The many factors that influence clients to enter treatment are often the same ones that keep them in treatment. Treatment retention refers to the quantity or amount of treatment received by a client. Today, retention is more likely defined using the term “length of stay,” and is measured by months or a timeframe rather than by the number of sessions (Comfort and Kaltenbach 2000; Greenfield et al. 2007a). Historically, literature has reflected that treatment duration (retention) has served as one of the most consistent predictors of posttreatment outcome, yet literature remains limited regarding the specific relationship between retention and outcome among women with substance use disorders. (For literature reviews on retention and outcome factors for women with substance use disorders, see Sun 2006; Greenfield et al. 2007a.)
Gender is not likely to predict retention in substance abuse treatment. For some time, it has been assumed that women are more likely to leave treatment, but some literature counters this view (Joe et al. 1999). Do women have lower retention rates than men? This is a difficult question to answer because treatment retention often involves the contribution and interaction of numerous variables. Studies have begun to identify these variables and how they relate to each other to influence treatment retention rates among women (see Ashley et al. 2004), but further research is needed to understand the complexity and interactions of these variables.
Psychiatric symptoms, drugs of choice, motivation levels, class, race, ethnicity, criminal justice history, addiction severity, and patterns of use are common factors that typically influence or predict retention among clients in general (see Simpson 1997). Among women, several factors have been identified that influence or predict retention. The following section highlights these factors. Nonetheless, this is not an exhaustive list of retention conditions or issues, but one that is limited to factors that are evident across several studies or that provide some insight into women’s issues that need further empirical exploration.
Factors That Influence Retention Among Women
Relationships: Support from a partner during treatment and recovery can contribute significantly to long-term maintenance of abstinence. Some treatment studies suggest that including a partner or significant other in a client’s treatment also contributes significantly to successful short-term outcomes (Price and Simmel 2002). For example, couples therapy for women in alcohol and drug abuse treatment contributed to favorable outcomes in one study (Trepper et al. 2000), and a study by Fals-Stewart and colleagues (2005) indicates that behavioral couples therapy was associated with abstinence and sustained recovery. Zlotnick and colleagues (1996) also found family therapy to be an effective component for women in an outpatient substance abuse treatment program.
It appears that women who develop relationships in treatment are less likely to successfully complete treatment if their new partner discontinues treatment. In one qualitative study, all of the women who did not successfully complete treatment established a sexual relationship during the early phase of outpatient treatment (Ravndal and Vaglum 1994).
Age: Age appears to be a factor that influences retention. According to the Drug Abuse Treatment Outcome Study (DATOS), age has a significant positive effect on retention in residential treatment (Grella et al. 2000). In a study examining variables associated with retention in outpatient services, women younger than 21 were not as likely to successfully complete outpatient treatment (Scott-Lennox et al. 2000). Likewise, criminal justice research found that women who are older at their first arrest were more likely to complete treatment (Pelissier 2004).
Education: Women with a high school education are more likely to stay in treatment. According to two studies (Ashley et al. 2004; Knight et al. 2001), women who have a high school degree or equivalent are more likely to stay in treatment longer and complete treatment than women with less than a high school education. While education level is influential, it may be a reflection of other client characteristics or socioeconomic conditions.
Women of color: Research typically reflects lower retention rates among women of color. While more research is needed to pinpoint the specific factors that lead to lower retention rates among ethnically diverse women, a key variable appears to be economic resources. According to Jacobson, Robinson, and Bluthenthal (2007), limited economic resources may play a more significant role in retention than specific demographics or severity of substance use disorder.
Criminal justice and child protective services referral and involvement
It appears that either referral or involvement with the criminal justice system or child protective services is associated with longer lengths of treatment (Brady and Ashley 2005; Chen et al. 2004; Green et al. 2002). Specifically, Nishimoto and Roberts (2001) concluded that women who were mandated by the criminal justice system to enter treatment and who also had custody of their children were more likely to stay in treatment longer. While some studies reflect mixed results on the effect of women being mandated to treatment by the court, another study (generated from the sample of participants in the Substance Abuse and Mental Health Services Administration’s [SAMHSA’s] Women, Co-Occurring Disorders, and Violence Study) found that retention was higher among women who had been mandated to treatment (Amaro et al. 2007).
Pregnancy status can significantly influence treatment engagement and retention. Grella (1999) concluded that pregnant women were more likely to spend less time in treatment, and that pregnancy interrupted treatment. Yet, the length of stay may be more related to the stage of pregnancy. In another retention study among women, women who entered treatment late in their pregnancies had good retention whereas women who entered treatment in their first trimester tended to leave treatment early (Chen et al. 2004).
Pregnancy and co-occurring disorders: Pregnancy often adds to the challenge of retaining clients who have severe psychiatric disorders in treatment. In one study (Haller et al. 2002) that compared retention rates across three groups of women, the group characterized by severe addiction, psychiatric (DSM Axis 1 diagnosis) and personality (DSM Axis 2 diagnosis) disorders had rapid attrition (a 36 percent dropout rate), whereas the groups described as clinically benign or with less severity but with externalizing personality deficits were more likely to complete treatment. In a similar study conducted by Haller and Miles (2004), women with more severe pathology were twice as likely to leave treatment against medical advice. While these studies have limitations, they do shed light on the role of psychiatric issues in retention among women, particularly pregnant women, and the need to provide appropriate intervention earlier in the treatment process. The findings of a study examining the effects of trauma-integrated services suggest that women who receive these mental health services may engage in treatment longer (Amaro et al. 2008).
Treatment environment and theoretical approach
Supportive therapy: The consensus panel’s clinical experience has shown that women who abuse substances benefit more from supportive therapies than from other types of therapeutic approaches. Review of the literature indicates that positive treatment outcomes for women are associated with variables related to the characteristics of the therapist (e.g., warmth, empathy, the ability to stay connected during treatment crises, and the ability to manage countertransference during therapy; Beutler et al. 1994; Cramer 2002; Crits-Christoph et al. 1991). Women need a treatment environment that is supportive, safe, and nurturing (Cohen 2000; Grosenick and Hatmaker 2000; Finkelstein et al. 1997); the therapeutic relationship should be one of mutual respect, empathy, and compassion (Covington 2002b).
The type of confrontation used in traditional programs tends to be ineffective for women unless a trusting, therapeutic relationship has been developed (Drabble 1996). Early research on women in treatment demonstrated that women entered treatment with lower self-esteem than their male counterparts (Beckman 1994). Hence, the traditional practice during recovery of “breaking down” a person who abuses substances and rebuilding her as a person is considered unduly harsh and not conducive to effecting change among women who abuse substances (Covington 2008a rev., 1999a; Drabble 1996; Kasl 1992). Although designed to break through a client’s denial, these approaches can diminish a woman’s self-esteem further and, in some cases, retraumatize her. Approaches based on awareness, understanding, and trust are less aggressive and more likely to effect change (Miller and Rollnick 2002). An atmosphere of acceptance, hope, and support creates the foundation women need to work through challenges productively.
