Family Therapy: A Comprehensive Guide for Substance Use Disorder Treatment

Family Therapy plays a pivotal role in initiating and sustaining recovery from substance use disorders (SUDs) by actively involving family members in the treatment process. When family members adjust their perspectives on substance misuse and modify their behavioral responses, the entire family system undergoes a transformative change. Family-based SUD interventions prioritize encouraging individuals with SUDs to start and maintain their recovery journey, enhancing family communication and relationships to provide robust support, and empowering family members to engage in self-care and their own recovery.

All family counseling approaches designed for SUD treatment are grounded in the principles of systems theory. This theory posits that the individual client is an integral component of multiple interconnected systems, including family, community, culture, and society. SUD treatment providers utilizing family counseling must possess a deep understanding of complex family dynamics and communication patterns. They also need to recognize how family systems organize themselves around the substance use behaviors of a member struggling with an SUD. Substance misuse frequently intertwines with other significant life challenges such as co-occurring mental health disorders, involvement with the criminal justice system, various health issues (including sexually transmitted infections), cognitive impairments, and socioeconomic limitations like unemployment or homelessness. The field of addiction treatment has effectively adapted family systems approaches to specifically address the unique circumstances of families affected by substance misuse and SUDs.

While a comprehensive exploration of all family therapy theories and counseling approaches is beyond the scope of this discussion, this article will delve into the most pertinent and research-backed family counseling approaches specifically tailored for couples and families where an SUD is the primary concern. We will examine the core concepts, objectives, and techniques associated with each approach, covering a range of family-based treatment methods.

Overview of Family-Based SUD Treatment Methods

Family counseling emerged in the 1950s, bringing a systemic lens to the understanding of family influence on an individual’s physical and behavioral health, and overall well-being. The evolution of family counseling models has resulted in diverse approaches. These generally fall into two categories: long-term treatment, which emphasizes intergenerational family dynamics and the family’s long-term growth, and brief counseling, which focuses on current family issues and cognitive-behavioral changes within the family system to improve its functioning.

Family-based counseling in SUD treatment aligns more closely with the latter model of family systems. In this context, family counseling concentrates on how family dynamics impact an individual’s substance use behaviors and how the family can learn to respond differently to substance misuse.

A fundamental principle is that when family members change their perceptions and reactions to substance misuse, the entire family system is positively restructured. These system-wide changes lead to beneficial outcomes not only for the family member struggling with substance use but also enhance the health and well-being of the entire family unit.

Family counseling in SUD treatment distinguishes itself from broader family systems approaches by shifting the primary focus from the process of family interactions to the content of family sessions. The counselor’s primary emphasis is on substance use behaviors and their consequences on family functioning. For example, in a couples session discussing a husband’s relapse after a period of abstinence, the counselor would observe the interaction between husband and wife but prioritize the relapse itself. This allows the counselor to collaboratively develop strategies for the couple to learn from the experience and proactively prevent future relapses.

While the specific family-based methods discussed vary in their strategies and techniques for addressing substance use behaviors, they share core principles in working with family systems. These include:

• Recognizing the therapeutic value of involving family members in the SUD treatment process, rather than solely focusing on the individual with the SUD.
• Adopting a non-blaming, collaborative approach, in contrast to an authoritative, confrontational style where the counselor is the sole expert.
• Including harm reduction goals alongside abstinence, acknowledging that even incremental reductions in harm can yield significant physical and behavioral health improvements for both the individual and the family.
• Broadening the definition of “successful” treatment outcomes to encompass the overall health and well-being of the entire family, in addition to the individual with the SUD.
• Acknowledging the crucial role of relationships within the family and broader social networks as vital sources of support and positive reinforcement.
• Emphasizing the importance of adapting family counseling methods to align with family values, cultural beliefs, and practices within the family’s community.
• Understanding the complexity of SUDs and recognizing the necessity of working with families to manage SUDs as chronic conditions that impact family functioning, health, and well-being.

Some family-based interventions are specific adaptations of general family systems approaches tailored for SUDs, while others were developed specifically to address SUDs from a family systems perspective. Each approach will be described with an overview, treatment goals, supporting research in SUD treatment, and relevant techniques and counseling strategies.

