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1. What are the risk and protective factors that you may see here in this case? What sort of things are noticing here?

2.  What would be the first steps you would take keeping in mind everyone’s readiness to participate?

3. If you were to recommend programs or therapy, what sort of programs would you recommend and why?Please share any thoughts that you might have moving forward thinking about this case and others like it.

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Engagement piece: breakout rooms/ Padlet

A family comes into your agency. This is their first visit with any sort of agency or therapy. You meet the father, John (55), mother, Lisa (50), teenage son Jack (16) and young daughter, Emily (9). After introducing yourself, you ask them what has brought them in today and Lisa speaks first. Lisa says that John has a drinking problem and that is tearing their family apart. John disagrees and tells you that he can tell you off the bat that he does not and “never gets drunk.” He then goes on to explain his drinking pattern. John shares that he has a beer in the morning before work at 9am, a beer with his lunch at the pub near his work and a beer or two after work before he comes home. When he arrives home at around 6pm he has a beer before dinner and will often grab one for dinner. After dinner, he often goes to home office and drinks a bottle of scotch or Jack Daniels. John can’t remember how much of this he usually has. He does think that this meeting is a waste of time and he does not have a problem but feels Lisa is too controlling. Lisa objects to this and says his drinking is affecting the kids. Jack then speaks up and says he is too embarrassed to bring any of his friends home and would rather come home late because his parents fight too much and his dad cares more about drinking and work than he does come to any of his football games. Lisa says she notices that Jack has become more irritable and breaks curfew more often now while Emily barely says a word anymore. Emily has not spoken at all at this point.

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Stress-Coping Perspective: Similar to behavioral models in recognizing the importance of family interaction however it does not view the family as a unit. The family is viewed from a more comprehensive perspective that focuses on stress, resources and coping with the individuals in the family. Al-Anon can be used for a stress-coping approach to develop skills.

Family Therapy Perspective : The Family Systems Theory assumes that a family is understood best by examining the family as one whole system. This one system is a complex, deeply-connected changing collection of parts, subsystems and family members, where each member has a known purpose or function. Each model applies alcoholism as the “presenting problem” and then focuses on the nature of the relationship among family members.

Effectiveness of Family Treatment: There is general support for positive outcomes of family therapy for alcoholism and substance misuse. More effective than individual therapy, peer-group therapy or family psychoeducation. Family therapy is proven to be more effective when working with adolescents and adults. Involvement of family helps reduce drug use and treatment drop out rates as well as increase participation in treatment.

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Johnson Intervention (JI): This approach has faced criticism because it raises ethical concerns around coercion and confidentiality. Essentially the alcoholic is in denial and the family engages in usually a confrontational matter to convince the alcoholic family member to commit to inpatient treatment. However, outpatient treatment has different outcomes which are usually negative.

ARISE, A Relation Intervention Sequence for Engagement: This approach is less confrontational but progressively more intense. However, there is limited research on the effectiveness of this approach. ARISE is a three-tiered approach and family-based intervention.

Unilateral family therapy - targets the family to engage the substance user in treatment. The primary goal is to improve family functioning and in turn, change the user’s behavior.

Community Reinforcement and Family Training (CRAFT) the goal of this treatment is to encourage the substance abuser to stop drinking, enter treatment, and engage in self-care.

Aftercare process: Involving the family in the aftercare process enhances effectiveness. A family-oriented approach conceptualizes the problem in terms of family functioning and thus the responsibility is not just enforced on behavioral changes of the alcoholic but the entire family system.

Behavioral Perspective: Based on Behavioral theory, social learning theory, and cognitive-behavioral theory which mediate between the individual and the environment.

Positive reinforcement : reward drinking through attention or caregiving

Negative reinforcement: protec the dependent individual from negative consequences

Punishment- inflict a penalty on the person for drinking

All of which encourage further substance use. A behavioral approach acknowledges these issues and works with the family to avoid such interactions and find positive reinforcements.

Behavioral Couples therapy (BCT) most common application of the behavioral perspective with families in the substance abuse field. Benefits of this approach are reducing substance use, improving relationship satisfaction, and greater adaptive function.