Collaborative approach: Leading practitioners in the field of substance abuse treatment for women suggest that effective therapeutic styles are best characterized as active, constructive, collaboratively and productively challenging, supportive, and optimistic (Covington and Surrey 1997; Finkelstein 1993, 1996; Miller and Rollnick 1991). Effective therapeutic styles focus on treatment goals that are important to the client. This may mean addressing issues of food, housing, or transportation first. Having her primary needs met builds a woman’s trust and allows her to address her substance use. A collaborative, supportive approach builds on the client’s strengths, encourages her to use her strengths, and increases her confidence in her ability to identify and resolve problems.
Effective therapeutic styles facilitate the client’s awareness of the difference between the way her life is now and the way she wants it to be. The client and counselor agree to work together to identify the client’s distortions in thinking— discrepancies between what is important to her and how her behavior and coping mechanisms prevent her from reaching her goals. Approaching treatment as a collaboration between equal partners—where the therapist is the expert on what has helped other people and the client is the expert on what will work for herself—may reduce the client’s resistance to change.
Type of treatment services
Same-sex versus mix-gender groups: While literature (Grella 1999; Gutierres and Todd 1997; Niv and Hser 2007; Roberts and Nishimoto 1996; Zilberman et al. 2003) generally supports same-sex groups as being more beneficial than mix-gender groups for women, most research surrounding this issue is either too small to generalize, fails to control for other factors that may influence results, or falls short in matching and evaluating same-sex and mix-gender groups using comparable services and program lengths. Inconsistent results are evident when comparing retention and outcome rates between both groups (Kaskutas et al. 2005). Historically, research has not controlled for the confounding variable that female-only groups provide more gender-responsive services than mix-gender groups. These enhanced services may be more responsible for retention and outcome than the gender constellation of treatment. In one study comparing women in a female-only program to a mix-gender group, the author concluded that just placing women in a same-sex group without women-specific treatment services is not effective in improving retention or outcome (Bride 2001).
More rigorous studies are needed to clarify factors. Several qualitative studies (Grosenick and Hatmaker 2000; Nelson-Zlupko et al. 1996; Ravndal and Vaglum 1994) have highlighted that women perceive same-sex or female-only groups as more beneficial than mix-gender groups because they provide the women more freedom to talk about difficult topics such as abuse and relationship issues and to focus on themselves rather than on the men in the group. TIP 41 Substance Abuse Treatment: Group Therapy (CSAT 2005d), provides more information on treatment issues and process using group therapy.
Service delivery: Women who have access to various services in one location appear to have higher retention rates (McMurtrie et al. 1999; Volpicelli et al. 2000). In addition, studies support that women who are involved in or initially receive greater intensive care, specifically residential treatment, are more likely to remain in treatment and in continuing care (Coughey et al. 1998; Strantz and Welch 1995). Retention is also heightened when treatment services also include individual counseling for women (Nelson-Zlupko et al. 1996).
Onsite child care and child services: In two randomized studies (Hughes et al. 1995; Stevens and Patton 1998) comparing women in residential programs whose children stayed with them versus women whose children did not stay with them, women whose children stayed with them had a longer length of stay (retention). Other less rigorous studies provide similar results (Ashley et al. 2004; Metsch et al. 2001; Nelson-Zlupko et al. 1996; Wobie et al. 1997). For more information on children in residential treatment programs, see chapter 5, “Treatment Engagement, Placement, and Planning.”
Note to Clinicians
While women may perceive female-only groups as beneficial, it is important for clinicians to prepare for and recognize that some women may express hostility toward other women in the group or treatment program. Women are as likely to impose the same societal gender stereotypes that they experience onto other women in the group (Cowan and Ullman 2006). Some women may see other women as a threat to their relationships and engage in competitive behavior in the group process, and other women may impose and project their internalized negative stereotypes onto other group members; e.g., blaming a woman who was victimized by violence or making assumptions about, calling attention to, or labeling another woman’s sexual behavior.
Therapeutic alliance and counselor characteristics
Although the relationship with the counselor is important to both men and women, each gender defines this connection differently. When women and men were asked what was important about the quality of their therapeutic relationships and their recovery from substance abuse, most women answered trust and warmth, and most men answered a utilitarian problemsolving approach (Fiorentine and Anglin 1997). Across studies, women have identified several counselor characteristics they believe contribute to treatment success: non-authoritarian attitudes and approach, confidence and faith in their abilities, and projection of acceptance and care (Sun 2006). Overall, the therapeutic alliance appears to play a paramount role in predicting posttreatment outcome (Gehart and Lyle 2001; Joe et al. 2001; Miller et al. 1997).
Staff gender: Research on the impact of gender differences in client–counselor relationships is limited across mental health professions and is nearly non-existent in the substance abuse field. Although women show greater preference for female staff in addiction treatment, further research is needed in examining the role of gender in treatment retention and outcome among women in individual versus group counseling, same-sex versus mix-gender groups and treatment programs, and women at different levels of substance abuse treatment. In a study that examined how clients in inpatient substance abuse treatment would view their ideal male and female counselor, gender was not considered an important variable even though the majority of clients preferred a female therapist (Jonker et al. 2000). Prior research on therapist preference in counseling highlighted that nearly 95 percent of women who expressed a preference specified a female counselor (Stamler et al. 1991). Grosenick and Hatmaker (2000) reported that 82 percent of the women and treatment staff in a residential program treating pregnant women and women with children believed it was important to have female staff, while 38 percent of the clients and 46 percent of the staff sample asserted that male staff were important. For those who endorsed the importance of male staff, they indicated that men serve as male role models for children and provide a male perspective on various clinical issues, such as relationships.
In a study that examined the influence of both client–counselor race and gender composition in treatment retention among African-American clients in intensive outpatient groups (Sterling et al. 1998), no significant gender differences were found. Nonetheless, several trends were evident. Female clients treated by female counselors stayed in treatment 5 days longer than mix-matched gender groups (mix-matched refers to clients being matched to counselors of the opposite sex), and women in gender-matched groups at discharge were more likely to continue outpatient care. The authors suggested that different results may have transpired if they had examined the role of gender and race in client–counselor relationships in individual substance abuse counseling versus group therapy. Research focused specifically on client–counselor race and gender composition in women’s treatment is lacking.
Implications for the Male Counselor
“Men may need to pay particular attention to certain issues when counseling women. The issues of anger, autonomy, power, and stereotypical roles have great impact on women clients and are extremely important issues for women in therapy. For some women, because of previous dependence on men, their emotional responses to anger are more likely to be repressed and viewed as unacceptable. For other women, autonomy and power are often seen as masculine traits and inappropriate for women. Men’s greater, or perhaps different, familiarity with anger, autonomy, and power can potentially provide therapeutic benefit for their women clients” (DeVoe 1990, p. 33).
Improving Transitions and Retention Rates for Women
Programs that maintain relationships or connections with women throughout their treatment and during step-down transitions from more intensive to less intensive treatment appear paramount in maintaining high levels of retention. Using supportive telephone calls between residential and outpatient addiction treatment is an effective strategy for women. Women are more likely than men to attend continuing care if a telephone intervention is implemented (Carter et al. 2008). In addition, women are more likely to stay in treatment during transitions to less intensive levels of care if it is the same treatment agency (Scott-Lennox et al. 2000).
