Who Is the “Family” in Family Therapy?
There is no single definition of “family.” Families are connected by their alliances, usually by blood, and almost always by powerful emotional ties. Family can be defined according to an individual’s closest emotional connections. Whether or not these connections are traditionally considered “family,” these are the people who should be considered for participating in family therapy.
According to the Substance Abuse and Mental Health Services Administration, three broad categories encompass most families:
- Traditional families, which include married heterosexual and same-sex couples and their children, single parents, blood relatives, adoptive families, foster families, grandparents raising their grandchildren, and step-families.
- Extended families, which include aunts, uncles, cousins, grandparents, and other relatives.
- Elected families, which are self-identified and joined by choice rather than blood, marriage, or law. For many, the elected family is more important than biological family ties. Examples of elected families include emancipated youth, godparents, unmarried heterosexual/gay and lesbian couples with or without children, and other non-biologically related people who have strong emotional ties.
Ultimately, a family is a system, and the overarching goal of family therapy is to strengthen the system and bring balance and function to the family unit.
How Addiction Affects the Family
- Stress: Addiction puts enormous stress on the family, affecting its stability, unity, physical and mental health, and finances. When a family member has an addiction, it’s difficult to establish and maintain normal, healthy routines when these are constantly being interrupted by unsettling and unexpected experiences. This is particularly true when the addicted family member is unpredictable or abusive.
- Coping: Families living with addiction develop dysfunctional coping mechanisms as the household is continually affected by stress, anger, fear, and sadness, which disrupt family life and affect the ability of other family members to make connections with each other.
- Children: Children who live in an unstable home environment often feel overwhelmed, and many children develop unhealthy ways of dealing with it, such as by withdrawing, acting out, or self-medicating their own pain and confusion with drugs or alcohol. Children of addicted parents often develop anger and trust issues down the road, and they’re at a higher risk of developing substance abuse problems themselves.
The Objectives of Family Therapy & the Stages of Family Change
High-quality addiction treatment programs put a strong focus on family therapy and other family programming to help solve problems at home, which are a major trigger for relapse. Stabilizing the family is essential for creating a calm, stable home environment that supports recovery. Family therapy helps families provide the highest level of support to their loved one in treatment while improving the family’s overall well-being.
Family therapy operates on the general assumption that when addiction affects a family, the entire family system needs to change, not just the person with the addiction. Family therapy helps families make interpersonal, personal, and environmental changes that support both the person with the addiction and the family as a whole.
According to the Substance Abuse and Mental Health Services Administration, the objectives of family therapy are to move the family from:
- Distrust to reconciliation
- Guilt to forgiveness
- Stress to strength
- Frustration to understanding
- Despair to hope
- Sadness to support
- Anger to peace
- Conflict to agreement
- Crisis to resolution
Family therapy provides a safe, neutral place for family members to work through a variety of issues and learn how to adjust to the changes that recovery brings. A trained family therapist helps family members look closely at how they interact with each other. Family members identify whether they’ve conducted themselves in a way that’s hurtful or helpful. They learn how to modify their behaviors so that they support the needs of the person in recovery as well as the needs of the whole family. Families develop healthy ways of relating, talking, and behaving with one another.
In some cases, a family has other issues that need to be addressed outside of the addiction. Often, these issues are hidden behind—or caused by—the drama and chaos that addiction and other mental illnesses bring to the household. When the addicted family member enters treatment, these issues may surface. Family therapy helps resolve these issues and repair damaged relationships.
Three Stages of Family Change
Families move through three stages of change during family therapy for substance abuse:
- Stage 1: Attainment of sobriety – During the first stage of change, when the addicted loved one achieves a state of recovery, the family system is unbalanced and dysfunctional, but healthy change is possible.
- Stage 2: Adjustment to sobriety – The family works together to develop a new, healthier system as they adjust to the changes sobriety brings. They work to stabilize familial relationships and the family unit as a whole.
- Stage 3: Long-term maintenance of sobriety – The family develops and maintains a healthier lifestyle that rebalances the family system. A healthier lifestyle and better family functioning promotes ongoing sobriety for the addicted family member.
Four Models of Family Therapy
The Substance Abuse and Mental Health Services Administration identifies four predominant models of family therapy that are used in substance abuse treatment:
- The Family Disease Model: The family disease model looks at addiction as a disease that affects the whole family. Family members often develop codependence and enabling behaviors that perpetuate the substance abuse. These behaviors must be addressed in order to successfully treat the substance abuse.
- The Family Systems Model: The family systems model operates on the assumption that families become organized by their interactions surrounding substance abuse, and family members adapt to the substance abuse in order to maintain balance. The family systems model attempts to identify and change maladaptive patterns of communication and examine each family member’s role in the addiction.
