the single young adult stage, in that they might not
be able to handle well the challenges of individual choice making and autonomy.
While we do not know much about Hannah’s family of origin, we would need
to consider whether Mark and Hannah find themselves in the sandwich genera-
tion. We know they are caring for their own children and there is the likelihood
that each of their parents has either retired or is close to retirement. Depending
on their physical and psychological health, Mark and Hannah may need to put
energy into thinking about and caring for their aging parents.
We can hypothesize that the Rothers family finds itself in the family addiction
cycle. In all likelihood, there are times when Mark does not drink as much and
begins to interact with the family. When this happens, Hannah may find that the
tension is not as severe and she might let her frustration and anger out at him
around non-drinking issues, such as his cleanliness around the house or his dis-
ciplining of the children. We would then likely see Mark increasing his drinking
and Hannah backing off on her criticisms of him. Instead, Mark and Hannah
would likely focus their attention on Steve’s misbehaviors.
Steve, Kayleigh, and Pete can be considered to be children of alcoholics. This
is a family experience that is multigenerational in the Rothers family as there is
alcoholism for several generations on the paternal side of the family. While it is
usually the oldest child who becomes parentified, that is not the case in this family.
134 Assessment 

If anyone is parentified, it would be Kayleigh, helping Hannah to look after

Pete. Out of the four primary problems that COAs experience, the Rothers are
dealing with acting-out behaviors, difficult emotional reactions, and some social
and interpersonal difficulties. Each of the children may be experiencing various
aspects of low self-esteem, manifesting differently in each person. While Steve is
the only child currently engaging in externalizing behavior problems, all may be
internalizing their pain, which will likely have a serious negative impact at some
point in their lives, whether it be depression, lack of confidence, or poor inter-
personal relationships.
While things may seem grim for the members of the Rothers family, all hope
is not lost as they likely have various resiliencies that can help them weather
the storm of addiction. Kayleigh seems to have the ability to positively engage
adults while Kayleigh and Pete both have a secure parent–child attachment with
Hannah. The more that all of the children utilize their various resiliencies, such
as creativity, humor, and positive relationships, the greater the likelihood that
they will be able to overcome the risk factors of growing up in an addicted family.

Summary
This chapter presented a way to view the developmental growth of the
family and how that growth can be hampered when addiction is involved.
As children, living in an addicted family can have many deleterious
effects. Children of alcoholics face a range of behavioral, psychological,
and emotional challenges that non-COAs usually do not come across. As
adults, the legacy of the addicted family will usually still be present. Adult
COAs find challenges in employment and their own adult relationships.
However, the more resiliencies present, especially from when the person
is young, the better able the person is to survive and to grow into a well-
functioning person.

Key Words
single young adult adult children of alcoholics
the new couple (ACOA)
families with young children cognitive life raft
the sandwich generation resilience
launching children insight
families in later life independence
children of alcoholics (COA) relationships
parentification initiative
attachment creativity
externalizing behavior problems humor
internalizing behavior problems morality
  Family Life Cycle 135

Discussion Questions
1. How might families adhere to the typical progression in the family life
cycle?
2. What are some factors that would lead families not to follow the
standard family life cycle?
3. How does addiction impact each stage of the family life cycle?
4. What are some of the main factors when exploring children of
alcoholics?
5. What are some of the main factors when exploring adult children of
alcoholics?
6. Discuss the seven types of resiliency. What impact do they have for a
person living within an addicted family?
eight

Issues in Substance-
Abusing Families

We previously talked about how families are both universal and idiosyncratic.
The processes that form and maintain a family happen in all families (thus, fami-
lies are universal); however, how these processes happen is unique to each family
(thus, families are idiosyncratic). In substance-abusing families, there are many
issues that tend to be present. Yet not all of these difficulties are present in every
family. In this chapter we will cover some of the common issues, outside the
actual addiction, that you may need to assess when you know that one or more
family members is dealing with some type of substance abuse.
The chapter starts with perhaps the most common of these issues, that of
domestic violence. While many families where alcohol is not involved have
some type of domestic violence, it tends to be more prevalent the more severe
the substance abuse. We then move to a more severe form of violence, that of
child sexual abuse. The chapter then shifts to a potential issue when the pregnant
mother drinks alcohol, leading to the possibility of fetal alcohol syndrome disor-
der. In many ways this can be considered a form of child abuse. Next, we cover
the prevalence of the association between substance abuse and criminal behavior.
The chapter then provides a widening of the assessment lens by exploring the
phenomenon of people tending to not only have a substance abuse disorder but
also having a mental health disorder—what is called dual diagnosis. We then end
the chapter focusing on how we can view how ready individuals and families are
for change, as well as ways of enhancing motivation.

Domestic Violence

Domestic violence is an extremely serious issue for families around the world.
The abuse can be from a parent to a child—what we will call child abuse—or
from an adult to an adult—what we will call intimate partner violence (IPV).
According to the National Coalition Against Domestic Violence (2014), in the
United States approximately 20 people experience intimate partner violence every
minute. Annually, this accounts for 10 million victims of abuse per year. One in
four women and one in nine men experience IPV. Thirty-three percent of women
and 25% of men have been the victims of IPV over the course of their lives. When
one or more members in a family is abusing substances there is an increased risk

136
  Issues in Substance-Abusing Families 137

of domestic violence occurring in the family. The American Society of Addiction

Medicine reported that 40–60% of domestic violence incidents also involve sub-
stance abuse. Although the use of alcohol and other drugs does not necessitate
that IPV will happen, addiction is one of the causal agents of violence in the
family (Flanzer, 2005; Leonard & Quigley, 2017). Flanzer provided some of the
intervening variables when examining the role of alcohol/drugs and IPV:

• alcohol as an instigator of violence;

• alcohol as a disinhibitor of social control;
• alcohol’s destruction of the normal growth and development of the indi-
vidual and the family system;
• alcohol as a rationalization for violence;
• alcohol’s alteration of brain functioning (p. 170).

Taken individually or together, these factors set the stage for an increased risk
that families dealing with addiction will come in contact with IPV.
While not all IPV occurs with the male being the perpetrator and the female the
victim (in heterosexual relationships), this is the most reported type of dynamic
and will be used as the framework to discuss this issue. However, I want to be
clear that domestic violence can take any combination: male-to-female, male-
to-male, female-to-male, and female-to-female. It can be from adult-to-adult,
adult-to-child, child-to-child, child-to-adult, child-to-elder adult, or adult-to-
elder adult. Whichever form it takes, violence in a family has the potential for
very deleterious effects—to the point of incarceration and death.
There are many forms of domestic violence. For purposes of clarity in this
section, we will focus primarily on adult–adult violence (see the next section for
a discussion on child abuse). Patterson et  al. (2009) estimate that violence of
some type is prevalent in 15–20% of all families. In families with some type of
substance abuse, this percentage will be higher as there is a significant relation-
ship between IPV and substance use and abuse (Cafferky, Mendez, Anderson, &
Stith, 2018). In general, we can look at five forms of domestic violence: physical,
sexual, psychological, emotional, and economic.

Power and Control

Many people have looked at domestic violence through the lens of power and
control. One way of viewing this is looking at the Power and Control Wheel (see
Figure 8.1), developed at the Domestic Abuse Intervention Project. Through their
work with women who had been abused, they developed a model of how male
batterers utilize various tactics to try to control their female partners.
At the heart of the wheel is power and control. These are the spokes of the
wheel and are the main intention of the abuser. On the outside of the wheel is
physical and sexual violence. Inside the wheel are eight pathways that the abuser
utilizes to maintain power and control: using intimidation; using emotional
abuse; using isolation, minimizing, denying and blaming; using children; using
male privilege; using economic abuse; and using coercion and threats.
The physical form of domestic violence is the most recognizable of the types.
It is the most visual, as it tends to leave bruises and scars. In IPV, one person
138 Assessment 

VIOLENCE
CAL SEX
HYSI UA
L
P
USING COERCION AND USING
THREATS INTIMIDATION
Making and/or threats to Making her afraid by using
do something to hurt her looks, actions, gestures
• threating to leave her,• smashing things
to commit suicide, to • destroying her property
USING • abusing pets
report her to welfare
ECONOMY ABUSE • making her drop • displaying USING
Preventing her from getting charges • making weapons. EMOTIONAL ABUSE
or keeping a job • making her do illegal Putting her down. • making
her ask for money • giving her things. her feel bad about herself.
an allowance • taking her money • calling her names • making her
• not letting her know about or think she’s crazy • play mind games
have access to family income. • humilating her • making her feel
POWER guilty.
AND
USING ISOLATION
USING MALE PRIVILEGE CONTROL Controlling what she does, who
Treating her like a servant • making
all the big decisions • acting like the she sees and talks to, what she
“master of the castle” • being the reads, where she goes • limiting
one to define men’s and women’s her outside involvement • using
roles jealousy to justify actions.
MINIMIZING,
DENYING, AND
USING CHILDREN BLAMING
Making her feel Making light of the
guilty about the abuse and not taking
children • using the her concerns about it
children to relay messages seriously • saying the abuse
didn’t happen • shifting responsibility
for abusive behavior
• Saying she caused it.
PH
YS L
ICA UA
L
VI O L E N C E SEX

Figure 8.1  The Power and Control Wheel

Permission to use by the Domestic Abuse Intervention Programs, 202 East Superior Street, Duluth, MN
55802, 218-722-2781, www.theduluthmodel.org

attempts to inflict bodily harm on another person. This may be in the form of
hitting, slapping, biting, kicking, or using an object against the other person such
as hitting the other with a piece of electrical cord, stabbing them with a knife,
etc. The consequences of this type of abuse are visual and may result in the vic-
tim needing medical attention. Perhaps a broken bone or severe lacerations lead
them to seek emergency room treatment, which can cause a major conflict as the
victim may try to protect the abuser through developing a false story as to how
they incurred their injuries. However, only about 34% of victims of IPV seek out
medical treatment.
Sexual domestic violence mainly occurs when one person attempts to engage
in any type of sexual contact with another without that person’s consent. A com-
mon misconception is that rape is usually committed by a stranger to the victim.
According to the National Health and Social Life Survey, most rape is commit-
ted by someone the victim is in love with (46%), knows well (22%), or who
  Issues in Substance-Abusing Families 139

is a spouse (9%) rather than a stranger (4%). It has only been in the last few
decades that there has been an awareness that rape can happen within a marital
relationship. Relational rape also occurs in same-sex relationships, although that
accounts for only 1% of all statutory rape incidents (Chaffin, Chenoweth, &
Letourneau, 2016).
The psychological type of domestic violence occurs when a partner tries to
instill fear in the other. This may happen through threats of violence or breaking
household items. For instance, a husband may break plates on the floor while
screaming at his wife. Although he never laid a finger on his wife, he still pro-
moted an atmosphere of aggression. A second type of psychological abuse is
when the partner attempts to isolate the victim. Here, the victim is told not to talk
with friends, co-workers, or even family members.
Emotional violence is when one partner belittles the other partner. This is usu-
ally through name-calling, cursing at, and insulting the person. In this situation,
as a means to keep her in the relationship, a husband may frequently tell his wife
that she is stupid and ugly and that no one would ever want her. The intent is to
lower the victim’s self-esteem and assert control over them.
The fifth type of domestic violence is economic abuse. In this situation, the
abuser is in command of the finances. Even if the victim works, the abuser will
gain control of the money in the house. The partner would then have to go
through them to get any money to use. The abuser may then only provide a small
allowance for the victim, thus asserting greater control over the person and mak-
ing it more difficult for the victim to leave the relationship since they do not have
access to money.
While drugs and alcohol play one role in the etiology of domestic violence,
there are many other possible causes. These include views on gender roles, cul-
tural upbringing, psychological well-being, and other situational variables. Any
or some of these (and other) factors converge to present a possibility for violence
in the home. However, there may be differing motivation for the violence. Greene
and Bogo (2002) distinguish between two types of violence; patriarchal terrorism
and common couple violence. Patriarchal terrorism is about control. The perpe-
trator of the violence is using it as a means to wield authority and control over
the victim. It is usually engaged in as a coping mechanism to ensure some type of
stability for the individual. Common couple violence, on the other hand, is not
about control, but is part of an escalation of conflict. In this type, either partner
may initiate the violence.
Just as addiction starts slow and builds up, violence does as well. Intimate
partner violence is a process; it does not start the minute that the two adults first
meet. It occurs slowly over time, building up to where the abuser shifts from a
subtle to more overt form of abuse. This leads to confusion for the victim as the
beginning of their relationship most likely did not contain the severity of abuse
that happens later. By slowly asserting power and control in the relationship, the
victim has usually developed caring feelings and dependence on the abuser.
While there may only be one cycle of abuse between members of a couple, usu-
ally there are many cycles that connect over time with one another. As each cycle
happens, the abuse tends to escalate so that the abuse in the first cycle between
the couple is not as severe as the most recent episode. For instance, two months
into the relationship the couple may have a fight and the man calls the woman
140 Assessment 

a degrading name. Several months later he may begin to try to isolate her from
friends and family. Perhaps a few months later he may slap her during a verbal
conflict. Each incident becomes a stepping-stone leading to heightened escalation
of abusive behavior as the abuser still does not feel like they have power and
control in the relationship.
The cycle of abuse begins with what might be considered normal behavior.
The couple is able to interact in what seems to be a peaceful environment. At
some point in time the abuser believes his partner has wronged him in some
fashion (perhaps by not listening to what he has told her to do or engaging with
people outside of the relationship such as friends or family). The cycle then moves
into the fantasy and planning phase where the abuser develops a scenario of how
he will let the person know of their offense. The third phase is the setting-up
of the plan. Fourth, the abuse, in whatever fashion (physical, emotional, etc.)
occurs. The next phase is guilt, where the abuser feels guilty, usually to reduce
the chance of the victim reporting the offense or leaving. This is where the abuser
would probably apologize. The next phase is one of excuses, where the person
rationalizes why the abuse happened, usually blaming the victim for putting them
in a position where they had to do what they did. Lastly is a honeymoon stage
where the relationship seems to be calm, which is also the first stage of the next
cycle that may come in a few days, weeks, or months. This process is visualized
in Figure 8.2.
This process can also be viewed within three phases: tension building, abuse,
and honeymoon. In the tension building phase the abuser feels tension and begins
to escalate insults and threats. The victim at this time minimizes the tension.

Honeymoon

Fantasy &
Rationalization
Planning

Guilt & Apology Abuse

Figure 8.2  The cycle of abuse where each subsequent cycle escalates in severity of the
abuse
  Issues in Substance-Abusing Families 141

Honeymoon

Abuse

Tension
Building

Figure 8.3  The tension building process of domestic violence

During the second phase, called abuse, the abuser reacts to a sense of losing
control by increasing the intensity of threats to the victim. The victim is unsure
of what to do and does not know how to reduce the tension or leave the environ-
ment. At this point the abuse incident occurs. Lastly is the honeymoon phase.
Here the abuser becomes very apologetic and loving. The victim is confused as
she was just hurt (physically and emotionally) yet she sees before her the potential
of what the person might be if they did not exhibit the controlling/violent side of
their actions. This three phase model is presented in Figure 8.3.
When assessing for domestic violence, clients are usually hesitant to disclose
on first inquiry. This is especially the case in couples or family sessions. Because
one of the main aspects of domestic violence is intimidation, the victim may be
very reticent to openly acknowledge the abuse in front of the abusing partner.
As such, one possibility in sessions is to see members separately, at least for the
assessment interview or first session.

Child Abuse
So far we have primarily focused on adult-to-adult violence. However, children
are also in the line of fire of violence when alcohol and other drugs are involved
in a family system. Children in drug-using homes are at risk for physical and/or
sexual abuse, as 25% of child abuse victims had adults who engaged in substance
abuse (www.acf.hhs.gov). This subset of the family is referred to as children of
alcoholics (see Chapter 7 for an in-depth discussion of COAs).
Data from the National Child Abuse and Neglect Data Systems showed
that in 2016 there were approximately 7.4 million children involved in
142 Assessment 

allegations of child maltreatment, which included abuse or neglect. Of these

investigations, 676,000 were substantiated or indicated as maltreatment with
over 388,000 victims receiving postresponse services. Younger children are
at higher risk of maltreatment as each year of life the number of children
abused decreased.

98,393 < 1
47,583 – 1 year old
44,800 – 2
42,045 – 3
40,312 – 4
39,773 – 5
39,990 – 6
38,900 – 7
36,776 – 8
33,848 – 9
30,529 – 10
28,155 – 11
27,544 – 12
27,560 – 13
26,784 – 14
23,303 – 15
15,334 – 16
2,493 – 17
671,622 – Total

Of these children 27.1% were 2 years old or younger, 19.6% 3–5, 16.4%
6–8, 13.7% 9–11, 12.9% 12–14, and 10.3% 15–17. There was also a distinction
on who was abused based on race (44.9% White, 22% Hispanic, and 20.7%
African-American). Although the total number is lower than other ethnic groups,
American Indian or Alaska Native children had the highest rate of victimization.
There does not seem to be a difference in child abuse as a whole in reference to
gender (48.6% were boys and 51.1% girls—the gender was not reported for the
remaining percentage). While a majority of abuse cases came under the subset
of neglect, 17.6% of these children were physically abused while 9.1% were
sexually abused. Of child maltreatment cases, 74.8% were categorized as neglect
  Issues in Substance-Abusing Families 143

while 18.2% were physical abuse. It is estimated that in 2016, 1,750 children
died from abuse or neglect.
While not all child abuse is perpetrated by the parents, an overwhelming per-
centage is (81%). Over 83% of perpetrators of child maltreatment were between
the ages of 18 and 44. Further, over 53% were women and just over 45% were
men (the other 1% were of unknown sex). Ethnically, Whites accounted for
almost 50% of perpetrators, African-Americans 20%, and Hispanics almost
19%. Of victims of child maltreatment, 11.5% had a caregiver suffering from
alcohol abuse and 28.5% had a caregiver dealing with drug abuse.
Even if the abuse is not directed at the child, witnessing IPV and being exposed
to the various incidents of domestic conflict has serious implications (Jaffe, Wolfe,
& Campbell, 2012). Witnessing IPV may be almost or as damaging emotionally
to a child as being the actual victim. According to the NCADV, each year, 1 in
15 children are exposed to IPV, with 90% of these children being an eyewitness
to the violence. Eiden et  al. (2009) found that children living in a house with
alcoholic fathers who engaged in marital aggression with their wives had higher
levels of anxiety and depression than children who did not witness IPV. While
externalizing their problems (acting out and getting in trouble at home or at
school) is more common for children in conflictual alcoholic families, they may
internalize problems resulting in psychological and/or emotional difficulties such
as anxiety and depression.
As discussed in Chapter 5, the substance-dependent adult will most likely
begin to abdicate their parenting responsibilities. This leaves the possibility that
the children in the family may become neglected. Since alcoholics tend to have
a low frustration tolerance, becoming autocratic and blaming others (Flanzer,
2005), they may utilize corporal punishment and violence as response mecha-
nisms when dealing with their children.

Child Sexual Abuse

Witnessing the violence of adults has negative impacts on the child during child-
hood, which can endure into adulthood. When the child is the victim of the
abuse, and specifically when the abuse moves from being emotional or physi-
cal to sexual, there may be more severe consequences. When the familial abuse
becomes sexual it is considered incest.
Incest can take many forms in a family, such as father–daughter, father–son,
mother–daughter, mother–son, sibling–sibling, grandparent–grandchild, or other
configurations (i.e., uncle–niece). The most common of these is the father–daughter
form of incest. According to the U.S. Department of Health and Human Services,
in 2011 there were over 61,000 cases of child sexual abuse. Of these, 48% of the
children were 12 or older.
The harm of child sexual abuse occurs not only in the present but in the future
as well. People who were sexually abused as children have a higher likelihood
than those who did not, when they are older, of problematic drinking, the poten-
tial for sexual revictimization, and riskier sexual practices (Sartor et al., 2008).
Having been a victim of sexual abuse as a child, the person is more at risk for
the use of cigarettes and cannabis as well as the abuse being a strong predictor of
early drinking of alcohol (Sartor et al., 2013).
144 Assessment 

Therapist Responsibility
As a therapist you are ethically obligated to report suspected abuse or neglect of
children or elders. Given that children living in addicted homes are at greater risk
for being abused (this includes neglect and psychological or physical maltreat-
ment), therapists should pay special attention to this possibility. Assessment is
critical at an early stage, as well as being clear with family members about your
role and your obligations regarding confidentiality and reporting (see Chapter 11
for a more in-depth discussion of therapeutic ethics and confidentiality).
The most important thing for the therapist to keep in mind is family members’
safety. This can be difficult in some families since the abuse has become part of
the family’s homeostasis and an accepted way of being. Although it shifts the
therapist’s position from service provider to more of a control agent, the welfare
of family members, especially children, takes precedence. The therapist can be
very overt about the assessment, asking family members if violence is present in
the family. Some possible questions to ask include:

• Has there been any type of violence in the family?

• When you become very angry, how do you tend to engage others in the family?
• Are there any weapons in the house?

However, therapists need to be ready to act on the information they receive—

be it calling the child protection services in the area if there is abuse present or
developing a safety plan if one or more members feel fearful.
Given that addicted families tend to operate based on secrets, the family ther-
apist may consider, especially in the first session, to meet with each member
separately and then the family as a whole. Being alone with the therapist may
allow a family member to discuss what is going on in the house without fear
of the abuser while they are saying this. Separated sessions may also be used in
addicted families to try to counteract some of the underlying rules of maintain-
ing secrets.

Fetal Alcohol Abuse Syndrome

As discussed in Chapter 2, the substances that we utilize have direct impact on

our brain. Whatever consequences they have for us, there is the possibility that
they can also effect a fetus if the substance user is pregnant. For pregnant women
who are abusing alcohol, they run the risk of giving birth to a child with fetal
alcohol abuse syndrome (FAS). Originally called fetal alcohol syndrome, it was
later referred to as fetal alcohol abuse syndrome to reflect that it was not alco-
hol but the abuse of alcohol that causes the pattern of abnormalities the fetuses
acquire (Abel, 1998). Thus, a pregnant woman who drinks one glass of alcohol
will not cause FAS. It takes a pattern of heavy episodic consumption. However,
heightened use of alcohol in the last trimester of pregnancy may have the most
severe effects. One area of optimism is that FAS does not need to occur as FAS
is the most preventable cause of birth defect and developmental disabilities
(Mohammad, 2016).
  Issues in Substance-Abusing Families 145

Fetal Alcohol Syndrome Disorder (FASD) can be broken down into three types,
depending on the symptoms of the individual. The primary type is Fetal Alcohol
Syndrome. This is the most severe of the FASD types—and the most severe outcome
of this is fetal death. The second FASD type is Alcohol-Related Neurodevelopmental
Disorder where the individual has some type of intellectual disability. This usu-
ally leads to the child having learning and behavior problems in school. The third
FASD type is Alcohol-Related Birth Defects. Here, the newborn may have physio-
logical problems with their heart, lungs, kidneys, or other organ or bodily systems.
There is usually a major change in women’s consumption of alcohol once they
become pregnant (Armstrong, 2003). Before becoming pregnant, 61% of women
do not drink alcohol at all, 29% engage in low consumption (fewer than three
drinks per week), 9% have medium use (3 to 13 drinks per week), and 1% engage
in high alcohol consumption (14 or more drinks). However, once pregnant, these
percentages change drastically; 83% of women have no alcohol use, 15% low
consumption, 2% medium, and 0.5% high consumption. While these are very
positive data, where 83% of women do not drink during pregnancy, 2.5% still
engage in medium to high usage.
The good news is that FASD and FAS do not occur that often. The bad news
is that they occur. According to the Centers for Disease Control and Prevention
(www.cdc.gov), FAS occurs in approximately 0.2 to 1.5 cases per 1,000 live
births. Since FASD has a somewhat wider catchment, it is estimated that there
are three times as many FASD cases than FAS cases. There is not a direct cor-
respondence between the amount of alcohol consumption and a specific impact
on the fetus. As Pagliaro and Pagliaro (2012) explained, teratogenesis (the pro-
cess of embryonic or fetal congential malformations) occurs through a multitude
of factors including drug/substance factors, maternal factors, placental factors,
time factors, environmental factors, and fetal factors (see Figure 8.4). This is why

Environmental
Fetal Factors
Factors

Placental
Time Factors
Factors

Drug/Substance
Maternal Factors Teratogenesis Factors

Figure 8.4  The various factors that impact the level of teratogenesis
146 Assessment 

the same amount of repeated consumption by two different pregnant women can
lead to very different results.
Fetal Alcohol Syndrome Disorder requires that the mother drinks heavily dur-
ing pregnancy. There are many factors that lead to a woman drinking at high
risk factors during pregnancy (Armstrong, 2003). For instance, Black women
have the highest odds of high-risk drinking (2%), then all other races (1.4%),
with White women having odds of 1%. Those who have not finished their high
school degree have higher odds of risky drinking. However, as women get older,
the odds of high-risk drinking during pregnancy increases (with women over 35
at 1.7%, whereas women under 20 are just below 0.5%). Married and single
women have just about the same odds of high-risk drinking, but the biggest dif-
ference comes in family income. The lower the family income the higher the risk
of drinking during pregnancy (3.1% for those under $10,000; 2.25% for family
income between $10,000–$19,000; 1.6% for income between $20,000–$34,000;
and 1% for family income over $35,000).
In 1996 the Institute of Medicine developed diagnostic criteria for FAS
Category 1. These included:

A. Confirmed maternal alcohol consumption:

• excessive drinking characterized by considerable, regular, or heavy epi-
sodic consumption.

B. Characteristic facial features include:

• short palpebral fissures;
• characteristic premaxillary features, e.g., flat upper lip, flattened
philtrum, flat midface.
C. Growth retardation:
• decreased birth weight for gestational age;
• failure to thrive postnatally not related to nutrition;
• disproportionate ratio of weight to height.
D. CNS abnormalities, including at least one of the following:
• small head size;
• structural abnormalities, e.g., small brain, partial or complete absence
of corpus callosum, decreased size of cerebellum;
• neurological hard or soft signs (age appropriate), such as impairment of
fine motor skills;
• neurosensory hearing loss;
• incoordination;
• impaired eye–hand coordination.

Not all of these characteristics will be present in a child born with FAS, which
makes diagnosing it difficult as there is not a specific test that can be given but a
confluence of symptoms. To reiterate, these symptoms are prenatal exposure to
alcohol, abnormal facial features, lower-than-average birth weight and/or height,
and central nervous system problems.
  Issues in Substance-Abusing Families 147

Children with FASD are born into a situation that is extremely complex, as they
must face individual difficulties (such as learning, motor skills, social skills, and
attention deficits) as well as social difficulties. Their development is also hampered
by being born with physiological impairments (e.g., low birth weight or depressed
immune function). However, what makes these symptoms even more problematic
is that the FASD child is likely born into a family that is currently dysfunctional.
One of the distinguishing features of FAS is growth retardation. This may hap-
pen at two points in the individual’s life; prenatally or postnatally. Prenatally,
these growth anomalies will be visible at birth including low birth weight (less
than the 10th percentile). However, symptoms of growth retardation can also
begin displaying themselves after birth—postnatally. These symptoms include
reduced height or weight at any point in the person’s development. When there
is heavy prenatal alcohol exposure, the child, when born, may experience severe
damage to the central nervous system—which will include the cerebellum, basal
ganglia, and cerebral cortex (Nguyen et al., 2012). One deficit of this damage will
come in the form of difficulties in fine motor activity.
Unfortunately there is no “cure” for FASD. However, the earlier the child
receives intervention, the greater the chance to improve the child’s development.
The Center for Disease Control suggests possible treatment options including
medications for various symptoms, parent training, and behavior and education
therapy. The child will most likely need the inclusion of various social services
and special education access as well as frequent medical care. Children with FASD
can have better outcomes when there are family-focused interventions in place
(Reid et al., 2017). These interventions may include focusing on self-regulatory
skills of the child with FASD, incorporation of mindfulness-based techniques,
and improvement of the parent–child relationship. Wilhoit, Scott, and Simecka
(2017) concurred, stating that children with FASD have the best outcomes when
their family collaborates with school, therapists, and medical professionals.

Criminality and Substance Abuse

There is a high correlation between substance use and criminal behavior (Diehl
et  al., 2016; Nam, Matejkowski, & Lee, 2016; Newbury-Birch et  al., 2016).
Diehl et al. found that approximately 27% of people in treatment for substance
abuse had engaged in criminal behavior. These crimes were more against people
rather than property. Newbury-Birch et al. found much higher rates, with rates
of over 64% of those in police custody, 53% in probation settings, 60% in the
prison system, and 64% of young people in the criminal justice system having an
alcohol use disorder.
Much work with substance abusers, especially adolescents, is geared toward
reducing their substance use as well as reducing the risk for criminal activity
to prevent their involvement in the juvenile justice system. However, youth do
find themselves involved in the juvenile justice system. There are many evidence-
based programs for youth who are in the juvenile justice system to help them
reduce substance use as well as reduce criminal behavior. These include several
that will be presented in Chapter 15, including Brief strategic family therapy,
Multidimensional family therapy, and Multisystemic therapy. Other programs
148 Assessment 

include Alcohol Treatment Targeting Adolescents In Need (ATTAIN), Adolescent

Contingency Management (Adol CM), Familias Unidas, and Motivational
Enhancement Therapy + Cognitive-Behavioral Therapy (MET-CBT). Each of
these programs have juvenile justice youth as their target population, but they
may have different inclusion criteria based on age, severity of substance use and
criminal issues, as well as ethnicity. The programs also differ based on the number
of sessions and treatment aims. For example, Multidimensional therapy typically
lasts three to six months while MET-CBT typically lasts five to seven sessions.
Dauria, McWilliams, and Tolou-Shams (2018) summarized some of the key
elements for empirically supported interventions when working with substance-
abusing juvenile justice clients, which included cultural consideration, motivation
enhancement, family involvement, and a focus on co-occuring disorders.
For adults who engage in illegal activity, they may find themselves involved
in the criminal justice system and perhaps even incarcerated, leading to physical
separation from the family. Miller and Miller (2016) explained that a major-
ity of inmates in state and federal prisons have substance abuse histories. Some
criminal offenders engage in diversionary programs where they take part in sub-
stance abuse treatment as a way to avoid prison time or reduce the amount of
time served. Depending on the correctional institution, treatment programs for
substance abuse may or may not be available. These programs occur within the
correctional institution, which may make it difficult to include family. Lemieux
(2009) explained that families of criminal offenders with substance abuse issues
have been underutilized as a resource for change. This is unfortunate since a
focus on the family is in line with the principles of correctional systems.
Approximately 3–11% of jail and prison inmates have a dual diagnosis (see
the next section), where they have both a substance abuse issue and a mental
disorder (Ruiz et al., 2007). Usually there are more programs in prisons than in
jails as prisons have more resources and have the inmate incarcerated for longer
periods of time. Peters, Wexler, and Lurigio (2015) explained that incarceration
for those with dual diagnosis tends not to be effective. Rather than incarceration,
they suggested that this population would be better served through community-
level treatment.
Lemieux (2009) provided six levels of involvement when matching family-
based interventions to correctional settings (see Figure 8.5). Each level builds on
the strategies of the previous level, based on the correctional institute’s resources
and access to the families. Level 1 includes staff awareness and education. Level 2
focuses on client education. Level 3 addresses education of the family. Level 4
provides referral, usually to family support groups. Level 5 involves family collab-
oration, helping the family with crisis intervention and problem solving. Level 6
integrates family therapy into the treatment.
Treatment for substance abusers in the criminal justice system is designed
to reduce or eliminate problematic substance use as well as to prevent recidi-
vism. Substance abuse treatment seems to be more effective for older rather than
younger individuals, and for females rather than for males in preventing a sub-
sequent arrest (Kopak et  al., 2016). These authors found that risk of re-arrest
was higher for young males who continued to engage in drug use. These authors
suggested that treatment considerations include helping this population to gain
employment and move toward abstinence.
  Issues in Substance-Abusing Families 149

• Educate staff on family dynamics and addiction

Level 1 • Staff awareness of own skills and abilities

• All Level 1 strategies

Level 2 • Educate clients on family dynamics and addiction

• Level 1 & 2 strategies

Level 3 • Educate families on family dynamics and addiction

• Level 1, 2, & 3 strategies

Level 4 • Referral of family to family support groups

• Level 1, 2, 3, & 4 strategies

Level 5 •Help families with assessment and problem solving

• Level 1, 2, 3, 4, & 5 strategies

Level 6 • Inclusion of family therapy

Figure 8.5  The six levels of involvement for family-based interventions in correctional
settings

Dual Diagnosis

Dual diagnosis—also called co-occurring disorders or comorbidity—is when

two mental disorders are present at the same time. When two or more disor-
ders occur simultaneously, they are considered to be comorbid. The presence
of a substance abuse disorder along with a mental health disorder is quite
high. According to the 2016 National Survey on Drug Use and Health, 43%
of adults who experienced a substance abuse disorder in the past year had a
co-occurring disorder. This worked out to 8.2 million people. Only 16% of
adults without a diagnosed substance disorder in the past year had any men-
tal illness. For those with co-occurring disorders, most fall within the 18 to
25 year old range. The percentage decreases significantly for people over 50
years of age. Mason et al. (2016) noted that 1.4% of adolescents in the U.S.
had a dual diagnosis in the past year. However, that number jumps to over
50% for those involved in substance abuse treatment. For these adolescents,
the co-occurring psychiatric disorder tends to be externalizing disorders such
as conduct disorder or attention deficit hyperactivity disorder. Yet, there are
still a significant number with internalizing disorders such as depression and
anxiety disorders.
Comorbidity does not mean that one disorder causes another. However, they
usually interact with one another in some fashion. For instance, someone might
have a diagnosis of major depression while also having a diagnosis of cocaine
addiction. Neither caused the other, however they happen to be occurring at
the same time. Yet, when there is comorbidity, there is usually a higher impair-
ment for both disorders (Mason et  al., 2016). Substance abuse disorder is the
most prominent disorder involved in dual diagnosis. When alcohol use disorder
150 Assessment 

is one of the dual diagnostic disorders, the other comorbid disorders tend to be
attention deficit hyperactivity disorder, post traumatic stress disorder, anxiety
disorders and mood disorders (Mulsow, 2007).
The two (or more) disorders that are involved in dual diagnosis can be viewed
as being primary or secondary disorders. The distinction is which disorder had
the earliest onset and whether they are independent of one another. For instance,
if a client comes in with cocaine addiction and delusional disorder, the therapist
would need to determine which of these two came first. Further, a primary disor-
der should not be based on the effects of the drugs that are being abused.
When working with a client who is dually diagnosed, the therapist will need to
decide whether to address either diagnosis separately or at the same time. Many
people believe that it is important to focus on the substance disorder first as that
is the one that is more amenable to change. Someone can go cold turkey with the
substance they are using (depending on the drug and their usage level) yet cannot
do the same with a diagnosis such as bipolar disorder or panic attacks. According
to the 2016 NSDUH survey, just over 48% of adults with a dual diagnosis received
either substance abuse or mental health treatment. Almost 7% received both sub-
stance abuse and mental health care. While these data seem promising, it is still
concerning that a majority of those with dual diagnosis received no treatment.
When looking at treatment, we can distinguish between partial, sequential,
and parallel treatment (see Figure 8.6). Partial treatment focuses only on the
diagnosis that the therapist believes is more imperative. Sequential treatment first
focuses on the primary diagnosis and then, once that is addressed, on the second-
ary diagnosis. Parallel treatment targets both (or more) diagnoses at the same
time. This has also been called integrated treatment. Some of the possible key
features of integrated treatment include medication management, family work,
self-help programs, psychoeducation, enhancing motivation, and relapse preven-
tion (Scheffler, 2014).
For those clients who have a dual diagnosis, the therapist should be aware that
things can quickly deteriorate. Watkins, Lewellen, and Barrett (2001) explained,

Regardless of which disorder came first, dual disorders are

difficult to treat because of the vicious cycle of the substance
abuse worsening the coexisting disorder, which in turn
increases the client’s tendency to use drugs to relieve the dis-
comfort of the coexisting disorder. (p. 137)

Partial Sequential Parallel

Treatment Treatment Treatment

• Treat Only • Treat • Treat Both

One Primary Diagnoses
Diagnosis Then
Secondary
Diagnosis

Figure 8.6  Treatment for dual diagnosis can be partial, sequential, or parallel
  Issues in Substance-Abusing Families 151

Thus, co-existing disorders are more problematic than either disorder separately.
Further risk factors for this population are that they have low treatment attend-
ance and high dropout rates (Thombs & Osborn, 2013). When a client does
have a comorbid disorder, the likelihood that they complete treatment is reduced
as compared with having only one disorder (Mulsow, 2007). They also have a
greater chance of relapsing. One of the reasons for this is that their social support
system—their family—experiences greater levels of stress, perhaps to the point of
engaging in a cut-off with the addicted individual, which puts greater levels of
stress on the substance abuser.
Family-based interventions for dual diagnosis have been found to be more
effective than individual-based treatment (Mason et al., 2016). Scheffler (2014)
explained that family involvement is important since families likely provide emo-
tional, physical, and financial support for the client. The more the families of
those with dual diagnosis are unsupportive and critical, the greater risk of relapse
(Daley, Salloum, & Thase, 2003). When working with the family, the therapist
will likely provide psychoeducation about both the substance abuse and the psy-
chiatric diagnosis.
Despite understanding the impact that dual diagnosis has for the client and
client’s family, we also need to consider the role of the therapist. Pinderup (2017)
stated that therapists have tended to have counterproductive attitudes toward
clients with dual diagnosis. Pinderup found that therapists’ attitudes changed
considerably for the better when they were trained in areas surrounding dual
diagnosis. This suggests that therapists working in the substance abuse field get
additional training on the implications of treatment for those with dual diagnosis
so that they can be the most effective.

Readiness for Change

When working with any client, but especially with those dealing with substance
abuse, having an understanding of where they are on a continuum of acceptance
of problems and desire of change is extremely important. Not all clients who
enter therapy are at the same point of motivation for change. By understanding
the client’s perspective of whether and to what degree a problem exists, as well as
their motivation in changing their own behavior, the therapist can more readily
join the client where the client is at. This sets up a more collaborative therapeutic
relationship.
There have been many different models for understanding a client’s position in
therapy. In this book we will present two models. In this chapter, we present the
stages of readiness for change model that was originally developed by Prochaska
and DiClemente and then further elaborated upon (Connors, Donovan, &
DiClemente, 2001; DiClemente, 2003). In Chapter 15, you will read about a
solution-focused view of client relationship types. At that point we will discuss
how these two models overlap.
The stages of readiness for change model has changed over the years. When
originally developed, Prochaska and DiClemente (1986) proposed a four-stage
model that included precontemplation, contemplation, action, and maintenance.
A fifth stage, called preparation, occurring before the action stage, was inserted
152 Assessment 

Precontemplation

Termination Contemplation

Maintenance Preparation

Action

Figure 8.7  The circular process of the stages of readiness for change

to highlight how people get ready to make changes. A sixth stage was then added
to the end of the process; termination (see Figure 8.7). However, many times
when you come across this model in the literature you will not see this last stage.
The Precontemplation stage is when the individual does not think that they
have a problem, and, as a consequence, they do not intend to change. For sub-
stance abusers this is usually toward the beginning and middle of their addiction.
Although things have not completely deteriorated, the problems that have been
occurring have been managed to some degree. Since this person does not view
their drug use as being problematic, the therapist should not target behavioral
change, as this will not make sense for the client (DiClemente, 2003). If the thera-
pist pushed for the client to do something different, a rift would most likely
be created between the client and therapist. Instead, therapists might consider
using motivational strategies. To move from the precontemplation to the con-
templation stage the person must first acknowledge that there is a problem and
understand the negative consequences associated with it.
In the contemplation stage, the individual realizes that there is a problem yet
they are not ready to make any proactive changes. In this stage, the person is
doing a lot of thinking around their role in the problem and what the problem
has brought to their life and what life will be like without it. They tend to try to
find out more information, such as the course of the drug or what therapy might
entail. While they are thinking about what change might look like, they are not
yet prepared to engage in different behaviors. Therapists working with clients
in the contemplation stage help clients in consciousness raising. To do this, the
therapist might present educational information to the client about the effects of
  Issues in Substance-Abusing Families 153

the drug of choice. The therapist may also encourage the client to reevaluate their
connection to the drug and the associated consequences. This includes when,
where, and with whom they use and the impact to self and others from this use.
To move to the preparation stage, the client will need to get off the fence and
decide that it is in their (and perhaps others’) best interest to make a change.
People in the preparation stage are in a place in their life where they want
change because there is an issue that they want different in their life. However,
they have been unable to make changes in the last year (Prochaska, DiClemente,
& Norcross, 1992). They do intend to begin taking action in the next month.
This stage was originally called the decision-making stage because the individual
has to come to grips with the problem as well as actually deciding to change their
behaviors. There may be some very small changes made during this stage. The
therapist helps the client to increase their commitment to moving toward a goal
(usually a decrease or cessation of the drug use). Before moving into the action
stage the client needs to set clear goals and develop a plan of action to get there.
The action stage is the implementation of the decision to change that occurred
in the preparation stage. Here, individuals are actively altering their behaviors to
address whatever problem they were encountering in their lives. Besides moving
toward some goal, the person is also learning how to ensure that the problem
does not return. The therapist working with a client in this stage is able to give
direct action tasks, since the client is ready and motivated to move toward change.
Before moving to the maintenance stage, the person will most likely have made
and sustained the changes; approximately for six months (DiClemente, 2003).
While therapists would likely prefer their clients to be in the action stage (or even
maintenance and termination), most people dealing with addictions are not in the
action stage (Prochaska et al., 1992).
In the maintenance stage, the individual has made positive changes and is now
working to maintain those changes. This does not mean they do not actively
work on keeping these changes going. The individual is attempting to prevent
relapses and engaging in other activities to keep on the positive path they devel-
oped in the action stage. The therapist can focus on the resources the client has
exhibited in the action stage to move from problem to non-problem. Further, the
client moves beyond the addiction to see what other areas of their life they can
improve upon to ensure their continued stability (DiClemente, 2003).
Termination is the sixth and final stage of the change process. At this point
the person has made productive changes and has been able to maintain them.
They have increased their ability to cope with life and do not have to actively try
to change anything (they are not focused on what was the problem but on the
resources and aspects of their life that are working). At this stage, they do not
have temptation to use and have increased their self-efficacy.
There is not a set amount of time that someone will stay in one stage, although
there are some averages (such as from three to six months in the action stage).
There is also the possibility that when a person moves from one stage to another,
they may then move back to a previous stage. Prochaska et al. (1992) explained
that people usually move through a spiral pattern where they go through several
cycles of these stages until the point they get to termination (see Figure 8.8).
Included in this spiral is the possibility of relapse where the person uses and then
readjusts their view of how their use is impacting their life.
154 Assessment 

Spiral 1

Spiral 2

Spiral 3

Figure 8.8  People tend to spiral through the stages of readiness several times before
entering into the maintenance/termination stage

While we can look at these stages of readiness for change as an individual

model, we can also see it as a family process as well. This tends to be a par-
allel process where both the individual and the family follow similar courses
(Connors, Donovan, & DiClemente, 2001). The family may not see that the way
they have organized is problematic and deny that there is a problem with the
individual as well as themselves (precontemplation). Over time, they realize that
there are problems, but they may not be sure what they are exactly or what they
could do differently (contemplation). The family may then want their family
functioning to be different and might talk about going to therapy (preparation).
Family members may take small actions to try to fix things or they may search
out possible avenues of change—such as gathering names of therapists. They
also might try to encourage the abuser into therapy. As a whole the family could
make changes of how they interact with one another (action). At this point,
the substance abuser has most likely refused to go into treatment or perhaps
has agreed to go into treatment and sabotaged it somehow. However, family
members have decided to work on themselves. After making these changes, they
engage in ways of being, not only to prevent the problem behaviors, but to
enhance other areas of their lives (maintenance). After many months of actively
ensuring that they are functioning well, this behavior becomes their homeostasis
and they will not have to even think about how to be; they just will be with one
another (termination).
Therapists are encouraged to alter their treatment and interventions based on
the current stage of the client (Prochaska et al., 1992). For those in the precon-
templation stage, the therapist will likely not push too much as the person is the
least motivated to change. For those in the contemplation stage, the therapist
will likely use consciousness raising and self-reevaluation activities as clients
  Issues in Substance-Abusing Families 155

are better able to use the cognitive, affective, and evaluative processes of change.
During the preparation stage, the therapist might include some countercondi-
tioning and stimulus control interventions as the client is taking the first steps
toward change. In the action stage, the therapist taps into the client’s self-liberation
and willpower, building on the client’s renewed sense of agency and autonomy.
In the maintenance stage, besides using all of the previous interventions, the
therapist also highlights how the person is becoming who he or she wants to be.
This might be through reinforcement management and the therapeutic benefits
of the helping relationship.

Enhancing Motivation

In the previous section we discussed how substance abuse therapists assess how
ready individuals, couples, or families are for change. This readiness is related to
the person’s motivation to engage in treatment. One of the therapeutic tasks is
to help enhance this motivation. Miller and Rollnick (2012) provided five areas
that therapists can keep in mind which help influence engagement or disengage-
ment in therapy as well as potential questions to ask clients:

1. Desires or goals. What did you want or hope for in going? What is it that
you’re looking for?
2. Importance. How important is what you’re looking for? How much of a
priority is it?
3. Positivity. Did you feel good about the experience? Did you feel welcomed,
valued, and respected? Were you treated in a warm and friendly manner?
4. Expectations. What did you think would happen? How did the experi-
ence fit with what you expected? Did it live up to (or even exceed) your
expectations?
5. Hope. Do you think that this situation helps people like you to get what
you’re seeking? Do you believe that it would help you? (p. 46, italics in
original)

The answers to these questions help connect the therapist to the client’s
perspective.
These five areas lead to five therapist actions that can build engagement
between therapist and client, which will likely lead to increased motivation for
change.

1. Asking the client why they are coming to therapy at this point in time.
2. Thinking about how significant the person thinks his or her goals are.
3. Figuring out how to join with the person, providing an accepting
atmosphere.
4. Explain the process of therapy and see how much this overlaps with the cli-
ent’s expectations.
5. Explain how you think therapy can be helpful to build the client’s sense of
hope for change.
156 Assessment 

These actions put the client in a more respected position. This is important
since motivation can be viewed as purposeful behavior (Thombs & Osborn,
2013). These authors explained,

Learning the purpose or function of a behavior requires direct

interaction with, and listening to, an individual with substance
use problems or persons from a targeted population at risk for
developing addiction (e.g., low-income adolescents who have
been exposed to repeated trauma). (p. 277)

A person’s motivation for change changes over time and is based on the
situation in which they currently find themselves (Hanson & El-Bassel, 2014).
Motivation is based upon the person’s level of distress, goals, outcome expectan-
cies, perceived self-efficacy, environmental resources, and personal skills. Given
that each of these elements changes as people experience themselves and life dif-
ferently, people’s motivation also changes.
Thus, therapists working with substance-abusing clients are encouraged
to listen to and assess the client’s current motivation, finding out what they
want from therapy. This can be done for therapy of any length or intensity
level. Bien, Miller, & Tonigan (1993) reviewed 32 controlled trials of therapy
for addiction issues and found brief interventions for problem drinking to be
more effective than no treatment and similar in effectiveness to more intense
interventions. These researchers also suggested six common components of
effective brief therapies, which are found in the acronym FRAMES: Feedback,
Responsibility, Advice, Menu, Empathy, and Self-efficacy (Miller & Sanchez,
1994) (see Figure 8.9).

Feedback • Providing client with personalized feedback

• Client drinking and sobriety is solely the

Responsibility responsibility of the person

• Therapist provides possible pathways to reduce or

Advice stop drinking

Menu • Multiple strategies for reduced drinking

Empathy • Therapist is warm, accepting, and understanding

Self-eficacy • Focus on client's strengths & resources to change

Figure 8.9  FRAMES is an acronym used to explain six common components of brief
therapies
  Issues in Substance-Abusing Families 157

Motivational Interviewing
One of the leading approaches in working with people dealing with substance
abuse to enhance their engagement and motivation for change is motivational
interviewing (MI). Motivational interviewing is an evidence-based approach that is
client-centered and is usually used when a substance abuser is ambivalent for change.
Miller and Rollnick (2012) provided a definition of this approach, “Motivational
interviewing is a collaborative conversation style for strengthening a person’s own
motivation and commitment to change” (p. 12). The therapist mainly engages in
guiding the client, while at times utilizing elements of directing and following. This
leads the therapist to not try to persuade the substance abuser to change, as more
directing therapist styles are associated with the client having opposing arguments.
The spirit of MI is based upon four interrelated elements: partnership, accept-
ance, compassion, and evocation (Miller & Rollnick, 2012) (see Figure 8.10).
Partnership means that the therapist is not the expert who works with a passive
recipient. Rather, the client is viewed as the expert on who they are as a person.
Motivational interviewing is not done “to” someone, but rather is done “with”
and “for” them. This is important since change needs to come from the client’s
own motivation and resources.
Acceptance involves respecting and appreciating what the client brings with
him or her to therapy. Acceptance in MI has four aspects: absolute worth,
autonomy, accurate empathy, and affirmation. Absolute worth is related to Carl
Rogers’ (1961) notion of unconditional positive regard where the therapist does
not have to like or even approve of a person’s actions, but believes in the worth of
the client as a person. Accurate empathy is an attempt by the therapist to under-
stand the inner world of the client. Autonomy means that it is the client’s position
to choose the direction for his or her life. Affirmation relates to the therapist
acknowledging the client’s strengths and efforts.

Partnership

Spirit
Evocation of Acceptance
MI

Compassion

Figure 8.10  The spirit of motivation interviewing consists of partnership, acceptance,

compassion, and evocation
158 Assessment 

The third key spirit of MI is compassion. Miller and Rollnick (2012) explained,
“To be compassionate is to actively promote the other’s welfare, to give priority
to the other’s needs” (p. 20). Therapy is all about the client, rather than being in
the therapist’s self-interest.
The last key spirit of MI is evocation. This means that the therapist utilizes a
strength-based approach, focusing on the client’s strengths and resources rather
than deficits and failings. What is evoked is the client’s expertise on their own
self, beliefs, values, and actions.
Motivational interviewing is based upon four overlapping processes that guide
the client’s decision making: engaging, focusing, evoking, and planning (Miller
& Rollnick, 2012). Engaging is about developing a positive working relationship
with the client. Motivational interviewing holds that therapeutic relationships
should be collaborative, where both therapist and client are honored in terms of
ideas for therapy and are both working together for the same purpose. Focusing
relates to therapy’s agenda and goals. What to focus on is based on the client,
setting, and therapist, with the client’s focus being the most common source of
direction. The setting in which therapy happens may have an agenda for what
services are available and appropriate. The therapist is also able to bring forth
potential foci for therapy; however, it should be done in a way that has the cli-
ent’s buy in. Evoking in MI consists of the therapist listening for and enhancing
the client’s motivation for change. Planning, the last process in MI, involves
developing a specific change plan that the client is willing to work toward.
Therapists can pay attention to several signs to let them know there is readiness
to move from evoking to planning (Miller & Rollnick, 2012). These include
increased change talk, the person has taken steps in the direction of change,
diminished sustain talk (the person reduces their arguments against change),
increased resolve, envisioning a changed future, as well as the client asking ques-
tions about change. Figure 8.11 presents a pictorial representation of the four
aspects of client decision-making in MI.
Based upon the four key interrelated elements that form the spirit of MI—
partnership, acceptance, compassion, evocation—and the four primary processes—
engaging, focusing, evoking, and planning—there are many strategies used to
help enhance clients’ motivations for change (Hanson & El-Bassel, 2014). These
microskills can be summarized with the acronym OARS: open-ended questions,
affirmations, reflections, and summaries (Tooley & Moyers, 2012). A MI thera-
pist uses a lot of open-ended questions, as these help to elicit the client’s thoughts
and beliefs, allowing them to present their story in their own way. Additionally,
with a foundation of Rogerian therapy, MI therapists use reflective listening.
Instead of telling clients “what is,” reflective listening attempts to bring forth the
client’s meanings. Another MI strategy is affirming clients’ concerns. This is done
as a means of acceptance and working with the client’s goals. Motivational inter-
viewing therapists also use a lot of summarizing, where the therapist ties together
the client’s statements and concerns. Lastly, a major MI tactic is eliciting change
talk. This helps to address the client’s ambivalence and brings forth the direction
of the sessions.
While MI has been primarily used with individuals, it has also been used
with couples, families, and groups. However, the therapist should first make an
assessment that includes the client’s desire for family member involvement and
  Issues in Substance-Abusing Families 159

Engaging

Client
Planning Decision Focusing
Making

Evoking

Figure 8.11  Client decision making in motivational interviewing includes engaging,

focusing, evoking, and planning

investment in them as well as the significant other’s support of and ability to

engage in the treatment process (Hanson & El-Bassel, 2014). In use with fami-
lies, MI may be able to support a strong therapeutic alliance between therapist
and family as well as between family members (Lloyd-Hazlett, Honderich, &
Heyward, 2016). The use of MI in family therapy provides an opportunity for
family members to pause in trying to change each other and instead to listen to
one another. This allows them to hear what each person deems as important
and what change and goals they have that might overlap. This leads to the
possibility of second-order change (a change in the rules of the system) rather
than first-order change attempts (change within the existing rules), since family
members stop trying to get the substance abuser to stop using, leading to new
interactional processes.
When using MI with families, the same four primary processes of MI can
still be used (Belmontes, 2018). The therapist needs to figure out how to engage
the family, developing a positive therapeutic alliance with multiple members. In
focusing with the family, the therapist follows various family members’ goals
while also seeing if the family is open to discussing substance-related issues. Next,
the therapist evokes the multiple motivations to change from the various family
members. Lastly, the MI therapist works collaboratively with the family to plan
for change and develop a treatment plan.
In work with couples, the MI therapist might engage partners in one of three
ways for the purpose of therapeutic intent (Burke, Vassilev, Kantchelov, &
Zweben, 2002). The first is including the partner in the session for the substance
abuser’s benefit. Second, MI might be used with both partners, usually if both see
160 Assessment 

themselves as clients, if the partner is dealing with some issues that hinder him or
her in supporting the substance abuser, or if the partner is ambivalent about his
or her actions in maintaining the partner’s substance use. Lastly, the MI therapist
might work with partners when focusing on the couple’s interactions that main-
tain the problem.
Miller and Rollnick (2012) recommended that when utilizing MI with the sub-
stance abuser and a significant other, the therapist should establish ground rules
with the partners to ensure that sessions do not include blaming and instead focus
on positive change. However, when a significant other is involved in the MI ses-
sion, the therapist might be able to gain additional information that will help
to enact the four key principles of expressing empathy, developing discrepancy,
rolling with resistance, and supporting self-efficacy (Burke et al., 2002). A further
benefit of working with couples is that the therapist can teach the couple how to
engage in effective listening and communication skills.
Motivational interviewing has been found to be effective with a wide range
of presenting problems, various abused substances, treatment lengths, and cli-
ent populations including adolescent substance abusers (Jensen et  al., 2011).
Motivational interviewing has been found efficacious with those trying to reduce
their use of alcohol, tobacco, and marijuana, as well as, to a lesser extent, cocaine
(DiClemente et al., 2017), and may have more positive effects early in treatment
(Carroll et al., 2006).
Steinglass (2008) integrated notions from family systems with motivation
enhancement to develop the systemic-motivational model (SMM). The SMM
assists families dealing with chronic alcoholism in accessing their strengths and
resources in an effort to develop their own solutions. Based on a “both/and” per-
spective, the therapist brings forth the multiple perspectives of all family members
as well as the therapist’s position. This model utilizes three phases: assessment/
consultation, family-level treatment, and aftercare and relapse prevention.
Steinglass explained the overlap between family systems and motivational inter-
viewing principles:

As explicated by Miller and Rollnick, MI has five basic princi-

ples that underscore the approach to be taken by the therapist
treating a patient with a substance abuse problem: (1) express
empathy about the patient’s condition; (2) develop discrepancy
regarding the patient’s beliefs about his/her behavior; (3) avoid
argumentation with the patient about continued alcohol use;
(4) roll with the patient’s resistance to change; and (5) sup-
port patient self-efficacy regarding decisions about behavior
change. It would be our contention that every one of these
principles is compatible with a family therapy approach to
alcoholism treatment. (p. 21, italics in original)

The SMM model utilizes a harm reduction approach to help educate family mem-
bers of the possible pathways to change and works with them to develop pros
and cons for each change option.
Another adaptation of motivational interviewing is Motivational Enhancement
Therapy (MET). This brief intervention, using principles and strategies of MI,
  Issues in Substance-Abusing Families 161

was developed for Project MATCH (1993) and provides personalized feedback
to the participant that compares their drug and alcohol use with that of peers
and national standards of use. It is this feedback component that separates MET
from MI (Thombs & Osborn, 2013). Motivational enhancement therapy is a
brief manualized intervention that has been found to be effective across popula-
tions and with most abused substances (Lenz, Rosenbaum, & Sheperis, 2016).
Motivational enhancement therapy is benefitted when the client’s significant
other (SO) is involved. The client’s change talk is significantly increased when the
SO engages in pro-change talk (Bourke, Magill, & Apodaca, 2016).

Case Application

The Rothers family find that they are experiencing some of the issues for families
dealing with addiction, but not all of them. Fortunately, as far as we know, there
has not been any issue of congenital problems because of drug or alcohol use dur-
ing pregnancy and no report of child physical or sexual abuse. However, Mark
has a history of violent episodes in close relationships. This includes having a fist-
fight with his brother Mick, centering around Mark’s use of alcohol. This fight
occurred while Mark was drunk one night. Since then Mark and Mick have not
talked with one another. Mark also was arrested for physically assaulting his first
wife Angelina, when they were going through the process of divorce. At that time,
Mark was at one of his highest points of alcohol consumption. While this was an
isolated instance of physical violence, we might hypothesize the potentiality for
other means of power and control that have been used by Mark in his relation-
ships with Angelina and Hannah. The Rothers’ therapist might explore whether
Mark has used male privilege, minimized and blamed, or engaged in emotional
abuse in his current relationships. At this point Hannah has not expressed that
Mark has threatened, intimidated, or isolated her emotionally or economically.
Criminality has not had a major role in the Rothers’ family life besides the
domestic violence arrest that Mark had over 15 years ago when he pushed his
then wife Angelina. However, there is cause for concern that Steve may find him-
self involved in the juvenile justice system. His externalizing behaviors seem to be
increasing, where he is engaging in more disruptions outside of the house. While
Steve is currently not part of the juvenile justice system, he seems to be at serious
risk for escalation of problematic behaviors, including the potential for drug and
alcohol abuse as well as criminal mischief. The Rothers’ therapist should keep
these possibilities in mind and focus on prevention issues.
At the current moment there is no one in the Rothers family that has been
diagnosed by a mental health professional. However, we can hypothesize that
Mark and Steve would likely be diagnosed if they were to present for assessment
and treatment. In all likelihood, Mark would receive a diagnosis of alcohol use
disorder. Further, given some of his other behaviors, such as isolating himself
and suicidal ideation, there may be a co-existing psychological disorder. If so, the
therapist would need to consider how to work with this dual diagnosis. While we
do not know the specifics of Steve’s problematic behaviors at school, we might
consider whether any of the patterns of behavior falls within the category of
conduct disorder.
162 Assessment 

Mark is most likely currently either in the precontemplation or contemplation

stage. From what we know, he does not believe that his drinking is problematic.
However, he is likely aware of some of the interpersonal discord in the family
and that his drinking plays a role in these problematic interactions. If he is aware
of this, then he may be in the early part of the contemplation stage. Hannah is
likely in the preparation stage, viewing her own behavior as not doing enough
to change Mark but still aware that she has likely been allowing his drinking
and disengagement. Steve seems to be in the precontemplation stage as he likely
views any problems he is experiencing as the result of others, such as his parents,
friends, or teachers. We do not have enough information to determine what stage
of readiness Kayleigh or Pete are currently in.

Summary
Addicted families have many issues that may or may not be present in
non-addicted families. Given that members tend to feel like their own lives
and the family as a whole are becoming chaotic, they have a tendency
to try to control others. This may lead to domestic violence. Children in
domestic violence families are at greater risk for being physically and sexu-
ally abused. Toward the extreme end of consequences of coming from an
addicted family is developing fetal alcohol syndrome, depending on the
severity of drug use by the mother during pregnancy. Therapists must also
consider assessing for multiple disorders, as there is a heightened prob-
ability of dual diagnosis. Yet, whatever substance is being used, therapists
can assess for how ready the individual and/or family is to make changes in
their lives. One means of enhancing the client’s motivation is through moti-
vational interviewing, a model of working with clients that is collaborative,
focusing on the client’s desired changes.

Key Words
child abuse teratogenesis
intimate partner violence dual diagnosis
physical domestic violence comorbid
sexual domestic violence partial treatment
psychological domestic violence sequential treatment
emotional violence parallel treatment
economic abuse stages of readiness for change
patriarchal terrorism model
common couple violence precontemplation
tension building phase contemplation
abuse consciousness raising
honeymoon phase preparation
children of alcoholics action
incest maintenance
fetal alcohol abuse syndrome termination
fetal alcohol syndrome disorder
  Issues in Substance-Abusing Families 163

Discussion Questions
1. Discuss the relationship between domestic violence and power/control.
2. What are the differences between the various types of domestic
violence?
3. What implications are there for the family system when child abuse is
present?
4. Discuss how fetal alcohol syndrome disorder impacts the child as well
as the family.
5. Why should the therapist consider assessing for dual diagnosis?
6. Explain how a client (and a family) can proceed through the stages of
readiness for change.
nine

Behavioral Addictions
Myron Burns

As human beings we seek relief and pleasure in our lives, whether that is
having a drink and a bite to eat after a long hard day of work or enjoying
family and friends during a night on the town. However, as the old say-
ing goes, “Too much of anything is not good for you.” Historically, people
have excessively engaged in addictive behaviors like drinking, gambling, sex,
and shopping. Behavioral addictions can lead to problematic behaviors that
put the individual at risk or in danger and possibly lead to other psychologi-
cal disorders.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) recently
added a category of Substance-Related Addictive Disorders (APA, 2013).
Gambling is the only non-substance-related disorder included in this diagnostic
section. However, in Section III, Internet Gaming Disorder has been proposed
as a diagnosis for future study. There are neurobiological similarities between
behavioral addictions and substance use disorder. For example, serotonin,
which helps prevent excitability and the rapid firing of nerve cells that leads to
anxious feelings, and dopamine, involved with seeking pleasure and rewards,
motivation, and impulse control, may contribute to both disorders (Potenza,
2008). Brain imaging studies suggest that the dopaminergic mesolimbic path-
way may be involved in substance use disorders and pathological gambling
(Reuter et  al., 2005; Wrase et  al., 2007). The American Society of Addiction
Medicine (ASAM) (2014) and the American Psychiatric Association (2013) have
acknowledged the similarities between the brain pathways of substance use dis-
orders and behavioral addictions.
In this chapter non-substance-related disorders and behavioral addictions will
be discussed. This chapter provides an overview of the prevalence rates, gen-
eral criteria for diagnosis, relationship to substance use, and family dynamics of
behavioral disorders. The specific criteria for the DSM-5 diagnosis of gambling
disorder will be discussed. Although they have no formal diagnosis in the DSM-5,
compulsive buying, internet, and sex addiction have been identified in the mental
health field and will be discussed. Because of a void in research related to sub-
stance abuse and the family with exercise addiction, this disorder is not covered.
Disorders related to eating are also not discussed as they are listed in the DSM-5
under Feeding and Eating Disorders.

164
  Behavioral Addictions 165

Definition of Behavioral Addiction

Behavioral addictions are difficult to define. One of the reasons is because behav-
ioral addictions involve “normal” activities (sex, food, etc.) and the other reason
entails behavioral addictions being dismissed as habits. Behavioral addictions
are typically defined as compulsive and impulsive behaviors where an individual
persistently and repetitively engages in actions without it necessarily leading to
a reward or pleasure, nor does the individual reflect about the consequences of
their actions (Stevens & Smith, 2018).
Like substance abuse, the individual with a behavioral addiction will con-
tinue to engage in these behaviors despite the consequences of endangering one’s
health, and the loss of one’s job and loved ones or spouse. Moreover, if we use
gambling as an example, like those with substance use disorders, the individual
will lie to cover up their behavior and/or engage in increasing the risk of the
stake to feel “alive” or excitement. Other similarities between behavioral addic-
tions and substance abuse include spending a considerable amount of time on
the activity or behavior, having cravings and urges, and producing a conditioned
response (e.g., use drugs or gamble to feel good or when stressed).
Mental health care professionals trained in addiction are careful not to label
people based on their behaviors alone. For example, there are professional gam-
blers who know how to manage their money or recreational gamblers who do
not gamble to excess. Also, many mental health professionals are concerned that
these behaviors may be used to excuse actions like compulsive buying or infidel-
ity. Nevertheless, valid diagnoses should involve detailed structured interviews,
psychological testing and assessments, and the use of the DSM-5.
Previous editions of the DSM only referred to the misuse of substances; how-
ever, the current edition (DSM-5) lists gambling disorder as the only behavioral
addiction alongside substance use disorders. The other addictions (sex, compul-
sive buying, and internet) discussed in this chapter have no DSM-5 criteria. Sex
addiction, while not an official diagnosis in the DSM-5, has been included in
previous editions and still merits attention. Compulsive buying disorder shares
similar processes to substance use disorders. Internet addiction disorder could
entail shopping, sex, and gambling, and internet gaming disorder is a form of
internet addiction and has been listed in section III of the DSM 5 for future study.

