Family Therapy:

A Critical Part of Recovery

Family Therapy: A Critical Part of Recovery

Family Therapy:

A Critical Part of Recovery

Self-Care Steps During a Loved One’s Rehabilitation

When you have a loved one who is battling a substance use disorder, it can take some time to arrange for enrollment in a residential treatment program. You might have struggled with this for this for years, and now it’s finally happening. Many families who have a loved one in recovery from a substance use disorder, tend to also find family therapy helpful for the entire family. 

The Benefits of Therapy for Family Members

When a close friend or relative has entered addiction recovery, you have every reason to hope for a different future. Your relationship with the person going to treatment will likely change, but you will also be an important part of continued support during and after treatment. It is typical for relatives and friends of people with substance Use Disorders to go through a whirlwind of feelings as their loved one enters a residential treatment program.

Experiencing Mixed Feelings is Normal

As a close family member or friend of someone with a substance use disorder, please understand that your feelings are a normal part of the recovery process. Rest assured that throughout addiction treatment,  patients must also work through a variety of thoughts and emotions as they process the addiction.

You Aren’t to Blame

A loved one’s addiction is not something for which you should assume personal responsibility or blame. The factors that led to your loved one’s substance abuse are complex. In family therapy, coping strategies for dealing with feeling are discussed as well as healthy ways to support a loved one in rehab.

It’s OK to Not Have All the Answers

As a loved one who is providing social and emotional support to someone with a substance use disorder, you may believe that you understand the disease. However, addiction is different for every person. The recovery process is unique to each individual. There are also many types of mental health conditions that can contribute to addiction. That’s why a professional rehabilitation team is recommended for successful recovery.

Treatment is Private

An addiction recovery program will be confidential, but participants may choose to share aspects of it with you at different times. While each person’s substance abuse is individual, you can help by encouraging full participation in the rehabilitation process. Your job is to offer words of love and support.

Recovery is a Process

When a person decides to enter a recovery program, it’s common to have a tough time understanding all aspects of the substance use disorder. For example, it’s common to be aware of common symptoms and the steps toward recovery, such as detox and counseling sessions. However, the experience of building better personal habits to replace addictive habits may be completely new. That being said, some people have entered rehab before and need to go through it again.

Waiting is Part of Recovery

Allowing your loved one time to get well without your help is hard because you must sit back and let the professionals do their job. Your participation may be limited and there may be periods of time when you are not permitted to have contact with the patient.

Educate Yourself About Addiction

You don’t have to be a medical professional to learn more about addiction. There are many resources online, including through the National Institutes of Health and the Centers for Disease Control, that explain different forms of addiction and related conditions in detail. Public health fact sheets from these sources are a great way to understand what your loved one is going through.

The Risk of Relapse

In therapy, you will learn important information for supporting recovery for the future. At any time after recovery, it’s possible to experience a relapse and require further treatment. It’s common to experience temptations or cravings after recovery, especially during times of stress. Family therapy sessions can help with the acceptance that this pattern is not your fault. You can process feelings like anger, frustration, sadness, and grief. You can also learn the signs of relapse. Therefore, if your loved one slips up after rehab is complete, you can be there to provide support. Early intervention after a relapse greatly increases the chances for success at long-term recovery.

Stay Positive

It’s important to keep yourself in a positive mindset. Remember, the road to recovery will be long and challenging. Recovery is both emotionally and physically draining, leaving a person feeling the desire to escape from the world. There are many issues to deal with, and each person can only handle so much at one time. Recovery from a substance use disorder often requires the acceptance of previously self-destructive behaviors and understanding why these might have occurred. To be supportive, be patient and consistent with the boundaries you’ve developed in family therapy.

Why Attend Family Therapy in Addiction Treatment

When a family member seeks treatment for a substance use disorder, the whole family goes into recovery. Research shows that family involvement in treatment is a major sign of success. According to an article in the journal Social Work and Public Health, treating an addiction without family involvement limits how well treatment will work. 1 When someone has a substance use disorder and seeks treatment, their entire environment and routine needs to change, not just the person with the substance use disorder. The family is a primary source of support for their recovering loved one. This support is crucial for successful recovery.

Family therapy is commonly used in addiction treatment programs to create positive and meaningful change in family dynamics and interpersonal relationships. The better the family functions, the better the chances of successful long-term recovery.

