Executive Summary

Introduction

This Treatment Improvement Protocol (TIP) update provides information and guidance on the latest science-informed, family-based interventions and family counseling approaches for substance use disorders (SUDs). Intended audiences include SUD treatment providers such as drug and alcohol counselors, licensed clinical social workers, licensed marriage and family therapists, psychologists and psychiatrists specializing in addiction, psychiatric and mental health nurses (specialty practice registered nurses), and peer recovery support specialists. The TIP’s audience also includes SUD treatment program administrators, supervisors, and clinical/program directors.

SUDs are complex, lifelong conditions that affect not just people in recovery but their families as well. To give a person struggling with alcohol and drug addiction the greatest chance at lasting, successful recovery, families often need to be included in treatment and services. This TIP is designed to help providers and administrators better understand how to do this by describing the unique impacts of SUDs on families; how family functioning and dynamics can both support and interfere with recovery; and how treatments, services, and programs can best be tailored to families’ needs.

An expert panel developed the TIP’s content based on a review of the most up-to-date literature and on their extensive experience in the field of alcohol and drug addiction treatment and family counseling. Other professionals also generously contributed their time and commitment to this publication.

The TIP is divided into six chapters so readers can easily find material they need most. Below is a summary of the TIP’s main messages, followed by a description of each chapter’s key content areas.

Overall Key Messages

Families affect and are affected by SUDs. In most cases, including family members in a client’s treatment or services for substance misuse is beneficial and makes achieving and sustaining long-term recovery more likely.

Family-based SUD interventions are supported by empirical evidence and have been shown to be effective in promoting long-term behavior change, including recovery. A wide variety of family-based treatment models and approaches are available. You can select from these based in part on the family’s makeup, needs, readiness for change, treatment setting, and level of care required.

No two families are identical, and as such, the ways in which family members function and interact with one another will vary from family to family. As a clinician, you should be prepared to adapt SUD treatments and services to each family’s unique background, structure, and situation.

Each family has its own ways of behaving and relating to one another. Those dynamics infuence substance misuse and recovery and should be considered when making shared treatment decisions with clients and their family members. You should be able to identify common family structures and dynamics and understand how they infuence substance misuse. This will help you develop more targeted treatments that directly address a given family’s dysfunctions and needs.

Most families are doing their best to adapt to the situation of a family member struggling with substance misuse. In general, families usually are just trying to maintain a steady state (or homeostasis). Sometimes that means engaging in behaviors that actually support the family member’s substance misuse. Avoid blaming, shaming, and using judgmental labels (e.g., referring to family members as “co-dependent” or “enablers”) when working with families. Instead, offer them education, empathy, and support.

There are several ways you can integrate family-based treatments and services into care. Motivational interviewing (MI), family-focused interviews and assessments, genograms, and family-based treatment goals are just a few options.

Families are diverse and may need treatments and services tailored to factors such as their racial/ethnic background, level of acculturation, immigration/nativity status, and history of military service.

It is not enough for clinicians to learn about and offer family-based treatments and services for substance misuse. Administrators, directors, and clinical supervisors also play a role in delivering family-based SUD treatment and ensuring programs adopt and maintain a family-centered culture. This means comprehensively addressing a wide range of program development and workforce factors, like hiring and retention, training, clinician and supervisor core competencies, and licensing and credentialing.

Programs that establish and foster close ties to the surrounding community can better help clients and families access resources that meet their needs. Administrators are vital to this process as well.

Content Overview

This TIP is divided into six chapters designed to thoroughly cover all relevant aspects of the ways in which families are touched by SUDs and how providers can offer treatment and services to help meet families’ full range of needs.

Chapter 1: Substance Use Disorder Treatment: Working With Families

This chapter lays the groundwork for understanding the treatment concepts and theories of family-based SUD treatment discussed in later parts of this TIP. It is for providers and administrators.

Families are complex entities; no two are the same. To provide effective family-based services for SUDs, one must understand different types of families and the common characteristics families often possess (including their rules, roles, boundaries, and communication styles).