Gambling Disorder

About 1.5 million Americans experience severe gambling disorders and between
3 to 6 million fall in the “mild to moderate” category (Kessler et  al., 2008).
African Americans have the highest prevalence rates (0.9%), in comparison with
Caucasians (0.4%), and Hispanics (0.3%). Men gamble at a higher rate than
women. Someone with a gambling disorder is obsessed with gambling and rarely
refuses a bet. Despite the loss of money, the gambler will continue to bet and
“double down” (i.e., double or increase the amount of their previous wager to
try and regain lost funds) until no more funding options are available. A person
166 Assessment 

diagnosed with a gambling disorder may be preoccupied in thoughts of past win-

nings or future ventures and will repeatedly engage in the behavior despite the
negative consequences it may cause to their finances and intimate relationships.
These individuals may gamble when stressed or depressed and find it difficult
to cut back or stop their gambling. Like those diagnosed with a substance use
disorder, those with a gambling disorder will lie to cover up their behavior or
excitement and engage in increasing the risk of the stake to feel “alive.”
It is important to note, as Griffiths (2014) and Marjot (2006) state, that
problem gambling should not be confused with a gambling addiction or dis-
order. Those with a gambling addiction or disorder can be problem gamblers,
but problem gamblers are not necessarily gambling addicts. Addictions rely on
constant reward expectations and frequency of the behavior. So, while placing a
bet or buying a lottery ticket once or twice a week can be problematic, particu-
larly when it causes a financial burden, the frequency and reward expectation is
much lower in comparison with someone who gambles every day or pulls the slot
machine lever 11 times in a 1-minute interval.

Gambling and Substance Abuse

“Whatever happens in Vegas stays in Vegas.” This is a phrase synonymous with
vacations in Las Vegas. Also synonymous with Vegas are gambling, drinking,
smoking, drug use, and sex. Some of these behaviors will often occur simultane-
ously. It is not uncommon for a gambler to be given a free drink in the casino or
smoke cigarettes while at the slot machines, blackjack, and “craps” table. These
behaviors can become an engrained conditioned habit (cannot do one without the
other, or while engaging in one behavior will automatically engage in the other).
Given its role in drug addiction and rewarding behavior, dopamine has been
heavily investigated in the neurochemical abnormalities of pathological gamblers
(Clark et al., 2013). Patients with Parkinson’s disease display sudden onset gam-
bling as a side effect of dopamine agonist medications (Ambermoon, Carter, Hall,
Dissanayaka, & O’Sullivan, 2011). Higher levels of dopamine release are also cor-
related with greater subjective excitement (Linnet, Møller, Peterson, Gjedde, &
Doudet, 2011) and gambling severity (Joutsa et al., 2012). Campbell-Meiklejohn
et al. (2011) found that serotonin and dopamine appear to play separate roles in
the tendency of individuals to gamble to recover, or to judge whether previous
losses are worth chasing. Based on their findings, lowering of brain serotonin by
acute tryptophan depletion was associated with a reduced number of decisions
made to chase losses and the number of consecutive decisions to chase losses in
which participants completed a computerized loss-chasing game following treat-
ment. D2/D3 receptor activity was found to produce changes in the value of loss
chasing. Pramipexole, which is a dopamine agonist, was significantly related to
placing a high value on loss chasing and being associated with valuing losses less.
Meta-analysis has revealed that substance abusers engage in gambling at
higher rates than the general population (Shaffer, Hall, & Vander Bilt, 1999).
Welte, Barnes, Wieczorek, Tidwell, and Parker (2001) reported that 25% of
pathological gamblers met the diagnoses for alcohol dependence, compared with
1.4% of non-gamblers. Not surprisingly, Maccallum and Blaszczynski (2002)
found nicotine dependence to be highly related to gambling. In their investigation
  Behavioral Addictions 167

of treatment-seeking poker players, 65.3% smoked cigarettes and 37% met the
nicotine dependence criteria. If we look at methadone specifically, rates of patho-
logical gambling have ranged from 7% to 18% in comparison with the general
population (0.4% to 2%) (Petry, 2007).
Gamblers with a substance use disorder also have significantly more mental
health problems than gamblers without a substance use diagnosis. In a nation-
ally representative sample of 43,093 households aged 18 years and older, Petry,
Stinson, and Grant (2005) collected data on lifetime prevalence and comorbid-
ity of pathological gambling with other psychiatric disorders. Results revealed
pathological gambling was significantly associated with having a mood disorder
(49.6%), anxiety disorder (41.3%), and personality disorder (60.8%). Gamblers
with a substance use disorder also have more severe legal, employment, and fam-
ily difficulties than those without a substance use disorder (Ladd & Petry, 2003).
For cocaine-dependent patients, those with a gambling problem were more
likely to be unemployed, involved in illegal activities, have more legal problems,
and spend more time in prison than cocaine-dependent patients without a his-
tory of a gambling problem (Hall et al., 2000). In relation to sexual behavior,
which will be discussed in more detail later in this chapter, gambling problems
in substance abusers are also related to risky sexual behaviors. In a sample of
134 substance abusers, Petry (2000) reported that high severity of gambling
problems in substance abusers significantly predicted more sex partners, and less
frequent use of condoms with casual and paid sex partners, in comparison with
non-problem gamblers. When looking at the relationship between gambling and
substance abuse, both behaviors together could be more problematic than either
behavior alone.

Gambling and Family Dynamics

Like substance use disorders, the etiology for gambling disorders is similar (e.g.,
biological, genetics, environment, conditioning, and social/cultural factors).
Most of the studies which have looked at the relationship between gambling and
the family have investigated the development of the disorder beginning in ado-
lescence. Vachon, Vitaro, Wanner, and Tremblay (2004) found that adolescent
gambling was related to parents’ gambling (primarily that of the father), low
levels of parental monitoring, and lack of discipline. In a study of 2,336 students,
Grades 7–13, Hardoon, Gupta, and Derevensky (2004) investigated the impact
of adolescent gambling. In their sample, 4.9% of adolescents met the criteria for
pathological gambling and 8% were found to be at risk. Problematic gambling
predicted substance use (primarily alcohol and tobacco), conduct problems, and
strained family relationships.
Adults who were diagnosed as being problematic gamblers were more likely
to have first-degree relatives (parents, siblings, and children) who were problem-
atic gamblers than control families (Black, Monahan, Temkit, & Shaw, 2006).
Moreover, these relatives were also more likely to have significantly higher life-
time rates of substance use disorders and antisocial personality disorder. The
adult gambler will often isolate themselves from the family and pay little atten-
tion to family needs and concerns. As inattention to family and preoccupation
with gambling increases, so does family strife. The individual will lie to hide
168 Assessment 

losses and increased debts, and relationships with spouses deteriorate. This puts
a financial strain and burden on the entire family.
Gambling addiction is related to a lower quality of life. Using a health utility
index, Kohler (2014) compared the Health-Related Quality of Life costs of path-
ological gamblers recruited from treatment centers in Western Switzerland with
the general population. Pathological gambling was shown to be associated with a
significant loss of quality of life in comparison with the general population. This
loss is then transferred to both the gambler’s family and society.

Treatment Possibilities for Gambling Addiction

Some of the same practices used to treat substance use disorders are also appli-
cable in treating gambling disorder. For example, motivational interviewing,
cognitive behavioral therapy (CBT), and 12-step programs appear to be effective
in treating gambling addiction. According to Gooding and Tarrier (2009), CBT
is considered the widely recognized evidence-based treatment for gambling addic-
tion. In their meta-analysis, Gooding and Tarrier found that various forms of CBT
were effective in reducing pathological gambling. These treatment approaches
encourage individuals to identify use patterns, learn how to recognize and avoid
triggers, and identify lifestyle changes to avoid high-risk situations. Topf, Yip,
and Potenza (2009) found similar approaches were beneficial in relapse preven-
tion strategies.
The FDA has no approved medication for specifically treating gambling dis-
order; however, Naltrexone, which is an opioid antagonist, has shown some
positive results. Grant, Kim, and Hartman (2008) found that a treatment group
which received Naltrexone reported a 40% abstinence rate post one-month fol-
low up in comparison with a placebo group. Other medications that have shown
to be effective in treating gambling disorder includes Nalmefene, N-acetylcysteine
(NAC), and antidepressants (Stevens & Smith, 2018).
Engaging family members in the treatment process is also highly important.
Families may feel distrust over the gambler’s lies, and possible legal and employ-
ment issues. This can lead to increased stress on the family system. Steinberg
(1993) highlighted the importance of including the family in treatment and stated
that, typically, the spouse of the gambler initiates therapy. In addition, Steinberg
further stated that including the family in therapy can offer an accurate picture
of the gambling problem, prepare the family for involvement in the treatment
process, and provide a clearer understanding of the family dynamics. Families
need to be able to communicate financial concerns, issues of power and control,
and role reversal. Gamblers Anonymous for families (GAM-ANON) can provide
support and education for family members.
Makarchuk, Hodgins, and Peden (2002) modified the Community Rein­
forcement and Family Training (CRAFT) program (see Chapter 10) to address
problem gambling and the specific needs and issues of the family. Community
Reinforcement and Family Training places an emphasis on three aspects: (1)
Persuading the gambler to enter treatment, (2) helping to reduce gambling, and
(3) encouraging family members to take care of themselves. In this modified
version of CRAFT, a self-help manual was used rather than the traditional face-
to-face format commonly used in the treatment of alcohol and drug addiction.
  Behavioral Addictions 169

The manual included topics such as: Motivation to help, self-care and help,
awareness and knowledge of the gambling problem, and helping the gambler.
Makarchuk et al. (2002) noted that the self-help manual provides a private treat-
ment option where family members are actively involved in addressing their issues
surrounding the addiction.
In Makarchuk et al.’s study, 31 significant others were randomly assigned to
receive either CRAFT or a control package. Post three-month follow up showed
that CRAFT participants’ gambling members had significantly decreased gam-
bling and that participants felt the program met their needs. There were no
adverse consequences for either group related to gambling (e.g., financial, legal,
employment), which might suggest that any treatment is better than no treatment
at all. However, for the control group, some participants sought additional treat-
ment and reported separating from the gambler, something that did not happen
in the treatment group. Those who were in the CRAFT intervention reported
utilizing various coping strategies they had learned in treatment (e.g., managing
finances, open communication, understanding enabling behaviors, and finding
activities to do outside of gambling). Participants in CRAFT reported that the
self-help manual helped them understand the severity of the problem, reduced
their guilt, and they reported feeling better about their situation.

Sex Addiction

The adage that “sex sells” has never been more popular than today. What was
once a taboo topic is now seen almost daily in advertisements, T.V., film, and
media coverage. The adult entertainment industry generates close to 4 billion dol-
lars a year (Stevens & Smith, 2018). Patrons gain access through films and videos
sold in retail stores, on the internet (for purchase and free), and cable providers
(both home and in hotels). Strip clubs and/or escort services are also available in
almost every city worldwide. Given the access to sexual material and content,
defining sex addiction can be tricky.
Sex addiction was deleted from the DSM-IV and is not included in diagnoses
for future research in the DSM-5. The difficulty in defining sex addiction lies
in what constitutes it, as many experts in the field cannot agree on a defini-
tion. Part of the problem lies with sex being a normal behavior that, while many
people may engage in it, some may not be as forthcoming in describing their
sexual habits. Also, there is such a wide variety in sexual behaviors in terms of
gender, age, sexual orientation, race, ethnicity, etc., that what may be abnormal
to one person may be totally normal to others. Despite the limitation in defin-
ing sex addiction, it is possible to look at the consequences of sexual behavior.
Sex addiction involves hypersexual and compulsive behaviors. The individual
may spend considerable time engaging in recurrent and intense sexual fantasies,
sexual urges, and/or sexual behaviors. These behaviors lead to repeated engage-
ment and psychological distress, despite the danger to one’s health and strain in
social, family, and work life.
Similar to defining sex addiction, it is difficult to determine the prevalence
rates. Estimates indicate that between 3% and 6% of Americans suffer from
some type of sex addiction (Kuzma & Black, 2008). Sex addiction is more
170 Assessment 

common among middle-aged Caucasian males who are primarily in the middle-
to upper-class income bracket. Sex addiction is also more common among
gay and bisexual men, with studies reporting close to 60% of them displaying
behaviors like compulsive sexual behaviors. Sexual addiction has comorbidity
with substance use disorders, personality disorders, depression, and anxiety
(Rosenberg & Feder, 2014).

Sex Addiction and Substance Abuse

“Sex & Drugs & Rock & Roll” is a song by Ian Dury from the late 1970s and
a popular phrase that has been used in our society since its release. The use of
alcohol and sexual activity often occur together. Alcohol and drugs can lower
one’s inhibitions, distort thinking, and lead to risky sexual behavior (Rawson,
Washton, Domier, & Reiber, 2002; Washton, 1989). Some individuals report
that stimulants like cocaine and methamphetamine increase their interest,
desire, and arousal for enhanced sexual fantasies (Washton & Zweben, 2006).
Moreover, Washton and Zweben (2006) report that drug users with increased
sexual desire will often display impulsive behaviors such as seeking out prosti-
tutes and hooking up with strangers. The use of drugs and engaging in sex can
become a conditioned habit in which one behavior often triggers the other.
Some studies identifying compulsive sexual behaviors have found that a
comorbid diagnosis of substance abuse ranges from 39% to 71%, with alco-
hol being the primary drug (Black, Kehrberg, Flumerfelt, & Schlosser, 1997;
Kafka, 2010). Raymond, Coleman, and Miner (2003) found that 38% of sex
addicts met the criteria for a lifetime cannabis substance use disorder. For more
severe and illicit drugs, Reid et al. (2012) found that those meeting the criteria for
methamphetamine dependence reported using drugs so that they could act out
sexually. Among homosexual men, results from Benotsch, Kalichman, and Kelly
(1999) indicated that men scoring high on sexual compulsivity reported engaging
in more frequent unprotected sexual acts with more partners, greater cocaine use
by self and partner in conjunction with sexual activity, rated high-risk sexual acts
as more pleasurable, and reported lower self-esteem.

Sex Addiction and Family Dynamics

According to the Augustine Fellowship (1986), most individuals with compul-
sive sexual behaviors come from disengaged and rigid families. Early childhood
trauma and poor attachment styles play a major role. They often grow up in fam-
ilies with neglect, abuse, poor boundaries, and the absence of healthy courtship
modeling (Turner, 2009). Turner further states that children in these families
may experience emotional incest and have emotional boundaries violated in
which the child is labeled as being “special” to a parent. The child then assumes
responsibility for the emotional well-being of the parent. When the original
caregiver is also an abuser, this sets the stage where future relationships often
become one of abuse.
For women who have a sexual addiction, childhood trauma and sexual abuse
are major contributing factors. Women with broken relationships with their
mother and men with their father were reported to be at a higher risk for sexual
  Behavioral Addictions 171

addiction (Rosenberg & Feder, 2014). Shame from early childhood trauma can
develop into sexual addiction. As a result, the behavior of the sex addict can put
a strain on a relationship, marriage, or family.
The sex addict may unconsciously use adult sexuality and sex as a means for
coping with traumatic childhood events and trying to escape and numb feelings
(Kasl, 1989; Turner, 2009). This type of behavior may become maladaptive in
adulthood, which could destroy and exploit future relationships (Carnes, 1991).
The partners of sex addicts may get caught up in this process and lose their sense
of identity by worrying about the sex addict’s behavior and putting the addict’s
needs and issues first. Healthy dating relationships are usually not possible for
someone with a sex addiction without receiving proper treatment. Dysfunctional
attachment styles obtained from parents can become generational legacies for
children. As adults, the sex addict’s dating relationships often lack true intimacy
and respect. Ultimately the sex addict feels flawed.

Treatment Issues for Sex Addiction

Like substance use and gambling disorder, treatment for sexual addiction uses some
of the same clinical practices. Group therapy has been identified as the primary
mode for treatment (Hook, Hook, & Hines, 2008). Group therapy can help with
shame, relapse prevention, and developing ways for healthy intimacy. Treatment
programs are often supplemented by 12-step groups, such as Sex Anonymous,
Sexaholics Anonymous, Sex Addicts Anonymous, and Sex and Love Anonymous.
Additionally, psychoeducational groups and Sex-Anon family groups can help fam-
ily members understand the nature of sexual addiction and the recovery process.
Many partners of sex addicts may also have a history of addiction (i.e., sex and
drugs) and dysfunctional intimacy patterns from their family of origin (Turner,
2009). Therefore, it is imperative that treatment should include the spouse. For
those sex addicts whose partner does not have a history of sexual addiction,
the sex addict’s recovery can be seen as a sign of rejection (i.e., sex addicts are
instructed to not engage in sex until the root cause of addiction is uncovered and
treated). Because couples’ behaviors have become engrained, partners are helped
not only to overcome their own problems, but to maximize and repair their rela-
tionships. It is crucial that the recovering sex addict learns and discovers how to
engage in sex in a loving, caring, and healthy manner. Because of the addict’s past
struggles, couples are faced with the challenge of overcoming issues of trust and
consistency. Feelings of anxiety, guilt, remorse, and forgiveness will need to be
explored in a safe, nonjudgmental, and caring environment.
Sexual genograms maybe useful for exploring generational issues (Berman,
1999). According to Berman (1999) the therapist should assess for abuse, neglect,
and family attitudes towards sex. Bibliotherapy is also useful to help in the recov-
ery process (Hastings, 2000). Through this process the couple is helped with
understanding mutually satisfying sex and the relationship can begin to grow
from there. As an adjunctive therapy, Eye Movement and Desensitization and
Reprocessing (EMDR) is a commonly used alternative therapy for sexual addic-
tion (Weiss, 2004). This form of therapy can help with a patient’s defenses by
working to unblock emotional states. According to Weiss (2004), EMDR is most
helpful in dealing with traumatic memories and pent-up emotional experiences.
172 Assessment 

As with gambling addiction, there is no FDA-approved medication for sex

addiction. However, the same drugs that were mentioned for treating gambling
disorder could also be used to treat sexual addiction. Naltrexone and selective
serotonin uptake inhibitors (SSRIs) have shown promising results (Stevens &
Smith, 2018), and Citalopram has been associated with a reduction in masturba-
tion to pornography (Tosto, Talarico, Lenzi, & Bruno, 2008). As was previously
mentioned, a co-occurring diagnosis of substance use disorder is common and
may also need to be treated. For example, the addict when engaging in one
behavior (sex) may automatically engage in the other (drug use) or vice versa.

Compulsive Buying Disorder

The role of advertisement and the internet was briefly mentioned in the selling
of sex, and for compulsive buying disorder it is no different. Consumers are con-
stantly exposed to commercials or ads promoting products that often emphasize
wants as opposed to actual needs for goods. The increased availability of goods
and ease of access in purchasing have contributed to compulsive buying disorders.
Like sex addiction, it is difficult to define compulsive buying disorder. Potenza,
Koran, and Pallanti (2009) have considered this behavior to involve impulses
(continued urge to purchase even after the behavior has been acted upon) and
compulsions (inability to resist the urge to purchase). The individual may engage
in this behavior more so to reduce anxiety than receive pleasure. As with sub-
stance use, when the buying starts to disrupt and effect the individual’s personal,
social, work, and finances, these behaviors can be defined as an addiction or
disorder. A key characteristic is that the compulsive buying will continue despite
negative feedback from others (Sohn & Choi, 2014).
In the United States, estimates of compulsive buying range between 1% and
10%, primarily by those with a low income (Benson & Eisenach, 2013; Black,
2007; Hartston, 2012). Most buyers are under the age of 30, and the general
age of onset of the buying compulsion is from late teens to early 20s (Black,
2012). The behavior is seen more in developed Western countries, with the
rates being equal for men and women (5.5% vs 6% respectively; Koran, Faber,
Aboujaoude, Large, & Serpe, 2006). Men tend to purchase functional, technol-
ogy, and collector items, whereas women purchase items more tied to identity
and appearance (e.g., clothing, shoes, jewelry, cosmetics, and household items)
(Mueller et al., 2011). The compulsive shopper experiences the negative conse-
quences of increased debts, not being able to pay off debts, criminal activity, and
legal ramifications. While there is no formal diagnosis in the DSM-5, Rosenberg
and Feder (2014) proposed three criteria: (1) “the act of buying is irrepressible
(the urge)”; (2) “one’s buying tendencies are uncontrollable (the behavior)”, and
(3) “one’s behavior continues regardless of the negative consequences” (p. 288).

Compulsive Buying Disorder and Substance Abuse

Limited research is available with respect to compulsive buying and substance
abuse. However, individuals with compulsive buying disorder do present with sub-
stance use disorders diagnoses. Between 21%–46% of patients presenting with a
  Behavioral Addictions 173

compulsive buying disorder met the diagnosis for a substance use disorder (Black,
Repertinger, Gaffney, & Gabel, 1998; Christenson, Faber, & de Zwann, 1994). In
another example, Roberts and Tanner (2000) investigated compulsive buying and
risky behaviors among teenagers aged 12–19 and found that self-report measures
of illegal drug use were significantly associated with compulsive buying. What’s
still not clear from research is if substance use triggers compulsive buying behav-
iors or vice versa (Zhang, Brook, Leukefeld, & Brook, 2016).
Compulsive buyers are more likely to have first-degree relatives who suffer
from mood and personality disorders, and 20% suffered from severe alcohol
disorders (Black et al., 1998). Like substance use and gambling disorders, com-
pulsive buying shares similar neurocircuitry (e.g., decreased serotonin) and
activates the same brain reward mechanisms (dopamine) (Raab, Elger, Neuner,
& Weber, 2011). As a result, the etiology for compulsive buying has the same
biological, genetic, environmental, conditioning, and family social/cultural expla-
nations as other addictions.

Compulsive Buying Disorder and Family Dynamics

There is also limited research with compulsive buying and family dynamics.
Compulsive buying was related to families emphasizing materialism, and children
whose parents went through a divorce were more likely to engage in compulsive
buying as a means of coping (Rindfleisch, Burroughs, & Denton, 1997). Roberts,
Manolis, and Tanner (2003) found similar results, except that divorce was not
supported as a determining factor. They speculate that the age of the child when
the divorce happens is a more important factor, as previous research suggests
that divorces which happen when children are between the ages of 11–16 may
be more detrimental than when children are between the ages of 7–11 (Chase-
Lansdale, Cherlin, & Kiernan, 1995). Baker, Moschis, Rigdon, and Mathur
(2011) state that the previous studies mentioned focused only on the stressful
experiences of disruptive family events and failed to consider the negative conse-
quences these family events may have had on the child’s socialization experiences
and psychological development. Their research suggests that compulsive buying
is the result of family disruptions experienced early in childhood, which leads to
a strain on socioeconomic resources that interferes with the child’s socialization
practices and leads to ineffective parent–child communications.
Research has shown that compulsive buyers often experience family and marital
conflict (Lejoyeux & Weinstein, 2010). Because of the disorder, compulsive buyers
find it difficult to provide the attention and care needed by their family. A partner’s
sense of being neglected increases because of the spending habits of compulsive
buyers. This also puts a strain on joint finances. As one of the major sources of
family discord, family finances play an important role with respect to marital sta-
bility and satisfaction. Financial difficulties and dissatisfaction with one’s financial
status can lead to marital conflict and divorce (Poduska & Allred, 1990).

Treatment Options for Compulsive Buying Disorder

No one treatment strategy for compulsive buying disorder is more effective
than the other. Psychodynamic approaches have been used in the past; however,
174 Assessment 

cognitive behavioral therapy and dialectical behavior therapy are often used
now (Black, 2007; Stevens & Smith, 2018). Benson (2006) developed a self-
help program that contains a workbook, diary, and CD-ROM program. The
overall program contains cognitive-behavioral strategies for self-monitoring.
Self-help books and bibliotherapy are also helpful (Arenson, 1991; Catalano
& Sonenberg, 1993). Those with compulsive buying disorder may also develop
financial problems and can benefit from financial counseling (McCall, 2000).
Group therapy, couple counseling, and 12-step approaches are also effective.
Groups can provide support, encouragement, and offer insight on how to live
within one’s means and abandon compulsive buying disorder traits (Andrews,
2000). Couples counseling may be particularly helpful when the compulsive
buyer has disrupted the dyad (Mellan, 2000).
Pharmacological treatments are also beneficial. Antidepressants and mood
stabilizers have helped with managing emotions and impulses associated with
compulsive buying (Rosenberg & Feder, 2014). Grant (2003) and Kim (1998)
have highlighted cases in which those with compulsive buying disorder showed
improvement with the opiate antagonist Naltrexone.

Internet Addiction Disorder

With the advancement of technology, the internet may serve as both a blessing and
curse. The internet allows for immediate and easy access to education, entertain-
ment, news, banking, social, work, and leisure activities. As with the previously
mentioned behavioral addictions, the internet is no different. Contributing fac-
tors to internet addiction include depression, loneliness, low self-esteem, lack of
impulse control, and neurological and brain region deficiencies (Han, Hwang,
& Renshaw, 2011; Ko et al., 2009; Rosenberg & Feder, 2014). In fact, internet
addiction could entail viewing pornography, usage for shopping, and gambling.
While internet addiction is not an official diagnosis in the DSM-5, internet gaming
disorder (i.e., limited to gaming and does not include problems with general use
of the internet, online gambling, use of social media or smartphones) has been
included in Section III of the DSM-5 for future research.
Despite the DSM-5 exclusion of internet use in general, constantly checking
one’s email, phone messages, social media page, and other websites or electronic
services can become an obsessive and conditioned habit, where the individual
develops a fear of missing out on something which leads to psychological dis-
tress. Internet addiction can also indirectly affect one physically. For the chronic
user, sleep deprivation contributes to fatigue, impairs mental functioning, and
may decrease one’s immune system (Young, 1999). Moreover, lack of physical
activity outside of computer use may contribute to carpal tunnel, back strain,
and eye strain.
Because there are no standard diagnostic criteria for internet addiction, esti-
mates for prevalence rates have ranged from 0.1% to 50% (Hur, 2006; Zhang,
Amos, & McDowell, 2008). Prevalence is higher among college-age students.
Asian countries have the highest rates with adolescents in Taiwan and South
Korea reporting 17.9% and 16% respectively (Rosenberg & Feder, 2014). Rates
in China range from 0.6% to 10.2%. Estimates in the U.S range from 0.3% to
  Behavioral Addictions 175

12.5% (Aboujaoude, Koran, Gamel, Large, & Serpe, 2006; Christakis, Moreno,
Jelenchick, Myaing, & Zhou, 2011; Shaw & Black, 2008).

Internet Addiction and Substance Abuse

Internet addiction is highly related to substance use and substance use disorders.
Among the young adult population, studies have reported that the risk of internet
addiction is associated with an increased prevalence of substance dependence (i.e.,
alcohol, marijuana, and other illegal drugs) (Bakken et al., 2009; Padilla-Walker
et al., 2010). Recently adolescents have been a focal point in studies because of
the high prevalence in internet use. Adolescence is a time period of vulnerability
and risk taking. Preoccupation with body image and the internet is common.
Adolescents may also display impulsivity and experiment with sex and drugs.
Ko et  al. (2006) report that adolescents with internet addiction were more
likely to have substance use experience. Lee, Han, Kim, and Renshaw (2013)
found that alcohol, smoking, and other drug use predicted internet addiction for
adolescents. Logistic regression analysis has found that adolescents’ hostility and
depression were associated with internet addiction as well as substance use (Yen
et al., 2008).
While internet addiction can affect both genders, data suggests that adoles-
cents with internet addiction are more likely to be male and have experienced
substance use (Ko et al., 2006). Moreover, these males primarily engage in online
gambling and computer gaming (i.e., video games), with problematic computer
gaming being associated with cannabis use, and problematic gambling associated
with tobacco, alcohol, and cannabis use (Walther, Morgenstern, & Hanewinkel,
2012). The accumulation of these factors can lead to family dissatisfaction and
has been related to arguments with one’s parents (Rosenberg & Feder, 2014).

Internet Addiction and Family Dynamics

Marriages, dating relationships, parent–child interactions, and friendships can be
disrupted by internet addiction. Those addicted to the internet will spend more
time alone with the computer and less time with family and friends (Young,
1996). Obsessive internet use interferes with responsibilities and obligations at
home, leaving the spouse feeling neglected. Those addicted to the internet will
avoid discussing these issues and, like substance abuse, may minimize the prob-
lem (e.g., “it’s just the internet,” “at least I am home”) and forget important
obligations (e.g., picking up a child from school).
Young (1999) reports that family members will initially rationalize their loved
one’s internet use as “a phase” in hopes that the behavior will decrease. However,
when the addiction continues or increases, arguments develop in which those suf-
fering from internet addiction will deny their issues. For adults addicted to the
internet, divorce may be common as marriages deteriorate and are replaced with
online activities or companionship.
For adolescents, higher parent–child conflict, habitual alcohol use of siblings,
perceived parents’ positive attitude to adolescent substance use, and lower family
functioning predicted internet addiction (Yen et al., 2007). Habitual alcohol use
of siblings, perceived parents’ positive attitude to adolescent substance use, and
176 Assessment 

lower family functioning also predicted adolescents’ substance use. Park, Kim,
and Cho (2009) conducted a study concerning the relationship between family
factors and internet addiction among South Korean adolescents. Their results
showed that positive parenting attitudes, family communication, and family
cohesion served as protector factors against internet addiction, whereas marital
violence and parent to child violence were strongly associated with internet addic-
tion. Adolescents who receive more support from parents are less likely to display
conduct disorder behaviors, while adolescents whose parents provide insufficient
attention and support are more likely to be psychologically distressed, which
could lead to overuse of the internet to escape their home environment.

Treatment Issues for Internet Addiction

Treatment for internet addiction is relatively new. Cognitive behavioral treat-
ment strategies have been used (Young, 2011). As with treating other disorders,
CBT encourages the individual to identify maladaptive thoughts and triggers
related to the addictive behavior. Another treatment strategy suggested by Young
(1999) is Practicing the Opposite. For example, if the person normally uses the
internet first thing in the morning, the therapist might suggest that the individual
take a shower or eat breakfast first before logging in.
In addition, abstinence, harm reduction, and moderation strategies could also
be used. While the individual may not completely abstain from the internet, the
client could be instructed to abstain from certain activities, particularly if they are
the most problematic (e.g., chat room). The individual could also be instructed
to cut down on the number of hours spent on the internet, for example 20 hours
a week instead of 40. This could entail usage from 9:00 pm to 11:00 pm every
weeknight, and 12pm to 5pm on Saturday and Sunday. Relapse prevention
strategies used in substance abuse could also be employed. For example, “Think
Beyond the High Play the Tape to the End” (see Washton, 1990; Washton &
Stone-Washton, 1990), where the individual might keep reminder cards identify-
ing major problems caused by addiction to the internet.
Many individuals may use the internet because of a lack of tangible social sup-
port. Real-life support groups outside of the internet could be employed where
alternative activities and hobbies could be explored and developed. Groups
based on the 12-Step principles can help address maladaptive thinking which
may lead to internet addiction and provide an opportunity to share common
concerns, issues, and build a meaningful real-life relationship. These groups can
help individuals rely less on the internet for the support, companionship, and
communication that may be missing in their lives.
For marriages and families that have been disrupted by internet addiction,
family therapy may be helpful and beneficial. Young (1999) identified several
areas where interventions should focus: (1) Educating the family about the nature
of internet addiction; (2) reduction of blaming the addict for their behavior;
(3) opening communication about the problems and issues which may have
driven the addict to seek out fulfillment of psychological and emotional needs
online; (4) encouraging the family to help in the recovery process by finding new
hobbies, taking a vacation, and listening to the addict’s feelings. Family support
is crucial in order to help the addict in the recovery process.
  Behavioral Addictions 177

Lastly, pharmacological treatments have included SSRIs and extended-release

methylphenidate, which is a drug used to treat ADHD and OCD (Dell’Osso,
Allen, Altamura, Buoli, & Hollander, 2008). A dopamine and norepinephrine
inhibitor, Bupropion, which is used in substance abuse treatment, has been asso-
ciated with a reduction in internet use and depression (Han et al., 2011). As an
alternative treatment, electronic acupuncture was associated with a reduction in
internet addiction and impulsiveness scores (Yang et al., 2017). Because adoles-
cents who are addicted to the internet are vulnerable to drug use, a comorbid
diagnosis with substance abuse should be evaluated and treated if found.

Case Application

Based on the information that we know about the Rothers family, there has not
been any stated behavioral addiction. However, during our assessment, it will be
very important to ask questions around several of these areas as there is a higher
preponderance of behavioral addictions when there is a substance abuse disorder.
Thus, the therapist should assess what happens when Mark is alone and whether
he is having issues with the internet in regards to online gaming or internet sex.
Exploration of his engagement with sports and whether he is involved in sports
betting and to what degree would help to determine whether Mark may be a
problem gambler. The therapist should assess whether Mark, when he is using
drugs and/or alcohol, changes his usage of gambling and the internet.
While Mark may or may not engage in a behavioral addiction, other fam-
ily members may as well. The therapist should assess all family members for
their use of drugs and alcohol as well as for the possibility of someone having a
behavioral addiction. Pete is least likely in the family to exhibit symptoms while
Kayleigh is also unlikely—both due to their age. Given his age, Steve is likely to
frequently engage the internet, which would lead the therapist to assess if his (or
anyone’s) internet use is problematic. Lastly, the therapist’s assessment should
also explore Hannah’s drug and substance use, as well as possibilities for com-
pulsive buying as well as internet usage and sexual behaviors.

Summary
In this chapter the behavioral addictions of gambling disorder, sex, com-
pulsive buying, and internet were presented along with their relationship
to substance abuse and family functioning. It appears there is much over-
lap between these behavioral addictions and substance use disorders.
Behavioral addictions encompass time consumed pursuing the addiction,
excessive and repeated use of engaging in the behavior, and lack of ability
to stop or change the behavior despite negative consequences.
Therapists should be aware of the behavioral addictions mentioned
above, as well as how substance use often accompanies them. Treatment
for behavioral disorders includes many evidence-based approaches such

(continued)
178 Assessment 

(continued)

as 12-step self-help groups, family therapy, cognitive behavioral therapy,

dialectical behavior therapy, and pharmacological interventions. Because
of the similarities between the brain pathways of substance use disorders
and behavioral addictions, and the fact that both disorders often occur
together, it is imperative that research is continued in this area to effectively
treat these disorders.

Key Words
behavioral addictions compulsive buying disorder
gambling disorder internet addiction
sex addiction internet gaming disorder

Discussion Questions
1. What are behavioral addictions?
2. What are the similarities and differences between gambling disorder,
sex addiction, compulsive buying disorder, and internet addiction
disorder?
3. What is the relationship between substance use disorders and behavio-
ral addictions?
4. What role does the family play in the development of gambling disor-
der, sex addiction, compulsive buying disorder, and internet addiction
disorder?
5. What is the impact of gambling disorder, sex addiction, compulsive
buying disorder, and internet addiction disorder on the family?
6. What are the treatment options for gambling disorder, sex addiction,
compulsive buying disorder, and internet addiction disorder?
PART II

TREATMENT
ten

Working with Partial

Systems

The family therapist’s job would be substantially easier if every member of the
family was fully engaged and committed to moving the family forward. However,
this is usually an unrealistic expectation to have when working with families;
especially those that are dealing with some type of addiction. As we discussed in
Chapter 8, people may be at different stages of readiness for change. We can look
at a family, as a whole, being in the precontemplation, contemplation, prepara-
tion or action stage, yet there is also each member who may be at varying stages.
For instance, the wife may be at the preparation stage, the addicted husband in
the precontemplation stage, and the child at the contemplation stage (and this is
only talking about their readiness for change in one particular issue—people and
families deal with multiple issues at the same time).
Given this, when therapy is started, not all family members may be willing to
come to the session. Sometimes the non-addicted family members may think that
the fault lies completely with the addicted individual and that they do not need
to attend a session. In other families, it may be that the addicted person does not
see a problem and refuses to attend therapy. Depending on the therapist’s orien-
tation, the level of motivation of each person in the family, and the presenting
problems, the therapist may work in a variety of ways with families where one or
more member is abusing substances. The Center for Substance Abuse Treatment
(2004, p. xxii) provided four levels of therapist involvement when working with
families dealing with addiction:

• Level 1: Counselor has little or no involvement with the family.

• Level 2: Counselor provides the family with psychoeducation and advice.
• Level 3: Counselor addresses family members’ feelings and provides them
with support.
• Level 4: Counselor provides family therapy (when trained at this level of
expertise).

Working with the family can be quite daunting for therapists, especially those
not trained in family therapy. This can lead to tension between the therapist and
the family members, particularly parents of substance-abusing youth (Misouridou
& Papadatou, 2017). The rest of this book will focus on concepts and programs
that address each of these levels of family engagement in order to better help
substance abuse therapists enhance their relationships and better utilize family

181
182 Treatment 

members in the treatment process. This chapter primarily focuses on level 2, and
Chapters 13–15 on levels 3 and 4. This current chapter explores possibilities of
working with the family system when you only have a partial family—i.e., where
not all of the members agree to engage in therapy.
The primary person who will most likely not engage in treatment is the person
dealing with the substance abuse. Of substance abusers, 90–95% in any given
year do not seek therapy or self-help (Landau et  al., 2000). Usually, once the
family members have gotten to the point of not accepting the drinking/drugging
behavior (and the associated consequences), they attempt to get the addicted per-
son into treatment. This is usually met with resistance, as the abuser is most likely
in the precontemplation stage regarding the issue. Given this, what can family
members do to make their situation better? One possibility is that they can attend
a self-help support group, find a different way of getting their family member/
loved one to engage in treatment, or seek therapy for themselves.
This chapter explores various self-help programs related to substance abuse,
primarily 12-step programs. It also focuses on several prominent treatment pro-
grams for people in the abuser’s social network, which can be beneficial for them,
even if the addicted individual never enters treatment. While these programs may
be geared specifically for the non-addicted family members, they have the added
potential benefit of helping to get the addicted individual to engage in treatment,
whether it be individual or family therapy or a self-help group. The use of therapy
for a cooperative member, usually for changing the behavior of a uncooperative
member, is generally called unilateral family therapy (Thomas & Santa, 1982).
This chapter presents several programs that can be considered to be under the
auspices of unilateral family therapy.

Self-Help Groups

Millions of individuals dealing with various types of addiction, as well as

their loved ones, seek help and support through self-help groups. Alcoholics
Anonymous, the most famous and largest self-help group for addiction, has a
worldwide active membership of over 2 million people. Self-help groups occur
outside the realm of formal therapy, where individuals who are dealing with a
particular substance or issue (alcohol, cocaine, gambling, etc.), or their family
members, come together to talk about how they are impacted by the addiction.
Self-help is a bit of a misnomer as one of the main benefits of these groups is
being supported and helped by others.
One of the benefits of self-help groups comes through the notion of universality
(Yalom & Leszcz, 2005), where the individual can take solace knowing they are
not alone in the problem and that many other people experience the same thing.
Further, many of these self-help groups utilize a sponsor—a person who is farther
along in the process who acts as a guide. Sponsors usually are available any day
of the week, at any time, as a first response in case the individual has serious
urges to use whatever substance they are trying to stop using.
As a mental health professional you will not, unless you are in active recov-
ery, have any direct involvement in self-help groups. They are not therapist-led.
However, it is important to know how they function, as they can be a key
  Working with Partial Systems 183

component in the change process for clients. Having a thorough understand-

ing of the various groups, as well as how a client can access them, is important
in case a client and/or family that you are working with might find benefit
from them.
Yet not all self-help groups are the same. Depending on your client and their
values, one group might be a better fit than another. For instance, some are more
confrontational than others or there might be a spiritual component that a person
may or may not appreciate. This chapter provides you with an overview of some
of the most significant self-help groups in the substance abuse realm.

Alcoholics Anonymous
The most famous and most popular addictions self-help group is Alcoholics
Anonymous (AA). Alcoholics Anonymous began in the 1930s through a conflu-
ence of events. Rowland H. sought help for his alcoholism from Carl Jung. Jung
believed that Rowland did not need medical help, but, rather, spiritual help. He
referred him to the Oxford Group, which was a religious movement that focused
on self-improvement through an exploration of one’s actions, making amends for
wrongs committed, prayer, meditation, and then bringing this message to oth-
ers. Over time Rowland recruited Ebby T. to the Oxford Group. One of Ebby’s
drinking buddies was Bill W., a past successful stockbroker who had declined in
functioning based on the effects of alcohol. Although he was reluctant at first,
Bill W. had a spiritual awakening and dedicated himself to helping others dealing
with alcoholism.
Bill W. then joined the Oxford Group and began to attend meetings, providing
his voice of hope to others. In 1935, Bill W. was introduced to Dr. Bob. From
their first meeting, the two men realized the importance of two alcoholics talking
to one another. Dr. Bob’s last drink was on June 10, 1935. This date is consid-
ered to be the birth date of Alcoholics Anonymous.
Eventually AA developed The Twelve Steps. These steps have become one of
the most influential guidelines in the substance abuse field. They are that we:

 1. Admitted we were powerless over alcohol—that our lives had become
unmanageable.
  2. Came to believe that a power greater than ourselves could restore us to sanity.
  3. Made a decision to turn our will and our lives over to the care of God as we
understood Him.
  4. Made a searching and fearless moral inventory of ourselves.
  5. Admitted to God, to ourselves, and to another human being the exact nature
of our wrongs.
  6. Were entirely ready to have God remove all these defects of character.
  7. Humbly asked Him to remove our shortcomings.
 8. Made a list of all persons we had harmed, and became willing to make
amends to them all.
  9. Made direct amends to such people wherever possible, except when to do so
would injure them or others.
10. Continued to take personal inventory, and when we were wrong, promptly
admitted it.
184 Treatment 

11. Sought through prayer and meditation to improve our conscious contact
with God as we understood Him, praying only for knowledge of His will for
us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to
carry this message to alcoholics, and to practice these principles in all our
affairs.

Although Alcoholics Anonymous is strictly a self-help program, where meet-

ings are run by members (some of whom may be mental health professionals, but
engaging in their role as someone in recovery rather than in a clinical capacity),
many therapists discuss with their clients the benefits of engaging in AA as an
auxiliary to more formal therapy. Alcoholics Anonymous can be a useful com-
ponent of a wider treatment regimen, or can stand on its own for the individual.
Usually, if done in conjunction with therapy, the individual continues engaging
in AA long after termination with their therapist.
There are three types of AA meetings; Speaker meetings, Discussion meetings,
and Step meetings (see Figure 10.1). In Speaker meetings, various members, one
at a time, self-disclose to the other participants about their own experience with
addiction—in essence, they tell their story. There may be some discussion about
the person’s story afterward. In Discussion meetings, members talk about their
own experience with addiction yet the meeting centers on a specific topic related
to substance abuse. For Step meetings, one of the 12 steps will be chosen as the
focal point of the conversation wherein members talk about their personal expe-
riences trying to engage that step.
Most AA meetings, especially Speaker meetings, are open meetings, meaning
that anyone can attend. Closed meetings only allow people who are members or
prospective members. Alcoholics Anonymous meetings are all free, regardless of
meeting type. When someone first begins to attend AA, they are encouraged to
attend 90 meetings in 90 days. As the person reaches certain temporal milestones

Speaker Meetings
• Various members tell their stories

Discussion Meetings
• Members tell their stories around a topic

Step Meetings
• Focus on one of the 12 steps
Figure 10.1  Alcoholics Anonymous has three different types of meetings: Speaker,
Discussion or Step meetings
  Working with Partial Systems 185

of sobriety, they receive a token, called a sobriety coin, which is a reminder of

their accomplishment. Most people who attend AA will eventually read the Big
Book, which was written by the founders of AA in 1939 and has become the
foundation upon which the groups operate.
Alcoholics Anonymous conducts a triennial survey of its members to obtain
demographic data. The 2014 survey found that almost 90% of AA members
identified as White, 4% as Black, and 3% as Hispanic. Approximately 50% of
members were between 41 and 60 years old. Forty-one percent were married or
had a life partner, 32% were single, and 21% were divorced. Fifty-seven percent
of AA members were referred by a counselor, medical, or mental health profes-
sional. Thirty-two percent were introduced to AA by an AA member, 30% were
self-motivated, 27% were introduced by family, and 12% by the judicial system.
Approximately 50% of AA members have been sober for five or more years;
22% being sober for over 20 years. On average, members attend 2.5 meetings
per week. Fifty-nine percent of members received some type of treatment before
beginning AA, with 74% of them finding this treatment useful in helping to get
them connected to AA. After going to AA, 58% of members received treatment,
with 84% saying this treatment was important for their recovery. Alcoholics
Anonymous attendance for those wanting help with alcohol problems leads to
short and long-term decreases in alcohol use (Humphreys, Blodgett, & Wagner,
2014). However, for those who already were part of the AA community, increas-
ing attendance may not impact the level of alcohol consumption.

Al-Anon
While AA and similar groups such as Narcotics Anonymous (NA), Cocaine
Anonymous (CA), and others are designed for the person who is utilizing the
substances, groups such as Al-Anon are geared toward the loved ones who
are in relationship with the addicted person. However, the two movements
are intertwined.
Lois W., the wife of AA cofounder Bill W., was a cofounder of Al-Anon.
Having traveled with him across the country to various AA groups, she was able
to talk informally with other addicts’ family members, and gained benefit from
these interactions. Family members realized that when they, as well as the alco-
holic, lived by the 12 steps, family relationships improved (although it was still
a process of growth in dealing with the continuing changes based on everyone’s
new contributions to the family). These informal meetings came to be known as
Family Groups.
Al-Anon began more formally in 1951 when the various Family Groups were
unified. Given their belief in the 12 Steps, Al-Anon petitioned AA to use them.
Once this was granted, Al-Anon changed only one word of the steps. This was
in the last and final step where instead of “carry this message to alcoholics”
Al-Anon uses “carry this message to others.”
Al-Anon meetings are less about the alcoholic and more about the family
members living with the alcoholic. Many of these family members, particularly
spouses, view themselves as just as sick or sicker than the alcoholic. Al-Anon is
the most utilized support source for family members of someone dealing with
problem drinking (O’Farrell & Clements, 2012). Al-Anon is viewed as beneficial
186 Treatment 

because of its philosophy, accessibility, effectiveness, format, and the possibility

of having the alcoholic reduce or stop drinking (Young & Timko, 2015).
O’Farrell and Fals-Stewart (2003) found that family members of alcoholics
who were referred to Al-Anon or engaged in Al-Anon-facilitated therapy showed
increased coping abilities. As we will discuss in systems theory (see Chapter 11),
when one part of the system changes, the other parts are perturbed and may
change as well. Thinking back to our discussion of family roles, these roles were
developed as a means of coping for the current state of the addicted family. When
members can cope in other, more functional ways, it changes the rules of the
system leading to change from the remaining family members. However, there is
a fundamental difference between how 12-step fellowships and traditional fam-
ily therapies view the role of substance abuse (Nowinski, 1999). Twelve-step
fellowships hold that addiction is a primary dysfunction whereas many family
therapies view addiction as a symptom of family dysfunction. This is why 12-step
programs primarily focus on helping people become sober and maintain sobriety
for the rest of their lives.
Just as Alcoholics Anonymous has expanded to cover various drugs such as
Narcotics Anonymous and Cocaine Anonymous, Al-Anon has grown as well.
Groups such as Alateen (designed specifically for younger members) and Nar-
Anon (developed for friends and family of drug addicts) provide a resource for
family members living in a house that has drugs and/or alcohol as a primary
organizing component.

Twelve-Step Facilitation
The previous 12-step groups are usually not therapist-led and can be used by peo-
ple alone or in conjunction with psychotherapy. However, for therapists working
in the addictions field who support these programs, one of the keys is to help get
the substance abuser to actually go to the meetings and then have them become
active in working the steps. One way of doing so is through twelve-step facilitation
(TSF). Twelve-step facilitation, originally developed in the early 1990s for the
Project MATCH program, is a means for therapists to encourage their clients to
attend and use various 12-step programs (Nowinski, 2006, 2012, 2015; Nowinski
& Baker, 2018). Twelve-step facilitation can be used for individuals, couples,
families, or in a group setting. One of the benefits of TSF is that the therapist does
not have to be an expert on 12-step programs; just that they have the desire to
help their clients access this resource. Twelve-step facilitation is considered to be
an evidence-based treatment (Nowinski, 2006, 2012; Nowinski & Baker, 2018).
There are two primary goals to TSF: Acceptance and surrender (Nowinski
& Baker, 2018). These goals correspond to the first three steps of AA. These
authors explained that, “By acceptance, we mean the breakdown of the illusion
that the individual, through willpower alone, can effectively and reliably limit or
control his/her use of alcohol and/or drugs” (p. 3). Acceptance here is viewed in
terms of the substance abuser accepting they are dealing with a chronic illness,
that their life has become unmanageable, they don’t have the willpower alone to
fix things, and the only solution is abstinence. Nowinski and Baker continued,
“Surrender involves a willingness to reach out beyond oneself and to follow the
program laid out in the twelve steps” (p. 3). Surrender is related to recovery being
  Working with Partial Systems 187

only through sustained sobriety, faith that a Higher Power can help them, a belief
that fellowship with other addicts is a path to sobriety, and a belief that their best
chances for sobriety are through the twelve steps and twelve-step community.
Twelve-step facilitation is organized around three programs: core, elective,
and conjoint (Nowinski, 2012; Nowinski & Baker, 2018). The core or basic
program is designed for those in early recovery, where the individual most likely
is experiencing ambivalence. It involves an introduction and assessment, focus on
acceptance, exploration of people, places, and routines, exploration of surren-
der, and promotes getting active. The core program is an in-depth conversation
between therapist and client that addresses the first three steps of the 12-step
program as well as how the person might get active in meetings and seek a sponsor
(Nowinski, 2015).
The elective program is designed to assist the person in making AA or NA an
active lifelong aspect of their recovery (Nowinski & Baker, 2018). This program
usually lasts between four to six sessions. It focuses on six topics: genograms,
enabling, people-places-routines, emotions, moral inventories, and relationships.
Depending on the needs of the client, any of these elective topics might be cov-
ered. During this stage of the program, the facilitator might cover areas from
both the core and elective programs. Whichever topics are covered, the elective
program always is focused on three behavioral objectives: Helping the substance
abuser go to meetings, being active in AA or NA, and getting and using a sponsor.
In the conjoint program, the facilitator works with the substance abuser and
his or her partner. This program lasts for two sessions. The purpose is to help
educate the partner/family member about alcoholism and/or addiction as well
as inform them about the 12-step model. During this program, the facilitator
explores issues such as enabling and detaching. The partner is encouraged to
attend at least six Al-Anon or Nar-Anon meetings.
Nowinski (2012) explained that TSF’s objectives can be broken down into
two categories: (1) active involvement and (2) identification and bonding. For
TSF, active involvement means that the person who has been abusing drugs or
alcohol is going to 12-step meetings. And not just going to meetings, but working
the steps. This may necessitate the therapist helping the person to work through
issues of resistance. During early recovery when using TSF, the therapist might
explore with the person how many meetings they go to, the type of meeting (i.e.,
Speaker, Step, or Discussion), and how active the person is during the meetings.
One means of doing this is through a recovery journal. The recovery journal is
used by the client to record all of the meetings he or she went to, the type of meet-
ing, as well as their own reactions to the meeting.
The second category of TSF objectives is that of identification and bonding
(Nowinski, 2012). Part of this happens through a process of psychoeducation
where therapist and client talk about the various stereotypes the person has about
12-step programs, its members, and the process of what happens at meetings.
Then the therapist encourages the person to attend a meeting and further evaluate
the stereotypes they had. After having attended at least one meeting, the therapist
will likely ask whether there was a person whose story the client identified with
and to which they could relate. This is the beginning stage of helping the client in
bonding to the 12-step community. Figure 10.2 presents the goals, programs, and
objectives of twelve-step facilitation.
188 Treatment 

Goals Programs Objectives

Core Active
Acceptance
Involvement
Elective
Identiication
Surrender
Conjoint and Bonding

Figure 10.2  Twelve-step facilitation is based on two goals, two objectives, and three
different programs to help get the addicted individual to attend a twelve step
program

Termination in TSF happens when there is a “turning over” of the person

to the 12-step community (Nowinski, 2012). The goal of TSF is to enhance the
identification and bonding of the individual to the 12-step program to enhance
their active involvement. The belief is that greater bonding to the twelve-step
community leads to greater active involvement in it and a higher likelihood of
lifelong sobriety.

Moderation Management
The self-help groups that we have discussed thus far all operate from the disease
model of addiction and have abstinence from the substance as the goal for the
individual. They believe that the person should not use the substance (or simi-
lar substances) for the rest of their lives. However, not all groups abide by this
philosophy. One such group is Moderation Management (MM). Developed in
1994 by Audrey Kishline, Moderation Management is an alternative to AA and
other 12-step groups. Rather than a disease model, it is based on a cognitive-
behavioral approach. Instead of targeting the alcoholic—someone whose use of
the substance is severe—MM is designed for the problem drinker. Since there
are many more problem drinkers than alcoholics, MM has a wide catchment of
potential participants.
Moderation Management views alcohol abuse as a habit; a pattern of learned
behavior rather than as a disease (Kishline, 1994). This distinction between a
habit and a disease is a very consequential one. Whereas with a disease the person
needs to always be aware of the disease and take steps to keep it in remission,
habits are much more temporary. Once the person changes their learned behavior
and continues to engage in the new behavior rather than the previous pattern,
  Working with Partial Systems 189

Abstinence Moderation Addiction

Figure 10.3  Moderation Management does not specifically push for abstinence, but
instead attempts to help the person reduce the harm of alcohol consumption

they do not need to think about the problem as they used to. This goes counter
to the notion that alcoholism is an irreversible progression wherein the individual
does not have control over themselves.
In MM, the person is not directed to abstinence (see Figure 10.3). Instead, a
treatment matching occurs where the level of treatment coincides with the level
of the problem (Kishline, 1994). For those people whose problems are less severe,
intervention will be reduced. For those with more severe alcohol problems, more
significant self-management tools will be implemented. This goes counter to the AA
model where everyone, regardless of severity, is instructed to follow the 12 steps.
To explain this in more depth, if a client came to MM and was in the begin-
ning stages of heavy alcohol consumption, they might be directed to lessen the
amount of alcohol consumed, but would not need medical services. However,
a heavy alcohol consumer might need more medical supervision to deal with
withdrawal symptoms.
Moderation Management groups are free and are led by volunteers. When
someone begins in the group they are asked to abstain from alcohol for 30 days.
This is to allow them to shift out of their current problematic drinking behav-
ior patterns. During this time they are asked to think about how alcohol has
impacted them, what their priorities are, and the conditions of their alcohol use
(who, what, where, when). Once the 30-day abstinence period is up, the indi-
vidual sets moderate drinking limits. They begin to make small steps toward
changing their lifestyle. At this point they review their progress and revise their
goals, if needed.
Participants in MM tend to be White (98% of participants), female (66% of
participants), and educated (94% having attended at least one year of college)
(Kosok, 2006). A majority of members utilize MM as their first attempt at help in
reducing their drinking (56% of participants). The other 44% had unsuccessfully
sought help through AA or therapy. Before starting MM, 61% of members had
engaged in daily consumption of alcohol, averaging six drinks per day.
Sanchez-Craig, Wilkinson, and Davila (1995) determined that there is an
upper limit of drinking that people who have been problem drinkers should fol-
low. For men, they should drink no more than four standard drinks in a day and
no more than 16 in a week. For women, they should drink no more than three
standard drinks in a day and no more than 12 in a week. These authors found
that their results compared with guidelines from other official bodies and recom-
mended that those who are working toward moderation, rather than abstinence,
adhere to these limits.
190 Treatment 

Moderation Management is not as widely popular or known as Alcoholics

Anonymous and other self-help programs. This may be because it is not as pub-
licized as AA, and therapists and other medical professionals base their view of
addiction on a disease model rather than the possibility of controlled drinking
(Kosok, 2006). However, for some who are dealing with problem drinking, mod-
eration and harm reduction is a viable option.

Working With the Non-Addicted Family Members

Usually in families where there is some type of substance abuse, it is usually the
person who is abusing the substance who is the last person who wants to attend
therapy sessions. In this case, effective therapy can still occur, even without
this person. Marriage and family therapy can be used with the non-addicted
individuals. This can be for two purposes (O’Farrell & Clements, 2012). First,
the therapy allows the family members to cope with the family situation. Since
we know that a change in one part of the system can lead to system-wide
change, even if the addicted person never comes to therapy, if other family
members change, the repetitive dysfunctional transactions in the family have
a higher likelihood of being altered. A second purpose for the non-addicted
family members to go to treatment is that it helps to motivate the addicted
individual to enter treatment themselves.
When family members go to therapy without the addicted person, they
decrease their emotional distress (O’Farrell & Clements, 2012). This is based
on unilateral family therapy, which occurs when one or more family members
engage in therapy around the substance abuse issue, but where the person who
is using is not involved in the therapy (Thomas & Santa, 1982). One of the first
tasks when working with the non-using family member is to help them to change
their enabling behaviors (Zelvin, 2014). The focus on problem-maintaining inter-
personal patterns is important since familial support for all members is integral in
the change of family rules and roles.
Various programs/models have been developed to either work with the family
alone (regardless of whether the dependent enters treatment) or with the family to
bring the abuser into the treatment fold. In this section we will talk about three of
the most prominent: ARISE, CRAFT, and the Johnson Intervention.

ARISE
One such program to work with the non-addicted family is ARISE. Initially this
acronym stood for the Albany-Rochester Interventional Sequence for Engagement
(Garrett et al., 1997); it now stands for A Relational Intervention Sequence for
Engagement (Garrett & Landau, 2007; Landau & Garrett, 2008). The ARISE
model is a manual-driven relational intervention that assists non-substance-
abusing family members to get the addicted individual into treatment (Landau &
Garrett, 2008). The ARISE model was born from families not using the Johnson
Intervention (see below) and based on ideas from systems theory and addictions
treatment. However, one of the main factors that sets ARISE apart from typical
  Working with Partial Systems 191

interventions is that it is an invitational model, where the substance abuser is

invited at each stage of the program to participate rather than having a surprise
approach. Landau and Garrett (2008) explained, “It draws on the connectedness,
interest and commitment of other concerned members of the extended family and
support system to motivate the alcoholic or substance abuser to enter treatment”
(pp. 148–149).
The ARISE model is rooted in the notion of engagement methods, where the
network of the substance abuser is the focus of intervention (Landau et al., 2000).
The therapist works with these individuals until the substance abuser enters treat-
ment/self-help. Sometimes the abuser is part of these meetings, but is not yet
seeking treatment; many times they are not. As noted, ARISE focuses on engage-
ment of the substance abuser to encourage them to seek therapeutic services.
As such, ARISE is not a therapy model but rather a pre-treatment engagement
technique (Landau & Garrett, 2008).
The Family Motivation to Change model is based on the notion that the family
can play a key role in helping in the recovery from alcoholism for a member of
the family. These underlying assumptions form the groundwork for the effective-
ness of the ARISE model (Landau et al., 2000). The abuser’s social network is
viewed as being competent and accessible; concerned individuals who are able
to help the abuser. Part of the intervention is to get members of the social net-
work to realize their own competencies so that they can be more successful in
their interactions with others. This is important since it is the individuals in the
abuser’s social network who truly care for and love them, and spend a majority
of time with them, rather than treatment professionals. The ARISE model helps
the support system to utilize honesty in contacting the abuser to establish trust
and an implication that a long-term relationship is desired. This investment in the
person’s recovery is significant since the abuser’s social network will most likely
have the greatest impact on them.
Family Motivation to Change is based on the multifaceted forces that occur in
a family, pushing it toward health during an unhealthy or crisis period (Garrett
& Landau, 2007). When disruption happens in a family, one member usually
sacrifices him/herself for the protection of the family. This may come in the form
of developing a substance abuse disorder. While this may not seem to be use-
ful, they are providing a way for the family to distract themselves from other
problems (perhaps loss and grief) and put the focus on them and their newfound
problematic behavior instead.
There are three stages to the ARISE program (Garrett & Landau, 2007; Garrett
et al., 1997; Landau & Garrett, 2008). The therapist will work with the family
members starting at level 1 and will stop at the first level where the person with
the drinking problem enters into treatment. As such, it is a brief approach that is
focused on efficiency. Level 1 is when the treatment professional begins to work
with one or more concerned individuals in regards to a substance abuser. These
may be phone or face-to-face meetings. It is designed to get information on who is
involved in the family and encouraging members, including the substance abuser,
to come to treatment. The person who contacts the therapist (called the “First
Caller”) is told that they did right by calling, that the ARISE method can help,
that they should get as many family members and concerned others to help them
as possible, that they should operate with love and respect, and that they do not
192 Treatment 

have to deal with the alcoholic on their own anymore. Through the First Caller’s
attempt at inviting the alcoholic into treatment, 55% of alcoholics decide to come
for the first session (Landau et al., 2004). At this level, the therapist attempts to
increase the level of hope in the family.
Level 2 is when the therapist meets with the family, usually for two to five
sessions. These sessions may or may not have the alcoholic involved. They are
designed to develop motivational strategies for family members; all in the pursuit
of getting the substance-dependent into treatment. Most families are able to get
the alcoholic into treatment while working at this stage, thus meaning there no
need to proceed to level 3.
The third and final stage is level 3, to which only 2% of families need to get
in order to motivate the alcoholic into treatment (Garrett & Landau, 2007;
Landau & Garrett, 2008). This level includes the therapist helping family mem-
bers to set limits and consequences for the dependent person. This is done in a
respectful and supportive way by family members. In a manualized treatment
study, the ARISE approach was found to have an 83% success rate of working
with the concerned other to help engage a substance abuser into either treatment
or some type of self-help (Landau et al., 2004). Figure 10.4 presents the three
levels of the ARISE program.
The ARISE model is a cost-efficient approach since the concerned others of the
substance abuser take on a lot of responsibility for getting the substance abuser
into treatment (Landau & Garrett, 2008). In a National Institute of Drug Abuse
(NIDA) study, the average total time per case was 1.5 hours and lasted a median
of seven days (Landau et al., 2004). The ARISE model is also an effective method,
as, based on the NIDA study, it has helped concerned others get the substance
abuser into therapy or self-help groups 83% of the time. Ninety-five percent of
people chose treatment while 5% chose self-help. The model has primarily been
used for people with a substance-abusing family member, but has also been used
for those with online sex addiction (Landau, Garrett, & Webb, 2008).

• Motivational techniques
Level 1 • Establish hope
• Recovery message

Level 2 • 2-5 face-to-face sessions

• Establish an Intervention Network

Level 3 • Friends and family set limits & consequences

• Intervention Network supports each other

Figure 10.4  The three levels of the ARISE program. Treatment does not move to the next
level if the addicted individual enters treatment
  Working with Partial Systems 193

CRAFT
Robert J. Meyers developed the Community Reinforcement And Family Training
(CRAFT) program. Based on learning theory, CRAFT was designed for con-
cerned significant others of individuals with alcohol and/or drug problems who
refused to go to treatment. This program is an off-shoot of the Community
Reinforcement Approach, developed by Azrin, which was geared toward the
alcohol/drug user (Meyers, Roozen, & Smith, 2011). Through the principles
of operant conditioning, community reinforcement attempts to shift the drug
user from a problematic to pleasurable lifestyle without alcohol or drugs.
This new rewarding lifestyle is enhanced through the community of family
and employment.
The family members of the addict are referred to as Concerned Significant
Others (CS0s). There are three main goals of the program (Smith & Meyers,
2004). The first is to attempt to get the abuser into treatment. While that is
occurring the second goal is to get whoever is overusing substances in the family
to decrease their use. The last goal focuses on how CSOs can enhance other prob-
lematic areas of their lives to move towards a more enjoyable life. This program
is viewed as a motivational rather than confrontational style (Smith, Meyers, &
Austin, 2008).
The CRAFT program shifts the development of a rewarding non-drug lifestyle
from the person who is using the drugs to the significant others of that individual.
The program is useful for those whose partner/family member/friend is refus-
ing to go to treatment. Participants in CRAFT are taught how to arrange the
home environment so that when the drug-using individual engages in behaviors
of sobriety/non-drug use they are rewarded, via operant conditioning princi-
ples. Unlike Al-Anon, which does not intentionally try to change the drug user,
CRAFT is geared to help not only the concerned significant other but the drug
user as well.
Because the focus of CRAFT is on the CSO rather than the substance-abusing
individual it is important for the therapist to ensure they are building rapport
and motivation with the CSO. This is because CSOs tend to enter the CRAFT
program highly enthusiastic and motivated, but to change the behaviors of the
substance abuser. As Smith, Meyers, and Austin (2008) explained,

This enthusiasm sometimes waivers a bit when, in the course

of the CRAFT program description, CSOs discover that they
are the ones who are going to have to do all of the hard work
to influence this behavior change [the other’s substance use].
(p. 175, italics in original)

Further, CSOs are encouraged in the program through understanding that there
will most likely be an enrichment in their own lives.
During the program, the clinician asks the CSOs to conduct a CRAFT func-
tional analysis, which looks at the purpose of the drinker’s behavior from the
perspective of someone other than the substance abuser (Smith, Meyers, and
Austin, 2008). It explores the positively and negatively reinforcing behaviors of
the person’s drinking through exploration of the person’s patterns of use, external
194 Treatment 

triggers (i.e., the who, where, and when of drinking), and internal triggers (i.e.,
the person’s thoughts and feelings associated with the initiation of drinking). The
analysis then is used to help develop a plan of action.
The CSOs are taught positive communication skills since they usually want
to maintain relationships with the problem drinker (Smith, Meyers, and Austin,
2008). The basic rules for positive communication that are taught in the program
include: be brief, positive, specific, label one’s feelings, provide an understanding
statement, accept partial responsibility of non-drinking problems, and offer help.
Further, CSOs are taught how to positively reinforce non-drinking behavior. This
includes an understanding of what might serve as reinforcers for the drinker.
Given that sober behaviors are being rewarded, drinking behaviors are met by
withdrawing reinforcers. That is, if the CSO was going to spend quality time with
the person if they did not drink, they should not spend that quality time if the
person is not sober.
From the beginning of their involvement in the CRAFT program, CSOs are
prepared to think about when and how to invite the substance abuser to enter
treatment. Usually this comes after the previous interventions of positive com-
munication skills, knowledge and facility of providing positive reinforcement for
sober behavior, and withdrawal of positive reinforcement for drinking behav-
ior. The therapist works with the CSO to identify the most promising times and
places for the invitation to enter treatment (Smith, Meyers, and Austin, 2008).
Suggestions for the CSO to use during the invitation includes telling the drinker
they can have their own therapist (and not the CSO’s), they can use therapy for
issues above and beyond alcohol, they will be a co-collaborator of treatment and
treatment goals, and they can go to therapy on a trial basis to see if it is helpful
for them. Figure 10.5 presents the pathways to the goal of the CRAFT program—
getting the substance abuser into treatment.
Meyers, Miller, Smith, and Tonigan (2002) found that CSOs who participated
in 12 sessions of CRAFT or CRAFT plus aftercare had higher rates of partner
engagement in therapy than a group that attended Al-Anon and Nar-Anon facili-
tation therapy. In the CRAFT group, 58.6% of unmotivated drug users engaged
in treatment. This engagement percentage increased to 76.7% for the CRAFT
plus aftercare group. In the Al-Anon/Nar-Anon facilitation group the unmoti-
vated drug user only engaged in treatment 29% of the time. One potential reason
for this discrepancy is that Al-Anon is not designed to attempt to get the using
family member into treatment, but as a program to focus on oneself.
These results compared favorably with a previous study focusing on CRAFT’s
efficacy (Miller, Meyers, & Tonigan, 1999). In this study, the CRAFT program
was the most effective in getting previously unmotivated alcohol/drug users into
therapy as compared with Al-Anon or the Johnson Intervention (which is a
confrontative method of getting a drug-using partner into treatment; discussed
next). Sixty-four percent of drug-using partners entered treatment for those in
the CRAFT program. This is in contrast to 13% in the Al-Anon group and 30%
in the Johnson group. Similar results were found by Roozen, de Waart, and van
der Kroft (2010) where drug-user partner engagement was highest in the CRAFT
group, second highest in the Johnson Institute Intervention and lowest is the
Al-Anon/Nar-Anon condition. The CRAFT program is effective in an individual
or group format (Manual et al., 2012).
  Working with Partial Systems 195

Positive
Communication
Skills

Substance
CSO Life Abuser Positive
Reinforcement
Enrichment
Entering of Sober Behavior

Treatment

Reinforcement
Withdrawal of
Drinking Behavior

Figure 10.5  The CRAFT program is designed to get the substance abuser to enter into
treatment

Besides getting the substance abuser into treatment, CRAFT is also useful for
the concerned others. The CRAFT program has been found to lead to significant
reductions in symptoms of depression for CSOs as well as increases in relational
happiness and mental health (Bischof, Iwen, Freyer-Adam, & Rumpf, 2016). This
is significant since there can be a negative spiral between drug use and relational
dysfunction but also a positive spiral between relational happiness and substance-
use recovery.