Objectives and Outcomes of Family Therapy

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), family therapy in a substance abuse treatment setting has two overarching objectives:

  • To use the strengths and resources of the family to develop a family recovery plan and find ways to promote a life of sobriety for the addicted family member.
  • To reduce the negative impact of the addiction on family members and on the family system.2

These objectives are achieved by addressing a wide range of issues unique to each family. Depending on the family, the goals of family therapy might include:

  • Fostering healing among family members.
  • Helping the family become aware of its own needs and meeting them.
  • Improving communication within the family system.
  • Promoting a substance-free lifestyle through environmental, interpersonal, and intrapersonal lifestyle changes.

Family therapy provides neutral ground where families can address a range of issues in a safe environment that is facilitated by a trained professional. Therapy helps families learn how to adapt to a world with reduced substance use and identify their own needs while supporting their loved one in recovery.

Goals of Family Therapy

According to SAMHSA, family therapy aims to move families from:

  • Crisis to resolution
  • Anger to peace
  • Despair to hope
  • Frustration to understanding
  • Stress to strength
  • Guilt to forgiveness
  • Sadness to support
  • Conflict to agreement

Levels of Recovery in Family Therapy

Families move through three levels of recovery during family therapy for substance abuse treatment. These levels are:

Attainment of Sobriety:

The family member with the substance use disorder becomes sober. While the family system is unbalanced; healthy functioning is still possible.

Adjustment to Sobriety:

The family adjusts to the changes sobriety brings by developing a new system and becoming more stabilized.

Long-term Maintenance of Sobriety:

The family rebalances and develops a new lifestyle that supports recovery.

Who is Family?

SAMHSA recognizes families in three broad categories:

Traditional Families:

Traditional families include heterosexual couples and their offspring; single parents; adoptive and foster families; blood relatives; children being raised by grandparents; and blended, or step, families.

Extended Families:

Extended families consist of biological or adoptive aunts and uncles; cousins; grandparents; in-laws; and other people who are related by blood, marriage or the law.

Elected Families:

Together by choice, elected families aren't necessarily joined by blood, marriage or the law. For many people, the elected family is more important than legal or biological relatives. Elected families include LGBTQ couples with or without children; godparents; emancipated youth who live with peers; and other unrelated people who have a strong emotional bond.​​​3

Different families are affected by addiction in different ways, depending on the type of family and who in the family is addicted. Family therapy addresses the specific and unique issues within any given family system.

Most family therapists approach therapy from a systems standpoint, wherein changes in one part of the family system produces changes in other parts of the system. If the changes are positive, they contribute to solutions. If the changes are negative, they contribute to problems. The interdependent nature of a family system produces complex relationships and a major focus of family therapy is intervening in these relationships and altering them in a way that produces meaningful, positive changes in the entire system.

How Addiction Impacts the Family

Addiction impacts every member of the family. With it comes uncertainty, chaos, unsettling experiences, emotional highs and lows, and changes in thoughts and behaviors. Family members must somehow cope with the dysfunction that addiction brings. The resulting coping mechanisms are often very unhealthy. According to SAMHSA, children may act out or withdraw. They have higher rates of mental and behavioral disorders and have an increased risk for substance abuse later on.4 Spouses or partners of someone with an addiction may develop unhealthy habits like overeating, over-shopping, or may begin abusing drugs or alcohol themselves.

To cope with a loved one’s substance abuse, family members commonly develop co-dependent and enabling behaviors as well as unhealthy thought patterns that can affect relationships and their grip on reality. These unhealthy behaviors and thinking patterns perpetuate drug abuse, increase the dysfunction of the family system, and reduce the quality of life of everyone involved.

Co-Dependent Behaviors

Co-dependence develops as family members struggle to adapt to the dysfunction caused by substance abuse. It leads to a lack of self-care and self-esteem. It can affect other relationships within the family system. 

Co-dependent behaviors include:

  • Worrying obsessively about the loved one’s substance abuse and its consequences.
  • Lying to yourself or others about the extent or severity of the substance abuse.
  • Isolating yourself from friends and extended family members so you will not have to talk about the addiction or make excuses.
  • Developing unhealthy coping behaviors like binge eating or obsessively exercising.
  • Adjusting your mood to match the mood of the addicted loved one.
  • Putting all your energy into worrying about and taking care of your loved one.
  • Aiming your anger at your loved one toward other, innocent people.
  • Reacting irrationally or violently to negative events related to the substance abuse.

Enabling Behaviors

Enabling occurs when family members directly or indirectly and knowingly or unknowingly support the substance abuse of their loved one. Enabling behaviors prevent natural consequences of the addiction from affecting the loved one and serve to keep the loved one in denial that the substance abuse is problematic. Family members may develop enabling behaviors to keep the peace, increase feelings of control over the situation, or ensure the safety of the loved one with the substance use disorder. 

