FAMILY THERAPIES
Dysfunctional families, characterized by impaired communication among family members and an inability of family members to set appropriate limits or maintain standards of behavior, are associated with poor short- and long-term treatment outcome for patients with substance use disorders. Family therapy may be delivered in a formal, ongoing therapeutic relationship
or through periodic contact. Goals of family therapy include obtaining information about the
patient's current attitudes toward substance use, treatment adherence, social and vocational adjustment, level of contact with substance-using peers, and degree of abstinence, as well as encouraging family support for abstinence, maintaining marital and family relationships, and improving treatment adherence and long-term outcome. They may also include behavioral contracting to maintain treatment (e.g., contracting with a partner for disulfiram treatment) or increasing positive incentives associated with sober family activities. Even the brief involvement of family members in the treatment program can enhance treatment engagement and retention.
Controlled studies have shown positive outcomes of involving non-alcohol-abusing family members in the treatment of an alcohol-abusing individual. More recent studies have demonstrated the effectiveness of family involvement in substance use disorder treatment for both women and men, including patients on methadone maintenance (170). Family therapy, often in combination with other approaches, has also been studied extensively and has shown good evidence for efficacy in adolescents.
Different theoretical orientations of family therapy include structural, strategic, psychodynamic,
systems, and behavioral approaches. Family interventions include those focused on the nuclear family; on the patient and his or her spouse or partner; on concurrent treatment for patients, spouses or partners, and siblings; on multifamily groups; and on social networks. Of the many types of family therapy used to treat substance use disorders, the preponderance of clinical trial evidence has been obtained for the behavioral and strategic approaches. The support for behavioral couples treatment is particularly strong.
Family intervention is indicated in circumstances in which a patient's abstinence upsets a
previously well-established but maladaptive style of family interaction and in which other family members need help adjusting to a new set of individual and family goals, attitudes, and behaviors. Family therapy that addresses interpersonal and family interactions leading to conflict or enabling behaviors can reduce the risk of relapse for patients with high levels of family involvement. A major role for family and couples intervention is to enlist concerned significant others to foster treatment seeking and retention in family members who are unmotivated to change substance abuse behaviors. As reviewed by Miller et al., most attention has been paid to behavioral coping strategies, 12-step approaches, and confrontational interventions, all of which are associated with high rates of treatment entry for patients who receive the intervention. However, in helping family members engage their significant others in
treatment, concerned significant others and identified patients are more likely to follow through and show better results with less confrontational approaches, including CRA and community reinforcement and family training, than with more traditional interventions. Couples and family therapy are also useful for promoting psychological differentiation of family members, providing a forum for the exchange of information and ideas about the treatment plan, developing behavioral management contracts and ground rules for continued family support, and reinforcing behaviors that help prevent relapse and enhance the prospects for recovery.
There is also some evidence that these approaches can improve the psychosocial functioning and decrease the likelihood of substance use in children living with a parent abusing alcohol or other substances.
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