Interventions
Perhaps the most iconic understanding that the lay population has of how fami-
lies try to get the addicted individual to change is through interventions. There
has even been a reality television show that presents families engaged in this
process. Interventions are meetings, usually as a surprise to the person abusing
substances, where family members and friends get together and let the addicted
person know their fears for them and their hopes that the person will change.
Interventions, developed by Vernon Johnson in the 1960s, have come to
be called either interventions or the Johnson Intervention. The belief behind
interventions is that anyone who wants to help the addicted individual, regard-
less of background or clinical training, can help that person (Johnson, 1986).
Interventions are based on the disease model of addiction (see Chapter 1).
196 Treatment 

This is why people who endorse interventions believe it is so important for those
who care about the addicted individual to do something. If not, and the person
does not get help, they believe the addicted individual will die. As Johnson
explained, “Chemical dependency is a disease that kills. It is also a disease
from which people can and do recover” (p. ix).
Interventions do not have to happen when a person “hits bottom” but can be
enacted at any time that the individual is experiencing a loss of functioning in
one or more areas of his or her life. Johnson (1986) defined an intervention as
“presenting reality to a person out of touch with it in a receivable way” (p. 61).
As we know, most individuals who are dealing with addiction live a life full of
secrets, denials, and lies. They engage in many behaviors and beliefs to hide and
mask the actual drug use as well as the physical, emotional, and behavioral con-
sequences. Interventions provide a space for friends, family, and loved ones to try
to get the substance abuser to move from behind the curtain of their denial to see
the impact that their drug use is having on their own lives as well as on the lives
of others. In intervention language, this process is called confrontation.
Interventions can be informal (not involving a mental health professional)
or can be a formal intervention, defined as “a professionally guided, organized
response to an individual that is intended, in part or total, to facilitate change
in his or her substance using behavior” (Fernandez, Begley, & Marlatt, 2006,
p. 207). Interventions are well-planned events that bring together individuals
who care about the addicted person to help these individuals to shift from caring
for the substance abuser. This is an important process as many members of the
addicted individual’s support system have either become co-dependent or helped
to enable and maintain the problem behavior. Interventions not only provide a
crisis for the substance abuser—to step up to the plate and deal with the reality
of their addiction—but a crisis for the friends and family—to find a different way
of caring about the person.
Instead of individuals trying to help one-on-one with the substance abuser,
interventions bring the significant people in the abuser’s life together so that they
cannot be easily dismissed. The more people who are jointly concerned, the big-
ger the statement to the person that what is occurring is serious. Besides allowing
the addicted person to see the enormity and reality of the situation, being a cohe-
sive group helps to support the individuals involved. As a group, each member
will more likely hold his or her ground and be honest with the addicted person as
to the impact their behaviors are having.
The intervention team (see Figure 10.6) should be people who are meaningful
to the addicted individual, have first-hand knowledge of the impact that chemical
dependency has had on the person’s life, are emotionally stable, and are willing to
put their relationship with the person on the line (Johnson, 1986). This last char-
acteristic is a very important point, as members must follow through in whatever
it is they lay on the table.
The team members do not go into the intervention blindly, but come prepared
with thoughts, ideas, and data that they can clearly provide for the abuser. There
are two types of data they should have with them: facts about the individual’s
drug use and possibilities for treatment (Johnson, 1986). In terms of facts of drug
use, they may compile lists of previous drug behavior and the consequences of
that behavior. For instance, in the Rothers family, they might approach Mark
  Working with Partial Systems 197

Family
Member

Co- Substance
Abuser Friend
Worker

Family
Member

Figure 10.6  The intervention team in an intervention consists of people who are close and
meaningful to the substance abuser

and talk about how when he drank on a specific night he forgot to visit his
child, Nina, when he was supposed to. Since team members are encouraged to
write down their prepared statements, they should do so in the second person:
“Last Thursday, you went to the bar after work and had four beers, then you
drove home and passed out having forgotten that you had arranged to pick your
daughter up and take her out for ice cream.” Each team member should have
many of these specific incidents that they observed first-hand. It is important to
be specific (i.e., “On Thursday you screamed and cursed at your son”) rather
than general (i.e., “Your drinking is problematic”) since the more detailed the
account the more difficult it is for the person to deny or rationalize it.
Given that the purpose of the intervention is to help the substance abuser get
into some type of treatment, having a sense of these various opportunities is very
important. Depending on the severity of the addiction, team members may come
up with lists that include private practice therapists, outpatient facilities, inpa-
tient facilities, various self-help groups or other possibilities.
Before the actual intervention, the team should meet to do one or two rehearsals
of the intervention (Johnson, 1986). These rehearsals help prepare members for
what is to come and help provide the confidence for them to follow through—as
they are most likely expected to receive denial and resistance from the substance
abuser. Team members can also use these rehearsals as a support system for one
another and to help each other prepare better for the actual intervention. For
instance, they might suggest to one member to develop a more detailed list of how
they saw the person impacted by chemical dependency.
198 Treatment 

At the rehearsal, the first step for the group will be designating a chairperson.
This is the person that will help facilitate the process of the intervention. This
person’s job is to ensure that the rehearsal, but more importantly the interven-
tion, are focused on helping the person rather than turning it into an attack on
the person—since the intervention is an attack on the addiction. Thus, those clos-
est and most emotionally connected to the substance abuser may not be the best
choice as chairperson.
The second step of the rehearsal is for each person, sequentially, to read their
lists and have each item approved by the rest of the group. This helps to prevent
an attack on the person and maintains a focus on the impact of the addiction.
The list items should demonstrate each person’s concern for the individual rather
than other emotions such as anger, hostility, pity, or blame. The third step is
determining the order of who will present their lists during the intervention. The
chairperson makes sure everyone knows this order and that it is followed so that
the intervention flows rather than turning into chaos.
The fourth step of the rehearsal is getting someone to role-play the addicted
individual. This may be one person throughout or each team member may take a
turn, as this step will allow each person to voice possible responses, denials, and
reactions that the addicted person will likely have during the intervention. Step
five is for team members to think about how they will respond to the abuser’s
replies. This allows them time to prepare a realistic response. Here, people take
an internal audit of what they are willing to do in the situation and to agree to
follow through on it. For instance, if Mark’s wife, Hannah, threatens to take the
kids and leave, she should be prepared to do this if he does not seek help after
the intervention. False promises and unfulfilled ultimatums send a message to the
abuser that they can continue to provide their excuses without real consequences.
The last step is having the actual rehearsal.
At the time of the intervention, the chairperson will begin by trying to set the
context that everyone is there because they care about the person and are hoping
that something useful and productive comes from the meeting. Johnson (1986)
provided a possible opening for the intervention:

(the name of the chemically dependent

person), we’re all here because we care about you and want
to help. This is going to be difficult for you and for us, but
one of the requests I have to start out with is that you give us
the chance to talk and promise to listen, however hard that
may be. We know it’s not going to be easy for the next little
while . . . Would you help us by just listening? (p. 81)

The intervention is not intended as a dialogue, as the substance abuser would most
likely take it as an opportunity to deny and possibly blame others, but as a chance
for the addicted individual to really hear the concern that others have for him.
Interventions may or may not involve a mental health professional. If so, the
therapist shifts in their role of therapist to that of the chairperson of the interven-
tion. This is important since this is not an actual therapy session but an attempt
to get the substance abuser to recognize that drugs have negatively impacted them
and others and that they need to engage treatment in some manner.
  Working with Partial Systems 199

However, before the intervention takes place there are some contraindications
to its use (Johnson, 1986). These include the substance abuser having a dual
diagnosis, there having been violence or abusive behavior, the substance abuser
having been depressed for an extended period of time, or that there is a possibility
that the person is abusing multiple drugs (but that the team members are not sure
what the other drug use is).
To summarize interventions, Johnson (1986) developed the Five Principles of
Intervention:

1. Meaningful persons in the life of the chemically dependent person are

involved.
2. All of the meaningful persons write down specific data about the events and
behaviors involving the dependent person’s chemical use which legitimatize
their concern.
3. All of the meaningful persons tell the dependent person how they feel
about what has been happening in their lives, and they do it in a nonjudg-
mental way.
4. The victim is offered specific choices—this treatment center, or that hospital.
5. When the victim agrees to accept help, it is made available immediately.
(p. 103)

It is important for the treatment team to have set up the treatment options, so
that if the addicted individual agrees to enter therapy they can do so immediately.
The longer that it takes from the intervention to the availability of a treatment
option, the greater the likelihood that the person will renege on their agreement.
One of the critiques of the Johnson Intervention is that it focuses exclusively
on getting help for the addicted person and does not target change in the family
system (Fernandez, Begley, & Marlatt, 2006). However, this is not necessarily the
case. Once the intervention has ended, the team should meet with the therapist
to process what happened and to talk about what they each might do to change
themselves and their family (Connors, Donovan, & DiClemente, 2001).
According to Johnson (1986), interventions are effective in getting the sub-
stance abuser to agree to go for treatment 80% of the time. However, these
results have been questioned as other studies have found quite different results.
While the Johnson Intervention was found to be more effective than other types
of referrals to outpatient therapy (coerced, noncoerced, unrehearsed, and unsu-
pervised) in getting the addicted individual into treatment (Loneck, Garrett, &
Banks, 1996a), it also had one of the highest relapse rates (Loneck, Garrett,
& Banks, 1996b). The Johnson Intervention had a lower effectiveness (30%)
of getting unmotivated problem drinkers into treatment than CRAFT (64%),
but a higher rate than Al-Anon (13%) (Miller, Meyers, & Tonigan, 1999).
These authors also found that 70% of the concerned significant others that had
planned to engage in the family confrontation did not, but, for those that did,
75% were successful in getting the person into treatment.
A Johnson Intervention is perhaps one of the most controversial actions in the
whole of the substance abuse field. This is an interesting conundrum since it is also
the type of action that is perhaps most expected from the lay population besides
attendance at AA. Some of the arguments against this method is that this type of
200 Treatment 

“in your face” confrontation does not keep the individual in treatment. One of the
problems with the approach is that if the person refuses treatment the team mem-
bers are put on the spot to follow through with their ultimatums. Also, since it is a
group of people who “surprise” the individual with this intervention, the addicted
person may feel ganged up on as if a conspiracy is occurring against them.

Working Only With the Addicted Individual

We are not spending much time in this book discussing how to work only with
the addicted individual, as that is the purview of most other substance abuse
therapy books. Further, this is a book designed to help contextualize addiction
within a family systems lens. As such, we will only use this small space to explain
that there are many ways to work with only the addicted individual; however,
this is not the preferred way of operating when dealing with addictions.
As we discussed in Chapter 1, family therapy can be done with only one family
member. Although it may look like individual therapy (one client talking with one
therapist), the content of what is being talked about will be different. Instead of
talking about intrapsychic processes (i.e., unconscious conflict, faulty cognition,
anxiety, and meaninglessness), the focus of family therapy with an individual
will explore interpersonal transactions—what is going on between people rather
than within a person. Although some of the models that we will talk about in the
subsequent chapters are amenable to work with only one family member present,
most of them are more effective when multiple family members are in session
working together to change the family system.

Working with Multiple Systems

In this chapter we have explored therapeutic implications when the clinician

is only able to work with a part of the family when there is substance abuse
involved. This came in the form of the substance abuser or impacted family mem-
ber going to a self-help group as well as several programs that are designed to
help family members and friends get the substance abuser into treatment. In this
last section we switch the focus to explore how therapists might work with mul-
tiple systems concurrently.

Multisystemic Therapy:
Joshua Leblang
Multisystemic Therapy (MST) is an evidence-based model designed to work
with the caregivers of adolescents who are displaying anti-social behaviors,
including substance use (Henggeler & Schaeffer, 2016; Henggeler et al., 2009).
Dr. Scott Henggeler created the model after trying to identify a model to work
with high-risk youth and finding little empirical evidence for most treatments.
Multisystemic Therapy is designed to work with youth engaging in antisocial
behavior, who are usually referred by the juvenile justice system (Henggeler &
  Working with Partial Systems 201

Schaeffer, 2017). The overarching goal of MST is to empower families to resolve

the serious problem behavior of their youth as well as to develop and utilize the
resources to handle future potential problems (Sheidow & Henggeler, 2008).
While effective for various presenting problems, such as anti-social behavior
as well as serious emotional disturbance (Henggeler, Schoenwald, Rowland, &
Cunningham, 2002), this section will focus more on MST’s application with
juveniles who are using and abusing substances. The Pathways to Desistance
study (which followed more than 1,300 youths who committed serious offenses
for seven years after their court involvement) found that the most common men-
tal health problem was substance use disorder (76%) (Espinosa, Sorensen, &
Lopez, 2013). However, the principles and procedures of MST remain the same,
regardless of the presenting complaint.
Multisystemic Therapy is built upon the foundation of the social ecological
model created by Bronfenbrenner (1979). Behaviors that we see are complex and
multidetermined (e.g., while the adolescent may be doing the behavior, such as
smoking marijuana, this is influenced by the systems around him/her, such as
being around peers who smoke, having easy access to money, gaps in supervision,
lack of clear expectations, etc.). Thus, an adolescent substance user may be influ-
enced (positively or negatively) by their family, extended family, peers, school,
and the greater community in which they reside, while at the same time exerting
influence on these other systems (Henggeler et al., 2009).
Research indicates that working primarily on an individual basis with adoles-
cents is challenging (Gearing, Schwalbe, & Short, 2012; Song & Omar, 2009;
Sylwestrzak, Overholt, Ristau, & Coker, 2015). Often times, teenagers are not
motivated to change their behavior. This creates problems in getting adolescents
to appointments, keeping them in treatment as they may engage in stonewalling
once in treatment, and little to no lasting changes as change in behavior is often
mood- or time-dependent and can fluctuate from moment to moment. Adolescent
development is a significant barrier as adolescents tend to have an increase in
impulsive/risk-taking behaviors (including substances) (Willoughby et al., 2014).
The adolescent brain goes through a period of myelination and pruning, as
the prefrontal lobes are being developed (Squeglia, Jacobus, & Tapert, 2009).
Additionally, there are often shifts in social groups as well as a pushing away
from traditional family values, making it more challenging to manage effectively.
In contrast to the individual approaches listed earlier in this chapter, MST is
focused on the ecological aspects that lead to substance use and abuse. Elliott,
Huizinga, & Ageton (1985) identified that the greatest predictor of adolescent
substance use is prior use. While this is informative, unfortunately no inter-
ventions have the ability to go back in time to prevent it from occurring. The
second greatest predictor is an adolescent’s peer group. The variables that lead
to involvement with negative peers include elements from the family (high con-
flict, low warmth, low monitoring) and school (low academic achievement, poor
school involvement). Hence, MST posits that the most effective way to achieve
changes in youth behavior is by working with the family (Henggeler & Schaeffer,
2017; Henggeler et  al., 2009). By doing so, the family is able to: change the
way they interact with their youth; learn how to assist the school to better meet
the needs of their child; increase involvement with prosocial peers; and thereby
decrease opportunities for substance use.
202 Treatment 

Peers

Improved
Improved
MST Family School
Behaviors
Functioning

Community

Figure 10.7  Multisystemic Therapy is designed to improve behavior through improved

family functioning as well as coordination through peers, school, and
community resources

Multisystemic Therapy therapists work using a home-based model of service

delivery where master’s level therapists work with a caseload of four to six fami-
lies and are available 24 hours a day/7 days a week (Henggeler & Schaeffer,
2017). An advanced MST practitioner [supervisor] supervises a team of two to
four therapists. The treatment team takes an ecological treatment approach to
help the youth and caregivers first assess and then intervene on the factors lead-
ing to the youth’s substance use (Figure 10.7). Commonly, these factors include
low structure and monitoring by the youth’s family and other adults in the com-
munity, limited access to positive activities at school or in the community, family
conflict, school failure, boredom, favorable attitudes toward drug use, and asso-
ciation with substance-using peers. In fact, being with other individuals who use
drugs has been established as the best predictor of adolescent drug use (Farrell &
Danish, 1993). In light of the strong influence of negative peers, MST therapists
work with caregivers to change the people with whom they associate—finding
positive pro-social friends to replace the negative or anti-social peers.
When MST therapists develop interventions for youth drug use, or other prob-
lem behaviors, care is taken to follow certain principles (See MST Nine Principles
and Figure 10.8), and these are considered to be key ingredients in MST’s success
(Henggeler & Schaeffer, 2017; Henggeler et al., 2009). First, a critical emphasis
is placed on caregiver involvement. Parents know their children best, so these
caregivers play a central role in helping MST therapists assess, plan, and carry
out interventions. Second, MST therapists are comprehensive in their approach;
they work with the multiple individuals and systems in the youth’s life that may
contribute to or help solve the youth’s problems.

MST Nine Principles

Multisystemic Therapy is based upon nine treatment principles to which all inter-
ventions adhere (Henggeler & Schaeffer, 2017; Henggeler et al., 2009; Henggeler
et al., 2002). These principles help determine the treatment specification process,
which connects the causes of problem behavior to actions that manage those
problems (Henggeler et al., 2002).
  Working with Partial Systems 203

Finding the Fit • Connection between the identiied problems and systemic context

Positive and Strength • Emphasizing the strengths as pathways for change

Focused

Increasing Responsibility • Focus on positive personal agency

Present Focused, Action • Take steps to address current speciic problems

Oriented, and Well Deined
• Focus on interpersonal and intersystemic problem-maintaining
Targeting Sequences patterns

Developmentally • Appropriateness to the client and family

Appropriate
• Inclusiveness of the client/family's hard work on a daily/weekly
Continuous Effort basis

Evaluation and • Inclusiveness of multiple perspectives of effectiveness

Accountability

Generalization • Interventions focus on change across multiple systemic contexts

Figure 10.8  Multisystemic Therapy is based upon nine principles which inform all
treatment decisions

Principle 1: Finding the Fit

Multisystemic Therapy ensures that treatment matches the context of the sit-
uation. This happens by first understanding the fit that happens between the
identified problem and the context. The fit serves to answer the question “why”
the behavior occurs or does not occur, looking for reasons (drivers) from the
individual, family, peer, school, and community.

Principle 2: Focusing on Positives and Strengths

Problems (weaknesses) are best addressed by using the strengths of the family. If
a family was to state that they fought six days a week, looking at what was dif-
ferent on the seventh day highlights a resilience factor on which we can expand.
It’s far easier to build off a foundation of strength than deal with the flood of
problems/reasons that keep a family “stuck.”

Principle 3: Increasing Responsibility

Regardless of the identified problem, the youth as well as those in his or her rela-
tional field can engage in responsible behavior to more effectively manage the
problem. The goal is to ensure that the family/youth have the skills to manage their
own behaviors/actions and take accountability for solving their own problems.
204 Treatment 

Clinicians are constantly looking for opportunities to increase effective behaviors

by stakeholders and decrease reliance on the MST therapist for success.

Principle 4: Present-Focused, Action-Oriented

and Well-Defined
Clinicians are focused on moving the discussion of problems to the present
and future and avoiding (as much as possible) getting pulled into the history of
past problems. This prevents both blaming and helplessness, which can hamper
positive movement. Given that MST treatment occurs in four to five months,
considerable time is needed to take the steps to make changes, rather than just
talk about them. Additionally, therapists focus on ensuring that interventions
are clear; that is, easily measured and understood, not just from the therapist’s
perspective but from that of anyone involved with the youth/family.

Principle 5: Targeting Sequences

Multisystemic Therapy is based on the belief that problem behavior is maintained
through repeated sequences of interactions that happen on multiple levels, includ-
ing youth, family, peers, school, neighborhood, and/or community. Treatment
then focuses on targeting and stopping these problem-maintaining patterns.

Principle 6: Developmentally Appropriate

While MST is based on these nine principles, treatment is individualized, as each
problem situation is housed within a unique context. One aspect of this context
is the developmental stage of the individuals as well as the family. Different treat-
ment strategies would be used for someone who is 12 than for someone who is
16, or for someone in foster care, a one-parent or two-parent family. The MST
therapist pays attention to each person’s social, psychological, intellectual, physi-
cal, and emotional needs and incorporates that into the treatment regime.

Principle 7: Continuous Effort

Given that interactions between systems levels maintain problematic behaviors,
continued positive interactions between systems levels are needed to maintain
prosocial behaviors. Thus, MST is designed to get all stakeholders to continu-
ously engage in behaviors that maintain the gains of treatment. This effort usually
occurs on a daily basis or as frequently as possible.

Principle 8: Evaluation and Accountability

Evaluation in MST comes from utilizing multiple perspectives in the assessment
process. It is the MST clinician’s responsibility to identify possible treatment bar-
riers and develop ways to overcome them. When identified goals are not being
met, it is the responsibility of the MST clinician to reconceptualize the drivers
for the problematic behavior and modify the intervention strategy accordingly.
  Working with Partial Systems 205

Principle 9: Generalization
Multisystemic Therapy is not designed to fix a problem in the here and now, but
rather to address systemic issues and have the treatment gains maintained for the
long term. By focusing on the strengths of the youth, caregivers, and other stake-
holders, MST interventions are designed to assist in the current problem as well
as prepare people to address possible future problems.

MST Interventions
Multisystemic Therapy interventions are individualized to the specific case, yet
guided by the nine treatment principles listed above, as well as by utilization of
the analytical process (Henggeler et al., 2009; Sheidow & Henggeler, 2008). A
key factor involved in working effectively is ensuring that the clinician is aligned
and engaged not only with the family, but also with all the stakeholders work-
ing with or around the family. Multisystemic Therapy’s systemic approach is
designed to look at problematic behaviors from all the different systems, as well
as assuring alignment between the various systems, not only to what the goal
is, such as reducing substance use, but also to the specific steps to achieve this
goal. This emphasis on engagement/alignment is paramount, as the ability of a
caregiver to be successful is highly contingent on the other systems around him/
her supporting these changes. If an adolescent hears a mixed message, they are
experts in exploiting these loopholes. Multisystemic Therapy clinicians spend a
great deal of time and effort to gain engagement/alignment, not only at the begin-
ning of treatment but also throughout the treatment process.
When using MST with substance-abusing adolescents, the addition of contin-
gency management (CM; Higgins, Silverman, & Heil, 2008) may be considered
(Henggeler et  al., 2009; Sheidow & Henggeler, 2012), which has been used
effectively in various empirical studies (Henggeler et al., 1999; Henggeler et al.,
2008; Schaeffer et al., 2008). While MST on its own can be very effective when
dealing with adolescent substance abuse, also incorporating CM may speed the
therapeutic process. Multisystemic Therapy and CM are both action oriented,
appreciate systemic contexts, goal oriented, use variations of functional analyses,
are based on behavioral and cognitive interventions, and are focused on empirical
validations (Henggeler et al., 2009).

The Analytic Process

The MST analytic process, also called the “do-loop,” is used as a broad road
map to help the clinician in treatment planning and intervention development
(Henggeler & Schaeffer, 2017; Henggeler et al., 2009). It helps the clinician to
prioritize youth and family problems that have been targeted for change (Sheidow
& Henggeler, 2008). Once there is a referral, the first step in the analytic process
is to engage and align with the various stakeholders of the case, which includes
the youth, family members, and various individuals in the social ecology. During
this step, the clinician obtains the desired goals of each key participant. These are
then integrated into about three or four overarching measurable treatment goals.
Next comes the “loop” of the analytic process. First, the MST team engages
206 Treatment 

in hypothesis testing by developing a conceptual framework, which is known

as finding the “fit” of the problem. The therapist and team prioritize fit fac-
tors as targets of intervention. These fit factors are used to develop intermediary
goals, whereupon the clinician, with the support of the MST team, supervisor

Referral
Behavior MST
Desired Outcomes
Analytical
of Family and Other
Key Participants
Process
Overarching
Goals
Environment of Alignment and Engagement
of Family and Key Participants

MST Conceptualization
of “Fit”

Re-evaluate
Prioritize

Assessment of
Advances & Barriers to
Intervention Effectiveness Intermediary
Goals

Measure

Intervention Do Intervention
Implementation Development

Environment of Alignment and Engagement

of Family and Key Participants

Figure 10.9  The MST analytical process

Henggeler, Schoenwald, Borduin, Rowland, & Cunningham (2009). Multisystemic therapy for antiso-
cial behavior in children and adolescents (2nd Ed.). Copyright holder: Guilford. Reprinted with permis-
sion of Guilford Press.
  Working with Partial Systems 207

and expert/consultant, develops and implements empirically-based interventions.

At approximately weekly intervals, the therapist assesses and evaluates the pro-
gress and, if needed, repeats the “do-loop” until the treatment goals are obtained.
To illustrate the analytical process, we will hypothesize about the Rothers
family and take one behavior (Steve’s marijuana use) through the analytical
process. It is important to note that substance use is typically one of multiple
behaviors that are usually addressed (including school refusal, conflict at home,
absconding, stealing, physical aggression, etc.). The referral behavior in this
situation is Steve’s use of marijuana three times a day, which has occurred for
the past 18 months. Key participants could include: Parents Mark and Hannah,
who want Steve to stop smoking; Steve, who wants to get off probation and
have everyone leave him alone; siblings Kayleigh and Pete, who want better
relationships with Steve; the high school football coach, who wants Steve to be
able to play again and pass the drug tests; and the probation officer, who wants
Steve to stop using.
The next step is the creation of an overarching goal. In this case it would be:
Steve will reduce substance use by 90% by the end of treatment as evidenced by
parental reports, youth reports, and probation/family urinalysis tests. We now
move into following the analytical process. Principle 1 of MST is finding the fit—
we want to look at all the systemic drivers that allow/encourage use of marijuana:

Individual: impulsive, enjoys the feeling, assists in dealing with boredom and
past traumatic events, access to money.
Family: lack of monitoring, no effective consequences, limited incentives,
modeled in the past, lack of awareness of peers.
School: opportunities for use, limited opportunities for prosocial activities.
Peers: peer encouragement, lack of non-using peers.
Community: easy access, modeled in neighborhood, places to use.

Step two is to prioritize, which often focuses on drivers within the family
domain, as it may be faster to change a parenting practice than some of the
other issues. The clinician may address the lack of monitoring as well as lack of
effective consequences as primary drivers (as there is evidence that Steve does
not use when well monitored). Unfortunately, things often times are not as easy
as they may appear—as efforts to create a monitoring and behavior plan may be
stalled due to low follow-through by the caregiver. At this point, the clinician
may need to do a subfit to look at the potential barriers of low follow-through
by the parent. This assessment may identify drivers such as parental cognitions
(I feel bad about what he went through when he was younger, and I don’t want
to make things harder than they already are), fear of youth (past violence in the
caregiver’s life by youth), low supports (caregiver may not be around to monitor
or hold youth accountable), past negative experiences (youth has made things
harder for parents in the past when they tried to change behavior), low skills
(caregiver lacks skills/knowledge on how to create and maintain a plan), or oth-
ers (could even include substance use by the caregiver, caregiver’s mental heath
or physical health issues).
208 Treatment 

Clinicians utilize this process to identify the main problems (including sub-
stance use), to look at all the reasons for the behavior (Principle 1: finding the
fit), prioritize the driver(s) for change, create an intervention, implement it,
and measure the outcome (both successes and failures), and then go around
the analytical process again and again until the behavior to be addressed is
reduced/eliminated.

Empirical Support
Multisystemic Therapy has been researched for over 30 years and has served
over 200,000 youth and families. Although developed initially in the United
States, MST has been implemented worldwide, being currently active in 15
different countries (see Porter & Nuntavisit, 2016; Schoenwald, Heiblum,
Saldana, & Henggeler, 2008; Wells et  al., 2010). It currently has the largest
body of evidence of successful interventions for high-risk youth and is con-
sidered an empirically supported treatment (Henggeler & Schaeffer, 2017).
Multisystemic Therapy has been successfully used with adolescents dealing
with substance abuse and dependence (Henggeler, Clingempeel, Brondino, &
Pickrel, 2002; Henggeler et al., 2009; Sheidow & Henggeler, 2012; Sheidow &
Houston, 2013; Wells et al., 2010) as well as with a range of other anti-social
youth behaviors.
In a meta-analysis of family-based treatments of drug abuse, the MST effect
sizes were among the highest of those reviewed (Stanton & Shadish, 1997). Van
der Stouwe et  al. (2014), in their meta-analysis of the effectiveness of MST,
identified that small but significant treatment effects were found regarding delin-
quency, substance abuse, family factors, psychopathology, and out-of-home
placement and peer factors. In this analysis, MST was most effective for those
under 15 years of age and with severe starting conditions. Multisystemic Therapy
also improved the outcomes for substance-using youth in their experiences in
drug court (Henggeler et al., 2006).
As per the aim of MST, intervention is systemic. Utilizing family therapy rather
than individual therapy helps not only with the identified youth’s problematic
behaviors, but supports those in his/her relational field. Rowland, Chapman, and
Henggeler (2008) found that the siblings of juvenile offenders decreased their
own substance use. Furthermore, caregivers of youth in which MST was used
had 94% fewer felonies and 70% fewer misdemeanors than caregivers of juve-
nile offenders who received individual therapy (Johnides, Borduin, Wagner, &
Dopp, 2017). Use of MST in communities has a serious economic benefit as MST
saves $4,600 per youth in the behavioral health domain, $15,000 per youth in
the juvenile crime domain, and gives a $3.34 return for every dollar spent (Dopp
et al., 2018).

Case Application

As we hypothesized in Chapter 8, Mark Rothers is likely in the late precon-

templation or early contemplation stage of readiness for change. Given this,
  Working with Partial Systems 209

as well as his previous negative experience of couples therapy with his first
wife Angelina, we can assume that he is unlikely to quickly seek out or agree
to go for therapeutic services. This leads to a high likelihood that the Rothers
family will engage in unilateral family therapy, with Hannah being the most
likely person to seek assistance in helping the family during their current time
of conflict.
At some point in the addiction process, Mark is likely to utilize a self-help
group. Given that alcohol is his drug of choice, this may be a group such as
Alcoholics Anonymous, Rational Recovery, or SMART Recovery. His partici-
pation in this type of program would be most likely to lead to him becoming
abstinent in his use of alcohol and other drugs, or perhaps engaging in harm
reduction and moderation management principles. Participation in these types
of self-help groups attempts to change his relationship to drugs and alcohol,
and changes to his relationships with his wife, children, others, and himself
will happen as well. The difficulty for the Rothers family will be in getting
Mark to attend his first meeting. At this point he probably does not believe
he is an alcoholic. While he may have experience with AA through his father
or brother Mick, Mark may find a program such as Moderation Management
to be more amenable to his view of his behaviors at this point in time. The
therapist working with this family may do well in educating the family about
the various self-help groups to help each of them determine which would
serve their needs the best.
There are several avenues for the other members of the Rothers family to
try to get Mark to either attend a self-help group or go to a therapy session.
Al-Anon seems to be an appropriate group for Hannah while Alateen may be
more useful for Steve, Kayleigh, and Pete. The Rothers family members, if Mark
declined to go to therapy or self-help, might find themselves in either the ARISE
or CRAFT programs, designed to help them help Mark to agree to treatment.
For instance, Hannah would be the First Caller for the ARISE program and she
and perhaps one or more of the children would be involved in inviting Mark to
engage in treatment. It is likely that it may take the Rothers several sessions and
Level 2 to get to when Mark would agree to at least try some type of treatment.
If the family was instead to utilize the CRAFT program, we can hypothesize
that the person who would make the biggest changes would be Hannah, who
would start to reinforce Mark’s positive sober behaviors rather than focus on
his drunken behaviors. However, the Rothers may be more likely to try having
an intervention since interventions are more widely known, having been shown
on television shows.
While Mark seems to be a likely focus for who needs therapy, the Rothers
may find themselves engaged in the therapeutic system through Steve’s increas-
ing problematic behavior. Given the intergenerational use of substances in the
family, along with his age and externalizing behaviors, Steve is likely to come
to the attention of the juvenile justice system or the school system. A program
such as multisystemic therapy might be useful for the Rothers to not only
prevent more serious problems such as substance abuse or criminal behavior,
but to help change the patterns in the family that are leading to the current
tumultuousness.
210 Treatment 

Summary
In the substance abuse field, self-help groups can play a prominent role in
the engagement, treatment, and maintenance of the substance abuser
as well as the family members and significant others. The most utilized
self-help program is Alcoholics Anonymous. Depending on the person’s
drug of choice, they may seek out an alternative 12-step program, such as
Narcotics Anonymous, Cocaine Anonymous, Gamblers Anonymous, etc.
For family members, self-help programs such as Al-Anon or Alateen have
been developed so that they can change their own problematic behaviors.
Since the substance abuser is likely not to willingly enter treatment, family
members may utilize one or more programs to deal with the family situ-
ation or to help get the abuser into treatment. Three of the more popular
programs in working with the non-addicted family members are ARISE,
CRAFT and the Johnson Intervention. For adolescents who are engaged
in problematic behavior, a program such as Multisystemic Family Therapy
may be useful.

Key Terms
self-help groups Level 2
unilateral family therapy Level 3
universality Community Reinforcement And
sponsor Family Training (CRAFT)
Alcoholics Anonymous program
The 12 Steps Concerned Significant Others
Speaker meetings (CSOs)
Discussion meetings functional analysis
Step meetings interventions
open meetings confrontation
closed meetings chairperson
sobriety coin Five Principles of Intervention
Al-Anon Multisystemic Therapy
Family Groups social ecological model
Moderation Management fit
ARISE Contingency Management
Family Motivation to Change (CM)
model analytic process
Level 1 do-loop
First Caller

Discussion Questions
1. Describe the purpose of Alcoholics Anonymous. What is the relation-
ship between AA and the disease model of addiction?
  Working with Partial Systems 211

2. How do programs such as Al-Anon help non-addicted family

members?
3. What are the differences between ARISE, CRAFT, and the Johnson
Intervention?
4. Discuss some of the areas of concern when planning an intervention.
5. How does Multisystemic Therapy utilize the important systems in the
adolescent’s life to provide effective treatment?
eleven

Ethics in Substance Abuse

and the Family

Therapists, regardless of their training (i.e., psychologist, family therapist, or social

worker), the population they work with (i.e., substance use, eating disorders, or
depression), or the context in which they work (i.e., private practice, university,
or agency) must abide by a set of professional standards. These standards, called
ethics, designate the minimum standards therapists follow when interacting with
clients. There are many different ethical codes, depending on the organizing body
to which the therapist or agency adheres. This might make needing to know the
various differences in ethical codes seem quite overwhelming. However, in most
cases, the many ethical codes overlap a lot more than they differ.
In this chapter we explore some of the key ethical concepts to consider when
working with an individual or family with the presentation of substance abuse
or addictions. This chapter will not be able to do justice to the variety of ethical
considerations needed when working with clients, and in particular with clients
dealing with substance abuse and family issues. We also will not be able to do
a cross comparison of the various organizations’ ethical codes. Rather, we will
focus on their similarities to provide a foundation to consider when working in
the addiction field. However, throughout the chapter, we provide examples from
many different organizations’ ethical codes to demonstrate the variety of codes
along with their particular wording for that ethical principle and guideline.

Core Ethical Principles

Most ethical bodies hold core ethical principles, primarily focusing on the thera-
pist’s respect for the client as a person who can make his or her own choices.
These core ethical principles can be viewed as moral principles focusing on what
is good and moral behavior (Kumpf, 2013). These ethical principles are in place
to ensure that clients are treated in ways that enhance them as human beings and
so that the therapist does not take advantage of them. In this section I present
some of these basic principles.

Beneficence
Therapy is about helping another person. This principle is called beneficence—
seeking to do good. Beneficence is about having some type of benefit for the client

212
  Ethics in Substance Abuse and the Family 213

based on the therapeutic work. While many therapists view beneficence in terms
of enhancing the well-being of the person they are working with, others view
this concept on an individual, group, societal, and population level (Campbell &
Morris, 2017; Corey, Corey, & Corey, 2019). Corey et al. explained, “Ideally,
counseling contributes to the growth and development of clients within their
cultural context” (p. 17). The principle of beneficence is so important that if the
therapist finds that he or she is not helping the client, then the therapeutic rela-
tionship should end.

The International Association of Marriage and Family Counselors’ code of

ethics holds that:

Couple and family counselors withdraw from a coun-

seling relationship if the continuation of the relationship
is not in the best interests of the client or would result in
a violation of ethical standards.

Nonmaleficence
Conversely, the therapist should not do any harm. This principle is called non-
maleficence. Most people know this from the Hippocratic Oath that is used in
the medical profession—“first, do no harm.” It is the therapist’s responsibility
to not exploit or intentionally inflict harm on the client, as well as thinking
ahead to avoid possible future harm (Corey et al., 2019). The client’s life should
hopefully be better for coming to therapy, or, at the least, not worse. However,
despite the best of intentions from the therapist, some clients experience more
difficulties after coming to therapy (Snyder, Castellani, & Whisman, 2006).
Traditionally, therapists who primarily worked in the substance abuse field
were themselves in recovery (Bissell & Royce, 1994). Therapists who help others
in their recovery while they themselves are going through recovery have unique
potential ethical issues, different from those of therapists not in recovery. These
include whether to self-disclose to clients about their own recovery, the possibility
of encountering clients at self-help groups, appropriate training, and complica-
tions from slips or relapses in their own recovery.
Obviously, therapists need to be competent. Historically, in the substance abuse
field, many counselors got their training through their own recovery rather than
through academic education. This was because, in the mid part of the 20th cen-
tury, addictions counseling became more prominent and there were not enough
trained professionals to work with the large amount of clients. Thus, those who
had gained sobriety were recruited to become counselors and given on-the-job
training (Doukas & Cullen, 2011). Over time, greater expectations were placed on
education so that therapists had to be certified and then licensed. Education does
not end when the person gets their degree or license. As in many other health care
professions, licensed therapists are required to keep up to date on new develop-
ments in the field. One way this happens is through the attainment of continuing
education, usually acquired through participation in workshops and conferences.
214 Treatment 

Based on one’s training, therapists can have quite varied scopes of competence.
For instance, some therapists might have been trained in being able to assess and
work with clients with dual diagnoses. However, another therapist may not have
had that education. The first therapist would be working within his or her scope
of competence when agreeing to work with a client with a co-occurring disorder,
while the second therapist would not. It is the therapist’s responsibility to gain
the appropriate and necessary training to work in his or her chosen area. Further,
when getting trained in an area, the therapist must ensure that no harm is coming
to the client. To do so, the therapist should only use new skills after appropriate
training and supervision.
Competence also refers to the therapist’s ability to be professional and conduct
themselves appropriately in their clinical work. Thus, therapists have an ethical
obligation to seek appropriate professional assistance if they are experiencing
any personal issues that impair them in their professional capacity. For those
therapists who are in recovery, one obstacle to competence may be whether the
therapist has had a slip or a relapse.

The Commission on Rehabilitation Counselor Certification’s ethical code

states:

Rehabilitation counselors are alert to the signs of

impairment due to their own health issues or personal
circumstances and refrain from offering or providing pro-
fessional services when such impairment is likely to harm
clients or others. They seek assistance for problems that
reach the level of professional impairment, and if neces-
sary, they limit, suspend, or terminate their professional
responsibilities until it is determined they may safely
resume their work. Rehabilitation counselors assist col-
leagues or supervisors in recognizing their own profes-
sional impairment, provide consultation and assistance
when colleagues or supervisors show signs of impairment,
and intervene as appropriate to prevent harm to clients.

It is imperative for therapists in recovery that find themselves experiencing

a slip or a relapse to ensure their own emotional and psychological well-being
before continuing to work with clients. The therapist’s recovery is of utmost
importance to make certain that they are able to be completely focused on help-
ing the client rather than being hampered by their own issues.
Alcoholics Anonymous disseminated guidelines for AA members who work
in the addictions field and recommended that therapists in recovery have several
years of uninterrupted sobriety before working in the field. Therapists should
then be clear which context they are operating in and only function in one role
at a specific time. Thus, they should not be sponsors for their clients or have cli-
ents as their sponsors. In their role as AA member, it is recommended for them
to maintain regular attendance at meetings to have a personal AA life in trying
  Ethics in Substance Abuse and the Family 215

to stay sober. All in all, therapists who are AA members should use common
sense and make sure they are following and maintaining the AA traditions.
For all therapists, regardless of their training or the population they work with,
self-care is an important component of being competent (Knapp, VandeCreek,
& Fingerhut, 2017). Self-care is when therapists focus on their own personal
welfare, including being physically, mentally, and emotionally sound. Physically,
therapists might exercise, eat well, and get regular medical checkups. Mentally,
therapists might meditate, engage in thought-provoking conversations with non-
clients, and engage in activities that are not therapy-related (giving themselves
a moratorium on therapy when they are not working). Emotionally, therapists
might connect with loved ones and friends or perhaps seek out their own therapy.
When therapists ignore their own self-care, they put themselves at risk of thera-
peutic burnout or of not being as effective with their clients as they could be.

Autonomy
Therapists are tasked with respecting people’s decision-making capabilities—that
is, their self-determination—as pertains to that person’s social and cultural frame-
work (Corey et al., 2019). This ethical principle is called autonomy. Wilcoxon,
Remley Jr., and Gladding (2013) explained, “Autonomy proposes that an indi-
vidual has a right to make his or her own decisions if those decisions do not
violate the rights of others” (p. 112). As long as clients are mentally competent
and able to make their own choices, while also not harming or potentially harm-
ing others to the point where the therapist would need to engage in a duty to
warn, therapists need to operate so that clients make their own choices.

The National Association of Social Work code of ethics states the follow-
ing about autonomy (what they call self-determination):

Social workers respect and promote the right of clients

to self-determination and assist clients in their efforts
to identify and clarify their goals. Social workers may
limit clients’ right to self-determination when, in the
social workers’ professional judgment, clients’ actions or
potential actions pose a serious, foreseeable, and immi-
nent risk to themselves or others.

Therapists should not tell clients what to do or that clients have to do some-
thing, but rather should encourage clients to make their own choices. However,
this does not mean that therapists do not inform clients about rules. Many sub-
stance abuse clients find themselves in treatment programs, which have rules
about behavior. Therapists should be clear and upfront with clients about what
those rules are and the consequences of breaking them. For instance, a client
might be removed from a treatment program if they use a substance while at
216 Treatment 

the facility. The therapist can inform the client of the rule and encourage the
client not to use, however it is the client’s choice of whether to use or not.
Another aspect of autonomy is informed consent. Therapists need to clearly
inform clients as to the nature of the services that the therapist intends to offer.
This presentation should be in clear language that the client can understand. This
means the therapist may need to alter how the information is presented based
on the client’s age and/or understanding. For those not legally able to provide
consent to treatment (i.e., children or those with mental status difficulties), the
therapist procures consent from a legal guardian. However, the therapist should
also attempt to obtain assent from the client. The AAMFT code of ethics includes
five components for informed consent: (1) the client can consent; (2) the thera-
pist informs the client about the treatment process; (3) the therapist informs the
client about potential risks and benefits of treatment; (4) the client freely con-
sents to treatment; and (5) the consent is appropriately documented. One issue of
informed consent that is more likely to occur in substance abuse treatment than
in other settings is that of drug testing. Many addictions facilities will utilize urine
testing to ensure client sobriety. If drug screening or testing is a component of the
treatment, it is necessary for the client to be informed about this at the beginning
of treatment, which should come during the informed consent.
For therapists working in the substance abuse field, there is a high likelihood
that they will work with clients who have been mandated to treatment. The ther-
apist is then confronted with attempting to work collaboratively with a client
who may feel coerced to engage in the therapeutic process. On the surface, then,
mandating clients to therapy would seem to restrict their autonomy.

The American Counseling Association code of ethics states the following

when working with mandated clients:

Counselors discuss the required limitations to confidenti-

ality when working with clients who have been mandated
for counseling services. Counselors also explain what
type of information and with whom that information is
shared prior to the beginning of counseling. The client
may choose to refuse services. In this case, counselors
will, to the best of their ability, discuss with the client the
potential consequences of refusing counseling services.

Given the movement of therapy from therapist-as-expert to client-as-expert,

the notion of informed consent has also changed. Most therapists utilize informed
consent in terms of a consent event (Lidz, Appelbaum, & Meisel, 1988). However,
some therapists are moving to a consent process wherein the client’s motivation
for treatment and change is continually considered. This is in line with the stages
of readiness for change (see Chapter 8). As such, the treatment regime changes
to account for the client’s current position. This requires the therapist to update
what he or she is doing therapeutically. Basing treatment on a consent process
  Ethics in Substance Abuse and the Family 217

puts the client in a more respected position, wherein the client is continually
agreeing to participate in a collaborative treatment plan.
Perhaps the most widely known ethical principle is that of confidentiality. For
the most part, confidentiality holds that, except based on what is required by law,
the therapist will not disclose with anyone what was spoken about in session. The
client does have autonomy and could give consent (i.e., by signing a release of
information), allowing the therapist to speak to specific people about a specific
aspect of therapy. For instance, the client might want the therapist to speak with
his or her lawyer about the goals and progress of the therapy. Therapists are
required to maintain confidentiality except for a few instances, such as if there
is imminent harm to the client or someone else, there is suspected child or elder
abuse, an emergency situation, or through a written court order.

The American Mental Health Counseling Association code of ethics states:

Confidentiality is a right granted to all clients of mental

health counseling services. From the onset of the coun-
seling relationship, mental health counselors inform
clients of these rights including legal limitations and
exceptions.

While therapists are bound by the limits of confidentiality, clients are not. This
becomes a potential issue when there is more than one client in the therapy room,
as in family or group therapy. Since many clients dealing with substance abuse
disorders may find themselves in family or group therapy, therapists should
encourage clients to maintain the confidentiality of the other members. In many
groups, this comes in the form of the therapist saying, “What happens in the
group stays in the group.” For those clients who attend self-help meetings, such
as AA or NA, confidentiality is not assured, as there is most likely not a trained
therapist who is held to professional ethical standards. However, AA has a tradi-
tion of respecting member anonymity. Anonymity is the spiritual foundation of
all of the AA traditions so that principles are put before personalities.

Justice
Most therapists will likely come into contact with clients from a variety of cultural
groups. It may be the rare therapist in today’s society that lives in a remote loca-
tion with little diversity. Regardless, therapists are ethically accountable to engage
in non-discrimination. That is, they should provide services to people regardless
of the client’s race, age, gender, gender identity, ethnicity, religion, national origin,
socioeconomic status, sexual orientation, disability, health status, or relationship
status. This refers to the ethical concept of justice. This does not mean that a ther-
apist cannot specialize, for instance, by working primarily with LGBTQ clients or
with religious clients if engaged in pastoral counseling. However, therapists can-
not refuse service based on any of these demographic characteristics.
218 Treatment 

The International Association of Marriage and Family Counselors’ code

of ethics states:

Couple and family counselors do not abandon clients and

do not withhold treatment to clients for discriminatory
reasons such as race, disability, religion, age, sexual ori-
entation or identification, cultural background, national
origin, marital status, affiliation or socioeconomic status.

One of the biggest recent movements in psychotherapy is incorporating the

notion of social justice into therapeutic practice. Becvar (2008) defined this term,
“That is, in general, social justice may be understood as the achievement of fair-
ness in terms of the treatment and the sharing of a society’s benefits for all of
its members” (p. 139). Justice also refers to ensuring that intervention strategies
and program formats are relevant to all segments of the population (Corey et al.,
2019). For instance, therapists can accommodate those who have transportation,
childcare, and poverty issues by making home visits or perhaps through telether-
apy. Many therapists view social justice practices on a macrolevel, exploring how
to change economic and political policies that marginalize people. However, there
are microlevel practices that can enhance a social justice perspective when working
with individuals and families. This section briefly discusses both levels of influence.

The American Psychological Association code of ethics states the following

about the ethical principle of justice:

Psychologists recognize that fairness and justice entitle

all persons to access to and benefit from the contribu-
tions of psychology and to equal quality in the processes,
procedures, and services being conducted by psycholo-
gists. Psychologists exercise reasonable judgment and
take precautions to ensure that their potential biases, the
boundaries of their competence, and the limitations of
their expertise do not lead to or condone unjust practices.

The National Association of Social Workers takes it a step further and promotes
social workers to pursue social change, especially for marginalized populations.
This may come at the local level of city or county politics, or perhaps state and
national organizations and policies.
Taking a social justice position might be difficult for family therapists who
have to utilize categorizing assessments such as the DSM-V or the ICD-11.
Sutherland et al. (2015) noted that diagnostic labels have the possibility of objec-
tifying people and limiting the scope of the sociocultural dynamics of dominance
  Ethics in Substance Abuse and the Family 219

and subordination that lead to people experiencing their current problems. One
way to move forward is to utilize discursive resources, holding both social jus-
tice and medical perspectives together in the therapeutic conversation to see
how each might be resourceful for the therapeutic situation. Sutherland et  al.
explained, “Engaging in critical practice with respect to the DSM can help thera-
pists re-conceptualize clients’ concerns with reference to the social context in
which dominant norms for being and relating may have constraining or distress-
ing effects on individuals and groups” (p. 95).
Another possibility for therapists operating from a social justice perspective
is to engage in activism (D’Arrigo-Patrick, Hoff, Knudson-Martin, & Tuttle,
2017). This might be through challenging larger social discourses that tend to
be marginalizing and oppressive. That is, ethically, some therapists believe their
work happens both in the therapy room and in larger policy and societal fields.
These activities can be considered as consciousness-raising and social education.
In the therapy room, therapists can work more locally with clients to address
social justice issues and engage in consciousness-raising activities. Kosutic and
McDowell (2008) provided several of these activities:

• Engage in a discourse about the client’s social context and impact of various
forms of oppression.
• Use cultural genograms to discuss family systems’ impact of oppressive forces.
• Deconstruct oppressive family myths and cultural narratives.
• Use externalizing language to offset internalized oppressive social discourses.
• Promote strength-based and resource-focused narratives.
• Promote affirming personal and family narratives.
• Encourage client activism to change social situations.

Each of these activities leads to greater awareness of intrapersonal and inter-

personal understandings by individuals, families, and groups.

Fidelity
Fidelity focuses on trust, where the therapist engages in ways that enhance the
client’s belief in the therapeutic relationships and process. Corey et  al. (2019)
explained, “Fidelity means that professionals make realistic commitments and do
their best to keep these promises” (p. 18). One primary way that therapists can
enhance trust in the therapeutic relationship is to ensure that the relationship stays
therapeutic. Not only should the therapist not have any type of sexual relation-
ship with the client, but also should take care not to engage in a dual relationship.

The American Psychological Association code of ethics states the following

about fidelity:

Psychologists establish relationships of trust with

those with whom they work. They are aware of their

(continued)
220 Treatment 

(continued)

professional and scientific responsibilities to society

and to the specific communities in which they work.
Psychologists uphold professional standards of conduct,
clarify their professional roles and obligations, accept
appropriate responsibility for their behavior, and seek
to manage conflicts of interest that could lead to exploi-
tation or harm. Psychologists consult with, refer to, or
cooperate with other professionals and institutions to
the extent needed to serve the best interests of those with
whom they work. They are concerned about the ethi-
cal compliance of their colleagues’ scientific and pro-
fessional conduct. Psychologists strive to contribute a
portion of their professional time for little or no com-
pensation or personal advantage.

Dual relationships occur when the therapist has a relationship with the client
in a different context; for instance, as a work partner or a known neighbor.
Ethical codes attempt to reduce and limit therapists having dual relationships
with clients since the therapist may gain knowledge about and power over the
client that they would not normally have.

The AAMFT code of ethics holds the following about multiple relationships:

Marriage and family therapists are aware of their influ-

ential positions with respect to clients, and they avoid
exploiting the trust and dependency of such persons.
Therapists, therefore, make every effort to avoid condi-
tions and multiple relationships with clients that could
impair professional judgment or increase the risk of
exploitation. Such relationships include, but are not
limited to, business or close personal relationships with
a client or the client’s immediate family. When the risk
of impairment or exploitation exists due to conditions
or multiple roles, therapists document the appropriate
precautions taken.

While some dual relationships cannot be helped, especially in small commu-

nities, others are completely unethical and potentially unlawful. These include
sexual intimacy with current clients or utilizing a client’s career for personal ben-
efits, such as getting stock tips from a stockbroker. Therapeutic organizations
such as AAMFT also prohibit the therapist from having sexual intimacy with a
client’s family members, or with past clients and known family members.
  Ethics in Substance Abuse and the Family 221

For substance abuse therapists, concerns about dual relationships involve

types of self-disclosure, identification with the client, asymmetry of power, cli-
ents potentially entering careers in the substance abuse field, risk of relapse, and
difficulty of objectivity (Chapman, 1997; Hecksher, 2007). This is because many
therapists who work in the substance abuse field have personal experience with
addictions. This might be through their own or a family member’s past or cur-
rent use. There has also been a notion by clients that they can only be helped by a
therapist who has also experienced addictions. Given this, many clients ask thera-
pists about their own addiction history and recovery. This question, as well as the
therapist’s own beliefs of treatment, lead to the therapist possibly self-disclosing;
usually regarding their own past use and recovery. While many therapists utilize
self-disclosure as a means of joining with clients, there is the possibility of the
blurring of boundaries and the shift of focus of the session from the client to the
therapist. For instance, the client may become inquisitive about the therapist’s
process of recovery and the possibility of a threat to the therapist’s well-being in
case there is a slip or a relapse.
Recovering therapists can minimize the potential dangers of dual relationships
(see Figure 11.1). The following are several guidelines these therapists can use
to more ethically engage in therapeutic relationships (Doyle, 1997; Stevens &
Smith, 2018). First, therapists should be up to date and aware of all ethical codes
that relate to their work. The better the fluency with the ethical codes, the more
knowledge and awareness therapists have to make informed decisions. Second,
the therapist should access consultation and/or supervision from experienced
colleagues or a supervisor. This protects therapists from narrow thinking, as an
outsider will be able to better view the context and provide alternative ways of
viewing situations that the therapist may not have been able to do previously.
Third, therapists should utilize self-help groups in a thoughtful manner, where
there is a reduced chance of interacting with clients. For instance, the therapist
might access his or her own self-help group in an area quite a ways away from
where they practice to reduce the chances of coming into contact with local clients.
Fourth, the therapist should be cautious in how he uses self-disclosure to ensure it
is purposeful. Sometimes, if the therapist self-discloses often, with quite personal
information, the client may attempt to gain greater amounts of personal informa-
tion about the therapist, which may blur the therapeutic boundaries. Fifth, the
therapist should use common sense when potential dual relationships surface. For
many situations, therapists are implicitly aware of what is best to do to ensure
ethical standards. Lastly, therapists are encouraged to advocate to organizational
bodies for clarification in ethical codes surrounding therapists in recovery.

Veracity
Veracity relates to the therapist being truthful and upholding truth in the therapy
context. This comes into play by bringing clarity and honesty into therapeutic
relationships. Corey et al. (2019) stated, “Unless practitioners are truthful with
their clients, the trust required to form a good working relationship will not
develop” (p. 18).
Based on the principle of veracity, therapists working with multiple members
of a system tend to implement a no secret policy (Caldwell & Stone, 2016).
222 Treatment 

Aware of
ethical
codes

Advocate for
Consultation
clarity

Guidelines to
Minimize
Dual
Relationships

Cognizant of
Common
self-help
sense
group

Cautious of
self-
disclosure

Figure 11.1  Guidelines help to minimize the potential harm of dual relationships

When secrets are present between one member of the family and the therapist, the
therapist may be engaging in dishonest and disloyal behavior to other members
of the family. We present more about dealing with secrets in therapy later in the
chapter. Figure 11.2 presents the six core ethical principles that all therapists use
as a foundation for being ethical in their work with clients.

Risk Factors and Suicide

According to the 2014 National Survey on Drug Use and Health, suicide was
the 10th leading cause of death in the U.S. in 2013. This number was higher
for those aged 15 to 54. In 2014, almost 3% of adults in the U.S. had serious
thoughts of suicide, which is about 9.4 million people. During the previous year,
2.7 million people had made suicidal plans and 1.1 million made nonfatal suicide
attempts. Of these individuals, 0.9 million made suicide plans and 0.2 million
made no suicide plans. This works out to 1 out of 9 adults with serious suicidal
thoughts making a suicide attempt. Approximately 55% of those who made a
suicide attempt received medical help, with almost 43% staying overnight or
longer in a hospital.
Individuals with alcohol and/or drug problems are much more likely than
the general population to experience lethal or non-lethal overdose, attempt sui-
cide, and complete suicides (Bohnert, Roeder, & Ilgen, 2011). While overdoses
  Ethics in Substance Abuse and the Family 223

Beneicence
Do Good
Nonmaleicence
Do no harm
Autonomy
Self-determination
Justice
Fairness
Fidelity
Trustworthiness
Veracity
Truthfulness

Figure 11.2  Core ethical principles form the basis of good therapeutic practice regardless
of therapeutic role or context

and suicide attempts are distinct behaviors, they each are related to substance
use. That is, those who engage in substance use are more likely to overdose or
make a suicide attempt. Males complete suicide at a rate of 4 to 1 over females
(Yuodelis-Flores & Ries, 2015). Yet, the correlation between substance abuse
disorder and suicide is stronger for females. Based on the 2014 NSDUH survey,
almost 137 million adults were current alcohol users with 5.6 million having
serious thoughts of suicide in the previous year. Suicide plans were made by
1.6 million adults and 658,000 made a suicide attempt. Of those with heavy
alcohol use in the past month, 6.2% had serious thoughts of suicide, 1.9%
made suicide plans, and 1.2% attempted suicide in the past year. These numbers
increase when illicit drug use is included. For instance, almost 12% of adults
diagnosed with drug or alcohol dependence or abuse had suicidal thoughts, 4%
had suicidal plans, and 2% made suicide attempts. In comparison with those
without a substance abuse disorder, 3% had suicidal thoughts, 1% suicide plans,
and 0.3% made suicide attempts.
Let’s take a second to ensure we are clear about the terms we are using.
Suicidal ideation refers to thoughts about suicide. Just because someone has ide-
ation does not mean that they are about to attempt to kill themselves. However,
it increases the risk of them making an attempt. Most people, at various times
in their lives, think about suicide. Suicidal intent means that the person has kill-
ing themself as a goal. While suicidal ideation may not lead to anything more
than thoughts, suicidal intent leads to a much greater level of risk for the person
224 Treatment 

Ideation Intent Plan Attempt

Figure 11.3  The relationship between suicidal ideation, intent, plan, and attempt

engaging in self-harming behaviors. A suicide threat is a verbal or nonverbal

communication by the person that they may attempt suicide in the near future.
This could be hinting at or telling others, through conversation, text, or notes,
of wanting to be dead. A suicide plan is the person’s specific means of killing
themselves, such as with a gun, pills, or slitting of one’s wrists. The more access
that a person has to aspects of the suicide plan, such as a gun or pills, the higher
the risk. A suicide attempt is behavior taken intended for self-killing. See
Figure 11.3 for the relationship between these concepts in levels of severity.
Risk factors for suicide attempts for those dealing with substance use include
relationship, financial, and occupational stressors, co-occurring disorders, and
previous substance and sexual abuse (Yuodelis-Flores & Ries, 2015). For those
with alcohol-use disorder, having interpersonal conflicts, co-occurring disor-
ders, and aggressive behavior are associated with higher rates of suicide (Kōlves,
Draper, Snowdon, & De Leo, 2017). Forty percent of primary care patients who
had recently used drugs had at least one suicide attempt in their lifetime (Carmel,
Ries, West, Bumgardner, & Roy-Byrne, 2016). Those with a high risk of suicide
had higher levels of severity in substance use, used more than one substance, and
had a co-occurring disorder. Bohnert, Ilgen, Louzon, McCarthy, & Katz (2017)
found that, for veterans, there was an increased risk of suicide for those with
current diagnoses of alcohol, cocaine, cannabis, opioid, amphetamine or other
psychostimulant, and sedative hypnotic or anxiolytic-use disorders. This risk was
increased for females; particularly those with only any substance use disorder and
opioid use disorder.
Client suicidal intent is a significant ethical factor for therapists as they have a
duty to protect their clients. It is the therapist’s responsibility to assess for suici-
dality, and, if the therapist has good reason to suspect suicidal behavior, he or she
must break confidentiality to ensure the welfare of the client.
  Ethics in Substance Abuse and the Family 225

The code of ethics for NAADAC, the association for addiction profession-
als, states:

Addiction Professionals may reveal client identity or

confidential information without client consent when
a client presents a clear and imminent danger to them-
selves or to other persons, and to emergency person-
nel who are directly involved in reducing the danger
or threat. Counselors seek supervision or consultation
when unsure about the validity of an exception.

When assessing for or working with suicidal clients, it is imperative for the
therapist to document all of the steps he or she has taken to ensure the client’s
welfare. Corey, Corey, and Callanan (2007) described these steps:

• Conduct a thorough assessment.

• Obtain a relevant history.
• Obtain previous treatment records.
• Directly evaluate suicidal thoughts.
• Consult with one or more professionals.
• Discuss the limits of confidentiality with the client.
• Implement appropriate suicide interventions.
• Provide resources to the client.
• Contact authorities and family members if a client is at high risk for suicide.
(p. 238)

While these steps are a guide, the therapist still must decide what represents a
threat that requires a breach of confidentiality.
Flemons and Gralnik (2013) proposed a relational suicide assessment (RSA),
which empathically explores risks, resources, and possibilities of people who
have expressed suicidal thoughts. This is different than other suicide assess-
ments, which primarily focus on risks without honoring the client’s strengths
and resources. The RSA is an interactive dialog that has three overlapping steps:
empathically explore the intra- and interpersonal world of the client, come to a
safety decision, and develop a safety plan.
Flemons and Gralnik (2013) explained that there are four main areas that
therapists should explore in terms of risk and protective factors: Disruptions
and demands; suffering; troubling behaviors; and desperation (see Figure 11.4).
Therapists can explore both risks and resources of the client and the client’s
significant others for each of these areas. For instance, client risks for the area of
disruptions and demands include the ending of a relationship, job, or legal dif-
ficulty. Resources could include the ability to problem solve as well as positive
interpersonal relationships. Client significant other risks in this same area might
include separation from, abuse to, and high demands of the client. Resources
would include reasonable expectations and help and support of the client.
226 Treatment 

Disruptions and
Suffering
Demands

Risks and
Resources

Troubling
Desperation
Behaviors

Figure 11.4  The four areas of focus in a relational suicide assessment to determine the
intra- and interpersonal risks and resources for clients

If it is determined that the client is at risk but that immediate hospitalization is

not necessitated, the therapist should collaboratively develop a safety plan with
the client. The safety plan helps the client access various resources to manage the
current and near future situation successfully. Flemons and Gralnik (2013) devel-
oped an eight-step safety plan guideline which includes identifying resourceful
significant others, restricting access to the means of suicide, exploring alterna-
tives to troubling behaviors, establishing safe havens, helping alter demanding
schedules, encouraging treatment, mobilizing personal resources, and identifying
and employing emergency resources. This safety plan (see Figure 11.5) is not the
same as a no-harm or no-suicide contract, which are more so impositions on the
client rather than collaborated steps the client chooses and endorses.

Duty to Warn
As we previously discussed when talking about informed consent, there are cer-
tain times when the therapist must break confidentiality. One of these relates to
the duty to protect, that was just explained, when therapists are working with
clients who exhibit suicidal ideation, threats, and behaviors. Another is based on
the duty to warn if the therapist believes that the client may harm someone else.
This is based on the Tarasoff v Board of Regents of the University of California
court ruling. In that case, a university student, Prosenjit Poddar, had informed his
therapist that he wanted to kill Tatiana Tarasoff. The therapist initially contacted
campus police, who interviewed Poddar and found him to be rational. No one
informed Tarasoff about the threat to her. Poddar eventually killed Tarasoff.
Her parents then sued various individuals and organizations that were involved
in the situation. Since then, there is a duty to warn; letting the intended target of
  Ethics in Substance Abuse and the Family 227

Identify
Resourceful
Signiicant
Others
Restrict
Employ
Access to the
Emergency
Means of
Resources
Suicide

Explore
Mobilize
Personal
Safety Alternatives
to Troubling
Resources Plan Behaviors

Encourage Establish
Treatment Safe Havens

Alter
Demanding
Schedules

Figure 11.5  The eight components of a safety plan for a client who may self-harm

violence know about the threat to their person. The two primary factors for ethi-
cal decision making when determining if there is a duty to warn are whether the
intended victim is identifiable and if there is imminent danger.
For therapists working with couples where there is intimate partner violence
(IPV), they need to determine what responsibility they have to break confiden-
tiality and report. Corey et  al. (2019) described the therapist’s position, “The
therapist’s goal is to protect victims from any further harm, including protecting
any children the couple may have at home” (p. 415). If the child witnessed the
domestic violence, therapists are most likely required to report since there may be
negative psychological consequences for the child. However, reporting require-
ments are dependent on the state in which the therapist is practicing.
If there is domestic violence, couples therapy is not warranted and may even be
seen as unethical (Corey et al., 2019). Therapists need to determine what poten-
tial physical and emotional danger might be present and the impact that having
conjoint sessions could have for the partners. Two important factors to consider
are violence history and current violence risk (McLaughlin, 2017). McLaughlin
recommended that therapists working with IPV clients become familiar with gen-
eral IPV issues, assess regularly for IPV, and maintain self-awareness of potential
biases as well as their own competence when working with this population. Kress,
Protivnak, and Sadlak (2008) explained that therapists should not encourage the
IPV victim to leave the relationship, but should instead focus on promoting that
person’s safety. One reason for this is, when a woman is a victim of IPV, her
228 Treatment 

greatest risk of injury is when she is leaving an abusive relationship. Having a

safety plan in place first is extremely important.
Besides clients becoming violent toward others, therapists may have a duty to
warn if they suspect someone may be harmed in other ways. Individuals who are
dealing with substance abuse disorders may have a higher likelihood of engaging
in unprotected sex or sharing infected needles. This leads to higher rates of sexu-
ally transmitted diseases. For those with HIV and/or AIDS, therapists are then
placed in an ethical situation where they must balance the duty to protect confi-
dentiality versus the duty to warn a potential sexual partner (Alghazo, Upton, &
Cioe, 2011). Burkemper (2002) found that family therapists prioritized ethical
principles when making ethical decisions regarding therapeutic situations where
a client was HIV+. In order of primacy, therapists chose to operate from non­
maleficence, fidelity, justice, autonomy, and beneficence.