It is crucial for SUD treatment providers incorporating family-based interventions to operate within the boundaries of their training, licensure, and scope of practice, and to be mindful of state-specific professional requirements.

MST (Multisystemic Therapy)

Much of the research on family-based SUD treatment interventions centers on adolescents. Meta-analyses have shown family counseling to be more effective for adolescent SUDs than individual or group approaches alone, or treatment as usual. Advancements in family-based treatment approaches for adolescent SUDs serve as valuable models for adult treatment.

MST, for example, was initially developed for adolescents with SUDs involved in the criminal justice system. A recent adaptation of MST for emerging adults transitioning out of child welfare systems retains MST principles but shifts the primary change agent from parents to the emerging adult and their social network, which may or may not include parents. Pilot studies of this adapted approach have demonstrated promising outcomes. Another pilot study adapting MST for mothers with SUDs (MST-Building Stronger Families) showed significant reductions in substance use among mothers and fewer anxiety symptoms in their children.

Systemic-Motivational Therapy

Systemic-motivational therapy is an SUD family counseling model combining systemic family therapy and Motivational Interviewing (MI). Developed by Steinglass, it was initially designed for alcohol use disorder (AUD) within families but is applicable to other forms of substance misuse. Key goals include assessing the relationship between substance misuse and family dynamics, understanding family beliefs about substance misuse, and fostering collaborative family strategies for abstinence.

This approach facilitates families in forming hypotheses about the causes of SUDs and creating “mini-experiments” to address substance misuse. Counselors and families work together to establish criteria for evaluating the success of these experiments and adjust treatment strategies accordingly.

Family interventions are valuable tools in SUD treatment. It is often recommended to start with less intensive options, such as counseling and Al-Anon or CRAFT, before progressing to more intensive interventions if necessary.

Psychoeducation

Psychoeducation was among the first family-based SUD treatment approaches widely adopted, introducing the value of family system involvement in treatment and serving as a long-standing component of SUD treatment programs. Psychoeducation is more than simply providing information; it aims to engage family members in treatment, offer education, strengthen social support networks, develop problem-solving and communication skills, and connect families with ongoing community-based support services. Psychoeducation can be delivered in individual or group sessions with family members, in single-family or multi-family group settings.

While engaging families in more intensive SUD treatment is a potential outcome of psychoeducation, many family members benefit significantly from simply gaining knowledge about addiction, recovery, and effective responses to a family member’s substance misuse. Psychoeducation can include providing access to online resources, pamphlets, multimedia materials, and recovery-focused literature. It also serves to inform families about and facilitate referrals to community-based family support systems like Al-Anon and Nar-Anon.

Psychoeducation empowers family members to:

• Understand the biopsychosocial impacts of SUDs on both the individual and the family.
• Learn about the SUD treatment process and what to expect during ongoing recovery.
• Recognize the importance of their support in helping their loved one initiate and sustain SUD recovery.
• Develop their own support systems and acquire coping strategies and skills from other families facing similar challenges.
• Increase feelings of support and decrease isolation and shame.

Incorporating family members in psychoeducation can improve treatment outcomes for individuals with SUDs, reduce relapse rates, and enhance overall family functioning and well-being. Family psychoeducation has become a primary treatment approach for individuals with co-occurring SUDs and mental disorders. Research has demonstrated its effectiveness in reducing relapse in this population and it is recognized as an empirically supported cognitive-behavioral therapy (CBT) approach for SUD relapse prevention.

Psychoeducation is a valuable component of relapse prevention within individual, family, and group therapy. Psychoeducational strategies to help prevent relapse include:

• Providing brief in-session education on SUDs, relapse processes, and prevention strategies.
• Assigning homework for clients and family members to complete between sessions.
• Teaching and practicing problem-solving and communication skills during sessions.
• Providing educational handouts for home review.
• Suggesting relevant reading, audio, or video materials.
• Creating a family recovery maintenance notebook with educational materials, exercises, session notes, and reflections on insights, communication strategy effectiveness, and questions for future exploration.

MDFT (Multidimensional Family Therapy)

MDFT is a flexible, family-based counseling approach integrating individual counseling and multisystemic methods to treat adolescent substance misuse and conduct-related behaviors. MDFT addresses both personal and interpersonal factors contributing to adolescent substance misuse.

