Counseling Family Members by pcherukumalla

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									Counseling Family Members
of Addicts=Alcoholics: The Stages
of Change Model
Katherine van Wormer, Ph.D., MSSW
ABSTRACT. This article adapts the stages of change model, a model
in which specific interventions of harm reduction are directed toward
the client’s readiness for treatment, as a guiding framework for counseling
family members of alcoholics=addicts. Interventions at each stage
of the family’s readiness for change, from precontemplation to action,
are described.
KEYWORDS. Alcoholism, families, stages of change, transtheoretical
approach
The family is a system composed of members in constant and
dynamic interaction with each other. Patterns of interaction get
established: who interacts with whom, who talks and who listens,
who has the authority and who is the controlling force behind the
scenes. The family has a pattern, a rhythm that is more than the
sum of its parts. Any change in the behavior of one of its members
affects not only each of the others but the system as a whole.
Addiction, accordingly, is often defined as an illness not just of the
Katherine vanWormer, Ph.D., MSSW, is Professor of Social Work, University
of Northern Iowa.
Address correspondence to: Katherine van Wormer, University of Northern
Iowa, 30 Sabin Hall, Cedar Falls, IA 50614.
Journal of Family Social Work, Vol. 11(2) 2008
Available online at http://jfsw.haworthpress.com
# 2008 by The Haworth Press. All rights reserved.
202 doi: 10.1080/10522150802174319
individual but of the whole family. Sometimes the misery is so intense
that the system barely functions.
Families are important in both the etiology of addiction and its recovery
(Gruber & Taylor, 2006). In relapse prevention, success in establishing
a social support network raises the chances of long-term treatment
success. Family therapy, even in only a few sessions, can be invaluable
in reducing the feelings of guilt or confusion in significant others. Family
counseling, moreover, can be invaluable in preparing the family for
changes that are needed to enhance and maintain the addicted person’s
recovery. That is what this paper is about—the change process itself
and motivation for change at every level of the treatment process.
Paralleling the individual substance user’s pathway from experimentation
to addiction is the family’s progression along a continuum
from stability to a loss of control over events relevant to the family,
employment, child care, and general family functioning. Changes in
the addictive behavior—for example, gambling—are met by changes
in family roles and relationships. The changes may not be direct. One
truth about relationships is that there tends to be a lag between the time
when a condition, such as addiction (etc.), surfaces and when the reality
becomes truly accepted. The situation can become even more complex
as individual family members are at different places along the continuum
of recognition of the need to take action against a serious problem.
To reflect this developmental process and the need to shape treatment
interventions accordingly, I have chosen as the most appropriate
model, the stages of change model. This model initially was developed
by Prochaska and DiClemente (1986) to describe the process of
smoking cessation and further developed and modified by Miller
(1999) and Miller and Rollnick (2002). Patricia Dunn (2000) finds
the stages of change model appropriate for social work because it is
compatible with the mission and concepts of the profession, is an
integrative model, and is grounded in empirical research. Through
building a close therapeutic relationship, the counselor can help the
client develop a commitment to change and proceed at his or her
own pace. In working with families with substance abuse issues, such
patience and empathy are paramount. Yet there is much work to do
in families of this sort; the anger and denial can be palpable.
Sometimes, the anger and resentment by significant others need to
be addressed before a recovering family member is returned to the
family setting. Sometimes, of course, the family environment itself
is toxic, several of the participants having serious problems with
Katherine van Wormer 203
boundary issues or drugs, for example. Here, too, interventions must
be directed toward the whole family. To treat the individual in isolation
is to ignore the context in which much of that behavior takes
place. To know the context, an understanding of the systemic intergenerational
nature of addiction is essential.
Even more than ordinary illness, addiction is a source of major stress
that reverberates through the family system and affects the family’s
interactions with every other system in the community. The emotional
and financial resources of the family may be almost entirely depleted
by the stress of the addict’s illness. The havoc wreaked on the family
by alcohol misuse is even more dramatic and progresses more rapidly
when a drug such as methamphetamine (meth) enters the picture.