Ethics Specific for Marriage and

Family Therapy

While all therapists, regardless of whether they work with individuals, couples,
families, or groups, are held to the various ethical principles previously described
(i.e., informed consent, beneficence, nonmaleficence, confidentiality, etc.), those
who work with families have some additional ethical concerns. A few of these will
be addressed in this section. Morrison, Layton, and Newman (1982) described
four specific ethical concerns for family therapists (see Figure 11.6). The first con-
cerns whose interest the therapist has and how that relates to informed consent.

Multi-
con
identiality

Family
Therapy Secrets
Equity Ethical
Concerns

Diagnosis

Figure 11.6  Family therapists have ethical concerns that are specific for working with
multiple clients simultaneously
  Ethics in Substance Abuse and the Family 229

Part of this is the issue of multiconfidentiality. Second, therapists must decide on

how to handle secrets that will come forth when working with multiple members
of a family. Third, therapists should be thoughtful and careful in if and how they
label clients and families. In psychotherapy, labeling tends to take place through
the process of diagnosing. The fourth specific ethical issue for family therapists is
whether the therapist takes one member’s side over another member. This relates
to the concept of equity.

Multiconfidentiality
Therapists who work with couples and families face an issue that therapists who
only work with individuals don’t deal with, the issue of multiconfidentiality.
Therapists have to navigate each person’s confidentiality, as well as that of the
group as a whole. That is, therapists have to keep clear what was said to them
in single session or with others present. Most therapists working with couples
and families view the system as the client rather than the individual. As such,
their actions are geared toward the well-being of all individuals, but also the
family system.
When working with multiple members of a family system, therapists need to
be cautious of whom they talk with and what information is divulged regarding
treatment. While gaining a release of information is essential before talking with
outside parties (excluding crisis situations), the release needs to be given by all
adult family members. Corey et al. (2019) explained, “The family therapist and
the family members need to agree to the specific limitations of confidentiality
mandated by law and also to those the family practitioner may establish for effec-
tive treatment” (pp. 402–403).

The American Mental Health Counseling Association code of ethics states:

In working with families or groups, the rights to con-

fidentiality of each member should be safeguarded.
Mental health counselors must make clear that each
member of the group has individual rights to confidenti-
ality and that each member of a family, when seen indi-
vidually, has individual rights to confidentiality within
legal limits.

Given that many clients who are dealing with substance abuse are increasingly
being referred by the legal system, therapists working with the substance abuser
and his or her family need to be clear as to what information should be discussed
with the attorney and/or other legal parties and what should not (Gallagher,
2014). For instance, the substance abuser’s progress and use or non-use of sub-
stances is most likely quite appropriate, while discussion of the non-abusing
members’ romantic disconnections may be a breach of confidentiality.
230 Treatment 

An additional issue of confidentiality is when the therapist needs to dis-

close to the parents of an adolescent client. Health Insurance Portability and
Accountability Act of 1996 holds for patient confidentiality. However, depend-
ing on the state in which treatment is occurring, the law may or may not require
the health care professional to disclose to parents that a minor has sought therapy
and the content of those sessions. This becomes even more blurred in that, in most
states, adolescents can consent for alcohol and drug treatment and do not need
their parents’ consent. However, family therapists tend to want to include more
rather less family members in treatment. Ruiz and Strain (2014) recommended
that, as much as possible, the parents of adolescent substance abusers be involved
in all decisions. This is due in part to getting the parents to work together with
one another as well as the adolescent and the therapist in a treatment team.

Secrets
In the ethical principle section, you read about the concept of fidelity, where the
therapist works from a position of trustworthiness. This ethical principle becomes
muddier when multiple family members are seen, especially individually. Further
complication comes when working with families dealing with substance abuse, as
they tend to have interpersonal rules that support the keeping of secrets.
Therapists are divided on whether to meet with family members separately.
On the one hand, meeting individually with members leads to the possibility
that people would more likely discuss very important issues, such as domestic
violence or marital affairs, in the privacy and safety of a lone session without
other family members present. On the other hand, some therapists believe having
separate sessions provides the opportunity for the perpetuation of problematic
interpersonal interactions that maintain secrets and dysfunctional interactions.
These separate sessions may unwittingly provide clients with opportunities to
triangulate therapists. Whichever position therapists take, they need to be clear
with clients as to the expectations of therapy and whether there will or will not
be a secrecy policy. Wilcoxon, Remley Jr., and Gladding (2013) stated, “Unless
clients are informed of a nonsecrecy policy when they initiate therapy and are
able to adequately consider its consequences, many will seek to influence the
therapist using secrets” (p. 75).
One of the primary secrets in families, and particularly couples, is that of infi-
delity. The disclosure of infidelity by one member outside of the presence of his or
her partner leads the therapist into a quandary. They are placed between the ethic
of confidentiality and the ethic of equity. Butler, Rodriguez, Roper, & Feinauer
(2010) promoted the use of facilitated disclosure under most situations, where
the therapist assists the client in telling the other member about the infidelity.
Exceptions to facilitated disclosure might include if the couple is divorcing or
separating, if there is physical or emotional risk if there is disclosure, if the other
partner has a serious or terminal illness, or if the infidelity occurred long ago and
is not relevant to the current partner issues.
Fall and Lyons (2003) suggest that when dealing with the issue of secrets in
family therapy, therapists are clear with clients about informed consent and the
benefits and risks of therapy, accurately assess the boundaries in the family, and
be clear in how they will assess the impact of the disclosure. For some disclosure
  Ethics in Substance Abuse and the Family 231

of secrets, there may be potential risks in the family system. For instance, the
disclosure of a marital affair, a member coming out in terms of their sexuality, or
the loss of a significant amount of family money, perhaps due to gambling, may
potentially lead to physical or emotional assaults.
An alternative way to view the issue of secrets in family therapy is through
the concept of selective disclosure. Rober, Walravens, and Versteynen (2012)
explained,

It [selective disclosure] refers to a process of selection as to

whom to tell what, how much to tell, when to tell, and so
on. Implied in the concept of selective disclosure is the idea
that the sharing of secret information would not resolve every-
thing, as it suggests that whatever is said, other things remain
unsaid. (p. 538)

Selective disclosure honors the family members’ ways of dealing with sensitive
issues while also enhancing fidelity in the system. Rather than have a reveal of
the secret, disclosure is viewed as a process that occurs over time, with sensitivity
and thoughtfulness.
Overall, therapists need to make therapeutic choices as to how they want to
handle the notion of secrets. By having a clear understanding of how they want
to operate, therapists are better able to, from the start of therapy, be clear with
clients as to what will happen in therapy and how the therapist will handle indi-
vidual disclosures within the family. Southern (2013) provided the following
ideas for family therapists as they relate to secrets in therapy:

• Although related, secrecy, privacy, and confidentiality are separate constructs.

• Generally, the more the secret relates to violation of family rules or the more
extreme the taboo, the greater is the need for disclosure.
• How the couple and family counselor handles secrets is the issue.
• Counselors should avoid triangulation and other alignments that perpetuate
family problems.
• Clients have the right to informed consent regarding how disclosures will be
handled.
• Counselors should not harm a client system through the process of disclosure.
• Codes of ethics are biased in favor of reviewing disclosure from the perspec-
tive of an individual client’s right to confidentiality.
• Disclosure is a process not a discrete event. (p. 252)

Ultimately, it is up to the therapist on how to navigate the dilemma of secrets

in sessions.

Diagnosing
For many couples and family therapists who operate from a relational perspec-
tive, the notion of an individual having a specific diagnosis might be anathema.
This is because diagnosing tends to be based on a linear, pathologizing description
of people (Negash & Hecker, 2010). This goes against a circular perspective that
232 Treatment 

many family therapists utilize. Diagnosing based on the DSM primarily focuses
on individual psychopathology, which may go against the family therapist’s posi-
tion that problems are housed in relationships rather than individual people. If
the therapist does diagnose one member of the family, the likelihood of that
person being considered the identified patient by other family members increases.
This situation becomes even more important as many insurance companies
require someone to be diagnosed before they will reimburse. Therapists need to
be cognizant of potential stigma to clients of being diagnosed. Given this, thera-
pists need to ensure that they do not engage in misrepresentation of diagnosis
(Wilcoxon, Remley Jr., & Gladding, 2010). Any diagnosis given must be accu-
rate. Some therapists may believe that providing any diagnosis so that the client
receives services is better than not giving a diagnosis and the client is not seen.
However, therapists are ethically bound not to “up-code”—to provide a cover-
able diagnosis. As Corey et al. (2019) explained, “Under no circumstances should
clinicians compromise themselves regarding the accuracy of a diagnosis to make
it ‘fit’ criteria accepted by an insurance company” (p. 383).
So what is the way out of this dilemma? DSM-5 is just one type of discourse,
whereas many family therapists operate from a different discourse. Family ther-
apy training teaches therapists how to engage in active discourses with multiple
perspectives. Strong (2015) suggested that therapists utilize discursive resources,
which are ways of understanding that are provided by multiple discourses. This
may come in the form of utilizing multiple discourses when working with clients
so that both DSM terminology and client-preferred language are used to satisfy
administrators, insurance companies, and clients.

Equity
As discussed previously, one of the core ethical principles for therapists is that
of equity. Therapists are ethically obligated to consider the welfare of all of their
clients. That is, all members of the family are held in equal regard concerning
their well-being. This has impact regardless of how many members of the family
come to the therapy sessions. One of the key ideas of systems theory (on which
family therapies are based) is that one change in the system leads to system-wide
change. Thus, therapists need to be conscious of the impact their actions have
for the members in the immediate session as well as those people who clients will
contact outside of the session.
Boszormenyi-Nagy and Krasner (1986) promoted the therapist stance of
multidirected partiality. These authors defined this term, “It consists of a set of
principles and technical guidelines that require the therapist to be accountable to
everybody who is potentially affected by his or her interventions” (p. 418). This
accountability is to whoever is coming to sessions as well as those people who
clients come in contact with outside of the session. For instance, if the therapist
met with the Rothers family, he or she would need to be cognizant that changes
made by Mark in his interpersonal relationships will likely impact others, such
as Angelina and Nina. By acknowledging all members’ positions and merits, the
therapist enhances the various resources that are housed in interpersonal rela-
tionships. The therapist does not take a juridical role, but instead attempts to
help family members to be able to speak and listen to one another.
  Ethics in Substance Abuse and the Family 233

Another way for ensuring that therapists do not take sides is by being neutral.
Palazzoli, Boscolo, Cecchin, and Prata (1980) described neutrality as the therapist
allying with every member of the family and none of the family members at the
same time. What this means is that the therapist, while talking with one member,
accepts what that person says in the moment. Then, when talking with the next
member, the therapist accepts whatever that person says, regardless of whether
it coincides with or contradicts what the first member said. While engaging the
family in this manner, the therapist does not approve or disapprove of thoughts,
feelings, or behaviors, as this judgment would likely lead to taking sides.

Ethics of Harm Reduction

The primary view in the addictions field is to push for abstinence. This is based
on the notion of the disease model of addiction. However, there are alternative
models of substance use. One of these is the harm reduction model. In this per-
spective, health care providers attempt to minimize the potential negative impact
that drug and/or alcohol use can have on people. Harm reduction also focuses
on social justice, holding high the rights of people who use drugs and/or alcohol.
Abstinence-based programs, such as the Just Say No campaign, attempt to
eliminate certain behaviors, such as use of illegal drugs or sex before marriage.
While this may be effective for some people, the vast majority of people will
drink, use some type of licit or illicit drug, and/or have sex before marriage. The
harm reduction viewpoint takes into account that abstinence is not the desired
modus operandi for all people. As such, it attempts to reduce as much as pos-
sible the negative consequences of engaging in these behaviors. Some examples of
harm reduction programs include methadone programs (for those dealing with
opioid use), needle programs (for those who inject drugs and might engage in
needle sharing, which increases the risk of spreading HIV), and free condom
programs (for those who are at risk of engaging in unprotected sex).
While harm reduction has become a legitimate viewpoint over the last 20–30
years, therapists may face negative consequences by encouraging this approach.
For instance, some of the concepts of harm reduction may go against 12-step or
treatment programs that focus exclusively on abstinence. Therapists are held to
the ethical mandate of ensuring client autonomy. Thus, it is the client’s choice of
which decisions to make in their own lives, including whether they want to work
toward abstinence or moderation and harm reduction.
Kleinig (2008) provided four ethical challenges when operating from a posi-
tion of harm reduction. The first ethical challenge is focusing on the bottom line.
That is, on the larger macrolevel of harm reduction policies, as many of them
are designed to minimize the financial costs rather than focusing on the physical,
mental, and emotional benefits of such programs. The second ethical challenge
is whether participation in the harm reduction program is voluntary or compul-
sory. Some programs, such as banning smoking in public places, have become
compulsory. Other programs, such as access to free condoms, are voluntary.
The implications for whether the harm reduction policies are imposed or offered
delve into ethical areas of autonomy. The third ethical challenge is about the
permissible strategies; that is, which strategies are ethically legitimate. Given that
234 Treatment 

most mental health fields have been moving toward supporting evidence-based
approaches, harm reduction strategies will most likely find themselves legitimized
with empirical support. The fourth ethical challenge concerns the delivery condi-
tions. This relates to having a code of ethics when delivering the harm reduction
strategies and programs.

Ethical Decision Making

For any situation therapists come across, they will need to make decisions as to the
best possible strategy that is both ethical and effective. When attempting to deter-
mine the most ethical course of action, there are sometimes no clear-cut guidelines.
Therapists must weigh the pros and cons to determine what is in the client’s best
interests as well as the therapy field and the legal system. While there are times when
things are black and white (i.e., therapists should never have any type of sexual
contact with their client), other decisions are more difficult, such as when to break
confidentiality. To help therapists determine the best pathway, they can utilize a
model of ethical decision making. “Decision-making models clarify and configure
the process of coming to and enacting an ethical decision” (Kumpf, 2013, p. 54).
Knapp, Gottlieb, and Handelsman (2015) and Knapp et  al. (2017) utilize a
principle-based ethical decision-making model. This model is based on the five-
step model developed by Knapp and VandeCreek (2012). Knapp et  al. (2017)
explained, “Principle-based ethics allows the decision maker to have one more
principle trump another if there is good reason to do so. However, an effort
should be made to minimize harm to the offended moral principle” (p. 42).
Step one is identifying the problem. Here the therapist determines the most
relevant ethical principles involved in the situation and how these may conflict.
On the surface this seems like it is an easy step. However, there are times thera-
pists aren’t even aware that they are dealing with an ethical issue where they
will need to engage in the ethical decision-making process. This step requires
therapists to have good working knowledge of the ethical codes that they follow.
Further, therapists should be open and connected to their own reactions, as their
gut might tell them something is not right and they should more closely analyze
whether there are any ethical issues that need to be addressed.
Step two is developing alternatives or hypothesizing solutions. The thought is
that the best ethical decisions may come from careful consideration that explores
the range of possible pathways. In this step, therapists listen and talk with col-
leagues to help expand the range of appropriate behaviors. This allows therapists
to reflect on which choice seems to be the most appropriate. Therapists might
also review overarching ethical principles, ethical codes, and pertinent laws.
These actions help move ethical decision making from a solitary endeavor to a
social process.
Step three is to analyze, evaluate, and then select the best option from the
range of choices of what to do that were brainstormed in step two. The evalu-
ation includes an understanding of the advantages and disadvantages of each
ethical choice for a variety of contexts including the practical, clinical, and legal.
The best choice may be a combination of different solutions that incorporates the
best elements of each.
  Ethics in Substance Abuse and the Family 235

Step four is for the therapist to act or perform. This is when the therapist puts
into practice the strategy that was chosen in step three. At this point, the ethical
decision-making process should still be a social process as therapists can consult
others about various ways to implement the strategy they’ve determined seems
best for this situation in that context. This may come through both the content of
their actions as well as the process of delivering the intervention.
Step five is to look back and evaluate. At this point the therapist may determine
that the ethical dilemma has been solved. At other times, further considerations
will need to be made. For instance, having gone through these five steps may
make the therapist aware of additional ethical dilemmas. If so, the therapist
would begin the process again regarding this new dilemma. As such, the five-step
model may be more dynamic and circular than linear (see Figure 11.7).
Corey et  al. (2019) provided an eight-step ethical decision-making process.
These steps include identifying the problem, identifying the potential issues,
reviewing relevant ethical codes, knowing applicable laws and regulations,
obtaining consultation, considering possible courses of action, considering the
possible consequences of those actions, and choosing the seeming best course.
Although it seems to be a linear process, this decision making model increases
therapists’ self-reflection of their own beliefs and actions as well as engaging in
further discussions around important issues with clients and colleagues.
Whichever ethical decision making model is used, they all tend to have the
following components in common: having the therapist aware of his or her own
values, avoid emotional decision-making, and understand the varied possibilities
that are available during the decision-making process (Caldwell & Stone, 2016).
Therapists that work with couples and/or families have additional complexity
in ethical decision making as they must take into account potentially competing
needs of family members and subsystems.

Identify the
Problem

Look Back & Developing

Evaluate Alternatives

Act or Analyze &

Perform Evaluate

Figure 11.7  Knapp et al.’s five step principle-based ethical decision-making process
236 Treatment 

Case Application

The therapist working with the Rothers family will need to keep the various
ethical principles in mind as he or she engages the family. Beneficence helps the
therapist focus on improving the family members’ lives; however, the question
might be, “Whose opinion of what is ‘good’ will be used to determine whether
the outcome of therapy falls under beneficence or nonmaleficence?” One way
to help ensure the therapist is doing good is to focus on the goals the clients
bring with them to therapy. This helps support the ethical principle of autonomy,
where the family members take the lead in determining what they think will be
useful for them and what they want. The therapist might provide suggestions and
concerns, but, ultimately, the Rothers will have to lead their own lives.
During the informed consent with the Rothers, the therapist will need to be
upfront and clear that, while the intent of therapy is to change their lives to how
they wish them to be, therapy may also lead people to view self and others in a
different way that may lead to discord in the relationship. This may be likely for
Mark and Hannah as they are currently able to live with one another. Depending
on the model of therapy being utilized by the therapist, problematic patterns may
be brought to the forefront in an effort to reduce or eliminate them. This process
may invoke upset and resentment.
Depending on the context of working with the Rothers family, it seems proba-
ble that Mark would receive a substance abuse disorder diagnosis. The therapist
would then need to consider the implications of this diagnosis, not only for
Mark—as it will become part of his client file—but for the therapeutic process as
well. This diagnosis, if known by other members of the family, may keep Mark
in the identified patient position. If the therapist did not think Mark qualified
for a diagnosis, or was just morally opposed to diagnosis, they would need to
consider the ramifications for the family to engage in treatment, especially if the
family was seeing the therapist through an insurance company. Whatever posi-
tion the therapist took, he or she would need to ensure that, if a diagnosis was
made, the person receiving the diagnosis fits the criteria for that diagnosis.
Like many families dealing with addiction, the Rothers have many secrets that
are both internal to the family system and between the family and external larger
systems. The therapist working with them will need to determine what type of
rules he or she wants to have with the family’s surrounding secrets. In order to
uphold the ethical principle of veracity, as well as to maintain appropriate con-
fidentiality, the therapist must inform the family, preferably during the informed
consent, as to how he or she will handle information told to him or her by family
members when other family members are not present. This may be dependent on
the type of information disclosed, who it would most likely impact, as well as the
age of the other people. For instance, if in an individual session Mark disclosed
that he was having an affair, the therapist may be more likely to think about and
discuss disclosure of this information to Hannah rather than to Pete.
The therapist working with Mark will need to take extra caution surrounding
a suicide assessment. While it seems that Mark has not made a suicide attempt,
he has expressed suicidal ideation and the possibility of suicidal intent. Given
that he is also a substance abuser, he is at higher risk for making a suicide
attempt. Mark’s problems sleeping, difficulties at work, and his comment,
  Ethics in Substance Abuse and the Family 237

Disruptions • Risks: Trouble at work, sleeping problems, and felt expectations from
Hannah.

and Demands • Resources: Nuclear family care and concern.

• Risks: Feelings of depression, insomnia, and family members who are

Suffering disappointed in him.

• Resources: Variability in severity of symptoms and family support to seek
mental health services.

Troubling • Risks: Withdrawing from family members, substance abuse, vocalization of

suicidal ideation, and familial con­lict.
• Resources: Engaging in regular activities (i.e., playing video games and
Behaviors watching sports) and family support in seeking therapy and safety.

• Risks: Hopelessness, possible suicidal intent, and communicating about

Desperation suicidality.
• Resources: Hope for better connections with family, variability in sense of
suicidality, and family active participation in a safety plan.

Figure 11.8  Information from a relational suicide assessment with Mark Rothers would
provide risks and resources in the four categories of suicidal experience

“It would be easier if I were dead” are all risk factors that should concern the
therapist and he or she should make sure that a proper and thorough assess-
ment is conducted. However, the therapist should also pay attention to Mark’s
resources. If the therapist conducted a relational suicide assessment, the infor-
mation may be gathered to help the therapist make a determination about client
safety (see Figure 11.8).

Summary
All therapists operate from a set of guidelines for proper therapeutic
behavior—ethics. These ethics are based on a foundation that puts the
client in a respected position to increase their free choice and limit the
potential harm that may come from therapy. Therapists attempt to
work so that the core ethical principles of beneficence, nonmaleficence,
autonomy, justice, fidelity, and veracity inform all of their therapeutic
decisions.
While therapists have a duty to protect clients, this is not always pos-
sible. However, therapists are in a position where they attempt to keep not
only the client safe, but also others in the client’s relational world as well.
This duty to protect and duty to warn may be at odds with other ethical
imperatives, such as confidentiality. Thus, therapists need to make hard
ethical decisions. To do so they can follow the steps of one or more ethi-
cal decision-making models. One of these serious ethical dilemmas comes

(continued)
238 Treatment 

(continued)

when a client expresses suicidal intent. All therapists should assess for
suicidality with all clients, but will need to take extra precautions when
the client is at risk for suicidal behavior. In those cases, engaging in an
assessment, such as the relational suicide assessment, helps provide the
therapist with necessary information to make a determination on how best
to keep the client safe.
For substance abuse therapists working with couples and families,
extra ethical dilemmas may surface. These include issues of multiconfi-
dentiality, secrets, diagnosing, and equity. Therapists must respect the
individual confidentiality of all members as well as that of the whole
family. Further, the therapist should have a clear policy on what he or
she will do with secrets that are told outside the presence of the other
family members. Therapists also must determine whether they will
engage in the use of diagnosing and how this will impact the therapeu-
tic process. Lastly, therapists working with multiple individuals must
consider the equity involved in therapy and consider the welfare of all
involved. They might do so in a variety of ways including acting from a
stance of neutrality or of multidirected partiality.

Key Words
ethics veracity
ethical principles suicidal ideation
beneficence suicidal intent
nonmaleficence suicide threat
competence suicide plan
self-care suicide attempt
autonomy duty to protect
informed consent relational suicide assessment
assent duty to warn
consent event multiconfidentiality
consent process facilitated disclosure
confidentiality selective disclosure
non-discrimination multidirected partiality
justice neutrality
social justice harm reduction
fidelity ethical decision making
dual relationships

Reflection Questions
1. How might a substance abuse therapist who is working with the family
system be able to navigate the primary ethical principles of benefi-
cence, nonmaleficence, autonomy, fidelity, veracity, and equity?
  Ethics in Substance Abuse and the Family 239

2. What are some of the major implications in the ethical imperatives of

the duty to warn and the duty to protect?
3. What are some of the unique ethical quandaries that therapists face
when they work with the family system?
4. How does the notion of social justice play a role in therapy with fami-
lies dealing with substance abuse?
5. What are the key ideas of ethical decision making when working with
families?
twelve

Systems Theory

Family therapy is predicated on the notion that the family is a system, and, as
such, one part of the system impacts some or all of the other parts. The family is
also a subsystem of larger systems such as each adult’s family of origin, aspects
of diversity such as culture, religion, or sexual orientation, as well as societal
processes such as social class and education. In this chapter we will explore the
various components that make up systems so that you will have a foundation of
understanding family process when working with families.
Systems theory was primarily introduced into psychotherapy through the
work of Gregory Bateson and his application of cybernetics to humans and fami-
lies (Bateson, 1972). Cybernetics can be considered “the science of pattern and
organization” (Keeney, 1983, p. 61). It is based on how systems process feedback
to self-regulate. While not all family therapists utilize the cybernetic metaphor,
many of the models of family therapy have aspects of cybernetics, or at least
systems theory, as foundational concepts. For a more in-depth discussion of the
interactional and cybernetic bases of systems theory, as well as other systems
theories that undergird various models of psychotherapy (natural systems and
language systems), see Reiter (2019).

Systems

Perhaps the place to start in understanding systems theory is to gain clarity on

what a system is. A system can be defined as a group of parts that come together
to function as a whole. When applied to families, this functioning occurs via the
transactional patterns of family members. Patterns are sequences of interactions
that occur repetitively over time. In families, patterns form and are maintained,
usually for lengthy periods. When these patterns are to our liking, we say that
things are “going well” or therapists might call them “functional.” However,
when the patterns are not fulfilling, we might explain it as being “in a rut” or
“dysfunctional.” The patterns, if judged severe, might also become problematic
and conflictual. Thus, we can see that patterns are not in and of themselves prob-
lematic. Family therapy is geared toward helping families keep patterns they find
useful and effective, while changing patterns they believe are problematic to pat-
terns they desire.

240
  Systems Theory 241

While the family is a complete system, it is also a subsystem of larger sys-

tems. In a family, this comes into play through each partner’s family of origin.
The nuclear family of husband–wife (or two partners in a same-sex relation-
ship) is a subsystem of two larger family systems, which are subsystems of
other extended families. The current nuclear family is also a subsystem of
various larger systems such as religion, culture, work, education, etc. The lens
that the therapist uses allows either wider or more zoomed views of the larger
family system. For instance, if only working with a couple, the therapist may
be so zoomed in that they only see two partners and do not see how those
individuals are impacted by their children (and thus their parental roles),
their parents (and their roles as offspring), their brothers and sisters (and their
roles as siblings), as well as their work, friends, and other factors impacting
them. This is where creating a genogram (see Chapter 1) with the family may
be useful.
In Chapter 1 we discussed the notion that the whole is greater than the sum
of its parts through the equation of 1 + 1 = 3. However, this was a very limited
view of the dynamics of systems as two people are not isolated from others. If
we look at a family, we can add a child and look at the equation of 1 + 1 + 1 = 7,
or the addition of two children is 1 + 1 + 1 + 1 = 15, and the addition of a
grandparent to this family is 1 + 1 + 1 + 1 + 1 = 30. Let’s take a step back to
see how we got to 30 different relational dynamics that we need to look at in a
five-person system.
If we changed the numbers that represented people into letters our equation
will be as such: A + B + C + D + E = 30. Now we can explore all of the two, three,
four, and five-person relational permutations that exist.

• Individual people: A; B; C; D; E.
• Two-person relationships: A + B; A + C; A + D; A + E; B + C; B + D; B + E;
C + D; C + E; D + E.
• Three-person relationships: A + B + C; A + B + D; A + B + E; A + C + D; A +
C + E; A + D + E; B + C + D; B + C + E; B + D + E; C + D + E.
• Four-person relationships: A + B + C + D; A + B + C + E; A + C + D + E; B +
C + D + E.
• Five-person relationships: A + B + C + D + E.

As you can see, the addition of another person exponentially increases the
complexity of the relational dynamics of the system. To help give the interper-
sonal nature of families as well as an understanding of subsystems, we will now
substitute the letters for the members of the Rothers family.

• Individual people: Mark; Hannah; Steve; Kayleigh; Pete.

• Two-person relationships: Mark + Hannah; Mark + Steve; Mark + Kayleigh;
Mark + Pete; Hannah + Steve; Hannah + Kayleigh; Hannah + Pete; Steve +
Kayleigh; Steve + Pete; Kayleigh + Pete.
• Three-person relationships: Mark + Hannah + Steve; Mark + Hannah +
Kayleigh; Mark + Hannah + Pete; Mark + Steve + Kayleigh; Mark + Steve
+ Pete; Mark + Kayleigh + Pete; Hannah + Steve + Kayleigh; Hannah +
Steve + Pete; Hannah + Kayleigh + Pete; Steve + Kayleigh + Pete.
242 Treatment 

• Four-person relationships: Mark + Hannah + Steve + Kayleigh; Mark +

Hannah + Steve + Pete; Mark + Steve + Kayleigh + Pete; Hannah + Steve +
Kayleigh + Pete.
• Five-person relationships: Mark + Hannah + Steve + Kayleigh + Pete.

A word of caution here. We will never be seeing the “whole” family. While
we might get to the point where we are seeing the five-person family, we know
that each person has connections outside of the family system that impact their
behaviors and sense of self—which impact how the individual operates within the
family. Although not arbitrary, we have to choose to make distinctions as to how
wide we see when working with families.

Larger Systems
The family therapist will need to be able to shift back and forth from a very
narrow focus on the individual, gradually widening the lens to see the various
two-person relationships, three-person relationships, etc., depending on how
many people are in the session and in the family. The systems therapist then needs
to have the ability to take a very wide focus to be able to see how the individuals
who have come together as a system and are now in the therapy room impact and
are impacted by larger systems such as culture, religion, socioeconomic status,
health, and work (see Figure 12.1). These larger systems influence the various
members differentially, which then possibly has a role in determining how the
two (or three or four) people find their relationships to be.
For instance, some cultures espouse a paternalistic viewpoint. Understanding
this allows the therapist to see how the father is the central arbiter in the family.
Other cultures may be more maternalistic. For some families, they may be organ-
ized around the medical system where one or more members are dealing with
disability or illness (such as a family member having cancer). The families we

• Religion and Culture

Larger Systems • Economics

• Nuclear & Extended

Family • Family Life Cycle

• Subsystems
Dyads & Triads • Coalitions & Afiliations

• Personality
Individual • Human Development

Figure 12.1  The family therapist sees multiple levels at one time and how those levels
impact each other
  Systems Theory 243

are talking about in this book are organized around addiction. This most likely
draws in several larger systems such as the legal system (i.e., the substance abuser
may have been arrested for DUI, possession of an illegal substance, or other
crimes such as theft), the education system (i.e., when one or more children have
difficulty in school), and the therapeutic system (i.e., self-help groups, outpatient
or inpatient therapy, or family therapy).

Boundaries
A system may be an individual, a dyad, a family of 20, or a whole country.
So how can we distinguish between one system and another? This is where the
notion of boundaries comes into play. Boundaries are what separate one system
from another system. While physical boundaries, like fences between houses, eas-
ily demarcate one “thing” from another “thing,” the boundaries between the
systems we are talking about in this book are a bit more difficult to determine as
they can only be seen in transactions. They are determined by who is allowed to
do what, where, when, and to whom.
Minuchin (1974) distinguished three types of boundaries: rigid, diffuse, and
clear (see Figure 12.2). Rigid boundaries do not let a lot of information through
from system to system. In families, parents may have a rigid boundary with the
child subsystem. Here, parents may restrict the flow of information, making it
primarily the parents presenting information and not allowing feedback from the
children. In families with rigid boundaries, the parents make and keep the rules
and the children are not allowed to challenge them. This is the type of boundary
that is prevalent in addicted families. The more rigid the boundaries, the more
likely that subsystems are keeping information from one another—which leads
to the presence of secrets.
Diffuse boundaries are the opposite of rigid boundaries. Here, too much
information flows back and forth. Families with diffuse boundaries might tend
to know everyone else’s business. For instance, if mother and father get into a
fight, one of the parents may go to a child and tell them what is happening to
try to get emotional support from the child. In subsystems with diffuse bounda-
ries, members are very connected to one another; usually over-connected in

Diffuse Boundary Clear Boundary Rigid Boundary

Boundary
Subsystem 1 Subsystem 1 Subsystem 1

Subsystem 2 Subsystem 2 Subsystem 2

Figure 12.2  Family mapping diagram of the three types of boundaries

244 Treatment 

Rigid Clear Diffuse

Figure 12.3  Therapists tend to help families shift from rigid or diffuse boundaries to clear
boundaries

inappropriate ways. When this happens we say that the two individuals are
experiencing enmeshment.
The third type of boundary is a clear boundary. Here, information is allowed
to move across boundaries, however the information is appropriate for the con-
text. Parents who have clear boundaries with their children will make the rules,
yet, depending on the age of the children and the situation, will allow flexibility
in those rules. Children would be allowed to talk with the parents and negotiate
temporary or permanent changes in interactions. Families usually enter therapy
displaying boundaries on the extreme; either diffuse or rigid. Therapy is usually
designed to help change the interpersonal rules so that more clear boundaries are
present (see Figure 12.3).
The type of boundaries parents have with their children lead to various types
of parenting styles. For instance, if we look at the four categories of parenting
developed by Baumrind (1967), we can see how these styles may be related to the
boundaries between the parental and child subsystems. Authoritarian parents tell
their children what the rules are and what the child is supposed to do, allowing
little to no negotiation and most likely involving a rigid boundary between the
parent and child systems. Indulgent parents tend to allow their children to do
whatever the children want, which may be most indicative of a diffuse boundary
between parents and children. Authoritative parents provide rules and guidance
but are somewhat flexible, allowing potential negotiation. Here, there is most
likely a clear boundary between subsystems. The last type of parenting is negligent
where the focus is not on the children but something else. For addicted families
where the addiction has become severe enough, negligent parenting may occur.
This style of parenting is likely to utilize rigid or diffuse boundaries.

Alliances and Coalitions

There are individuals in families that get along better than others. There are also
times where one or more members go against other family members. When two
or more members get along very well with one another we call that affiliation.
People with an affiliation for one another will tend to hang out together and
think and act positively toward one another. At a higher level, these people may
form alliances, where they make sure that they are supporting the other person
in the alliance rather than looking out for other people. At a still stronger posi-
tion, people may engage in coalitions where they actively work to focus negative
energy on a third party. There may be coalitions within alliances.
The television show Survivor is an excellent forum to be able to see many of
the systems processes in action. Strangers are placed together into two teams.
  Systems Theory 245

Within each team, members come together and form alliances where they agree
to play the game together and help one another through the game. The partici-
pants form positive affiliations with one another, where they like the other as a
person. They also agree to enter into coalitions where they actively try to vote
off someone else. Throughout the course of the show/game, alliances may shift
to where someone a player was in a coalition against becomes part of their alli-
ance and someone who was part of their alliance may become the focus of a new
coalition. Families also have this shifting of allegiances where members configure
with one or more individuals for a time and then shift to connect with others (but
fortunately usually not in trying to get a member out of the family!).

Open and Closed Systems

How open or closed a system is depends on the boundaries that have been devel-
oped. Systems where the boundaries are looser, where information can more
readily move from one system to another, are known as open systems. Here,
the boundary between the family and a larger system is most likely a diffuse
boundary or a clear boundary on the diffuse side of the continuum. This allows
the family to more readily adapt to what the outside systems need. For instance,
a family in recovery may be open to outside systems such as the legal system,
extended family, or the work system as to how the recovery process is going.
Conversely, the larger systems are allowed to input information, such as treat-
ment programs or moral support, into the family.
In contrast, closed systems are more inflexible where there is a clear distinction
between systems. Information does not easily flow from one system to another.
Closed systems tend to operate from rigid boundaries and do not readily exchange
information. This is where addicted families, especially during the more severe
stages of the process, fall. Addicted families usually become more closed over the
course of their life-span as long as the addiction is present. Figure 12.4 presents a
visual distinction between open and closed systems.

Open System Closed

System

Adaptability Inf lexibility

with Larger with Larger
Systems Systems
Figure 12.4  Open systems are adaptable in their interactions with larger systems while
closed systems maintain a rigidity
246 Treatment 

Lineal and Circular Epistemologies

One of the biggest components of systems theory is the shift away from a lineal
causality model to one that is circular. Viewing action from a lineal perspec-
tive, A causes B. For instance, your partner yelling at you causes you to become
angry. However, that view is severely limited. It does not take into consideration
temporality—what occurred prior to this action. Where did your partner’s yell-
ing come from? By only looking at the yell–anger transaction, the context of the
interchange is lost. Context is perhaps one of the most important concepts in
all of systems theory. Without it, behavior may not make sense. Context is the
situation in which interactions occur. There are times when you have looked at
someone’s reaction and were quite confused as to why they were happy, sad, con-
flictual, etc. However, later you found out the context of the situation and then
it was clear to you why they acted as they did (for instance, your drinking buddy
was very mad at a celebration party, and then you later found out their partner
left them that morning).
Another problem with viewing actions from a lineal perspective is where to put
the punctuation. Punctuation in systems theory explores where to put a starting
and ending point. Usually, people punctuate a transaction starting from the other
person’s action and ending with their response. For instance, I see that my wife
did not remember my birthday (the cause) so I am mad with her (the response).
Yet, if we expand the punctuation to include the time before this, we might see
that I did not recognize our anniversary and she was upset about this. The further
back we start punctuating the transaction, the greater the context to understand
the situation.
A circular perspective takes into consideration the idea that two (or more)
people simultaneously and mutually influence one another (see Figure 12.5). We
do not act in vacuums of relationships. When you are having a conversation with
your partner, although you may be doing most of the talking, they are being
influenced by and influencing you. You, at the same time, are influencing and
being influenced by them. During the conversation you are taking in information,
both verbal and nonverbal, as to whether they are understanding what you are
saying, agreeing or disagreeing with it, as well as metacommunication to tell you
to continue to talk or to stop talking. Metacommunication is communication
about communication (Watzlawick, Bavelas, & Jackson, 1967). This is verbal
and nonverbal messages to let each person understand how to make meaning of
the communication. As an example, Hannah says to Mark, “Honey, could you
please put down the beer and join us for dinner.” She is sending several messages.
The first, what is known as the report of the message, is the content—“Put down
the drink, come eat dinner.” The second and more important component is the
command of the message. It describes the relationship between the two people—
“I am your spouse and as such I have the right to tell you that I am worried about
you and expect you to listen to me.”
The punctuation of a circular view includes both individuals over time. For
instance, in a parent–child situation, instead of viewing it as child acts out—
parent punishes, it can be seen as more of a pattern, over time. Yet this pattern
will be punctuated differently by the various players. For the parent, it would most
likely be the more the child doesn’t follow the rules the more the parent tries to
control the child’s actions, which leads to the child going against the parent’s rules,
  Systems Theory 247

Person Person
A B

Figure 12.5  Circular causality holds that two people mutually influence one another

which leads to more control attempts from the parent, ad infinitum. However, the
child would most likely punctuate it differently. For them, the more the parent
tries to control them the more they try to assert their individuality (go against the
parent’s rules), which leads to the parent trying to control more, which leads to
more attempts by the child to be independent (see Figure 12.6).

Parent's Child's
View View

Assertion of Parent tries

Individuality to Control

Parent tries Assertion of

to Control Individuality

Assertion of Parent tries

Individuality to Control

Parent tries Assertion of

to Control Individuality

Figure 12.6  People have different punctuations of their patterned relationship

248 Treatment 

Mutuality
Behind this notion of circularity is that of mutuality. Systems theory does not see
the individual as separate from the context but an active agent in it. While we can
look at the individual as a distinct system with a group of parts (our brains, heart,
lungs, blood, etc.) working in conjunction to form a whole (us as a person), the
individual is a subsystem of larger systems (dyads, triads, larger families, etc.).
Individual parts do not function on their own, but in relation to other parts. For
instance, take your heart. It beats in your body, but if we disconnected it from
your brain it would not function for longer than a few minutes—and neither
would you, unless connected to an alternative life-support system.
People can be seen to function similarly; however, perhaps not to the extreme
of separating a person from a relationship (say a divorce) and then not function-
ing (dying) soon after. Yet, the part—in this case, the person—functions based
on how it is connected to the other parts in the system. This is why your friends
may find it odd when they first interact with you when you are around a person
they have never seen you with before (perhaps a new romantic partner, your sib-
ling you haven’t seen recently, or your grandparent); they think you are “acting”
like a different person. When connected to that other person there are different
pushes and pulls for you to act in certain ways.

Homeostasis
The understanding of families as systems occurred through the application
of cybernetic principles, which looked at how systems regulated themselves.
Homeostasis stands for “same state” and holds that systems attempt to maintain
a steady state of functioning through the use of feedback processes. This occurs
through the combination of two opposing but necessary processes—stability and
change (see Figure 12.7).
Perhaps the easiest example of a homeostatic process is that of an air condi-
tioner. Think about what temperature you set your thermostat on. Let’s say it is
at 74 degrees Fahrenheit. Your HVAC system continually takes in information
from the home air, registering the current temperature. When this information
confirms that it is at the 74 degree mark, the system does not activate. In systems
terminology, we call this negative feedback. Negative feedback helps to main-
tain the status quo (see Figure 12.8). However, if the sun comes out and shines
through the windows, the indoor temperature quickly rises. Your HVAC system

Stability
Change

Figure 12.7  Homeostasis is the combination of two interlocked processes; stability and
change
  Systems Theory 249

brings in this hotter air and registers that it has exceeded a certain threshold,
which activates the system to turn on and cool the system. This process is called
positive feedback. Thus, positive feedback is an attempt by the system to bring
components back into the standard acceptable way of operating (see Figure 12.9).
Once the HVAC system registers that the air temperature is back to 74 degrees it
shuts off—or, as we would now call it, negative feedback occurs.

Negative
• Homeostasis Feedback • Homeostasis
• Homeostasis

Negative Negative
Feedback Feedback

Figure 12.8  A visual representation of how negative feedback maintains the current
homeostasis level

• Positive
Homeostasis Feedback

New • Positive
Homeostasis Feedback

New • Positive
Homeostasis Feedback

Figure 12.9  A visual representation of how positive feedback maintains the current
homeostasis level
250 Treatment 

This is how homeostasis happens in a mechanic system. How might it occur in

a family system? Let’s use the Rothers family as an example. The family, consist-
ing of mother, father, and three children—15, 12, and 9 years old. In this family,
there are rules in place for everyone to get along with each other. The 15 year
old, Steve, has started to try to gain a sense of independence and is hanging out
with a new crowd, one that tends to engage in delinquent activities such as skip-
ping school and smoking marijuana. Slowly, Steve begins to argue more with
Kayleigh and Pete and to challenge the parents. One or two small challenges to
harmony (such as refusing one night to eat dinner with the family or calling Pete
a curse word) do not get the system to change—they are still within the realms
of the steady state and lead to negative feedback. However, Steve has been told
he cannot smoke marijuana, but he does so anyway. When confronted by Mark
and Hannah, Steve states, “You do not control me. I can do what I want.” This
offense to getting along is past the boundaries of acceptability and becomes posi-
tive feedback—information that the system needs to put something in place to
get back to the original steady state. Thus, the parents begin to put restrictions in
place, such as grounding and taking away of privileges, all in the attempt to get
Steve to be more harmonious in the house.
However, if a family maintained the same homeostasis for the course of its life it
would cause serious difficulties as families must reorganize along various points of
their life to help accommodate the requirements of that life stage (see Chapter 7 for
the explanation of family life cycle). Systems theorists hold that families are more
vulnerable to symptoms during these transition phases between life stages when
they have not reorganized to be able to better navigate the new requirements. In the
Rothers family, the family is moving from the family with children/adolescents to the
family with a young adult. This transition requires the parents to be less rigid in their
boundaries with Steve so that he can learn to be able to gain a sense of independence,
since he will soon be involved in launching away from the family and needing to be
able to function on his own (we use this phrase liberally—as the person is not liter-
ally on their own but also not under the direct auspices of their parents).

Patterns
Almost all family therapists pay attention to the patterns of transactions that
occur between people. These come in many different forms, yet we can look at
three in particular: symmetrical, complementary, and parallel. Symmetrical rela-
tionships are when each person matches what the other person does; in essence, it
is a more of the same. In an escalating symmetrical relationship (sometimes called
a competitive symmetrical relationship) the more person A engages in a behavior
the more person B engages in that behavior (see Figure 12.10). For instance,
Mark comes home and starts yelling at Hannah. As he does this Hannah yells
back, which leads to more yelling by Mark and more yelling by Hannah. This
is just one punctuation of the pattern. We could also say that the more Hannah
yells at Mark the more Mark yells at Hannah. In a deescalating symmetrical rela-
tionship the less Person A does a behavior the less Person B does that behavior
(see Figure 12.11). The less Mark opens up emotionally to Hannah the less she
opens up to him and vice-versa; the less Hannah opens up to Mark the less
he opens up to her.
  Systems Theory 251

Instead of matching the other person’s behavior, two people may engage in
alternate or opposite behavior; what we would call a complementary relation-
ship. Here, the more person A engages in a behavior, the less person B does
that behavior. We can see this in pursuer–distancer relationships where the more

Mark's Hannah's
Behavior Behavior
Yells at Other Yells at Other

Gives Rude Gives Rude

Response Response
Gives Terse Gives Terse
Response Response

Figure 12.10  Escalating symmetrical relationship between Mark and Hannah where
each person attempts to engage in the same or one-up behaviors of the
other person

Mark's Hannah's
Behavior Behavior
Doesn't Open Up Doesn't Open Up

Doesn't Open Up Doesn't Open Up

Doesn't Open Up Doesn't Open Up

Figure 12.11  Deescalating symmetrical relationship between Mark and Hannah where
each person attempts to engage in the same or one-down behaviors of the
other person
252 Treatment 

Less of
Behavior

More of
Behavior
Figure 12.12  Complementary relationships involve the two people in interaction engaging
in opposite yet connected behaviors

one person pursues the more the other distances. It is also the main type of
relationship in families where one of the partners underfunctions leading to the
other partner overfunctioning (see Figure 12.12). In the Rothers family, as Mark
begins to find his life being chaotic and is not taking care of his home respon-
sibilities like child care or cleaning, Hannah tends to overfunction and take on
more of these duties. Again, we can punctuate this differently as Hannah taking
over caretaking duties and Mark giving up his parental duties.
Parallel relationships occur when there is a back-and-forth give-and-take
between the two people. There is a negotiation between the people where they
are able to swap roles. For instance, the husband may engage in primary caretak-
ing duties three days a week while the wife caretakes for three other days. The
seventh day they might both caretake together.

First-Order Change
There are many different ways that families might change how they function. The
two general classes of change attempts we will talk about in this book are first-
order and second-order change. First-order change is change within the existing
rule structure of the system. Sometimes first-order change attempts work, and
whatever the people wanted to be different changes after they make the attempt.
However, when it does not work, families tend to keep trying to change within
this class of attempt. First-order change is the type of change that most people/
families attempt as it fits within a Western perspective of “If at first you don’t
succeed, try try again.” The difficulty is that family members are not aware that
they are engaged in this process of “more of the same” where they try solution
strategies that, although different, maintain the current structure and function
of the family. However, the family believes they are trying many different solu-
tion attempts; none of which seem to be working. Further, these failed solution
attempts may actually become the problem (Watzlawick et al., 1974).
For instance, the Rothers family members may be very frustrated with Mark’s
substance abuse and subsequent related behavioral problems (i.e., not engaging
  Systems Theory 253

with the family in a positive manner). Each member attempts solutions to try to
fix the situation. Hannah sits down with Mark and tells him she is very concerned
about him and that he needs to get his act together. Steve yells at him when Mark
forgets his birthday. His mother tells him that she is disappointed in him and he
needs to clean up his life. Each of these solution attempts, while different, all fall
under the family rules that it is the family members’ responsibility to help one
another. The members may change what they do (i.e., Hannah may write a let-
ter to Mark on how he is not the man she married or she may even threaten to
leave or actually leave), yet it usually does not work because it is a continuation
of a class of events that hasn’t been useful. A change of change attempts is what
is necessitated.

Second-Order Change
Second-order change is when there is a change of the rules of the system. Here,
the Rothers family members might change the rule of them being responsible for
each other’s behaviors. They might do this by stating, “Mark, although we are
your family, we cannot decide what you do. We care about you, but the choice
of what you do is up to you.” They have changed the system from being domi-
nated by responsibility for others to people having to take responsibility for their
own actions.
A common way of understanding the difference between first- and second-
order change is through the nine dot problem. Look at Figure 12.13.
Here are the rules to solve this problem. Using only four straight lines, con-
nect all nine dots. Once you put your pen down on the paper you cannot lift it
up until you finish. See how many times it takes you to solve this before reading
any further than this!
Did you solve it? Most people cannot because they work within the given
rules, as well as one extra rule that they added; that you cannot go outside of the
boundary of what looks like a box. And if you use this additional rule, the puzzle
cannot be solved. However, if you change the rule of staying within the box (and
follow the old dictum to “think outside the box”) to be able to draw your line
anywhere you want, the puzzle is more readily solved. Most likely your initial
attempts to solve the nine-dot problem, by staying within the confines of the box,
were all first-order change attempts; change within the existing rule structure.
Once you changed the rules—that you could draw anywhere—you were oper-
ating via second-order change. Figure 12.14 presents a three-line and four-line
solution for the nine-dot problem.

Figure 12.13  The nine-dot problem

254 Treatment 

Figure 12.14  The three-line and four-line solutions to the nine-dot problem

Second-Order Cybernetics
In this chapter we have presented the primary principles of viewing the family as
a system. However, when a therapist comes in contact with a family, they are not
seeing the family as the family is, but as the family is in relation to someone (a
therapist in this case). While the family is most likely similar to how they operate
at home, there may be differences based on family members either trying to look
more favorably to the newcomer, an attempt to make someone else look worse,
or an attempt to get the therapist on someone’s side.
This new combination—of the family and the therapist—is known as the
therapeutic system (see Figure 12.15). And this new system operates by all of
the principles that were discussed within this chapter; rules, roles, boundaries,
etc. Looking at this in a different way, we can talk about it as the observer

Family

Therapeutic
System

Therapist

Figure 12.15  The therapeutic system is comprised of the client and the therapist who
mutually influence one another
  Systems Theory 255

becoming part of the observed system. This viewpoint is known as the cybernet-
ics of cybernetics—or second-order cybernetics (Keeney, 1983).
Because the observer is part of what is being observed, the notion of objectivity
is questioned. Instead, therapists understand the recursive nature of interactions;
the mutuality that happens between family members as well as the dynamics in
play between clients and therapist. Each part of the system perturbs the other. So,
instead of a therapist being able to sit in a session and provide an objective diag-
nosis of the client, the therapist has to be self-referential—understanding how the
knowledge they have is biased on their own perspective as well as how the clients
present themselves.
When family therapists work with a family, they must keep in mind how they
enter the system. There are several positions they can take, such as an expert, a
control agent, or a one-down position. For instance, if a family enters with an IP
who is abusing substances, they are making demands to the therapist. In essence,
they are saying, “We are concerned about person X who is addicted and making
our lives miserable and we expect you to help us do this.” This demand has the
potential of putting the therapist in an untenable position. If agreed upon, the
therapist will be operating from the expectations and anxiety of others instead
of their own therapeutic principles. Family therapists must challenge the family’s
certainty; that the family knows what the problem is (or more specifically who
the problem is) and that the therapist can help them fix this person (Minuchin,
Reiter, & Borda, 2014). This is because families tend to view an individual as the
problem rather than the interpersonal transactions. To do this the therapist must
be aware of his function in the therapeutic system.

Systems Theory in Practice

We have been talking about how families function, yet that understanding
needs to be connected to what the family therapist does while working with the
family. By understanding that “the problem” the person/family brings to ther-
apy is just a symptom of an underlying organizational issue in the family, the
therapist is less focused on the content of what the family is talking about
and more concerned about the process of interactions occurring between the
family members.
This is perhaps one of the most difficult skills for the family therapist as ther-
apists tend to be trained to examine what the problem is, when the problem
happens, and what the person thinks and feels about the problem. To get away
from this mindset, the family therapist adopts a relational perspective, focusing
on how one person’s actions impact another person. Here are several relational
questions and their individual question relatives:

Individual:  When you drink, what do you think about?

Relational:  When you drink, what happens with your wife?
Individual:  What type of drunk is your wife?
Relational:  Who is most impacted by your wife’s drinking?
Individual:  How do you feel when you are drugging?
Relational:  How do your children react when you are drugging?
256 Treatment 

Parent Parent

Child

Figure 12.16  Detouring triangulation happens when two people focus on another instead
of addressing the underlying conflict between themselves

Symptoms
Symptoms that family members develop usually serve some type of function in the
family. For instance, an adolescent who is acting out may unconsciously be doing
so as a way to divert attention away from a mother and father who are having
marital difficulties. By focusing on the adolescent’s problematic behaviors, husband
and wife do not have to address their own anger, upset, or disappointment with
one another. This is called a detouring triangulation (see Figure 12.16). As another
example, a husband’s drinking may seem isolated from the larger family. However,
in looking closer, we may see that his father has recently passed away, and, through
his underfunctioning via drinking, his mother is helping out more with the raising of
his children. This prevents her from experiencing the grief of the loss of her husband.
Given that families tend to enter therapy offering up an identified patient
(IP)—the person in the family who is most demonstrating the symptoms of the
family—one of the first steps for a family therapist is to deconstruct the symptom
(Minuchin et al., 2014). The family therapist should be able to hear the family’s
presenting concern yet expand the scope of the problem—externalizing the prob-
lem from a trait of an individual to a transactional pattern between several people.
Minuchin et al. describe this process as that of a detective uncovering a mystery:

Knowing that the symptom is but one piece of a larger puzzle

that, when put into the context of relationships, uncovers the
mosaic of the family, the therapist begins with the symptoms
but searches underneath for the relational rules in place that
maintain the symptom (p. 11)

Thus, the therapist enters the family transactions via the presenting problem (and
the associated IP), with the understanding that family transactions are maintaining
that symptom. Thus, the symptom is usually not the focus of therapy but how
family members engage one another.
  Systems Theory 257

Case Application

The Rothers family can be viewed as a system. They are five individuals that
function as a whole. However, they are also a subsystem of larger systems, such
as Mark’s family of origin, Hannah’s family of origin, and Mark’s previous
marriage and first child. They are also a subsystem of families in the United
States. They maintain themselves as a family by engaging in patterned relation-
ships, where there are typical ways that they interact with one another. These
repetitive interactions, such as the kids going to Hannah rather than Mark
when they are asking for privileges, or Mark and Hannah going to what is
called “our bedroom” at night, help distinguish the family in their unique way
of being.
There are various boundaries at play in the Rothers family. Between husband
and wife seems to be a boundary somewhere between clear and rigid. There
is a rigid boundary between Mark and the children. Hannah seems to have a
somewhat rigid boundary with Steve, a clear to diffuse boundary with Kayleigh,
and diffuse boundary with Pete. There is likely a rigid boundary between the
Rothers family and larger systems such as extended family and the school sys-
tem. Thus, the Rothers tend to function as a closed system. A family map of the
Rothers is presented in Figure 12.17. We can hypothesize that Mark attempts
to use an authoritarian parenting style while Hannah uses an authoritative par-
enting style.
There are several affiliations, alliances, and coalitions in the Rothers family.
For instance, there is a coalition of Hannah and the children against Mark.
While they may not engage in open conflict with him, there is a sense of an
“us against him” mentality. Hannah and Pete have a strong affiliation with
one another. Kayleigh has an affiliation with both Hannah and Pete. Mark
likely feels an outsider in the family as does Steve, who is finding affilia-
tions and alliances more important with those outside of his family and in his
peer group.
There are many patterns in the Rothers family that maintain their current
way of function—their homeostasis. Each person punctuates these patterns,
sometimes with overlap, other times not. If we looked at one small difference in
punctuation between Mark and Hannah (see Figure 12.18) we can see that they
are each reacting off of the other person’s behavior in what will likely be a game
without end (Watzlawick, Weakland, & Fisch, 1974).

Mark Hannah Larger Systems

Steve Kayleigh Pete

Figure 12.17  Family map of the Rothers family’s boundaries where rigid boundaries
separate the family from larger systems and Mark from the rest of the
family
258 Treatment 

Mark's Hannah's
View View

Hannah Hannah
Nags Nags

Mark Mark
Withdraws Withdraws

Hannah Hannah
Nags Nags

Mark Mark
Withdraws Withdraws

Figure 12.18  Mark and Hannah punctuate their patterned relationship differently

Summary
Systems theory is the foundation for many family therapy approaches.
Based on a model of information processing and feedback, families try
to maintain stability—homeostasis. The family’s functioning level is
predicated on the patterned relationships that have developed over time
that determine who is in which subsystem and the associated boundaries
between those subsystems. These boundaries are determined by the family’s
rules; overt and covert rules that let people know how they are allowed
to be with one another and with those outside of the family. When family
members stray too far from the family’s homeostasis, various processes
become enacted to try to regulate the members’ behaviors so that they shift
back into the standard way of being. These processes are best seen using
a circular epistemology where mutuality between members demonstrates
the interconnectedness of people and the development and maintenance
of symptoms.

Key Words
cybernetics subsystem
system boundaries
patterns rigid boundary
  Systems Theory 259

diffuse boundary command

enmeshment mutuality
clear boundary homeostasis
authoritarian parents negative feedback
indulgent parents positive feedback
authoritative parents symmetrical relationship
negligent parents escalating symmetrical
affiliation relationship
alliance deescalating symmetrical
coalition relationship
open system complementary relationship
closed system parallel relationship
lineal perspective first-order change
context second-order change
punctuation the therapeutic system
circular perspective second-order cybernetics
metacommunication detouring triangulation
report

Discussion Questions
1. Discuss how a family can be viewed as a system.
2. Explain the notion that 1 + 1 =3.
3. How do interactional processes such as alliances, coalitions, and affili-
ations impact the family homeostasis?
4. Provide several examples of symmetrical, complementary, and parallel
relationships.
5. What are the differences between first-order and second-order change?
6. Describe some of the implications of using a systems view when work-
ing with a family.
thirteen

Family Therapy Overview I

Psychotherapy, as a field, has been around for just over 100 years. Yet family
therapy has only been present for approximately half of that time. For various
reasons, the beginning of counseling and psychotherapy focused on the individ-
ual. It wasn’t until the mid-1950s, in which a confluence of events occurred, when
therapists brought forth the understanding that person-in-context, specifically
family involvement in therapy, was imperative for effective change (although the
notion of social systems’ involvement in people’s lives was present previously).
Today, there are approximately 400 different types/methods of psycho-
therapy, depending on how one distinguishes between approaches. Of these,
perhaps 50 are couples/family therapy theories. Studies have found that no one
approach is better than any other (Lambert & Bergin, 1994); however, hav-
ing an approach, even if it is an integrated/eclectic approach, is imperative. As
such, being grounded in the various family therapies is necessary for someone
to be able to have the flexibility to work systemically with individuals, couples,
and families.
The primary goal of psychotherapy is change, in whatever form that may come
(which depends on the client’s goals as well as the theory of problem resolution
of the approach the therapist is working from). Change comes for a client, generi-
cally, in the form of having more response options when they leave therapy than
from when they entered (Reiter, 2018). To do this, the therapist must increase
his or her response options. The more that you, as a therapist, can operate from
multiple theories and multiple positions via the client (at one point being warm
and supportive and at another being challenging), the greater chance you have of
being able to navigate the unknown of the therapeutic encounter.
In this and the next chapter you will read about some of the most influential
family therapy approaches. These are not the only therapies available to you;
however, they are perhaps the most prominent. While they each have their idi-
osyncratic ways of viewing family functioning, they all focus on the dialectic
of how people can be individuals while still being a functioning member of the
family system (see Figure 13.1). Problems tend to occur when people move
to either side of this continuum. Either they try so hard to be an autonomous
individual that they lose the sense of togetherness and do not respect other
people’s autonomy, or they try to become part of the system and lose their
sense of self.

260
  Family Therapy Overview I 261

Individual Family Member

Figure 13.1  Family therapies focus on the ability of people to be unique while also staying
connected to their family

Although there are varying ways to classify the different family therapies, in
this book we will distinguish them based on their main focus. We can look at the
various family therapies based on six categories: intergenerational approaches,
experiential approaches, communication approaches, strategic approaches, sys-
temic approaches, and postmodern approaches. The current chapter explores the
intergenerational, experiential, and communication approaches. Chapter 14 cov-
ers the strategic, systemic, and postmodern approaches. We understand that this
will only be an introduction to these various family therapies and highly encour-
age you to go to the writings of the founders and the second and third generation
theorists to gain a more in-depth understanding of each model.

Intergenerational Approaches

Intergenerational approaches examine how family processes occur within and

across generations. They explore how the current nuclear family is impacted by
what occurred in the nuclear families (the families of origin) of the adults in
the family. This exploration might be one, two, or three generations previous.
Through these models, family members pass on behavior patterns, family val-
ues, expectations, and cultural ways of thinking. In this section we will discuss
two of these approaches: Murray Bowen’s Natural Systems Theory and Ivan
Boszormenyi-Nagy’s Contextual Therapy.

Natural Systems Theory

Murray Bowen developed one of the most comprehensive theories of family func-
tioning. His approach is rooted in Natural Systems Theory, which holds that
there are certain, predictable forces, which act on and shape the behaviors of all
living systems. One of these crucial forces in shaping human relationship systems
is the counterbalancing forces of individuality and togetherness (see Figure 13.2).
262 Treatment 

Individuality
Togetherness

Figure 13.2  People experience two co-equal forces of nature; the push to be oneself while
also being connected to others

Bowen Family Systems Theory rests on the premise that there is a relationship
in families between the overall level of anxiety and the level of differentiation
individual members display. All families demonstrate what Bowen calls distur-
bances of their “emotional system,” and these are most easily thought of in terms
of the interplay of anxiety and differentiation among members (Kerr & Bowen,
1988). For families with lower overall levels of differentiation, not much anxiety
is needed in the system to lead to one or more members becoming symptomatic
(i.e., depression, anxiety, addiction). Families who function at the higher end of
the differentiation scale may still become symptomatic, but such expressions are
seen in the face of progressively increasing levels of anxiety. Regardless of how
well members are differentiated, if chronic and situational anxiety become high
enough, members may become symptomatic. Thus, alcoholism happens when
family anxiety rises (Bowen, 1992). It is important to understand that the exces-
sive drinking is a symptom of intergenerational family processes.

Societal Differentiation of
Emotional Self
Process Emotional
Cutoff

Multigenerational
Transmission
Process
Natural Sibling
Position

Family
Projection
Process
Systems Nuclear Family
Emotional
Triangles Process

Figure 13.3  Bowen proposed eight interlocking concepts that form the basis for Natural
Systems Theory
  Family Therapy Overview I 263

These concepts perhaps can be best explained using Bowen’s eight interlocking
concepts: differentiation of self, triangles, nuclear family emotional process, mul-
tigenerational transmission process, family projection process, emotional cutoff,
sibling position, and societal emotional process (see Figure 13.3).

Bowen’s Eight Interlocking Concepts

Differentiation of Self
Bowen’s most recognized concept is that of differentiation of self. Differentiation
is the innate tendency of the person to grow to be an emotionally separate person
(Kerr & Bowen, 1988). When we are born we are completely dependent on oth-
ers. However, as we develop, two life forces weigh upon us; the push to think,
feel, and act as a distinct individual as well as a push toward togetherness—to
stay emotionally connected to others.
Along this continuum, people can function too autonomously or too con-
nected to others. Bowen thought of either extreme as two sides of the same coin,
and people in such positions are vulnerable to problems in their overall function-
ing. The ideal is for one to be able to be connected to others while at the same
time maintaining one’s autonomy. When we are too together, we lose ourselves,
through a process Bowen called fusion (Kerr & Bowen, 1988). This poorly dif-
ferentiated position does not allow us to use our own thinking processes. When
we are on the other extreme of trying to be totally independent we are also func-
tioning from a poorly differentiated position as our “self” is not a real self but
operates in isolation of others.
What distinguishes people along the continuum of differentiation is their
ability to distinguish between their feeling system and thinking system (Kerr &
Bowen, 1988). Those who are better able to choose which process they are oper-
ating from tend to function higher on the scale of differentiation. Those who
cannot choose and are governed by their feeling process rather than their own
thinking process are considered to be functioning toward the lower end of the
differentiation scale.

Triangles
The notion of triangles highlights how people are connected to multiple individu-
als. For Bowen, the smallest stable unit of the emotional system is the three-person
system (Bowen 1992). The two-person system is stable when anxiety is low.
However, once the anxiety in the relationship increases and the individuals are
not able to resolve it between themselves they recruit (triangulate) a third person
to offset that anxiety (see Figure 13.4). However, alcohol/drugs could become the
third part of a triangle. For instance, if Mark and Hannah are having conflict,
Mark may go drinking to reduce the anxiety in the system. This is a useful tem-
porary maneuver, but creates more anxiety in the long haul.
In Bowen therapy, the therapist attempts to help people to de-triangle. This
comes in two main forms. The first is working with people so that they under-
stand how they become triangled by others as well as how they try to triangulate
264 Treatment 

Tension

Figure 13.4  Triangulation occurs when two people are unable to handle the anxiety
in their own relationship and incorporate a third person to help offset the
anxiety

others (Kerr & Bowen, 1988). The second way is that the therapist enters into
a triangle with family members (usually a couple) as a nonreactive third person.
This is important since people, especially couples, come to therapy expecting
the therapist to take their side against one or more other people (i.e., “See how
wrong and bad my husband is being to me by drinking all the time”). By being
connected but not being reactive, the therapist can serve the function of lowering
the overall level of anxiety in the system. Doing this may allow the couple to fig-
ure out a way to address what is happening between them in a more thoughtful,
less reactive manner.