Client’s confidence in the process
A woman’s successful experience in other life areas and her level of confidence in the treatment process appear important to staying in treatment. Kelly, Blacksin, and Mason (2001) compared two groups of women—a group that completed treatment and another group that did not—to ascertain factors affecting substance abuse treatment completion. They found that women who had prior successes were more apt to complete treatment. While self-efficacy may play an important role, methodological issues and other factors may be as responsible for the study’s results, namely the limited economic resources in the group of non-completers. In addition, other general retention studies have highlighted the importance of the therapist’s prognosis of client retention; thus the counselor’s confidence may be as significant to retention as the client’s confidence (Cournoyer et al. 2007). Further gender-specific retention research is needed to address the role of self-confidence and confidence in the treatment process.
Theoretical Approaches for Women
In a meta-analysis of studies on treatment approaches, Wampold (2001) attributed more than half of the effect of therapies to therapeutic alliance—a key element of all the theoretical approaches. Some approaches have significant clinical and empirical support in substance abuse treatment research literature (including motivational interviewing, cognitive– behavioral therapies, and some psychodynamic approaches), however, research highlighting the role of gender differences is in its infancy, and limited research is available that delineates gender-specific factors that contribute to the effectiveness of these therapies. Data available at the time of publication is referenced throughout this TIP. For general information on counseling theories, refer to TIP 34 Brief Interventions and Brief Therapies for Substance Abuse (CSAT 1999a); TIP 35 Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b); and TIP 47 Substance Abuse: Clinical Issues in Intensive Outpatient Treatment (provides an overview of counseling theories; CSAT 2006c).
Women’s Treatment Issues and Needs
Relationships and the Need for Connection
Relationships are central in women’s lives—as part of their identities, as sources of self-esteem, as the context for decisionmaking and choices, and as support for day-to-day living and growth (Covington and Surrey 1997; Finkelstein 1993, 1996; Miller 1984). Connections are relationships that are healthy and supportive— mutual, empowering, and emotional resources. “Disconnections” involve relationships that are not mutual and empowering: one member is dominant, there is imbalance in the give and take, or a disparity exists in emotional supportiveness. Disconnections range from feeling “unheard” or “unknown” to extreme forms of disconnection, such as sexual abuse and violence. Disconnections create major difficulties for most women, such as lowered self-esteem, feelings of powerlessness, and lack of assertiveness. The experience of relationships as connections and disconnections is a central issue in personality development, with repeated severe disconnections potentially having serious psychological and behavioral consequences.
The Influence of Family
Treatment providers should be sensitive to the relational history women bring into treatment, both positive and negative. For instance, the extended family often functions as a safety net that provides women with child care, financial support, and emotional and spiritual guidance (Balcazar and Qian 2000). However, few studies have examined the role of the extended family in the development of substance abuse and recovery. While research on the extended family tends to define its role as primarily protective, drinking and drug use in the family can contribute to the development of abuse. Many women who abuse substances were raised in families where there was chemical abuse, sexual abuse, violence, and other relational disconnections. These family relationships form a basic model for the relationships women later develop with others.
Women with a substance-using family background may develop adult relationships that mimic these broken family dynamics. Thus many women who have family members who used substances also may have a partner or friend who abuses substances. Relationships that center on substance use, or include emotionally or physically negative, harmful behavior (whether past or present), can play a significant role in enabling a woman’s continuing substance use.
To assess the impact of a client’s family relationships, treatment providers should explore the role of the extended family in her life and try to determine how her substance abuse has affected her relationships with family members. Counselors should also help a client to explore her current relationships outside her family in the light of her substance use. Counselors may need to work with some clients to help them understand the negative effects these relationships can have.
In addition, skills related to improving the quality of relationships—such as communication, stress management, assertiveness, problemsolving, and parenting—can be an important part of treatment. To help clients learn these skills, treatment providers can model connection with clients, provide support, help clients repair or replace hurtful or damaging relationships, and help clients “redefine” their families (Knight et al. 2001b). Family therapy is a more essential approach in substance abuse treatment for women. For more guidance in employing family therapy, refer to TIP 39 Substance Abuse Treatment and Family Therapy (CSAT 2004b). If maintaining or reconnecting with extended family members is not an option, plans should be made to find alternatives in developing a support system or a “family of choice.” However, the grief associated with the loss of the original family needs to be addressed. Treatment programs can help women connect with natural supports in the community—friends, work colleagues, and significant others (Knight and Simpson 1996). Developing or maintaining positive relationships can improve women’s self-esteem and increase their feelings of self-efficacy (Finkelstein et al. 1997). Further, a high degree of social support is positively related to better treatment outcomes (Laudet et al. 1999).
Advice to Clinicians: Relational Model Approach
Beginning in the 1970s, a number of theorists started to examine the importance of gender differences in psychological development. Jean Baker Miller’s Toward a New Psychology of Women (1976) offered a new perspective on the psychology of women that challenged the basic assumptions of traditional theories. Carol Gilligan, a developmental psychologist, gathered empirical data on fundamental gender differences in the psychological and moral development of women and men (Gilligan 1982).
Drawing on Miller’s and Gilligan’s work, theorists have been developing a relational model of women’s psychology. The three major themes in relational theory are:
Cultural context. Recognizes the powerful effect of the cultural context on women’s lives.
Relationships. Stresses relationships as the central organizing feature in women’s development. Traditional developmental models of growth emphasize independence and autonomy. This model focuses on women’s connection with others.
Pathways to growth. Acknowledges women’s relational qualities and activities as potential strengths that provide pathways to healthy growth and development.
The relational-cultural theory affirms the power of connection and the pain of disconnection for women, with repeated disconnections having adverse consequences for mental health (Covington and Surrey 1997; Jordon and Hartling 2002). As a result, the approach requires a paradigm shift that has led to a reframing of key concepts in psychological development, theory, and practice. For example, instead of using the “self” as the sole focus, the model focuses on relational development.
According to Miller, “Women’s sense of self becomes very much organized around being able to make and then to maintain affiliations and relationships” (Miller 1984, p. 83). More than men, women find an activity more satisfying and more pleasurable when others are involved. Therefore, for women, relationships directly affect their feelings of empowerment, self-worth, and self-esteem.
Substance abuse treatment often provides a woman her first opportunity to establish new, healthy relationships—especially relationships with other women. Accordingly, counselors should help women to “examine past relationships, including issues of loss, violence, and incest; to validate and build upon [their] relational skills and needs; to learn how to parent successfully; …to let go of problematic, abusive relationships” (Finkelstein 1996, p. 28); and to confront the loss of a primary relationship with their drug of abuse (Cramer 2002).
Many women drink and use substances to maintain relationships and cope with the pain and trauma of lost relationships. Some women feel they are expected to maintain relationships at all costs, even if those relationships are undermining, abusive, or otherwise detrimental. Women may stay in harmful relationships because of economic or social dependence. Treatment providers sometimes unknowingly reinforce this expectation by focusing on the importance of relationships to the exclusion of helping their clients increase their feelings of autonomy, healthy solitude, and individuality— also important needs for women.
