Family Therapy & Problem Alcohol Use: Opportunities and Cautions when working

systemicallyA Presentation to the The Association of

Family and

Conciliation Courts, Ontario ChapterBrenda Spitzer, MSc, RMFT

Problem alcohol use is a family problem

Problem alcohol use is a family problem

Problem alcohol use is a family problem Problem Alcohol Use..... Transforms family relationships, roles, rules, and rituals. Isolates the family from potential sources of extended family, social, and community support. Usually has far reaching, long-lasting effects on the physical and emotional health of the family and children.

How do family therapists and other therapists who work with a wide range of clinical issues encounter problem alcohol use?

As the primary presenting issue of a self-referred individual client.As a major presenting issue in couple therapy. As an identified goal for the therapy by a referral source or collateral system (CAS, criminal court).As a secondary issue arising after individual, couple or family therapy has started and goals have been established not directly related to alcohol use.

What is the rationale for working with the family in therapy?

Shouldn’t the client be referred for specialized addiction service before couple or family sessions are considered?

Doesn’t family therapy assign responsibility for problem drinking to family members inappropriately?

Including families in treatment of problem alcohol use is important to address the effects of problem drinking on the family and the effects of family dynamics on problem drinking

It is important to bring the whole picture into focus to explore and address the not-so-visible symptoms as well as the easily visible ones, with concern for how they manifest themselves in each individual in the family. Dysfunctional family dynamics often result from problem alcohol use and problem alcohol use can be reinforced by family dynamics or be one manifestation of family dysfunction.

Areas to Explore when Assessing Problem Alcohol Use:

1. Level and pattern of alcohol use (of “the drinker”)

2. Consequences of alcohol use 3. How the family system organizes around the

problem drinking

Level of alcohol use of “the drinker” Continuum of Problem Alcohol Use

No/Low Risk

At Risk Mild Moderate Severe

Triangle represents North American adult population

Areas to Explore when Assessing for Problem Alcohol Use:Level and pattern of alcohol use of “the drinker”:

Level of use can range from no/low risk to severe on a continuum that described Alcohol Dependence.

Low Risk/Mild Risk Drinking can include experiencing some adverse reactions from drinking such as disagreements with family members about what constitutes too much drinking.

Severe Drinking/Alcohol Dependence reflects a physical/psychological dependence on alcohol with several negative physical, psychological and social effects.

A referral to specialized services for acute problem drinking is important if drinking is causing serious medical, psychological or interpersonal problems.

Level of alcohol use of “the drinker”

No/Low Risk

At Risk Mild Moderate Severe

Brief treatment interventions that include family interventions are well-suited to mild or moderate alcohol problems

Areas to Explore when Assessing for Problem Alcohol Use:

Consequences of alcohol use:Is alcohol use a regular issue that a couple has disagreements about?Is alcohol use something that is hidden or a “secret” in the family?Who is most upset about the alcohol use?What activities does alcohol use interfere with or negatively impact?How did alcohol get introduced into the therapy?Is the alcohol use impacting the client and family’s ability to attain identified therapy goals?

When drinking is identified as a problem for a family: questions to consider next:How is the family system organized around the problem drinking? Family members may be extremely cautious in their behavior in order to avoid exacerbating existing problems (that may not be directly related to alcohol use). Family members often adapt their behaviour in order to minimize or survive an unhealthy situation. Adaptation can have harmful effects on those who are adjusting and also may inadvertently reinforce the problem alcohol use. Three typical family characteristics emerge: family denial, avoidance of social and emotional engagement

When drinking is identified as a problem for a family: questions to consider next:

How is the family system organized around the problem drinking?

How is the family system organized around the problem drinking? Family denial is common and often occurs in at least three ways: Systemic denial: the entire family system denies or minimized the existence of a problem. This usually occurs when the family members do not want to admit that one of them is a problem drinker or because they perceive the problem alcohol use as a reflection upon themselves. This may lead to “negative anonymity;” where the family seeks anonymity which, in turn has a negative impact on the family. Denial prevents others from knowing or judging the family but keeps the family from getting support and help.

How is the family system organized around the problem drinking? Family denial of alcoholism occurs in at least three ways: Protection against Exposure : A second form of family denial is protection against exposure which is accomplished by not talking about the problem or pretending it does not exist. Conversely, exposure means not only experiencing the problem, but recognizing it, discussing it, and overcoming any effects.