Enabling behaviors include:

  • Drinking or doing drugs with the loved one to “keep an eye” on things.
  • Holding your feelings inside to avoid upsetting your loved one.
  • Accepting the loved one’s excuses about drinking or doing drugs.
  • Convincing yourself that things could be a lot worse.
  • Minimizing the consequences of the addiction to protect your loved one, such as by putting up bail or taking over his or her responsibilities at home.
  • Going out of your way to assure everyone that everything is fine at home.
  • Feeling like it’s your fault when the consequences of the drug abuse catch up to your loved one.

Stinking Thinking

People with substance use disorders commonly develop dysfunctional thought patterns known as cognitive distortions. Psychologists call them “stinking thinking.” A major focus during treatment is helping to recognize faulty thought patterns and learn to think in healthier ways.

It is not just the person with the substance use disorder who may develop cognitive distortions. Family members may also begin to think in ways that are unhealthy, causing problems within the family system. Family therapy helps family members end these dysfunctional thought patterns, which helps restore function to the family unit.

Common cognitive distortions include:

Jumping to Conclusions:

When someone jumps to conclusions, they interpret things negatively even though the evidence does not support the conclusion. For example, with no supporting evidence, they may predict that a situation is going to turn out badly or they may decide that someone is reacting negatively to them.

"Should" Statements :

"I should have..." and "I should really..." are "should" statements that only make the person uttering them feel guilty and frustrated by setting up an expectation without an action.

Over-generalization:

A single negative event becomes an "always" or "never" situation, such as "You always get in trouble when you drink," or "You never take my feelings into consideration."

Black-and-White Thinking:

Also known as all-or-nothing thinking, this cognitive distortion involves seeing things as all good or all bad. If something is not totally perfect, it is a complete disaster. There is very little gray area.

Catastrophizing:

When someone reacts to every negative event, big and small, as though it is a total catastrophe, they invite big, negative emotions in. This clouds judgment and makes it difficult to think calmly and rationally about a situation.

Just because a loved one enters recovery does not mean that family members’ enabling, co-dependent behaviors, and cognitive distortions will automatically stop. These behaviors can make recovery difficult for the whole family and ending them is essential for healthy family functioning and supporting long-term sobriety.

Family therapy helps family members identify their own dysfunctional thought and behavior patterns surrounding the addiction and how these affect the family system as a whole. Families learn how to look at substance abuse and the recovery process in healthy, honest ways and respond appropriately to negative situations.

Four Models of Family Therapy

Four family therapy models are commonly used in substance abuse treatment settings.

Family Disease Model:

The family disease model considers substance use disorders as a disease that affects the whole family, who may develop co-dependence and enabling behaviors and negative thought patterns that perpetuate the drug abuse. The therapist helps families identify and change these behaviors and faulty thought patterns.

Family Systems Model:

The family systems model is based on the idea that families become organized by their interactions around substance abuse and the therapist looks for and tries to change maladaptive communication patterns and family role structures that rely on the substance abuse for stability.

Cognitive-Behavioral Model:

The cognitive-behavioral model assumes that dysfunctional behaviors, including substance abuse, are reinforced through interactions within the family. The therapist works to improve family communication and interactions, reduce behaviors that trigger substance abuse and impart coping skills to the family.

Multi-Dimensional Family Therapy Model:

The multi-dimensional family therapy model integrates several different techniques that put emphasis on the relationships between thinking, emotions, behavior, and environment. The therapist helps family members become more aware of their environment, thoughts and emotions and how these affect their behaviors.

In most cases, family therapists will use a variety of techniques from different models to address the family’s unique issues.

What to Expect in Family Therapy

Family therapists are specially-trained professionals who meet the legal and professional requirements for a family therapist. During the first family therapy session, the therapist gets to know the family and sets expectations for each session. Some therapists will ask the family to sign a contract agreeing to certain standards of behavior, such as not interrupting and keeping an open mind.

During the initial session, the therapist observes the way family members interact and communicate with one another. The strengths of the family quickly become apparent and the therapist can get an idea of what skills are missing.

How Long Do Sessions Last?

Sessions typically last an hour and involve the whole family, although the therapist may ask for sessions with individual family members or subgroups within the family. During the session, the therapist asks questions to help keep the conversation productive and guide it to a beneficial conclusion.

What Do Families Discuss During Therapy?