Once a woman’s significant relationships have been examined relative to her substance use, the counselor and client can work together on a plan for reconnecting with significant others during recovery (if possible). Yet, engaging a partner in a woman’s treatment can be challenging, especially in balancing issues of the woman’s and her partner’s needs, safety concerns, and lack of funding for partner and family services. Few models within women’s treatment programs exist that include partners and other family members, and even fewer address lesbian partners. Price and Simmel (2002) provide an overview of the issues surrounding a partner’s influence on a woman’s addiction and recovery and examples of model programs. They recommend starting with a thorough assessment after a woman has identified her partner(s) and given permission to involve the partner in treatment.
As women become healthy through participating in treatment and developing appropriate relationships, and as other supports (e.g., financial, housing) are put in place, it is hoped they will choose to reevaluate relationships that are detrimental to their well-being and recovery. When women decide to end significant relationships, counselors should realize that ending these significant relationships is a real loss that must be mourned while new attachments are being created. However, some women often choose to continue to participate in, or may be unable to escape, destructive relationships.
Tolerating or accepting a client’s relationships that the counselor finds objectionable is complicated because a woman’s substance abuse frequently is maintained in connection with her partner (Amaro and Hardy-Fanta 1995), and maintaining this relationship can increase her risk of relapse. Thus, any relationship that enables a woman to continue to abuse substances or threatens her safety becomes a therapeutic issue between a counselor and a female client. The counselor should acknowledge a woman’s feelings about that relationship, regardless of the counselor’s opinion about what is best for the client. However, if a client is in danger of being victimized, the counselor should primarily be focused on ensuring her safety. Initially, staff should take immediate measures to increase physical safety in the treatment environment— in both outpatient and inpatient settings. In addition to validating her experience, it is important to help facilitate a safety plan that may necessitate additional referrals to domestic violence hotlines and shelters. To review a sample personalized safety plan for domestic violence, refer to Appendix D in TIP 25 Substance Abuse Treatment and Domestic Violence (CSAT 1997b).
Safety issues for the client or her children may preclude the partner’s involvement. If the client does not feel safe involving her partner, the emphasis should change to safety planning.
Several curricula focus on a woman’s relationships in recovery and help her identify, assess, and evaluate both destructive and empowering relationships and support systems. Covington’s curriculum, Helping Women Recover (2008a, 1999a), allows women to examine their relationships and support systems. Najavits’ Seeking Safety (2002a) and Woman’s Addiction Workbook (2002) include information that assists women in understanding healthy and unhealthy boundaries, strategies for identifying persons who can be positive (supportive) or negative (destructive) influences on their recovery, tactics for enhancing or minimizing those influences, and activities to enhance support from other women. Cohen’s Counseling Addicted Women: A Practical Guide (2000) provides client and staff activities surrounding relationship issues.
Advice to Clinicians: Considerations in Involving the Partner in Treatment
In deciding whether or not to involve a woman’s partner in treatment, primary consideration should be given to her safety and to the partner’s willingness to participate in treatment. The following important issues should also be assessed to determine participation and level of treatment involvement and to establish an appropriate treatment plan:
History of violence: Has there been a history of violence in the relationship, including threats and other emotional, physical, and/or sexual abuse; protection orders; police reports; or citations for domestic violence or assaults? Is there a history of impulsivity with client or partner? Has there been a history of violence outside the relationship, in previous relationships, or with children? Is there a recognizable progression of violence in the relationship?
History of substance use in the relationship: How influential has this partner been regarding the client’s continued drug and alcohol use? Does the partner see the woman’s alcohol and/or drug use as a problem needing treatment? Has the history of the relationship been centered upon using or providing drugs and alcohol? How often are alcohol and other drugs used when engaged in activities with each other or during sexual intimacy? Is the client or partner worried about having sex without being under the influence of substances? Has the client left prior treatment experiences prematurely due to this relationship? Is the client worried that her partner is going to leave either as a result of her use or of her treatment? Does the client acknowledge that her use has impacted the relationship? Is she able to describe how her substance use has affected the relationship?
Partner’s history of substance use: What is the partner’s attitude toward alcohol and drug use? Does he/she use as well? Is he/she in recovery? Has the partner been arrested, charged, or convicted of alcohol or drug related offenses? Does the client minimize the influence of her partner’s current drug and alcohol use?
Accessibility: Does the partner have the financial resources and transportation to attend treatment? Are there potential barriers that limit physical attendance, such as distance from program, transportation, work schedule, financial resources, childcare responsibilities?
History of mental illness: Are there any known mental health issues with the partner or client that have or will impact the relationship?
Relationship support of the partner: Has the partner been emotionally supportive throughout the history of the relationship? Currently, how emotionally supportive is the partner regarding the client’s treatment and recovery? Does the partner play an essential role in childcare? Does the partner provide financial support? Has the partner ever threatened to leave, withdraw financial support, or threaten the custody of the children?
Commitment to relationship: Is there a current commitment to maintaining the relationship?
Note to Clinicians
Safety issues for the client or her children may preclude the partner’s involvement. If the client does not feel safe involving her partner, the emphasis should change to safety planning.
Healthy sexuality is integral to one’s sense of self-worth. Sexuality represents the integration of biological, emotional, social, and spiritual aspects of who one is and how one relates to others. If healthy sexuality is defined as the integration of all these aspects of the self, it is apparent how substance abuse can have an impact on every area of a woman’s sexuality. In addition, sexuality is one of the primary areas that women say change the most between substance abuse or dependence and recovery and is a major trigger for relapse (Covington 2008a, 1999a, 2007).
Women and men are socialized into different gender roles. For example, many men are taught to seem knowledgeable about sex and be comfortable with their bodies. In contrast, women struggle more with body image and are socialized to be less assertive sexually or risk being labeled as promiscuous. This polarization of sex roles is mirrored in society’s belief about male and female substance use. Women who use substances are perceived as being more eager for sex and more vulnerable to seduction (George et al. 1988). This is reflected in the stronger stigma against women with substance use disorders, which is often expressed in sexual terms and labels women as promiscuous or sexually loose. Sexual terms are rarely used to describe men with substance use disorders.
Recovery and healing goes beyond abstinence from alcohol or drugs to developing relationships with others. Many women will need to explore the connections between substance abuse and sexuality, body image, sexual identity, sexual abuse, and the fear of sex when they are alcohol and drug free. Therefore, the consensus panel believes that discussion of women’s sexual issues is an important part of substance abuse treatment. The following are some of the sexual concerns that women report during early recovery:
Sexual identity. Counselors may need to help a woman determine her sexual identity as a heterosexual, lesbian, or bisexual person. Substance abuse during adolescence can interrupt the healthy development of sexual identity. Circumstances such as prostitution or incarceration may lead women to participate in sexual activity with other women. Some women use drugs to suppress their sexual feelings toward other women. Others use drugs to act on their erotic attachment to other women and may feel confused about their sexual identity when in recovery. Once the substance of abuse has been removed from a woman’s life, the counselor can help her discover whether her identity is heterosexual, lesbian, or bisexual (Covington 1997). For review of sexual identity stages of development and its relationship to substance abuse, see A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals (CSAT 2001bp. 61–67).
