Substance Abuse

A common reason for seeking treatment for substance abuse is a problem with interpersonal relationships (Tucker and Gladsojo 1993). Given the evidence showing the influence of family and social relationships on substance abuse, cited above, treatment attempts to improve the quality of inter-personal relationships and to teach problem solving skills to couples and families with a substanceabusing member. Interactions between family members are important in the etiology and maintenance of substance use. Family interactions are interdependent and, over time, become patterns of behavior that the family maintains. Family interventions focus on identifying and changing the patterns that support the problematic substance use. Some family-based interventions also acknowledge that the family system is maintained in a broader context of peers, work, school, and neighborhood and attempt to engage elements from these systems in therapy. Although there are different models of family-based interventions, the common focus is on changing the patterns of interaction within the family (Robbins and Szapocznik 2001).

Reviews of the substance abuse treatment literature in the mid-1990s noted that modest benefits could be ascribed to family-based interventions (Edwards and Steinglass 1995; Liddle and Dakof 1995). The reviews concluded that although the research at that time indicated the promise of family-based interventions, there were not enough randomized clinical trials to warrant an endorsement of efficacy, defined as a high degree of confidence that the intervention reduced or eliminated substance abuse.

Treatment of alcohol abuse and alcohol dependency. Three interventions that effectively reduce alcohol abuse and dependency among adults are Behavioral Couples (or marital) Therapy (BCT), Behavioral Family Therapy (BFT), and the Community Reinforcement Approach (CRA). BCT is highly structured and guided by a treatment manual principally developed by Timothy O'Farrell, Barbara McCrady, and their colleagues (Fals-Stewart, Birchler, and O'Farrell 1996; McCrady 2000; O'Farrell, Van Hutton, and Murphy 1999). Early sessions focus on helping the couple to increase positive verbal exchanges and behaviors. Later sessions build skills at positive marital communication and problem solving. Sessions include review of disulfiram (an alcohol antagonist) contracts, homework assignments, and the client's drinking or urges to drink. Sessions continue with the introduction of new material, modeling of new skills by the therapist, and rehearsal of the skills by the couple. To complement the approach, a module of fifteen sessions is used to establish and maintain a relapse prevention plan that includes how to identify and manage warning signs of lapses.

BFT, an efficacious and promising intervention across groups and substances (Azrin et al. 1996; Edwards and Steinglass 1995; Stanton and Shadish 1997), is based on the assumption that behaviors are maintained by consequences. Change is unlikely to occur unless more rewarding consequences result from different behaviors. For example, parent skills training, a feature of BFT, teaches parents to increase reward for positive behaviors and ignore negative behaviors to produce change. Patients in a temporary heroin detox clinic attempt to quit using the drug. A behavioral approach to the treatment of heroin abuse can be especially effective when combined with medications such as methadone. ED KASHI/CORBIS A strategy often used is to improve communication between the parents and the adolescent.

CRA is an efficacious and comprehensive intervention that involves spouses, family members, and others in the drinker's social network to change the marital, familial, and social reinforcers that support the drinker's behavior (Kirby et al. 1999; Miller, Meyers, and Hiller Sturmhoefel 1999). Beginning with a functional analysis of the drinking behavior (i.e., a review of persons, places, and contexts that act as triggers for substance use behavior), significant others are trained to help the drinker to engage in treatment and to remove positive reinforcers during drinking episodes. Drink refusal skills, relaxation, control of drinking urges, and methods to deal with risky social situations are taught. Often disulfiram contracts are included.

Two other interventions that show promise in reducing alcohol abuse and dependency are Functional Family Therapy (FFT) and Multi Systemic Family Therapy (MSFT). FFT is a manually guided intervention involving eight to thirty sessions spread over a three-month period (Stanton and Shadish 1997; Weinberg et al. 1998). The approach evolved from the need to serve at-risk adolescents and their families with few resources or who were difficult to treat. FFT has phases that consist of engagement and motivation, behavior change, and generalization. Each phase involves assessment and intervention. For example, in the engagement and motivation phase, assessment focuses on the level of negativity and blaming in family exchanges. The intervention in this phase would target the development of behaviors and communication that reduce negativity and blaming. Similarly, in the generalization phase, assessment identifies the range of situations to which the family can apply new behaviors. The objective of intervention in this phase would be to maximize the functional range of the family's new behavior(s).

MSFT views substance abuse as antisocial behavior that develops from a complex network of interconnected systems: the individual, the family, and extrafamilial factors such as peers, school, and neighborhood (Henggeler, Pickrel, and Brondino 1999; Schoenwald et al. 1996). The intervention is primarily targeted to adolescents. MSFT attempts to alter parenting skills and resources as well as improve the adolescent's coping skills. The intervention integrates strategic family therapy, structural family therapy, behavioral parent training, and cognitive-behavioral therapy. The home-based intervention is designed to reduce service barriers, increase family retention in treatment, allow for the provision of intensive therapy, and enhance treatment gains. MSFT is designed for approximately sixty hours of contact with the family, but family needs determine the frequency and duration of contact.

Treatment of drug abuse and drug dependency. Although some of the interventions described above are useful in treating drug abuse and dependency, Brief Strategic Family Therapy (BSFT), Multidimensional Family Therapy (MDFT) and the Matrix model (MM) are also promising. BSFT and MDFT target adolescent drug abuse. BSFT is a short-term, problem-focused intervention based partly on classical and operant conditioning (Stanton and Shadish 1997; Szapocznik and Williams 2000). Substance abuse is viewed as the result of problematic family interactions that are rewarding based on familiarity and habit. The focus of the intervention is on improving family interactions so that new behaviors are rewarded and replace the substance abuse by the family member. The techniques used in this process are joining (engaging and entering the family system), diagnosing (identifying the maladaptive interactions as well as the family strengths), and restructuring (transforming maladaptive family interactions). BSFT is delivered in twelve to fifteen sessions over three months. BFST was developed for application with inner city Hispanic/Latino and African-American families. Therapists are trained to assess and facilitate healthy family interactions based on the cultural norms of the family.

MDFT views the development of adolescent drug use as the result of individual, family, peer, and community influences (Liddle and Dakof 1995; Schmidt, Liddle, and Dakof 1996). Reducing unwanted behavior and increasing desirable behavior occurs in multiple ways and within different settings (e.g., in the home, school, and community). MDFT interventions typically include individual sessions held in parallel with family sessions. In the individual sessions, adolescents learn effective decision making, negotiation, and problem-solving skills. In the family sessions, parents identify their parenting style and learn positive developmentally appropriate skills to influence their child's behavior.

The MM recognizes the important influence of the family on the development, maintenance and consequences of drug abuse (Rawson et al. 1995; Shoptaw et al. 1994). The intervention includes family education groups to assist families in understanding the effects of the drug abuse of the member. The intervention requires therapists to use nonconfrontational methods to promote the individual's self-esteem, dignity, and self-worth. Sessions include early recovery skills groups, conjoint sessions, family education groups, twelve-step programs, relapse analysis, and social support groups.