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Family Therapy Blog by Terry Peck – Robert F. Peck, LICSW
I have been interested in family therapy since I saw a demonstration by Virginia Satir at Butler Hospital in Providence, RI, in 1967. Freud identified the family as the root of who we are good and bad. The family offers us love no matter what our age and that is a basic necessity for humans. The curative capacity of love is storied in poetry and song. To unleash the love within a family is to marshal a powerful healing force. To do that psychotherapists have been very creative. Everyone is unique and every family is even more unique because it is, of course, composed of more than one individual. What I plan to do with this blog is to review some of the family therapy theorists I have encountered over the years. The list cannot be encyclopedic because I am only one person. But it is a good project for me because I regard myself as a family therapist and I haven’t reviewed the literature in many years. As I do my research, I will include all bibliography references. This therapeutic strategy’s greatest challenge is getting the addict and family to start treatment. Stephen R. Andrew, LCSW, LADC, CCS, CGP presentation on Motivational Interviewing: Working with Families Dealing with Substance Misuse and Abuse”. I decided to do this blog to prepare for the RI NASW Addictions Committee workshop Andrews will be presenting on November 9th. I welcome any cogent comments anyone might have as I go along. Reading all this material has been a humbling experiience. Terry

Blog 11-4-2018 Further proof that family therapy works

Blog 11/4/2018 I scanned what looked like relevant articles published in the Journal of Family Therapy. Collins, Ready, Griffin Walker and Mascaro “The Challenge of Transporting Family Based Interventions for Adolescent Substance Abuse to Urban Community Settings.” Pages 429-445 October 3, 2007. They were offering a 15 session ecologically based family therapy. What mattered was how quickly the therapy began after the juvenile was arrested and placed. The degree of substance abuse wasn’t a factor. The initial crisis was the motivating factor. The authors were concerned about whether research on urban African American was under reporting the extent of drug abuse, over identifying in the criminal justice system and the state of research on this population. The bottom line was that family therapy worked with this population.

Robbins et al (2011A) found in a multi-site, multi-therapist study of 480 families treated by 49 therapists in eight agencies that family therapy was more effective in reducing the number of days of self-reported drug use. Families were more engaged in treatment and the reports of family functioning indicated improvement. These outcome assessments were comparisons to standard drug treatment outcomes.

Also in 2011 there was a special issue of the journal of Family Psychotherapy (vol 22 no 3) on family therapy and substance misuse. Also in 2011 Klosterman et al produced a comprehensive review BCT for substance users in the journal of Substance Use and Misuse and showed strong and extensive empirical support the use of BCT for substance abuse problems. And O’Farrell and Fals-Stewart (2006) created a BCT treatment manual for family therapy with substance abusing adults.

I am sorry I don’t have more precise citations to share, but I felt I should bring up the fact that there is now a large amount of empirical research supporting the fact that family therapy is an effective treatment model to use with substance abusers.
Terry Peck

Murray Bowen

Point Judith sunset

Murray Bowen included a chapter on alcoholism 1) in his book, Family Therapy in Clinical Practice.  As he discusses this topic, he describes situations and gives advice that effectively parallels what Alanon preaches.  Sometimes he works with the person he sees as most functional to sharpen that person’s sense of identity. His goal is to assist all members of the family to differentiate their egos. A single person with a well- defined sense of self can help all members become clearer about who they are and what role they should assume in the family. He believes that as other members of the family interact with a person with a well defined self their selves become better defined also. He believes that a person emerging from the mutual fusion causes those who interact with him to refine who they are.