Fear of sex while abstinent. Many women enter treatment with little or no experience of sexual relationships without being under the influence of substances. For women with a history of sexual trauma, using alcohol and drugs to manage emotions while having sex may have served as an important coping mechanism. Subsequently, women may become fearful of having sex without the assistance of substances (Covington 2000, 1997). Trauma survivors may view sex as taboo or hurtful and their sexual responses as bad. In addition, sexual relationships sometimes can trigger painful memories of past abuse that can create difficulties for women, particularly in early recovery (Covington 1997; Finkelstein 1996).
Sexual dysfunctions. Alcohol and drugs interfere with sexual sensitivity and enjoyment in many ways. They disrupt the delicate balance of a woman’s hormonal system, interfering with her body’s emotional, reproductive, and physiological functions (Greenfield and O’Leary 2002). Women with substance use disorders have the same kinds of sexual dysfunctions as those without the disorder (lack of orgasm, lack of lubrication, lack of sexual interest, etc.), but they have more problems more often (Covington 2000).
Sexual and interpersonal violence. Sexuality often is associated with violence and abuse for female clients with histories of trauma. Consequently, they may be fearful, angry, and distrustful, and have difficulty functioning sexually. Given the association between substance abuse and sexual abuse (Ullman et al. 2005), women who have been abused may use alcohol or drugs to numb the emotional pain of the abusive experience. This can create a spiraling relationship where many women use substances to alleviate the sexual difficulties they are experiencing. But the alcohol or drugs only exacerbate the problem. Women who are under the influence of drugs are at greater risk for sexual and physical aggression (Blume 1991; Testa et al. 2003), and this remains true with pregnant women who have substance use disorders (Velez et al. 2006).
Sexually transmitted diseases (STDs). The use of alcohol and drugs increases the likelihood of contracting STDs, including HIV/AIDS. There are three primary reasons for this increased risk. When drunk or high, many women neglect to protect themselves against STDs or to make sure they do not use contaminated needles (Evans et al. 2003; Pugatch et al. 2000). Often women with substance use disorders find themselves in relationships with men who are also chemically dependent, thereby increasing the risk that their partner may have STDs or are HIV positive. In addition, rates of other infectious diseases among women with substance use disorders tend to be higher than among other female populations (CSAT 1993c; Grella et al. 1995). Notably, preliminary findings suggest that women who inject illicit drugs and have sex with other women exhibit increased HIV infection and risk behaviors in comparison to other people who use injection drugs (Young et al. 2005).
In addition to research pertaining to prevalence, counselors need to address clinical issues associated with infectious diseases. Specifically, shame and stigma are highly associated with sexually transmitted diseases and HIV infection (Fortenberry et al. 2002), and, as a result, women who are addicted and infected with a sexually transmitted disease are likely to perceive and experience a more profound sense of shame and higher levels of stigma— potentially serving as a barrier to engaging in help-seeking behavior.
Clinical Activity: Exploring the History and Influence of Relationships: Sociogram
Using a simple diagram (referred to as a sociogram) that was pioneered by J. L. Moreno in the 1940s, clients can highlight their most influential female and/or male relationships (including positive and negative attributes). Starting with this diagram, counselors can use this activity as a foundation to help women explore how these relationships influence current relationship patterns, preference for male or female friends, attitudes toward other women and/or men, and the development of support systems.
Depending on your goal, you can have the client focus only on the men or women who have been most influential in their lives. Generally, the exercise provides more clarity for the client if you focus on only one gender at a time. Yet, your selection depends on your treatment goal, the client’s current struggles, and previous relationship history. If the woman is having a difficult time connecting with other women in treatment, it may be helpful to start with a history of her female relationships. Even though there are other ingredients that influence how a woman relates to and views other women (namely gender socialization), a sociogram that begins with the history of female relationships may enhance awareness of the issues that impede her ability to relate to other women. At other times, it may be more fruitful to focus on the history of male relationships with women due to clinical issues that involve men. Here are directions and a sample of a sociogram on female relationships:
Provide the client with a piece of paper and a pencil, and ask her to list the most influential females throughout her life. The list should include women who have had the most significant impact—both positive and negative. It should not be limited to family members, but instead include women throughout her lifespan up to the present day. The list should consist of women who have had a powerful influence even if the encounter was brief. You could ask her to limit the list to six to eight women for this exercise. She can always go back and add individuals later on.
After compiling this list (it takes about 3 to 5 minutes), have the client turn the page over and draw a circle (about the size of a quarter) in the middle of the page and have her place her own name within the circle. Referring back to her list of influential women, ask the client to draw a circle for each influential woman on the piece of paper and to place the circles in reference to how influential they have been in her life—placing the most influential women closer to her circle and other women with less influence farther away on the page. The circle can be placed anywhere on the paper. For example, if you have a client with a physically abusive mother and the client feels that this history prevented her from trusting other women, she may place the circle, labeled “Mother” quite close to her circle.
After instructing the client to draw and place the circles on the page so that the placement represents how influential or how much she believes this relationship affected her, ask the client to go back and list three things in each circle that she learned about other women based on each specific relationship. For example, you may say to the client, “What did you learn about women based on your relationship with your mother and how your mother was with you? Select three things and write them in the circle that is labeled ‘Mother.’”
Upon completion, have the client present her sociogram. This exercise works quite well in a women’s group and in individual counseling. In group, it promotes a dynamic discussion on how women learn to relate to each other, and it creates an opportunity to understand how each client’s history of female relationships can influence current relationships in treatment and recovery. As a counselor, you can promote further discussion by asking the following questions:
Are there any themes or recurrent patterns in this sociogram?
How does this history influence your relationship with other women in treatment, in therapy groups, and in support groups?
Can you provide a specific and recent example of how your history of relationships affected or contributed to a specific situation in treatment?
Sample Sociogram Exercise: “What have I learned from each relationship about other women?”
Pregnancy creates stress for many women. Literature suggests that this stress can come from the woman’s physical discomfort; her anxiety about the health of her fetus and how she will care for her baby; or her shame from the social stigma of using drugs, alcohol, or tobacco while she is pregnant (Daley et al. 1998). Providers can create an atmosphere that supports talking freely about pregnancy and recognize that ambivalence toward pregnancy is a normal reaction. Counselors should make a careful assessment of the woman’s existing parenting and other family responsibilities and of the social services and economic resources the mother needs.
Family structures in America have become more complex—growing from the traditional nuclear family to single‐parent families, stepfamilies, foster families, and multigenerational families. Therefore, when a family member abuses substances, the effect on the family may differ according to family structure. This chapter discusses treatment issues likely to arise in different family structures that include a person abusing substances. For example, the non–substance‐abusing parent may act as a “superhero” or may become very bonded with the children and too focused on ensuring their comfort. Treatment issues such as the economic consequences of substance abuse will be examined as will distinct psychological consequences that spouses, parents, and children experience. This chapter concludes with a description of social issues that coexist with substance abuse in families and recommends ways to address these issues in therapy.