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Goals set for Family Orientated Approach

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Goals set for Family Orientated Approach

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1. Stop drinking or isolate the drinking member

2. Stop life-threatening or destructive behavior

3. Disengage children from parental roles and alter inappropriate parent/child alliances

4. Help re-form the parental alliance and authority

5. The support member in obtaining necessary resources outside of the family

Recommendations during treatment are to target inflexibility, boundary confusion, parent-child conflict, scapegoating, communication, discounting feelings, and unhealthy rules.

Three broad categories in family intervention treatment of alcohol and drug problems

1. Working with the family to promote engagement of misusers into treatment

2. Joint involvement of family

3. Responding to the needs of family members

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Assessment and Treatment of Alcoholic Families 

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Assessment and Treatment of Alcoholic Families 

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- Usually, treatment for Alcohol has been seen as an individual problem, however, research has developed ways in which involving family members can benefit the alcoholic’s individual treatment.
- Family members can: Provide Information about the patient, they may be struggling with alcohol or emotionally disturbed themselves and are likely to enable the patient dependency

Ways in which families come into treatment

1. A family may be seeking therapy for the misbehavior of a child or teen because of a reaction ot family dysfunction caused by a hidden addiction
2. The family may have acknowledged an alcohol problem and has had major conflicts 3. Family may present alcoholism as a major problem and there have been severe changes in drinking which are extreme and problematic.
4.The family is returning to therapy as a result of new changes

**Important to consider that families may be resistant to entering treatment because it is common that families want to keep alcohol abuse a secret.

If the family acknowledges the problem but the alcoholic or addict does not, this process is called an intervention developed by Vernon Johnson.

“It is unproductive to treat an individual separate from the system if he or she will be returning to live with the family”

Family members can be experiencing stress, and need help. Treating a family as a whole can change maladaptive behaviors and family dynamics.

* There is evidence that alcoholics show a better response to treatment when it includes family members, especially the spouse

Studies have shown that family-involved treatment is particularly effective in motivating alcoholics to enter treatment

In family treatment, the goal is not only to help the identified alcoholic reach sobriety but improve family functioning.

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Three significant areas of family systems literature on alcoholism: rituals and routines, shame, and rules and roles

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Three significant areas of family systems literature on alcoholism: rituals and routines, shame, and rules and roles

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1. Rituals and Routines for an Alcoholic family

1. In these families, alcoholism no longer operates at the individual level but has been incorporated into nearly every aspect of the family.

1. The alcoholic's behavior over time often influences other family members and elicits certain responses. Their behavior becomes impaired and contributes to the reciprocal nature of the alcoholic’s drinking which also establishes a reciprocal pattern within the family.

2. The family may accommodate alcohol-related behaviors in an effort to create short-term stability.

1. This increases the likelihood that the drinking will continue as the system has been inadvertently been organized to maintain it. P. 260

3. In each developmental phase (early, middle, and late), the alcoholic family makes crucial yet unconscious decisions to either challenge or accommodate the drinking behaviors of a family member which can often affect the family identity.

2. Shame

1. Guilt offers the opportunity to reaffirm personal values, repair damages and grow while shame is more likely to make the individual feel unworthy and incapable of growth.

2. Shame can affect the family system in one of two ways

1. It can lead the family to create elaborate ways to hide the alcoholic’s behavior from each other and their community.

2. Alcoholism can be associated with physical, emotional, mental and sexual abuse. These types of abuse are often enrobed in secrecy. This secrecy inhibits family members from changing their behaviors and continues to perpetuate this addiction.

3. These examples demonstrate how important it is for a child’s basic needs (physical and emotional) to be met which will lead them to being understood and acknowledged. Doing so will allow the child to develop healthy self-esteem. If these needs are not met, the child will be susceptible to shame.

3. Rules and Roles

1. Families adjust to alcoholism through the process of establishing roles.

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We don’t see a shift in this individualist perspective until the 1970s to 1980s when we can see a gradual shift.