Family counseling can help families facing SUDs in many different ways, including by teaching them to better understand how their interactions and behaviors are contributing to a family member’s substance misuse and learning how to adapt their behaviors to support a family member’s recovery. Family-based interventions are often centered on helping families learn how to change their behaviors toward and interactions with one another, how they can be a positive infuence on recovery, and how to prevent substance misuse in future generations. There are numerous familybased treatment models, approaches, settings, and formats for SUDs, giving providers (and their client families) a wide range of tools and options from which to choose.

In Chapter 1, you will learn about:

• The benefits and challenges of offering family counseling for SUDs, including why you should include families in SUD treatment and services and in goal setting for those treatments and services.
• The history of family-based SUD treatment and how the incorporation of families into traditional treatment approaches and settings has changed over time.
• The core objectives of current family-based treatment for SUDs, such as helping the family become a source of strength in their family member’s recovery and helping them understand how they influence their family member’s substance-related behaviors.
• Common characteristics present in nearly all families (e.g., roles, rules, communication patterns, degree of loyalty, culture) and how those characteristics vary—and subsequently affect a family member’s recovery.
• The various pathways by which family-based SUD treatment and services are delivered, such as parallel, sequential, and integrated approaches. Different pathways may be more appropriate for certain families depending on their particular structure, way of functioning, and dynamics.
• The different degrees of family involvement that can occur in SUD treatment across different levels of care and settings (e.g., residential treatment, outpatient care).

Chapter 2: Influence of Substance Misuse on Families

This chapter summarizes the ways in which substance misuse affects family dynamics (the ways in which families behave toward and relate to one another) and family systems and the ways in which those in turn infuence substance misuse. This chapter is for providers.

Families operate in their own unique ways. Family dynamics play a large role in both sustaining and reducing/preventing substance misuse. Although all families are different, certain families affect and are affected by SUDs in similar ways. You should be aware of how the dynamics among specifc family types—such as families with young or adolescent children, families with adult children, childless couples, and blended families—are affected by and contribute to the risk of substance misuse in the family. This will help you better determine which treatment/services are best suited to the family and their dynamics.

This chapter also presents the latest empirical evidence about common traits of families touched by drug and alcohol addiction. Again, although each family is different, this discussion will help you understand and identify possible targets of intervention, such as poor communication style, high levels of family confict, ineffective parenting approaches, and lack of family connectedness.

In Chapter 2, you will learn the following:

• Families with SUDs tend to share certain characteristics, which are often the focus of treatment and services. These include problems with communication, confict, parenting skills, family cohesion, and family attitudes about substance use.
• Most families engage in behaviors to try to maintain homeostasis, or balance. Family members often try to keep things as “normal” and consistent as possible, and in doing so may behave in ways that actually make substance misuse more likely. Sometimes this is called enabling. Rather than criticize or shame families for such behaviors (which are completely normal and, in a way, adaptive), instead work with families to help them learn how to develop healthier behaviors and dynamics.
• There may be gender-specifc differences in how family dynamics affect and are affected by SUDs. These gender differences may need to be taken into consideration when offering treatment and services. For instance, women are often socialized to be caretakers and to not be confrontational. A mother or daughter may feel that it is not her place to criticize a family member’s substance misuse and may instead engage in caretaking or “enabling” behaviors. These gender beliefs may need to be addressed in treatment if they are contributing to family dysfunction and preventing recovery.
• In couples in which one partner has an SUD, research suggests there is a high risk of interpersonal violence and mistreatment. Be sure to screen for all forms of abuse.
• Parents struggling with SUDs may not be able to properly care for their young or adolescent children, possibly leading to negative physical, emotional, economic, and social outcomes for offspring. Neglect and other forms of abuse also may be present. This raises professional and legal issues related to safety, and means loss of child custody may become a factor at some point during treatment/services.
• Children of parents with SUDs may be forced to take on roles inappropriate for their developmental stage. For instance, a teenager may feel that he has to become the “father” of the household because his father has alcohol use disorder and cannot reliably earn a living and help support the family. This can be a significant source of stress for the child.
• It is easy to sympathize with young children living with parents with drug and alcohol addiction, but do not overlook the effects of SUDs on adult children. Even when grown, children can be negatively affected by their parents’ substance misuse, including being at risk for substance misuse themselves as well as other unhealthy outcomes (e.g., suicide attempts, higher mortality).
• Just by nature of their structure, blended families often struggle with certain difficult dynamics and situations (like loss of a biological parent or stepparents/stepchildren feeling like “outsiders”). When SUDs are thrown into the mix, this can raise the family stress level even higher. Be particularly sensitive to the difficulties facing blended families with SUDs, and understand how helping them strengthen their bonds with one another can be a powerful factor in supporting recovery and preventing substance misuse.
• Adolescent substance misuse can negatively affect parents and siblings and also place the youth at risk for dangerous or unhealthy outcomes (like car accidents, dropping out of school, or continued substance misuse into adulthood). A family may need help identifying dynamics and functions that are supporting the teen’s SUD and making recovery more difficult.