 

 

  1. Murray Bowen- Family Therapy in Clinical Practice, Chapter 12, pages 259-268.

Family Therapy Paradigms

Ken Israelstam gives an insightful overview of the four major schools of family therapy at the time the article was written. There are enough technical references to specific techniques that the problem of that a neophyte would be challenged to understand what he is saying. Furthermore, his plan for training family therapists would be highly cumbersome and confusing. I don’t think it would be practical. However, his article does offer important insights for anyone wishing to compare the major theories. He compares the four theories on the basis of the time differential, the present or historical context. He also points out the locus and goals of change which each theory uses. He also compares the activities of the therapists. I did find this to be a useful and interesting article.Bibliography reference 7/29/2018 Israelstam, Ken Contrasting four major family therapy paradigms: Implications for family therapy training Journal of Family Therapy (1988) 10: 179-196

Attachment Theory and Family Therapy

Attachment Theory and Family Therapy
When I was in graduate school, object relations and attachment theory were popular. Bowlby is quoted by Jane Akister as postulating that humans are able to be most effective in deploying their talents and are happiest when they are confident that one or more trusted persons are there for them and provide a secure base from which to function. That is also the condition which Deepak Chopra believes is the most effective for the “healing self”. This idea would seem to be the goal for family therapy for the addict. If the problems in his relationships with his family can be moderated enough to be a healthy supporting base, he has a better chance of staying free of his addiction. Concurrently his family also has its best opportunity for healthy functioning. Family therapy by its nature is an opportunity for a family to resolve distorted relationships and heal old psychic wounds. But this is a lofty goal which is probably not fully realized very often. It would be ideal recovery.

SAMHSA Tip 19 Substance Abuse Treatment and Family Therapy

This Tip 19 is an encyclopedic survey of the topic. It deals with such topics as “Interventions” and the difference between substance abuse treatment and family therapy. Each type of treatment may be governed by different assumptions. Family involved therapy is not identical to family involved treatment. In family involved treatment the family is acting supportive of the addict’s treatment and family therapy treats the whole family. “Denial” may be seen by the family therapist as an attempt by the family to maintain homeostasis and by a drug counselor as an impediment to treatment. Drug counselors rend to look at the addiction from the point of view of the disease model. Yet a family therapist sees addiction as a symptom of the family’s dysfunction. The comparisons the article provides are extensive. The article is an exhaustive guide for anyone in any kind of drug treatment to follow as they work with families. The TIP 39 is a 63 page summary of a far more extensive manual on involving families in drug treatment.

Summary Article for SAMSHA TIP 39

Blog: “The Executive Summary – Substance Abuse Treatment and Family Therapy – NCBI Book Shelf”
This summary is a big help. It covers the entire SAMSHA TIP 39 on the topic and is far more manageable than trying to read and use the entire TIP. It presents the current reality that drug treatment programs face in using family-based approaches. It even addresses the different types family therapy and how it can be used in different family situations and something about what types of family therapy could work in different situations. It is hard to conceive of all possible situations and how a program might mix and match its resources. Yet this summary provides definitions useful for starting points. Consulting the full TIP39 would be needed once someone begins a process of integrating these concepts and procedures into a drug treatment program. But it delineates different type of family involvement in treatment and even describes some stages of change and readiness to change and some red flags, such as domestic violence and child abuse.
I found this article to be a nice summary of what I had been uncovering in the research and theory articles.

Research Post: Stanton and Todd

“The Family Therapy of Drug Abuse” by M. Duncan Stanton, Thomas C. Todd and Associates.  This ia a compilation of 21 research articles.  The work was funded by a NIDA grant.  To summarize a about 40 of the best minds in the family therapy field, including for example Jay Haley, Salvado Minuchin and Harry Aponte, participated in this very large project in Philadelphia in the 1974 to 1976.  An adolescent project ran from 1977 to 1980.  This was an amazing project.  The participants had to  figure out all the practical issues, such as, the therapist had to be the official requesting Methadone if that was being used or he would lack the authority to conduct the family therapy.  The outcome was that those addicts who participated in family therapy were more likely to remain clean.  This is a 430 page book and i can’t summarize it all here. Continue reading “Research Post: Stanton and Todd”