As sessions progress, the therapist teaches techniques and strategies for behaving and communicating in healthy ways. Through these lessons, the family develops essential missing skills, such as listening, managing expectations, coping with negative emotions, and reality-testing faulty thought patterns.

The topics that come up during family therapy are as unique as the family itself. Common themes of conversation include:

  • Issues of concern family members have
  • How to navigate a crisis that needs to be solved
  • Changes in the family dynamics
  • Healthy ways of coping with feelings of anger, resentment or sadness
  • Ways of communicating effectively
  • How to best support the loved one in recovery
  • Setting boundaries
  • Preventing misunderstandings through better listening and communication skills

What Do Families Do Outside of Therapy?

In many cases, the family in therapy is expected to complete homework between sessions. This may include things like having fun by spending time together, writing family goals, or creating a family statement. Homework helps the family stay mindful of how they interact with one another and it gives them opportunities to explicitly practice new, healthier ways of thinking and behaving within the family system.

If a need is apparent, the family therapist will recommend additional help for certain family members, such as individual therapy, trauma-based therapy, anger management training, or parenting classes.

Why Some Family Members May Resist Therapy

While families generally want to help their loved one recover and forge better relationships with one another, not everyone is comfortable with the idea of family therapy. Some of the reasons why a family member may opt out include:

Fear:

Change is often unsettling and family members who have adapted to the status quo may feel more comfortable with the way things are. Additionally, a family member may be afraid of having to reveal family secrets or they may fear being judged by the therapist or the rest of the family.

Distrust:

If someone in the family distrusts the other family members and is unwilling to talk openly or is suspicious of therapists or therapy, that family member may choose not to participate.

Fatigue:

A family member who has been deeply and negatively affected by the addiction or who has been dealing with it for a long time may be tired of the drama and the family issues it brings up.

Embarrassment:

Some people feel very embarrassed at the prospect of "airing their dirty laundry" to a complete stranger. They may also feel embarrassed about some of their own behaviors.

Skepticism:

If the family has been through therapy before or has particularly challenging problems, one or more family members may feel that family therapy just will not work. If their loved one has been in recovery before but relapsed, some family members might feel like another round of treatment is pointless and may refuse to participate.

Power Dynamics:

Family members who feel powerless may refuse to participate in family therapy, believing it to be futile. Those in power may want to maintain their advantage by leaving things alone.

If a family member is reluctant to participate, the therapist may request a meeting and try to identify and resolve the reasons why they are resistant and offer reassurance. At any rate, the unwilling family member will often choose to participate down the road. Meanwhile, the other family members – and the overall family system – will benefit from the therapy sessions.

In some rare cases, family therapy may do more harm than good. For example, family therapy should not take place unless everyone participating has a voice and can talk about relevant issues, even if a more dominant family member does not want the topic discussed. If someone in the family is extremely angry or violent or if there is neglect or abuse happening in the family, family therapy may lead to poor treatment and an increases risk of abuse.

The family therapist will evaluate the family situation and, if necessary, change the structure of therapy to avoid dangerous or unhelpful situations or suspend therapy until everyone’s safety can be ensured.

Family Therapy Works

The process of recovery is complex and multi-faceted. Substance use disorders affects the entire family, therefore, the entire family should actively participate in treatment for the best possible outcomes. 

Research shows that family therapy helps improve the health of the family system and the functioning of the individuals within the family. It also improves communication and promotes long-term recovery for loved ones with a substance use disorder. 

A high-quality addiction treatment program will utilize family therapy to help restore peace to the household, repair damaged relationships, and help family members support their loved one effectively.

Family therapy works, and it can work for your family, too.


Resources

  1. Lander, L., Howsare, J., & Byrne, M. (2013). The impact of substance use disorders on families and children: from theory to practice. Social work in public health, 28(3-4), 194–205. doi:10.1080/19371918.2013.759005
  2. Center for Substance Abuse Treatment. Substance Abuse Treatment and Family Therapy. Treatment Improvement Protocol (TIP) Series, No. 39. HHS Publication No. (SMA) 15-4219. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
  3. Center for Substance Abuse Treatment. Substance Abuse Treatment and Family Therapy. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2004. (Treatment Improvement Protocol (TIP) Series, No. 39.) Chapter 1 Substance Abuse Treatment and Family Therapy. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64269/
  4. Lipari, Rachel, and Struther Van Horn. “Children Living with Parents Who Have a Substance Use Disorder.” SAMHSA, The CBHSQ Report, 24 Aug. 2017, www.samhsa.gov/data/sites/default/files/report_3223/ShortReport-3223.html.