The Conundrum of Family Therapy

Historically, substance abuse treatment was characterized by the belief that substance misuse was an individual problem, best treated on an individual basis [1]. However, over the past 5 decades, this understanding among clinicians and researchers alike has largely given way to recognition of the importance of the family’s role in the growth and preservation of substance use difficulties. More specifically, substance abuse and relationship dysfunction appear to share a reciprocal relationship, with both factors influencing and perpetuating ongoing struggles within a negative feedback loop. For example, having a partner with a substance use disorder creates stress and chaos within families and partnerships and negatively impact relationships which in turn, may serve as triggers for client use or relapse, which further decreases relationship satisfaction and dyadic functioning; thus producing an unhealthy bi-directional relationship of dysfunction that may ultimately result in separation or divorce. Moreover, parental substance misuse also has a ripple effect on others within the family and negatively impacts children’s psychosocial adjustment. In response to this awareness of the systemic implications of substance abuse for both the identified client and the family, providers have begun to focus on individuals and their families as a means of reducing or eliminating substance abuse.


The Conundrum of Family Therapy
Historically, substance abuse treatment was characterized by the belief that substance misuse was an individual problem, best treated on an individual basis [1]. However, over the past 5 decades, this understanding among clinicians and researchers alike has largely given way to recognition of the importance of the family's role in the growth and preservation of substance use difficulties. More specifically, substance abuse and relationship dysfunction appear to share a reciprocal relationship, with both factors influencing and perpetuating ongoing struggles within a negative feedback loop. For example, having a partner with a substance use disorder creates stress and chaos within families and partnerships and negatively impact relationships which in turn, may serve as triggers for client use or relapse, which further decreases relationship satisfaction and dyadic functioning; thus producing an unhealthy bi-directional relationship of dysfunction that may ultimately result in separation or divorce. Moreover, parental substance misuse also has a ripple effect on others within the family and negatively impacts children's psychosocial adjustment. In response to this awareness of the systemic implications of substance abuse for both the identified client and the family, providers have begun to focus on individuals and their families as a means of reducing or eliminating substance abuse.
In doing so, couple and family therapy approaches have two primary goals:

1.
To utilize the power of the family and/or partnership to support the client's recovery efforts and 2.
Alter negative family environments by supporting positive interaction patterns that are increasingly conducive to long-term recovery.
Simply stated, the goal of couple and family approaches is to replace the vicious cycle with a more virtuous one in which the relationship is healthier and can be used to reinforce the client's positive recovery-related efforts. The purpose of the current paper is to provide support for the use of family/couple's therapy for the treatment of substance use by discussing empirical evidence supporting their use, potential barriers to implementation among clients and therapists, and recommendations for specific areas of future research.

The Evidence
Over the past several decades, there has been increased research acknowledging that partner-and family-involved treatments produce better outcomes across several domains of functioning compared to individual-based interventions. For example, behavioral couples' therapy (BCT) and behavioral family counseling (BFC) have demonstrated superior relationship outcomes, decreased substance use, and reductions in partner violence as compared to individual therapy [2]; moreover, BCT is cost-effective [3]. Other approaches (e.g., "Families Facing the Future") have demonstrated lower drug use in parents addicted to opiates, as well as positive parenting gains upon treatment completion (e.g., more rules for children's behavior; [4]. Overall, couples-and family-based treatments for substance abuse can increase client involvement in treatment through work with and involvement of collaterals [5,6], which further demonstrates the importance of these treatment modalities. In response to these findings, the Joint Commission on Accreditation of Health Care Organizations (JCAHO) standards for accrediting substance abuse treatment programs in the United States requires that an adult family member be included at minimum, in the initial assessment phase of the treatment process.

Barriers
Despite impressive research evidence supporting their efficacy and often superiority to individual based treatment, couple-and family-based interventions for substance use have not been widely adopted in practice. There are several clinically significant barriers that may attest to this discrepancy. One such impediment is partner violence; per Murphy and O Farrell (1995), approximately 40% of men admitted into substance abuse treatment have perpetrated some form of violence toward their partner in the year preceding treatment. Although couples therapy has been found effective in reducing substance use and improving relationship functioning (including reductions in partner-violent behavior) in carefully screened cases of non-severe violence (i.e., the violence is bidirectional, infrequent, and not being used as a form of power and control), risk of severe violence (i.e., aggression that has the potential to result in serious injury or is life threatening) is always a contra-indication due to a need for safety [7]. In addition, there may be legal restrictions in place (i.e., restraining orders, no contact orders) that automatically rule out conjoint family sessions as a treatment option. Another potential barrier to couples and family therapy is the presence of family members and/or partners with co-occurring substance abuse. These situations may be especially concerning if the client and his or her significant others/family members collaboratively engage in substance use, as this would encourage ongoing use as opposed to reduction or abstinence [8]. Research on concordant-using couples is lacking, though it is recommended that individual therapy be used as the primary treatment modality due to varying levels of commitment to change and the recovery process amongst members. Yet another barrier to family-based interventions for substance abuse is the perceived possibility for increased blame and shame from family members toward the client [9]. Interestingly, there appear to be important practical and logistical barriers that are distinct from the clinical barriers discussed above. Some of these impediments include extensive distance among and between family members as well as the treatment provider; family members who are separated (e.g., divorced) or physically unavailable (e.g., incarcerated); difficulty coordinating meeting times due to differences in family members' schedules; and increased complexities around billing due to the involvement of multiple individuals within the therapy process [10]. Overall, couples and family approaches add a level of complexity for everyone involved (e.g., clients, clinicians, agencies; [11]. For example, both clients and their partners/families must agree to attend and participate in treatment. This may be difficult for some individuals, especially in instances where partners/families do not understand the purpose of their presence (e.g., "It's his problemwhy do I have to go to therapy?"). As such, engagement and retention in outpatient substance abuse treatment is challenging [12,13], which is unfortunate given that partner-involved substance abuse treatments have been consistently shown to be more efficacious than individual treatments [8]. Lastly, the complexity of couples and family approaches may contribute to clinician hesitance/avoidance to using these modalities which may explain why the majority of clinicians conduct individual psychotherapy (98%), as compared couples (49%) and family therapy (34%).

What to do?
It has been widely acknowledged that there is a gap between the most commonly provided treatments for substance abuse and the ones with the strongest empirical support. However, it is also important to note that empirical support does not make treatments immune to the individual differences/responses that can occur; even for the most efficacious treatments, there are a certain number of people that do not respond to treatment. Moreover, results of recent studies suggest that psychological treatments have not significantly improved over the last four decades. As a result, research on standardized interventions to treat substance abuse disorders is beginning to shift from a "one-size-fits-all" perspective towards more adaptive interventions focused on practice-based evidence with treatment tailored towards client preferences. These interventions provide room for individualization of treatment depending on the clients' and their families' needs across time. Still, the variability of client/familial characteristics and response to treatment indicate a need for additional interventions (e.g., family, individual, couples, groups) that can be tailored to clients' preferences, initial response to treatment, and changes in symptom severity. The presence of flexible interventions may be more appealing to patients and improve individual outcomes, dyadic functioning, and family environment which may also have a trickledown effect on the psychosocial adjustment of children living in these homes. More research is also needed around the potential impacts of culture and ethnicity on couple/family therapy for substance abuse. More specifically, it would be useful to explore how acculturation and ethnic identity influence treatment, including members' views of the substance use problem and the therapy process.