How is the family system organized around the problem drinking? Family denial of alcoholism occurs in at least three ways: Blaming all family dysfunction on alcohol use: Traditionally when problem alcohol use was identified in a family, it was assumed that the problem drinker was the primary concern to be treated before any family work could be done. Many problem drinkers do not quit drinking – families may deteriorate while waiting for a change in the drinker’s behaviour. Viewing the “drinker” as the primary concern may lead to lost opportunities to intervene to support family members, to identify and name unspoken family concerns and address family dysfunction.

How is the family system organized around the problem drinking? How is the family system organizing around the problem drinking? Social disengagement: Social disengagement is the withdrawing of family members from interaction with others. This often comes from the family’s fear of the consequences of encounters that include the drinker and a wish to protect itself from exposure, embarrassment, discomfort and fear. The family often becomes isolated making it harder to access support.

How is the family system organized around the problem drinking?How is the family system organizing around the problem drinking?Emotional withdrawal: Emotional disengagement is a response to anticipation of negative emotions, such as anger and tension. A common reaction is to become “non-feeling,” that is, to deny and minimize negative feelings to prevent further pain. Avoidance becomes the norm for handling negative emotions, but may end up cutting off the benefits of positive relationships.

When drinking is a problem for a family: questions to consider next: How and when should the family therapist address the drinking problem? It’s important to introduce drinking earlier in the sessions if it appears to underpin the presenting problems or if it appears to interfere with achieving treatment goals. The issue of problem drinking can wait until later in the sessions if it seems to be more marginally related to presenting problems and therapy is progressing well.

When drinking is a problem for a family: questions to consider next: Should the therapist work with the family or just the “identified problem drinker”? Working with the family allows for support for family members even if the problem drinking is ongoing. Working with the family may facilitate disruption of unhelpful family patterns that have inadvertently reinforced drinking behavior or hidden problem drinking.

When drinking is a problem for a family: questions to consider next: Should the therapist work with the family or just the “identified problem drinker”? Seeing the entire family may reduce isolation and create greater opportunities for family members to receive support and for new family patterns of relating to emerge. Separate sessions for the problem drinker may be important if drinking is more severe and if the drinker is motivated to make behavioural changes.

When drinking is a problem for a family: questions to consider next: Should the children be included in the family therapy? Opportunities: Addressing drinking with children present allows for identification and exploration of a subject that may have been secret or taboo. This may lead to relief, create opportunities to share in an honest way about drinking and other family dynamics and may make it safer for kids to discuss the issue going forward. The presence of kids for a discussion of alcohol use may make it more difficult for all family members to avoid, minimize or hide difficult family issues including drinking.

When drinking is a problem for a family: questions to consider next: Should the children be included in the family therapy? Risks: a discussion of the problem drinking in front of children may be inappropriate if it is linked to intimate couple issues that would be too “adult” for children to explore. Discussion of problem drinking in front of children may not be appropriate in families where there are power and control dynamics that lead children to feel unsafe in discussing challenging issues. In these families, prioritizing safety should take precedence over challenging family denial.

Features of family therapy with problem drinking: What are some helpful ways to raise the issue of the problem drinking?1. Empathic responses to client and family members2. Circular and interventive questions to explore and

create change opportunities for the family system3. Focussing on Goals identified by the Client(s)4. Tolerance of Client(s) Ambivalence about Change5. Providing the Client with Choices

Family therapy with problem drinking: What are some helpful ways to raise the issue of the problem drinking? Empathic responses to client and family members: Research indicates that it is more effective for therapists to work to understand the complex emotions and communicate understanding the emotion to clients as a facilitator of change compared to a traditional confrontational style that attempt to “break through” client denial

Family therapy with problem drinking:What are some helpful ways to raise the issue of the problem drinking?Circular and interventive questions: These are questions designed to explore the relational aspects of the family system allowing the therapist and the family to better understand and be aware of their cyclical sequences of interactions which interconnect with family beliefs.Circular questions may reveal the family’s patterns of relating and believing that perpetuate dysfunctional behaviors and cognitions.

Family therapy with problem drinking:What are some helpful ways to raise the issue of the problem drinking?Circular and interventive questions: Examples: “How does dad’s behaviour bother you differently than it bothers mom?”“Who would be most relieved if dad cut down on his drinking?” “Who is most likely to agree with dad that drinking is not a big problem for the family? Who is least likely to agree with dad?”

Family therapy with problem drinking:What are some helpful ways to raise the issue of the problem drinking?Focussing on Goals identified by the Client(s): It is typically more effective to focus the therapy on what the client(s) identify as most important to change even if it does not directly involve problem alcohol use.The therapist can explore how problem drinking contributes to the gap between the client’s presenting situation and their preferred situation creating opportunities for the client to create linkages between drinking and non-preferred outcomes.