MDFT counselors work across four treatment domains, each with specific goals:

• Adolescents: Enhance emotional regulation, social skills, and coping mechanisms; improve communication with adults; identify alternatives to substance use; reduce association with substance-using or antisocial peers; and improve academic performance.
• Parents: Increase emotional and behavioral involvement with their adolescent, reduce parental conflict, improve teamwork, discover positive ways to influence their adolescent, enhance parent-adolescent communication, and improve positive parenting knowledge.
• Family members and extrafamilial supports: Reduce family conflict, strengthen emotional bonds, improve communication, and enhance problem-solving skills.
• Community: Enhance family members’ ability to advocate for themselves within larger social systems like schools and the criminal justice system.

MDFT recognizes that behavior change occurs through multiple pathways, contexts, and mechanisms. It aims to “retrack” adolescent development through treatment in these four domains, guided by knowledge of adolescent development and family dynamics.

Counselor focus in MDFT shifts across three stages:

• Stage I: Build the foundation.
  • Develop therapeutic alliances with all family members.
  • Explain the MDFT process.
  • Assess risk and protective factors within individual, parental, family, and extrafamilial systems.
  • Identify personally relevant treatment goals.
  • Use crises and stress to build motivation for change.
• Stage II: Prompt action/activate change.
  • Promote positive changes in feelings, thoughts, and behaviors.
  • Use active listening to empathize and build hope for change.
  • Encourage adolescent self-disclosure.
  • Enhance parenting skills through psychoeducation and coaching.
  • Encourage parental limit-setting, monitoring, and support.
  • Teach parents to manage difficult family interactions.
  • Teach advocacy skills for community systems interactions.
  • Engage community supports to sustain family system changes.
• Stage III: Seal the change and exit.
  • Reinforce behavioral changes.
  • Explore strategies to maintain change and prevent relapse.
  • Terminate treatment when changes are stable.

MDFT treatment includes individual, family, and extrafamilial sessions in varied locations like clinics, homes, courts, or schools. The format is adaptable to different clinical populations. A full course of MDFT typically involves 16 to 25 sessions over 4 to 6 months, with session frequency adjusted to individual and family needs.

Research supports MDFT efficacy, with counselor adherence to the model improving SUD treatment outcomes. MDFT has been successfully implemented across diverse settings and populations, including ethnically diverse, low-income, inner-city adolescents at risk for or experiencing substance misuse, juvenile justice involvement, and co-occurring disorders.

Randomized clinical trials have shown MDFT’s clinically significant impact on reducing adolescent drug use and related behavioral problems in both controlled and community settings. Data also indicates improved family functioning during MDFT, with sustained gains at follow-up. For some adolescents, MDFT can be an effective alternative to residential treatment.

Behavioral Couples and Family Counseling

Behavioral couples and family counseling approaches promote recovery by enhancing relationship quality, communication skills, and positive reinforcement within family relationships. Two prominent variations are Behavioral Couples Therapy (BCT) and Behavioral Family Therapy (BFT).

BCT (Behavioral Couples Therapy)

BCT is a structured approach for individuals with SUDs and their intimate partners, focusing on the partner’s role in rewarding abstinence and supporting recovery. BCT aims to reduce relationship distress, improve interaction patterns, and strengthen relationships to lower relapse risk for the partner with the SUD. The core goals are to support abstinence and improve relationship functioning.

Typically involving 12 to 20 weekly sessions, BCT is suitable for couples where:

• Partners are married or cohabitating for at least a year.
• Neither partner has a severe co-occurring mental disorder.
• Only one partner has a current SUD.
• There is no risk of severe intimate partner violence.

BCT employs two main components:

• Substance-focused interventions to build support for abstinence.
• Relationship-focused interventions to enhance caring behaviors, shared activities, and communication.

“[T]he goal of BCT is to create a ‘virtuous cycle’ (i.e., enlisting the … partner’s support in the client’s recovery) between substance use recovery and relationship functioning by using interventions designed to address both sets of issues concurrently and reinforce positive behaviors.”