Qualitative data based on interviews with former meth addicts reveal
that communication and caregiving duties break down to the extent
that the well-being of the children and the family as a whole are in dire
jeopardy (see Brown & Hohman, 2006). In Iowa, as revealed in media
reports, hundreds of parents are losing custody of their children, a trend
seen only in recent years as meth has secured its grip statewide (Reiter,
2003; Rood, 1999; van Wormer & Davis, 2008).
Perhaps because of the difficulty of working with such chaotic
families and the stigma of addiction in general, the family therapy field
has devoted little effort to addictions-focused treatment and has
tended to refer drug-afflicted members to specialized services or selfhelp
groups. And because of the difficulty that substance abuse treatment
centers face in working with the whole family, combined with
third-party reimbursement disincentives to do so, often little more
than lip service is given to family members’ needs by these treatment
centers. The recent emphasis on the importance of engaging members
of social networks in treatment appears to be focused on retention of
the alcoholic or addict in treatment or in getting the family to see that
the individual take recommended medications rather than to be
actively involved in the treatment process as a family (Loughran,
2006). Too often, any family that does not match the traditional mold
tends to be invisible, while the importance of the extended family as a
vital resource goes unrecognized. Yet, for children and partners in the
family system, the need to sort out their feelings and to learn more
about the nature of the problem that has so consumed them over the
years is crucial for long-term recovery of everyone involved.
In contrast to traditional family therapy, the family treatment
interventions described in this paper are designed to elicit resilience
204 JOURNAL OF FAMILY SOCIAL WORK
and healing in family members rather than to uncover the family’s
presumed role in causing and perpetuating the addiction. I have
adapted interventions to parallel the readiness of the family for
change, a phase approach. The phase approach views treatment
needs in terms of the five basic intervals stretching from precontemplation
through the maintenance period. Keep in mind that, in
reality, there is no clear-cut division among the stages and that the
sequence of the progression is oversimplified here for the sake of
explanation. The stages of family needs, moreover, may or may not
directly correspond to the alcoholic or addict’s stage of recovery.
Family members, for example, may be far more ready for change
in the direction of sober lifestyle than is the person with the severe
problems.
THEORETICAL FRAMEWORK
Sometimes called a transtheoretical approach because it relies on
several theories of social psychology, the stages of change model
was first proposed by Prochaska and DiClemente (1986) to describe
how smokers who were able to break their nicotine habit successfully
did so. Their concern was with the movement of people from denial
of the need to change (called precontemplation) to the reaching of a
decision to adopt a healthier lifestyle (preparation) and then the taking
of steps to do so (action). The focus of this model was on the individual’s
motivation to change. This framework has played an integral
role in the development of motivational interviewing.
Miller and Rollnick (1991) set forth an empirically based formulation
of motivational interviewing (MI) in their groundbreaking
text Motivational Interviewing: Preparing People to Change Addictive
Behavior. The goal of MI is basically harm reduction. The method is
to elicit statements in the individual with substance use or other
destructive behaviors that are in a positive, health-seeking direction
and to reinforce those statements. Miller and Rollnick incorporated
in their model Prochaska and DiClemente’s notion that change
involves a psychological progression, that therapist interventions
must be carefully tailored to the client’s readiness to change
(Prochaska & Norcross, 2007).
Europeans, immersed in the harm reduction perspective, had earlier
in the 1980 s adopted this theoretical approach and incorporated
Katherine van Wormer 205
it in treatment programs (van Wormer & Davis, 2008). The United
States, reticent at first and steeped in a tradition of harsh confrontational
strategies directed toward clients who had ‘‘hit their bottom,’’
has begun now to move in this direction. The dual influence of favorable
empirical research proving the effectiveness of short-term, motivational
treatment and of decisions by insurance companies to
reimburse such evidence-based practices has reshaped the treatment
industry in the United States (van Wormer & Davis, 2008). The concept
of stage-based treatment is central to integrated treatment for
addicted clients with mental disorders as well, in that it provides a
framework for assessing clients’ motivational states and gearing interventions
corresponding to the client’s degree of readiness (Mueser,
Noordsy, Drake, & Fox, 2003).