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We don’t see a shift in this individualist perspective until the 1970s to 1980s when we can see a gradual shift.

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1. Today, we see some sort of family involvement in most alcoholism treatment programs.

2. Most self-help programs also recognize that family members also have problems of their own due to the dynamics of alcoholism. P. 258

1. This understanding leads to concepts such as, “codependency, children of alcoholics, and adult children of alcoholics.” p. 258

3. Self-help groups and advocacy groups were created for children as it was now understood that alcoholism could negatively impact generations.

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The 1960s lead to the rise of systems and behavioral theory which lead to a broader understanding that focused on the interactive and reciprocal nature of the family process.

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The 1960s lead to the rise of systems and behavioral theory which lead to a broader understanding that focused on the interactive and reciprocal nature of the family process.

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1. Family treatment for alcoholism continued to consist of “concurrent program for non-alcoholic spouses.”p 258

1. This was due to “general ignorance” on alcoholism by family therapists as most believed alcoholism to be an individual disease.

2. Many family therapists avoided family perspectives due to lack of training or just the general belief that this perspective was incompatible with the alcoholism model.

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Psychoanalytic practice wisdom prohibited family members from being present in  therapy sessions with those dealing with alcoholism.

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Psychoanalytic practice wisdom prohibited family members from being present in  therapy sessions with those dealing with alcoholism.

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1. Practitioners believed that involving family members could “contaminate the therapeutic transference” p. 257

2. At the same time, children and marriage therapy arose in popularity and practitioners would collaborate with separate family members and the therapists would consult each other on treatment.

3. In the 1940s and 1950s, theories and research involving alcoholism grew but continued to be limited in terms of focus as it centered on the physiological and emotional effects on the individual.

1. Distressed personality model

1. The theory rooted in psychoanalysis states that psychopathology in the wife led to the development and maintenance of drinking problems in the husband.

2. Stressed personality model

1. This applies to both genders and views personality disturbance in the spouse has resulted from chronic stress at home that has been caused by the alcoholic. P. 257

3. One of the first programs attempting to include families in treatment involved group therapy for alcoholics and their wives.

1. Involving the spouses was demonstrated an increase in the completion and success rates of treatment.

4. By 1948, the wives of AA members created Al-Anon

1. This was the first family group that targeted spouses of both genders.

5. 1957, Alateen was formed for teenage children of alcoholics.

1. Alalot was also developed for children much later on.

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1. To examine “the etiology and treatment of the family processes associated with chemical dependency.” p.25

1. . Although the focus is on alcoholism, this research and literature can also be generalized to drug addiction.

2. Three dominant theoretical approaches will be examined: Behavioral, stress coping, and family systems

3. The following constructs will also be examined:

1. Codependency

2. Adult children of alcoholics

3. Both of which relate to family dynamics.

4. The goal is to explore the different ways in which theory shapes to practice with chemically dependent family systems.

1. Specific information involving treatment will be provided.

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1. Definitions:

1. Alcoholism at the family level lacks specificity despite their being an “intuitive appeal” p. 256

1. Most literature can refer to it as” family disease, alcoholic family, addicted or chemically dependent family” and more

2. Family is no longer clearly defined in society.

1. This research applies to many different types of families including nuclear, extended, single-parent, communal, kinship and LGBTQ+ families. P. 256

2. Background

3. Studies surrounding alcoholism begin in the early 20th century in the social sciences.

1. It was restrained early on because of stigmas attached to the issue.

4. By the 1930s, alcoholism began to be treated as a disease and opened the doors to Bill W founding AA (Alcoholics Anonymous) in 1935.

1. AA was initially geared towards men who would discuss the effects of alcoholism on their lives. (Fun Fact: W’s wife Lois actually organized the first meeting)

2. Simultaneously, psychoanalysis was growing in popularity and also explained alcoholism in psychopathy.

1. Both models were limited in that they examined the etiology of alcoholism at the individual level.

2. This is not to say that psychoanalysts did not acknowledge the impact of family dynamics on alcoholism, rather they examined the psychopathology in terms of each individual's partner.