Chapter 3: Family Counseling Approaches

This chapter reviews research-based family counseling approaches specifically developed for treating couples and families in which the primary issue facing the family system is an SUD. It describes the underlying concepts, goals, techniques, and research support for each approach. This chapter is for providers.

The numerous family-based SUD treatments that exist differ in the strategies and techniques used to address substance misuse. However, these treatments share certain features, such as an emphasis on treating the family as a whole rather than focusing only on the individual with an SUD; using a non-blaming, collaborative approach to care; and adapting to the culture and values embraced by each family. Specific family-based treatments that can be used effectively to help families improve their functioning and enhance recovery include psychoeducation, multidimensional family therapy (MDFT), behavioral couples and family therapy, brief strategic family therapy (BSFT), functional family therapy, and solution-focused brief therapy. This chapter discusses each in detail.

In Chapter 3, you will learn the following:

• Family-based treatment guides families in enhancing their thoughts about and reactions to substance misuse. This in turn typically leads to major changes within the family as a whole.
• Regardless of approach, all family-based treatment shares certain core aspects. Aspects include improving the health and well-being of the whole family, not just the person with substance misuse; respecting the value of family and other social relationships as a key part of recovery; and meeting harm-reduction goals other than abstinence, which can still benefit the family and the individual.
• Psychoeducation is a widely used approach to family-based SUD treatment, and many families can improve their functioning and dynamics simply by learning about drug and alcohol addiction and recovery. Do not underestimate the power of this seemingly simple intervention.
• MDFT has good empirical support for reducing SUDs, especially among adolescents. It addresses individual behaviors and family processes. It has improved functioning among adolescents, parents, families as a whole, and families’ relationships within their communities.
• Behavioral couples and family counseling approaches help support recovery by teaching clients to improve the quality of their relationships, engage in healthier communication, and build positive relationships with one another.
• BSFT uses a problem-focused, practical approach to reduce or eliminate youth substance misuse and enhance family functioning.
• Functional family therapy also takes a problem-solving approach to engaging, motivating, and creating behavior change among clients. Families are also taught how to apply their newfound skills to future situations.
• Solution-focused brief therapy invites families to build a positive vision of their future and identify interpersonal changes and improvements in target behaviors needed to make that vision a reality.
• Network Therapy uses a combination of individual and group therapy approaches and involves members of the client’s network of supportive family members and friends in sessions. The main goal is for members of the supportive network to learn how they can reinforce the client’s efforts to achieve and maintain abstinence.
• In addition to understanding specific treatment approaches, consider offering other family-based skills and services that can support recovery across the continuum of care. These could include engaging the family in treatment, linking members to community and mutual-aid recovery supports, facilitating behavioral contracts between the person in recovery and his or her family members, and teaching relapse prevention techniques (e.g., family-based problem-solving).
• Case management services can help families address problems within larger systems of care, like healthcare-, education-, legal-, and childcare-related issues. These commonly occur in individuals and families with SUDs and thus should be a standard part of family-based SUD treatment.
• Family peer recovery support services offer families the valuable opportunity to learn from others who have walked in their shoes. This can be incredibly powerful and healing, as families touched by drug and alcohol addiction often feel isolated and struggle with stigma, shame, and confusion.

Chapter 4: Integrated Family Counseling To Address Substance Use Disorders

This chapter discusses the advantages and limitations of integrated treatment models and the degree of providers’ involvement with families. It offers guidelines on how to deliver family counseling in combination with specific SUD treatment and to match counseling approaches to each family’s specific level of recovery. The intended audience is providers.