Counselors begin with substance-focused interventions to establish abstinence, then introduce relationship-focused interventions, emphasizing communication skills and positive activities. Relapse prevention is addressed in the final phase.

Benefits of BCT in Relapse Prevention and Recovery Promotion

Substance use and marital conflict are mutually reinforcing. Substance misuse contributes to relationship dissatisfaction, instability, conflict, and stress, all linked to relapse. This creates a damaging cycle difficult for couples to break.

Couples counseling helps to address substance misuse directly, leveraging partner support for abstinence and reshaping relationship dynamics to foster a recovery-conducive environment. This reduces stress, relapse risk, and interpersonal violence.

BCT Interventions

BCT sessions are highly structured, involving: (1) reviewing substance use, relationship concerns, and homework; (2) introducing new material; and (3) assigning home practice. Out-of-session assignments are integral to the process. Initial sessions focus on developing a recovery contract. Counseling strategies include this contract, activities to increase positive feelings, shared activities, constructive communication, and relapse prevention planning.

BCT is a family-based treatment with strong evidence of efficacy, proving significantly more effective than individual treatment in reducing substance use, increasing abstinence, and improving relationship functioning for both men and women with SUDs. Research also highlights its cost-effectiveness due to reduced relapse rates. While initial research focused on men with SUDs, BCT is also effective for women and has shown promise with same-sex couples.

BCT is generally recommended when only one partner has an SUD, but research indicates it remains effective even when both partners are in recovery. Key elements contributing to success include partner involvement, less confrontation, and supportive communication regarding recovery efforts. BCT is particularly effective when both partners are motivated to change and support each other.

Adaptations of BCT, such as adding parenting skills training or adapting it for family counseling beyond intimate partners, have shown promising results in pilot studies, expanding its applicability in SUD treatment.

Parenting Skills Training in BCT

BCT has positive secondary effects on children, improving psychosocial adjustment even without direct child participation. Integrating parenting skills training into BCT (PSBCT) further enhances these benefits for the entire family. Studies show PSBCT leads to significant improvements in child adjustment compared to individual treatment and standard BCT, without compromising BCT’s effectiveness for the couple.

BCT for Family Counseling

Behavioral family counseling adapts BCT for clients living with family members other than intimate partners, typically a parent. This adaptation involves 12 sessions focused on establishing a “daily trust discussion” where the family member reinforces abstinence, reduces conflict, improves communication, and promotes positive activities.

Behavioral family counseling emphasizes daily support for abstinence, similar to BCT, but places less emphasis on shared activities and communication practice at home, aligning better with the developmental needs of emerging adults living with parents. Research supports its efficacy over individual treatment in treatment retention, increased abstinence, and reduced substance misuse.

BFT (Behavioral Family Therapy)

BFT approaches are rooted in social learning and operant conditioning theories, viewing substance misuse within a family context. Counselors see substance misuse as a learned behavior potentially reinforced by peers, parents, and role models.

BFT emphasizes contingency management strategies that reward abstinence, reduce reinforcement of substance use, and increase positive behaviors and social interactions incompatible with substance use. Counselors coach families to adopt new behaviors that enhance positive interactions and improve communication and problem-solving skills. BFT, while not manual-based, applies evidence-based practices like contingency management, communication skills training, and CBT within family counseling.

BFT techniques to facilitate behavioral change include:

• Contingency contracting: Agreements outlining reciprocal behaviors and rewards.
• Skills training: Education and practice in communication and conflict resolution.
• Cognitive restructuring: Helping families challenge and replace unrealistic or self-limiting beliefs contributing to substance misuse.

Family Behavior Loop Mapping

Family behavior loop mapping is a detailed behavioral chain analysis of family interactions leading to substance use or abstinence. It involves the entire family in visually mapping out sequences of events, emphasizing the systemic, interactive nature of substance use issues and highlighting that no single person is solely responsible. This process identifies alternative behaviors and pathways to “not using,” facilitating discussions on breaking negative cycles.

This is a complex strategy requiring specialized training from experienced family counselors.