Return to Stanton and Todd

9-19-2018 Blog Return to Stanton and Todd
When I first looked at Stanton and Todd’s 474 page tome, I did the “read the beginning and the end and come back to it later routine.” Today I decided I wanted to look a what they did in more depth and I discovered Chapter 5 “Principles and techniques for Getting “Resistant” Families Into Treatment.” As it turned out, they found getting the families of addicts into family therapy was a very difficult challenge. This research was carried out by 40 different professionals and the book has 200 citations in their bibliography. They discovered that the professional literature showed that everyone had had great difficulty with this issue and even the successful programs had low percentages of engagement. They encountered the same problems.
This is the best reason for us to do a workshop on engaging families. Unless a professional pays serious attention to this initial problem, the chances of success are quite low. My personal hypothesis is that family therapy offers a fast track to assist the addict to develop the “Healing Self” that Deepak Chopra talks about. Although the percentage of addicts and alcoholics who become clean and sober isn’t large, those who do reach that point are faced with the challenge of becoming comfortable in their own skin, forgiving of themselves and others and becoming self-confident and resourceful. Beginning their treatment with family therapy would give a person a big head start on achieving that and on achieving enduring sobriety.
One major problem Stanton and Todd’s group discovered in trying to engage families in family therapy was that getting fathers to come in and participate was very important and very difficult. The therapists believed that getting both parents to come in was very important and wanted siblings to come as well. But getting fathers in tended to be most difficult. Sometimes it was very difficult to reach a father directly. Eventually the program began to pay the therapists bonuses for recruiting and successful recruitment. The addicts’ families tended to project the cause of their son’s addiction onto schools, courts, friends, etc. or simply denied the possibility that they could be helpful, probably because they felt helpless after failing to deal with the problem in the past sometimes even with the help of previous treatment programs. White and more affluent families were sometimes more amenable, but not often.
Stanton and Todd called their program Addicts and Families Program or AFP. The therapists were aware that previously treatment programs often shunned families, rather than involving them. Many addicts had been involved in other treatment programs and, therefore, the addicts and their families didn’t expect that families would be involved. But the family’s dysfunction also made engaging them difficult. The AFP therapists found that the sooner the families were contacted the better. Therapist would try to get them in the participate in the intake session or sometimes the therapist would call the parents from the intake session. The AFP program came up with 21 principles to follow when recruiting families: Principle #1. Don’t let the addict be the one to choose which family members will attend the family therapy sessions. If he chooses, only certain family members will show up. such as, a sister or a sister and mother. Principle #2 If possible, involve one or more family members in the intake session. Principle #3 Don’t expect the addict to bring in the family on his own. Principle #4 Whenever possible obtain permission from the addict to contact the family in the intake session and make the contact during the session. The family therapy treatment was presented as a key aspect of the treatment. The therapists became very resourceful in finding ways to persuade families to engage. Principle #5 The therapist needed to be the treating professional from the first contact with the addict. Initially the addicts were assigned to an addiction counselor and a family therapist. But it was found that the family therapists had to assume both roles and that was Principle #6. The split roles diminished the therapist’s authority with the addict and the family and practice demonstrated that the therapist needed that leverage. With engagement, Principle #7, the sooner the better. Principle #8 View the engagement of the family is a crisis for the family opening up an opportunity for change.
Stanton and Todd go on to refine the Principles for engaging families. They specified the qualities of the therapist: “energetic”, “enthusiastic”, “persistent” and “flexible” and convinced of the validity of the endeavor. As mentioned before, they found that they needed to give the therapists incentive bonuses for their recruiting efforts. They found that a mechanical approach to recruiting fell flat. The agency has to have flexible policies which support the therapist’s flexibility and a willingness to provide the tangible supports the therapists need to make the engagement process work. 2 If possible, involve one or more family members in the intake session. Principle #3 Don’t expect the addict to bring in the family on his own. Principle #4 Whenever possible obtain permission from the addict to contact the family in the intake session and make the contact during the session. The family therapy treatment was presented as a key aspect of the treatment. The therapists became very resourceful in finding ways to persuade families to engage. Principle #5 The therapist needed to be the treating professional from the first contact with the addict. Initially the addicts were assigned to an addiction counselor and a family therapist. But it was found that the family therapists had to assume both roles and that was Principle #6. The split roles diminished the therapist’s authority with the addict and the family and practice demonstrated that the therapist needed that leverage. With engagement, Principle #7, the sooner the better. Principle #8 View the engagement of the family as a crisis for the family opening up an opportunity for change.
Stanton and Todd go on to refine the Principles for engaging families which specified the qualities of the therapist: “energetic”, “enthusiastic”, “persistent” and “flexible” and convinced of the validity of the endeavor. As mentioned before, they found that they needed to give the therapists incentive bonuses for their recruiting efforts. They found that a mechanical approach to recruiting fell flat. The agency has to have flexible policies which support the therapist’s flexibility and a willingness to provide the tangible supports the therapists need to make the engagement process work.