Nuclear Family Emotional System

The nuclear family emotional system refers to how a family—in this case look-
ing at two generations (parents and children)—come together and impact one
another. There are four basic relationship patterns, or categories, of dysfunction
(Kerr & Bowen, 1988). Based on which patterns the family operates from will
lead to symptoms developing in a particular person or relationship. The four
categories are illness in a spouse, marital conflict, impairment of one or more
children, and emotional distance (see Figure 13.5).
Illness in a spouse is when one of the adult partners (in a two-parent family)
underfunctions. This may be due to a physical or psychological ailment such
as major depression, addiction, social anxiety, or any other of a multitude of
problems. In this situation, the partners engage in a dance where the functioning
partner accommodates to the underfunctioning partner to provide harmony in
the relationship. However, if chronic anxiety rises enough, symptoms will occur
in one or more members. Usually, this will be with the person who makes the
most adjustments in their own thoughts and behaviors.
This over/underfunctioning complementarity plays itself out in unique ways
in substance-abusing families. As the drinking escalates, social, emotional, and
physiological consequences occur. Physically and neurologically, the person may
  Family Therapy Overview I 265

Marital
Conlict Projection
onto
Children

Emotional
Distance
Spousal
Dysfunction
Nuclear Family
Emotional
Process

Figure 13.5  Couples bind their anxiety through the nuclear family emotional process

experience blackouts and memory loss, sexual dysfunction, and cirrhosis of the
liver. Further, the person is not able to think and be as goal-directed as they once
were (McKnight, 1998). These factors not only impact the substance abuser, but
permeate the multitude of relationships within and without the family.
Marital conflict occurs when both partners sense the tension increasing and,
instead of looking inwardly at their own process, tend to focus externally on
what their partner is doing that they think is wrong. Both individuals tend to
believe this and try to control what the other person does. They each then try
not to be controlled by the other. This escalation perpetuates itself. As emotional
reactivity increases, the more fixed each person gets into how they view who
needs to change, instead of looking at themselves as part of the process.
A third category in the nuclear family emotional system is that of impairment
in one or more of the children. Here, children are at risk of developing symptoms
when their level of differentiation is low. The lower the differentiation level, the less
chronic anxiety is needed to develop symptoms. Once a child does develop symp-
toms (which may be physical, psychological, or social) the parents tend to focus their
energy and anxieties on that child. This increases the anxiety level in the system.
The last category is emotional distance. When the pull for togetherness is too
great, and people are not able to figure out how to extricate themselves from this
pull while still being engaged, they push away to the point of distancing them-
selves. If they push too much they will isolate themselves. This is problematic as
other people, and especially our family members, are social supports.

Family Projection Process

Problems do not just form in an individual, even if that is where the symptoms
reside. They are inextricably wrapped within the dynamics of relationships.
266 Treatment 

The family projection process describes how parents transmit their level of
differentiation onto one or more children (Kerr & Bowen, 1988). This process
has three steps. The first occurs when the parents focus on a child, believing
that there is something wrong (psychologically, emotionally, and/or physically)
with the child. Second, whatever the child does, the parent views this as con-
firmation of their fear for the child. Lastly, the parent then behaves toward the
child as if their fear for the child was actually real. This process increases the
anxiety in the symptom and targets it primarily on one child.
The family projection process can be seen as a triangle in which two par-
ents triangulate a child to offset their anxiety (see Figure 13.6). By focusing
so much attention on the child in trying to get the child “better” they do not
have to address whatever issues may be present in their own relationship. As
a child, the alcoholic usually experienced one of two extremes in their early
attachment with their parents (Bowen, 1992). On one extreme is where the
individual attempted to deny the attachment. Instead, they utilized a super-
independent posture wherein they operated from a stance of saying, “I am
a completely separate entity from you and I can handle everything on my
own.” Most likely, as an adult, they utilize this posture in their career and
new nuclear family. In their career, they try to do all job tasks on their own
rather than through collaboration. In their new family, with their spouse and
perhaps children, they may attempt to overfunction. The other type of emo-
tional attachment that potentially leads to alcoholism is the person who had
an over-attachment to their parents. In this case, the person becomes emotion-
ally fused with their parent. They do not become a distinct “self.” While their
counterpart was able, at least for a while, to function quite well in life (i.e.,
holding jobs, getting promoted, developing a family), this individual tends not
to be able to function well. They may find themselves being a type of social
outcast; having a need for connection yet a denial of it. Alcohol may fill a void
of connection.

Parent Parent

Child
Figure 13.6  The family projection process occurs when parents attempt to bind their
anxiety by overfocusing on a child
  Family Therapy Overview I 267

Multigenerational Transmission Process

Bowen’s theory is an intergenerational one, where the functioning of people
today is closely tied to the functioning of their ancestors (and will be connected
to the children and grandchildren who are yet to be born). This is because of the
multigenerational transmission process. This concept explains how, over time,
there comes to be small differences in individuals and nuclear family differentia-
tion levels.
People tend to marry and find partners at roughly the same level of differ-
entiation that they are at (Kerr & Bowen, 1988). When they have children, the
children are born into an emotional system and tend to function at the level of
their parents. However, as was seen with the family projection process, one or
more children can become the focus of the parents’ anxiety, and will tend to
develop a slightly lower level of differentiation. One or more other children might
be able to function slightly more effectively and develop a slightly higher level of
differentiation (see Figure 13.7). Over generations, one branch of the family can
be functioning at a much lower level of differentiation than another branch. But
keep in mind that someone at a higher level of differentiation may show symp-
toms before someone at a lower level. This is because it is the combination of
self-differentiation and chronic anxiety that determines whether someone experi-
ences symptoms. If anxiety becomes too high, anyone is potentially symptomatic.

Emotional Cutoff
At times, the pull for togetherness becomes so strong that individuals fear the loss
of self. At that point they may engage in emotional cutoff (Kerr & Bowen, 1988).

Parent Parent

Child A Child C
Higher Functioning Child B Lower Higher Functioning
Functioning

Figure 13.7  The multigenerational transmission process occurs when, over succeeding
generations, one child is the focus of the family projection process and
develops lower levels of differentiation and then does the same in their own
children later in life—with this repeating itself over multiple generations
268 Treatment 

This may come in a physical form by the person moving away from their family
and not having contact with them. Or it may be a psychological cutoff where
they can be around family members but not engage them emotionally. Either way
is problematic.
When a person engages in emotional cutoffs they are still operating based on
the unresolved push and pull of individuality and togetherness. Their response is
part of the emotional reactivity of the family. Instead of getting involved in what
is going on in the family and potentially getting swept up in the family anxiety,
they back out. Yet it is an emotional reaction based on their feeling system rather
than a chosen response from their intellectual system.
Many times what happens when people cutoff from their family is that the
anxiety and tension they are trying to get away from appear in their new relation-
ships. For instance, in starting a new romantic relationship the individual may
become overinvested in how the partner thinks, feels, and behaves. They also
have not learned how to maintain connection within conflict. Thus, they may be
quick to exit the relationship if the partner brings up issues they are having in
the relationship.

Sibling Position
Bowen, based on the work of Walter Toman, found importance in sibling position.
Bowen explained, “An individual’s personality is shaped, to some extent, by being
in a certain functioning position in the family” (Kerr & Bowen, 1988, p. 315).
As used here, the notion of sibling position is more about functional position than
birth order, as the two are many times the same but not necessarily so.
For instance, suppose in a family there are two children. The first child, who
is two years older, was born with autism. Growing up, the younger child had
to develop caretaking skills for his older brother. Chronologically this person
is the youngest sibling. However, if we applied the notions of what personality
characteristics are attributed to youngest children (i.e., they tend to want to be
babied, are usually the jokesters of the family, and tend not to feel the pressure of
having to succeed like their older siblings), we would not understand what was
happening. This child’s functional position is that of the older sibling. With this
knowledge, we would look to them as potentially being more responsible, care-
taking, with higher expectations on them from self and others.
Sibling position can also be related to the family projection process. Perhaps
in the previous generation there was a strong focus on oldest males. This would
lead us to suspect that in the current generation there might be more focus and
anxiety placed on the oldest male of the sibling group.

Societal Emotional Process

Societal emotional process was one of the last concepts that Bowen introduced.
This concept describes the notion that everything that has been presented so far
about Natural Systems Theory happens in systems other than the family. Here,
instead of just focusing on a nuclear family or three-generational family, issues
of differentiation, culture, and transmission process occur at a societal level.
  Family Therapy Overview I 269

What may have been seen as family emotional system shifts can be seen as cul-
tural forces at play, not only upon the few members of the family but also upon
the millions of people in that society.

The Process of Therapy

Bowen therapy helps family members to explore the patterns that have happened
in past generations and that are displaying themselves in the present. The thera-
pist acts a coach, helping family members to gain insight into their reactions in the
family. By helping members to take an I-position, the therapist works to increase
each member’s differentiation. The more differentiated the person can become the
more they can engage other family members in a non-reactive manner. This may
happen through the use of developing a genogram (see Chapter 1) and discussing
the family patterns that have occurred over generations. There are not many tech-
niques in Bowen therapy, but rather it is more an intellectual exploration of the
client’s family’s emotional system, which will lead to the client being able to stay
connected to family members while also holding to their own position.

Contextual Therapy
Contextual Therapy is a multigenerational therapy approach developed by Ivan
Boszormenyi-Nagy. The model focuses on how the past issues of relational eth-
ics (what may be considered fairness) impact current transactions, which, when
placed in balance, aid future generations in having more trustworthy interactions
(Boszormenyi-Nagy, 1987). As such, although it may help to relieve existing
difficulties, it is also a preventative approach, assisting family members to dis-
continue problematic patterns of engagement so that those who come later can
have more effective family legacies.
Boszormenyi-Nagy originally developed four dimensions of relational real-
ity: facts, individual psychology, systemic transactions, and relational ethics
(Boszormenyi-Nagy & Krasner, 1986). Before his death he made overt a fifth
dimension; the ontic (Ducommon-Nagy & Reiter, 2014). Each of these dimensions
can be talked about on their own, however they operate in conjunction with one
another, with relational ethics being at the core. The family therapist must under-
stand how they all come together to help highlight the individual’s and the family’s
current context. Figure 13.8 presents the five dimensions of relational reality.
Facts are the components of ourselves and our lives. These include our gender,
birth order, race, past physical history, socioeconomic status, ethnicity, etc. That
you were born in the United States to parents who divorced when you were two,
wherein your mother was an alcoholic, and that you had asthma as a child, are
all facts of your life. These are components that you cannot change. Some facts
lead to us engaging others productively, while others have the potential for us
to expect to be repaid. For instance, someone who grew up in an addicted and
chaotic family may expect that they are owed by society for their situation since
they were not given a fair deal growing up.
The relational reality of individual psychology takes into account how the
person functions as a distinct entity. This would include the person’s intelligence,
270 Treatment 

Individual
Facts
Psychology
Relational
Ethics
Systemic
Ontic
Transactions

Figure 13.8  The five dimensions of relational reality in Contextual Family Therapy

developmental capabilities, life goals, motivations, and other aspects of person-

hood. In this component are various facets of psychodynamic understandings;
a focus on ego defense mechanisms, individual desires, and how each person
understands themselves. When therapists explore this dimension, they are paying
attention to the basic needs of each person in the family.
The third dimension of relational reality is systems of transactional patterns.
Here, the therapist understands how the conglomeration of members of the fam-
ily, with their own facts and individual psychology, come together and form a
system. The components that we covered in Chapter 12 are all understood here;
boundaries, rules, roles, etc. While the previous two dimensions place attention
on the internal aspects that make a person distinct, this level of understanding
helps the therapist to conceptualize the external aspects that regulate behavior.
This dimension is used in contextual therapy for guidelines on tactics, while
the fourth dimension, that of relational ethics, is mainly used for designing
interventions (Boszormenyi-Nagy & Krasner, 1986).
The fourth dimension of relational reality is relational ethics. This focus sets
Contextual Therapy apart from most other approaches of therapy. Ethics here is
not the ethics that we think about in terms of guidelines by organizing bodies (see
Chapter 11), but rather what is needed to earn credit—what is called merit. Here,
the focus is on how trustworthy people’s relationships are, including how they
view what they have given to others and what they have received. This dimension
is based on the interweaving of the previous three dimensions. Boszormenyi-
Nagy and Krasner (1986) explained, “A consideration of the overall fairness
(Dimension IV) of the interpersonal ledger requires weighing factual, psychologi-
cal, and transactional circumstances from each partner’s vantage point” (p. 58).
Thus, a person has an internal sense of whether they have been treated with due
concern by others that they have shown concern for; in essence, have they given
more than they received or received more than they’ve given.
The fifth dimension is the ontic. This is the self in relation; describing ourselves
as unique beings, based on not being someone else. This comes from an I–Thou
relationship where each person understands that they are a distinct being, with
  Family Therapy Overview I 271

different thoughts and viewpoints than the other. However, we develop our iden-
tity by distinguishing ourselves from the other person. In the Rothers family,
Steve may grow up always assessing whether he is a better or worse person/
father than his own father, Mark. Thus, his sense of self is based on “not being”
someone else. This process would be utilized with a multitude of people in the
individual’s relational web.

The Development of Debt and Credit

As Contextual therapists view human transactions, problems are predicated
on imbalances of people’s relational ledgers (Boszormenyi-Nagy & Krasner,
1986). Each person keeps a subconscious accounting of what they have given
to others and what they have received from others. This ledger is based upon
our indebtedness—what we owe to others—and our entitlement—what we
are owed.
We earn merit when we provide consideration for others. The debt that is
accrued in this process can only be repaid by the person to whom the considera-
tion was given. For instance, if you help out a friend who went through a loss by
being there for them to talk to, at some later point in time, only that person can
repay that debt. Their giving to you should be in proportion to what you gave to
them. It does not have to be a one-for-one process where you give them a ride and
then they have to give you a ride. Perhaps they look after your cat while you are
on vacation or they set you up on a date if you were in the market.
When our indebtedness and our entitlement are in alignment—when we have
a balanced ledger—we engage others in trustworthy relationships. We are more
open and accepting. However, if we give due caring to someone and do not
receive the due caring back that we gave, or, conversely, when we receive from
others but do not give them back due concern, problems may develop.
These imbalances can come, over time, from vertical loyalties or horizontal loy-
alties. Loyalty regards placing the interests of those who have shown us concern
over those who have not (Boszormenyi-Nagy & Krasner, 1986). Vertical loyalties
happen between generations. These invisible loyalties occur when a child tries
to pay a debt to his parents. Horizontal loyalties usually happen in the nuclear
family; such as between spouses. Loyalty is not problematic unless the person is
caught between two people with competing loyalty pressures (Boszormenyi-Nagy
& Krasner, 1986). One of the most destructive forms of loyalty conflict is split
loyalty. This is when a child is placed in a position of having to choose between
parents; giving loyalty to one parent at the expense of loyalty to the other. This
may be the case for Nina in the Rothers family where she may feel disloyal to
Angelina if she shows love and affection to her father, Mark.
When people have given due consideration to someone and not received in
kind from that person, destructive entitlement may develop. When this happens,
the person who is owed looks toward others to repay a debt that that person did
not accrue. Boszormenyi-Nagy and Krasner (1986) hold that substance abuse is
usually based in destructive entitlement. Remember that people only owe when
they are given. If they give due consideration to someone who is owed by some-
one else, after a certain amount of time, they will expect to be given back in kind.
The first person who is caught up in destructive entitlement will not think they
272 Treatment 

Destructive
• Not Shown Due Entitlement • Not Shown Due
Concern • Not Shown Due Concern
• Seek Debt Concern • Seek Debt
From Other • Seek Debt From Other
Destructive From Other Destructive
Entitlement Entitlement

Figure 13.9  Destructive entitlement happens when one person seeks repayment from
another who does not owe them. This process can lead the second person to
seek recompense from a third person who did not accrue the original debt

owe since they view that they were owed and did not have to give to this new
person reciprocally. This process can keep going ad infinitum where one person
pays a debt not owed to them and then looks to someone else to repay them (see
Figure 13.9). Contextual therapists will attempt to stop this process and help
people to balance their ledgers with the people who they owe or are owed.

The Process of Therapy

One of the main therapist attitudes and positions Contextual therapists take is
that of multidirected partiality (Boszormenyi-Nagy & Krasner, 1986). This is
when the therapist helps family members to explore the position of each per-
son who is connected to what is happening in the therapy room. The therapist,
in engaging in multidirected partiality, demonstrates inclusiveness by siding with
each person sequentially, discovering what credit the person can be given. This
acknowledgment, first by the therapist and then by each family member, helps
to humanize people, demonstrating that people behave based on their situation.
One of the outcomes of multidirected partiality is that of exoneration. In
families, there is usually at least one, but sometimes more, family member(s)
who seem to bear the brunt of the ire of the family. The process of exoneration
explores how family members may be able to understand the context in which
the other person acted. This is important since they usually only view what the
person did (the offense) rather than how that person’s actions made sense given
their situation. Exoneration allows people to shift from a stance of blame to an
appreciation that the other person was limited in what they could do based on
the context of their life. In addicted families that are in a state of despair, the
Contextual therapist will have a good chance to establish a therapeutic contract
by exploring the past and how the addicted individual had previously contributed
positively to the family (Boszormenyi-Nagy & Krasner, 1986).
  Family Therapy Overview I 273

The overarching goal of Contextual Therapy is stabilization of trust and posi-

tive initiatives by people. This occurs by a therapeutic focus on due and fair
resources. The therapist helps family members to view their own and each oth-
er’s relational resources; how they are capable of giving and receiving with one
another. This happens when members are able to acknowledge how, in their
own way, others have attempted to give them due concern. The following case
example by Boszormenyi-Nagy (1987) is a good summary of how a Contextual
therapist may work with someone dealing with the impact of substance abuse:

A case in point is the situation of the daughter of an alcoholic

father. Bearing the weight of her father’s former behavior and
apparent failure, she may press her son toward perfection to
make up for her filial shame. Overburdened by unfair legacy
expectations, her son is faced with the unacceptable choices of
abandoning his mother physically or emotionally or of submit-
ting to her impossible demands. More realistically, contextual
therapy offers him still another choice: he can help free him-
self and his mother for a new balance of trust and fairness in
their relationship. Overcoming the mistrust, resentment, and
stagnation that have accrued from his mother’s undue substi-
tutive and compensatory expectations of him, her son can find
ways to discover aspects of his grandfather’s behavior, which
serve to exonerate his life. Through active strategic work he
can also determine and implement his own terms for account-
ably fulfilling his legacy rather than becoming entrapped into
deferring to his mother’s terms or simply learning to evade
them. (pp. 220–221)

Experiential Approaches

Experiential family therapies focus on the in-session interactions of family

members where the therapist helps individuals come in touch with their own
experiences as well as the other members of the family. Experiential therapies
tend to be focused on the here and now, looking at what is occurring, in the
moment, in the therapy room. This does not mean that they are devoid of explor-
ing the past, but they do so with a focus on how the past is manifesting itself at
the present time. Experiential approaches became popular in North America dur-
ing the 1950s and 1960s and are known as the “third force”—as an alternative
to psychodynamic and behavioral approaches (Pos, Greenberg, & Elliot, 2008).
While many Experiential therapies, in some ways, eschew theory, they are
predicated on many similar assumptions. Personal growth is the hallmark for
positive therapeutic work as family members’ individualism has been stifled by
the family process. Rather than attempt to have members gain intellectual insight
into what is happening in their lives, Experiential therapists connect with clients
on a person-to-person basis for them to have an experience, in the session, that
is growth-producing (Pos et al., 2008). This may come through a myriad of tech-
niques, none of which are planned before the start of the session.
274 Treatment 

In many ways, the Experiential therapies can be viewed as humanistic

approaches, where the self of the person is key. While it may seem that these
theories are mainly focused on the individual, an understanding of the person
does not occur outside of the realm of the family and the constraints the family
makes on the person; leading each individual to adopt rigid roles and find insuf-
ficient coping mechanisms. As such, family members are not provided with an
environment in which they can self-actualize.
Experiential models are based on the notion that individuals develop symptoms
because of emotional suppression. The rules of the family do not allow them to
have free range of their emotional experience. They may not be able to acknowl-
edge their enjoyment, or others may restrict family members from expressing pain
or disapproval. This suppression disconnects people from themselves, which dis-
connects them from each other. What happens in the therapy room then is about
reconnecting people to aspects of self that they disavowed, while getting them to
allow other people to be unique as well. This process can be viewed as working
from the inside out where people understand and accept their own feelings and then
develop more honest and genuine relationships with one another. What becomes
important in the therapy room is engagement and communication, which is the
medium in which people will risk being true to themselves and real with each other.
Two of the main Experiential approaches are Virginia Satir’s Human
Validation Process Movement and Carl Whitaker’s Symbolic-Experiential Family
Therapy. We will discuss each of these in this chapter to provide you an overview
of how they understand how families function, the development of symptoms in
individuals, the resolution of symptoms, and the process of change.

Satir’s Human Validation Process Movement

Virginia Satir was one of the most iconic of the originators of family therapy. She
was a huge figure, both in stature and in influence. Her approach stretched across
several areas of therapy including communications theory, systemic therapy, and
Experiential approaches. I have included it in the latter since, perhaps more than
anyone (besides Carl Whitaker), Satir’s approach focuses on getting family mem-
bers to engage one another and have a new and unique experience within the
therapeutic session that they will then keep with them as they leave the session
and enter their home context.
Satir’s approach has been called many things, but here we will use a name she
developed, the Human Validation Process Movement. This is because her work
was intended to help people move toward a progressive validating of not only
other people, but of themselves as well. This comes through an appreciation of
the uniqueness that each person brings to an encounter (Satir, Banmen, Gerber,
& Gomori, 1991). When people feel validated, they can more easily be themselves
and accept others. Thus, the therapist helps people to take self-responsibility, a
valuing of the self and other, and a movement toward congruent communication.
The approach is not the elimination of problems, as all families have problems.
The main issue is how the family copes with these problems. If the family tightens
up, living by more rigid rules, with a foundation of low self-esteem, one or more
members will most likely become symptomatic. Although one person is likely to
be the identified patient, all family members feel the pain of the situation.
  Family Therapy Overview I 275

Self Other

Context

Figure 13.10  Virginia Satir viewed people as being connected in relationships based on
the concepts of self, other, and context

For Satir, humans move naturally toward growth. At times, based on various
issues such as low self-esteem, they are not in unison with themselves, others, and
the world. This is where Satir viewed humans engaging others based on three
concepts: the self, the other, and the context (Satir et al., 1991). These need to
be in unison with one another for the person to be congruent within themselves
as well as in their interactions with others (see Figure 13.10). When we do not
honor any of these three aspects, we tend to engage the world problematically.
We learn about our connection to self, other, and context via our connection
with others; usually in our family of origin. Satir called this the primary family
triad, which usually consists of mother, father, and child (but, based on family
configuration, could be mother-mother-child in a same-sex family or father-
grandmother-child in a family where extended family plays an integral role)
(Satir & Baldwin, 1983).
When the marital partners respect each other as unique beings, they then allow
the child to develop a unique self. This situation leads to a functional family tri-
angle (Satir, 1983). Conversely, a dysfunctional family triangle occurs when the
partners have low self-esteem and are not honest in their communications. They
then do not allow themselves or others to be real in their transactions. As an exam-
ple, think back to growing up in your family. Were you allowed to let your parents
know that you were mad at them? I am not talking here about cursing at them, but
that you were disappointed in them. Did you experience yourself as knowing that
you couldn’t reach out to them, hug them, and tell them that you loved them? If
so, a dysfunctional family triangle may have been present in your family as people
were not able to have productive communication with one another.

Communication Stances
Productive communication, which leads to each party honoring each other,
comes when the communication actors focus on all three aspects of experience;
276 Treatment 

self, other, and context. However, when people engage each other through
low self-esteem they tend to communicate in one of four incongruent ways:
placating, blaming, superreasonable, and irrelevant (Satir et  al., 1991). These
stances are not permanent and people are able to engage in the multitude of
stances during the course of their day, but usually with different people.
The person who operates from the placating position focuses on the other
person and the context yet discounts the self (see Figure 13.11). Placaters will
quickly give in to the other person, usually in an attempt to appease them. In
doing so they do not get their own wants and needs met. For a time this might
please the other person, but, after a while, they will want the placater to make
their own decisions and hold firm to their convictions. The placater also feels bad
that they are not stepping up and getting their position across. In many ways the
placater feels weak and could potentially develop a type of learned helplessness
where they do not believe in themselves.
Unlike the placater, the blamer does focus on self, but to the exclusion of the
other (see Figure 13.12). The self sits at the forefront for the blamer, but they do
not honor the personhood of the person they are in contact with. When conflict
happens, they find fault in the other person instead of themselves. This is usually
done so that they do not have to accept their own faults. If energy and attention
is focused on where the other person is wrong, that attention is not focused on
what they may be doing wrong. Thus, the blamer comes across as very strong,
but underneath they are quite scared.
The superreasonable places their focus on the context and discounts the self and
the other (see Figure 13.13). This person tends to talk about facts and concepts,
using them to prevent a focus on inner feelings. Instead of being personal, using
pronouns such as “I” and “you,” the superreasonable (also sometimes called the
computer) tends to use impersonal pronouns such as “one” or “a person.” For
instance, a parent upset with their child might say, “One wouldn’t want to talk

Other Self

Context

Figure 13.11  Placaters discount the self in favor of the other and the context.
  Family Therapy Overview I 277

Self Other

Context

Figure 13.12  Blamers discount the other in favor of the self

Other Context

Self

Figure 13.13  Superreasonables discount the self and other in favor of the context

to one’s parent like that if one wanted to get along.” The superreasonable comes
across as intellectual, yet cold and distant. This emotional distance protects them
from the possibility of connection, disappointment, and anger.
The fourth incongruent stance is the irrelevant. This person discounts the self,
other, and context (see Figure 13.14). Instead of keeping the focus on whatever
is being discussed, the person operating from the irrelevant stance attempts to
change the topic. The intent is that if the conversation does not continue, they do
not have to experience the initial topic because the other person may forget about
it or give up trying to get their idea (usually disappointment in the person) across.
278 Treatment 

Other Self

Context

Figure 13.14  The irrelevant communication stance discounts the self, other,
and context

For others, the irrelevant might be enjoyable for short periods, usually until they
have something serious to discuss with the person, and then they feel very discon-
nected from the person.
There is a fifth communication stance; that of the congruent or the leveler.
This person honors the self, other, and context. They are able to express their
ideas and feelings honestly, while also being open to hearing the other person’s
ideas and feelings. The person operating from the congruent communication
stance is able to stay involved in a transaction, even if there is conflict. What
is happening on the inside for this person is coming across on the outside.
While taking into account other people’s feelings, the congruent commu-
nicator connects to them through an honest and genuine means of relating.
Thus, the therapist will try to help all members function more from the congru-
ent position.
Drugs and alcohol, as well as many other symptoms, are dysfunctional means
of coping (Satir et al., 1991). They occur when the individual has unmet needs or
has unfulfilled expectations. They are ways for people to feel better, after expe-
riencing frequent and perhaps long-standing discomfort. Satir et  al. explained
this process:

When a family system comes to the stage of unbearable pain,

some members might try to cope through extensive use of alco-
hol or drugs, for example. After some time of alcohol abuse,
that becomes the new problem. And when the family finally
goes for therapy, the alcohol abuse is often the focus, while
the original systemic family pain has gone underground. In the
Satir model, the therapeutic task is to find the thread that leads
back to the original systemic crisis. (pp. 100–101)
  Family Therapy Overview I 279

What is usually present in families dealing with addiction is a process of pro-

tection. This may be through denials, excuses, or presenting some other symptom
(i.e., child misbehavior).

The Process of Therapy

Satir therapy has three stages (Satir & Baldwin, 1983) in which the therapist
connects with the family, helps them to experience their situation differently,
and then to integrate their learning into their everyday lives. The first stage is the
making contact stage, where the therapist connects with each family member that
is present. This is important since it highlights how each and every individual is
unique and distinct, yet connected to one another. Usually, families coming to
therapy are not valuing one another; perhaps feeling left out of the family pro-
cess. The second stage is that of chaos, wherein family members are challenged
to experience themselves and others in a different way than they have in the past.
There is a movement from surface understanding to a deeper level of knowing
oneself and other. The therapist also helps family members move from a focus
on the past to the present; to the here and now of their contact with one another.
The last stage is called integration. Here, family members take their new experi-
ences from the chaos stage and integrate them into their lives for a more hopeful,
trusting, honest way of being with self and others.
In therapy, the therapist helps family members to learn how to engage one
another in congruent means of communication. This comes in the form of clear
communication, where members are honest with one another while being respect-
ful of the other person’s thoughts and feelings. People are able to get across their
message while being willing to receive what the other person is trying to get
across to them. To do so, the therapist has to be clear and honest; engaging in
congruent communication. This modeling of positive communication opens the
door for family members to learn how to be clear communicators—checking with
other members whether they understand the person correctly and if the other
person understands them (Satir, 1983).
One means of doing this is to have people experience each other in new and
unique ways. This comes in the form of interactive techniques, where the therapist
gets family members to interact in a very different manner. For instance, one of the
most famous techniques that Satir utilized is known as family sculpting (Satir &
Baldwin, 1983). Here, the therapist gets one member of the family to move other
family members into physical and spatial positions, including themselves, that rep-
resent what it is like to be in the family. For instance, in the Rothers family, Mark’s
picture of his family may be with Hannah standing over him, pointing her finger
down on him. He may place Kayleigh with her hands over her ears, Pete clinging
tightly to Hannah, Steve looking angry with his fists up ready to fight, and himself
down on the ground with his hands up in a pleading tone. Family sculpting may
allow the family to bypass their normal conflictual ways of dealing with each other
and be more open to appreciate another person’s position. People can only do this
when they develop an awareness of their own deeper level of experiencing, which
allows them to understand another person’s deeper level of experiencing.
Satir’s therapy brought drama into the therapy room, actively engaging peo-
ple. Sessions are not static entities with people sitting in the same spot for one
280 Treatment 

hour and talking about their problems. Rather, people engage one another to
encounter self and other in new and more genuine ways. Another technique Satir
developed was the family reconstruction. A family reconstruction is a technique
“in which a person relives formative experiences that were influenced by three or
more generations of his or her family” (Satir et al., 1991, p. 121). Usually, this
occurs in four acts: sculpting the family of origin; sculpting the family of origins
of the Star’s parents; sculpting the meeting and courtship of the Star’s parents;
and then resculpting the Star’s family of origin. Thus, the historical past is recon-
stituted into the present where the person can tune into themselves and resolve
unfinished business.
Whatever technique is used in the Human Process Validation Movement, it
is designed to have people access their inner self and be able to raise their self-
esteem. Techniques are a movement away from content and toward intrapersonal
self-growth, which will translate into interpersonal growth. When a person can
trust themselves to be real, they are more willing to allow and trust the people to
whom they are connected to live genuinely as well. This results in a transforma-
tion of each individual as well as the family system. Satir et al. (1991) explained
this process when working with those dealing with addictions:

With alcohol dependency, the transformational approach

quickly moves to the inner yearnings and then helps individuals
and families examine their survival patterns. Replacing sur-
vival patterns with coping patterns and coping patterns with
healthy self-care patterns brings about major transformations
instead of changing some simple behavioral pattern. (p. 165)

Symbolic-Experiential Family Therapy

Carl Whitaker was another iconic figure in the history of family therapy. Playful,
provocative, serious, and spontaneous, Whitaker brought drama into the therapy
room, where family members experienced each other as they previously had not,
allowing them to move away from the restricted roles they were living. He called
his approach Symbolic-Experiential Family Therapy to highlight the notion that
people create symbolism to their experiences (Whitaker & Bumberry, 1988).

The Person of the Therapist

Although Whitaker viewed his approach through a non-theoretical lens, there are
some common aspects of his approach that help us understand it better. We will
discuss these aspects here, however this approach is very difficult to manualize as
a lot of what happens in the room rests upon the person of the therapist. The goal
of therapy is to get the family members to engage one another in more genuine
ways, and to do this the therapist needs to be able to have a human encoun-
ter with the family. Whitaker explained this process, “Your willingness to bring
more and more of yourself to the sessions is the catalytic ingredient that can trig-
ger the family’s growth experience” (Whitaker & Bumberry, 1988, p. 39). Since
the therapist expects family members to be present and engage each other, the
  Family Therapy Overview I 281

therapist must be willing to be present, evoking interaction and being impacted

by those he or she is in contact with in the therapy session. In many ways, the
therapist grows as much as the family—although perhaps in different ways.
Whitaker (1975) sometimes called his approach the “psychotherapy of the
absurd.” He embraced craziness, as being crazy meant that you were not tied
down by the rules of the system but had the full spectrum of your creativity, emo-
tionality, and behaviors. Whitaker explained, “I believe craziness is where life is.
Personal confrontation, like accented fantasy, and sharing my own irrational free
associative and symbolic experiences, is a stimulus for the other to expand his
own model and mode of operating” (Neill & Kniskern, 1982, p. 34). As such, the
primary tool in Symbolic-Experiential Family Therapy is the therapist.
However, the therapist is usually not a lone entity. Whitaker believed that
co-therapy was an important process as each therapist could agree, disagree,
counteract, and augment the other (Whitaker & Bumberry, 1988). This is an
important point since the therapist is not supposed to be a cold and technical
worker but an emotionally engaged individual—provoking and being provoked
by the people with whom he or she is in contact.

The Battles of Therapy

There are two battles that happen in therapy. The first is the battle for structure.
The therapist must set the stage for what is going to happen in therapy. This
includes who comes to therapy. At one point in time, Whitaker demanded that
three generations of a family must come to the session if he was going to work
with the family, which would be much more difficult in today’s migratory cul-
ture where adult children may live very far from their parents, who live far away
from their own parents. The battle for structure also deals with who the therapist
addresses first, what definition of the problem the therapist accepts, and what
techniques are to be used (Whitaker & Bumberry, 1988). In this part of therapy,
the therapist demonstrates an “I” position, signaling that the family will not be
able to control the therapy—and beginning to introduce the notion to the family
that they cannot control each other—once they each develop their unique “I”
positions. The therapist must win the battle for structure as it is a statement to
the family that they will have to play by someone else’s rules and cannot use their
normal coping strategies to survive in the session.
The second battle is the battle for initiative, which the family must win (see
Figure 13.15). They must make the choice of how to live their lives. After the
therapist has won the battle for structure, the family may try to capitulate to
the therapist and do as they say. This can be very problematic as they will con-
tinue to be stifled if they are basing their behaviors on other people’s demands.
Thus, the therapist gets the family members to take responsibility for their own
living. They must trust themselves to decide how to be a person instead of being
told by the therapist exactly what they should do.
Once these battles have been played out in the session, therapist and fam-
ily members will then be more free to challenge each other (Neill & Kniskern,
1982). The therapist will push the clients, even when they begin to feel pain, as
Whitaker believed that growth necessitates pain. Yet the therapist also expects
the family members to challenge him, as he needs to be a spontaneous being in
282 Treatment 

Battle for Battle for

Structure Initiative
Therapist Must
Family Must Win
Win

Family
How Therapy is
Responsible for
Organized
Their Life

Figure 13.15  The battle of structure is won by the therapist while the battle for initiative
is won by the family

the room. By engaging each other in this unique manner, therapist and family
members become a team, developing a symbolic togetherness.

The Process of Therapy

The beginning portions of therapy usually center around a history-taking.
Understanding the intergenerational patterns helps the therapist to understand
what may be situated below the surface in the current family members. Further,
this process suggests to the family that the therapist does not accept their offering
up of a scapegoat, but that a larger family systems view is important (Whitaker
& Bumberry, 1988). The identified patient’s problems are explored within the
multitude of interactions that have happened within the nuclear family as well as
between generations.
For Whitaker, people live in a symbolic world, where our emotional life hap-
pens outside of our view and awareness (Whitaker & Bumberry, 1988). These
symbols become the way that we take in life and make sense of ourselves and
our connections to others. This is one of the main reasons why Whitaker did not
think that education should happen in the therapy room, because people can-
not process these understandings cognitively, but needed to do so experientially.
Thus, techniques in Symbolic-Experiential Family Therapy are engaged to have
family members interact with one another. For instance, Whitaker would give
batacas (foam bats) to a husband and wife who had not been able to tell each
other how disappointed or angry they are with one another. He would inform
them that they are able to hit one another since they are soft bats and do not
hurt. However, the importance of this technique is getting people in touch with
  Family Therapy Overview I 283

their upset so they can have the symbolic experience of pummeling their partner.
Whitaker explained the importance of an experience such as this, “But ordinary
people are so afraid of their own fantasies that if you can help them have their
fantasies in a justified, nonterrifying way, then they don’t have to worry about
the behavior” (Whitaker & Bumberry, 1988, p. 187). This expansion of the cli-
ent’s fantasies to absurd ends is a hallmark of Whitaker’s work with families.
In order to push family members beyond their comfort zones, the therapist
joins with the family and listens and watches for various bits and pieces of the
symbolic world of each individual as well as how those individuals have come
into contact with one another. These bits are usually outside of the family mem-
bers’ awareness, so the therapist brings them to the forefront; in a way making
the unconscious family process conscious.
The Symbolic-Experiential family therapist is not problem-focused. Although
the talk in the room might be on a specific issue the family brings, that is usually
just a pathway to something deeper—how the family members have constructed
a symbolic experience with one another. Usually, this way of viewing each other
has been limiting. For instance, family members may have taken on various roles
such as the Black Sheep, White Knight, Dutiful Mother, or the Disengaged Father.
Once these roles are developed, people restrict what they expect out of self and
others. Therapy, then, challenges people to move beyond their constructed roles
and to shift their viewpoints of other people’s roles so that they can have access
to the full range of their being.
One of the main keys for the therapist is to be able to move back and forth,
from being joined and connected to the family to backing out and individuat-
ing (Whitaker & Bumberry, 1988). It is an isomorphic process that the family
members will need to learn as well. Family members are having trouble being
a unique individual while still being engaged in the togetherness of the family.
By the therapist demonstrating this freedom to join and individuate, that we are
individual people who are involved in relationships, family members may more
actively be themselves and stay connected.

Communication Approaches

Communication models of family therapy are based primarily upon the commu-
nication research led by Gregory Bateson, the renowned anthropologist.
These approaches are very problem-focused, where the therapist addresses
patterns of interaction centered around the problem behavior—or the attempts
to solve the problem. These approaches hold a general systems theory/cybernetic
philosophical approach (see Reiter, 2019).

Mental Research Institute: Brief Therapy

In our current therapeutic culture, the notion of brief therapy is commonplace.
However, 50 years ago when family therapy was developing, psychoanalysis was
still the prominent approach, which had a long-term focus (i.e., several sessions
per week for several years). The therapists who developed the Brief Therapy
284 Treatment 

Project of the Mental Research Institute (MRI) were perhaps some of the first
brief therapists. This model was based on the cybernetic and communication
work led by Gregory Bateson, and developed and adapted to family therapy by
Don Jackson, John Weakland, Paul Watzlawick, Richard Fisch, and others.
The MRI therapists believe that families try to maintain homeostasis. For all
families normal life problems happen. These are not problematic in themselves.
It is how the individual/family attempts to solve this problem that leads to a
maintenance of problems. This is why MRI therapists say that “the solution is the
problem.” We can differentiate between difficulties and problems (Watzlawick,
Weakland, & Fisch, 1974). Difficulties are undesirable states that people can fix
based on first-order change strategies (change that happens within the existing
rule structure). Problems happen when people mishandle difficulties; that is, how
they try to fix the difficulty creates more of a problem.
Given that it is the failed solution attempts that are actually the problem, the
MRI therapist will target these solution attempts as the avenue of intervention.
Getting people to find a different way of trying to solve the problem can solve
the problem of incorrectly trying to solve the problem. This usually entails a shift
from first-order change strategies to second-order change strategies.
First-order change is a change attempt within the existing rule structure of
the family. For instance, families may operate from a rule that the parents are in
charge of the family and have a responsibility to try to ensure that the children
are doing what the parents think is right for them to do. When a child misbe-
haves, the parents will act in ways that provide a message (a metamessage) that
they are in charge and the child needs to listen to them. They might do this
through lecturing, rewarding, or punishing the child. If the child stayed out past
curfew, the parent might ground the child for the next week. This is a first-order
strategy, where the rule of the parent being in charge is maintained.
However, some difficulties that have become problems require a second-order
change strategy. This is a change outside of the existing rule structure. For instance,
parents who have a 17-year-old child who is failing at school have probably lec-
tured the child, pleaded with them, punished them (i.e., taken away car privileges),
etc., all in attempts to get the child to do well. These were all first-order change
attempts. Second-order change would be the parents apologizing to the son stat-
ing, “We are sorry we were not better parents for you and did not prepare you as
well to handle these types of things.” Here, the parents have moved out of the rule
system of the parents being responsible for the child’s behavior. By not engaging
in the same strategies of past attempts, they move out of the game without end
(Watzlawick et  al., 1974), where the more one party engages in a behavior the
more the other engages in a behavior (i.e., the more the parent attempts to get the
child to do well at school, the more the child does poorly at school, and the more
the child does poorly at school, the more the parent attempts to get the child to do
well at school). This dynamic is known as a symmetrical escalating relationship.
In the addictions field, treatment professionals may also engage in failed solu-
tion attempts by focusing on first-order change rather than second-order change.
For instance, methadone treatments may become “addictive” for the person
dealing with heroin addiction, where the methadone becomes the next addictive
substance (Watzlawick et al., 1974). Instead of viewing addictions in terms of a
physiological basis, these authors suggest viewing them as behavioral problems.
  Family Therapy Overview I 285

Problem

Change the Class Failed Solution

of Solutions Attempt

Solution is the
Problem

Figure 13.16  The MRI Brief Therapy targets the failed solution attempts that have been
perpetuating the problem

Perhaps the most important component for the MRI therapist is exploring
where one or more individuals have unsuccessfully attempted to change the
behavior (Fisch, Weakland & Segal, 1982). In essence, people are using “more of
the same” solution attempts; attempts that not only are not fixing the problem,
but are creating more of a problem (i.e., people getting more frustrated, angry,
disappointed, etc.). The therapist will focus on interrupting these failed solution
attempts in the expectation that once they are no longer happening the problem
will solve itself (see Figure 13.16).
The MRI therapists view the mishandling of problems in one of three ways
(Watzlawick et al., 1974). The first is when people deny that there is a problem.
Here, change is needed but not taken. The second mishandling of problems hap-
pens when people try to change something that does not need changing or is
unchangeable. Change is made when it should not have been made. The last, and
perhaps most important, is when change is made at one level when it needs to be
made at a higher level (first-order change is attempted when second-order change
is necessitated).

The Process of Therapy

Therapy consists of six stages (Weakland et al., 1974): (1) introduction to the
treatment setup; (2) inquiry into the nature of the problem; (3) past solution
attempts; (4) setting goals of treatment; (5) selection and implementation of
interventions; and (6) termination. To work effectively, the therapist must have
a conceptualization of what to look for when working with clients. Segal (1991)
provided the following five questions that are useful in gathering adequate
information:
286 Treatment 

1. What is the attempted solution? 2. What would be a

180-degree shift from the attempted solution? 3. What specific
behavior would operationalize the shift? 4. Given the client’s
position, how can the therapist frame the behavior in a way
that the client will accept and take action? 5. What might the
client report that would signal that the intervention has been
successful and the case is ready for termination? (p. 182)

There are two classes of interventions MRI therapists tend to use (Segal,
1991). The first is getting the clients to do something different. This is usually in
the form of something that is the opposite of the failed solution attempts. The
second class is to get clients to do “more of the same.” Here, clients are asked to
continue to engage the problem as they have been. This paradoxical intervention
has a twofold possibility. If the clients agree to “go slow” and not change, they
are going along with the therapist and their behavior becomes controlled rather
than spontaneous. On the other hand, if the clients go against the therapist and
do not continue the solution sequence, they are then doing something different;
something that might get them out of the game without end.
Whichever class of intervention is chosen, it will target one of three change
areas: the problem behavior; the attempted solution; and/or the client’s defi-
nition of the problem (Fisch et  al., 1982). In changing the definition of the
problem the therapist can utilize a reframe. Reframing is when the therapist
provides an alternative explanation for a behavior from the client’s explana-
tion (see Figure 13.17). For instance, Hannah might say, “Mark keeps using
drugs, which shows that he doesn’t love me.” The therapist might reframe this
by saying, “It seems the more Mark uses drugs the more he’s telling you, I need
you—to help me.”

Reframe
New Class
Membership
Frame

Therapist's Client's Perspective

New Class Membership
of Reality
Perspective
of Reality

Figure 13.17  Reframes are the therapist’s altering of how a client understands a situation
  Family Therapy Overview I 287

For a family where the parents are taking care of an adolescent child, when
the adolescent refuses to take care of themself, they may be asked to engage in
benevolent sabotage (Fisch et al., 1982). This intervention has the parents inten-
tionally making mistakes but apologizing for them. As an example, the parents of
an adolescent who will not make their own food may be told by the therapist to
make the adolescent’s food but to burn it and then say to the adolescent, “I apol-
ogize for burning your food. I have been so stressed out lately I haven’t been able
to concentrate well.” The intent is for the adolescent to take control of their own
food preparation. This technique can be used with an adult, where the spouse
makes mistakes in caretaking (i.e., food preparation, cleaning, bill paying), which
may force the underfunctioning, adult (perhaps dealing with substance abuse) to
increase their functioning.
The MRI approach was one of the first brief therapy approaches as, from the
get-go, they contracted with the client for a maximum of 10 sessions. On aver-
age, therapy lasts for six sessions (Ray & Brasher, 2010). Termination occurs
when the client states that the complaint they came in for is gone or at a level
that is no longer problematic. For the therapist, there are three criteria of ter-
mination (Segal, 1991). The first is that a small but significant change in the
problem has happened. The second is that this change will most likely last. The
third criteria is that the client expresses they can maintain these changes without
the therapist’s help.

Case Application

A Bowenian therapist working with the Rothers family would likely only meet
with the adults in the family. Given what we know about the family, Hannah is
the most likely person to be able to work at differentiating herself. Thus, therapy
would likely be with only Hannah or with Hannah and Mark. However, it would
be important for the therapist to let the couple know from the beginning that
therapy would not be a place for blaming, but rather as a place to reflect on
and explore the intergenerational patterns that are impacting them in the pre-
sent. While people tend to find partners at similar levels of differentiation, there
seems to be a gap between husband and wife’s levels of differentiation. Mark
experiences greater levels of both chronic and situational anxiety. The chronic
anxiety comes from his family of origin, having grown up in an alcoholic fam-
ily with high demands made on its members. This led people to not be able to
take I-positions and instead they try to force others to be in certain ways. This
can be seen in the emotional cutoff between Mark and his brother Mick. Mark
is also experiencing high levels of situational anxiety, especially surrounding his
job, Steve’s troubles at school, and underlying tension in the marriage. These all
would make it more likely for him to become symptomatic, such as his having
sleep disturbance, increased substance use, and suicidal ideation.
There are multiple interlocking triangles in the Rothers family. Perhaps the
primary one at this point in time is between Mark, Hannah, and Steve. It is likely
that during the family projection process, Steve was focused upon by the parents,
leading to that relationship being fraught with anxiety. This may be because of
his birth order as the oldest child. Further, when exploring the nuclear family
288 Treatment 

emotional process, it seems that the way the Rothers bind their anxiety is through
problems in a child—Steve. Mark may also, when in conflict with Hannah, bind
his anxiety through his use of alcohol. The Bowenian therapist will need to be
aware of the likelihood during sessions of the couple trying to triangulate him or
her into their emotional systems and will need to stay connected to them but not
get caught up in their anxiety. This process of de-triangulation will help them to
take an I-position and better handle their anxiety.
While a Bowenian therapist is likely only to meet with Mark and Hannah, a
Contextual therapist would invite as many members of the family as possible.
The Contextual therapist will consider the five dimensions of relational reality
for all members in the therapy room. Although this is not a formal assessment,
these dimensions help to contextualize the family’s current situation and lead to
pathways for growth and more trustworthy interactions with one another. If we
just take Mark to focus upon, we can see that some of the facts of his life include
being born into an alcoholic family, having an older brother and a younger sister,
and having had a divorce where his ex-wife gained custody of their daughter. The
dimension of individual psychology helps us to see that he is an intelligent person,
which allowed him to go to and graduate college, approaching middle age, and
a bit lost as to goals for himself. When viewing the dimension of transactional
patterns, we can see the various triangles in Mark’s life including Mark/Mick/Ian,
Mark/Hannah/Steve, and Mark/Angelina/Nina. Focus on relational ethics would
help the therapist view how Mark’s ledger is balanced and whether he is living by
constructive or destructive entitlement. Given his growing up in an addicted fam-
ily, the dissolution of his first marriage, semi-estrangement from his first child,
and his current job difficulties, we can hypothesize that he is operating from a
sense of destructive entitlement where he thinks he is owed by people and society.
This is leading him to not engage others, especially those in his current nuclear
family, in trustworthy ways. Mark likely feels that he has given more to others
than he has received back. Unfortunately, it seems Hannah is showing Mark due
concern, yet he may be expecting retribution from her for other people’s past
transgressions against him. Therapy would then focus on helping him to balance
his ledger with the people who owe him or whom he owes.
The Contextual therapist will maintain a position and attitude of multidi-
rected partiality. In this, all people who come in contact with members of the
Rothers family are given acknowledgment and concern. This would include all
five members of the Rothers nuclear family as well as extended family such as
Nina, Angelina, Ian, and Mick. One primary technique that will likely be used
by the therapist is exoneration. Given the cutoff between Mark and Mick, the
therapist may help Mark to exonerate Mick, exploring how Mick was trying to
show his concern for Mark, but in a way that, at that time, Mark was not want-
ing to receive. The therapist may also help the children and Hannah to exonerate
Mark, which may lead them to engage him differently and offer him due concern
in a manner he is more readily able to acknowledge and receive.
An Experiential therapist working from a Satir-based approach would prob-
ably meet with the whole family, helping them to be with one another in a more
genuine manner during the session. It is likely that none of the members of the
Rothers family feels secure enough that they can be themselves while still being
accepted in the family. As such, each is operating from a primary survival stance,
  Family Therapy Overview I 289

which decreases their own and the others’ ability to grow as human beings. The
Rothers have most likely been engaging each other through several dysfunctional
family triangles, where people have felt a low sense of self-esteem and have not
interacted with one another in honest ways. This can most clearly be seen in the
primary family triangle of Mark/Hannah/Steve where anger and blame is the pri-
mary communicational medium rather than love, disappointment, and concern.
We can speculate on the various communication stances of each member of
the family. Mark tends to communicate from a blaming stance, holding oth-
ers accountable for the misery in his life. This may be that the discord with his
brother is all Mick’s fault, problems at work are because of a jerk of a boss, and
problems at home are because Steve is out of control. Hannah seems to move
back and forth from a placating to a blaming stance, sometimes trying to appease
Mark so things do not spiral out of control while at other times getting on his
case for him to change. Steve, like Mark, operates primarily from a blaming
stance, holding his parents, teachers, or society at large as the antagonists for his
struggles. Kayleigh may function primarily from the superreasonable position,
where she focuses on the facts and thus does quite well at school, but may not be
able to have strong emotional connections with people. Pete likely has qualities
of the irrelevant communication stance, where, regardless of the situation that is
happening, he tries to make a joke and have people laugh. One of the goals of
therapy would be to help each member become more congruent.
A Symbolic-Experiential family therapist working with the Rothers family
would meet with all five members of the nuclear family and might even push for
other extended family members to attend, such as Mick and Ian or even Angelina
and Nina. This would be part of the Battle for Structure, where the therapist
would attempt to organize the sessions in a way that disorganizes the family
around their view that the problem is the identified patient. Rather, it would
send a message that the problem rests in the interpersonal relations in the family.
Mark finds himself stuck in the role of the disengaged father while Hannah is
the dutiful mother. Steve is finding that he has become the black sheep, Kayleigh
the perfect student, and Pete the loving son. Each of these roles is only partial, as
each of the members has the full range of their experience at their disposal but
are not able to access this in the current configuration of the family. Therapy
will involve talk and techniques that raise the anxiety in the room so that
the members’ normal ways of dealing with the anxiety are not effective. This
will lead to them expanding their range of experiences, feelings, and behaviors.
Therapy with the Rothers will be successful not just when Mark stops drinking
so much, but when each member is able to be more real and have a fuller range
of their emotional and behavioral repertoire.
The MRI therapists tend to work with customers rather than the identified
patient or window shoppers. In all likelihood, Hannah would be the person who
would attend sessions. An MRI therapist would enter the first session with the
Rothers ready to hear what their complaint is, but with a focus on how the fam-
ily members have tried to solve the problem. It is these failed solution attempts
that will be the target of change. Most likely the family will discuss Mark’s isola-
tion from the family as the problem and would explain various ways that they
have tried to include him or recruit him to participate more in family life. These
attempts all have the same thing in common—family members believing that
290 Treatment 

the way to show care is to push the other person into connection. Thus, they
are mishandling the problem by trying first-order change attempts rather than
second-order attempts. Intervention would come by getting family members to do
something 180 degrees different than the theme of the failed solution attempts.
That is, they would do something that did not push Mark into connection. This
may be by saying something like, “We are going to the park. You most likely
would not like to come and it would probably be better for everyone if you didn’t
as you wouldn’t have to worry about us.”

Summary
This chapter provided an overview of five of the most prominent family
therapy approaches available. Bowen’s Natural Systems Theory is perhaps
the most comprehensive theory of individual and family functioning, uti-
lizing an evolutionary perspective to discuss how differentiation of self is
related to anxiety and symptom expression. Contextual therapy highlights
the relational ethics that people hold; the ledger of our earned merit and
debts. Satir’s Human Process Validation Movement addresses how family
members cope with crises through problematic communicational stances.
Symbolic-Experiential Family Therapy attempts to challenge family mem-
bers to shed their prescribed roles and to gain access to the full continuum
of their humanness. The MRI Brief Therapy Model focuses on the failed
solution attempts of families; ways in which they tried to solve an initial
problem, which only perpetuated and maintained the symptom.

Key Words
intergenerational approaches sibling position
family of origin societal emotional process
Natural Systems Theory Contextual Therapy
emotional system facts
differentiation of self individual psychology
triangles systems of transactional
de-triangle patterns
nuclear family emotional system relational ethics
illness in a spouse merit
marital conflict ontic
impairment in one or more of ledgers
the children indebtedness
emotional distance entitlement
family projection process loyalty
multigenerational transmission vertical loyalty
process horizontal loyalty
emotional cutoff split loyalty
  Family Therapy Overview I 291

destructive entitlement chaos

multidirected partiality integration
exoneration family sculpting
Experiential family therapies family reconstruction
here and now critical impact reconstruction
Human Validation Process Symbolic-Experiential Family
Movement Therapy
primary family triad craziness
functional family triangle battle for structure
dysfunctional family triangle battle for initiative
placating difficulties
blamer problems
superreasonable first-order change
irrelevant second-order change
congruent game without end
leveler reframing
making contact benevolent sabotage

Discussion Questions
 1. Describe how Bowen Theory views the interplay of anxiety and
differentiation.
  2. How do Bowen’s eight interlocking concepts work in unison to deter-
mine a family’s functioning?
 3. What is the theory of problem formation and problem resolution
based on Bowen Theory?
 4. What is the theory of problem formation and problem resolution
based on Contextual Therapy?
  5. How do the five dimensions of relational reality in Contextual Therapy
help the family therapist understand what is happening in the family?
  6. What are some of the core tenets of Experiential family therapies?
  7. In Experiential therapies, what is the relationship between the indi-
vidual and the family?
  8. How does the Human Process Validation Movement understand the
connection between self-esteem and communication?
  9. How does the notion of craziness play a role in Symbolic-Experiential
Family Therapy?
10. In what ways does the Human Process Validation Movement and
Symbolic-Experiential Family Therapy overlap?
11. Explain how MRI: Brief Therapy is problem focused.
fourteen

Family Therapy
Overview II

In the previous chapter we covered some of the intergenerational, experiential,

and communications approaches to family therapy. In this chapter we will explore
the strategic, systemic, and postmodern models. While there is a connection
between these models (for instance, the Strategic, Milan, and Solution-Focused
models were heavily influenced by MRI’s Brief Therapy, and Strategic and
Structural Therapy were, for a time, viewed as one integrated model), they
each have their own unique perspective on family function and interven-
tion. In this chapter we will cover Jay Haley’s Strategic Therapy, the systemic
approaches of the Milan Associates and Minuchin’s Structural Family Therapy,
as well as Solution-Focused Brief Therapy and Narrative Therapy from the
postmodern orientation.

Strategic Approaches

As with the MRI: Brief Therapy, strategic approaches were founded on the
notions of cybernetics promoted by Gregory Bateson, as well as the therapeu-
tic techniques of Milton Erickson, the world-famous hypnotherapist. Strategic
approaches were very popular during the 1970s and 1980s. However, the advent
of the postmodern collaborative approaches (see below) saw a shift from the
directive strategies (what some people might view as manipulative) in these mod-
els to a focus on language, meaning, and a hesitancy of the therapist pushing for
change. Yet these approaches developed some of the seminal and foundational
ideas of family therapy. Here, we will discuss Strategic Family Therapy.

Strategic Family Therapy

Strategic Family Therapy was developed primarily by Jay Haley, as well
as Cloe Madanes, who for a time were husband and wife and developed the
Family Therapy Institute in Washington, DC. Haley was one of the pioneers of
the Palo Alto group along with Gregory Bateson. The Bateson group studied
communication—and more specifically paradox in communication. Haley pri-
marily explored paradox in hypnosis. To do so, Bateson connected Haley with
Milton Erickson, at that time the world’s foremost hypnotherapist. After working

292
  Family Therapy Overview II 293

with Bateson, Erickson, and the pioneers of the MRI: Brief Therapy (Weakland,
Jackson, Watzlawick, etc.), Haley moved to Philadelphia to work with Salvador
Minuchin (see later in this chapter for a description of Minuchin’s Structural
Family Therapy). Through this collaboration, he incorporated the notion of hier-
archy and family structure into his directive model. Toward the end of his life
Haley was calling his approach Directive Therapy, as he saw the responsibility of
therapy on the therapist to provide appropriate directives for the family to change
(Haley & Richeport-Haley, 2007).
Haley’s approach combines the symptom focus of the MRI group, the struc-
tural view of Minuchin, as well as the strategic emphasis on directives as related
to Erickson. Families tend to have difficulties at family life cycle transitions (i.e.,
moving from a family with young children to a family with an adolescent) based
on a faulty organization (Haley, 1987). Perhaps the family did not adjust their
rules to allow more autonomy for the adolescent. The family then continues to
operate in their previous patterns that are not useful in the new family context.
They maintain their current homeostasis rather than making changes in the rules
of the family to develop a newer and more functional state.
The strategic therapist, like the MRI therapist, is less interested in the past but
more focused on the present. Problems are occurring in the family not because
they happened in the past but because they are continuing in the present. They
are repetitive behavioral sequences involving more than one person, which are
maintained by the people’s continued actions (Haley, 1987). The Strategic thera-
pist’s interventions are designed to not only disrupt the sequences of interactions
around the problem behavior, but also to change the structure of the family.
The problems that people have are often associated with a failure to adapt to
a change in the family life cycle. These stages include: birth, infancy, childhood,
school, adolescence, leaving home, being a parent, being a grandparent, and deal-
ing with old age (Haley, 1993; Haley & Richeport-Haley, 2007). The symptoms
that people have are signals that the family organization has not changed and
that the family is operating from a previous level of homeostasis which is not
functioning at this new life cycle; one which requires a reorganization of the
family system to develop new rules to function more effectively (see Figure 14.1).
Given that families are systems that organize hierarchically, problems can
be viewed through the interplay of three generations (Haley, 1987). Symptoms
may develop when there are violations of boundaries across the generations; for
instance, if a grandmother tries to usurp her child and take over parenting of her
grandchild rather than letting her daughter, the grandchild’s mother, have the

Life Stage
Transition
Original Original Needed New
Homeostasis Homeostasis Homeostasis
Needed
Adaptation

Figure 14.1  Families tend to have symptoms at life-cycle transitions when they maintain a
homeostasis that was functional at the previous life stage
294 Treatment 

primary caretaking duties. Conversely, a child may try to take over leadership
from the parent. This is problematic as parents should be on top of the hierarchy.
The Strategic therapist views the problem as a symptom of underlying fam-
ily discord. Haley described the story of a husband and wife coming to therapy
because the wife believed the husband’s drinking had ruined their marriage
(Richeport-Haley & Carlson, 2010). The husband complained that if he was to
stop drinking she should stop smoking. After discussion with the therapist they
both agreed. By the next session the husband had stopped drinking and the wife
stopped smoking. However, there was a lot of tension between them. The follow-
ing week the husband entered the session inebriated and the wife was smoking.
Haley explains that in this case the couple was saving their unhappy marriage
through smoking and drinking.

The Process of Therapy

When Haley was working at the Philadelphia Child Guidance Clinic, he developed
a format for the first session to help new therapists (this was for lay profession-
als who were being trained to be family therapists). There are five stages for the
first session: social, problem, interaction, goal-setting, and task-setting (Haley,
1987). The social stage only lasts a few minutes, but the therapist makes a con-
nection to each member of the family. In therapy, we call this process joining. In
the problem stage, the therapist asks every member their perception of what is
occurring in the family. In the third stage, the interaction stage, the therapist gets
family members to engage one another. This can be seen to be an enactment (see
below in the Structural Family Therapy section), wherein the therapist gets family
members to interact with one another, usually around the problem, which allows
the therapist to take a step back and think about his or her position vis-à-vis the
family as well as assessing the family organization and process. For the goal-
setting stage, the therapist gets the family to come up with a consensus of what
it is they want to work on in therapy. Based on everything that was discussed
during the session, the therapist ends the first session with a task, a directive that
helps to shift the problem sequences and the family organization to something
that is more functional. Figure 14.2 provides a visualization of Haley’s five stages
of a first session.
This last stage is the hallmark of the strategic approach. Madanes (1991) is
famous for saying, “The directive is to strategic therapy what the interpretation
is to psychoanalysis. It is the basic tool of the approach” (p. 397). Haley believed
that it was the therapist’s responsibility to develop an effective directive, and that
if the family did not change it was on the therapist and not on the family. In that
case, the therapist had not developed a directive that made sense in the context
of the family. There are three purposes for directives (Haley, 1987). The first is
that they function to get the family to do something different. Second, directives
help connect therapist and family in a therapeutic relationship. Third, whatever
the outcome of the directive, there is information for the therapist to understand
the family dynamics and develop another intervention that will move the family
one step closer to their goals.
One of Madanes’ primary directives was the pretend technique (Madanes,
1981). They are mainly used in families where there is a loving and helpful
  Family Therapy Overview II 295

Social

Problem

Interaction

Goal-Setting

Task-Setting

Figure 14.2  Haley’s five stages of a first session

relationship between family members. They are not encouraged in families deal-
ing with violence and abuse. Pretend techniques are when the clients are told
to pretend to have the symptom. One of the reasons for this is that when the
person is pretending to have the symptom they cannot actually have the symp-
tom. Further, it makes what is usually thought of as an uncontrolled event (the
symptom) into something that can be controlled.
Based on Milton Erickson’s work, Haley would occasionally utilize an ordeal
(Haley, 1984). Ordeals are tasks given to clients where if they engage in the
symptom then they have to do the task—and that doing the task is more severe
than having the symptom, although it is something that will be beneficial to
the person.
There are two types of ordeals that can be developed; straightforward and
paradoxical. A straightforward task is where the therapist provides the specifics
of what the client or family is to do if the symptom occurs. The second type of
ordeal is a paradoxical ordeal. This will most likely come in the form of symptom
prescription, where the person is told to engage in the symptom if the symptom
happens, but even more so.
The directive a therapist develops is an attempt to move the client one step
closer to the goal. Whatever the outcome, or even if the family did not do the
given task, there is information for the therapist to utilize in creating the next
directive. Each time, the directive is focused on changing the structural organiza-
tion of the family as well as the interactional sequence around the problem.

Systemic Approaches

Systemic approaches in family therapy focus not only on the interdynamics

between members of a nuclear family, but the connections between that family
and larger systems, which may include their families of origin as well as social
institutions such as the medical, legal, socioeconomic, and psychiatric systems.
While the therapist may work with only one part of this equation, the therapist
296 Treatment 

keeps in mind that the problem-maintaining interactions are occurring on multi-

ple levels with various subsystems involved.