Family therapy with problem drinking: What are some helpful ways to raise the issue of the problem drinking? Tolerance of Client Ambivalence: Traditional treatments have often emphasized the bottom line where goals and behavioural plans are set. Intentionally focussing on clients ambivalence can be very effective and decentralizes the change in drinking behaviour as a goal for therapy. Therapists work with clients to take up both sides of the ambivalent conflict with the goal of inviting the drinker to stay present to considering both sides.

Family therapy with problem drinking: Tolerance of Client Ambivalence cont’d By focussing on ambivalence the therapist is able to give the message that the client has a choice as opposed to communicating that the therapist “knows best” Giving permission for ambivalence provides the psychological space necessary for making difficult decisions. It is important for the therapist not to declare a position with regard to the outcome and to respect the autonomy of their clients by being clear about all their potential options while also being clear about the dangers.

Family therapy with problem drinking: How can the therapist work with the family if the problem drinker is not present? Family sessions without the problem drinker can be helpful in addressing family coping, family safety, family reactions and interactions. Changing family coping: these are interventions that aim to reduce family behaviours that protect the problem drinker. Feedback to the drinker: factual, objective, caring, provided when there is no drinking and with specific requests, providing family support for drinker’s efforts to change. Family member self care: socializing, creating supportive networks, resuming some “normal” and positive family routines.

Pitfalls and cautions: Triangulation“Triangulation” can undermine progress in family therapy: Triangles form when two parts of a system (family/therapist system) are allied against another part.Triangles form to reduce tension or pressure in one part of a system by creating an alliance against a third part of a system.

Pitfalls and cautions: Triangulation“Triangulation” can undermine progress in family therapy when two parts of a system form an alliance against a third part of a system:

Family members

Problem drinker

Therapist

Therapist

Problem drinker

Family members

Therapist and family members allied against the problem drinker

Family members and problem drinker allied against the therapist

Pitfalls and cautions: Triangulation“Triangulation” can undermine progress in family therapy:

Triangles form when two parts of a system (family/therapist system/collaterals) are allied against another part

CAS

Family

Therapist

CAS

Family

Therapist

Therapist and CAS allied against the family (including the drinker)

Therapist and family (including the drinker) allied against CAS

How can conflicts and pitfalls be avoided when working systemically? Ethical Principles to consider when attempting to avoid pitfalls in systemic work: Autonomy (the promotion of personal choice) Fidelity (make honest promises) Beneficence (work to promote good for the client(s) Nonmaleficence (do no harm) Justice (all individuals to be treated fairly; equals as equals, unequals to be treated in a way most beneficial to their specific circumstances)

Pitfalls and cautions:Triangulation can easily be triggered when there are multiple systems working with a family where there is problem drinking when:The differing mandates of the “helpers” are not made clear and explicit and the potential for conflicts in mandates is not considered.Narrow goals are defined by a 3rd party not directly involved in the therapy and with considerable power.

Pitfalls and cautions: Triangulation can easily be triggered when there are multiple systems working with a family where there is problem drinking when: Alliance between family and therapist against 3rd party with evaluative mandate – may lead to the family avoiding taking responsibility for problematic behaviour that led to 3rd party involvement. Therapeutic work becomes fractured and uncoordinated or there is “too much therapy” because the service providers of the family systems are not coordinated or parts of the family system are treated in an uncoordinated way. What is helpful for the family system may not be identified as preferred outcomes for individual family members.

How can conflicts and pitfalls be avoided when working systemically? Therapists need to be aware of the potential for boundary violations that occur as a result of triangulations, especially if there are imbalances of power in the system. Therapists should be mindful when information-sharing, even when there are releases permitting this when this is not be in the best interests of the clients or undermines the family’s trust in the therapy. Agencies with high degrees of “legitimate power” or institutional power such as child welfare, schools, courts should avoid relying on information attained through family therapy which can lead clients to become guarded and secretive which undermines the therapy.

How can conflicts and pitfalls be avoided when working systemically? Therapists should seek supervision or consultation if they are becoming aware of unhelpful alliances that appear to be preventing progress in the therapy.

Therapists should be aware of the potential for an alliances with another helping professional whom often are more similar in social location relative to clients and families seeking assistance for problem alcohol use.

How can conflicts and pitfalls be avoided when working systemically? Therapists should consult with clients and be transparent about information shared with 3rd parties, ideally in advance to obtain informed consent (even when releases have been signed) except in cases when doing so creates a safety risk.

Therapists should consult with other systems working with the family to coordinate service, avoid duplication of service, to avoid working at cross-purposes with other services and do so in a way that includes the family in the process.

Questions & Comments

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