Family Check-Up (FCU)

Lack of parental involvement predicts later substance use, while parental monitoring and communication reduce this risk. FCU is a brief assessment and feedback intervention targeting family risk factors like poor monitoring and parent-child relationships. FCU integrates MI principles to motivate families to change practices to prevent future substance use in children and address current substance use in adolescents.

FCU for adolescents consists of two family sessions:

1. Intake interview: Identifying strengths, challenges, engaging family, and videotaping parent-adolescent interactions.
2. Feedback session: Using MI to support positive parenting and address practices linked to substance misuse.

The feedback session includes:

• Self-assessment: Parents reflect on family insights gained from the assessment.
• Support and clarification: Counselor clarifies family issues and practices related to substance use risk reduction.
• Feedback: Personalized feedback on expectations, supervision, monitoring, and communication.
• Parenting plan: Collaborative development of a written plan to improve communication and monitoring.

Research shows FCU completion lowers adolescent substance use and SUD risk. Meta-analyses support FCU’s effectiveness as part of school-based prevention programs in reducing marijuana use.

BSFT (Brief Strategic Family Therapy)

BSFT aims to reduce youth drug misuse and modify family interactions that support it through a problem-focused, directive, practical approach. Rooted in structural and strategic family theory, BSFT addresses dysfunctional family interactions (e.g., inappropriate alliances, boundary issues, blame-shifting) as linked to adolescent substance misuse.

BSFT interventions target family interactions influencing youth substance misuse. Structural family counseling strategies in BSFT include:

• Joining: Building a working alliance with each family member and the system.
• Enactments: Recreating dysfunctional patterns to assess and restructure them through coaching and modeling.
• Working in the present: Focusing on current interactions rather than past events.
• Reframing negativity: Reinterpreting negative perceptions to promote care and concern.
• Reversals: Coaching family members to act opposite to typical patterns to disrupt interactions.
• Working with boundaries and alliances: Addressing roles, boundaries, and power dynamics to improve family functioning.
• Detriangulation: Removing less powerful members from conflicts between others.
• Opening closed systems: Facilitating open expression of feelings and constructive conflict resolution.

Decades of research support BSFT’s effectiveness in engaging families, addressing cultural factors, reducing adolescent and parental substance use, and improving family functioning. BSFT also shows long-term benefits in reducing arrests, incarceration, and externalizing behaviors.

BSFT is a complex, manual-based approach requiring extensive training and supervision for proper implementation.

Functional Family Therapy (FFT)

FFT is another behaviorally based family counseling approach aiming to change dysfunctional family patterns that maintain substance misuse and promote positive problem-solving. Based on an ecological model of risk and protective factors, FFT has three phases:

• Phase 1: Engagement and motivation
  • Engage all family members and enhance motivation.
  • Frame the counselor-family relationship as collaborative.
  • Reduce negativity and blame through reframing.
• Phase 2: Behavior change
  • Assess risk factors and relational patterns.
  • Develop parenting, communication, and supervision skills.
  • Encourage active listening and clear communication.
  • Develop and implement rules and consequences.
• Phase 3: Generalization
  • Teach generalization of skills to new situations.
  • Anticipate and plan for future challenges.
  • Reframe challenges as normal, not failures.
  • Link families to community supports.

FFT has been widely disseminated and meta-analyses support its effectiveness compared to other treatments like CBT, individual, group counseling, and probation services.

Solution-Focused Brief Therapy (SFBT)

Developed in the 1980s and 90s, SFBT helps families find solutions rather than focusing on problem causes. It assumes identifying causes is unnecessary; solution-focused counseling is sufficient for change.

In SFBT, families define treatment goals. The counselor emphasizes times when the problem is absent and helps identify achievable solutions to enhance motivation and optimism.

SFBT helps families create a detailed vision of a problem-free future and take steps to achieve it. Its narrow focus makes it compatible with various SUD treatment strategies.

SFBT techniques include:

• Developing a vision of the future: Envisioning life without substance misuse to inspire solutions and hope.
• Asking the miracle question: Eliciting each family member’s vision of a resolved problem.
  

  “Suppose that while you’re sleeping tonight and the house is quiet, a miracle happens. The miracle solves the problem that brought you here. But you’re asleep, so you don’t know that the miracle has happened. When you awake tomorrow morning, what will be different to show you that a miracle happened and that the problem that brought you here has been solved?”