Milan Systemic Family Therapy

Milan Systemic Family Therapy was developed by Mara Selvini Palazzoli, Luigi
Boscolo, Gianfranco Cecchin, and Guiliana Prata. These Italian therapists were
originally psychoanalysts who were working individually with schizophrenic
patients. Realizing that this was not as effective as they would have hoped, they
decided to take a family systems lens in working with clients. They consulted
with members of the Mental Research Institute and based a lot of their work on
the cybernetic epistemology as put forth by Gregory Bateson (Boscolo, Cecchin,
Hoffman, & Penn, 1987). However, in 1980, the Milan team split with Palazzoli
and Prata, maintaining more of the original strategic positioning while Boscolo
and Cecchin adopted a more postmodern approach.
The Milan group viewed families as self-regulating systems based upon family
rules (Palazzoli, Boscolo, Cecchin & Prata, 1978a). When a couple comes together,
they each bring aspects of their families of origin; the overt and covert rules of
family functioning. At the beginning of the new family’s development, the partners
must integrate these different patterns of behavior to create their own homeostasis.
Since all families have problems, problems are not inherently bad. However,
when family members display symptoms, it is based upon a family system that
has rules that maintain those problems in an effort to preserve the family homeo-
stasis (Palazzoli et al., 1978a). Yet, homeostasis is a twofold process; on the one
hand it focuses on the stability of the system. On the other hand, it involves the
capacity of change. Like the person who stands up in a canoe, the way to main-
tain balance (stability) is to slightly rock oneself back and forth (change).
Although the family may come to therapy talking about change, their actions
are usually focused around keeping the stability in the family; maintaining the
family rules. The therapist then has a choice of whether to focus on the stability
(perhaps through some type of symptom prescription) or to push for change. This
is what the Milan team talked about in terms of paradox and counterparadox
(Palazzoli et al., 1978a). The family comes in with a paradox (we want change
but do not want to change), which leads the therapist to develop a counterparadox
(keep doing what you are doing [no change] which will change you).
One of the fundamental issues in family problems is that of control (Boscolo
et al., 1987). One person will attempt to unilaterally control the family system.
However, this fundamental premise is flawed, as a part of the system cannot
control the system. But by operating from this position, one or more members
attempt to maintain a superior position over others. This tends to be a viola-
tion of the family rules and the other person responds in kind; by attempting
to reestablish his or her control. This is where a systemic view comes into play.
The therapist understands that power does not happen within an individual
but within the rules of the system (Palazzoli et al., 1978a). How the system is
currently functioning, with members trying to attain control and usurping one
another, becomes the repetitive pattern of the family; what is known as the family
game. The family game is the rules that distinguish the family transactions around
the maintenance of the problem.
  Family Therapy Overview II 297

One of the difficulties in families is that people view each other through the use
of the verb “to be” (Palazzoli et al., 1978a). This captures the person into a posi-
tion of not being able to change since they “are” a certain way (i.e., he is an angry
person or she is a pushover). Instead, the Milan team viewed people through the
verbs of “to seem” or “to show.” This change in perspective provides a greater
sense of maneuverability by people and focuses more on the interactional aspects
of relationships rather than a linear perspective. The more family members use
“to be” the more they will focus on an identified patient (i.e., “Mark is alcoholic
and needs to go to therapy for anger management” or “Hannah is codepend-
ent and needs to change”). The label the family puts on a member becomes an
operating principle of the family. By shifting the view to “seem” or “show” the
therapist is able to highlight transactions (i.e., “Mark seems to be reacting to a
change in how the family is engaging each other”).
Having an identified patient in a family is both problematic and beneficial.
For the non-IP family members, they tend to be more united with one another;
usually around a notion of being healthier while the IP is unhealthy (Boscolo
et  al., 1987). The IP’s problematic behavior also shifts the focus of the family
from other potentially problematic areas to the IP. Instead of having to deal with
a marriage that seems to be drifting apart, the parents can maintain their energy
on their child who is not doing well in school.
The family is usually not aware of these potential benefits. They have devel-
oped a family myth; a way of viewing what is occurring in the system (Boscolo
et al., 1987). This is the family’s viewpoint on why they are having problems and
what needs to happen for things to get better. Usually the family myth centers
around the IP; the scapegoat of the family. Given that the family myth maintains
the rules around the problem, the therapist attempts to change the rules of the
family, which will then most likely lead to a change of the symptom. This is a
move from rigidity to flexibility.

The Process of Therapy

Milan Systemic Family Therapy was originally premised on strategic practice. As
such, many of its original techniques centered around strategic purposes. Two
of these interventions included the positive connotation and family rituals. A
positive connotation, in its fundamental form, is a reframe. It positively describes
the IP’s symptomatic behavior as well as the patterns around it as being for the
benefit of the family (Boscolo et al., 1987). Through its use, the therapist tells the
family that the behavior makes sense within the family context. Positive connota-
tions are counterparadoxes in that they focus on the stability aspect of the family;
yet the intention is for some type of change in the problem transactions to occur.
Family rituals are actions that the therapist directs the family to do together
to happen outside of the therapy session (Palazzoli, Boscolo, Cecchin, & Prata,
1977). The target of the rituals is on the family games; changing the problem-
atic sequences of interactions. The therapist does not explain the rationale for
the ritual, as rituals operate on a different level than explanation. One of the
most famous Milan rituals is the odd days/even days ritual (Palazzoli, Boscolo,
Cecchin, & Prata, 1978b). A therapist would most likely give this ritual to a
family when the adults (usually the parents) are undermining one another. One
298 Treatment 

parent is directed to make all decisions for the family on odd days (Monday,
Wednesday, and Friday) while the other parent is told to make all decisions on
even days (Tuesday, Thursday, and Saturday). On Sunday the parents are told
to respond spontaneously. This ritual is intended to block the problematic sym-
metrical interactions between the parents around childrearing.
In 1980, Palazzoli, Boscolo, Cecchin, and Prata published one of the most
important articles in family therapy history, where they proposed three guidelines
for the family therapist in conducting a session; hypothesizing, circularity, and
neutrality. Hypothesizing is when the therapist develops a systemic understand-
ing of what is occurring in the family. This is only a tentative view and not looked
at as “truth.” The hypothesis is a type of family assessment that is always chang-
ing based on the influx of new information. However, it helps to inform the types
of questions and/or interventions the therapist makes.
The second guideline has become perhaps the most influential factor; circular-
ity. Circularity in this context refers to the therapist taking in feedback from the
family while also exploring family process in a reciprocal rather than lineal man-
ner. While it is a way to understand transactions, it has become an interviewing
technique in itself. This came through the development of what have become
circular questions. These are triadic questions, asking one member about the
relationship between two or more other members. Circular questions are predi-
cated on the notion of information, which, based on Bateson’s explications, is a
difference that makes a difference. Further, difference is a relationship. Examples
of circular questions include: “Who first noticed the problem?”, “When your
daughter is upset who does she tend to go to for support?”, or “When mother
and father are fighting, what happens with the children?”
The last guideline that the Milan team put forth is that of neutrality. Here, the
therapist accepts each family member’s viewpoint without judging whether one
person’s position is more correct than another person’s. Neutrality is also about a
non-normative way of viewing families. The therapist does not expect the family
to be a certain way, but is curious as to how the family will reorganize itself. The
therapist attempts to perturb the system in the expectation that the family system
can be creative and heal itself. Cecchin (1987) later talked about this notion in
terms of curiosity.
The Milan team had several process innovations. The first was working in teams,
especially male/female co-therapists. They also developed a five-stage format for
operating a session. These parts include the presession, session, intersession, con-
clusion, and postsession (Boscolo & Cecchin, 1982; Boscolo et al., 1987; Palazzoli
et al., 1978a). The presession occurs before the therapist(s) meets with the family.
Based on previous information (either the intake if a first session or what occurred
in previous session(s) if a second or subsequent session), the therapists make some
initial hypotheses. These then help to inform the initial interactions in the second
stage; the session. Here, the therapist utilizes circular questions to help bring forth
information. The third stage is the intersession, where the therapists in the room
take a break and consult with the other team members who have been observing
behind a one-way mirror. If there are no team members the intersession is still
used as it allows the therapist(s) to take a pause in the action and reevaluate their
hypotheses. It further allows the therapist to develop any end-of-session inter-
vention. The conclusion of the session is usually the shortest segment, where the
  Family Therapy Overview II 299

Presession

Postsession Session

Conclusion Intersession

Figure 14.3  The five stages of a Milan Systemic Family Therapy session

therapist delivers the team message and/or intervention. Once the family leaves,
the therapists have the postsession where they discuss what occurred and come
to some final hypotheses about what happened and what might occur during the
next session. Figure 14.3 presents a visual of the five stages of a Milan session.
Another innovation made by the Milan team is the spacing of sessions. Instead
of having weekly sessions they tended to meet with families once a month
(Palazzoli et al., 1978a). This development was serendipitous as they were meet-
ing with families weekly, but some families were traveling long distances in Italy
and could only make the several-day trip once a month. The Milan team discov-
ered that the families that had spaced out sessions had more positive gains. The
team believed that it took more than a week for some of the interventions to
take hold. Similar to the MRI group that they initially consulted with, the Milan
therapists tended to contract for a maximum of 10 sessions.

Structural Family Therapy

Structural Family Therapy was primarily developed by Salvador Minuchin, an
Argentinian Jewish immigrant, originally trained in psychoanalysis. Working at
the Wyltwick School for Boys, he and his colleagues realized the children they
were working with might have positive changes while at the institute but reverted
back to symptomatic behaviors once they returned to their home environment.
They began to bring the families into the treatment room and developed a theory
of understanding the family structure and techniques to help reorganize the sys-
tem. This approach can be seen as the therapist challenging the certainties of the
family (Minuchin & Fishman, 1981; Minuchin, Reiter, & Borda, 2014).
300 Treatment 

Child
1
Child Partner Partner Caregivers
2 1 2
Child
3

Sibling Subsystem Spousal Subsystem Parental Subsystems

Figure 14.4  There are three primary subsystems in families: sibling, spousal, and parental.
However, subsystems may be based on age, gender, interest, etc.

Families are organized based on the rules of the system, which comprise its hier-
archy. This organization leads to three primary subsystems: parental, sibling, and
spousal (Minuchin, 1974). In most families, the adults are usually in the parental
subsystem and are at a higher position than the children, who are located in the
sibling subsystem. The third main subsystem in a family is the spousal subsystem
(see Figure 14.4). Problems tend to form in families when there is some type of
organizational imbalance. For instance, if spouses are in conflict and disengaged
from one another one of the parties may recruit a child to emotionally replace the
partner; thus, the child finds themself in the spousal subsystem.
What distinguishes one subsystem from another are boundaries. Boundaries
are the rules that distinguish who and how people can participate in that subsys-
tem (Minuchin, 1974). There are three types of boundaries: rigid, diffuse, and
clear. These can be seen on a continuum where the extremes move from less
permeability (rigid) to very high permeability (diffuse) with clear boundaries in
the middle.
Rigid boundaries prevent much information from moving back and forth.
They establish a clear hierarchy with one group holding power over the other.
Subsystems with rigid boundaries have a tendency to be disengaged, where
there is a separation between members. For instance, a family may be organized
where there is a rigid boundary between the parental and sibling subsystem.
Here, the parents would develop the rules and the children would not be able to
challenge the rules.
Diffuse boundaries are on the other extreme; too much information is passed
back and forth. In this family, there is the possibility of enmeshment where mem-
bers are too close to one another and not able to establish appropriate separation.
An example of a family with diffuse boundaries might have the mother going to
her 13-year-old daughter and telling her about the conflict that she is having with
her substance-abusing husband.
The last type of boundary is a clear boundary, where there is an appropriate
amount of back and forth between members. This is most likely the normal range
of functioning (although, at times, rigid or diffuse boundaries may be more func-
tional to help a family through some type of life situation). Families with clear
boundaries have parents who set the rules but the children are able to talk to their
parents about the rules with the possibility that they may be adjusted.
  Family Therapy Overview II 301

Figure 14.5  The Yin-Yang represents complementarity. For white to change, black must
also change. For black to change, white must change

People in relationships develop a complementarity, where one plays the Yin

to the other’s Yang (Minuchin & Fishman, 1981) (see Figure 14.5). As one
member moves the other moves as well to fill the space just vacated. In a couple,
complementarity can be seen as the more one spouse caretakes for the children,
the more the other backs off. Reciprocally, as the one backs off of caretaking,
the other spouse must fill that role. Since families are tied together in mutual
ways of accommodating, a change in one person’s functioning changes how the
others behave.
Families engage each other through transactions, which involve multiple
individuals. Some of these include alliances, coalitions, detouring, and overin-
volvement (Minuchin, 1974). Alliances, or affiliations, are when two or more
family members have a connection to one another. There is nothing problematic
in alliances, as families have some members that get along better than others.
However, there are times when two members come together against a third mem-
ber; known as a coalition. When the two members in the coalition are from
separate subsystems it is known as a cross-generational coalition. This is a type of
triangulation, where two members involve a third person into the transaction. A
dysfunctional type of triangulation, a detouring conflict, occurs when two mem-
bers (usually the parents) are unable to deal with the conflict between themselves
and instead shift the focus to a third person (usually the identified patient).

The Process of Therapy

In therapy, the Structural therapist engages in two main processes; joining and
restructuring (Minuchin, 1974). This is played out in three steps: joining from a
leadership position, distinguishing the family structure, and changing the structure.
Joining operations are what the therapist does to develop the therapeutic
system (Minuchin, 1974). This happens from the very first moment of the thera-
peutic encounter all the way to the last meeting. It is the agar upon which the
therapist can challenge the family. One way of joining is through accommodation,
where the therapist adjusts based on the family’s organization. One of the main
accommodation techniques is tracking, where the therapist follows along with
302 Treatment 

what the family is discussing and gets them to continue. This usually happens as
the family explains their view of what they see as the problem. Another joining
technique is that of mimesis, where the therapist adapts his or her body language
and style of speech to be more in line with that of the family. Here, the therapist
may speed up their rate of speech with families that are fast talkers, or use more
intellectual language with families that do as well.
While therapists join with the family they are also challenging the family’s
view of the problem. Given that families will most likely present the problem as
residing within the IP, therapists must challenge their certainty (Minuchin et al.,
2014). This can happen from the very beginning of therapy when the family first
explains why they have come to therapy. For instance, if the family states, “We
are here because our son, Steve, is disrespectful” the therapist might respond,
“Where did he learn that from?” This question moves the problem out of the
individual and into the systemic world of transactions.
This challenge to the definition of the problem begins a process of unbalancing,
where the therapist attempts to change the hierarchical organization in the family
(Minuchin & Fishman, 1981). One way of doing this is boundary making. This
is when the therapist will join with the members of one subsystem to help demar-
cate that subsystem from another. However, this is a temporary alignment, where
some time later in the session or a subsequent session the therapist will align
with a different subsystem. As an example, in a family where a grandparent is
attempting to take over caretaking responsibilities from the adults in the parental
subsystem, the therapist might join with the grandmother and explain, “Rebecca,
you’ve done an excellent job of mothering your children. So good that it is now
Pauline’s opportunity to do the same for her own children.” Another boundary-
making action is that of physical proximity. Minuchin became famous for having
people switch seating positions to help distinguish one subsystem from another.
For instance, if Mark and Hannah are engaging in a detouring conflict by trian-
gulating in Steve, the therapist may ask Steve to move his seat from between the
parents. This highlights that husband and wife are in the spousal subsystem and
will need to deal with one another rather than bring focus onto the child.
Perhaps the hallmark of Structural work is the technique of enactments. An
enactment is when the therapist gets the family to engage one another in the
session, usually around the dysfunctional transactions (Minuchin & Fishman,
1981). Enactments are multipurposed. They allow the therapist to move from a
proximal position, involved in the therapy drama, to a more distal position (see
Figure 14.6). This provides the therapist with a chance to sit back and breathe,
observe, and think. Enactments are also opportunities for the therapist to then
engage in some type of organizational realignment; perhaps through unbalanc-
ing or boundary making. In a family where a parent is overwhelmed with their
child not following directions, the therapist may ask the two to interact around
the parent trying to get the child to do something (i.e., a discussion around not
turning in school work). Besides gaining first-hand knowledge of the interac-
tional patterns, the therapist can also intervene. They might, after watching for a
while, say to the parent, “Your child is not listening to you. Can you say this in
a different way that he can better hear you?” Or if there is a spouse in the room
the therapist could say, “Mark, your wife needs your support. What can you do
to help her?”
  Family Therapy Overview II 303

Therapist

Client A Client B

Figure 14.6  A therapeutic enactment occurs when the therapist gets clients to talk with
one another around the problem situation to observe family process

The goal of therapy is for the therapist to help realign the family into a more
functional hierarchical structure. There is not one set structure that must be in
place for the family, yet a movement from rigid or diffuse boundaries to more
clear boundaries is usually important to help the family navigate the various life-
stage transitions it experiences. Once the family rules and boundaries have been
altered, the IP’s symptomatic behavior will tend to dissipate.
In families dealing with addiction, the person abusing substances will most
likely be presented as the IP. The therapist will then have the difficulty of joining
with each member of the family and challenging the notion of the person not
being deviant, as not only the family but larger social systems (i.e., courts, law
enforcement) view him as the problem. Minuchin and Fishman (1981) explained
the importance of therapy in these situations, “Family therapists believe that,
given a change in circumstances, people—even people who have been defined as
deviant for many years—can experiment with alternatives that are made avail-
able to them” (p. 163). This usually entails the therapist challenging the notion
that families (and larger systems) have of addiction being an individual problem
that needs individual therapy (Minuchin, Nichols, & Lee, 2007).

Postmodern Approaches

Postmodern approaches to therapy focus more on the meanings that people

attribute to what occurs in life. This happens through a deconstruction of the
person’s belief system and a reconstruction of aspects of self that were not high-
lighted or notated. Thus, change happens by changing the focus of where people
look and how they view their lives, as this new understanding of self-in-context
shifts people’s internal as well as behavioral experience. Postmodern approaches
are predicated on constructivist and/or constructionist philosophy where truth is
not Truth, but that people develop truth based on how they language their mean-
ings (see Reiter 2019 for a more in-depth explication of constructivist and social
constructionist aesthetics and pragmatics).
304 Treatment 

Solution-Focused Brief Therapy

Solution-Focused Brief Therapy (SFBT) was developed by Steve de Shazer, Insoo
Kim Berg, and colleagues in Milwaukee, Wisconsin. The model had its roots in
the work of the Brief Therapy of the Mental Research Institute as well as the
hypnotic work of Milton Erickson. As opposed to the problem-focused view of
the MRI group, where the therapist explores the failed solution attempts that
increase the problem, the SFBT therapist examines the non-problem times, as the
difficulties that people have are not constant parts of their lives (de Shazer et al.,
1986). Solution-Focused Brief Therapy works well with clients from a variety of
diverse ethnic, cultural, and religious backgrounds as the therapist honors the
client’s perspective, bringing forth the client’s understandings and ways of doing
things rather than having a normative framework (Shafer & Jordan, 2014).
Solution-focused therapists operate from three primary rules (Berg, 1994). The
first is if it is not broken, don’t fix it. Sometimes people try to change something
that doesn’t need to be changed. For instance, if having a “date night” for a mar-
ried couple helps them maintain their connection as a couple while also raising
children, this should not be changed, although there might be other concerns in
the family. The second rule is that if it doesn’t work, don’t do it again, do some-
thing different. In the United States, the phrase “If at first you don’t succeed try
try again” may not always be beneficial. Doing more of the same is similar to our
discussion of first-order change; change attempts that are within the existing rule
structure (see Chapters 12 & 13). Solution-focused therapists agree that change
needs to happen when clients come in with concerns, yet usually the way people
have been trying to change is not working because they have been focusing on
the “not working” aspect of the problem sequence. This leads to the third rule of
SFBT; once you know what works, do more of it. This is the most important rule,
as the model uses this guideline as the foundation for change. The therapist, dur-
ing the session, will pay attention to any instance in the client’s past where they
have experienced a “non-problem” time. These are known as exceptions—times
when the problem could have happened but did not (de Shazer, 1991). Once
exceptions are uncovered, the therapist will help the client to figure out how to
engage in more of these non-problem times.
Perhaps out of all of the approaches being covered in this book, SFBT is the
one least likely to focus on the past. When it does it is usually because of two
reasons. First, it is for the therapist to explore the exceptions that people have
experienced. Second, clients may come in expecting to talk about the problem.
When clients talk about what is not working in their lives, SFBT refers to this as
problem-talk (Berg, 1994). Most clients, especially during the first session, will
want to discuss what is not right in their lives and what they want to be differ-
ent. The therapist will stay with the client talking about their concerns as a way
to join as well as to see where the non-problem times are occurring. When the
therapist shifts the focus from the problem to the non-problem they are engaging
in solution-talk. In this manner, therapist and client engage in a language game
of where each is placing their focus (Reiter & Chenail, 2016) (see Figure 14.7).
Solution-Focused Brief Therapy is an action-oriented approach similar to MRI,
Strategic, and Structural Family therapies. Change happens by getting people to
do something different from what they have been doing (shifting from a problem
  Family Therapy Overview II 305

• Problem • Problem
Talk Talk
Therapist
Client focus on focus on
complaints client's focus
(complaints)

Therapist
Client focus on focus on non-
non-complaint complaint
focus future
• Solution (solutions) • Solution
Talk Talk

Figure 14.7  Solution-Focused Brief Therapy consists of a language game where client
and therapist move back and forth between the focus on problem talk and
solution talk

focus to a non-problem focus). A huge transformation is not needed for therapy

to be successful. Instead, minimal steps get the process going, which will build
upon themselves, like a snowball picking up steam. Once the process of change is
started, further changes will be generated by the client.
When exploring the development of problems, SFBT views, in a way similar
to the MRI school, that the solutions people are using are the problem, not the
presenting problems themselves (de Shazer, 1985). Problems are maintained by
clients’ rigid adherence to doing more of what they believe will fix the prob-
lem. These solutions happen through a focus on the problem sequences rather
than the non-problem sequences. Thus, the family pays attention to all the times
that alcohol is negatively impacting their lives rather than those times when
alcohol has not been present and they have been interacting in ways that they
desire. When clients come to therapy, they come with complaints. Complaints
are viewed behaviorally at face value. When the clients say that the complaints
are gone or have lowered to a level that is no longer a concern for them, therapy
has been successful.
Solution-focused therapists tend to classify clients into one of three types:
visitors, complainants, and customers (Berg, 1994; de Shazer, 1988). Visitors
are people who have no overt complaints. Their rationale for being in therapy
involves someone telling them to be there. This is someone who may be court
ordered to attend therapy or an adolescent whose parents are taking them to
therapy because the parents are concerned about the adolescent’s behavior.
306 Treatment 

• Compliment them for coming

Visitor • No task

• Observation task
Complainant • Thinking task

• Behavioral task
Customer • Do something different

Figure 14.8  Solution-focused therapists will work differently depending on the type of
client relationship they are interacting with

The complainant is the person who has complaints, yet they are expecting some-
one else to engage in change to resolve the situation. This would be a spouse
of an alcoholic. There are things they want different, but to them it all rests on the
other person stopping their drinking. The last type of client is the customer;
the person who has a complaint and believes that they have a role in changing
to make things better.
It is important to determine what type of client is in the room, as therapists
do not collaborate with all clients in the same way; they must adapt what they do
based on the client-type relationship (Berg, 1994). The therapist promotes coop-
eration in the relationship by using interventions that correspond with the client’s
manner of cooperating. For the visitor-type relationship, the therapist will most
likely compliment the person for coming but will not give them a task. This is
because the person does not see a problem and will not think that they need to
change. If the therapist tried to get them to change by giving them a task it would
not make sense for the client. With the complainant-type of relationship, the
therapist would probably give an observation and/or thinking task. Here, the
person recognizes that there is a problem, but believes someone else needs to do
something different. By getting the person to do an observational task—centered
around viewing interactional processes—the person may come to recognize their
own role in the problem sequence patterns. For the customer-type relationship,
the therapist will give the client a behavioral task as the person sees a problem
and sees their role in it; they are ready to initiate change (see Figure 14.8).

The Process of Therapy

Solution-Focused Brief Therapy is a therapy that is predicated on questions. There
are three main types of solution-focused questions; miracle questions, exception
  Family Therapy Overview II 307

questions, and scaling questions (there are also pre-session change, coping, and
what’s better questions). They are all used in conjunction with one another, all with
the goal of helping to uncover the client’s preexisting strengths/solutions—which
can usually be seen during nonproblem times.
What has perhaps become the hallmark of SFBT is the miracle question. This
intervention happened by circumstance when Insoo Kim Berg was told by a client
that the only thing that would help was a miracle (DeJong & Berg, 2012). Insoo
then asked the client what would happen if a miracle did happen. This prompt
led to a positive avenue in the therapy. The miracle question goes something like:

Suppose tonight when you go home and go to sleep a mira-

cle happens. The miracle is that all of the difficulties that
you are having are gone. Since you were sleeping you do
not know that anything special happened. So what will be
the first thing in the morning that will let you know that the
miracle happened?

Besides getting clients to shift their focus from an unsatisfactory past to a desired
future, it is also one of the first steps in developing goals. Goals in SFBT involve
several components: small, measurable, salient, realistic, presence of something,
interactional, and inclusive of the client’s hard work (Berg, 1994). Figure 14.9
presents a visual depiction of how these components form well-formed goals.

Small

Social
Interactional Measurable

Presence Well- Client's

of formed Hard
Behavior Work
Goal

Salient to
Realistic
the Client
Start of
New
Behavior

Figure 14.9  Goals in SFBT are designed to be client-centered and bring forth the personal
agency of the client
308 Treatment 

The second main question type involved in SFBT is exception questions.

Exceptions are times when the problem could have occurred but did not (Berg,
1994; de Shazer, 1991). Since problems do not always happen or at least do not
happen at the same level, there are times in the clients’ lives when the problem
was not there or was at lower levels. Exception questions help to uncover these
important points in clients’ experiences. When a great deal of attention is paid
to the interactional patterns around these periods, it provides clues to what the
client needs to do more of. Clients may be asked, “What was happening the last
time the two of you were able to get along” or “When was the last time that you
hung out with your friends but did not drink.”
It is very important to ask exception questions after the miracle picture has
been developed to let clients know that what they view as being miraculous are
situations that have already existed in their lives. For instance, in the Rothers
family, whose miracle picture would most likely include no drinking by Mark,
people sitting down to dinner and not arguing, and peace and calm instead of
chaos? The therapist can inquire when the last time was that each of these com-
ponents occurred. Next, the therapist would expand the exception to find out
how the clients were able to make the exception happen.
The third type of SFBT questions are scaling questions, which help to make
abstract concepts concrete. Scaling questions help to define problems in terms of
a gradient from more to less (Berg & de Shazer, 1993). They can also be used to
develop a baseline and then to chart client progress. Most of us are familiar with
scaling questions; especially if you have ever had to go to an emergency room.
When interviewing you in the ER, the nurse will most likely ask you to rate your
pain on a scale of 0 to 10 with 10 being the higher end. Solution-focused thera-
pists can scale anything, including motivation (“On a scale of 1 to 10 where 1 is
none at all and 10 is the most you can have, how motivated are you right now to
address this problem”), happiness, or hopefulness.
The exploration of the answers to the miracle question and the exceptions sur-
rounding the various pieces may be interventive in and of themselves. However,
since SFBT is an action-oriented approach, some type of task is usually given to
clients. Whatever the task, they are usually designed to get the client to do some-
thing different. These tasks tended to be generic enough to work with a variety
of clients dealing with a variety of problem complaints and came to be called
formula tasks (de Shazer, 1985). What all SFBT tasks (sometimes called experi-
ments) have in common is the infusion of hope and expectancy of change and
difference (Reiter, 2010).
One of the original formula tasks is the structured fight task. This is designed
for partners who engage in a repetitive type of conflict with one another. The
task has four steps: (1) flip a coin to decide who goes first; (2) whoever wins
bitches uninterrupted for 10 minutes; (3) after 10 minutes the other person
bitches for 10 minutes; and (4) then 10 minutes of silence, after which another
round can be begun. Another popular formula task is the do something
different task, which was originally developed for a family who kept on com-
plaining about one member’s behavior and kept trying to fix it in the same way
until everyone felt stuck. The therapist giving this formula task might say to
the family:
  Family Therapy Overview II 309

Between now and next time we meet, I would like each of you
once to do something different when X (the identified patient)
does Y (the complained-about behavior). It does not matter
what you do—which may be silly, crazy, or off-the-wall. The
important thing is that whatever you do is different than what
you are now doing when s/he does Y.

Perhaps the most famous of the formula tasks is the first session formula task;
given at the end of the first session and generic enough to address any type of
clients or problem situations (de Shazer, 1985). The task can be worded as:

Between now and the next time we meet I would like you to
pay attention to all of the things that are happening in your
family that you would like to either have continue to happen
or have happen more often.

This task goes against everything clients think therapy is about—that between
sessions you keep a list of all of the things that are bothering you (either about
yourself or your family members) so that you can address them the next ses-
sion. One of the biggest benefits of this task is that it switches family member
expectations from looking for problems—and we know that when we look for
something we will find it—to looking for exceptions. Whatever the family brings
to the next session can be used as the foundation for what to expand on in
therapy since these are things they are already doing that are working for them.
Although it is not a task, one of the important interventions in SFBT work
is complimenting. Compliments are statements from the therapist to the client
highlighting things that the client is doing that are good for him (DeJong & Berg,
2012). These are not the typical compliments about hairstyle or clothing choice,
but are focused on actions that people make that lead to exceptions. A therapist
might say, “Mark, I just wanted to acknowledge that this week instead of going
to the bar with your friends you decided to go home to your family to spend time
with them. How were you able to make that decision?” We will explore how
SFBT has been used around issues of substance abuse in Chapter 15.

Narrative Therapy
Narrative therapy was developed by Michael White and David Epston. While all
of the other approaches we’ve covered, besides Milan Systemic Family Therapy,
were developed in the United States, this approach has origins in Australia and
New Zealand. Originally working from a cybernetic epistemology based upon the
work of Gregory Bateson (White, 1986), White met Epston and both began to shift
the foundation of their approach to include narrative and literary metaphors as
well as being influenced by the work of the French philosopher, Michel Foucault.
People story their lives, putting segments of their experience into a coherent
order, including past, present, and predicted future (White & Epston, 1990). This
grouping of events is called a story or self-narrative. It is created by the individual
and creates the individual. We live our stories and are lived by the stories that
310 Treatment 

we develop. Yet we do not do so in isolation. They are grounded in the society

in which we are housed. This is where White and Epston borrowed the ideas of
Foucault to help explain how the dominant culture influences people based on
knowledge and power.
Foucault was interested in the politics of power. He viewed language as an
instrument of power. When many people agree to believe in the same ideas,
they engage in a “dominant discourse,” a way of understanding what should
or should not be. When individuals do not adhere to the dominant discourse,
society implements consequences—usually leading to some type of oppression.
For instance, the dominant discourse in the United States is not to engage others
outside of one’s house when seriously drugged or inebriated. The consequences
of doing so are to possibly be arrested.
The dominant discourse comes to be seen as “objective truth” which people
internalize. When we internalize the dominant discourse, we begin to self-police
ourselves. This may be when we take the labels that others have used about us
and act in accord with them (i.e., “I am depressed so I cannot be happy at this
party” or “I am the scapegoat in the family so it doesn’t matter what I do because
I will get in trouble anyway”). Figure 14.10 presents a visual depiction of the
impact of the power dynamics associated with dominant discourses.
The dominant discourse helps frame what people’s self-narratives will become.
It is based on the culture one is raised in, gender orientation, sexual orienta-
tion, socioeconomic status, religious orientation, and other national and cultural
doctrines. In developing our self-narratives we take in and story those experi-
ences that match the theme we have created—the dominant story (White, 2011).
Experiences that occur outside of this dominant story are usually excluded from
our self-account; we do not pay much attention to them.
The self-narrative, while seemingly an individual process, is actually a rela-
tional one. Many of the societal dominant discourses influence the creation and
maintenance of people’s narratives, as well as the primary relationships in which

Individual's
Various Social Thoughts,
Discourses Feelings, and
Behaviors

Power
Dynamics
Figure 14.10  Individuals are impacted by the power dynamics associated with various
social discourses
  Family Therapy Overview II 311

we are engaged. For instance, parents in countries where drinking (especially

wine) with one’s family is acceptable will include their adolescents in family
rituals, such as wine at dinner. This would be storied into being a close family.
However, families in countries, such as the United States, would have extended
family, friends, and the legal system looking down on a family that allowed and
encouraged someone under the legal age of drinking to drink alcohol on a regular
occurrence.
The dominant story that people develop—housed within cultural/societal
expectations as well as more local knowledge—is limiting as it usually provides
a restricted range of how people can view themselves and how they can behave.
This dominant story is only one of many as people are multistoried; yet they tend
to not have the substories of their lives readily available (White, 1995). The diffi-
culty here is that the story that we live our life by lives our life—it gets us to think,
feel, and behave in certain ways. When people have problems, it is a sign that
the dominant story in their lives is not being useful. The stories they are living
by have become problem-saturated. As such, people tend to seek therapy when
the stories they are living their lives by are not in line with their lived experience
(White & Epston, 1990).
Once a problem-saturated story takes hold, it usually inculcates itself into a
multitude of avenues (i.e., the individual’s view of self, family members’ views
of the individual, larger systems’ expectations of the individual). This process,
where family members respond and cooperate with the expectations around
the problem, is known as the life support system of the problem (White, 1986).
When people begin to view the problem as “the truth” as to who someone is,
the problem becomes further storied and concretized, leaving little room for the
person to establish an identity outside of the problem.
People can have many different identities, yet their dominant story helps to
inform which one, at that point in time, takes precedence. Those events that go
counter to the dominant story, and are most likely not highlighted and storied, are
called unique outcomes (White & Epston, 1990) (see Figure 14.11). These events

Figure 14.11  Unique outcomes are events that occur outside of the dominant story that is
informing people of their identity
312 Treatment 

most likely are the preferred outcomes that people want for themselves (White,
1995). For instance, Mark may have developed a self-narrative of being a “major
disappointment” based on currently engaging in substance abuse, not having a
loving marriage, and not being a “good father” by being present and active with
his children. However, there were times when he did not drink as much, showed
caring for his wife, and spent quality time with his children. Although these times
may have been few and far between, they were not placed in the narrative of the
Rothers family’s narrative, and thus, were not significant.
When people story their lives, two types of landscapes unfold (White, 1993).
The first is the landscape of action, which is the content of the story. It consists of
all of the events that occurred put together in a sequential frame. This then forms
the plot of the story. The second landscape is the landscape of consciousness,
which White (2007) later renamed the landscape of identity to highlight how
there is a renegotiation of the person’s identity. This is the interpretation that the
reader of the story has on what the characters in the story did; a focus on their
beliefs, values, and motives. In the Rothers family, the landscape of action would
include Mark drinking alcohol, having an episode of domestic violence, divorcing
his first wife, remarrying his second wife, etc. The landscape of identity would
include his perception that he was a bad husband (at least to his first wife), a bad
father, and a disappointment to his parents.
In viewing substance abuse through a Narrative Therapy lens, addiction can
be viewed as “the addiction to control” (Diamond, 2000, p. 10). Here, there is a
push from individuals to try to control their behaviors, feelings, thoughts, as well
as trying to control other people. Substances provide a false sense that people
have control over what is happening. This process is based on a body of laws and
principles that delineate how people should think and act. Diamond explained
that many people use substances to not play by the rules but then find out later
that not playing by the rules (via substances) has its own rules, which informs
how people should be, think, and feel.

The Process of Therapy

Given that the dominant story that people develop and live by does not fit
their desired experience, therapy centers around development of new stories
with different meanings (White & Epston, 1990). These new stories are called
subordinate storylines (White, 2007). They are usually filled with unique out-
comes; times when the problem could have dominated the person’s life but
did not.
The hallmark of the Narrative Therapy approach is a process called external-
izing. White and Epston (1990) explained that externalizing is an objectifying of
the problem—personifying it and describing a relational perspective of the per-
son/family to the problem. Whereas MRI therapists stated that “the solution is
the problem” Narrative therapists say, “The problem is the problem.” Through
externalization, there is a shift from an internal state understanding to an inten-
tional state understanding (White, 2007). Mark is no longer “an alcoholic” but
has a relationship with alcohol; one where alcohol is taking over and totalizing
Mark’s identity of who he is as a person, father, husband, and son (as well as
impacting each member of the family).
  Family Therapy Overview II 313

The Narrative therapist focuses on how the problem has recruited the family
into how they are currently thinking, feeling, and behaving. However, this does
not abdicate the person from responsibility. Clients must take personal agency to
not allow the problem to recruit them into the problem-saturated experience. The
Narrative therapist helps to highlight how the person has stood up to the prob-
lem in the past and how they can in the future—shifting their view of themselves
from that of victim to that of hero. This happens through a process called taking
responsibility, where the person connects their actions and the consequences
associated with them (White, 2011). In essence, they determine what sort of iden-
tity they want for themselves, what type of life they want to live, and what steps
they need to take to get there.
In therapy, the Narrative therapist engages the family in various types of con-
versations that help this process of determining the impact of the dominant story
and developing subordinate storylines that are more in line with what people
want in their lives. There are six main types of Narrative conversations: external-
izing conversations, reauthoring conversations, “re-membering” conversations,
definitional ceremonies, conversations that highlight unique outcomes, and scaf-
folding conversations (White, 2007).
In an externalizing conversation, the family’s “truth” of the problem (i.e., who
the problem is) is deconstructed and an alternative view of the problem devel-
ops. This process shifts the location of the problem from internal to a person to
housed within the societal constructs that inform people of how they “should”
and “should not” be. One of the main aspects of externalizing conversations is
when the therapist invites the family to name the problem. In the Rothers family,
members might call it “Alcohol,” “Anger and Despair,” or “The Big Ugly
Liquid.” This allows a shift in questioning from “When did you become alco-
holic” to “When did alcohol enter your life” or “What types of negative things
do you do when you are drunk” to “How do you react when alcohol is present.”
Reauthoring conversations includes a focus on the subordinate storylines of
people’s lives rather than the dominant stories. This is usually a shift from deficit-
focused views of people to that of people having more personal agency over the
problem. These conversations usually surround aspects of self that people desire that
they had already engaged in but had not placed into the plot of their lives. In starting
to uncover these subordinate plots, the therapist becomes curious as to how they
happened, in hopes that the family becomes curious as well. These conversations
usually move from a focus on the landscape of action to the landscape of identity.
Because our dominant story is both an internal and relational development,
other people are important in the formation of our identity. One way to explore
how others have influenced our identity and how they also have a role in shap-
ing our subordinate stories is when Narrative therapists have “Re-membering”
conversations. There are two lines of inquiry that happen in these conversations
(White, 2007). The first is a focus on how the other person (usually someone
significant in the client’s life) contributed to the person’s identity and how that
person would view the client. The second line of inquiry is how the client contrib-
uted to the other person’s identity. These conversations usually revolve around
how the other has seen the client stand up to the problem. For instance, Mark
may be asked how his parents have seen him not let alcohol get the better of him
and how he has contributed to their sense of being good parents.
314 Treatment 

In unique outcome conversations, the therapist talks with the family about
the counterplots to the dominant story. These conversations usually entail nam-
ing the unique outcome and how those events and experiences are the preferred
outcomes (White, 2007). When people give value to these occurrences, they are
more likely to become central features in a new plotline.
Given that problems develop based on people internalizing dominant dis-
courses, one way of helping families is to connect them to people who will
support the subordinate story that runs counter to the original problem-saturated
description. Narrative therapists do this through definitional ceremonies, where
people are able to tell their newfound stories in front of others who can support
this new identity. This process usually happens via outsider witness practices.
Outsider witnesses are an audience that listens to clients tell their story and then
comments on their experience of hearing that story (see Figure 14.12). Usually
they are either significant people in the client’s life or perhaps other clients who
have had similar issues. They may be drawn from a registry where the therapist
has asked if they would serve as a support network for others. For instance, a
family who overcame addiction in their own lives may serve as outsider witnesses
for the Rothers family. They would sit in on a session and observe the conversa-
tion between the Rothers and the therapist. The therapist would then interview
them about their experience of listening to the story while the Rothers family
listened to this telling. The therapist would then talk with the Rothers about what
it was like to listen to the outsider witnesses.

Client Telling
of Story

Outsider
Witness
Accounts

Client Account
of Outsider
Witnesses

Figure 14.12  In outsider witness practices, clients tell their story in front of outsider
witnesses, who then discuss what they were drawn to in the discussion,
which is then followed by the client discussing what they were drawn to in
the outside witness conversation
  Family Therapy Overview II 315

One of the original aspects of Narrative Therapy was its use of documents in
therapy. Once something is written down, people perceive it as having “truth”
and it becomes a large part of defining someone. In the mental health realm, these
documents would be biopsychosocial assessments and treatment plans. Narrative
therapists have developed many counter documents, documents that help to pro-
vide an alternative identity of the person—one less pathologizing and that exhibit
the person’s personal agency (White & Epston, 1990). These counter documents
can come in the form of certificates, awards, or letter-writing campaigns. For an
adolescent who was using marijuana to extremes, the therapist and client may
have externalized the problem as “Big Green.” Once the client developed personal
agency and did not let Big Green rule his life to where he was failing in school,
having poor exercise and health, and had disputes with his parents, the therapist
might create a certificate called “Escape from Big Green”. This document could
then be disseminated to his parents, friends, teachers, probation officer, or other
significant figures to help support the client’s new story.
In discussing substance abuse and addiction, White (1997) examined the notion
of a culture of consumption where the therapist has to appreciate how some people
utilize drugs and others do not. Questions the therapist might ask the client include,
“How, given your situation, have you developed the desire to stop using” or “In
what ways have you nurtured your push for an alcohol-free life.” When working
with people dealing with substance abuse, White recommends the use of the rite
of passage metaphor. Here, the person goes through three stages: the separation
phase, the liminal phase, and the reincorporation phase. The separation phase is
the beginning of the ritual where the person separates or breaks from their known
life. In the liminal phase, the person experiences disorientation as they are living in
ambiguity, not knowing what is happening or will happen. During the reincorpora-
tion phase the person recognizes that they’ve achieved a new way of life.
Termination in Narrative Therapy occurs when family members have not only
uncovered new storylines for their lives, but are acting and performing these
alternative plots (White, 1995). Their new identity is in line with their preferred
outcomes and they are able to distinguish “local knowledge” (their own perspec-
tives) in relation to the dominant discourse.

Case Application

The Strategic therapist of the Rothers family would take responsibility for change
in the system. In the assessment of the family, the therapist might hypothesize
that the Rothers are having difficulty transitioning from the family with young
children stage to the family with adolescent children stage. This may be seen in
boundaries that are more on the rigid side where the parents attempt to have
greater influence on most aspects of the child’s life. Steve is now 14 and is looking
for greater levels of independence. The system’s homeostasis may be organ-
ized around ensuring parental responsibility for children’s behaviors. Mark’s
increased drinking and emotional despair along with Steve’s acting out behaviors
signal that there is something problematic in the family organization.
Therapy with the Rothers would likely involve all five members of the nuclear
family. The first session would find the therapist not only joining with the family,
316 Treatment 

but assessing their interactional rules as well as each member’s goals for therapy.
The session would end with the therapist giving a directive—a task for the fam-
ily to do outside of the session. If the Rothers presented with Mark’s reduced
drinking as the goal, a potential directive would be to give the family a paradoxi-
cal technique, and, more specifically, an ordeal. The family could be told that
if Mark drank, then during the night, perhaps at 1am, the whole family would
have to wake up and Mark would need to help each child with their schoolwork
while Hannah oversaw. The thought here is that it would be easier not to have
the symptom—drinking—than having to do the ordeal.
A Milan systemic family therapist would develop a systemic hypothesis to
understand the Rothers’ current homeostasis. The family game holds that Mark
distances himself from the family, through both alcohol, time, and emotionality,
while Hannah puts more effort into childrearing. Steve’s increasing acting out
behavior serves as a message that he will not be under the control of his parents.
While the family will come in saying that they want change, the change they want
is for someone else to do something different (i.e., Steve wants his parents to lay
off him, Hannah wants Mark to stop drinking and be more engaged, etc.). They
have developed a family myth centered around Mark being an alcoholic and that
he needs the support from the rest of the family so he does not become like his
father, Ian.
In the Rothers family, a positive connotation may be that Mark’s drinking
behavior helps to keep his wife from being upset at Steve’s problems at school. If
the family came in focusing on Steve’s acting out behavior, the positive connota-
tion could be that Steve’s behaviors are helping the family as father and mother
are so focused on him that they do not have to deal with the tension between
themselves. Similar to the ritual of ordeals in Strategic therapy, the Milan thera-
pist might prescribe a ritual for the Rothers such as the odd days/even days ritual.
This would be in an attempt to disrupt the family game of Mark not taking own-
ership of child care while Hannah takes full responsibility.
A Structural family therapist working with the Rothers family would likely
see all members as this would provide more information to help assess their
current family hierarchy. The Structural case conceptualization might focus on
understanding the problem, processes, patterns, power dynamics, proximity,
and possibilities of the family (Reiter, 2016). There seem to be some disruptions
in typical subsystem membership. That is, Steve seems to be on the outside of
the sibling subsystem, not really connecting with Kayleigh or Pete. Mark is an
infrequent participant of the parental subsystem, having abdicated much of that
responsibility to Hannah. While Mark and Hannah are in the spousal subsystem,
they are not clearly a unit wherein Hannah is spending more of her emotional
energy in her relationships with her children. The symptoms in this family (i.e.,
Mark’s drinking and Steve’s acting out) are likely related to the disengagement
between spouses and the concomitant adjustment in the family’s organization.
This is leading to the detouring triangulation occurring between Mark, Hannah,
and Steve where Mark and Hannah are focusing more energy on Steve’s behav-
iors than on the dynamics of their marital relationship.
There will likely be many enactments during the Structural session, bringing
to light the various interactional processes of the family. Boundary making will
also occur, where, depending on seating position, the therapist will ask Mark
  Family Therapy Overview II 317

and Hannah to sit next to each other while they discuss either couple or parental
issues. This will demarcate them as a unit in either the spousal or parental sub-
systems. Another goal of therapy would be to bring Steve closer to Kayleigh and
Pete in the sibling subsystem.
A Solution-Focused Brief therapist working with the Rothers will first attempt
to determine what type of relationship type of client they are working with, with
the understanding that this may change over the course of therapy. Hannah
is mainly a complainant, having concerns over Mark’s drinking and isolating
behaviors as well as Steve’s acting out behaviors. Mark is likely a visitor, think-
ing that he doesn’t have a problem. Regarding Steve’s behavior, Mark may be a
complainant. Steve, as well, is likely a visitor or complainant. He would prob-
ably say that he does not have an issue, and would point to Mark’s alcohol
consumption as the problem. Kayleigh and Pete are likely complainants, with
Kayleigh perhaps stating that her father isn’t as loving as she wants and that
Steve isn’t the nicest brother. One goal of therapy would be to see if, during the
therapeutic conversation, one or more individuals might see themselves as a cus-
tomer for change as this would help the motivation of family members to make
personal change attempts.
It is likely that during the first session the therapist will ask the miracle ques-
tion. The technique does not end at the end of asking the question, but, more
importantly, in the back-and-forth of developing the various miracle pictures
that emerge. For instance, Hannah might say, “Mark wouldn’t be drinking any
more.” The therapist would then want to help language these pictures in terms
of qualities of good goals. This might be through questions such as, “And if he
wasn’t drinking anymore, what would you be doing?” (inclusive of the client’s
hard work), “What would he be doing instead?” (presence rather than absence of
behavior), or “What would be the first thing that you would notice that let you
know that path was happening?” (small and measurable).
The SFBT therapist would keep an ear open for various exceptions in the fam-
ily’s life. These might include times when Mark engaged the family in ways all
members thought of as pleasant, Steve was engaging in prosocial behaviors, or
Mark and Hannah were feeling more loving toward one another. The therapist
could then scale a variety of these exceptions, such as, “On a scale of 1 to 10, how
hopeful are you of having the type of marriage you want with one another?” The
first session will likely end with the therapist giving the family an experiment, the
first session formula task, which would help family members switch their lenses
from looking for and expecting problems to looking for and expecting things to
go right in their lives. The therapist would then help the family members to build
on these events so that they occur more often.
A Narrative therapist would not view the Rothers family in isolation, but see
them as housed within the ideologies and belief systems of various dominant
discourses of who people are. These discourses may be based around gender,
age, religion, culture, socioeconomic status, or a variety of other constructs
that inform people as to how they should think, feel, and behave. One of these
dominant discourses is around gender roles and what men and women should
experience in raising children. It seems Mark has internalized more traditional
views that women should be the primary caregivers of children as he has accepted
that Angelina should be the primary caregiver of Nina and Hannah should be the
318 Treatment 

primary caregiver of Steve, Kayleigh, and Pete. This internalization has led him
to act in ways that may go against who he wants to be as a man and a father.
One pathway in therapy would be to help uncover the unique outcomes for
the family. This would help bring forth subordinate storylines that were more in
line with how the Rothers wanted to be as a family. One means of doing so is by
externalizing the problem. Externalizing alcohol would help the family to work
together against a common issue rather than viewing Mark as the problem. The
therapist might incorporate definitional ceremonies or counter documents to help
substantiate the new subordinate plotline the Rothers are developing about who
they are as a family.

Summary
This chapter covered five of the most prominent family therapy theories.
Strategic Family Therapy showcased how the therapist is responsible for
changing a family by developing directives intended to change problematic
sequences. The Milan Systemic approach focuses on how a therapist uti-
lizes guidelines such as hypothesizing, circularity, and neutrality to infuse
difference into the family system. Structural Family Therapy pays atten-
tion to the family organization and gets families to enact new and more
functional hierarchies. Solution-Focused Brief Therapy shifts the focus of
the therapeutic conversation from problem development to solution devel-
opment; uncovering times in the family’s life when the problem was not
present. Narrative Family Therapy explores how individuals and families
have become totalized by dominant discourses, internalizing views of who
they should be and then working with people to deconstruct these under-
standings and reconstruct more hopeful storylines.

Key Words
pretend techniques information
ordeals neutrality
straightforward task presession
paradoxical ordeal session
paradox intersession
counterparadox conclusion
family game postsession
family myth parental subsystem
positive connotation sibling subsystem
family rituals spousal subsystem
odd days/even days ritual rigid boundaries
hypothesizing diffuse boundaries
circularity clear boundaries
circular questions complementarity
  Family Therapy Overview II 319

alliances compliments
coalition story/self-narrative
cross-generational coalition dominant discourse
detouring conflict dominant story
joining problem saturated
accommodation life support system of the
tracking problem
mimesis unique outcomes
unbalancing landscape of action
boundary making landscape of consciousness
enactment landscape of identity
exceptions subordinate storylines
problem-talk externalizing
solution-talk personal agency
visitors taking responsibility
complainant externalizing conversations
customer reauthoring conversations
miracle question re-membering conversations
exceptions unique outcome conversations
scaling questions definitional ceremonies
formula tasks outsider witnesses
structured fight task counter documents
do something different task rite of passage metaphor
first session formula task

Discussion Questions
  1. Why is the directive so important in Strategic Family Therapy?
  2. How does the Strategic Family therapist view one spouse’s substance
abuse?
  3. What is the importance of operating from a stance of hypothesizing,
circularity, and neutrality?
  4. What is the relationship between the family game in Milan therapy
and addiction in a family?
  5. How do enactments help the Structural Family therapist work with
families in session?
  6. How might addiction impact a family’s organization? Of what use is
this conceptualization for the Structural Family therapist?
 7. What role do the three main questions in Solution Focused Brief
Therapy hold?
  8. How do formula tasks adhere to the three rules of SFBT?
  9. How does Narrative Family Therapy conceptualize addictions?
10. Explain the purpose of externalization in Narrative Family Therapy.
fifteen

Family Therapy
Application

In the previous two chapters we presented many of the most popular family
therapy approaches. While any of them can be used with families who are dealing
with a wide range of presenting problems, including substance abuse, this chapter
focuses on the specific application of family therapy to the field of addiction.
Stevens (2018) explained that family therapy for substance abuse attempts to
stop current use while protecting against later multigenerational use. Each model
of therapy does so in their own ways based on their unique theories of problem
formation and problem resolution (Reiter, 2014).
First, we will explore Multidimensional Family Therapy, a model developed
to work with adolescent substance abusers and their families that incorporates
family therapy, developmental theory, ecological theory, and risk and protective
factors. Next, we will discuss Brief Strategic Family Therapy, an approach devel-
oped for families with an adolescent substance abuser that combines Structural
and Strategic Family Therapy. Third, we will explore how Solution-Focused
Brief Therapy has been applied to substance abuse. Lastly, we explore Behavioral
Couples Therapy for addictions. This is not to say that the other models of fam-
ily therapy previously presented are not appropriate for substance abuse. They
all have and can be used effectively with families dealing with addictions. This
chapter just provides a slice of how various models can be specifically applied
when it comes to this population.
Specific programs for family therapy and addictions are important since alco-
hol counselors have traditionally avoided the use of family therapy (Lawson &
Lawson, 1998). This may be because they believe family therapy goes against
the disease model, they do not have training in family therapy, they view fam-
ily therapy as not in line with 12-step programs, they may not have support
from the agency they work for, and they may not have access to the family.
However, family-based substance abuse treatment can be both efficacious and
cost-effective (Morgan & Crane, 2010).
When using family-based interventions with families dealing with substance
abuse, therapists and programs usually have four goals (Thombs & Osborn,
2013). First, they attempt to bring the user, partner, and/or other family mem-
bers into a collaborative interaction to develop a plan to change the family
system. Second, interventions are designed to help clarify and stabilize family
rules and roles. Third, given that substance abuse is having a significant negative
impact on the family, family-based interventions are usually designed toward

320
  Family Therapy Application 321

Family
System
Change Plan

Positive Family- Stabilize

Family Based Family Rules &
Interactions Interventions Roles

Abstinence
or Harm
Reduction

Figure 15.1  Family-based interventions are designed to reduce drinking and increase
family stability and positive family interactions

abstinence. However, based on the model of therapy, harm reduction might be

the goal rather than abstinence. Lastly, interventions target family interactions
in an attempt to improve them and make them more desirable for all members.
See Figure 15.1 for a visualization of the four goals of family-based interven-
tions for substance abuse.

Multidimensional Family Therapy

Multidimensional Family Therapy (MDFT) is an empirically validated family-

based therapy that was designed to work with adolescent substance abusers
and their families (Greenbaum et al., 2015; Liddle, 2002, 2010, 2016; Liddle
& Dakof, 2002; Liddle, Dakof, Parker, Diamond, Barrett, & Tejada, 2001).
Multidimensional Family Therapy was influenced by Structural Family Therapy
and Strategic Family Therapy (Liddle, 1991) as well as Problem-Solving
Therapy (Liddle, 2009). The model also incorporates ideas from the risk and
protective factor framework, the ecological perspective, as well as a develop-
mental perspective (Liddle, 2010). Multidimensional Family Therapy takes into
consideration intra-individual, interpersonal, and intersystem interactions to
provide a multicontextual understanding of behavior (Liddle, 2016). It devel-
oped with a core understanding that research-based knowledge (regarding
322 Treatment 

adolescents, psychopathology, risk and protective factors, and family therapy)

could help treat adolescent substance abuse (Liddle, 1991).
Multidimensional Family Therapy works not only with the adolescent who
is abusing substances (or involved in the juvenile justice system) but also their
family, as well as the larger systems in which the teen is involved (i.e., school,
juvenile justice, and social services). It is an integrative approach that has been
manualized to make it functional as well as cost effective (Henderson, Marvel,
& Liddle, 2012; Liddle, 2009). Multidimensional Family Therapy can be used
as an in-patient, out-patient, or home-based model, and can vary in terms of
treatment length, intensity (how much contact between therapist and client), and
what other services are used (i.e., drug screening or social services).
The intent behind the approach is that what is needed to help adolescents deal-
ing with substance abuse is to change the adolescent’s lifestyle (Liddle & Dakof,
2002). This is because the adolescent’s drinking and drug use is based upon a
variety of interrelated risk factors (Rowe & Liddle, 2008). Substance abuse is not
a healthy or adaptive way of being, especially for adolescents. Multidimensional
Family Therapy is designed to help the adolescent develop a more functional
developmental pathway (Liddle, Rodriguez, Dakof, Kanzki, & Marvel, 2005).
This involves working at multiple levels/dimensions (or what are known as mod-
ules), which include the (1) adolescent, (2) parent, (3) interpersonal (the family
as a unit), and (4) extrafamilial domains such as school or other social contexts
(Liddle et  al., 2005). Since the substance abuse is a result of a complex set of
factors, treatment and the focus of change targets those multidimensional areas
(Rowe & Liddle, 2008). These include a focus on alcohol expectancies, parental
substance abuse, and family-based relapse prevention.
Multidimensional Family Therapy rests on 10 therapeutic principles, which
help guide the therapist in the pursuit of change. These principles are:

  1. Adolescent drug abuse is a multidimensional phenomenon.

  2. Family functioning is instrumental in creating new, developmentally adap-
tive lifestyle alternatives for adolescents.
  3. Problem situations provide information and opportunity.
  4. Change is multifaceted, multidetermined, and stage oriented.
  5. Motivation is malleable but it is not assumed.
  6. Multiple therapeutic alliances are required and they create a foundation for
change.
  7. Individualized interventions foster developmental competencies.
  8. Treatment occurs in stages; continuity is stressed.
  9. Therapist responsibility is emphasized.
10. Therapist attitude is fundamental to success. (Liddle, 2010, pp. 417–418)

These principles set the stage for a flexible yet targeted approach that focuses
change in the four dimensions (adolescent, parent, family, and extrafamilial).

Multidimensional Family Therapy Treatment

Treatment in MDFT follows three stages (Liddle, 2002; Liddle et  al., 2005).
Stage 1 involves an assessment and joining process. In the adolescent module,
  Family Therapy Application 323

incorporating the adolescent’s involvement from the very beginning of therapy is

key, as their active engagement helps them to get their needs met (Liddle, 1991).
The therapist uncovers the problematic areas in the adolescent’s life (i.e., perhaps
depression, conflict with parents, issues at school—or a combination) as well as
the strengths available in the system. During this stage the therapist will procure
the adolescent’s life story, which allows the therapist to understand the adoles-
cent’s connection to various aspects of his or her life, which may include drug
use, their belief system, family history, peers, health and lifestyle issues, and pos-
sible mental health issues. The adolescent is encouraged to discuss their concerns
as well as what they are hoping for from therapy and their hopes and dreams for
their life. At this point, the therapist might use drug screening or other assess-
ments to determine whether drug use is continuing. Further, the therapist will
assess the possibility of dual diagnosis (see Chapter 8), as this is the norm in this
clinical population (Liddle et al., 2005).
The parent assessment focuses on the person as an individual as well as a
parent, which explores their psychological and emotional state along with their
parenting style. The therapist collects all past solution attempts and determines
what worked and what did not work. This helps to highlight problematic pat-
terns but also strengths and competencies (Liddle et al., 2005). Just as work with
the adolescent is designed to join with the individual and increase their motiva-
tion and cooperation, the therapist needs to recruit the parent to buy in to the
idea that therapy is for all family members.
During the familial module assessment, the MDFT therapist focuses on the
story and family history. At this point, how the family interacts with one another,
especially in the affective area, is key (Liddle et  al., 2005). Although it is the
assessment phase, the therapist may begin to try to help family members to com-
municate more productively with one another.
The last part of Stage 1 assessment occurs in the extrafamilial module.
Depending on the family and the situation, some larger systems will play a more
important role than others. Several areas of exploration include school, court,
recreational services for youth, and social services/support for family (Liddle
et al., 2005). Based on their connection or disconnection from these extrafamilial
systems, the therapist may help connect the family to various services they may
find useful. The information obtained in the Stage 1 assessment is used as a thera-
peutic map, providing the therapist with a framework of where in the adolescent’s
dimensional world intervention needs to occur (Rowe, 2010). Figure 15.2 pre-
sents a visualization of the four modules in Stage 1 of MDFT.
Stage 2 is where change is attempted, focusing within and between dimen-
sions. This is the longest stage of treatment (Dakof, Godley, & Smith, 2010).
Treatment takes a variety of forms including working with the adolescent alone,
the parent(s) alone, and the family as a whole. This is done as a leveraging to
increase the therapeutic alliance and motivation (Liddle, 2010).
Multidimensional Family Therapy targets three primary risk factors: substance
expectancies, parental substance abuse, and family-based relapse prevention
(Rowe & Liddle, 2008). During this part of treatment, the therapist will chal-
lenge the adolescent’s motivations for using substances as well as motivation for
or ambivalence to change. The discrepancies of what the adolescent wants and
what the adolescent is doing help to demonstrate that the individual’s drugging
324 Treatment 

Adolescent

Stage 1:
Extrafamilial Assessment & Parent
Joining

Family

Figure 15.2  Stage 1 of MDFT involves joining and assessing the adolescent, parent,
family, and extrafamilial systems

(and problematic) lifestyle (i.e., doing poorly in school or engaging in delinquent

behavior) is not in line with their desired lifestyle.
Besides working with the adolescent, MDFT therapists work individually with
parents. The rationale behind this is that the adolescent is impacted, on many
levels, by what the parent does and how the parent engages the teen. Rowe and
Liddle (2008) explained this further, “The therapist motivates parents to take
steps to change their own lives by resuscitating their love and commitment for the
child, and by highlighting the links between the parent’s own functioning, their
parenting deficits, and the child’s problems” (p. 114). Thus, the therapist may
work with the parent to reduce/eliminate their own alcohol/drug use, improve
their mental health functioning, and learn more effective parenting skills.
Stage 3 incorporates the changes made and prepares the adolescent and fam-
ily to utilize what they have learned to maintain the positive changes. Once the
individuals in the family have developed a foundation toward positive changes,
family sessions can explore the past hurts each member has experienced in
the family (Rowe & Liddle, 2008). Family sessions may also focus on relapse
prevention, since one aspect of adolescent substance use is based on familial
interactions. The goal is that the family, rather than the therapist, becomes the
healing agent. One way this occurs is through the Structural technique of enact-
ments (see Chapter 14). During sessions, the MDFT therapist gets the family to
discuss issues around substance abuse and then encourages and supports new
and more effective responses from and toward one another. See Figure 15.3 for a
visual of the three stages of MDFT.
  Family Therapy Application 325

Stage 1 • Assessment (of adolescent and parents)

• Joining

Stage 2 • Change is attempted

• Work with subsystems & family as a whole

• Utilize what they have learned

Stage 3 • Relapse prevention
• Family members heal each other

Figure 15.3  Multidimensional Family Therapy is provided in three stages: assessing and
joining; initiating change; and enhancing change and relapse prevention

The change that comes from MDFT is multifaceted. Not only will the ado-
lescent most likely reduce his or her drug use, but family relationships may be
improved, as well as relationships between individuals in the family and larger
systems. These changes can be seen in the behavioral, affective, and cognitive
realms of members of the family (Liddle, 1991).
In today’s day and age of evidence-based and empirically-validated treat-
ment approaches, MDFT has had strong support for its efficacy (Dennis et al.,
2004; Greenbaum et  al., 2015; Liddle, 2002, 2016; Liddle et  al., 2001; van
der Pol et  al., 2017). For instance, adolescent substance abusers (marijuana
and alcohol) that received MDFT showed significantly less substance use than
those who received Adolescent Group Therapy or Multifamily Educational
Intervention (Liddle et al., 2001). In another study (Liddle, 2002), MDFT was
compared with Cognitive Behavior Therapy. While both approaches decreased
substance use, only MDFT decreased hard drug use. Further, those who
received MDFT had lower drug use at 6- and 12-month follow-up. Compared
with other empirically supported approaches (Motivational Enhancement
Therapy/Cognitive Behavioral Therapy, Adolescent Community Reinforcement
Approach), MDFT led to similar results, where adolescents reduced their usage
of substances by over 50% from the beginning of the study to the 12-month
follow-up (Dennis et  al., 2004). Multidimensional Family Therapy might be
most effective in working with families where the adolescent is dealing with
high severity problems such as severe substance abuse (van der Pol et al., 2017).
Multidimensional Family Therapy works well with adolescents of both genders
and varied ethnicities (Greenbaum et al., 2015). These researchers found that
MDFT was most effective, in relation to comparison treatments, for males,
African Americans, and European Americans, and just as effective for females
and Hispanic clients.
326 Treatment 

Brief Strategic Family Therapy

For many years the Strategic and Structural models were viewed as one approach,
called Strategic-Structural Family Therapy. This was because the founders of the
two approaches, Jay Haley and Salvador Minuchin respectively, worked together
at the Philadelphia Child Guidance Clinic. During the late 1980s Strategic-
Structural Family Therapy was perhaps the primary method by which people
were learning about family therapy. In this section we will present an adapta-
tion of these approaches as used specifically with substance abuse; Brief Strategic
Family Therapy (BSFT).
Brief Strategic Family Therapy was developed by Szapocznik and colleagues
to help families with an adolescent who is engaging in problem behaviors such
as drug use and delinquent behavior (Szapocznik, Scopetta, & King, 1978a,
1978b). Originally developed with a Hispanic population, the approach has been
expanded to work with all families that are engaging in patterns of functioning
that maintain the adolescent’s problem behavior. These patterns are the focus of
BSFT; where the goal is to change the ways the family interacts so that the fam-
ily rules change and the problem behavior is no longer acceptable (Szapocznik,
Schwartz, Muir, & Brown, 2012). When the family’s behavior becomes more
adaptive, the adolescent substance abuser will most likely decrease his or her
negative behaviors (drugs and/or delinquency).
Since families usually come to therapy with an IP—in this case the drug-
abusing adolescent—they may not understand the family dynamics that help
to maintain the problem. They have tried to enact change in the IP rather than
the relational transactions of the family. This ineffective focus has led to blam-
ing the IP and a sense of hopelessness. The BSFT model is thus designed to use
intervention strategies to help get and keep families in treatment as they try to
reduce the symptomatic behavior of the adolescent (Szapocznik et al., 2012).
Brief Strategic Family Therapy has been effective in reducing adolescent drug
use (Robbins et al., 2008; Robbins et al., 2011a; Robbins et al., 2011b). It has
become a manualized intervention (Szapocznik, Hervis, & Schwartz, 2003) and
is considered to be an empirically validated intervention (Briones, Robbins, &
Szapocznik, 2008). Brief Strategic Family Therapy leads to lower median levels of
drug use by adolescents, higher rates of engaging and retaining family members
in treatment, and higher family functioning than treatment as usual (Robbins
et al., 2011a). An additional benefit of BSFT is that, even though it is designed to
reduce adolescent substance use, it also reduces parental substance use (Horigian
et al., 2015). This is likely due to improvements in overall family functioning.
Brief Strategic Family Therapy is premised on three core principles: system,
structure, and strategy (Briones et al., 2008) (see Figure 15.4). The first principle
rests on the notion of family systems—where individual members are interde-
pendent. Children’s thoughts, feelings, and behaviors are primarily shaped by
their interactions with the family. Here, problem behavior is seen as a symptom
of an underlying dynamic within the family. This leads into the second core
principle of BSFT; that the family engages in repetitive sequences of behaviors
that influence how the various members behave. This is considered to be the
family’s structure. Families that come to therapy tend to experience a mala-
daptive family structure; one in which their repetitive ways of being with one
  Family Therapy Application 327

System

Core
Principles
of BSFT

Strategy Structure

Figure 15.4  Brief Strategic Family Therapy rests on the principles of system, structure,
and strategy

another lead to less than desired results. The third core principle of BSFT is
more strategic—the therapist designs interventions that target the family’s repet-
itive problem-maintaining sequences. These interventions tend to be practical,
problem-focused, and deliberate.
Brief Strategic Family Therapy interventions have been classified into four
domains; joining, tracking and diagnostic enactment, reframing, and restruc-
turing (Robbins et  al., 2011a). Joining operations are designed to develop a
therapeutic alliance between the family and the therapist. They occur throughout
the whole of the treatment. These techniques include the therapist making a con-
nection with the family. The alliance is extremely important as those families
that have a higher alliance with their BSFT therapist are more likely to complete
treatment than those with a lower alliance (Robbins et al., 2008).
The second domain of interventions is tracking and diagnostic enactment,
designed to assess the family’s strengths and weaknesses, which help the thera-
pist develop an appropriate treatment plan. The BSFT examines six elements of
family interactions (Briones et al., 2008), which include organization, resonance,
developmental stages, life context, identified patient, and conflict resolution.
A family’s organization can be viewed in terms of leadership, subsystem organ-
ization, and communication flow. Leadership can also be looked at in terms
of authority and hierarchy. Subsystem organization explores the formal (i.e.,
spousal and sibling) and informal subsystems (i.e., males, females, older kids,
those engaged in sports). The last organizational component is communication
flow where the therapist observes whether there is direct and specific communica-
tion (a sign of being a functional family).
The second element of family interaction is resonance, which is the closeness
and distance of family members. This is in regards to the emotional and psy-
chological connection family members have with one another. Minuchin (1974)
328 Treatment 

talked about these ideas in terms of enmeshment and disengagement. Enmeshment

signifies high resonance while disengagement is a sign of low resonance between
people and subsystems.
Brief Strategic Family Therapy explores developmental stages in two ways—
individual member development and family development. These two aspects are
not mutually exclusive. The individual’s growth impacts the requirement of the
family to transition into a new stage of development (for instance, the move of a
child into an adolescent requires the rules of the family to become more perme-
able). During the assessment of developmental stages, the BSFT therapist focuses
on the parenting, marital, sibling, and extended family’s tasks and roles.
A fourth element of family interaction that BSFT focuses on is life context. Life
context regards the interaction between the family system and larger systems such
as school, work, extended family, health care, etc. While working with adoles-
cents who are abusing drugs and getting into other types of behavioral problems,
their peer system is one of the primary life contexts that impacts them. If the
problem behaviors have become severe, the juvenile justice system may also be
involved in the family’s life.
Family interactions also involve the identified patient. As we know, families usu-
ally enter therapy with one member who they provide as being the problem—the
identified patient. This is the family scapegoat; the symptom bearer that signifies
that there is something problematic happening in the family (problematic repetitive
patterns of interaction). One important exploration in this area includes the idea
that families tend to view the IP through a limited lens, only seeing their substance
use rather than other aspects of their behavior.
The last element of exploration is in the area of conflict resolution. The
therapist assesses how the family is able to deal with issues that happen around
disagreements. Families with drug-abusing adolescents tend to manage conflict
in four ineffective ways: denial, avoidance, diffusion, and conflict emergence
without resolution. The effective means of handling disagreements is conflict
emergence with resolution.
Reframing interventions form the third domain of BSFT. The therapist relabels
family behaviors and interactions, deconstructing the view of the IP as “the prob-
lem” to a more systemic perspective. This intervention is intended to build hope
and motivation in the family.
The fourth domain is restructuring where the therapist engages in various
techniques (such as redirecting, blocking, unbalancing, and helping the family
develop conflict resolution and behavior management skills) to shift the problem-
maintaining sequences. These may include detriangulation, working in the pre-
sent, reframing negativity, working with boundaries and alliances, opening up
closed systems, and tasks.
These interventions are put together into an integrated strategy that follows
five steps: joining, enactment, interactional diagnosis, treatment plan, and restruc-
turing change (Briones et  al., 2008) (see Figure 15.5). Joining involves mutual
respect and acceptance while therapist and family develop a therapeutic system.
Enactments occur when either the therapist asks family members to interact with
one another or the family spontaneously does so. This interaction is usually cen-
tered around the presenting complaint. While the family interacts, the therapist
is able to sit back and observe the family’s process. Third, the therapist makes
  Family Therapy Application 329

• Respect and Acceptance

Joining • Development of Therapeutic System

• Assess Family Process

Enactment • Strengths & Maladaptive Patterns

• Structure
Interactional •
•
Resonance
Developmental Stage
Diagnosis • Identiied Patienthood
• Conlict Resolution

• Guide for the Therapist

Treatment Plan • Based on the Interactional Diagnosis

• Highlighting
Restructuring •
•
Reframing
Assigning Task
Change • Guiding or Coaching
• Providing Positive Feedback

Figure 15.5  Brief Strategic Family Therapy interventions are connected in five steps

an interactional diagnosis, which has five interrelated dimensions (Robbins et al.,

2001). These include structure, resonance, developmental stage, identified pati-
enthood, and conflict resolution. The fourth step of BSFT is the development of
a treatment plan, which is based upon the interactional diagnosis and informs
the therapist on which maladaptive interactional patterns to target and the best
means and interactions to do so. Lastly, the therapist engages in restructuring or
change-producing interventions. These include highlighting, reframing, assigning
tasks, guiding or coaching, and providing positive feedback.