A growing body of literature suggests that substance abuse has distinct effects on different family structures. For example, the parent of small children may attempt to compensate for deficiencies that his or her substance‐abusing spouse has developed as a consequence of that substance abuse (Brown and Lewis 1999). Frequently, children may act as surrogate spouses for the parent who abuses substances. For example, children may develop elaborate systems of denial to protect themselves against the reality of the parent’s addiction. Because that option does not exist in a single‐parent household with a parent who abuses substances, children are likely to behave in a manner that is not age‐appropriate to compensate for the parental deficiency (for more information, see Substance Abuse Treatment: Addressing the Specific Needs of Women [Center for Substance Abuse Treatment (CSAT) in development e] and TIP 32, Treatment of Adolescents With Substance Use Disorders [CSAT 1999e]). Alternately, the aging parents of adults with substance use disorders may maintain inappropriately dependent relationships with their grown offspring, missing the necessary “launching phase” in their relationship, so vital to the maturational processes of all family members involved.
The effects of substance abuse frequently extend beyond the nuclear family. Extended family members may experience feelings of abandonment, anxiety, fear, anger, concern, embarrassment, or guilt; they may wish to ignore or cut ties with the person abusing substances. Some family members even may feel the need for legal protection from the person abusing substances. Moreover, the effects on families may continue for generations. Intergenerational effects of substance abuse can have a negative impact on role modeling, trust, and concepts of normative behavior, which can damage the relationships between generations. For example, a child with a parent who abuses substances may grow up to be an overprotective and controlling parent who does not allow his or her children sufficient autonomy.
Neighbors, friends, and coworkers also experience the effects of substance abuse because a person who abuses substances often is unreliable. Friends may be asked to help financially or in other ways. Coworkers may be forced to compensate for decreased productivity or carry a disproportionate share of the workload. As a consequence, they may resent the person abusing substances.
People who abuse substances are likely to find themselves increasingly isolated from their families. Often they prefer associating with others who abuse substances or participate in some other form of antisocial activity. These associates support and reinforce each other’s behavior.
Different treatment issues emerge based on the age and role of the person who uses substances in the family and on whether small children or adolescents are present. In some cases, a family might present a healthy face to the community while substance abuse issues lie just below the surface.
Reilly (1992) describes several characteristic patterns of interaction, one or more of which are likely to be present in a family that includes parents or children abusing alcohol or illicit drugs:
Negativism. Any communication that occurs among family members is negative, taking the form of complaints, criticism, and other expressions of displeasure. The overall mood of the household is decidedly downbeat, and positive behavior is ignored. In such families, the only way to get attention or enliven the situation is to create a crisis. This negativity may serve to reinforce the substance abuse.
Parental inconsistency. Rule setting is erratic, enforcement is inconsistent, and family structure is inadequate. Children are confused because they cannot figure out the boundaries of right and wrong. As a result, they may behave badly in the hope of getting their parents to set clearly defined boundaries. Without known limits, children cannot predict parental responses and adjust their behavior accordingly. These inconsistencies tend to be present regardless of whether the person abusing substances is a parent or child and they create a sense of confusion—a key factor—in the children.
Parental denial. Despite obvious warning signs, the parental stance is: (1) “What drug/alcohol problem? We don’t see any drug problem!” or (2) after authorities intervene: “You are wrong! My child does not have a drug problem!”
Miscarried expression of anger. Children or parents who resent their emotionally deprived home and are afraid to express their outrage use drug abuse as one way to manage their repressed anger.
Self‐medication. Either a parent or child will use drugs or alcohol to cope with intolerable thoughts or feelings, such as severe anxiety or depression.
Unrealistic parental expectations. If parental expectations are unrealistic, children can excuse themselves from all future expectations by saying, in essence, “You can’t expect anything of me—I’m just a pothead/speed freak/junkie.” Alternatively, they may work obsessively to overachieve, all the while feeling that no matter what they do it is never good enough, or they may joke and clown to deflect the pain or may withdraw to side‐step the pain. If expectations are too low, and children are told throughout youth that they will certainly fail, they tend to conform their behavior to their parents’ predictions, unless meaningful adults intervene with healthy, positive, and supportive messages.
In all of these cases, what is needed is a restructuring of the entire family system, including the relationship between the parents and the relationships between the parents and the children. The next section discusses treatment issues in different family structures that include a person who is abusing substances.
Families With a Member Who Abuses Substances
Client Lives Alone or With Partner
The consequences of an adult who abuses substances and lives alone or with a partner are likely to be economic and psychological. Money may be spent for drug use; the partner who is not using substances often assumes the provider role. Psychological consequences may include denial or protection of the person with the substance abuse problem, chronic anger, stress, anxiety, hopelessness, inappropriate sexual behavior, neglected health, shame, stigma, and isolation.
In this situation, it is important to realize that both partners need help. The treatment for either partner will affect both, and substance abuse treatment programs should make both partners feel welcome. If a person has no immediate family, family therapy should not automatically be ruled out. Issues regarding a person’s lost family, estranged family, or family of origin may still be relevant in treatment. A single person who abuses substances may continue to have an impact on distant family members who may be willing to take part in family therapy. If family members come from a distance, intensive sessions (more than 2 hours) may be needed and helpful. What is important is not how many family members are present, but how they interact with each other.
In situations where one person is substance dependent and the other is not, questions of codependency arise. Codependency has become a popular topic in the substance abuse field. Separate 12‐Step groups such as Al‐Anon and Alateen, Co‐Dependents Anonymous (CoDA), Adult Children of Alcoholics, Adult Children Anonymous, Families Anonymous, and Co‐Anon have formed for family members (see appendix D for a listing of these and other resources).
CoDA describes codependency as being overly concerned with the problems of another to the detriment of attending to one’s own wants and needs (CoDA 1998). Codependent people are thought to have several patterns of behavior:
They are controlling because they believe that others are incapable of taking care of themselves.
They typically have low self‐esteem and a tendency to deny their own feelings.
They are excessively compliant, compromising their own values and integrity to avoid rejection or anger.
They often react in an oversensitive manner, as they are often hypervigilant to disruption, troubles, or disappointments.
They remain loyal to people who do nothing to deserve their loyalty (CoDA 1998).
Although the term “codependent” originally described spouses of those with alcohol abuse disorders, it has come to refer to any relative of a person with any type of behavior or psychological problem. The idea has been criticized for pathologizing caring functions, particularly those that have traditionally been part of a woman’s role, such as empathy and self‐sacrifice. Despite the term’s common use, little scientific inquiry has focused on codependence. Systematic research is needed to establish the nature of codependency and why it might be important (Cermak 1991; Hurcom et al. 2000; Sher 1997). Nonetheless, specifically targeted behavior that somehow reinforces the current or past using behavior must be identified and be made part of the treatment planning process.
Client Lives With Spouse (or Partner) and Minor Children
Similar to maltreatment victims, who believe the abuse is their fault, children of those with alcohol abuse disorders feel guilty and responsible for the parent’s drinking problem. Children whose parents abuse illicit drugs live with the knowledge that their parents’ actions are illegal and that they may have been forced to engage in illegal activity on their parents’ behalf. Trust is a key child development issue and can be a constant struggle for those from family systems with a member who has a substance use disorder (Brooks and Rice 1997).
