Addictions: Treating the Family Struggling with Sobriety

The professional literature identifies a variety of risk factors that indicate whether an adolescent is at risk of substance use (Hawkins, Catalano, & Miller, 1992). Many of these risk factors revolve around family composition and dynamics such as family drug use, family interaction patterns, and boundaries (Smith & Springer, 1998).

Therefore, in treating a substance-abusing adolescent, the family is a key target of intervention. Multifamily therapy groups (MFTGs) have been used to involve families in treatment and have been found to be effective with a variety of populations across many settings (Meezan & O'Keefe, 1998; O'Shea & Phelps, 1985).

We developed an MFTG model that was used in conjunction with individual and family therapy with substance-abusing adolescents. This article provides a theoretical overview of the MFTG model and describes and illustrates the implementation of the model with substance-abusing adolescents and their families.

Structure of MFTG
Our MFTG model was a treatment component of a therapeutic milieu for substance-abusing adolescents. As part of the program, adolescents and their families voluntarily attended weekly individual family therapy sessions and a multifamily therapy group. The average size of the MFTGs was four to five families, for a total of from 12 to 15 clients. (MFTGs much larger than this are not recommended because they can become overwhelming for all involved.) Each group session lasted 1 1/2 hours. The average age of the adolescent group members was 15 years. Most of the adolescents were polysubstance abusers, using primarily alcohol and marijuana, and had coexisting mental health diagnoses such as depressive and anxiety disorders, oppositional defiant disorder, and attention-deficit hyperactivity disorder.

The MFTG was an open group. Membership changed each week, so each group session began with introductions and a brief review of the group rules, such as "What we say in group stays in group." Adolescent members introduced themselves and the rest of their family. Sometimes, the group leaders began the sessions with a brief 10- to 15-minute presentation of psychoeducational material. However, some group leaders began sessions simply by inviting families to share how their week had gone and what type of progress they were making on their goals. Very often, this approach led to intense groups marked by member-to-member interaction.

Overview of MFTG Model
The proposed MFTG model integrates techniques and interventions primarily from four modalities: solution-focused and structural family therapy, and an interactional and mutual aid approach.

Solution-Focused Therapy
Solution-focused therapy (SFT) (Berg & de Shazer, 1991; de Shazer, 1985; Selekman, 1997) underscores the positive attributes that clients bring with them to treatment. It is a strength-based approach. Using SFT, clients are encouraged to develop future-oriented, positively worded goals. Practitioners are encouraged to work in partnership with clients and to foster collaborative relationships with resources that may benefit the client.

We used two techniques from SFT: ( 1) the scaling question and ( 2) the miracle question (Berg & de Shazer, 1991; de Shazer, 1994). The scaling question provides a direct and nonthreatening way to monitor client functioning on goals over time. Consider the following illustration.

Johnny's primary goal was to get along better with his parents. Using the scaling question, the group leaders asked Johnny to rate, on a scale from 1 to 10, how well he got along with his parents during the preceding week, with 1 indicating that he did not get along with them at all and 10 indicating that he got along with them great. Suppose Johnny gave a rating of 6. The leaders would then ask Johnny what he and his parents could do over the next week to make it from a 6 to a 7. Johnny's parents also would be invited to provide their own rating. The purpose of asking clients to think in terms of one-point increments when using the scaling question is to set them up for success by having them gradually implement new behaviors or coping skills.

The miracle question also provides a means to set goals with group members. It helps clients envision how things could be. Consider the following example: The leaders may have asked Johnny, "Pretend that you went home tonight and went to bed, and while you were sleeping a miracle happened so that when you woke up in the morning you and your parents got along great. When you woke up tomorrow, how would you know that this miracle happened? What would be the first thing that you would notice?"

Scaling and miracle questions were used to assist with individualized goal setting and to monitor client functioning over time. Both questions consistently generated detailed descriptions from clients, including identification of specific behaviors, thoughts, and feelings.

Structural Family Therapy
Structural family therapy (Minuchin, 1974) views families as a system that has boundaries, subsystems, and a hierarchical structure. Parents are seen as having the legitimate authority in the family to establish rules and set limits with their children. A structural family therapist might examine the family rules that maintain symptomatic behavior and work with the family to restructure the family's boundaries. This approach also considers the developmental life cycle of the family system, such as an adolescent's typical struggle for increased autonomy from the family system, and the nature of the social network between the family and the environment, such as the parents' employment status.

One technique used from structural family therapy was joining, which involves building a relationship with each family member in a strategic way. With one Hispanic family that maintained a patriarchal hierarchy, the group leaders typically addressed the father first in an attempt to respect their family system and its structure and to acknowledge the importance of their culture. A structural family therapist might label this process as maintenance, which involves acknowledging a family's current rules, roles, and structure.