Brief Strategic Family Therapy Treatment

While the assessment and understanding of the family functioning aspect of
BSFT is based on Structural Family Therapy, the intervention portion—the
strategic aspect of therapy—is based on Strategic Therapy. These interven-
tions can be viewed as the Three Ps; Practical, Problem-Focused, and Planned
(Briones et al., 2008). The practical aspect of interventions is important because
the therapist might use Structural or Strategic techniques, yet may also borrow
from other approaches. They are designed to be as efficient as possible, per-
haps focused on only one aspect of family restructuring rather than trying to do
everything at once. The problem-focused aspect of BSFT is that while families
are usually multi-problemed, the therapist specifically keys in to the adolescent
330 Treatment 

substance use issues. Since the way to do this is through changing family rules
and structure, other issues and problems the family may be experiencing might
also dissipate. The last aspect of interventions is that they are planned. This is a
straightforward approach where the therapist assesses the family structure and
then deliberately designs interventions, unique for each session, to target the
family hierarchy to help properly restructure the family.
The first task the BSFT therapist gives to the client is to get all family members
into the session. This is referred to as engagement and is perhaps the most impor-
tant task as most families that are dealing with adolescent drug use problems
never enter into therapy. Once the family does come for the first session, the first
task they will be given will happen inside the session so that the therapist can
help them to identify the family patterns and make constructive changes in the
therapist’s presence. This will help them to behave similarly when given a task
outside of the session.
While working with the family, the BSFT therapist needs to pay attention to
the process instead of the content of therapy (Briones et al., 2008). Content is the
“what” of what is being talked about in session. The process is the “how” the
talk occurs. For instance, if the family is discussing a fight that they had, what
the fight was about would be the content while an understanding of the rules
of the fighting (i.e., is the adolescent allowed to defend himself; do the parents
support each other during the exchange) would be the process.
When therapists adhere to the BSFT model, families are more likely to engage
in and be retained in treatment (Robbins et al., 2011b). Further, family function-
ing improves as well as a reduction in the adolescent drug use. Brief Strategic
Family Therapy lasts for approximately 8 to 24 sessions (Briones et al., 2008).
In a 12-month follow-up, those adolescents who went through BSFT had sig-
nificantly lower levels of arrests, incarceration, and externalizing behaviors
(Horigian et al., 2015). However, in these researchers’ study, the number of drug-
use days was higher than at baseline. This may be due to the frequency of relapse
in the adolescent/young adult population as well as these individuals no longer
receiving therapy. As of today, BSFT is designed for adolescent rather than adult
drug issues. However, it may be effective if the adolescent substance abuser has
a parent who moderately abuses drugs. When there is an adult in the family with
more severe drug issues, the BSFT therapist can help the adult find an appropriate
drug treatment.

Solution-Focused Brief Therapy

As described in the previous chapter, Solution-Focused Brief Therapy (SFBT—

not to be confused with BSFT just presented) is an approach that helps clients
shift from focusing on the problem times of their lives to those times when
the problem was not present or not as severe. This section describes how the
solution-focused model has been specifically applied to substance abuse. In this
realm it has been effectively utilized in individual, couple, family, and group
formats (Pichot, 2001; Smock et al., 2008).
Counter to the disease model of addiction, SFBT views someone dealing
with substance abuse as being able to change their lives without the necessity
  Family Therapy Application 331

of abstinence. People can alter even the most serious of cases with brief thera-
peutic interventions (Berg & Miller, 1992). For these authors, brief approaches
are extremely important, as their effectiveness enables a multitude of clients who
are dealing with addiction to be readily seen, as opposed to a more intensive
long-term view of treatment. If both brief and long-term treatments lead to the
same outcomes, it would seem the least restrictive treatment would be ideal.
Furthermore, SFBT has been shown to be as effective in use with addictions as
other evidence-based approaches such as cognitive behavioral therapy and moti-
vation interviewing (Kim, Brook, & Akin, 2018). This supports using a more
strength-based approach with clients dealing with addictions, who tend to find
others in their social circle taking an oppositional stance toward them. Shaima
& Narayanan (2018) supported the importance of having a therapeutic focus on
client strengths, which help instill well-being as well as destigmatizing addiction.
Berg and Miller (1992) do not believe in the traditional notion of alcoholism—
the progressive, irreversible view of the problem drinker to where the only avail-
able option is for them to be abstinent for the rest of their lives. Instead, they
believe that there are a multitude of alcoholisms, where a variety of treatment
approaches may be useful (or not useful) for that person. Solution-focused ther-
apy is just one of a myriad of approaches that can be applied.
There is also a very different view of the “codependent.” Solution-Focused
Brief Therapy views people who others would describe as codependent not in a
pathological way, but as people who are trying to maintain some type of control
and predictability in their lives (Berg & Reuss, 1998). This individual is facing the
unpredictability of life with a person dealing with a substance abuse and will try
to work extra hard to ensure the other person functions more productively. For
instance, in the Rothers family, Hannah may call Mark several times during the
day to ensure that he will be home to watch the children and not go to the bar as
she needs to attend a work meeting.
The solution-focused approach to addictions starts with the basic premise
of exploring mental health rather than mental illness (Berg & Miller, 1992).
This is a shift from pathogenesis (how diseases develop) to salutogenesis (how
health develops); a movement from what is going wrong to the resources toward
health (Mason, Chandler, & Grasso, 1995). Not much time in session is taken
to explore why the problem (the substance abuse) first developed or how it has
negatively impacted the person and/or their family. This is considered problem-
talk. Perhaps in the first session if the client introduces this information it will be
explored, but what is important for the therapist is to focus on the successes of
the clients—the non-using times. Thus, client strengths, resiliencies, and resources
are explored rather than weaknesses and deficits. This is an important concept
since most people, perhaps including the substance user, have been focusing on
the unhealthy patterns that exist rather than the healthy patterns, which are pre-
sent but not highlighted.
One of the key aspects of the SFBT model is the notion of utilization (de
Shazer, 1988). The founders of SFBT borrowed this concept from their study of
Milton Erickson. One of the hallmarks of Erickson’s approach was his utilization
of whatever the client brought with them to therapy (i.e., their resources). In
one of his cases with a retired police officer who was 80 pounds overweight,
drank too much, smoked too many cigarettes, had emphysema and high blood
332 Treatment 

pressure, and who had liked to jog but because of his current health could only
walk, Erickson gave him the following task (which utilized the client’s existing
propensity for walking):

You can do all the smoking you want . . . buy your cigarettes

one package at a time by walking to the other side of town to
get the package . . . As for your drinking . . . I see no objection
to your drinking. There are some excellent bars a mile away.
Get your first drink in one bar, your second drink in a bar a
mile away. And you’ll be in excellent shape before very long.
(Gordon & Meyers-Anderson, 1981, p. 112)

In this task Erickson utilized one client strength (walking) to help reduce areas of
complaint (smoking and drinking), while also improving desired areas of growth
(physical health). Solution-Focused Brief Therapy builds on this process of utili-
zation by exploring client strength areas—things the client has or is doing that is
beneficial—to help them move toward their goals. This happens when the thera-
pist understands and can operate within the client’s frame of reference (Berg &
Miller, 1992).
Solution-Focused Brief Therapy takes a nonnormative view of substance abuse
and instead adopts a client-determined perspective (Berg & Miller, 1992). Thus,
instead of expecting a substance abuser to exhibit specific characteristics and
progression, the therapist attends to how that particular client experiences their
own substance abuse and its impact. This shifts the therapist’s position from
being the expert to a more collaborative position, where the therapist does not
teach the client but learns from the client what the substance abuse is like . . . for
that particular client.
A premise of the approach is that it operates from the perspective of parsimony—
trying to operate from the simplest, most efficient, and straightforward way pos-
sible. Instead of viewing problems as a signal that there are larger underlying
problems, the approach takes the client’s statement of complaints at face value
and works to, as quickly as possible, address those issues. This is a change from
the typical top down view that most people have about addiction—that problem
drink/drug use is a sign that there is a progressive and chronic illness or that
substance use is a sign of some type of faulty intergenerational patterns. The
parsimonious therapist attempts to get the client moving in a positive direction
and then lets the client’s momentum continue the positive changes; this entails
using the simplest and least invasive approach (Miller & Berg, 1995). As such,
the therapist does not have to be there from start to finish as the client will be able
to maintain and build on the changes they have already made (see Figure 15.6).
In the previous chapter we explained that SFBT proposes that change is con-
stant and inevitable. This notion, in many ways, goes against the philosophy in
traditional substance abuse treatment where instead there is a view of constancy
and lack of change (Berg & Miller, 1992). These authors explain that in the
addictions field, the change that is usually explored is a change for the worse—
the person moving toward “rock bottom.”
Solution-Focused Brief Therapy is also premised on a present and future orien-
tation rather than an exploration of the past. However, the past is important—as
  Family Therapy Application 333

Therapist
Encourages
Focus on Continues
Strength Behavior

Client
Initiates
Change
Figure 15.6  Solution-Focused Brief Therapy holds that clients have personal agency to
continue to build on previous positive change

it relates to the present. This comes in the exploration of exceptions (past events
when the problem has not been present). Instead of a traditional view of sub-
stance abuse where the future is viewed as an uphill struggle where the person
will always be in recovery, SFBT views the future in a hopeful manner where
the client will be able to implement whatever past, present, and yet to be uncov-
ered strengths, resources, and solutions to lead a more productive life. One way
that this orientation presents itself in therapy is through the therapist’s language.
Instead of using the word “if,” the therapist will use the word “when.” This is
because “if” provides a possibility that change will not happen whereas “when”
presents an expectation that something different will occur. For instance, if a
therapist said, “If you were not drinking, what would be different” there is an
underlying assumption that the person may not stop drinking. However, when
the therapist says, “When you are not drinking, what will be different in your
life” the therapist expects this occurrence to happen, which then will promote
this expectation in the client.
Solution-Focused Brief Therapy does not view all clients in the same way.
There are three different therapist–client relationships: customer type, complain-
ant type, and visitor type (described in the previous chapter). This view of the
relationship between therapist and client differs from the traditional substance
abuse model where all addicts are the same (go through the same progression)
and thus the therapist treats them all in a similar manner (Berg & Miller, 1992).
For traditionally based therapists, those who do not listen to the therapist’s direc-
tions are considered to be “in denial” or “resistant.” However, who is likely
more resistant is the therapist, in that they are not understanding where the client
is at and adjusting accordingly rather than trying to get the client to adjust to
where the therapist wants them to be (de Shazer, 1984).
Therapists, especially addictions counselors, may incorrectly identify the type
of client they have. They try to work with a client as if they are a customer instead
of recognizing that, at that moment, there is a visitor-type relationship occurring.
When there is a visitor-type relationship, the therapist can try to identify the
334 Treatment 

“hidden customer” (Berg & Miller, 1992). This is when a client may not want to
address concerns that someone else has for them (i.e., the court or a spouse) but
other concerns that are more pertinent for them. For instance, instead of working
on the “drinking issues” that their spouse says they have, the person may want to
focus on “keeping one’s job.” This allows therapist and client to work coopera-
tively rather than in opposition (as the client and the referring body most likely
are). As a consequence of focusing on the client’s concern the other people’s con-
cerns may also dissipate. A correlate of this is the “other” customer—usually the
referring person. The therapist can consult with this person/agency to determine
what goals they may have for successful outcome. When these are reached, that
party is more likely to help reinforce the client’s gains.
We can also look at these categories in terms of the stages of readiness for
change model (as presented in Chapter 8). Visitors would most likely fall into
the precontemplation stage or perhaps the beginning of the contemplation stage.
Complainants would likely fall into the contemplation or beginning of the prepa-
ration stage. Customers would most likely be in the preparation or action stages
(see Figure 15.7).
Most substance abuse therapists spend the beginning portion of treatment
engaged in assessment of the client’s functioning and severity of addiction. This
may come through giving various psychological and behavioral surveys and writ-
ten assessments, problem checklists, and/or urinalysis. The SFBT therapists also
engage in assessment, yet through non-traditional means. Pichot and Smock
(2009) explained that substance abuse therapists utilizing SFBT assess through
the miracle question, scaling questions, and relational questions. These questions
help to assess information about the problem, but also about potential exceptions.
The SFBT model is predicated on a discovery of and expansion of the cli-
ent’s past exceptions—times when the problem could have happened but did
not. There are two types of exceptions: deliberate and random (Berg & Miller,
1992). Deliberate exceptions are times when the problem did not occur wherein
the client actively did something to ensure that it happened and can articulate

SFBT Readiness for Change

Visitor Precontemplation

Complainant Contemplation/Preparation

Customer Preparation/Action

Figure 15.7  Solution-Focused Brief Therapy categorizes the relationship-type of client,

which corresponds to the readiness for change model of client motivation
  Family Therapy Application 335

Past
Exception

Do More of
Works
What Wo
W rks

Solution
Building

Figure 15.8  Solution building is predicated on getting clients to do more of what works;
their past exceptions

this to the therapist. Random exceptions are those times when the problem did
not occur but the client cannot explain what they did to make it happen. For
instance, if Mark Rothers stated, “I knew that if I went to that party that I would
be around that wild group and I would end up drinking” would be a deliberate
exception, while “I didn’t do anything different, but I just came home and never
went to the cooler to get a beer” would be a random exception. The goal is to
get the client to increase both deliberate and random exceptions, as they are the
foundation for solution building (see Figure 15.8).
While exploring for exceptions, there are times when the client may state that
there are none. Although the therapist knows that this is not the case, stating this
to the client may not connect with where the client is at. Instead, the therapist
has several pathways to take. One of these is to get the client to do something
different. The therapist might give an observational task of keeping track of what
they did when they overcame the urge to drink/drug use (Berg & Miller, 1992).
Another intervention that was developed and applied, particularly to clients
dealing with alcohol who cannot uncover past exceptions and are not experiencing
hopefulness for change, is the nightmare question (Reuss, 1997). This question, in
essence, is the flip-side of the coin of the miracle question. It goes something like:

Suppose tonight when you go home and go to sleep, all of the

concerns and problems that brought you here to therapy hap-
pen. This would be a nightmare. And since you were sleeping
you did not know the nightmare happened during the night.
When you woke up, what would be the first thing you would
notice that would let you know the nightmare happened?
336 Treatment 

The nightmare question may best be used after several sessions where the client’s
miracle and exceptions have been attempted to be explored but without fruition.
Once asked, the therapist and client explore the usually negative and painful
thoughts and emotions of the client and then develop tasks that would prevent
the nightmare from happening (these tasks would be exceptions to the problem).
In families, the focus on the problem that comes from exploring the nightmare
question helps members stop blaming one another and focus on what they can do
together to stop or prevent the nightmare from happening (Berg & Reuss, 1998).
The SFBT therapist provides the client with compliments, highlighting what
the client has or is doing that is beneficial. These compliments need to be within
the client’s frame of reference so that the client is able to accept it as being honest
and relatable (Mason et al., 1995). For instance, the therapist might say to the
Rothers family, “I am very impressed with the determination that you have as a
family to be able to challenge each other.”
Most individuals who are dealing with substance abuse relapse at some point
in their treatment or post-treatment. Solution-Focused Brief Therapy does not
view these incidents as failures but as times when the client can reevaluate what
has been useful in the past. Instead of relapses, SFBT therapists call these times
setbacks (Berg & Miller, 1992). McCollum and Trepper (2001) proposed that
when a setback happens, the therapist should assess the setback to determine
what specifically happened. Next, in collaboration with the family, they can find
partial successes—exceptions in the family, no matter how large or small. The
therapist can then help to externalize the problem where there is a focus on the
client’s personal agency. This would be in the form of asking the client what they
specifically did to not let the drinking or drugging take over. After this, the thera-
pist can ask the client what they learned from the relapse so that they can refine
their solution attempts and then reinstate them.
Shafer and Jordan (2014) provided five steps to help people who have expe-
rienced a relapse (see Figure 15.9). Step one is for the therapist to enter the
interaction with the client based on a positive mindset that the client can begin a
new future immediately. Step two is a focus on past exceptions; times when the
person had stopped drugging or drinking. Step three is based on the notion that
clients tend to interact with therapists during times of non-use rather than in the
middle of an active relapse. Therapists can then ask about how, since the relapse,
the person was able to not use. Step four explores how the current relapse is
different than previous relapses. By expecting each relapse to be different, the
therapist brings hope into the conversation where the client has more personal
agency than they thought previously. Step five in dealing with relapses through
an SFBT orientation is talking with the client about what lessons they learned
from the relapse situation. Further, the therapist asks about what immediate
steps the client will make toward change.
When working with clients who are chronic relapsers, the SFBT therapist will
operate from the philosophy of the model but may make some modifications
(Berg & Reuss, 1998). These authors “suggest that therapy with the chronic
relapser will go better when the therapist spends less time focused on what the
client must do differently and more time focused on what she can do differently”
(p. 94). Further, the therapist may make an active effort to get others involved
such as previous professional helpers or significant others.
  Family Therapy Application 337

Hope for
Change

Lessons Past
Learned Exceptions

Relapse Nonuse Since

Differences Relapse

Figure 15.9  Solution-Focused Brief Therapy therapists use a five-step process when
working with clients who have experienced a relapse

Given that many people dealing with substance abuse are mandated into treat-
ment, SFBT therapists approach these clients in a way to enhance effectiveness
(Shafer & Jordan, 2014). Based on the notion of “beginning where the client
is,” the SFBT therapist engages in three steps with mandated substance-abusing
clients. First, they assess the person rather than the problem. This entails listen-
ing to the client’s perspective on how they came to treatment, how they came
to their current life situation, and what they value, believe, and want in their
life. Second, the therapist takes a not-knowing stance. Anderson and Goolishian
(1992) introduced the notion of a therapist’s not-knowing posture, where the
therapist cannot know another’s meanings. As such, the therapist, rather than
taking an expert position, helps the client bring forth their own meanings and
values. This puts the client in the expert position on themselves—their values,
beliefs, understandings, and meanings. Third, the therapist attempts to find ways
to cooperate with the client. Shafer and Jordan explained, “The most important
contribution a practitioner can make during the initial contact is to shape clients’
experience in a way that is different from the negative professional experiences
they may have encountered in the past” (p. 212). This entails the ability to view
the world from the client’s perspective while also holding one’s theoretical lens.
Solution-Focused Brief Therapy has been found to be quite effective in work-
ing with people dealing with substance abuse. In a group therapy format, level 1
substance abusers who had solution-focused therapy instead of a traditional
problem-focused treatment had significantly improved scores on the Beck
Depression Inventory and the Outcome Questionnaire (Smock et  al., 2008).
While clients who received the traditional treatment approach did improve, it
was not significant. Solution-Focused Brief Therapy has also been used with
alcohol-dependent single mothers and their children with good success (Juhnke &
338 Treatment 

Coker, 1997). Use of SFBT led to increased parenting confidence, increased par-
enting satisfaction, and an increase in alcohol abstinence. Solution-Focused Brief
Therapy can be used on its own as well as in conjunction with more traditional
aspects of substance abuse counseling (Linton, 2005). For instance, Foy (2017)
integrates solution-focused therapy and harm reduction since they are both
strengths-based, humanistic, empowering of the client, and view the client as expert.
In Bruges, Belgium, Isebaert developed the Bruges Model, which specifically
applies SFBT to problem drinking (de Shazer & Isebaert, 2004; Isebaert, 2017).
This model holds that substance use is based on choice, where clients learn to
make conscious choices between their different habits (various actions, including
the use or the non-use of substances). This program, which is both inpatient and
outpatient, has shown at four-year follow-up to be quite effective in helping clients
reach their goals as 81% of outpatient clients and 84% of inpatient clients main-
tained their goals of controlled drinking or abstinence (de Shazer & Isebaert, 2004).

Behavioral Couples Therapy

Behavioral Couples Therapy (BCT) is an evidence-based model that has shown

to be effective for couples and families where at least one adult is dealing with
substance abuse (O’Farrell & Fals-Stewart, 2006). Behavioral Couples Therapy
is designed to “build support for abstinence and to improve relationship func-
tioning among married or cohabiting individuals seeking help for alcoholism
or drug abuse” (O’Farrell & Fals-Stewart, 2008, p. 196). These two areas of
interventions—reduction of substance use and increase in positive couple
relationship—are significant since there seems to be a reciprocal causality
between relationship distress and substance use where relationship distress is
associated with increased substance use and substance use is associated with
increased relational distress (see Figure 15.10). Fals-Stewart, O’Farrell, and
Birchler (2004) recommended that, for treatment, couples either be married or

Increased Increased
Substance Couple
Use/Abuse Distress

Figure 15.10  Behavioral Couples Therapy is premised upon the notion that there is a
reciprocal causality between substance use and abuse and couple discord
  Family Therapy Application 339

cohabitating for at least one year. For those partners who are separated, they
believed the couple should be in the process of reconciliation.
While not designed to be a 12-step program, BCT aligns very well with
12-step concepts (O’Farrell & Fals-Stewart, 2006). They both have abstinence
as a goal and several of the BCT interventions, such as the Recovery Contract,
includes 12-step participation. Since most 12-step programs focus on individual
programs, the addition of BCT adds an additional element in people’s recovery
programs. O’Farrell and Fals-Stewart explained, “Patients who have a strong
commitment to a 12-step self-help program and make this part of their BCT
Recovery Contract may not need individual counseling” (p. 24).
Behavioral Couples Therapy has three primary objectives: abstinence of drug
abuse or drinking; increase of the family’s support of the substance abuser;
and change couple/family interactions for a positive foundation that leads to
continued abstinence (O’Farrell & Fals-Stewart, 2006). There are two main inter-
vention pathways to achieve these objectives. First, the therapist begins focusing
on substance-focused interventions (O’Farrell & Fals-Stewart, 2008). These
interventions occur throughout the whole of therapy to help promote the substance-
abusing partner to engage in abstinence. Second, after several weeks where there
has been attendance at the therapy sessions along with abstinence, the thera-
pist introduces relationship-focused interventions. These are designed to enhance
the partner relationship including better communication and more positive con-
nections between the two. Behavioral Couples Therapy usually lasts for 12–20
sessions over 5 to 6 months (Fals-Stewart et al., 2004; O’Farrell & Fals-Stewart,
2006). Sessions tend to be structured, with the therapist setting the agenda.
One of the primary BCT substance-focused interventions is a daily recovery
contract (O’Farrell & Fals-Stewart, 2006, 2008). In the spirit of the “one day at a
time” ethos, the daily recovery contract specifies the substance abuser’s intent to
not use that day as well as the partner’s intent of support. This is called the trust
discussion. The contract helps keep both partners focused on the immediate pre-
sent rather than the disappointment of past use or the fear of future use. The BCT
therapist usually gives the couple a calendar where they record the performance
of the daily contract. Other aspects of the contract might include attendance
at 12-step or self-help meetings, prescribed medication for recovery, as well as
drug testing. The couple brings in the calendar to BCT sessions to demonstrate
the continued progress in reaching their goals of abstinence and better couple
relationship (see Figure 15.11).
During BCT sessions, the therapist will discuss with the substance abuser
about thoughts, temptations, cravings, and urges to drink or use drugs (O’Farrell
& Fals-Stewart, 2006, 2008). This brings forth potential triggers for use as well
as positive coping strategies the individual utilized to not use during the week.
Like all approaches in working with substance abuse, slips and relapses do hap-
pen. When they do, the therapist works quickly to prevent an extended use of the
substance. This might be by contracting with the couple to enter a detoxification
unit or engage in alternative solution attempts. The beginning of BCT primarily
focuses on abstinence, highlighting triggers and stressors that lead to use and
ways to prevent and decrease these potentiates of substance use.
The relationship-focused interventions usually begin once the recovery con-
tract has been in place and working, the abuser has been abstinent, and the
340 Treatment 

Daily Trust Discussion

• Intent to not use

• Intent to support non-use
• Talk only about the present (not past or future)

Twelve Step/Self-Help Meetings

Drug Testing

Possible Medications

Recorded Progress on the Calendar

Figure 15.11  The components of the BCT recovery contract

couple has been regularly attending sessions (O’Farrell & Fals-Stewart, 2008).
Because these couples have usually been dealing with substance abuse for a long
time, much disappointment, resentment, and fear of future use is present. This
leads to the couple (and family) experiencing a lot of tension. Behavioral Couples
Therapy attempts to build goodwill, positive feelings, and a renewed commit-
ment to the relationship (O’Farrell & Fals-Stewart, 2006). Therapy sessions thus
focus on how to introduce more positive activities between the couple.
Behavioral Couples Therapy relationship-focused interventions tend to follow
four steps (O’Farrell & Fals-Stewart, 2008). These include the therapist instruct-
ing and modeling behaviors, the couple practicing these behaviors in front of the
therapist, the presentation of homework, and the review of homework that also
includes continued practice. Some specific homework activities might include
catching the partner doing something nice, planning shared rewarding activities,
or having a caring day assignment (where the spouse acts first to show caring to
the partner). Behavioral Couples Therapy therapists also teach communication
skills to the partners (see Figure 15.12). These include listening skills, expressing
feelings directly, communication sessions, negotiating for requests, conflict reso-
lution, and problem solving (O’Farrell & Fals-Stewart 2006, 2008).
Once the BCT therapist has engaged in the appropriate steps and actions for
substance and relationship interventions, the final task is continuing recovery.
This ending stage of therapy involves five aspects (O’Farrell & Fals-Stewart,
2006): continuing recovery plan, action plan to prevent relapse, check-up visits,
relapse prevention sessions, and a focus on couple/family issues to assist in long-
term recovery. O’Farrell & Fals-Stewart (2008) suggested that follow-up sessions
last for three to five years following stable recovery with an increase in length
between these sessions.
While BCT can be a very effective form of therapy for the substance abuser and
his or her partner, there are contraindications for its use (O’Farrell & Fals-Stewart,
  Family Therapy Application 341

Positive Activities Communication Skills

• Catch Your Partner • Listening

Doing Something Nice • Expressing Feelings
Directly
• Sharing a Rewarding • Communication
Activity Sessions
• Negotiating for
• Caring Day Requests
• Con lict Resolution
• Problem Solving

Figure 15.12  Behavioral Couples Therapy interventions focus on increasing positive

activities and communication skills for the couple

2006, 2008). Behavioral Couples Therapy should not be introduced if there is

a restraining order of no contact. Once the restraining order is lifted, BCT then
becomes a possibility. Further, BCT is not advised for couples when there is severe
domestic violence. O’Farrell and Fals-Stewart (2008) described that while many
couples dealing with substance abuse have experienced domestic violence, only
about 2% of couples have been excluded from BCT because of severe domestic
violence (where there were injuries that needed medical attention). Lastly, BCT
may not be appropriate if both partners are dealing with substance abuse
(Fals-Stewart et al., 2004; O’Farrell & Fals-Stewart, 2006, 2008). However, there
is the possibility, with proper client motivation, to work with the couple even if
they are both dealing with alcoholism (O’Farrell, & Fals-Stewart, 2006).
Behavioral Couples Therapy is primarily utilized with the substance abuser
and his or her partner; whether married or cohabitating. However, it can be
used with family members other than the partner, such as parents and/or siblings
(Fals-Stewart & O’Farrell, 2003). The research surrounding BCT has shown pos-
itive impact of the model (Fals-Stewart, O’Farrell, & Birchler, 2001; McCrady
et al., 2009). These benefits include a reduction in substance use, an improve-
ment of the couple’s relationship, and a decrease in intimate partner violence
(Fals-Stewart et al., 2004).

Case Application

There are various family therapy programs specific to substance abuse that could
be quite useful for the Rothers family. If they chose to utilize one, it would be
important for the therapist to develop family-based interventions that are likely
342 Treatment 

to help the family through this current difficulty in their life. The goals of any of
these programs will be to decrease the use of alcohol and drugs for all members
of the family, stabilize the family organization, and increase positive interactions
between family members. Each program will do so in different ways, but the
Rothers will likely become more cohesive. However, the process may not always
be easy.
If the Rothers were to engage in Multidimensional family therapy, they would
likely do so under the auspices of working with Steve. Currently his school
behaviors have become problematic. Given that he is growing up in a house with
an alcoholic parent and with a parental generational history of alcoholism, he
is at higher risk for substance use and abuse. Currently, in-home or outpatient
formats would be the least restrictive environment, as Steve’s behaviors are get-
ting more severe, but he is not at risk for harming self or others and does not
seem to be addicted to drugs or alcohol. While we do not know his current use,
we might hypothesize that he has tried drugs and alcohol, and perhaps is using
somewhat frequently, but not to the levels that could be considered addiction.
Stage 1 would include individual and joint sessions so the therapist could join
with everyone and assess the various subsystems and how they interact with one
another. Stage 2 would target change in multiple subsystems. Not only would
Steve’s substance use behavior be targeted, but also his delinquent behavior.
Further, therapy would likely also focus on reducing Mark’s substance use. Areas
such as increasing parenting skills and improving mental health would also be a
focus of this stage. Stage 3 would be geared around helping the family to ensure
that new interactional processes become more ingrained patterns.
Similar to MDFT, the Brief Strategic family therapist will likely come in con-
tact with the Rothers family because of problems being displayed by Steve, such
as drug use and disruptive school behaviors. Therapy will focus not on Steve, but
on the family’s relational patterns, which maintain Steve’s problem behaviors.
Thus, the rules of the family, such as the emotional distance between Mark and
Hannah as well as the children dealing primarily with Hannah rather than Mark,
will be targets for intervention. During assessment, the BSFT therapist is likely
to see a family in the early stages of a family with an adolescent child where the
oldest child is the identified patient. However, the therapist will likely also see a
detouring triangulation where Hannah and Mark tend not to have overt conflict
with one another and instead focus their energies on the IP, Steve. The therapist
might reframe the family’s difficulties from “Steve is a problem” to “The family
is keeping Steve young.” The therapist might then block the coalition of Hannah
and the children against Mark and try to strengthen the marital subsystem.
A Solution-Focused Brief therapist would work with whomever the Rothers
family chose to attend the session, as the more people that attended, the more
possible customers for change. The view of the members of the family would be
different as Mark would not be seen as just “an alcoholic” similar to all other
alcoholics. Rather, the therapist would attempt to understand the unique way
in which he and the other family members engage each other and their context.
Similarly, Hannah would not be seen as being codependent but rather that she is
trying to do her best in the current situation. Therapy will be focused on excep-
tions, times when the members were living lives without the problem or with the
problem reduced to a point where it was not problematic. For the Rothers, this
  Family Therapy Application 343

might be when Mark and Hannah are loving toward one another, where Steve
and his parents are getting along, and where the family has Sunday Fun Day
together. Focus on these times helps to bring forth patterns of behavior that are
desired and that when in place lead to the reduction or cessation of the problem-
atic behaviors.
A Behavioral Couples therapist would likely only see Mark and Hannah, as
change in the couple will likely lead to change in other family relationships. One
of the goals of BCT would be for Mark to become abstinent from alcohol, mari-
juana, and other drugs. A second goal would be to increase Mark and Hannah’s
marital relationship. Behavioral Couples therapy would start by helping Mark
become abstinent and then would expand to address the couple’s relationship.
Toward the beginning of therapy, the therapist would help them develop a recov-
ery contract. The trust discussion would cover Mark’s intent to not drink and
Hannah’s intent to support him in this. This contract would focus on the short-
term goals of that day rather than long-term goals. The recovery contract might
also include Mark’s attendance at AA and Hannah’s attendance at Al-Anon.
Therapy would focus on increasing Mark and Hannah’s communication skills so
that they can engage in more positive activities with one another, such as a date
night or even just noticing when the other showed a positive sentiment such as
bringing home the other’s favorite meal from their favorite restaurant.

Summary
Any model of family therapy can be used effectively in working with indi-
viduals and families dealing with issues of substance abuse. This chapter
presented how four models, Multidimensional Family Therapy, Brief
Strategic Family Therapy, Solution-Focused Brief Therapy, and Behavioral
Couples Therapy, each understand the process of addiction and what a
therapist from that model might do with a family. You are encouraged to
take any of the other models of family therapy presented in this book (and
those that were not presented) and apply them to addictions. There may be
modifications to the techniques and process of the model that may occur,
but each, in their own way, can help facilitate change for family members.

Key Words
Multidimensional Family tracking and diagnostic
Therapy (MDFT) enactment
Brief Strategic Family Therapy family organization
(BSFT) resonance
triggers developmental stages
joining operations life context

(continued)
344 Treatment 

(continued)

identified patient utilization

reframing interventions parsimony
restructuring hidden customer
Three Ps: Practical, Problem- other customer
Focused, and Planned deliberate exceptions
engagement random exceptions
content nightmare questions
process setbacks
pathogenesis recovery contract
salutogenesis trust discussion

Discussion Questions
1. Explain how Multidimensional Family Therapy works.
2. What is the process of Brief Strategic Family Therapy?
3. How does Brief Strategic Family Therapy integrate aspects of Strategic
and Family Therapy?
4. Discuss how Solution-Focused Brief Therapy’s philosophy goes counter
to that espoused by the 12-steps.
5. What are the benefits of viewing problem drinking through a behavioral
lens? How does Behavioral Couples Therapy help both the substance-
abusing and non-abusing partners?
sixteen

Family Recovery

Throughout this book we have seen how what may seem to be one person’s
problem, in this instance addiction, may actually be viewed as a more sys-
temic process. In Chapter 4 we presented the notion that not only is the
addicted individual impacted by the drug use, but the family as a whole can
go through a process of addiction. In this chapter we discuss how the family
goes through the process of recovery. Focusing more on the process toward
health rather than the process of dysfunction is important since the addic-
tions field has made a major shift from a pathology-oriented perspective to a
recovery-oriented perspective (White & Cloud, 2008).
As the substance abuser either reduces or eliminates the drug/alcohol from
his or her life, interpersonal relationships change and the family system needs
to adjust. Even when the substance abuser becomes sober, family members may
have a difficult time adjusting to the change. Some of the relational land mines
that family members of the newly sober might experience include monitoring,
resentments, and jealousy (Nowinski, 1999) (see Figure 16.1). In monitoring,
family members have spent a lot of time keeping track of how much the person
has been drinking or using drugs. However, how the monitoring comes across
tends to be experienced as nagging. Family members also experience resent-
ments, both to the drug or alcohol as well as to the person using them. These
resentments are associated with feelings of guilt and shame. Lastly, many family
members experience feelings of jealousy as they had previously lost their loved
ones to drugs or alcohol and now that person is spending much of their time and
energy in 12-step fellowships. These are some of the possibilities that therapists
should keep in mind when helping families who are in recovery.
Recovery here is being used to refer to the process of change when drugs/
alcohol are involved so that the drug use is not the organizing principle of the
family. This may be through one or more members maintaining abstinence—a
complete cessation of substance use—or moderation management—the use of the
substance but at levels that are not problematic. Whichever path is taken, recov-
ery for the family includes a reorganization so that family rules and processes
help people engage each other in more honest and open interactions.
This notion of reorganization is an important concept as the family has most
likely viewed the cessation of the drug use as the time when everything in the fam-
ily will go well. However, this is usually not the case. Lewis and Allen-Byrd (2007)

345
346 Treatment 

Monitoring

Family
Recovery
Jealousy Resentments

Figure 16.1  The process of family recovery has associated interpersonal difficulties while
the family is also improving

explained that “abstinence marks the beginning of a journey that is profoundly

difficult for all family members. Without guidance, support, and knowledge of the
recovery process, most people will relapse” (p. 106). Therapists can help families
by discussing how the family will continue to find new and different challenges
even after substances are no longer a daily part of their lives. For any problem
that a client initially comes into therapy with, a goal of therapy should not be
no further problems. Life brings with it difficulties, challenges, and pain. It also
brings successes, strengths, and happiness. The family will continue to experience
all of these throughout the life span. By developing a new way of being with one
another, the family may be able to more easily handle the adversity—as well as the
prosperity—that normally happens in life. Yet, one of the key factors to success-
ful recovery is that of hope (Bradshaw et al., 2015). Higher levels of family hope
pretreatment is related to later coping skills. This suggests that therapists, from
the beginning of treatment, should consider various ways of increasing clients’
sense of hope, perhaps through psychoeducation, empirically validated treatment
approaches, and positive therapeutic support.
In general, family recovery from substance abuse can be viewed in three stages:
attainment of sobriety, adjustment to sobriety, and long-term maintenance of
sobriety (Shelton, 2017) (see Figure 16.2). In the attainment of sobriety stage,
the substance abuser is likely still using, but there are usually periods of absti-
nence. The family system at this point is still unbalanced. Therapeutic goals at
this stage are to motivate the user to get treatment as well as provide support
for family members. During the adjustment to sobriety stage, there has been a
sustained period of abstinence from the drug or alcohol. The family system recali-
brates itself to develop stronger rules and roles while also being cautious about
potential setbacks. During the long-term maintenance of sobriety stage, there has
been complete abstinence and the family dynamics have changed to provide more
functional ways of being and feeling for family members. Treatment focuses on
relapse prevention and further support of positive family interactions.
  Family Recovery 347

• Complete
• Periods of • Sustained
Long-Term Abstinence
Attainment of Abstinence Adjustment Abstinence
Maintenance • Functional
Sobriety • Family is to Sobriety • Family of Sobriety
Family
Unbalanced Recalibrates
Interactions

Figure 16.2  Family recovery can be viewed as three progressive stages

There are various conceptualizations of family recovery. For instance, 12-step

programs view family recovery in terms of at least one member of the family
beginning the recovery process.

Specifically, that means taking the first step, which is to

acknowledge that one is powerless over another person’s
addiction (and consequently, not responsible for it) and begins
to move from an enabling relationship with the addict toward
a relationship characterized by caring detachment. (Nowinski,
1999, p. 10)

Other conceptualizations view family recovery in alternative ways, which we pre-

sent here in this chapter.

Developmental Model of Family Recovery

Since families are systems, changes in one member impact the other members.
As one person become physically and psychologically addicted, their behavior
changes and subsequently so does the behavior of the various family mem-
bers. Concomitantly, as the person decreases their physical and psychological
dependence on the substance, their behavior continues to be impacted by and
impacts the other family members. If we punctuate this arc in the family’s life—
from the beginning of the use of the substance to the reduction of the use of
the substance and how members operate to create, maintain, and then change
their functioning—we can view it as a developmental model of recovery. Brown
and Lewis (1999) and Schmid and Brown (2008) presented a four-stage devel-
opmental model of recovery for those families dealing with alcoholism, which
parallels the stages of recovery for individuals. This model can be expanded to
fit families in recovery of other types of drugs/addictions.
At each stage there are three domains of experience: the environment, the sys-
tem, and the individuals within (Brown & Lewis, 1999; Schmid & Brown, 2008).
The environment is the daily experiences of family life. It includes the who, what,
where, when, and how of family functioning. The system refers to the structure
and process of the family. The individual domain focuses on an individual’s physi-
ological, behavioral, emotional, cognitive, and intellectual development as well as
that person’s various attachments, especially to primary caretakers. Figure 16.3
348 Treatment 

Individual

System

Environment

Time

Figure 16.3  Each stage of family recovery involves the individual, system, and
environment, and how these change over time

presents a visual of the three interlocking domains of experience for each stage of
family recovery.
The first stage of the developmental model is the Drinking stage. In this stage
there are a lot of double messages family members are telling themselves, telling
others, and are experiencing themselves. These include the notions of pretending
that there is nothing wrong in the family while also knowing that there is a lot
going wrong in the family. Brown and Lewis (1999) described the defensive fam-
ily focus at this stage:

• To maintain denial of any problem with alcohol.

• To maintain a core belief that there is no alcoholism and no loss of control
over drinking.
• To invent explanations for the alcoholic reality.
• To cover up and maintain the family secret. (p. 103)

Family members alter their normal routines, which begin to center around
drinking or around trying to show themselves and the world that whatever drink-
ing is occurring is not affecting them. This is the starting point in the arc of family
functioning where the tension is beginning to rise, but is most likely not being
commented on.
When a family comes to therapy while in the Drinking stage, one of the main
keys is for the therapist to develop a strong therapeutic relationship with the
various family members. It is from this relationship that the therapist can help
members to challenge their denial. This happens when they accept that alcohol-
ism is, at the present moment, a core part of their lives; a part that is harming
each individual and the family as a unit. The therapist will also pay attention to
and bring forth family members’ beliefs about drinking. These are usually based
within a framework of denial. As we have seen, these distorted beliefs help to
  Family Recovery 349

maintain the family’s functioning around the addiction. The therapist helps mem-
bers to see that their beliefs are part of the life-blood of the addiction.
The environment domain is unsafe, and there may be tension, anxiety, and
emotional pain (Schmid & Brown, 2008). The system of the family is centered
around drinking, yet trying to protect members from the negative effects of the
drinking. There tends to be rigid rules and roles where there are impermeable
boundaries between the family system and outside systems. Individually, each
person in the family finds him or herself conforming to the needs of the drinker.
Individual needs tend to be suppressed.
The second stage of family recovery is Transition. Based on the previous stage,
family members are beginning to recognize how the way they have come to view
everyone’s role in the family has been problematic. Issues of control have come
to the surface, and people realize that they are not able to control one another.
Brown and Lewis (1999) operate from an abstinence model, explaining that in
the Transition stage one or more family members will begin to become abstinent.
However, effective moderation may also be a sign of the family being in the
Transition stage.
In the Transition stage family members have a high motivation to push their
newfound beliefs that patterns in the family need to change. Brown and Lewis
(1999) explained that the family’s focus when moving toward abstinence is “to
focus intensely on staying dry; to stabilize the out-of-control environment; to
allow the system to collapse and remain collapsed; to focus on the individuals”
(p. 107). While it may seem non-systemic to focus on the individual, we know
that there is a mutuality and complementarity between people. Thus, one per-
son’s self-focus will have consequences on others, whether intended or not.
The environment domain is increasingly unsafe as the negative effects of the
drinking increase along with the severity of the drinking (Schmid & Brown,
2008). Pressure in the family increases where there is likely more conflict and
anxiety. The system of the family is similar to how it was in the Drinking stage,
yet it becomes a bit more open to outside influences such as the legal and/or ther-
apeutic systems. Individually, each person in the family finds themselves starting
to think about their own role in the substance use.
The family therapist working with the family in the Transition stage will con-
tinue to focus on making sure that various members are not in denial. At this
point, one or more family members has already taken that step to move toward
acceptance of the family’s reality, pushing themselves to realize how alcohol has
been negatively impacting the family. This helps the other members to move past
the dictum of having to keep quiet and pretend that the family is doing well.
Families in the Transition stage begin to accept that the family has been out of
control; usually for a longer period of time than they realized. Each time this is
discussed or a different member of the family moves past his or her own denial,
the core beliefs in the family get challenged and become open for possible change.
The family has “hit bottom” and each member shifts from focusing on the family
to seeing how the individual can recover.
Family members will most likely begin to utilize some type of outside source
for support in the recovery. This might be AA, Al-Anon, or another self-help
group (see Chapter 10). This reconnection to self helps the individuals to update
their thinking about self; perhaps exploring their own childhood issues, the way
350 Treatment 

in which they currently view their own actions, as well as their hopes and dreams
for the future and whether they are on a path to make them happen. In the pre-
sent, for the adults, there is a reconnection to more positive parenting.
The third stage of family recovery is Early Recovery. If we explore our arc of
family recovery, we have passed the zenith and are moving on the downward
half of the arc. Here, people who were using are now abstinent, or perhaps have
learned how to engage in moderation management. The shift in core beliefs that
started in previous stages is now prominent and active. Members continue to
have a focus on self-recovery, and this is hampered or helped when other mem-
bers are either not on the same path or are also active in the recovery process.
The environment domain during Early Recovery is usually less conflictual as
family members are not spending as much time together as they had previously
(Schmid & Brown, 2008). One of the primary emotional impacts is that of fear;
fear of isolation, intimacy, emotions, relapse, and the future. For the family
system, life still revolves around alcohol, but, rather than around its use, life
centers around not drinking. The family is starting to find new rules of interac-
tion. Individually, each person in the family finds themselves primarily in their
own recovery.
Families in Early Recovery have several tasks:

• to continue to learn abstinent behaviors and thinking;

• to stabilize individual identities—I am an alcoholic, or I am a co-alcoholic,
and I have lost control;
• to continue close contact with 12-step programs and begin working the
steps;
• to maintain a focus on individual recovery, seeking supports outside the
family;
• to continue detachment and a family focus guided by individual needs;
• To reestablish and maintain attention to children; to maintain parenting
responsibilities. (Brown & Lewis, 1999, pp. 111–112)

Here, members may vary in how they engage in growth. While some may find
connection in a 12-step group, others may find sports, hobbies, or other means
to gain positive connections inside and outside of the house.
While drinking/drug use may go away, this does not mean that everything is fine
in the family. In Early Recovery, families tend to not have the coping skills neces-
sary for positive functioning (Higgins, 1998). Thus, abstinence (or moderation)
is only one of the goals of family recovery. Other goals include a reconnection to
one another—shifting relationships from being problematic to healing.
The final stage of the developmental model of family recovery is Ongoing
Recovery. This is the culmination of the focus on each individual’s recovery and
how the family as a whole can reconnect with new patterns of interaction that
support one another in more congruent means of engagement. Family members
will either be abstinent or have developed a very effective way of managing the
moderation of their use of substances. At this point, members are addressing
how living in a chaotic alcoholic family has impacted them; yet, they are able to
develop newer identities so that they can attain growth. Figure 16.4 represents a
visual model of how these stages of family recovery overlap.
  Family Recovery 351

Early Ongoing
Drinking Transition
Recovery Recovery

Figure 16.4  A developmental model of family recovery, developed by Brown and Lewis

The environment domain is now based upon peace and order (Schmid &
Brown, 2008). Pressure in the family increases where there is likely more conflict
and anxiety. The system of the family has likely developed a new family myth,
one that involves drinking and recovery. Previously rigid roles and rules are now
clear and the family experiences greater openness between itself and outside sys-
tems. Individually, each person in the family is able to grow psychologically,
emotionally, and interpersonally.
These stages have been supported by qualitative but not quantitative data
(Rouhbakhsh, Lewis, & Allen-Byrd, 2004). In these authors’ study their quantita-
tive data (MMPI-2, FACES-II, FAM-III, and FILE-C) stayed the same throughout
the stages of recovery, thus not showing the breakdown of denial, growth, and
learning on the part of family members. However, qualitative data (based on in-
depth semi-structured interviews) did demonstrate that the chaos and crisis that
families experienced in the early stages of recovery dissipated throughout the
recovery process.
There are also differences in how men and women experience the recovery
process (Petroni, Allen-Byrd, & Lewis, 2003). Males and females, as well as
alcoholics and co-alcoholics, have very different processes in recovery. Male alco-
holics tend to have more deviant beliefs than female alcoholics, which may come
in the form of various levels of paranoid ideation. This coincides with males’
general tendency to externalize (blame others) while females tend to internalize
(blame themselves). Males may also have issues in recovery since they tend to be
more self-reliant, which goes against many of the recovery principles espoused
by organizations such as AA (such as admitting powerlessness). Recovery may be
easier for females as they are more used to open expression of feelings.
One of the most interesting findings of Petroni et al.’s (2003) study were the
similarities between alcoholics and co-alcoholics. In males, these two groups only
differed in the beginning of the recovery process (0–5 years) on Situational Stress
Due to Alcoholism and Mental Confusion. For females in the beginning of recov-
ery, alcoholics had higher scores than non-alcoholics in Anxiety and Tension and
Somatic Symptoms. These results help support the notion that addiction impacts
more than just the addict and that recovery is a family affair. As recovery contin-
ues, the differences seen in the beginning tend to grow smaller.
While the previous developmental model has been useful to view family recov-
ery, it is not the only model. Curtis (1999) provided a six-stage developmental
model of family recovery. The pretreatment stage is the beginning of the recov-
ery process when something was significant enough in the family system to lead
them into therapy. Next is the stabilization stage where family members take
352 Treatment 

accountability on their own individual roles in the family’s functioning and not
just focus on the addicted individual. The third stage is early recovery where fam-
ily members begin to deal with their own issues. Here, they take responsibility
for their own actions. In the middle recovery stage, the family begins to readjust
family rules while also improving individual self-esteem. The late recovery stage
usually encompasses a focus on the resolution of intergenerational patterns that
have been problematic. The last stage is maintenance/remission where members
continue individual growth as well as not getting caught up in the dysfunctional
morass that was there at the beginning of treatment.

Family Recovery Typology

Lewis and Allen-Byrd (2001), based on the framework developed by Brown

and Lewis, developed the Family Recovery Typology Model, which classifies
alcoholic families in recovery into three types. Based on the type of family the
therapist is dealing with there are various treatment implications.
Type I families are when both spouses are in recovery. They have both hit
bottom and the family system has collapsed. This means that their old pat-
tern, roles, and rules of the system are no longer functional. Both partners have
acknowledged that their own drinking contributed to their own and the family’s
problems. Each person is actively in recovery—perhaps by going to therapy, self-
help meetings, or other such activities. Lewis and Allen-Byrd (2001) described the
characteristics of Type I families:

(1) a shift in the balance of power resulting in equality between

partners; (2) recovery as the central element of the functioning
of the spouses as a system and as individuals; (3) the ability
to be open, honest, and direct in the relationship; and (4) a
spiritual dimension within the couple’s interactions (e.g., they
universally feel closer, there is a deeper bond, and there is a
“specialness” to their togetherness). (p. 9)

In Type I families, individuals are working on self while reconnecting with oth-
ers to develop new patterns for a functional family. Family members in this type
of family are the most open for intervention and change. They realize that they
were part of the problem sequence and are part of the solution. As a unit, Type I
families are most likely in the action stage of readiness for change.
Type II families occur when only one spouse is in recovery. This is usually
the alcoholic, who finds themself attempting to change yet being the focal point
of other family members who do not trust that the changes they make will be
substantive and lasting. Thus, tension in these families occurs between the family
system and the individual who is in recovery. Type II families tend to include:

(1) an imbalance in the power structure such that there is ine-

quality between partners; (2) recovery that pertains only to
the alcoholic, thus there is a single IP; (3) denial at the marital/
  Family Recovery 353

familial level; (4) tenuous stability at the systems level; and (5)
the alcoholic having two identities—recovering alcoholic and
practicing (non-recovery) co-alcoholic. (Lewis & Allen-Byrd,
2001, p. 10)

Type II families require an individual and systems approach. For the individual,
exploration of what the recovering addict can do to stay in the action or mainte-
nance stages of change is important. For the family, the therapist might explore
how the family can change to not only help the substance abuser but to change
their own dynamics as well.
Type III families are those in which the substance abuser is now abstinent but
does not have a recovery program. In these families, it may seem on the surface
that positive changes have been made in the system since the alcoholic is no
longer drinking; however, the processes below the surface are still maintained.
Here, spouses are still in the Transition stage of recovery, where their thought
processes, feelings, and behaviors are the same as they were during the time of
drinking. Instead of alcohol being used, the person may transfer their focus and
dependence on their spouse (or perhaps a child). Since it seems that the problems
have been overcome, Type III families tend not to come to therapy unless they
are forced (based on court order or perhaps some issue with a child). Lewis and
Allen-Byrd (2001) explained the common characteristics of this type of family:

(1) an imbalance in the power structure; (2) abstinence only

with no developmental recovery process; (3) an attachment
with shifts from alcohol to a specific person (typically the
spouse); (4) a rigid and closed systems structure with tenuous
stability; and (5) split subsystems (lack of integration)—couple
and mother–children. (p. 11)

Type I Type II Type III

Both Substance
Partners in Abuser Only Abstinence
Recovery in Recovery

Family Family Does

No Recovery
System not Trust
Plan
Collapses Recovery

Figure 16.5  Family recovery can be viewed based on a typology of families

354 Treatment 

Type III families tend to view change as a threat to the person’s sobriety. Since
the person is no longer drinking, family members do not want to rock the boat,
so they maintain the status quo. As a unit, these families may be considered in the
contemplation or perhaps preparation stage of readiness. What might be useful
for these families is an educational approach where the family recovery process
is explored and members may become more open to the possibility that change
at this point can be useful and preventative of a breakdown in the system later
in the family’s life. Figure 16.5 presents a summary of the three types of families
in recovery.

Wet and Dry Family Systems

In determining where a family is in recovery and possible courses of action, the

therapist needs to understand what role alcohol presently has in the family.
Kaufman (1985) distinguished between “wet” and “dry” family systems. The
wet family system is one in which active alcohol use is present. This use is still
being problematic. A dry family system occurs when family members either do
not drink or do not drink problematically. A family in which the person using
alcohol has reduced their use and is currently engaging in moderation manage-
ment would be considered a dry rather than wet system.
For therapists who come in contact with a wet family system, one of the first
goals is to interrupt the problem drinking (Kaufman, 1985). This may come in
the form of a discussion with the person using, the family engaging in a form
of intervention, or even possible outpatient or inpatient services for the indi-
vidual. However, not all people using substances will try to reduce their use
before the start of family therapy. In this case the therapist can choose to either
work with the whole wet family system or see certain subsystems that are more
functional. For instance, if Mark Rothers is refusing to reduce his drinking and
not wanting to enter therapy, the therapist might work with Hannah and one
or more children.
The family therapist will change interventions based on the family moving
from a “wet” to a “dry” system (Myers & Salt, 2013). This includes learning
sober family living skills. These skills include:

• building healthy communication

• developing sober relationships
• staying in the here and now
• learning appropriate parenting skills
• having the children learn or relearn to be children
• adapting to a personality change of the recovering member
• adapting to a personality change of the recovering codependents
• adapting to a new family structure
• adapting to new activities and relationships of family members
• learning to express anger and sexuality in healthy ways
• letting go
• dealing with the emergence of masked problems
• continuing involvement in new support systems
  Family Recovery 355

• stopping “walking on eggs” with the recovering member

• building trust
• abandoning unrealistic expectations. (pp. 192–195)

During recovery, there are many transitions that occur individually and as a
family for each member of the family. As one member grows and changes, the
family system grows and changes, leading to further aspects of difference and
change emanating throughout the whole of the family system.
One of the primary factors leading to successful recovery for families dealing
with alcohol is that of resilience. This is because there is a connection between
how families access their resilience over their lifespan and the attachment and
connectedness to the family (Garrett & Landau, 2007). Resilience can be defined
as the organism/system to be able to recover from a difficult situation. For a more
thorough discussion of resilience, see Chapter 7.

Relapse

When things begin to go well for the family, the therapist might consider intro-
ducing the notion that there is a possibility of a relapse. As defined in Chapter
1, a relapse is a return to use once an improvement has been made. The relapse
might have the person (a) return to their previous use level; (b) use at an increased
level; or (c) use but at a reduced level. Family relapse might also have family
members returning to previous roles and interactional patterns that helped to
maintain the substance use. Families play a significant role in whether a relapse
occurs as well as the severity of the relapse. For instance, during the early stages
of recovery, people are more likely to relapse if they encounter stressful circum-
stances (Breese et al., 2005). This includes the chaos and stress that might occur
in a family exhibiting conflict.
It may seem counterproductive for the therapist to introduce the possibility of
a relapse since this is an action the therapist and family are working against. A
potential concern is that this could justify the user to use again. However, given
that relapses have been such a prevalent part of the process of overcoming an
addiction, it would be problematic for the therapist not to. While about 40–60%
of people treated for alcohol, opioid, or cocaine abuse remain abstinent for at
least one year following discharge, 15–30% may use the substance some, but
not to levels that would be considered dependent (McLellan, Lewis, O’Brien, &
Kleber, 2000). The remaining individuals may either use at previous levels or pos-
sibly even increase their usage. By understanding that relapse may be a normal
part of the recovery process (although it does not have to be present), families
can maintain higher levels of resilience by not thinking that all of their hard work
has gone for naught.
If a relapse occurs, therapists can focus on all of the changes that family mem-
bers have already made as a new foundation to work from, rather than as a sign
that treatment was not successful. When members can return to what they were
recently doing that was working, they can more quickly move forward in the
recovery process. In this way, they can connect back to the sense of accomplish-
ment and hope that they had before the slip or relapse.
356 Treatment 

We can also view recovery in terms of the stages of the readiness for change
model presented in Chapter 8. To refresh ourselves, these stages move from pre-
contemplation, contemplation, preparation, action, and maintenance (where
termination is the exit from the cycle). This pathway is a long process that usually
does not happen in a linear fashion (DiClemente, 2003). Part of the readiness for
change model is a spiraling where the person/family goes through the sequence—
perhaps several times—before the termination period. Given that the model was
originally developed with substance-abusing clients, there is an understanding
that people do not stay at one particular stage but may move more fluidly for-
ward or recursively. With issues of relapse, they will more likely experience slips
or relapses during the action stage rather than the maintenance stage. This pro-
cess of going back through the stages is referred to as recycling.
Recovery is based on patterns where the individual has changed their behav-
ior, where the substance does not play a role in their life (or one where problems
are not involved) and that these other, more productive, behaviors have become
habitual. At this point the person is focused on what is happening well in their
life rather than on being worried about a return to the substance use. DiClemente
(2003) warns that recovery philosophies such as AA, where there is a focus on
not drinking, may keep the notion of drinking in the person’s life and may lead to
the maintenance or reemergence of the habitual drinking—a paradoxical process.
Flemons (1991) discussed this paradoxical notion of how two things are
connected in terms of what he calls completing distinctions. The notion of not
drinking is ultimately tied to the notion of drinking; these two complete each
other. When we tell ourselves, “I cannot drink, I cannot drink” what stays with
us is “drink, drink.” This does not mean that we will drink, but that the thought
of drink (even if it is framed as “don’t do this”) is present. The way out of this
dilemma is a focus on a higher order understanding of the connection between
the two. In this case, drink/not drink might be viewed as being within the realm
of health. So we could view it as: HEALTH/(Not Drink/Drink). When focusing
on other aspects of health (such as exercising, positive relationships with others,
good nutrition, etc.) we do not focus on “not drinking” and thus do not carry
“drinking” with us. When someone has gotten to the termination stage, they will
be so focused on these other aspects of health that drug use is not an active part
of their thoughts.
If we expand this from an individual recovery to a family recovery, we can
see that the family would not be focused on keeping secrets surrounding sub-
stance use and trying not to upset the fragile balance in the house, where they
were once afraid of upsetting the addicted individual and having a situation that
spiraled into conflict. Instead, they are able to explore areas of family health;
times, situations, or rituals that they engage in where they are actively enjoying
one another’s company.
As we have seen, the development of addiction happens within a family envi-
ronment that helps to maintain the problematic functions within the whole
system. Conversely, the development and maintenance of recovery also hap-
pens within the family context. As the rules of the family change, so do the
roles that members adopt, shifting the boundaries between subsystems as well
as between the family and the larger systems. These new interactions, which do
not include the use of the substance or the emotional dynamics associated with
  Family Recovery 357

it, become habitual; they become the patterned interactions that set the family’s
homeostasis. Their new ways of being are most likely more desired than when
alcohol and/or drugs were a central focus.

Recovery Capital

One of the main factors that lead to recovery is what is known as recovery capital
(Davidson et al., 2010; White & Cloud, 2008). Recovery capital are the internal
and external resources that someone has to start and maintain change. There are
three types of capital; personal, family/social, and community (White & Cloud,
2008). Personal recovery capital are the individual factors that help support and
sustain the person. These can be divided into two forms: physical and human
capital. Physical capital can be things such as the necessities for people to live;
food, shelter, clothing, as well as being financially functional. Human capital are
aspects of the person that help them cope. These include, among other things,
having a sense of humor, intelligence, self-esteem, hopefulness, and having a
developed sense of self. Human capital can be thought of as extratherapeutic
factors (Lambert, 1992).
Family/social recovery capital contains the various interpersonal relationships
that help people overcome the challenges of their lives. These may include fam-
ily relationships as well as friends or other individuals who help them maintain
sobriety. Examples of family/social recovery capital may be that friends or family
attend treatment with the person, be empathetic, or may spend time with the
person away from drugs or alcohol.

Personal • Physical Capital: Food, Shelter, etc.

Recovery • Human Capital: Individual
Capital Resiliencies

Family/Social
• Positive Interpersonal Relationships
Recovery • Family, Friends, Co-Workers
Capital
Community • Local, State, and National Programs
Recovery • Policies that Support Drug
Capital Reduction

Figure 16.6  Recovery capital are the resources that help people to start and maintain
change
358 Treatment 

The last type of recovery capital is community recovery capital. This category
includes the local, state, and national programs, policies, and opportunities that
support the reduction of drugs and alcohol. Examples of this include various
drug treatment programs, programs that are designed to reduce the stigma of
addictions, drug courts, and various self-help organizations. Figure 16.6 sum-
marizes the three types of recovery capital.
Every person has some level of recovery capital, in personal, family/social, and
community. White and Cloud (2008) provide several suggestions of how thera-
pists can work with clients to enhance their recovery capital:

1. Support screening and brief intervention programs.

2. Engage people with low recovery capital through aggressive programs of
community outreach.
3. Assess recovery capital on an ongoing basis.
4. Use recovery capital levels to help determine level of care placement
decisions.
5. Target all three spheres of recovery capital within professionally-directed
treatment plans and client-directed recovery plans.
6. Support recovery-linked cultural revitalization and community development
models.
7. Use changes in levels of recovery capital to evaluate your program and your
own professional performance. (pp. 5–8)

The more resources, strengths, and support individuals and families have, the
greater the motivation, hope, and pathways they have toward changing the pat-
terns of problematic behaviors.
Therapists working from this perspective engage in recovery support services
where they try to enhance the addicted individual’s recovery capital. The person
may be coached or mentored to address basic needs such as food, finances, and
housing. Recovery support services are designed to:

(1) establish and maintain environments supportive of recov-

ery; (2) remove personal and environmental obstacles to
recovery; (3) enhance linkage to, identification with, and par-
ticipation in local communities of recovery; and (4) increase
the hope, inspiration, motivation, confidence, efficacy, social
connections, and skills needed to initiate and maintain the dif-
ficult and prolonged work of recovery. (Davidson et al., 2010,
p. 398)

The more people who are involved and supportive of the various changes that
the individual and the family make, the better chance there is that these changes
will last.
There are many possibilities for families to engage in a productive recovery.
The National Council on Alcoholism and Drug Dependence (NCADD) provides
several recommendations for family recovery, including having the family stop
isolating itself from larger systems. This would be a shift from the rigid bounda-
ries that cut-off individuals and the family system from possible outside support.
  Family Recovery 359

This might come in the form of educational or support groups. Another related
aspect of recovery is educational. When family members understand the addic-
tion process—both for the addicted individual and the family as a whole—they
are better able to act consciously rather than being swept up in the emotional
system that is currently organized around the substance abuse. Once family mem-
bers are aware of the addiction process, they are then better able to develop
alternative communication skills. Their previous communication has most likely
been inundated with secrets, hesitancy, and deception. All of these have nega-
tively impacted each member’s self-esteem.
The NCADD also suggests that members stop focusing so much on others
and take more responsibility for their own well-being. This skill will likely be
most difficult for the codependent and others in the family who engage in ena-
bling. To do this, individuals will need to stop old behaviors that have created
the dysfunctional patterns which shaped the family’s current homeostasis. These
behaviors include denial, lying, blaming, and enabling. Instead of these problem-
atic behaviors, there are several things families can do to heal, including engaging
the children in the recovery process, building on resilience, engaging in personal
and family activities, and preparing for relapse.