As a general rule, families should be incorporated into SUD treatment and services to give individuals the best chances at lasting recovery. Be sure to let the individual in recovery decide who in the family should be invited to participate in treatment. Barriers to participation may need to be problem solved, such as family members who live far away, have scheduling conflicts, or simply refuse to be a part of treatment. As in individual counseling, screening and assessment are critical components to information gathering, but in this context, both processes should be family based. For instance, discuss not only the individual’s history of substance misuse but also how substance misuse has occurred historically, throughout the family. Rather than focusing entirely on problems within the family, be sure to also explore family members’ strengths, including supportive qualities (e.g., warmth, compassion), talents, and goals. This will help you maintain a positive tone throughout treatment and can help keep families motivated and engaged in care.

In Chapter 4, you will learn that:

• In some instances, certain family members should not be included in SUD treatment and services. Such situations include when intimate partner violence has occurred, when child abuse or neglect has occurred, when individuals are currently withdrawing from substances, when clients with SUDs are also are struggling with psychosis or are suicidal, and when clients have significant cognitive problems (like severe learning or memory problems).
• Mandated family treatment can be difficult because family members are not seeking care willingly. In such cases, MI can help you build rapport with clients and enhance their willingness and desire to participate in treatment.
• As with individual treatment, screening and assessments should be conducted to identify current and past problems in need of intervention. Use a family-based focus that explores the family history of SUDs, mental disorders, abuse, legal problems, work and school issues, and overall health. Family interviews can help you gather this information and also serve as an opportunity for you to build rapport with families, educate them about treatments and services, and get their “buy-in” to enter and stay engaged in treatment.
• Family-based assessments help you determine the history of the family’s functioning and substance misuse. Do not forget to also explore the family’s strengths and supports.
• A genogram can help you and your client families visualize their current and history of substance-related problems. It is also a way to depict their strengths and resources.
• Family members may each have different goals for treatment, and that’s okay. Your job is to help them identify changes they would like to make, teach them how to make those changes, and guide them in becoming sources of support for one another. You can do this by educating families about SUDs and recovery, facilitating communication between family members, and linking them to community-based resources and support networks.
• It is common to encounter certain challenges in working with families with SUDs, but these can be overcome by helping families build healthier coping skills, educating them to correct myths and misconceptions about SUDs and recovery, offering case management services to help coordinate schedules and service needs, and addressing each family member’s particular stage of change.

Chapter 5: Race/Ethnicity, Sexual Orientation, and Military Status

This chapter discusses family counseling for SUDs among families of diverse racial and ethnic backgrounds; lesbian, gay, bisexual, or transgender (LGBT) families; and military families (including active duty personnel and veterans). Each section discusses the latest empirical evidence for family-based SUD treatment with that population as well as suggestions for how you can tailor family-based interventions to improve outcomes. This chapter is for providers.

Family-based counseling is supported by empirical evidence as a safe and effective option for overcoming drug and alcohol addiction. However, no SUD treatment is “one size fts all” for all families. Certain families may beneft more from particular treatment approaches, formats, and settings than from others, based in part on their attitudes, beliefs, and dynamics. These attitudes, beliefs, and dynamics often differ based on a given family’s culture or background. As such, it is critical that you as a clinician understand how diverse families may affect and are affected by substance misuse and tailor your treatments and services as needed. For instance, in families of certain racial or ethnic backgrounds, there may be language barriers or cultural beliefs that make treatment seeking less likely. In military families, there may be attitudes that normalize substance misuse and make recovery seem unnecessary. This chapter will guide you through some specific types of families and how their dynamics, functions, attitudes, and values could affect treatment.

In Chapter 5, you will learn that:

• Diversity among families is an important factor to consider when trying to understand how substance misuse fits into a particular family and which treatments and services may be best for them.
• It is not enough to just be culturally sensitive to such issues; rather, you should provide family-based treatment and services that are culturally responsive. This includes adopting cultural humility, in which you seek to learn from your client families rather than imposing onto them your own beliefs, ideas, and knowledge about a given culture.
• There are several factors to consider when working with diverse family cultures, including their family structure, role of extended family members, spiritual/religious beliefs, immigrant/ nativity status, family values, approach to communication, experience with racism or other discrimination, and history of extended separation (especially between parents and children).
• When working with African American families, you should consider tailoring treatments and services by using culturally relevant storytelling techniques, helping parents strengthen the bonds between each other, and addressing racial socialization (that is, the ways in which parents, directly and indirectly, teach their children about race and society).
• Outcomes of family-based SUD treatment for Latino families may be best when you offer treatments and services in their native language, explore the family’s history of migration and cultural transition, and understand how substance use is defined and discussed in their country of origin.
• For Asian American families, you can adapt family-based SUD treatment by discussing the concept of collectivism and how that might ft into the family’s views, values, and customs; exploring the family’s level of acculturation; and learning about help-seeking and coping behaviors common in their country of origin.
• For American Indian/Alaska Native families, a systemwide approach that involves the entire community, tribe, or clan is often needed. Helping families understand their interconnectedness, and how the behavior of one family member can have ripple effects on the rest of the family, is critical and may require clinicians to involve valued others who are outside the family (e.g., community elders, spiritual healers) in the treatment process.
• LGBT families have not been the subject of as much research as families of diverse racial and ethnic backgrounds. Nevertheless, evidence suggests that these families may benefit from strategies such as alliance building among family members, including nontraditional family members, in treatment and having separate counseling sessions with family members non-accepting of your client.
• If working with military families, you will benefit from learning about military culture, as it is very different from civilian life. This includes understanding power hierarchies, values and expectations for behavior, and attitudes about substance misuse. Military families may benefit from treatment and services that take into account their history of long periods of separation (e.g., deployment) and relocation, both of which are common in military culture and can be significant sources of strain that might make substance misuse by parents, adolescents, or both more likely.

Chapter 6: Administrative and Programmatic Considerations

This chapter outlines family-related aspects of substance misuse that programs should account for when providing alcohol and drug addiction treatment and recovery support services. This chapter is for administrators and clinical supervisors.

The key to developing and implementing family-based SUD treatment and services is to ensure treatment programs adopt a family-centered culture. This means administrators, directors, supervisors, and other leadership should work together to ensure existing treatment and services are family friendly, tailored to families’ full range of needs, and based on empirical evidence. A family-centered culture means an organization includes family members and their needs throughout the treatment and service provision process, including as part of engagement and in shaping the physical program environment. Integrating family counseling and program elements requires education and buy-in among staff as well as the families you serve. Efforts to enhance workforce development also must be present, such as the hiring and retention of clinicians competent and comfortable in working with families with SUDs.

In Chapter 6, you will learn that:

• Program policies and procedures should be implemented in ways that make treatment and services accessible and effective for families.
• Fully integrated family-based programs are those in which all staff understand the ways in which family can influence (and are influenced by) substance misuse. As a refection of this, administrators, program managers, and clinical supervisors should help create, implement, and document policies that are family friendly. Clinicians should understand how to incorporate these policies into practice.
• Clinical staff, including supervisors, should possess family-centered counseling competencies. This includes recruiting and hiring clinicians, supervisors, and administrators who already have the training and knowledge to support a family-based culture in your program setting.
• Core skills for SUD treatment and service providers include having knowledge of family-based interventions and treatment models; diverse cultural factors that affect families with substance misuse; the ways in which family dynamics, relationships, and communication affect recovery; and system concepts, theories, and techniques.
• Administrators and supervisors need to ensure that clinicians engage family members as appropriate throughout all stages of care and that they show families respect, honor their strengths, and recognize their unique needs.
• One way in which programs demonstrate their commitment to building and maintaining a family-centered culture is by making certain that staff have the necessary training, licensing, and credentialing in family counseling.
• By providing ongoing opportunities for staff training and education, programs and administrators help ensure clinicians and supervisors possess the latest evidence-based knowledge and practical understanding of working with families with substance misuse.
• Administrators should develop and maintain ongoing supportive partnerships with community-based organizations to help family members stay integrated within their community and access a wide range of services for all needs (e.g., those related to child welfare, social services, the legal system, housing, spirituality/faith, education/vocation). Building and maintaining strong relationships with the surrounding community will also help a program stay up to date on available and effective local resources for client families.

Citation

Substance Abuse and Mental Health Services Administration. Substance Use Disorder Treatment and Family Therapy. Treatment Improvement Protocol (TIP) Series, No. 39. SAMHSA Publication No. PEP20-02-02-012. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2020.

This work resides in the public domain, unless otherwise indicated.