- Cognitive-Behavioral Approaches: Cognitive-behavioral approaches look at maladaptive behaviors—including the substance abuse—that are reinforced through family interactions. This approach to treatment works to change those dysfunctional behaviors by improving communication, problem-solving, and coping skills.
- Multidimensional Family Therapy: Multidimensional family therapy integrates a number of techniques that place an emphasis on the complicated relationships between family members’ cognition, emotionality, behavior, and environment.
The model of family therapy that’s used in treatment may depend on the treatment program or the preferences of the family therapist. All four models have been shown effective for treating substance abuse in the context of the family, and some practitioners may borrow aspects from different models to meet the unique needs of the family.
What to Expect in Family Therapy
Family therapy sessions typically last an hour. Before starting the first session, the therapist may ask family members to sign a contract to show they agree on certain behaviors, such as not interrupting.
During family therapy, the whole family meets together initially. The family therapist listens and observes while the family talks. The therapist asks questions to help guide the conversation and keep it productive.
Through watching the family interact, the therapist begins to understand how family members communicate and behave with each other. The family’s strengths and needs become apparent, and the therapist helps family members develop skills, strategies, and techniques for changing their thought and behavior patterns and learning better ways to communicate their needs.
A family therapy session can cover any number of topics. Common topics include:
- Family concerns
- How the family is feeling
- A particular crisis that needs solving
- The changes that have been happening in the family
- How to deal with feelings of anger, resentment, or sadness
- Effective ways of communicating
- Setting boundaries
- Rephrasing statements in positive ways
- Listening and observing skills that can prevent misunderstandings
Sometimes, the therapist will give family members homework to complete before the next session. Examples of homework include doing a fun family activity together or watching for nice things other family members say during the week.
These homework assignments help family members:
- Practice the skills and strategies they’re learning in therapy
- Stay mindful of how they interact with each other
- Practice new, healthier ways of behaving with one another
During the course of therapy, the therapist may meet with different family members or groups of family members, and he or she may recommend extra help for some or all family members, such as individual therapy, anger management classes, or parenting workshops.
A Family Therapist’s Credentials
Anyone who leads a family therapy session is specially trained and meets the legal and professional requirements as a family therapist. Family therapists are trained to be sensitive to the unique characteristics of a family regardless of its culture, race, ethnicity, sexuality or any other factor. A trained and certified family therapist will be respectful and understanding and won’t pass judgment.
Family Education Is Not Family Therapy
Family education isn’t the same thing as family therapy. Family education is also offered through high-quality treatment programs and involves a variety of psychoeducational classes and workshops for family members. These classes provide information that helps families understand addiction and recovery so that they can better support their loved one during and after treatment.
Why Some Family Members Decline to Participate in Family Therapy
Sometimes, family members are reluctant to participate in family therapy for a variety of reasons. These may include:
- Fear: Change can be scary, and some family members may prefer to have things stay as they are rather than risk the unknown. Family members may also be afraid of being judged or having to reveal family secrets.
- Cynicism: One or more family members may be skeptical about the benefits of family therapy and think it a waste of time. Or, they may have tried family therapy before and found it unhelpful.
- Power concerns: A family member may feel at a better power advantage leaving things the way they are. Family members who already feel powerless may feel that family therapy won’t change anything.
- Distrust: An individual may not trust his or her family members or a therapist and may be unwilling to speak openly with them.
- Embarrassment: Family members may feel embarrassed at the prospect of “airing their dirty laundry” in front of a stranger.
- Fatigue: Family members may be tired of dealing with the addiction and the issues it brings up.
The therapist may meet with non-participating family members to identify the reasons why they’re resistant. The therapist may try to resolve concerns and explain the benefits of family therapy. In many cases, an unwilling family member will choose to participate eventually. Meanwhile, remaining family members can still get a great deal of benefit out of family therapy.
When Family Therapy Is Inadvisable
In rare situations, family therapy isn’t recommended. It may be ruled out due to legal issues or safety concerns. Assessing carefully for violence in the household is also essential before beginning family therapy. In some cases, extreme domestic abuse or patriarchal terrorism can escalate with family therapy.
Unless all participants have a voice in the therapeutic process and can feel safe raising important issues—even if a domineering family member doesn’t want these discussed—therapy won’t be as successful as it should be.
Family Support Is Central to Successful Recovery
According to the Substance Abuse and Mental Health Services Administration, home is one of the four major dimensions of successful recovery. Home is the place you live, and it’s the people you live with. A safe and stable home environment is central to ongoing sobriety.
Family therapy helps families create that safety and stability through improved awareness and mindfulness and essential communication skills. In the process, family members repair damaged relationships, restore trust, and learn how to interact with one another in healthy, respectful ways.
Family therapy is an important part of treatment, and what you learn in therapy is an important part of recovery for all family members. With the love and support of your family, your chances of recovery are much greater, and your overall quality of life—and that of the people you love—will improve for the long-haul.