Family-Based Substance Abuse Prevention:

Paul J. Kiser

Frequently lost in the discussion of interventions and treatments of substance

use and abuse is the concept of the prevention of the initiation of substance use
altogether (see Figure 16.7). The World Health Organization broadly describes

Prevention Treatment

Interrupts Initiation
Interrupts Use
of Use

Delivered through
Delivered to
Individual, Family,
Individual, Couple,
School, Community,
Family, & Group
& Media

Figure 16.7  Substance abuse prevention targets people before use while substance abuse
treatment targets people who are already using
360 Treatment 

the field of prevention as a combination of disease prevention and health pro-

motion. Disease prevention is “understood as specific, population-based and
individual-based interventions for primary and secondary (early detection) pre-
vention, aiming to minimize the burden of diseases and associated risk factors.”
Accordingly, health promotion is “the process of empowering people to increase
control over their health and its determinants . . . and usually addresses behav-
ioral risk factors such as tobacco use, obesity, diet and physical inactivity,
drug abuse control, alcohol control, and sexual health,” among others (WHO
EMRO, 2018). As the field of prevention further develops and more research and
longitudinal-based studies continue, novel and effective evidence-based practices
continue to be developed and refined to reduce the numbers of substance abusers/
addicts in society.
In any consideration of the onset of substance abuse issues, a preliminary
acknowledgment of the two main factors influencing that condition is essential.
Both genetic (“nature”) and environmental (“nurture”) elements play significant
roles in the adverse transition from the use of addictive substances to abuse and
subsequent addiction. Certainly one of these concerns is beyond the influence or
control of the clinician or therapist, save for yet-to-be-developed gene therapies or
genetic counseling practices based on the identification of genetic and epigenetic
markers that indicate higher risk of addiction upon use of these substances (Dick
& Agrawal, 2008; Xu, Wang, Kranzler, Gelernter, & Zhang, 2017). However,
multiple environmental factors have been identified that have been shown to
be modifiable and doing so can have significant impact in the effort to influ-
ence and reduce behaviors that ultimately lead to substance abuse and addiction.
The US Substance Abuse and Mental Health Services Administration recognizes
prevention as a continuum that extends from the deterrence of diseases and the
behaviors that promote them to the delaying of onset and reduction of severity
of illnesses when they do occur. They promote the systemic use of scientifically
proven, effective strategies to decrease risk factors and enhance protective factors
to help shield individuals from the negative consequences of engaging in high-risk
behaviors (SAMHSA, Rev. 2017).
The following narrative is frequently told in prevention circles to concisely
describe the differences between treatment, intervention, and prevention. A
group of well-intentioned individuals were standing by a river when they saw
a person floating downstream struggling for their life. Thinking quickly they
acted together to rescue the drowning man. Not a moment after they rescued
the one person another was found fighting to stay afloat in the current. Upon
saving that one, another was needing help, and the urgency was increasing. A
few members of the group left the scene, much to the chagrin of those rescuing
people in the current, and headed up-stream. There they found people falling
off a high cliff into the river. Thinking quickly they acted hastily to place a
net across the river and caught most of the individuals falling into the water.
Quite pleased with themselves some of the rescuers remained puzzled while a
smaller group started climbing the cliff to reach the top. When the climbers
were questioned by those manning the nets as to where they were going they
simply replied, “To build a fence.”
Prevention initiatives generally make use of the three-pronged public health
model emphasizing the interactions between an agent—i.e., alcohol, addictive
  Family Recovery 361

drugs, high risk sexual activity; a host—the individual/user and the environment;
and a setting—social, cultural, and physical settings in which the activity takes
place (see Figure 16.8). Effective prevention programs and initiatives work “up-
stream” of the potential problem to address all three components of the model to
reduce, or even avoid all together, the initiation and engagement of the individual
in high-risk activities.
In general, treatment of the disease of substance abuse and addiction is targeted
at “fixing” the problem or “curing” the individual by helping them to break the
cycle of addiction, understand the consequences of continued use, and develop
coping skills to avoid engagement in high-risk situations and behaviors to prevent
future use and abuse of the addictive drug. Effective treatment programs work to
not only include the individual user but also support systems around them includ-
ing partners, families, and groups. All of these therapeutic practices, however, are
focused on creating a localized environment supportive of individuals impacted
by the addiction to assist them with the skills they are developing to improve
quality of life and reduce the likelihood of future negative consequences.
Prevention approaches are not only targeted at individuals and selective popu-
lations but also work to change the societal environment in which the individuals
exist on a daily basis. In an effort to prevent initiation of high-risk behaviors,
obviously the approaches are most effective when they are delivered prior to any
interaction with the addictive drug or high-risk behavior. Education, messaging,
and policy change work together in a spectrum of prevention strategies devel-
oped in the mid-1980s to impact all three facets of the public health model. At
the most basic level this spectrum emphasized strengthening individual knowl-
edge and skills through classes, counseling, and curricula presented directly
to the target audience. In ever-broadening levels of impact the spectrum then
expands to include promoting community education through presentations and

Agent Host

Setting

Figure 16.8  Prevention initiatives target the agent, host, and setting
362 Treatment 

media messages, educating healthcare providers to promote prevention strate-

gies in their practices, fostering coalition and network development to increase
the strength of the message delivery system and encourage action, changing
organizational practices to establish new health-promoting norms, and improve
safety and utilizing all of the previous levels for influencing community policies
through legislation to gain population-based outcomes (Cohen & Satterwhite,
2002; Cohen & Swift, 1999).
These strategies have been used very successfully in the public health bat-
tle against cigarette manufacturers. At the individual level, evidence-based
curricula such as Life Skills Training and Project Towards No Tobacco Use
were implemented with fidelity in middle and high schools across the country
(Cowell, Farrelly, Chou, & Vallone, 2009; Farrelly, Davis, Duke, & Messeri,
2009; Farrelly, Nonnemaker, Davis, & Hussin, 2009; Johnston et al., 2016;
Thrasher et al., 2004). There were nationwide efforts to have doctors specifi-
cally monitor smoking habits of patients as a part of their basic intake interviews
and to encourage those who do smoke to quit. Nationwide anti-smoking coa-
litions flourished with development support from The National Center for
Tobacco-Free Kids and the Robert Woods Johnson Foundation, and even fund-
ing from the Master Settlement Agreement punitively collected from the tobacco
industry itself. These national and community coalitions worked tirelessly to
promote individual businesses and organizations to adopt smoke-free policies
in the workplace, increase health insurance rates for smokers vs non-smokers,
and encourage organizations to reduce their roles in tobacco-use promotion
to children including product placement in retail establishments or depictions
of tobacco use in movies. At the highest level, national legal advice was pro-
vided by groups like the Tobacco Control Legal Consortium and the American
Nonsmokers’ Rights Foundation supporting organized local, state, and national
policy initiatives to increase tobacco tax rates, restrict youth exposure to tobacco
advertising and youth access to tobacco products, remove flavorings from ciga-
rettes and enact laws to prohibit indoor consumption of tobacco products in
public places. The combined results of all of these efforts dropped the national
percentage of daily smoking by high school seniors from 24.6% in 1997 to 5.5%
in 2015, more than a 75% decline (Johnston et al., 2016).

Pathways of Prevention
Perhaps one of the most important things to be aware of in the understanding
and implementation of prevention strategies and programs at every level of the
prevention spectrum is that in order to truly be effective they must be based
in well-researched, documented, and reviewed methods. No matter the level of
conviction, sincerity of intent, or masterfulness of content delivery, a one-time
prevention presentation or event is unlikely to result in any long-term effect in
altering perceptions or changing behaviors. Neither will scare tactics, heartfelt
testimonials, or moralistic messages have any significant impact (Tobler, Lessard,
Marshall, Ochshorn, & Roona, 1999). Effective prevention campaigns and pro-
grams are based in evidence-supported strategies and concepts developed through
extensive research from decades of previous successful and failed initiatives. The
current foundational approaches of successful programs and campaigns focus on
  Family Recovery 363

interactive strategies for building resilience and coping skills in the target popu-
lation, changing societal norms to increase accurate and healthy perceptions of
substance use, and policy changes to both limit access to drugs and mitigate harm
to users and others from their consumption.
There are numerous credible private and governmental agencies track-
ing, evaluating, and monitoring substance abuse and addiction that serve as
reliable resources to assist in the development of comprehensive prevention
programs and initiatives at multiple levels. The US Department of Health and
Human Services Substance Abuse and Mental Health Services Administration
(SAMHSA), the National Institutes of Health National Institute on Drug Abuse
(NIDA), Community Anti-Drug Coalitions of America (CADCA), the Centers
for Disease Control and Prevention (CDC), the Search Institute, the National
Social Norms Center, scores of state and local coalitions, private foundations,
and many more agencies are all excellent resources for both funding and evidence-
based development of targeted and comprehensive prevention efforts.
Although the prevention spectrum outlines the tiered levels of prevention
initiatives involved in a comprehensive prevention campaign with large population-
based health improvement objectives, individual components of specific activities
and initiatives within that spectrum can also be viewed as key elements of a pro-
tective ring of prevention for very specific sub-populations or even individuals.
As comprehensive prevention curricula are implemented in schools and delivered
to individuals through mentoring and peer-to-peer relationships they should be
tied into consistent messaging, skill development, monitoring, and support from
family close to the target audience. When combined with community standards,
policies, and social norms messaging consistent with what is being taught at
school and in homes, the overall protective value increases. Every aspect of this
preventive web of protection should ultimately be supported by local, state, and
federal legislative action to not only limit access to illicit substances through legis-
lative action but also to provide funding and other forms of support for all of the
other pieces of a comprehensive prevention puzzle (see Figure 16.9).

Adolescent Prevention
By necessity, the overwhelming majority of prevention efforts are focused on the
adolescent years, when individuals are at greatest risk for initiating and engaging
in high-risk behaviors that could ultimately lead to substance abuse and behavior
problems. An inordinate amount of research conducted over decades has repeat-
edly shown that if an individual successfully navigates their adolescent years
without initiating the use of addictive drugs, the likelihood of them ever becom-
ing addicted diminishes significantly (Chen, Storr, & Anthony, 2009; Dawson,
Goldstein, Chou, Ruan, & Grant, 2008; Lopez-Quintero et al., 2011). There is
extensive evidence correlating age of initiation of substance use with significantly
greater risks of subsequent substance abuse and dependence. That is not to say
that there are not specific instances and examples of individuals that did not initi-
ate substance use until adulthood and became addicted, just that the incidence
of those occurrences is significantly less than in individuals that initiate use as an
adolescent. Likewise, as the population increases in average age, there is a grow-
ing incidence of seniors who become addicted to prescription pain medications
364 Treatment 

Individual

Legislative Family

Prevention
Programs

Community School

Figure 16.9  Prevention programs are focused on individual, family, school, community,
and legislative initiatives

and are as equally dependent upon them as the heroin addict strung-out in an
abandoned apartment. While programs and policies addressing the senior addict
are important and necessitate research and subsequent action, the vast majority
of prevention programs designed to be as effective as possible and provide the
greatest cost/benefit ratio are targeted at impacting the most vulnerable popula-
tion; youth.
In 2016 The US Surgeon General released the report Facing Addiction in
America: The Surgeon General’s Report on Alcohol, Drugs, and Health that
called for a public health approach to substance use, misuse, and abuse. Five
major recommendations were offered to address alcohol and drug misuse and
substance use as a society. These included: (1) the implementation of effective
prevention strategies and policies to reduce the injuries, disabilities, and deaths
caused by substance misuse; (2) implementation of comprehensive, evidence-
based community prevention programs that are sustained over time; (3) full
integration of the continuum of services for substance use disorders with the rest
of health care; (4) coordination and implementation of recent health reform and
parity laws to help ensure increased access to services for people with substance
use disorders; and (5) future research to guide the new public health approach
to substance misuse and substance use disorders (U.S. Department of Health and
Human Services (HHS), 2016).
It is with those recommendations in mind that we consider evidence-based
practices currently in use to reduce substance use and abuse, particularly among
  Family Recovery 365

youth and adolescents. These evidence-based strategies for reducing substance

use, specifically alcohol since it is the most widely used substance, include limit-
ing availability of alcohol, attempts to make it illegal for those under 21 to drive
after consuming alcohol, and developing ways to identify early problem drinkers
(Harding et al., 2016). Numerous empirically effective school-based prevention
programs have been developed over the past several decades that significantly
reduce the likelihood that participants who complete the programs will engage in
high-risk behaviors (Dent et al., 1995; Hansen, Johnson, Flay, Graham, & Sobel,
1988; Pentz et al., 1989; Thomas & Perera, 2006; Zollinger et al., 2009). Sadly
these multi-session programs, while undeniably effective when properly pre-
sented and attended, are fairly expensive and are far too often not implemented
with fidelity compromising the integrity and the beneficial effects that would
otherwise be gained. To quote the 2016 Surgeon General’s Report, “Prevention
programs and interventions can have a strong impact and be cost-effective, but
only if evidence-based components are used and if those components are deliv-
ered in a coordinated and consistent fashion throughout the at-risk period” (U.S
Department of Health and Human Services (HHS), 2016, p. 74).

Family-Based Prevention
While the vast majority of these preventive programs, policies, and practices
focus their efforts on the target individual, there are numerous evidence-based
programs and effective strategies designed with a specific approach to work
through families and family dynamics. An active and involved family can have a
preventive impact in reducing substance use (and subsequent abuse) through the
monitoring and prevention of high-risk behaviors and development of individual
resiliency factors that is as significant as any role they might play in helping inter-
ventions and treatments to break the cycle of addiction once it has taken hold.
Numerous studies have evaluated family-based prevention programs and have
derived a set of core components that have been found to be effective in reduc-
ing adolescent substance abuse and high-risk behaviors (Bailey, Hill, Meacham,
Young, & Hawkins, 2011; Kumpfer, 2014; Lochman & van den Steenhoven,
2002; Van Ryzin, Roseth, Fosco, Lee, & Chen, 2016). Kumpfer (2014) stated,
“Standardized family-based interventions are the most effective way of prevent-
ing or treating adolescent substance abuse and delinquency” (p. 1). Perhaps not
surprisingly, with the abundance of evidence that shows that delayed initiation
of substance use significantly reduces the likelihood of long-term addictions and
problems, many family-based prevention programs place an emphasis on directly
and indirectly achieving that goal. The Search Institute has initiated more recent
efforts to create and evaluate the impact of a Developmental Relationships frame-
work that identifies 20 key components of powerful relationships adolescents
encounter across different parts of their lives. With youth in the study identifying
parent–youth relationships as the strongest of categories identified, the impor-
tance of the role of parents (and families) in prevention efforts becomes even
more apparent (Roehlkepartain, Syvertsen, & Wu, 2017).
Distinctions are often made in these studies between specific parent-focused
components of prevention programs such as monitoring, involvement, behavior
management, and problem solving, and those youth-focused components to build
366 Treatment 

life skills, resiliency, and positive family relations. Family-based prevention pro-
grams tend to include psychoeducation components surrounding substance use
etiology, parents as role models, importance of anti-drug values, positive fam-
ily engagement and relationships, and proactive monitoring and supervision of
children. However, the largest and most current meta-analysis of family-based
prevention programs found that the addition of two specific components delivered
to the youth themselves will likely add significant impact to program effectiveness
(Van Ryzin et al., 2016). These are: content related to encouraging more positive
family relationships and the encouragement of concrete thinking about/planning
for the future. Inclusion of family-based prevention is significantly important as
family-based approaches have effect sizes two to nine times larger than prevention
programs working only with the child (Kumpfer, Alvarado, & Whiteside, 2003).
Historically, prevention efforts and studies have not had ethnic and racial
minorities as the primary focus (Blume, 2016). However, in recent years, preven-
tion (and treatment) programs have been targeting a wider range of populations,
becoming more inclusive and sensitive to the various contextual factors that vari-
ous racial, ethnic, gender, and sexual minorities experience. As Blume explained,

Culturally relevant prevention programs that focus on the fam-

ily rather than on individuals have been successful, because
they acknowledge beliefs held by many minority cultures
concerning the importance of the family (rather than the indi-
vidual) as the principal unit of function. (p. 50)

Case Application

The Rothers family has been going through the process of addiction. While
Mark is the person who drinks (although Hannah may occasionally consume
alcohol and Steve may be beginning to experiment with drugs and alcohol), the
whole family has developed rules and interactional patterns that are maintaining
and even increasing their misery. The Rothers will also be going through family
recovery. Each individual must adjust in their intrapersonal and interpersonal
functioning in order to develop new rules, roles, and patterns that are more ame-
nable to the family’s desires. For example, Hannah will likely have difficulty not
monitoring Mark’s behaviors, especially as to the possibility of whether he will
drink and what type of mood he is in. Her change in monitoring is related to
Mark not feeling like she is overseeing his behaviors. All members of the family
have developed resentments; some toward alcohol, but likely most toward Mark
and his isolating or angry behaviors. However, Mark has developed resentments
toward various family members; most likely Hannah for trying to get him to
change and Steve for his acting out behaviors.
As family recovery is a process, there may be relapses along the way. Mark
may take a drink or even get drunk. The family may also relapse in that they
engage in negative patterns that were present during the time of active drinking.
The therapist working with the family might engage in psychoeducation so the
family knows that one slip or relapse does not mean that individuals, but mainly
  Family Recovery 367

the family, are not improving. Further, the family can develop greater levels of
hope when they can hold on to and build on their past successes.
The Rothers are currently in the Drinking Stage of Developmental Recovery.
At this point, they would need to be made aware of their own beliefs about drink-
ing and how they may be experiencing aspects of denial. The Rothers have rigid
roles that are restricting the family from being able to grow. We can hypothesize
that the Rothers will, when entering the Transition stage, experience a lot more
conflict in their relationships as the pressure in the family is increasing as peo-
ple are recognizing that change needs to happen but do not know how that is
going to happen. In Early Recovery, their relationships will shift so that there are
more positive relationships occurring. This will help to diminish the monitoring,
resentments, and jealousy that are prevalent in recovering families.
The Rothers can be classified as being a Type II family in Lewis and Allen-Byrd’s
(2001) family recovery typology model. Mark is likely to be the only individual
in recovery. He is the focal point of the family, where most members probably
see his drinking and negative attitude and behaviors as the primary problem in
the family. Looking at the characteristics of Type II families, the Rothers match
them quite well in that there is inequality between partners, with Hannah having
an overwhelming difference in power, where she is the center point of family sta-
bility. Mark is the sole IP. Even though Steve’s behaviors are starting to become
problematic, he has not been expelled, arrested, or found to be doing drugs or
alcohol. The family is currently in some types of denial. Mark’s drinking is seen
as inconvenient and non-desired, but the family has not yet talked about alcohol-
ism or realized that they have organized around the alcohol. There are stability
issues in the family, with tension between Mark and Hannah as well as between
Steve and his parents. Therapy with the Rothers would focus on how to help all
members get to and remain in the action stage, until such time that abstinence
or moderation has occurred and there are positive transactional relationships. At
that point, the therapist would work with them as they transition to the mainte-
nance stage of change.
The Rothers are a wet family system. That is, alcohol is currently being con-
sumed and its use is leading to problems in the family. The therapist working
with them would likely have abstinence or a reduction in drinking as one of
the primary goals of therapy. Once Mark either stopped drinking or drank in
moderation, the therapist would likely focus more on sober family living skills,
which would include helping Mark and Hannah to more effectively co-parent,
supporting positive communication between all members, and developing a more
effective family structure where Mark is not an outsider but has positive influence
as a parent.
The Rothers family has a range of different recovery capital available for them.
Mark and Hannah are both maintaining occupations and are able to provide
for the family all of the basic necessities of life. Each person in the family has
individual resiliencies, such as Kayleigh’s intelligence, Hannah’s caring, Steve’s
independence, Pete’s sense of humor, and Mark’s enjoyment of video games.
Each person has interpersonal relationships that provide support such as Mark’s
friends, Hannah’s siblings, and school friends for the children. Lastly, commu-
nity recovery capital includes many self-help groups for substance abuse that are
located in their community.
368 Treatment 

Summary
Recovery from drugs or alcohol abuse is a process, where not only the ces-
sation of the use occurs, but the interactions of family members change.
Therapists working with families may assess where in the family recov-
ery process the family is in order to adapt and tailor their treatment to
match how the family is functioning. One avenue of treatment is a focus on
relapse, as people tend to view slips or relapses as a sign that nothing has
changed. However, by viewing recovery in a more recursive way, where
treatment spirals back and forth, the family can understand the gains they
have made and may more readily build on these changes. A significant
source of change is recovery capital—the elements in people’s lives that
help them to change and maintain those changes. Therapists can help
clients to access as wide variety of recovery capital to push forward the
change process and increase the possibility of the changes holding.

Key Words
monitoring Type I families
resentments Type II families
jealousy Type III families
recovery wet family system
abstinence dry family system
moderation management resilience
developmental model of relapse
recovery family relapse
Drinking Stage recycling
Transition completing distinctions
Early Recovery recovery capital
Ongoing Recovery personal recovery capital
externalize physical capital
internalize human capital
Family Recovery Typology family/social recovery capital
Model community recovery capital

Discussion Questions
1. What is the process of family recovery?
2. How might family recovery be enhanced by viewing families through
different family types?
3. Discuss recovery capital and the role it plays in people reaching their
goals.
4. How might relapse be viewed in a positive way?
5. What are some strategies of enhancing family recovery?
seventeen

The Self of the Family

Therapist

Regardless of one’s choice of model, understanding oneself, one’s relationship to

the model chosen, and one’s relationship to clients are perhaps the most important
aspects of being a family therapist; or a therapist of any modality. You are the
most important treatment tool that you have available at any moment. More than
a specific theory, empirically-based treatment, or type of intervention, the most
significant aspect that you bring to therapy is you. Understanding yourself and
your role in the therapeutic system is perhaps the key factor for effective treatment.
I have saved this topic for the end of the book because of the integral position
it holds in effective therapy, and I want you to be able to think about everything
you have learned in this book and let it all settle in to how you view people, ther-
apy, and yourself. If the therapist is not aware of who they are, including values,
belief about people, belief about how problems develop, and how they have been
impacted in life to have developed their personal style, therapy will most likely
be stilted. While understanding and being able to apply various therapy theories
is very important, it does not mean much if the therapist utilizing it is ineffective.
In most training programs a majority of the time is spent on understanding
diagnostic categories, counseling theories, and various assessment techniques.
However, what is usually missing is a focus on one of the main players in the
therapeutic system. While we learn about psychopathology and addiction—using
various personality and counseling theories to understand why the client/family
does what he/she/they do—we tend to overlook that the therapist is a human
being who brings themself into the therapy room.
Further, when therapists contact a client, not only is their personality in play,
but also their skills of being a therapist. These are intertwined in their personhood.
When therapists are unaware of self, they do not realize how techniques may be
coming across. For instance, two therapists may engage in the same technique, but
one may do it with a dominant one-up style while the other operates from a more
deferential one-down position. While it will be the connection of the therapist’s
style with the client’s preferences, the therapist should be aware of this dynamic.

Skills for the Family Therapist

Similar to a therapist that works with groups or individuals, the family therapist
has certain characteristics to help them be effective. These include the abilities/

369
370 Treatment 

core conditions that Carl Rogers (1961) put forth; accurate empathetic under-
standing, unconditional positive regard, and congruence. However, the family
therapist must also be able to move beyond the content of what the client is say-
ing and be able to observe, in the moment, the transactional patterns between the
various family members, as well as between the family and the therapist (i.e., if a
couple tries to triangulate the therapist into who between them is right).
In 2004, the American Association of Marriage and Family Therapy (AAMFT)
put forth the Marriage and Family Therapy Core Competencies. This consisted
of 128 competencies organized into six primary domains and five secondary
domains (see Figure 17.1). The primary domains are admission to treatment,
clinical assessment and diagnosis, treatment planning and case management,
therapeutic interventions, legal issues, ethics, and standards and, lastly, research
and program evaluation. The five secondary domains pertain to conceptual, per-
ceptual, executive, evaluative, and professional skills and knowledge.
Besides developing these Core Competencies, therapists working in the sub-
stance abuse field may also need to be able to set limits and boundaries (Myers &
Salt, 2013). Many individuals who are involved with addictions may try to push
boundaries, such as inquiring into the therapist’s past use. Here, it is important
for the therapist to develop boundary rules, which distinguish what each person’s
role is in the therapeutic relationship and what is and is not accepted. These
expectations try to define how each person should be with one another. This
may be difficult when working with an addicted family, as they are most likely
engaging one another through boundary violations (such as the codependent try-
ing to take over for the dependent). Family therapists will need to distinguish

Primary Domains Secondary Domains

Admission to
Conceptual
Treatment

Clinical Assessment
Perceptual
and Diagnosis

Treatment Planning
Executive
and Case Management

Therapeutic
Evaluative
Interventions

Legal Issues, Ethics, Professional Skills and

and Standards Knowledge

Research and Program

Evaluation

Figure 17.1  The AAMFT divides the Core Competencies of Family Therapists into
primary and secondary domains
  The Self of the Family Therapist 371

Family

Agency
Family Therapist Therapist

Therapist

System Family Individual

Figure 17.2  Therapists must develop boundaries that allow them to engage in self-
reflection while interacting with clients and larger systems

themselves when they are alone, in session with a family, or navigating the vari-
ous systems of therapy such as the family, agency, and larger systems (i.e., school,
legal) (see Figure 17.2)

Common Factors of Therapy

Over the last 25 years or so of therapy, there has been a push away from specific
theoretical models of therapy toward an understanding of the common factors of
therapy (Davis & Piercy, 2007; Grencavage & Norcross, 1990; Lambert, 1992).
These are the aspects that all models utilize, in their own way, that lead toward
positive client change. One of the main people in the area of common factors is
Michael Lambert. Lambert, through doing meta-analyses of prior studies into

• Hope and • Extra-

Expectancy therapeutic

15% 40%

15% 30%

• Model • Relationship

Figure 17.3  Lambert’s model of common factors

372 Treatment 

psychotherapy outcomes, delineated four common factors. Miller, Duncan, and

Hubble (1997) adjusted this understanding and provided the following common
factors: extratherapeutic factors, therapeutic relationship, hope and expectancy,
and model factors (see Figure 17.3).
Extratherapeutic factors, which account for 40% of therapeutic change, are
those aspects of the client that lead to change. These usually occur outside of the
session and do not really involve the therapist or the therapeutic process. They
may be issues such as the client maturing and overcoming the problem, having an
epiphany, or other learning situations. We can look at extratherapeutic factors in
terms of the resiliencies we discussed in Chapter 7 and the recovery capital you
read about in Chapter 16.
The therapeutic relationship accounts for 30% of positive change. This factor
addresses the connection between therapist and client and how the therapeutic
relationship acts as the agar for positive change to happen. One of the most
important things that you can do to ensure that your clients reach their goals is to
focus on, as quickly as possible, developing a positive alliance.
Hope and expectancy, accounting for 15% of change, highlights how, when
people expect to change, they tend to change. This can be found in just making an
appointment for therapy. Usually, between the time when the client calls to make
a first session and when they get to that first session, there has already been some
positive movement. This is why Solution-Focused therapists have developed the
pretreatment change question (Weiner-Davis, de Shazer, & Gingerich, 1987),
which asks clients what they noticed that is better between the time they made
the appointment and the actual appointment.
The last common factor Lambert proposed, accounting for 15% of change,
is that of model factors. Here, the aspects of the specific models make a dif-
ference for change. For instance, the use of enactments in Structural Therapy,
helping a client to decrease anxiety in Natural Systems Theory, exploring the
pieces to the miracle question in Solution-Focused Therapy, or providing a
directive in Strategic Therapy helps lead toward change. The model one uses
is important (even if it is an integrative model) as the more the therapist can
utilize the model and believes in it, the greater the hope they will have that
change will happen for the client. However, we know that one model is not
better than another.
Other therapy theorists have proposed that the therapist should be viewed as
a common factor (Sprenkle, Davis, & Lebow, 2009; Wampold & Imel, 2015).
Therapists, regardless of model, are differentially effective. That is, two thera-
pists may operate from the same therapy model but one will consistently get
better results than the other. This may be based on the therapist’s ability to
develop and maintain the therapeutic alliance as well as maintaining fidelity to
the treatment paradigm.
Miller and Moyers (2015) recommended that, in substance abuse therapy, the
variables of therapist effects, client effects, relational effects, and basic processes
are candidates to be studied to ensure effectiveness of treatment. Therapist effects
include the therapist’s ability to empathize, their warmth, reflection-to-question
ratio, and their ability to engage in motivational interviewing. Client effects
include change-talk-to-sustain-talk ratio, change talk strength, self-efficacy,
readiness for change, and experiencing. Relational effects focus on the working
  The Self of the Family Therapist 373

alliance, client feedback, discourse analysis, and talk time. Basic processes include
therapeutic model interventions as well as sequential analysis of therapist and
client discourse.
In this book we have very briefly covered some of the most prominent family
therapy theories. Knowing that one approach is not better than any other, but
that having an approach (including the possibility of an integrative approach) is
paramount to effective work, which theory should you operate from? To answer
this question you have to know yourself and determine which approach fits your
value system.

Matching the Approach to the Therapist

As we have just covered, there are common factors that cut across all therapeu-
tic models. In the field of family therapy there may be more particular common
factors, which include a relational conceptualization, the expanded direct treat-
ment system, and the expanded therapeutic alliance (Sprenkle & Blow, 2004).
There are also philosophical issues that help to determine which approach is a
good fit for the therapist; let alone a good fit with the client. Before an approach
can be useful for the client, it needs to be useful for the therapist. This means
that there is a harmony between the philosophical tenets of the model and the
value system of the therapist. Simon (2003) presented five issues that help to
determine this fit: individual/group; freedom from/freedom for; good/evil; mind/
body; and being/becoming.
The dialectic of individual/group is whether an approach highlights individ-
ual change or is more collectivist—exploring how the individual changes based
on change in the group. Individualist therapies, such as Bowen Natural Systems
Theory, Symbolic-Experiential Family Therapy, Human Process Validation
Movement, and Narrative Therapy understand problems as internal processes
that occur in reaction to others. Collectivist therapies, such as Structural,
Strategic, and MRI: Brief Therapy conceptualize problems at the group level.
The distinction of freedom from and freedom for are housed within an ethical
dimension. They focus on the notion of whether the person gives up self for oth-
ers or maintains the individual as opposed to the group. Therapies that focus on
the welfare of the larger system rather than the individual would be considered
operating from a freedom for perspective. They are freedom for the group. These
would be the Contextual, Strategic and Structural approaches. Freedom from
approaches highlight how the individual can become protected from the forces
of the relationships they are housed in. These models include Bowen Therapy,
Narrative Therapy and Solution-Focused Therapy.
A therapist, in determining where they stand on the good/evil dynamic,
examines whether they view people as naturally moving toward good based on
intellect or whether they are ruled by will. For the former, therapy is geared
toward highlighting what the person is doing that is problematic so that they
can choose to engage self and others differently. Approaches from this orienta-
tion would include Bowen Therapy, Solution-Focused Therapy, and Narrative
Therapy. Therapies based on the latter, where people are ruled more by will,
include the psychoanalytic family therapies, Structural, Strategic, and Symbolic-
Experiential therapies.
374 Treatment 

The mind–body problem explores how internal processes are related to

external events. Questions the therapist might ask include how much does
changing environmental factors influence internal psychological processes.
Idealist therapies put minimal emphasis on the external and much more on
internal meaning-making. Narrative Therapy is an example of this orienta-
tion. Aristotelian therapies place less importance on the power of words and
more on actions that put those words into effect. Approaches such as Symbolic-
Experiential, Bowen Therapy, Strategic and Structural family therapies fall under
this category.
The last area of value exploration for the family therapist that Simon pre-
sents is that of To Be or To Become. Therapies that focus on “To Be” are
more “in-the-moment” type therapies. They attempt to get clients to become
aware of themselves in the moment. Alternatively, “To Become” therapies view
change as a process. Here, what happens in one session of therapy makes sense
within the whole of the therapeutic encounter. Being therapies include Symbolic-
Experiential and Human Process Validation Movement. Becoming therapies
include the Strategic and Structural therapies, Bowen Therapy, and the postmod-
ern approaches.
I know that this is a very brief overview of these types of concepts, but hope-
fully you will begin to explore the underlying philosophical principles that each
approach of therapy is structured around. Once you have explored your own
value system you will be able to better determine which approaches fit your sen-
sibilities. For instance, if you believe in the moral model of addiction, where the
person chooses to engage in substance abuse, working from a model that high-
lights personal autonomy might make sense.
While Simon (2006) holds that it is the therapist that is the bridge between the
common-factors perspective and model-specific factors perspective, Sprenkle and
Blow (2007) argue that therapist expertise and effectiveness vary, even for those
who operate from a specified model. They also argue that therapeutic alliance is
not given enough importance in Simon’s position. This leads to therapists need-
ing to balance their own worldview with that of the client’s, as well as what is
happening in the therapeutic process. Sprenkle and Blow explained, “If a focus
on the therapist’s worldview leads to therapeutic rigidity, it could be iatrogenic”
(p. 111). Thus, they hold that the link between therapy model and common fac-
tors is a skillful/competent/expert therapist.

What Makes a Good Addictions Therapist?

As we talked about above, not all therapists are equal in their skill and effec-
tiveness. Why would some therapists be better than others? And, further, why
are some therapists better at working with individuals and families dealing with
addiction? The following section explores what we know about the characteris-
tics of effective substance abuse therapists.
In 1995, the Center for Substance Abuse Treatment (CSAT) organized the
Task Force on the Characteristics of Effective Addictions Counselors. The task
force developed the following characteristics that good addictions therapists
should espouse:
  The Self of the Family Therapist 375

• the mental health and personal adjustment of the individual counselor;

• therapeutic optimism;
• organizational ability;
• the ability to recognize and maintain appropriate boundaries and balance
client and counselor needs;
• positive experience and convictions about recovery;
• investment in personal and professional growth;
• appropriate ethics and values;
• sense of humor.

The task force recommended that further research occur on these characteris-
tics and whether and how they can be taught.
The task force then provided a list of skills the general therapist should develop
to be able to work effectively with clients dealing with substance abuse. These
new skills included:

• develop appropriate conceptualizations of addiction;

• examine the effects of alcohol and other drugs in their own lives and the lives
of their families;
• be prepared to deal with challenges around personal boundaries;
• view themselves as role models;
• become familiar with 12-step work;
• conceptualize the meaning of “powerlessness;”
• understand the effects of group processes on recovery;
• Learn to be direct if needed.

These skills, in conjunction with the therapist’s model of therapy, help them
to better make sense of how addiction develops and is maintained as well as the
dynamics that occur in the therapy process between client/family and therapist.
While mental health professionals have their perspective of what a substance
abuse therapist should be, so do clients. Rohrer, Thomas, and Yasenchak (1992)
surveyed substance abuse clients to determine the characteristics that they
viewed were important for their therapists to have (and not to have). The top
10 positive and negative traits substance abuse clients wanted/did not want in a
therapist were:

Positive Trait Negative Trait

 1. Understanding  1. Asshole

 2. Concerned  2. Can’t relate
 3. Caring  3. Dishonest
  4. Experienced   4. Treat like children
 5. Honest  5. Uneducated
 6. Certified  6. Bull-shitter
 7. Good listener  7. Rude
 8. Streetwise  8. Foul mouth
  9. Easy to talk to   9. Show favorites
10. Direct 10. Unfair
376 Treatment 

Grosenick and Hatmaker (2000) found that female substance abuse clients
perceived the following therapist characteristics as being influential in obtain-
ing treatment goals: knowledge and experience, supportiveness, nonthreatening
behaviors, and availability. As can be seen, there are some differences between
these various characteristics and those that the CSAT Task Force developed. It
seems that clients also hold that Carl Rogers’ understanding that an open and
honest therapeutic relationship is extremely important for productive therapeutic
work to occur.
There are so many factors that lead to the development of a positive therapeu-
tic relationship. These come in the form of how the characteristics of not only the
therapist but those of the client come together. Some of these may be age, gen-
der, past addictions experience, religion, ethnicity, and sexual orientation. For
instance, Lawson (1982) found that addictions clients experienced higher levels
of unconditionality with therapists who were older than they were. The results
may have interacted with past personal addiction history and therapist experi-
ence. This is something that the therapist cannot control (you cannot determine
that the client will not react to your gender, attractiveness level, accent, race,
etc.). But you do have influence on determining whether any of these factors is
impacting the therapeutic alliance and then discussing them with the client. One
way of doing this is to frequently utilize formal client feedback about the process
and outcome of what is happening in the therapy room (Miller et al., 2006).

One’s Relationship to Addiction

Doukas and Cullen (2010) provided several issues for therapists going into the
substance abuse field. These included their motivation to enter the field, rela-
tionship to self-help groups, potential over-involvement with clients, potential
over-involvement with work, potential over-identification with clients, risk of
relapse through work-related cue exposure, and the repercussions of relapse.
Many substance abuse therapists find themselves in the addiction field because
they want to give back to others having had the experience of being helped them-
selves. Others enter to maintain their sobriety and continue to work on their
own growth. In relationship to self-help groups, substance abuse therapists must
navigate both their clinical work as well as their personal work in the self-help
group. If other group members know the person’s clinical expertise, the therapist
needs to keep these two areas separate to avoid dual relationships. Given that
some substance abuse therapists have personal experience with addictions, they
may be more prone to want to help the addictions client avoid pain, which may
lead to the therapist becoming over-involved with the client. Further, therapists
in recovery who work in the addictions field place themselves into a context in
which they are consistently around substance use cues. This may heighten the risk
of relapse, which would have significant repercussions. This is why all therapists,
but especially therapists in recovery, are encouraged to ensure their own self-care
and maintain their recovery.
In most therapy situations clients do not ask the therapist whether they have
experienced a similar situation as what they are experiencing. Occasionally, a
client going through a divorce, a death of a close family member, or depression
  The Self of the Family Therapist 377

may inquire as to the therapist’s personal familiarity with that type of situation.
But these times are not frequent. In the substance abuse realm, the situation is
reversed. In most situations the client, from the beginning of therapy, delves into
the personal experience of the therapist in dealing with their own addiction. A
person’s desire for their own self-disclosure as well as the person they are in con-
tact with may be related to their exposure to 12-step programs. Mallow (1998)
explained that programs such as AA have a basic premise that growth comes
from opening up to others. If the therapist says that they have never dealt with
addiction personally, the client may seek out another therapist or not put faith in
the therapist being able to help. This is a common thought in the substance abuse
arena; however, it is not accurate.
In looking at the research literature regarding substance abuse therapists with
or without past addiction history, Culbreth (2000) found that client perceptions
of effectiveness of treatment did not change based on whether the therapist was
in recovery or not. These results differ from Lawson (1982) where clients of
therapists in recovery had higher scores on a therapy relationship inventory than
clients of therapists with no past alcohol experience. While there are not differing
treatment outcomes based on therapist recovery status, there are different treat-
ment methods and attitude differences. For instance, therapists in recovery were
found to be more concrete and rigid. Therapists in recovery may also exhibit
lower levels of conscientiousness and emotional stability (Saarnio, 2010).
It is a myth that the therapist has to have experienced addiction and be in active
recovery to help the person who is currently abusing substances. This is not an
expectation in any other area of mental health. The client dealing with obsessive
thoughts and behaviors does not demand that the therapist has been obsessive at
some point in their life. The client dealing with schizophrenia does not expect the
therapist to be in remission from schizophrenia. The couple dealing with domestic
violence issues does not seek out a therapist who was either an abuser of their
partner or had been abused.
While many therapists who work in the substance abuse field have experienced
some type of substance abuse in their own life (either their own addiction or a
family member’s), it is not a necessary criteria. It actually may make therapy
more difficult in some cases. One of the most important skills a therapist can
have is that of being able to be empathetic toward one’s client. The more the
therapist’s personal life is similar to a client’s, the more potential there is for both
understanding and misunderstanding.
Empathy is the ability to be able to feel what another person is feeling. When
we have experienced a similar situation to the person we are in conversation with,
we are able to use our past feelings and understandings as a template to what the
other person is probably experiencing. For instance, if I had been addicted to
cocaine for two years and during that span went through getting fired, a divorce,
and being homeless, I can understand the sadness and desperation of my client
who is now in that type of predicament.
However, although there are similarities, people deal with situations idiosyn-
cratically. There is a danger of misunderstanding and disengagement if I use my
experience as the template for my client’s experience. Perhaps my divorce was
pretty nasty with my partner serving me with restraining orders, attempting to
get sole custody of the children, and hiring lawyers to ensure that they come out
378 Treatment 

on top of the process. Yet my client’s divorce may be much more amiable. If they
tell me they are having a rough time and I say, “This sounds like one of the worst
experiences of your life” I may be overstating the client’s experience. Here, I am
not trying to feel what they feel but get them to feel what I felt in the similar cir-
cumstance, or at least using my own experience as a heuristic for understanding
others. One way to overcome this possible bias is to engage with clients in a “not-
knowing” manner, where the therapist is an expert on engaging in a therapeutic
discourse with the client but the client is the expert on his or her own experiences
and meanings (Anderson & Goolishian, 1992).
Given that overcoming an addiction, especially for those people whose brains
have been altered physiologically (see Chapter 2), is difficult, the non-addictive
addictions counselor might consider trying to change some type of habit they
have which they want to change (Miller, 2005). This prevents the therapist from
telling the client how they changed or what they changed, but may enable them to
be more empathetic to the difficulty of changing a long-standing pattern.
Another potential problem with being in recovery and working with substance
abusers is that your day is filled with talk and focus on substances. If you are
newly in recovery this may be too stressful for you. Therapy as a profession,
regardless of what types of clients and client problems you work with, is stress-
ful. Add a frequent focus on the issue that you are trying to get over and you may
experience more stress than you can handle.
If a client knows that you are in recovery, they may look to you to tell them
how you overcame your addiction. While it is potentially useful for the client
to realize that there is hope—if you were able to move away from substances
and into recovery then they should be able to—there are also potential problems
here. Your path to recovery may not be the same as the client’s. In systems theory
there is a concept called equifinality. In essence, there are many paths to the same
outcome. If we use a baseball analogy this might help to understand this. Take a
second to think about how many different ways there are for an offensive player
to get to first base.
There are six ways (see Figure 17.4). The first is that the batter swings the bat
and makes contact with the ball. The batter may get on first because of getting
a single, a fielder’s choice, an error, or a fielder or umpire obstruction, but they
swung and hit the ball and is at first base. Second, they may be walked (issued
four balls). Third, they might strike out, but on the third strike the catcher did
not cleanly catch the ball and the batter ran to first before the catcher threw the
ball to the first baseman. Fourth, the pitcher might hit the batter with the ball.
Fifth, they could be used as a pinch runner for an existing player on first base.
Lastly, the batter might get on by catcher interference—this is when the batter
swings and the bat hits the catcher’s glove. In using this analogy, hopefully you
can see that if either the therapist or the client expects the other to change based
on the way the therapist did they may be missing out on other potential pathways
toward reaching the client’s goals.
Thus, the substance abuse therapist will almost surely face the dilemma of self-
disclosure and whether to talk about whether or not addictions were a part of
their past. If the client asks the therapist about whether they are in recovery, the
therapist can first inquire with the client as to their worldview of asking that ques-
tion (Mallow, 1998; Nerenberg, 2009). This should be done in a nonjudgmental
  The Self of the Family Therapist 379

Hit

Catcher
Walk
Interference

Getting
to 1st
Base

Pinch Passed 3rd

Runner Strike

Hit by Pitch

Figure 17.4  Equifinality holds that there are multiple pathways to the same outcome,
such as the variety of ways for a baseball player to get to first base

manner so that it is based on a curiosity of the therapist into how the client under-
stands what they are going through as well as their desire for a positive therapeutic
relationship. It is important to work from a position of curiosity about the client
rather than defensiveness, as the former helps promote the therapeutic relationship
while the latter hampers it. Demonstrating to clients that you have an understand-
ing of the addiction process can be important, allowing the client to know that
you will be able to work with them. Diamond (2000) explained, “Most clients
are seeking reassurance that you have some frame of reference for understanding
their plight and are familiar with the language and customs of AA or other 12-step
groups” (p. 318).
When a therapist self-discloses, the boundaries shift between therapist and
client from somewhere more on the rigid side (as more strict psychoanalytic
therapists would be) to clearer boundaries. However, given that the substance
abuse field—especially those who are steeped in the 12-steps—have an expecta-
tion of self-disclosure, there is the possibility that the boundaries can move too
far toward the diffuse side (see Figure 17.5). Given that many clients dealing
with addictions have poor boundaries (Nerenberg, 2009), it is important for the
therapist to be conscientious about what gets disclosed and the impact that it will
have on the therapeutic relationship.
Another reason to potentially withhold information about one’s own recovery
status is that it can lead to the client worrying whether the therapist will, during
380 Treatment 

Low Self-
f Medium Self-
f High Self-
Disclosure Disclosure Disclosure

Rigid Boundaries Clear Boundaries Diffuse

Boundaries

Figure 17.5  Substance abuse therapists must determine how much they want to self-
disclose and the impact on the therapeutic boundaries

the course of the therapy, relapse (Mallow, 1998). While this may not always be
the case, any time a therapist self-discloses they impact the therapeutic relation-
ship. You become more of a person to the client, which changes their focus from
themselves to you.
Whether to self-disclose about one’s relationship to addiction may be based
on the therapist’s orientation as well as the therapist’s belief on the impact that
the disclosure or non-disclosure will have on the client and the dynamic between
therapist and client. Perhaps the deciding factor for the therapist is whether the
disclosure will enhance or detract from the therapeutic relationship.

Therapists in Recovery
For those therapists who happen to be in recovery, depending on the size of the
city that you live in, there may be times when you run into your clients at self-help
meetings. If this happens it is important to separate your working relationship
from what happens in the self-help meetings. Nerenberg (2009) provided several
suggestions for when therapist and client might attend the same 12-step meeting.
It is better for the therapist to attend a different meeting since this will allow them
a safe place to open up and be vulnerable, rather than thinking about how what
they say may impact their client and the therapeutic relationship during future
sessions with that client. As such, it would be up to the therapist to attend a dif-
ferent meeting. Several possibilities would be to attend an online meeting or to
find or develop a therapist-only meeting.

Therapy for the Therapist

When the field of psychotherapy began it was expected that therapists would
go through their own therapy. Given that psychoanalysis was the predominant
approach during the first half of the 20th century, psychoanalysts had to go
through their own analysis, usually consisting of many sessions over many years.
As psychotherapy started to be taught at universities, having a requirement of
one’s own therapy was a standard part of the training. However, in the last
quarter century, this is no longer the case. Most training programs do not require
therapy of their therapists-in-training, but might just suggest it as an overarching
benefit for all students.
  The Self of the Family Therapist 381

Should you go for your own therapy while you are training to become a
therapist? The answer to this is individualistic. There are advantages to having
experienced therapy. You can better understand the position that clients are in
when they first go to therapy. For instance, there is an expectation that during
the first session clients will divulge some of their most personal experiences. This
is not a common thing that we do when we meet people in other contexts, but
it happens in therapy. By going through the therapy experience and recognizing
this issue of immediate self-disclosure, you may be more hesitant to label a client
“resistant” who is hesitant to open up in the beginning phases of therapy.
As the field of family therapy developed, many of the founders thought it was
important for therapists-in-training to experience therapy for the purposes of
growing as a person. Bowen (1992) believed it was imperative that therapists
be able to differentiate from their own family so as not to experience anxiety
during what will inevitably be conflictual and stressful periods in the therapy
room. Minuchin, at the beginning of his career, engaged in his own psychoanaly-
sis (Minuchin et al., 2014). This allowed him to explore aspects of himself which,
when conducting therapy, helped him to develop a homunculus to be more effec-
tive in the room—a homunculus is a little you (metaphorically) that sits atop your
shoulder and provides you with a perspective of you in the situation. It is the
ability for you to be reflective and self-aware, in the moment.
Similar to this is the ability to be mindful while engaging clients. Mindfulness
has become an important concept in the field of therapy during this last decade.
Keane (2013) suggested that a therapist who practices mindfulness may more
readily develop and espouse the core skills necessary for effective therapeutic
relationships. These skills include the ability to stay attentive in the therapy room
as well as engaging in quality empathic contact. Another potential benefit of
mindfulness is that it heightens therapists’ awareness of self-care needs and the
possibility of addressing them. Although mindfulness is a mode of being, rather
than just a technique (Brito, 2013), just doing five minutes of mindfulness center-
ing before a session leads to the therapist believing they are more present in the
session and the client believing the session is more effective (Dunn, Callahan,
Swift, & Ivanovic, 2013).
All therapists have the potential of experiencing burnout. Corey et al. (2019)
explained, “Burnout is a state of physical, emotional, intellectual, and spiritual
depletion characterized by feelings of helplessness and hopelessness” (p. 60).
Elman and Dowd (1997) found the following to be correlates of burnout for sub-
stance abuse therapists: occupational stress, psychological strain, personal stress,
emotional exhaustion, role conflicts, poor attitude toward work, lack of occu-
pational recognition, emotional distress, excessive job demands, and frequent
physical symptoms. Substance abuse counselors are perhaps more at risk of burn-
out than other therapists since they work with quite challenging clients who tend
to not fully engage in therapy and have frequent relapses (Baldwin-White, 2016).
This leads to the possibility of substance abuse therapists leaving their jobs, lead-
ing to high turnover rates at many substance abuse facilities, which is one of the
most significant issues in the field (Young, 2015).
If you do experience distress in your personal life, then it is imperative that you
seek out help for yourself as there is too much risk that your own problems can
impact your ability to help others. This is also an ethical mandate. For instance,
382 Treatment 

Principal 3.3 of the American Association of Marriage and Family Therapy code
of ethics states, “Marriage and family therapists seek appropriate professional
assistance for their personal problems or conflicts that may impair work perfor-
mance or clinical judgment.”

Case Application

As the therapist for the Rothers family, you will need to decide what type of
therapy you think will be most beneficial for them. You will also need to decide
on what level of treatment to provide, such as inpatient, outpatient, individual,
group, or family. Further, you will need to negotiate your views of what will
be most effective with the various family member views. These decisions will be
based upon the setting that you are working at, who in the family initiates therapy,
and your beliefs as a therapist. You will need to be able to navigate the waters of
family relationships, where members will likely try to triangulate you to take their
side against someone else in the family. To be able to make all of these therapeutic
decisions, you will need to be self-aware of yourself before, during, and after the
session so that you do not get swept away in the process.

Summary
This chapter highlights perhaps the most important instrument in all of
therapy—the therapist. In this book, we have presented many different
models of family therapy and ways to conceptualize clients and families
and the various issues they are dealing with. However, if you are not aware
of yourself, your therapeutic style, and actively work to recognize how and
when you are or are not being effective, you will not be tapping into one
of the most important resources in the therapy room, you—the therapist
(Keeney & Keeney, 2013).
Being a family therapist utilizes the skills of the individual therapist
as well as other skills of being able to contextualize problems within
their social contexts. Being an addictions therapist requires the therapist
to understand how substance use and abuse impacts not only individual
functioning, but the familial and relational interchanges that promote and
maintain those symptoms as well.
My hope for you in reading this book is that you will have a more
expansive view of people and problems. So the next time an individual cli-
ent comes into your office stating that they are dealing with addictions (or
any other symptom), not only can you view them through an individualis-
tic lens, but that you will have more resources available to you—that you
can understand how their behavior makes sense within a systemic perspec-
tive. This will provide you with more possibilities of working with them,
either individually or relationally. I wish you good luck on your continued
journey through the field of substance abuse and the family.
  The Self of the Family Therapist 383

Key Words
Core Competencies individual/group
boundary rules freedom from/freedom for
common factors of therapy good/evil
extratherapeutic factors mind–body problem
therapeutic relationship To Be/To Become
hope and expectancy empathy
model factors equifinality
therapist effects self-disclosure
client effects homunculus
relational effects mindfulness
basic processes burnout

Discussion Questions
1. How might an understanding of the common factors of therapy be
useful when first engaging a family where there is addiction present?
2. Review Simon’s five philosophical dimensions and determine where
you fall in the various dialectics.
3. Where is the line in working with a client of self-disclosing too much?
4. Why is it important to focus on the self of the therapist, especially in
addictions counseling?
5. What are the pros and cons of having an experience that is closely
related to the client’s experience?
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Index

absent family system 61–62 Bateson, G. 240, 284, 292–293, 296

abstinence 6, 190, 345, 346, 347 battle for initiative 281–282
accommodation 301 battle for structure 281–282
acculturation 72, 76–78, 84, 86 behavioral addiction 165
addiction (definition of) 4–8 benders 13
adult children of alcoholics 128–130 beneficence 212–213
affiliation 244 benevolent sabotage 287
African American families 79–83; risk bioecological systems theory 16–17;
and protective factors 81–82; and exosystem 16; macrosystem 16;
substance abuse 79–80; youth 81 mesosystem 16; microsystem 16
Africentrism 82 Black, C. 104, 108
agonist drug 27 blackouts 13
Al-Anon 185–186 Black’s family roles 104–108; the acting-
alcohol dehydrogenases (ADHs) 49 out child 107; the adjuster 106;
alcoholic family types 61–63 codependent 105; the placater
Alcoholic Anonymous 182–185 106–107; the responsible child
alleles 42 105–106
alliances 244–245, 301 blood-brain barrier 42
American Indian families 87–92; risk and boundaries 55, 57, 63, 65, 120, 137,
protective factors 90–91; substance 243–244, 300, 379–381; clear 120,
abuse 88–89; youth 89–90 243–244, 300, 380; diffuse 243–244,
amino acids 41 300, 379–380; rigid 300, 349,
antagonistic drug 27 379–380
antianxiety and sedative hypnotics 32–34 boundary making 302
anxiolytic 32 boundary rules 370
ARISE 190–192; level 1 191–192; level 2 brief strategic family therapy (BSFT)
192; level 3 192 326–330
assent 216 BSFT elements of family interactions
Asian American families 83–87; risk and 328–329; conflict resolution 327;
protective factors 86; and substance developmental stages 328; family
abuse 84–85; youth 85 organization 327; identified
attachment 125–126, 266 patient 328; life context 328;
autonomy 215 resonance 327
authoritarian parents 244 BSFT intervention 329–330; planned 329;
authoritative parents 244 practical 329; problem-focused 329

423
424 Index 

chairperson 198 cross-tolerance 32

chaotic family 66 culture (definition of) 72
chief enabler 101 cybernetics 240, second-order 254
child abuse 141–143
child sexual abuse 143–144 deescalating symmetrical relationship
children of alcoholics 124–128 250–251
circular perspective 246 definitional ceremonies 313–314
circular question 298 delirium tremens 34
circularity 298 deoxyribonucleic acid (DNA) 40
closed system 245 dependent 98, 101, 104
coalition 244–245 destructive entitlement 271–272
codependency 105 detouring conflict 301
coding DNA 41 development model of recovery 347–352;
codon 41 drinking stage 348; early recovery
cognitive behavioral therapy 168 350; ongoing recovery 350;
cognitive life raft 130 transition 349
cold turkey 8 diagnosing 231–232
command message 246 Diagnostic and Statistical Manual 4
common couple violence 139 differentiation of self 263
common factors of therapy 371–373; difficulties (definition of) 284
extratherapeutic factors 372; hope dimensions of relational reality 269–271;
and expectancy 372; model factors facts 269; individual psychology
372; therapeutic relationship 372 270–271; ontic 270; relational
communication stances 275–279; blamer ethics 270; systems of transactional
276; congruent 278; irrelevant patterns 270
277; leveler 278; placate 276; directives 294
superreasonable 276 discussion meetings 184
Community Reinforcement and Family disease model of addiction 11–15
Training 168–169 disintegrated family system 62
comorbid see dual diagnosis diversity (definition of) 71
competence 214 domestic violence 136–141; power and
complementarity 264, 301 control 137–138
complementary relationships 251 dominant discourse 310
completing distinctions 356 dominant story 310
compliments 309, 336 dose-dependent 32
compulsive buying disorder 172 drugs (definition of) 6
concerned significant others 193 dry family system 354
confidentiality 217 dual diagnosis 149–151; definition of 6
confrontation 196 dual relationships 220–221
consciousness raising 152 duty to protect 224
consent event 216 duty to warn 226–227
consent process 216–217 dysfunctional family triangle 275
content 330
context 245 economic abuse 139
contextual therapy 269–273 emotional cutoff 267–268
core competencies 370 emotional disruptive families 66
counter documents 315 emotional system 262
counterparadox 296 emotional violence 139
covert rules 57 empathy 377
CRAFT program 193–195 enabler 101–102
craving 6 enactment 302, 329
craziness 281 enculturation 72
cross-generational coalition 301 endogenous chemicals 27
 Index 425

enmeshment 244, 300, 328 first-order change 252–253, 284

entitlement 271 Five Principles of Intervention 199
epigenetics 48–49 formula tasks 308; do something
equifinality 378 different task 308; first session
escalating symmetrical relationship 250 formula task 309; structured fight
ethical decision making 234–235 task 308
ethical principles 212 functional family triangle 275
ethics 212
ethnic identity 72 gambling disorder 165–166
exceptions 304, 308; deliberate 334; gene targeting see gene trapping
random 335 gene trapping 45
exogenous chemicals 51 gene-environment interaction model 43
exoneration 272 genes 40–41
experiential approaches 273–283 genetic risk scores (GRS) 48
exposing family 66–67 genetic vulnerability to addiction 42–52
externalizing (Narrative Therapy) 312 genogram 20–23
externalizing behavior problems 126 genogram within community context 22
externalizing conversations 313 genome-wide association studies (GWAS)
Eye Movement and Desensitization and 44–46
Reprocessing 171 genotyping 42

facilitated disclosure 230 Haley, J. 292, 326

familismo 74 hallucinogenic drugs 35–36
family ecomap 22–23 harm reduction 234
family game 296–297 here and now 273
family life stages 117–223; families with heritability 43
adolescents 119; families in later life hero 102
123; family motivation to change hidden customer 334
model 191; families with young Hispanic American families 73–79; risk
children 118; launching children 119; and protective 76–77; substance
the new couple 118; single young abuse 75; youth 75–76
adult 118 homeostasis 30, 55, 248–250, 293
family myth 297 homunculus 381
family projection process 265–266 horizontal loyalty 271
family reconstruction 280 human validation process movement
family recovery typology model 352–353; 274–280
Type I families 352; Type II families hypothesizing 298
352; Type III families 353
family relapse 355 identified patient 15
family rituals 297; odd days/even days incest 143
ritual 297 indebtedness 271
family sculpting 279 indulgent parents 244
family systems model of addiction 15 information 298
family therapist value system 373–374; informed consent 216
freedom from/freedom for 373; inhalation drugs 31–32
good/evil 373; individual/group 373; intergenerational approaches 261
mind-body problem 374; to be/to intermarriage 88
become 374 internalizing behavior problems 126
family typology of addiction 66–67 internet addiction 174
fetal alcohol abuse syndrome 144–147 internet gaming disorder 174
fetal alcohol syndrome disorder 145 interventions 195–200
fidelity 219–221 intimate partner violence 114,
first caller 191–192 136–137, 227
426 Index 

Jellenik, E. M. 12–13 multigenerational transmission process

Johnson’s family roles 111–114; the 262, 267
blamer 113; the codependent 114; the mutuality 248
controller 112–113; the enabler 113;
the intervener 114; the loner 113; the narrative therapy 309– 315
protector 111–112 Natural Systems Theory 261–269
joining 301, 322–323 negative feedback 248
justice 217 negativism 58
negligent parenting 244
Kaufman, E. 61–63 neurotic enmeshed family system 61
knockout mice 45 neurotransmitters 27
neutrality 233
landscape of action 312 nightmare questions 335
landscape of consciousness see landscape non-coding DNA 41
of identity non-discrimination 217
landscape of identity 312 nonmaleficence 213–214
larger systems 242–243 nuclear family emotional system 264–265;
ledgers 271 emotional distance 265; illness in a
life support system of the problem 311 spouse 264; impairment in one or more
life-long addiction 13–14 of the children 265; marital conflict 265
lineal perspective 246 nucleotides 40
linkage region 50
lost child 103 open system 245
loyalty 271 ordeals 295
lysergic acid diethylamide (LSD) 35 other customer 334
outsider witness 314
marianism 75 overt rules 57
marijuana 31
mascot 103–104 paradox 296
matricentric female-headed family paradoxical ordeal 295
pattern 79 parallel relationships 252
MDMA 35–36 parallel treatment 150
merit 270 parental denial 59
mesocorticolimbic dopamine system 30 parental inconsistency 58–59
mesocorticolimbic dopaminergic pathway 28 parental subsystem 300
mesocorticolimbic reinforcement system parentification 60, 124–125
28–31 parsimony 332
metacommunication 246 partial treatment 150
metamessage 99 pathogenesis 331
microRNAs (miRNAs) 49 patriarchal terrorism 139
Milan session format 297; conclusion 298; patriarchy 75
intersession 298; postsession 299; peer group affiliation 80
presession 298; session 298 personal agency 313
Milan systemic family therapy 296–269 phases of the alcoholic family 63–65; early
mimesis 302 phase of alcoholism 63; late phase
mindfulness 381 of alcoholism 65; middle phase of
miracle question 307 alcoholism 64
models of addiction 10–15 phase of alcoholism 13; chronic phase 13;
moderation management 188–190, 345 crucial phase 13; pre-alcoholic phase
moral model of addiction 11 13; prodromal phase 13
multiconfidentiality 229–230 phases of domestic violence 139–141;
multidimensional family therapy 321–325 abuse 141; honeymoon phase 141;
multidirected partiality 232, 272 tension building phase 140
 Index 427

physical domestic violence 137 self-disclosure 221, 378

polymorphisms 41–42 self-help groups 182–183
positive connotation 297 sequential treatment 150
positive feedback 249 setbacks 336
pretend techniques 295 sex addiction 169–170
primary family triad 275 sexual domestic violence 138–139
problem-saturated 311 short tandem repeats (STRs) 42
problem-talk 304 sibling position 268
problems (definition of) 284 sibling subsystem 300
process 330 slip 7
protective families 66 sobriety-intoxication cycle 64–65
protein 41 social justice 218–219
psychedelic drugs 35–36 societal emotional process 268–269
psychoactive drug action 26–31 solution-focused client types 305–306;
psychological domestic violence 139 complainant 305–306; customer
psychotropic drugs 6 305–306; visitor 305–306
punctuation 246 Solution-Focused Brief Therapy 304–309
solution-talk 304–305
reauthoring conversations 315 speaker meetings 184
receptors 27–28 species of alcoholism 12–13; alpha
recovery 345 alcoholism 12; beta alcoholism
recovery (definition of) 7 12–13; delta alcoholism 13; gamma
recovery capital 357–359; community alcoholism 13
recovery capital 358; family/social split loyalty 271
recovery capital 357; human capital sponsor 182
357; personal recovery capital 357; spousal subsystem 300
physical capital 357 stages of readiness for change model
recycling 356 151–154; action 153; contemplation
reframing 286 152; maintenance 153;
reframing interventions 328 precontemplation 152; preparation
relapse 7, 355–357 153; termination 153
relational suicide assessment 225 stages of Satir therapy 279–280; chaos
re-membering conversations 313 279; integration 279; making
report message 246 contact 279
resiliencies 130–132; creativity 132; humor step meetings 184
132; independence 131; initiative stimulants 34–35
132; insight 131; morality 132; story/self-narrative 309–310
relationships 131 straightforward task 295
restructuring 328 strategic family therapy 292–295; stages of
ribosomes 41 a first session 294–295
“risky” genes 49 structural family therapy 299–303
rite of passage metaphor 315 subordinate storylines 312
substance abuse (definition of) 7
safety plan 226 substance dependence (definition of) 7
salutogenesis 331 substance use (definition of) 7
sandwich generation 119 substance-related disorders 4; substance-
scaling questions 308 induced disorders 5; substance use
scapegoat 103 disorders 5
second-order change 253–254, 284 subsystem 240, 300
secrets 230–231 suicide 222; suicidal ideation 221;
sedative 32 suicidal intent 221; suicide attempt
selective disclosure 231 224; suicide plan 224; suicide
self-care 215 threat 224
428 Index 

survival roles 100 triangles 263–264

symbolic-experiential family therapy 274, twelve steps 183–184
280–283
symmetrical relationship 250 unbalancing 302
symptoms 256 unilateral family therapy 182
system (definition of) 240 unique outcome conversations 314
unique outcomes 311
taking responsibility 313 universality 182
tetrahydrocannabinol (THC) 31 utilization 321
therapeutic system 254
therapist responsibility 144 variable number tandem repeats (VNTRs) 42
therapists in recovery 380–382 veracity 221–222
tolerance 7 vertical loyalty 271
tracking 301–302
tracking and diagnostic enactment 327 Wegscheider-Cruse, S. 100–104
transcription 27 wet family system 354
translation 41 withdrawal 7