Once a family is engaged in the therapeutic process, it is then safe to gently unbalance the family system and restructure some of its rules or boundaries. Another technique used from structural family therapy was mimesis, which involves mirroring a family's mood, communication patterns, and so forth. Enactment, which entails allowing a family to "act out" its problems in front of the group, was used frequently. Such enactments gave group members material to work with, as members could provide direct feedback to the family based on what they had just observed. This approach is generally much more powerful than providing feedback solely on the basis of a family's description of the problem.

Interpersonal and Mutual Aid Approaches
The interpersonal (Shulman, 1992; Yalom, 1995) and mutual aid (Gitterman & Shulman, 1994; Schwartz, 1961) components of the MFTG potentially offer several additional benefits to the participants. As group members interact with one another in the group setting, they soon begin to show their "true colors," a phenomenon that Yalom referred to as the "group as a social microcosm." By focusing on the interactions among members and families that take place in the here-and-now of the group experience, group members can learn how they affect or are perceived by others, get feedback about their behavior, learn from one another, and practice new skills. These accomplishments are achieved in the context of the group members providing support to one another.

For example, the parents of one family argued with their 15-year-old daughter, Jessica, about basic household rules. With little apparent progress being made, one group leader gently interrupted this interaction and asked if any of the other families in the group were able to relate to what Jessica's family was experiencing. Several families provided feedback directly to Jessica's family about what they observed and offered suggestions for how to approach the problem differently on the basis of their own experience. Had the group leaders attempted to provide this feedback, it most likely would have had less of an effect. The leaders were able to use the here-and-now interaction of the group to create a mutual aid system between families.

Moreover, parents from various families provided feedback to Jessica about her behavior (objective parenting), and adolescents from various families provided feedback to Jessica's parents about their parenting style (objective childrening). The following interactions illustrate objective childrening. One adolescent shared with Jessica's parents that he thought they were being too strict about curfew and stated that he, too, would have a difficult time with this rule. However, another adolescent in the group supported Jessica's parents, stating that they were right to be strict with Jessica because she frequently broke rules at home. This kind of interaction across generations allows family members the opportunity to hear confirming or challenging perspectives from group members that can serve as a reality check. Notice that most of the real work was done by the group members, and not by the group leaders. This approach is a key aspect of the MFTG model.

Integrating the Models
The rationale behind choosing these particular modalities is straightforward. The mutual aid and interactional approaches together provide the context for how leaders regard group process and development, and they clearly borrow from systems theory (von Bertalanffy, 1968). Viewing the group through a mutual aid and interactional lens, the leaders' focus is on encouraging here-and-now member-to-member interaction so members can use each other as a source of mutual support. Yalom's (1995) therapeutic factors, such as "universality" and "instillation of hope," are also used to amplify positive member-to-member interaction. The mutual aid approach allows the leaders to consider factors such as the group members' culture and any oppressive forces. Within this context, the solution-focused approach provides the group leaders with clear, direct intervention techniques such as the scaling and miracle questions that are easy for both adolescents and parents to grasp. This approach also focuses on client strengths. The structural family therapy model provides a framework and specific techniques for the practitioner to assess and intervene around the family's boundaries, rules, roles, and subsystems. In summary, these models compliment one another very nicely.

Finally, the rationale for choosing these approaches was based on existing literature that supports the use of these modalities with children, adolescents, and families (Corder, Whiteside, & Haizlip, 1981; Fishman, Stanton, & Rosman, 1982; Nadelman, 1994).

Conclusion
Many substance-abusing adolescents have coexisting mental health or emotional problems and experience familial discord. All of these factors warrant careful consideration in the treatment planning process. As group leaders we have found that interactional MFTGs are a critical component of the therapeutic process from which adolescents and their families reap many benefits. Along with other modalities, and with careful planning, MFTGs can support adolescents and their families through the stages of treatment.
- Springer, D., & Orsbon, S. (Aug 2002). Families Helping Families: Implementing a Multifamily Therapy Group with Substance-Abusing Adolescents. Health & Social Work, 27(3).

Promising Strategies to Reduce Substance Abuse

- Promising Strategies to Reduce Substance Abuse. (2000). U.S. Department of Justice. Office of Justice Programs.

Update
Effects of family therapy for substance abuse:
A systematic review of recent research

- Esteban, J., Suárez-Relinque, C., & Jiménez, T. I. (2023). Effects of family therapy for substance abuse: A systematic review of recent research. Family process, 62(1), 49–73. https://doi.org/10.1111/famp.12841

Peer-Reviewed Journal Article References:
Bonnaire, C., Liddle, H., Har, A., & Phan, O. (2020). Searching for change mechanisms in emotion-focused work with adolescents and parents: An example from multidimensional family therapy. Couple and Family Psychology: Research and Practice, 9(2), 100–121.

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.

QUESTION 25
What is mimesis? Record the letter of the correct answer the Test.