Most available data on the enduring effects of parental substance abuse on children suggest that a parent’s drinking problem often has a detrimental effect on children. These data show that a parent’s alcohol problem can have cognitive, behavioral, psychosocial, and emotional consequences for children. Among the lifelong problems documented are impaired learning capacity; a propensity to develop a substance use disorder; adjustment problems, including increased rates of divorce, violence, and the need for control in relationships; and other mental disorders such as depression, anxiety, and low self‐esteem (Giglio and Kaufman 1990; Johnson and Leff 1999; Sher 1997).
The children of women who abuse substances during pregnancy are at risk for the effects of fetal alcohol syndrome, low birth weight (associated with maternal addiction), and sexually transmitted diseases. (For information about the effects on children who are born addicted to substances, see TIP 5, Improving Treatment for Drug‐Exposed Infants [CSAT 1993a].) Latency age children (age 5 to the onset of puberty) frequently have school‐related problems, such as truancy. Older children may be forced prematurely to accept adult responsibilities, especially the care of younger siblings. In adolescence, drug experimentation may begin. Adult children of those with alcohol abuse disorders may exhibit problems such as unsatisfactory relationships, inability to manage finances, and an increased risk of substance use disorders.
Although, in general, children with parents who abuse substances are at increased risk for negative consequences, positive outcomes have also been described. Resiliency is one example of a positive outcome (Werner 1986). Some children seem better able to cope than others; the same is true of spouses (Hurcom et al. 2000). Because of their early exposure to the adversity of a family member who abuses substances, children develop tools to respond to extreme stress, disruption, and change, including mature judgment, capacity to tolerate ambiguity, autonomy, willingness to shoulder responsibility, and moral certitude (Wolin and Wolin 1993). Nonetheless, substance abuse can lead to inappropriate family subsystems and role taking. For instance, in a family in which a mother uses substances, a young daughter may be expected to take on the role of mother. When a child assumes adult roles and the adult abusing substances plays the role of a child, the boundaries essential to family functioning are blurred. The developmentally inappropriate role taken on by the child robs her of a childhood, unless there is the intervention by healthy, supportive adults.
The spouse of a person abusing substances is likely to protect the children and assume parenting duties that are not fulfilled by the parent abusing substances. If both parents abuse alcohol or illicit drugs, the effect on children worsens. Extended family members may have to provide care as well as financial and psychological support. Grandparents frequently assume a primary caregiving role. Friends and neighbors may also be involved in caring for the young children. In cultures with a community approach to family care, neighbors may step in to provide whatever care is needed. Sometimes it is a neighbor who brings a child abuse or neglect situation to the attention of child welfare officials. Most of the time, however, these situations go unreported and neglected.
Client Is Part of a Blended Family
Anderson (1992) notes that many people who abuse substances belong to stepfamilies. Even under ordinary circumstances, stepfamilies present special challenges. Children often live in two households in which different boundaries and ambiguous roles can be confusing. Effective coparenting requires good communication and careful attention to possible areas of conflict, not only between biological parents, but also with their new partners. Popenoe (1995) believes that the difficulty of coordinating boundaries, roles, expectations, and the need for cooperation, places children raised in blended households at far greater risk of social, emotional, and behavioral problems. Children from stepfamilies may develop substance abuse problems to cope with their confusion about family rules and boundaries.
Substance abuse can intensify problems and become an impediment to a stepfamily’s integration and stability. When substance abuse is part of the family, unique issues can arise. Such issues might include parental authority disputes, sexual or physical abuse, and self‐esteem problems for children.
Substance abuse by stepparents may further undermine their authority, lead to difficulty in forming bonds, and impair a family’s ability to address problems and sensitive issues. If the noncustodial parent abuses drugs or alcohol, visitation may have to be supervised. (Even so, visitation is important. If contact stops, children often blame themselves or the drug problem for a parent’s absence.)
If a child or adolescent abuses substances, any household can experience conflict and continual crisis. Hoffmann (1995) found that increased adolescent marijuana use occurs more frequently when an adolescent living with a divorced parent and stepparent becomes less attached to the family. With fewer ties to the family, the likelihood increases that the adolescent will form attachments to peers who abuse substances. Weaker ties to the family and stronger ones to peers using drugs increase the chances of the adolescent starting to use marijuana or increasing marijuana use.
Stepparents living in a household in which an adolescent abuses substances may feel they have gotten more than they bargained for and resent the time and attention the adolescent requires from the biological parent. Stepparents may demand that the adolescent leave the household and live with the other parent. In fact, a child who is acting out and abusing substances is not likely to be welcomed in either household (Anderson 1992).
Clinicians treating substance abuse should know that the family dynamics of blended families differ somewhat from those of nuclear families and require some additional considerations. Anderson (1992) identifies strategies for addressing substance abuse in a stepfamily:
The use of a genogram, which graphically depicts significant people in the client’s life, helps to establish relationships and pinpoint where substance abuse is and has been present (see chapter 3).
Extensive historical work helps family members exchange memories that they have not previously shared.
Education can provide a realistic expectation of what family life can be like.
The development of correct and mutually acceptable language for referring to family relationships helps to strengthen family ties. The goal of family therapy is to restructure maladaptive family interactions that are associated with the substance abuse problem. To do this, the counselor first has to earn the family’s trust, which means approaching family members on their own terms.
Older Client Has Grown Children
When an adult, age 65 or older, abuses a substance it is most likely to be alcohol and/or prescription medication. The 2002 National Household Survey on Drug Abuse found that 7.5 percent of older adults reported binge and 1.4 percent reported heavy drinking within the past month of the survey (Office of Applied Studies [OAS] 2003a). Veterans hospital data indicate that, in many cases, older adults may be receiving excessive amounts of one class of addictive tranquilizer (benzodiazepines), even though they should receive lower doses. Further, older adults take these drugs longer than other age groups (National Institute on Drug Abuse [NIDA] 2001). Older adults consume three times the number of prescription medicine as the general population, and this trend is expected to grow as children of the Baby Boom (born 1946–1958) become senior citizens (NIDA 2001).
As people retire, become less active, and develop health problems, they use (and sometimes misuse) an increasing number of prescription and over‐the‐counter drugs. Among older adults, the diagnosis of this (or any other) type of substance use disorder often is difficult because the symptoms of substance abuse can be similar to the symptoms of other medical and behavioral problems that are found in older adults, such as dementia, diabetes, and depression. In addition, many health care providers underestimate the extent of substance abuse problems among older adults, and, therefore, do not screen older adults for these problems.
Older adults often live with or are supported by their adult children because of financial necessity. An older adult with a substance abuse problem can affect everyone in the household. If the older adult’s spouse is present, that person is likely to be an older adult as well and may be bewildered by new and upsetting behaviors. Therefore, a spouse may not be in a position to help combat the substance abuse problem. Additional family resources may need to be mobilized in the service of treating the older adult’s substance use disorder. As with child abuse and neglect, elder maltreatment is a statutory requirement for reporting to local authorities.
Whether grown children and their parents live together or apart, the children must take on a parental, caretaking role. Adjustment to this role reversal can be stressful, painful, and embarrassing. In some cases, grown children may stop providing financial support because it is the only influence they have over the parent. Adult children often will say to “let them have their little pleasure.” In other instances, children may cut ties with the parent because it is too painful to have to watch the parent’s deterioration. Cutting ties only increases the parent’s isolation and may worsen his predicament.