In every stage of the Prochaska and DiClemente model, extending
from precontemplation through maintenance or relapse, resolving
ambivalence is a central theme of focus (DiClemente, 2006). This
approach has been found to be helpful in work with partners with substance
abuse problems in regard to resolving ambivalence about change
(O’Farrell & Fals-Stewart, 2006). Helping people make decisions that
will benefit their lives, similarly, is the overriding goal of motivational
enhancement therapy. An important point enunciated by Prochaska
and Norcross (2007) is that if one tries to use strategies appropriate to
a stage other than the one the client is at, the intervention will be ineffective.
If the client is only barely motivated to contemplate giving up
a favorite habit and needing some guidance in weighing the pros and
cons of change and the counselor pushes for 12 Step involvement, the
result most likely would be treatment resistance or noncompliance.
Let’s consider a family member’s typical client statements at each
stage of the stages of change continuum (see Table 1).
Through a close therapeutic relationship, the counselor can help
people develop a commitment to change (Prochaska & Norcross,
2007). Motivational theory states that if the therapist can get the
client to do something, anything, to get better, this client will have
a chance at success. This is a basic principle of social psychology
(van Wormer & Davis, 2008). William Miller (1998) pinpoints the following
tasks as predictors of recovery: going to AA meetings, coming
to sessions, completing homework assignments, and taking medication
(even if a placebo pill). The question, according to Miller, then
becomes, How can I help my clients do something to take action on
their own behalf? A related principle of social psychology is that in
206 JOURNAL OF FAMILY SOCIAL WORK
defending a position aloud, as in a debate, we become committed to it.
One would predict, according to motivational enhancement theory,
that if the therapist elicits defensive statements in the client, the client
would become more committed to the status quo and less willing to
change. For this reason, explains Miller, confrontational approaches
have a poor track record. Research has shown that people are more
likely to grow and change in a positive direction on their own than if
they get caught up in a battle of wills. In their seven-part professional
training videotape series, Miller, Rollnick, and Moyers (1998) provide
guidance in the art and science of motivational enhancement. In this
series, the don’ts are as revealing as the do’s. According to this therapy
team, the don’ts or traps for therapists to avoid are:
. A premature focus such as on one’s addictive behavior
. The confrontational=denial round between therapist and client
. The labeling trap—forcing the individual to accept a label such as
alcoholic or addict (to this Iwould add chief enabler and codependent)
. The blaming trap, a fallacy that is especially pronounced in the
counseling of couples
. The question=answer habit, which is characterized by the counselor
asking several questions in a row and relying on closed yes or no
responses; this exchange paves the way for
. The expert trap, whereby the client is put down; the opposite of the
expert trap is a collaborative exchange of information
TABLE 1. Stage Specific Motivational Statements
Stages of change Family Member Comments
Precontemplation We really don’t have much to do with this problem; I’ve had
enough
of blaming by psychologists and interfering social workers.
Contemplation The assessment they did on B. was a lot of bunk. Who do these
‘‘experts’’ think they are? Still, there was one part of it that rang
true.
Preparation I can’t take it anymore. My home life is a shambles. B. was doing so
well, but now has had a relapse. Last week you said that there
were some things I could do to help.
Action Sobriety may be healthy, but it sure makes for a dull family life.
Maybe I’ll check out one of these Al-Anon groups that you
mentioned. Maybe there are others like me out there I can talk to.
Maintenance It’s been a few months; our family is not there yet, but the kids are
getting a lot out of the Al-Ateen group, and I’m beginning to set
some goals for myself.
Katherine van Wormer 207
These precautions relate exceptionally well to work with families,
as does the motivational theorists’ handling of family member resistance.
As he states in the videotape on motivational enhancement,
Miller is uncomfortable with the term resistance; his preference is
to think of clients as simply cautious in trusting the therapist. To
establish such trust and enable the client to elicit the desired selfmotivated
statements or insightful statements as, for example, ‘‘I
think I do have a problem,’’ the skilled therapist relies on open and
multifaceted questions, reflective listening, and purposeful summarizing
of the client’s story. Key to this process is the reframing of the
client’s story in the direction of decision making. A format such as
‘‘I sense that you are saying, on the one hand, that smoking means
a lot to you and, on the other hand, that you are beginning to have
some health concerns about the damage that the smoking is causing
you or may cause you in the future’’ provides helpful feedback to the
reluctant client by reflecting back to him or her what is heard. Keep
the precautions in mind, as we will return to them in our discussion of
the individual stages.
