The Sorry State of Family Treatment in the Treatment of Addiction

I am honored to write a monthly editorial for Serene
Scene Magazine. In this column I plan to discuss the
current state of the field of addiction treatment but
with a different twist. You see as a therapist I have been
trained to listen to what a client is not saying. This helps
me focus on what is missing in their lives and allows
me to help a client discover parts of themselves they
are unaware of, or solutions never considered. I want
to approach this task in the same way, discussing what
I see as missing in the field. It is my hope that this will
inspire a dialogue between us that will lead to better
treatment, better treatment program designs and better
outcomes. Therefore please send us your comments
or thoughts about these issues. They will be published
in the following issue with my reaction or comments,
when and if appropriate. So here we go.

As I step back and look at what we are currently doing
in the field I am alarmed to find that we have made so
little progress in treating addiction as a family disease.
Oh yes we play lip-service to this idea, but we aren’t really
integrating the family into the core of treatment.

We are still focused on helping the “alcoholic or addict”
which family therapists called the “identified patient.”
That’s a term I imagine you haven’t heard in quite some
time.

When family therapy first burst on the psychotherapy
scene in the early 50’s it was a revolutionary way
of thinking about problems and how to help people
change. This was an amazing time in the history of psychotherapy
and even in alcoholism treatment because
we started to see the so called “problem “as much more
than what was going on inside of a person. We now
shifted our focused on what was going on between
people, specifically between members of a family.

Family therapists where challenged with finding a better
way of describing the person who was labeled as
having the “problem.” They came up with terms like
“the identified patient.” From a family system perspective
the “identified patient’s” behavior was a function
of the family dynamics, it was an integral part of how
the family and was seen as having homeostatic value.
Therefore the identified patient had to be treated in
the context of the emotional unit of the family. Family
members where seen as enablers or co-conspirators.
One of the first terms used to describe this kind of cooperation
or collusion between family members who
were involved with an alcoholic was “co-alcoholic.”
Eventually the field adopted the term codependent,
but did this really maintain the original meaning it had
for family therapists – I don’t think it did. We have unfortunately
turned codependency into an individual
diagnosis.

Here are a few of the powerful ideas that where
spawned by the family therapy movement:

• If someone in a family has a problem,
then everyone has a problem.

• If your family makes you sick, it can help
you get better.

• The person who is the identified patient is
saying, “Ouch I have a pain in my family.”

• Change occurs when anyone member of
the family alters what they are doing because
it modifies the sequence of interaction
between the members of the family
and forces them to establish a new way of
interacting with each other.

It seems to me that many people in the field who considered
adopting this perspective were concerned that
it would blame the family for the addict’s addiction.
I can see where this could be a concern. We all know
that addiction is not caused by the family, it is a brain
disease and current research has proven that beyond
doubt. However, as my dear friend Bobby Mooney, M.D,
the medical director of Willingway Hospital commented,
“I have never seen a brain in my treatment program
that doesn’t have a person attached to it.” I’d go even
one step farther and say there isn’t a patient who enters
treatment that doesn’t have a family attached to them.
Often times addicts are estranged from their families,
but they are still out there and what is more important
is that their families are a very big part of the addict’s
psychological life.

The current standard for working with families in the
field of addiction is the family week. There are clearly
some benefits from this model. Family members are educated
about the disease of addiction. They learn how
family members take on roles and the way that these
roles play out when the family is stressed. Structured
communication exercises are often used to teach effective
communication and listening skills. Yet there is one
thing that is missing, helping the family become aware
of its process.

The only way that you can see how a family functions
is to invite them to interact with each other around a
major concern. This means giving them an unstructured
exercise and observing their sequence of interactions.
These interactions will necessarily take the shape
of a theme or pattern which the therapist or counselor
then brings to the attention of the family. The identified
theme or pattern becomes the family’s working point.
Interventions are directed at altering the sequence or
interactions or pattern of interactions. The most powerful
interventions are experiential. New experiences give
the family a here and now experience of doing things
differently and experiencing the benefit of the new behavior.
This is the gold standard of family counseling, so why
aren’t treatment centers using it?

I was having dinner with some folks from Cirque Lodge
the other day, Keith Fierman, Stephanie Fierman, and
Beverly Roesch, M.A.. We were having a great time, over
a great dinner, with some really exciting conversation.
Beverly and I were talking about the state of affairs in
family treatment and she stated, “Counselors are afraid
of what might happen if they don’t control the family’s
interaction.” I think she is right on. It’s our anxiety that
is the problem. But not every counselor would admit
it. Some counselors or clinicians would justify controlling
the family’s interaction because they are protecting
the newly clean and sober patient. They don’t want
the family members to trigger each other. Whatever the
rationale for this approach, it is wrong!

Do not fool yourself thinking that the family won’t do
what they always does when the identified patient
goes home. They will, they have to, they don’t have a
choice until they get help. You see whatever problem a
family is having, is not the problem. The problem is the
way they cope with it or how they function. The only
thing that will be different when your client goes home
is that you won’t be there to help them find a better
way to meet each other in the heat of battle.

To be a good family counselor you cannot be passive.
You must actively engage the family and help them
change from within. This is risky business but also very
exciting. But there’s no place for you, the counselor, to
hide. You need to be in the mix, sharing your observations,
challenging pathogenic ways of relating like silence
inducing strategies, encouraging personal reactions,
and helping each of them search for the words
that best reveal their personal desires while providing
them with necessary support and courage to say the
things that they have dared not say to each other.
So let’s stop fooling ourselves into thinking we are
treating families, we are not. But we can start. Get training
in family therapy. Get your staff training. Let’s start
really helping families learn how to make adjustments
at close range.