London Family Therapy Study

Dennis Yandoli, Ivan Eisler, Claire Robbins, Geraldine Mulleady and Christopher Dare- “A comparative study of family therapy in the treatment of opiate users in a London drug clinic.” This 2002 study was an interesting follow up to the 1970’s work reported in the Stanton and Todd group. They justified their effort on sociological research which showed that addicts tended to be connected to their families. The treatment subjects were divided into three groups: 1 received family therapy. 2 received standard individual and the third received monthly visits from the researchers who offered suggestions about resources available to the addict, such as housing suggestions and Narcotics Anonymous referrals.
The discussion of the results was very rigorous. For example, the number of subjects who died during the period of the study was looked at compared to the life expectancy of addicts who hadn’t begun treatment and fewer subjects died. The treatment was six months of family therapy with low doses of methadone and withdrawal from Methadone after six months. They did find that Methadone maintenance at a higher dose was more effective in preventing illegal drug use over time. They looked at the degree of illegal drug use at 6 months and a year. They admitted that they were unable to use urine samples to verify self reports.
Those participating in the family therapy who were living with a partner seemed to well. Those living with their family of origin did not do quite as well. Those who had more intensive individual seemed to maintain freedom from drug abuse initially. The flexibility of the individually treated and the methadone prescribing seemed to increase the confidence of those under that treatment regimen. The family therapy group had the greatest therapeutic gains, much more than the individually treated addicts. The degree of continuing depression was substantially less. But the subjects receiving monthly visits did almost as well. The researchers suspect that was due to the participation in self help groups, such as, Narcotics Anonymous, by that cohort.
I wondered what would have happened had the family therapist had more flexibility in prescribing the Methadone and the family therapy had lasted more than six months.
Terry Peck

Bibliography

Bibliography (10/12/2018):

Akister, J. Attachment theory and systemic practice: research update, Journal of Family Therapy (1998) 20: 353-366.
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Bowen, M. Alcoholism in the Family in Family Therapy in Clinical Practice- Chapt. 12 pgs. 259-268 Rowman Littlefield Publishers, Inc. 1984

Cag, P & Acar, N.V. A View of the Symbolic-experiential Family Therapy of Carl Whitaker through Movie Analysis EDAM June 2015 – 575-586.

Doherty, W.J. & McDaniel, S.H. Family Therapy “systems oriented therapy.” (unread)

GoodTherapy.Org Family Systems Therapy Approaches

Israelstam, K Contrasting four major family therapy paradigms: implications for family therapy training. The Association For Family Therapy, 1988

Schlict, J. & Kraemer, S. From System to Psyche – chapter in ‘The Space Between’ The Therapeutic Relationship: Recent Developments in Theory and Practice (eds.) Flaskas, C., Perlesz, A. & Mason. B London: Karnac , 2005.
.
SAMHSA #35 Enhancing Motivation for Change in Substance Abuse Treatment pgs. 1-145.
SAMSHA #39 Substance Abuse Treatment and Family Therapy pgs. 1-63
Journal of Family Therapy (2011 Vol. 22 no. 3) special issue on systemic intervention for substance misuse (as yet unread)

Simon, Rich Take It or Leave It: The Therapy of Carl Whitaker Psychotherapy Networker September/October 1985 1-23

Stanton, M.D., Todd, T. C. and Associates (Eds.) The Family Therapy of Drug Abuse and Addiction 1982 The Guilford Press, New York

Whitaker, C. Midnight Musings of a Family Therapist 1989 Penguin Books Ontario, Canada

Yardoli, D., Eisler, I., Robbins, C., Mulleady, G. & Dare, C. A comparative study of the treatment of opiate users in a London drug clinic. Journal of Family Therapy 24: 402-422.