Following the formulation set forth by Miller and Rollnick (1991;
2002), Prochaska and Norcross (2007), and Wallen (1993), major
tasks for the addiction counselor at each stage of decision making
directly parallel the family member’s state of mind. During the initial
period, for example, goals are to establish rapport, to ask rather than
to tell, and to build trust. Eliciting the person’s definition of the situation,
the counselor reinforces discrepancies between the client’s and
others’ perceptions of the problem.
DEVELOPMENTAL APPROACHES TO FAMILY
ILLNESS
In traditional substance abuse treatment, the family was often
viewed as dysfunctional, lacking healthy communication styles, and
so forth. In light of what counselors had come to know of life in
an ‘‘alcoholic home,’’ often such as the one they themselves had come
from, such negative expectations are understandable. Take, for
example, the words of one survivor of such family life:
Communication in my family was sick. I remember coming
home and feeling like I was walking on eggshells every day
208 JOURNAL OF FAMILY SOCIAL WORK
because I never knew what the mood would be. I spent a
lot of time being tense. We were not allowed to discuss our
problems with outsiders or bring outsiders into the home.
We were not allowed to have any feelings except laughter.
If we were hurt, we could laugh but not cry. I was told
exactly how to feel, so to this day I have a hard time
describing how I actually feel. (from van Wormer’s personal
files)
During family programming the focus has largely been on negative
patterns of interaction and signs of enmeshment or codependency,
rather than on their resilience in dealing with family illness. Family
members were often advised that their efforts to compensate for
the alcoholic or addict’s malfunctioning were only making the situation
worse, that alcoholics had to ‘‘hit their bottom’’ (van Wormer
& Davis, 2008). Fortunately, today professionals schooled in family
counseling techniques and a social work’s strengths perspective have
brought to addictions work a modified and highly useful understanding
of family pain and dynamics. And a gradual paradigm shift in
thought from family-as-enemy to family-as-treatment-ally is underway.
Work with the whole family is now recognized, at least theoretically,
as a vital component in addiction treatment (Center for
Substance Abuse Treatment [CSAT], 2004), and the family is now
commonly viewed as more of a resource than a hindrance on the road
to sobriety.
Wallen’s (1993) Addiction in Human Development offered a developmental
perspective to substance abuse family treatment. Because
alcoholic families often resist change, as Wallen noted, particular
attention must be paid to their life cycle stages as the system adapts
to the problem drinking of a family member. Families as well as individuals
move through stages of recovery, recovery which affects the
balance or equilibrium that has evolved through the underfunctioning
of one family member. The final stage of recovery, according to
Wallen, involves restoring the system to a balance to maintain
sobriety.
From systems theory we learn that each family will have its own
peculiar style of adaptation: coping through hiding key resources
(money), blaming, covering up for the addictive behavior, joining
in the addiction, and becoming extremely touchy with outsiders
(van Wormer & Davis, 2008). The stress of the addictive pattern
Katherine van Wormer 209
(for example, gambling and winning, gambling and entering a losing
streak) has a synergistic or multiplying effect throughout the family
system and related social networks. The family, awkwardly, may
come to serve in a mediating role between the addict and other systems
in the environment such as work, school, and extended family
members. Gradually, as the illness progresses, the bridges between
the alcoholic and his or her social world will be broken. The family
may then adapt to social isolation and continual stress of the progressing
alcoholism, or members may regroup and form a reconstituted
family without the addict. A third alternative, of course, is treatment
for the family, either separately or in conjunction with treatment of
the alcoholic or addict. Treatment considerations would focus on
the development of new, non-destructive communication patterns
and adaptation to changes associated with recovery.
Unilateral family counseling, as Miller (2006) indicates, utilizes an
approach that is conceptually opposite to Al-Anon. Whereas the
focus of Al-Anon is stressing the powerlessness of the family member
over the loved one’s substance use and on detaching from their chemically
dependent partner or relative, the focus in MI is in counseling
family members that indeed they can have substantial influence in
helping the drinker or user make some moves in a positive direction.