• Envisioning interpersonal change: Setting goals respecting family member needs.
• Identifying exceptions to the problem: Focusing on times when substance use is absent or less severe.
• Identifying problem sequences: Analyzing behavioral chains leading to substance use.
• Identifying solution sequences: Analyzing behaviors during problem exceptions to replicate successful patterns.

SFBT replaces expert-directed pathology correction with a collaborative, solution-seeking approach. It emphasizes future solutions over past problem analysis.

Research supports SFBT effectiveness, showing benefits for adults with mental disorders and promising results for family functioning, especially under stress. Studies also show its effectiveness in reducing substance use and trauma symptoms in parents involved in child welfare.

CRAFT (Community Reinforcement and Family Training)

CRAFT is a well-researched family-based intervention focusing on Concerned Significant Others (CSOs). CRAFT is a structured, positive reinforcement approach, typically 4-6 sessions, teaching CSOs strategies to encourage substance users to change their behaviors and enter treatment. It is based on the idea that environmental factors significantly influence treatment entry. The counselor works with family members to modify their interactions, impacting the substance user’s behavior. The intervention’s focus is the family system.

Community Reinforcement

CRAFT exemplifies community reinforcement, promoting recovery by engaging family and natural supports in treatment. Community reinforcement aims to provide positive incentives for abstinence, involvement in positive social activities, and treatment engagement. It encourages positive reinforcement over confrontation. CRAFT is effective for diverse populations and settings.

A Less Structured Approach

While CRAFT is structured, it can be adapted to a less structured, family-focused approach involving psychoeducation on substance misuse effects and communication skills coaching, including:

• Avoiding blame and shame.
• Expressing concern about substance use effects.
• Expressing hope for help-seeking.
• Offering affirmations for positive change.

Encouraging family members to attend support groups like Al-Anon and Nar-Anon is also important. Research supports Al-Anon’s positive psychosocial and physical outcomes for CSOs.

Network Therapy

Network Therapy combines individual, group, and family counseling, enlisting family and friends (ideally 3-4 people) to support abstinence. It uses cognitive-behavioral relapse prevention, social networks, and community resources.

Network Therapy goals include:

• Individual and group sessions involving the network.
• Immediate abstinence as the primary goal.
• Long-term stability through various SUD treatment tools (e.g., avoiding substance-using relationships, medication, mutual-aid groups, contingency contracts).
• Teamwork-oriented, non-confrontational sessions focused on support, not relationship dynamics.
• Emphasizing network solidarity and commitment to supporting abstinence.

Research shows Network Therapy is associated with decreased substance use, reflected in drug-free urine tests. Some research attributes these outcomes to improved therapeutic alliance. Adaptations combine Network Therapy with behavioral therapy, naltrexone, or community reinforcement approaches.

Family Approaches To Support Ongoing Recovery

Family-based interventions can be integrated into SUD treatment to varying degrees. Approaches to involve family in treatment and continuing care include:

• Engaging families and CSOs to help individuals enter treatment.
• Involving families and CSOs during treatment.
• Linking to family/CSO recovery supports and case management.
• Facilitating behavioral contracting around abstinence and medication adherence.
• Improving communication to address relationship conflicts.
• Enhancing problem-solving skills and supportive behaviors to prevent relapse.

Engagement of Families in Treatment

Family, social supports, and community resources are vital for long-term recovery. Recovery is a social process, not a solo endeavor. Support systems include spouses, partners, CSOs, parents, extended family, friends, community members, mentors, teachers, clergy, peers, employers, case managers, and healthcare providers.

Social factors protect against SUDs and aid recovery, including emotional bonds, social cohesion, goal direction, structure through work or faith, monitoring, positive role models, negative consequence expectations, self-efficacy, coping skills, and substance-free activities. These are reflected in how families, friends, and support groups promote recovery.

While families support individuals with SUDs, they also need their own recovery support. SUDs alter family structures, roles, rules, and relationships. These changes are deeply embedded and won’t spontaneously resolve with recovery initiation. Families experience stress, dependence, and difficulties navigating SUD treatment systems, alongside financial stressors.