For a detailed discussion of substance problems in older adults, see TIP 24, A Guide to Substance Abuse Services for Primary Care Clinicians (CSAT 1997a) and TIP 26, Substance Abuse Among Older Adults (CSAT 1998d). See also chapter 5.
Client Is an Adolescent and Lives With Family of Origin
Substance use and abuse among adolescents continues to be a serious condition that impacts cognitive and affective growth, school and work relationships, and all family members. In the National Household Survey on Drug Abuse, of adolescents ages 12 to 17, 10.7 percent reported binge use of alcohol (five drinks on one occasion in the last month before the survey) and 2.5 percent reported heavy alcohol use (at least five binges in the previous month) (OAS 2003a). In addition, two trends described in TIP 32, Treatment of Adolescents With Substance Use Disorders (CSAT 1999e), are increasing rates of substance use by youth and first onset of substance use at younger ages.
In a general population sample of 10‐ to 20‐year‐olds, roughly 12.4 percent (96 of 776) met criteria for a substance use disorder (Cohen et al. 1993). Alcohol and other psychoactive drugs play a prominent role in violent death for teenagers, including homicide, suicide, traffic accidents, and other injuries. Aside from death, drug use can lead to a range of possible detrimental consequences:
Risky sexual behavior, possibly leading to unwanted pregnancy or sexually transmitted diseases
Developmental impairment (Alexander and Gwyther 1995; CSAT 1999e)
As youth abuse alcohol and illicit drugs, they may establish a continuing pattern of behavior that damages their legal record, educational options, psychological stability, and social development. Drug use (particularly inhalants and solvents) may lead to cognitive deficits and perhaps irreversible brain damage. Adolescents who use drugs are likely to interact primarily with peers who use drugs, so relationships with friends, including relationships with the opposite sex, may be unhealthy, and the adolescent may develop a limited repertoire of social skills.
When an adolescent uses alcohol or drugs, siblings in the family may find their needs and concerns ignored or minimized while their parents react to constant crises involving the adolescent who abuses drugs. The neglected siblings and peers may look after themselves in ways that are not age‐appropriate, or they might behave as if the only way to get attention is to act out.
Clinicians should not miss opportunities to include siblings, who are often as influential as parents, in the family therapy sessions treating substance abuse. Whether they are adults or children, siblings can be an invaluable resource. In addition, Brook and Brook (1992) note that sibling relationships characterized by mutual attachment, nurturance, and lack of conflict can protect adolescents against substance abuse.
Another concern often overlooked in the literature is the case of the substance‐using adolescent whose parents are immigrants and cannot speak English. Immigrant parents often are perplexed by their child’s behavior. Degrees of acculturation between family members create greater challenges for the family to address substance abuse issues and exacerbate intergenerational conflict.
In many families that include adolescents who abuse substances, at least one parent also abuses substances (Alexander and Gwyther 1995). This unfortunate modeling can set in motion a dangerous combination of physical and emotional problems. If adolescent substance use is met with calm, consistent, rational, and firm responses from a responsible adult, the effect on adolescent learning is positive. If, however, the responses come from an impaired parent, the hypocrisy will be obvious to the adolescent, and the result is likely to be negative. In some instances, an impaired parent might form an alliance with an adolescent using substances to keep secrets from the parent who does not use substances. Even worse, sometimes in families with multigenerational patterns of substance abuse, an attitude among extended family members may be that the adolescent is just conforming to the family history.
Since the early 1980s, treating adolescents who abuse substances has proven to be effective. Nevertheless, most adolescents will deny that alcohol or illicit drug use is a problem and do not enter treatment unless parents, often with the help of school‐based student assistant programs or the criminal justice system, require them to do so. Often, a youngster’s substance abuse is hidden from members of the extended family. Adolescents who are completing treatment need to be prepared for going back to an actively addicted family system. Alateen, along with Alcoholics Anonymous, can be a part of adolescents’ continuing care, and participating in a recovery support group at school (through student assistance) also will help to reinforce recovery.
For more information on substance use among adolescents, see chapter 5. See also TIP 31, Screening and Assessing Adolescents for Substance Use Disorders (CSAT 1999c), and TIP 32, Treatment of Adolescents With Substance Use Disorders (CSAT 1999e).
Someone Not Identified as the Client Abuses Substances
Substance abuse may not be the presenting issue in a family. Initially, it may be hidden, only to become apparent during therapy. If any suspicion of substance abuse emerges, the counselor or therapist should evaluate the degree to which substance abuse has a bearing on other issues in the family and requires direct attention.
When someone in the family other than the person with presenting symptoms is involved with alcohol or illicit drugs, issues of blame, responsibility, and causation will arise. With the practitioner’s help, the family needs to refrain from blaming, and reveal and repair family interactions that create the conditions for substance abuse to continue.
Other Treatment Issues
In any form of family therapy for substance abuse treatment, consideration should be given to the range of social problems connected to substance abuse. Problems such as criminal activity, joblessness, domestic violence, and child abuse or neglect may also be present in families experiencing substance abuse. To address these issues, treatment providers need to collaborate with professionals in other fields. This is also known as concurrent treatment.
Whenever family therapy and substance abuse treatment take place concurrently, communication between clinicians is vital. In addition to family therapy and substance abuse treatment, multifamily group therapy, individual therapy, and psychological consultation might be necessary. With these different approaches, coordination, communication, collaboration, and exchange of the necessary releases of confidential information are required.
With concurrent treatment, it is important that goal diffusion does not occur. Empowering the family is a benefit of family therapy that should not be sacrificed. If family therapy and substance abuse treatment approaches conflict, these issues should be addressed directly. Case conferencing often is an efficient way to deal constructively with multiple concerns and provides a forum to determine mutually agreeable priorities and treatment plan coordination.
Some concurrent treatment may not involve the person with alcohol or illicit drug problems. Even if this person is not in treatment, family therapy with the partner and other family members can often begin, or family therapy can be an addition to substance abuse treatment. The detoxification period also presents valuable opportunities to involve family members in treatment. Family therapy may have more of an impact on family members than it does on the IP because it enhances all family members’ ability to work through conflicts. It may establish healthy family conditions that support the IP moving into recovery later in his or her life, after the episode of treatment has ended. Sometimes the person who abuses substances will not allow contact with the family, which limits the possibilities of family therapy, but family involvement in substance abuse treatment can still remain a goal; this “resistance” can be restructured by allying with the person with the substance use disorder and stressing the importance of and need for family participation in treatment. Resiliency within the family system is a developing area of interest (for more information see, for example, www.WestEd.org).
Chapter 2 Summary Points From a Family Counselor Point of View
•Consider the “family” from the client’s point of view—that is, who would the client describe as a family member and who is a “significant other” for the client.
•Assess the “family”—members’ effectiveness of communications, supportiveness or negativity, parenting skills, conflict management, and understanding of addictive disease.
•Don’t give up, and try, try again—many families or family members at first reject any participation in the treatment process. But, after a period of separation from the client who is abusing substances, family members often become willing to at least attend an initial session with the counselor.