This is not to say that Al-Anon does not have a role to play in helping
family members focus on their own needs but rather that the
approaches of MI and Al-Anon are somewhat different.
Despite the fact that the partners of alcoholics do not necessarily
have a disease, only the symptoms of struggling against someone
else’s disease, individual and family therapy can be extremely
beneficial in the healing process for these survivors. Work in the
area of self-esteem can do much to help resolve powerful feelings
accompanying years of abuse and unshared pain. Consistent with
motivational interviewing and the strengths perspective, use of
negative labels such as ‘‘chief enabler’’ and ‘‘codependent’’ should
be avoided. Terms such as survivor and family manager might be
used instead and the focus placed on survival skills rather than
enabling the addictive behavior to persist (van Wormer & Davis,
2008). Taking a cross-cultural perspective, Cable (2000) points out
the European-American middle-class bias of the codependency
movement with its ‘‘one-size-fits-all’’ prescription for normality.
This prescription includes an emphasis on detachment, on taking
care of oneself.
210 JOURNAL OF FAMILY SOCIAL WORK
THE STAGES OF CHANGE AND FAMILY
TREATMENT
Within Project MATCH, the widely cited comparative study that
validated treatment effectiveness of motivational as well as of other
strategies, the success of treatment outcomes was shown to be
related to the extent to which the client’s social network was supportive
of sobriety (U.S. Department of Health and Human Services,
1999). Project MATCH did not provide such treatment but
did conduct follow-up studies on subjects in the experiment.
Researchers found that emotional support from one’s partner was
a key factor in long-term recovery. In recognition of this finding,
we should perhaps do more than we have in the past to boost this
source of support.
In their review of the literature, Waldron and Slesnick (1998) and
McCrady (2006) concluded that family treatment is an effective
undertaking for both adults and adolescents with problem substance
use, in that such intervention is associated with higher rates of treatment
compliance and retention than is treatment without family
involvement. Having a functioning support system is crucial in promoting
change efforts and in preventing a lapse to previous problematic
behavior. Since family members often develop problems in
response to someone else’s drinking or other drug use, including early
experimentation with psychoactive substances by children, getting the
whole family together for counseling should be a standard of addiction
prevention (Velleman, 2000). Family sessions offer an opportunity,
moreover, to help children in the family understand some of
the stresses their non–problem drinking parent has been under, as
Velleman suggests.
Family therapy interventions, to be effective, need to be geared
toward the family’s stage of recovery. This stage may or may not parallel
the addict’s motivation for change or actual changed behavior.
The following scheme adapts Prochaska and DiClemente’s (1992)
and DiClemente (2006)’s stages of change model for therapeutic work
with family members. The four motivational interviewing principles
are key to this process. These are: expressing empathy, developing
awareness of discrepancy between goals and behaviors that obstruct
the goals, rolling with resistance instead of arguing with the resisters,
and supporting client self-efficacy or confidence in one’s ability to
Katherine van Wormer 211
overcome difficulty (Burke, Vassilev, Kantchelov, & Zweben, 2002;
Prochaska & Norcross, 2007). Note the development role of the
therapist in each of the following stages. In some ways, as Prochaska
andNorcross (2007) indicate, this sequence of stances parallels the changing
roles that effective parents play as their children grow through the
stages of personal development. The amount of structure provided varies
with the stage across the life course as it does in treatment.
Precontemplation
Family members of an alcoholic or addict are determined to be
precontemplaters if they are not ready to support the client’s process
of change. It is unlikely that members of such a family unit will
approach the treatment center for help on their own. They might
be encouraged to attend a family evening–type program, however,
as when a family member gets in trouble with the law such as through
a drinking while intoxicated (DWI) conviction and follow-up assessment
or through a child welfare referral. In any case, rules of the family
at this stage of recovery are likely to be of the ‘‘don’t talk, don’t
trust, don’t feel’’ variety (Black, 2002) so members are reluctant to
share their family secrets.
