Addictions: Treating the Family Struggling with Sobriety

Until the late 1980s, most substance abuse treatment programming was based on a model of service for the single male, with little attention paid to parent-child relationships or indeed to other familial or affiliative relationships [Finkelstein 1996]. Few treatment programs existed for women, and most of those that did exist were also based on this "single individual" model. At the same time, the child welfare service system and the substance abuse treatment system, often serving the same clients, interacted peripherally, and it was uncommon to find joint program or service planning [Finkelstein 1993, 1994].

In the late 1980s, two factors arose that altered this picture. One was the growing recognition that substance abuse treatment for women had to address relational issues, including parenting, to fully respond to women's needs and therefore promote successful treatment outcomes. At nearly the same time, the crack "epidemic" raised serious concerns about the effects of perinatal exposure to drugs and the need to provide specialized substance abuse treatment for pregnant and parenting women. This "epidemic" highlighted the fact that a large proportion of child welfare caseloads were families affected by substance abuse, a fact that continues to be true, with estimates that up to 80% of the caseloads are currently affected by substance abuse [CWLA 1998].

The demonstration project, which was the impetus for the development of this program, was innovative in its integration of parenting and parent-child services into substance abuse treatment. One effect of this integration was to increase coordination and planning with child welfare agencies serving the same families. Initially this coordination occurred between the programs involved in the demonstration project and local child welfare agencies. The demonstration project, however, heralded an increase in substance abuse treatment programs serving women with children and families, leading to more systemic coordination. In light of the time limits imposed by the Adoption and Safe Families Act (EL. 105-89) and the steady high percentage of child welfare involved families affected by substance abuse, improvement and expansion in coordination and joint service planning becomes critical.

Development
The Nurturing Program for Families in Substance Abuse Treatment and Recovery (the "program'), is an outcome of the parenting component of a Center for Substance Abuse Prevention demonstration project, the Coalition on Addiction, Pregnancy and Parenting (CAPP). The CAPP project, now known as the Institute for Health and Recovery (IHR), included the design, implementation, and management of a program of parenting and parent-child services at two women's residential substance abuse treatment agencies in Massachusetts. The goals of this component were to improve parenting skills, promote child development, and enhance parent-child relationships to improve treatment outcomes and reduce risk of relapse as well as to reduce developmental or abuse/ neglect risks to children. This project specifically focused on integrating successful treatment with improved parenting skills through enhancement of family relationships.

Families affected by substance abuse benefit in several ways from developing nurturing family relationships [Camp & Finkelstein 1997; de Cubas 1993] and particularly from enhancing parents' substance abuse treatment. Treatment and relapse prevention reports emphasize the importance of supporting the ability to form and maintain mutual and empathic relationships; the ability to experience success and enjoyment as parents; and the ability to cope with daily life stresses as crucial programmatic components [Bry et al. 1998; Camp & Finkelstein 1997; Castellani et al. 1997; Van Bremen & Chasnoff 1994].

For parents, family life and family relationships are critical areas for building coping skills. Incorporating these areas of concern into treatment programs can promote successful treatment and reduce relapse risk by keeping parents in treatment longer, as well as by increasing their self-esteem and sense of competence as parents [Camp & Finkelstein 1997; Chassin et al. 1991; U.S. Department of Health and Human Services 1999; Van Bremen & Chasnoff 1994]. Promoting nurturing parent-child relationships reduces both the risk of substance abuse for both parent and child, as well as intergenerational patterns of violence, abuse, and neglect.

The CAPP project selected the Nurturing Program for Parents of Children Birth to Five Years Old, by Stephen Bavolek, Ph.D., for use in the structured parenting skills group, one component of the program of services. The Nurturing Program has a well-established history as an effective intervention for improving parenting skills and reducing risk of child maltreatment, as well as a validated, reliable measure of effectiveness instrument, the Adult Adolescent Parenting Inventory (AAPI).

To make the Nurturing Program more responsive to the needs of the target population--parents in substance abuse treatment--strategic modifications were undertaken:

• To respond to the range of literacy levels and learning styles (52% of participants had not completed high school), formal didactic components of the Nurturing Program were reduced, and more experiential exercises were designed and implemented to allow for more effective learning for participants better able to express themselves through art, play, and interactive activity.
• Because a high number of participants had experienced childhood abuse and neglect (40% reported at intake that they had experienced sexual abuse in childhood; 37% reported that they had experienced physical abuse), additional material was developed to enhance parents' experience of nurturing through play, meditation, and self-expression, for example.

These adaptations addressed important intergenerational factors associated with substance abuse and with child abuse and neglect, the transmission of patterns of child maltreatment, and the increased risks of alcohol or drug abuse faced by children of substance-abusing parents. The adaptations also maintained adherence with the core domains of the Nurturing Program, that is: (1) enhancing appropriate developmental expectations; (2) increasing empathy for children's points of view; (3) valuing and using alternatives to corporal punishments; and (4) establishing and maintaining appropriate roles.

The modified version of the Nurturing Program was successfully implemented during the span of the demonstration project (1989 through 1995). Evaluation of the effects of the parenting program yielded encouraging findings, as reported in Camp and Finkelstein [1997]. Effects were measured to determine whether participants who completed the Nurturing Program exhibited improvement in parenting knowledge and attitudes and how the women who completed the Nurturing Program assessed its impact.
- Moore, J., & Finkelstein, N. (Mar/Apr 2001). Parenting Services for Families Affected by Substance Abuse. Child Welfare, 80(2).

Update
Mortality in adult children of parents with alcohol use disorder:
a nationwide register study

- Westman, J., Jayaram-Lindström, N., Kane, K., Franck, J., & Gissler, M. (2022). Mortality in adult children of parents with alcohol use disorder: a nationwide register study. European journal of epidemiology, 37(8), 815–826. https://doi.org/10.1007/s10654-022-00883-4

Peer-Reviewed Journal Article References:
Church, S., Bhatia, U., Velleman, R., Velleman, G., Orford, J., Rane, A., & Nadkarni, A. (2018). Coping strategies and support structures of addiction affected families: A qualitative study from Goa, India. Families, Systems, & Health, 36(2), 216–224.

Oberleitner, D. E., Marcus, R., Beitel, M., Muthulingam, D., Oberleitner, L. M. S., Madden, L. M., Eller, A., & Barry, D. T. (2021). “Day-to-day, it’s a roller coaster. It’s frustrating. It’s rewarding. It’s maddening and it’s enjoyable”: A qualitative investigation of the lived experiences of addiction counselors. Psychological Services, 18(3), 287–294.

Solomon, D. T., Nietert, P. J., Calhoun, C., Smith, D. W., Back, S. E., Barden, E., Brady, K. T., & Flanagan, J. C. (2018). Effects of oxytocin on emotional and physiological responses to conflict in couples with substance misuse. Couple and Family Psychology: Research and Practice, 7(2), 91–102.

Online Continuing Education QUESTION 19
What are the four core domains of the Nurturing Program? Record the letter of the correct answer the CEU Test.