Actively involving families helps initiate and sustain recovery. Guidelines for engaging families include:

• Discussing family involvement early in treatment.
• Addressing safety, cultural appropriateness, and confidentiality.
• Obtaining client releases for family involvement.
• Collaboratively planning to identify and invite supportive family members.
• Offering culturally appropriate information on SUDs, relapse signs, and the importance of family support.
• Facilitating behavioral contracting.
• Improving communication skills.
• Encouraging positive, substance-free experiences.
• Seeking family input on relapse warning signs.
• Discussing self-care for support systems.
• Sharing information on community resources and mutual-help groups.
• Facilitating contact with peer recovery support specialists.
• Planning follow-up meetings.
• Referring family members for individual counseling or family therapy as needed.
• Involving families in continuing care and relapse prevention planning.

Family Recovery Support Groups

Strategies for incorporating family recovery support groups:

• Assess family understanding and past participation in mutual-aid groups.
• Address misconceptions about support groups.
• Explore challenges and benefits of participation.
• Actively link families to aligned community-based groups.
• Use session time to discuss reflections on support group participation.

Familiarity with family-focused mutual-aid groups is crucial. Widely available groups include 12-Step groups like Al-Anon, Families Anonymous, and SMART Recovery Family & Friends.

12-Step Groups

Al-Anon Family Groups, founded in 1951, is the oldest mutual-help group for families affected by AUD. Based on AA’s 12 Steps, Al-Anon helps family members learn self-care and stress coping strategies, such as detaching from responsibility for the substance user’s behavior and focusing on their own well-being while supporting recovery.

Other 12-Step groups like Nar-Anon (for families affected by drugs other than alcohol), Co-Anon (cocaine), Adult Children of Alcoholics, and Alateen (for adolescents with parents with AUD) follow the Al-Anon model.

Mutual-Help Groups for Families of Individuals With Co-Occurring Disorders

NAMI (National Alliance on Mental Illness) offers peer-led psychoeducation for families of individuals with mental illness, improving understanding and coping skills. These groups empower families to advocate and provide support, helping them improve coping skills, share experiences, find self-acceptance, and understand mental disorders as chronic illnesses.

Case Management

Case management is a psychosocial intervention assessing life concerns, developing action plans, linking to community resources, coordinating care, and monitoring service participation. Meta-analyses show case management improves linkage and retention in SUD treatment.

Family case management addresses both client and family needs related to substance misuse. It is crucial for families involved with multiple systems (workplace, schools, healthcare, criminal justice, child welfare). SUD treatment providers should link clients needing intensive case management to specialized services, ranging from general support to wraparound services and assertive community treatment. For less intensive needs, providers act as community liaisons, informing clients about resources, collaborating with providers, and advocating for families.

Family Peer Recovery Support Services

Peer recovery support for individuals with SUDs is effective, and similar services exist for families. Family peer recovery support specialists are non-clinical providers with lived experience of family members with SUDs, mental disorders, or co-occurring disorders. They offer education, support, and resources, understanding the family perspective and challenges of recovery. They link families to resources within addiction treatment, mental health, criminal justice, child welfare, and community-based support groups like Al-Anon.

Familiarity with local family peer recovery support services is essential for actively linking families to specialists who can help them pursue their own recovery goals in conjunction with the family treatment plan.

Relapse Prevention for Families

Families, like individuals with SUDs, can experience “relapse” to old behaviors when stressed. Cues of relapse in the substance user can trigger anxiety, anger, and helplessness in family members, leading to ineffective coping mechanisms.

Relapse prevention principles apply to families and individuals alike. Family members can create their own relapse prevention plans by:

• Identifying personal triggers for old behaviors.
• Recognizing cognitive distortions preceding relapse.
• Re-engaging coping skills to manage stress.
• Creating a written plan with self-care activities, support contacts, and crisis numbers.

Where Do We Go From Here?

Family counseling approaches in SUD treatment are rooted in systems theory, viewing the individual as part of a larger family system. Family counseling focuses on family influences on substance use and how families can learn to respond differently. When families change their responses, the entire system improves, enhancing health and well-being for all. Moving forward, understanding and implementing these family therapy strategies in SUD treatment is crucial for comprehensive and effective care.