In working with a family in which there are addictive problems, the
therapist might start by helping members to identify their family’s
goals. He or she asks open-ended questions such as these: ‘‘What
brings you here?’’ ‘‘What would you like to happen on our work
together?’’ ‘‘If you change some things, what would they be?’’
As required by the court or insurance company, assessment most
often is solely of the individual addict, with input from family members
being provided, if at all, at a later stage. Zweben (1999) recommends,
however, involvement from the start. He assesses the family
members’ suitability for such involvement by meeting with the client
with the designated substance abuse with the family members to
assess for two things. The first is whether the significant other has
strong ties to the client, and the second is to determine whether
motivational statements made by the client will be supported by
the significant other.
Although participation of significant others in treatment has been
found to be one of the best predictors of cocaine abstinence, Laudet,
Magura, Furst, Kumar, and Whitney (1999) found the male partners
of cocaine-using women to be far more difficult to engage in family
212 JOURNAL OF FAMILY SOCIAL WORK
treatment than the female partners of users. The men’s active drug
use and their refusal to focus on this fact are among the reasons
hypothesized for this finding.
Contact with such family members who are reluctant to be
involved is apt to be short-term and superficial. Information-giving
sessions are the least threatening and will give the family time to think
about asking for help. As part of the educational process, family
members can be presented with diagrams of various family styles of
interaction that might or might not apply to them. Grouping reluctant
family members with others more eager for help is often helpful.
The challenge to practitioners in a field, the literature and other
teachings of which are guided by a language of damage and defects,
is to adopt a language that corresponds to concepts of strengths and
resilience.
When an alcoholic or addict enters treatment, the inclusion of family
members from the outset, whether with the addict or in separate
sessions, offers several advantages. Such inclusion provides a means
of observing how family members relate together as a unit, a means
for discovering strengths in the addict’s background, and an opportunity
to provide education into the biological and psychosocial
aspects of addiction. It is never too early, besides, to begin preparing
the family for the changes members will need to make in conjunction
with the addict’s recovery. The first session may close with the assignment
of tasks designed to get the members of the family to take some
small steps in areas where change is feasible. Getting the family to
take home reading material might be an example of a positive
first step.
The significant other’s involvement in treatment may be counterproductive,
as Burke et al. (2002) caution, if he or she is overburdened
with anger and resentment. In such a case his or her role
should be limited to being a bystander or witness in the client’s individual’s
sessions. Sometimes the family member is actively misusing
substances in the home and is better left behind in that case.
Discovering this fact through meeting with the family is often useful,
however, in the treatment process with the client.
Contemplation
Under one scenario, unilateral therapy, the family attends treatment
sessions to work on their problems and feelings surrounding
Katherine van Wormer 213
an alcoholic or addict who refuses to get help and who is destroying
the lives of those around him or her. As mentioned above, sometimes
the results are surprisingly positive, as the family members are taught
how to help set the stage for the substance user’s turnaround. Even if
the strategies are not successful, there is some evidence that the sessions
help unite the rest of the family and provide benefits in terms of reduced
levels of frustration and depression (Thomas & Corcoran, 2001).
During the contemplation stage the family member acknowledges
concerns and is considering the possibility of the need for change, for
example, in recognizing that the loved one has a serious addiction
problem. Psychologically the shift is from a reluctance to acknowledge
a problem to anger, anger caused by the suffering related to
the drinking, gambling, etc.
The therapist typically gets involved in family addictions work
when a client requests counseling for help with a marital problem,
domestic violence, or behavioral problems in the children. In assessing
the client’s needs and goals, the role of addiction in the family
life becomes apparent. Just as he or she does in working with addicts
in early stage treatment, the therapist strives to elicit self-motivational
statements of insight and ideas about solutions from the family clients.
Reinforcement of clients’ capabilities and survival skills are vital
to help these persons have the strength to take action toward the
desired solution. Possible actions that the family members might be
willing to contemplate are to meet with the therapist for several sessions
of family counseling to communicate needs and expectations; to
work toward getting the addict to get help for the addictive behavior,
perhaps through attending self-help group such as AA; or to work on
plans for a trial separation. Whether or not the situation improves,
family counseling of this sort can be a godsend for the partner and
other family members; having a dispassionate but compassionate
outsider to talk to can be immensely therapeutic.
Preparation
The theme for this stage of change can be summarized in the
addict’s partner or co-addict’s attitude of, ‘‘I can’t take it any more.
I am at the breaking point.’’ Tasks for the counselor during this
period are to help family members clarify their goals and strategies
for effecting change, to offer a list of options and advice if so desired,
and to steer the family toward social support networks. Boosting the
214 JOURNAL OF FAMILY SOCIAL WORK
partner’s confidence at this stage is tremendously important. The
therapist can affirm the significant other’s efforts to help the client
as well as his or her engagement in the family treatment process.
One step that might be introduced at this point, though tentatively,
is the suggestion of a visit to a relevant support group such as Al-
Anon or Nar-Anon; involvement in such a group can be invaluable
in helping members gain support from others in a similar situation.
Family members should be prepared for the fact that the stress on
detachment at the 12-Step meetings has its place when the addiction
has gone beyond a certain point, but there are some strategies they
can learn that will help support the client’s process of change and that
can be tried at this time. These strategies entail providing positive
feedback to the person when he or she is sober and withdrawing during
the bad times. Even if the strategies are not successful, there is
some evidence that the treatment sessions help unite the rest of the
family and provide benefits in terms of reduced levels of frustration
and depression (Thomas & Corcoran, 2001).
Action
At this point, let us assume the whole family is involved in counseling,
all except for the addicted individual (see Loneck, 1995). All family
participants are bent on seeing change happen. Family sessions at
this stage are crucial in building solidarity so that the addict will not
be able to play one family member off against another. The sessions
are crucial also in providing these individuals with the opportunity to
ventilate their feelings, grief, rage, despair, etc., and to learn about
addiction as an illness.
If the addicted family member is not in treatment, the family might
want to consider doing a formal Intervention. The Intervention is a
method of confronting the drinker or drug user for the purpose of getting
him or her into treatment (Loneck, 1995). Only a confrontation
that causes a family crisis will bring the substance-abusing member to
the painful realization that his or her substance use has caused problems
and that he or she cannot continue as he or she has been.
The first step in organizing an Intervention is to gather two or
more persons together who have witnessed the destructive
drinking behavior. The people could consist of family members,
friends, clergy, coworkers, employers, or a physician. In the second
Katherine van Wormer 215
step, each person prepares a detailed written list of specific examples
involving alcohol misuse that he or she has personally witnessed.
These actual events force the substance user to admit
that their concerns are legitimate. Another important aspect of
writing the lists and reading them to each other prior to the actual
confrontation is that it unites the group. It is important for members
to be prepared to talk about their feelings through using feeling
statements that help reduce the defensiveness of the challenged
person. Should this notwork or not be feasible, another action that
can be taken is to commit the person to treatment through a legal
process. The local prosecutor’s office or treatment center can
usually provide the details.
Going from the point of view of counselor to family member, a
young woman (in personal correspondence of January 28, 1999) provides
this poignant account of her childhood memory of an Intervention
with her father:
When I was around 13, we visited a counselor for a rehearsal. The
next week my Dad’s brothers and sister, close friends who were
recovering alcoholics, my Mom, my sister, and I gathered at
our house on the farm and Dad came home. I think he was aware
what was going on and became extremely emotional, crying with
his head down at the table. I remember exactly where I was standing,
at the end of the table against the wall with my sister and
when it came my turn to read my statement all I could say was,
‘‘I want you to go because I love you,’’ and began to sob. I
remember going up to my Mom and Dad’s room to get his suitcase
and Dad couldn’t say a word, he just cried and hugged us and
got in the car to go. It is one of the saddest memories I experienced
in childhood. He was gone for one month and about three months
after he returned we sold our farm and he relapsed yet to return
to treatment about a year later on his own will; he has been sober
ever since. I can honestly say I am very proud of him.
Maintenance
More important than the role of family in assessment and treatment
is the role of family in early recovery. As the addict’s progress
216 JOURNAL OF FAMILY SOCIAL WORK
toward health and wholeness becomes more and more a reality, the
family therapist may take on the role of facilitator to aid in the process
of reconciliation. Members of the family may want to come to
terms with lifelong feelings of rejection; there may or may not be a
desire for forgiveness.
Brown and Lewis (1999) provide a detailed delineation of the
therapeutic tasks and pitfalls involved in the process of recovery.
The Alcoholic Family in Recovery draws on the experiences of members
of four recovering families to describe the ways recovery has
challenged and changed their relationships. Much of this process,
as Brown and Lewis demonstrate, is painful.
Transition, as Brown and Lewis explain, is characterized by massive
change that affects children and adults at every level. The environment
feels unsafe; the family structure, after years of chaos, is not
strong enough to handle change. In the counseling session, the therapist
addresses the family concerns and recovery progress. Individual
members may have issues from the past that they will want addressed
at this time.
As behavioral changes are established in the family, the focus of
sessions shifts toward maintenance of change independent of the
therapist. Now that the problematic substance use has decreased
and other family interactions have improved, other family problems
(such as suppressed anger or an adolescent’s substance misuse) may
need to be addressed (Waldron & Slesnick, 1998). Family sessions
at this point can help make the difference between sobriety and failure
to change, and even between keeping the family together and divorce.
The therapist can help the family anticipate stressors and
support the addict in avoiding triggers and high-risk events.
A complete ‘‘what to do if’’ contingency plan needs to be set in
motion in case of backtracking. Clients are given numbers to call
and asked to come up with ideas for what to put in a step-by-step
plan for getting the help they need. Harm reduction strategies and
solutions to sustain the change in behavior should be explored in
treatment aftercare counseling. The couple, moreover, often can
benefit from receiving information concerning sexual problems that
arise in the absence of alcohol and drug use; if the issue is sexual
addiction, the posttreatment counseling needs are tremendous.
Together, the family members can benefit greatly with work in the
area of communication, decision making, and in discussing rules and
how the rules will be enforced. Now that progress toward recovery is
Katherine van Wormer 217
well underway, the stage is set for a shared groping for solutions to
problems that may never have been identified without outside help.
Ideally, the family therapist is a nonparticipant in the immediate,
emotionally charged issues within the family (such as who takes
responsibility over what and the division of labor). The focus of
the therapist is not on the content of the interaction but on the process
itself. The motivational therapist guides a family with a recovering
member toward its own process of recovery. As the newly sober
member regains responsibility within the family, other members have
to adapt accordingly. Acting as a coach or guide, the therapist can
help map the course of this adaptation. The entire family must be
prepared to accept as a member a sober and somewhat changed
person. Every person’s role in the family alters in the process of
one individual’s change.
CONCLUSION
Family counseling is an exciting dimension of addiction treatment.
Family work with alcoholics and other problematic drug users is an
area especially amenable to the motivational strategies that are currently
gaining popularity in the field of substance abuse counseling.
The potential for such strategies to be successful in engaging family
members to reinforce the work that is done in treatment, however,
is only beginning to be realized. Attending to each person’s stage
of adjustment to the problem ensures that interventions are appropriate
to the individual’s current motivational state and avoids setting
up a situation of a battle of wills between treatment provider and
family member.
Because the addiction or other problematic behavior did not arise
in a social vacuum and the addicts did not suffer the consequences of
the behavior alone, attention needs to be directed toward the social
environment. The growth process for the family often requires a period
of chaos that precedes the old state’s breaking down before the
formation of a new state can occur. Even if the treatment agency
lacks a full-fledged family program, individual counselors can usually
invite clients to bring their significant others with them to sessions.
Through the stages of change approach described in this paper,
specific interventions can be tailored toward the family’s readiness
to change. By closely attending to family dynamics and reinforcing
218 JOURNAL OF FAMILY SOCIAL WORK
statements conducive to healthy living, the therapist can help
prepare the family to cope with changes in the dynamics of the
family associated with sobriety, as well as with the inevitable
setbacks and even eventual separation from the addict if this is
the family’s decision. Through the use of various communications
exercises or of listening skills directed at where the family members
are in their recognition of a problem and of the need for help,
workers can help family members deal with their own feelings of
anger, shame, and guilt that may have plagued them for some
time.
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