Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Co-Occurring Disorders:
Integrated Dual Disorders Treatment
Integrated Dual Disorders Treatment Workbook
Chapter 15: Family Treatment
INTRODUCTION
Because families can be such a strong source of support for clients with dual disorders, it is important to include them in treatment. This chapter presents a young man with schizophrenia and alcohol abuse whose family played a critical role in his recovery. The clinical team can involve the family in different ways at each stage of treatment.
VIGNETTE
Jack is a 26-year-old, unemployed man diagnosed with schizophrenia and alcohol abuse. When he drank, his symptoms of schizophrenia seemed to worsen, including delusions of reference, poor attention, and disorganization. Jack had been hospitalized three times and had not worked in several years. He argued frequently with his mother and stepfather, with whom he lived. Though he wanted friends, he had difficulty meeting people.
One day Jack's mother called his case manager, furious because she had found a bag of what appeared to be marijuana in his bedroom. She demanded to meet with Jack's treatment team. When Jack's case manager mentioned this to Jack, he agreed that his substance use was causing problems with his parents and that they should all meet.
In a long family meeting, the treatment team tried to understand each person's view of the current situation and what each was hoping could happen. They offered Jack and his family several options. First, there was a monthly educational group at the mental health center. Second, The National Alliance on Mental Illness (NAMI) also held a monthly meeting of families who were trying to help a family member with mental illness. Third, they could work with a therapist to get family therapy. After explaining each of these options, they agreed that Jack's parents would attend a NAMI meeting and that the family would discuss the options and call the case manager about what they would like to do next.
Two weeks later, Jack's parents called again with the news that Jack had come in "stumbling drunk" and that a huge fight had ensued. They all returned to the mental health center and quickly decided to try family therapy.
The therapist met with each family member to understand their view of the problem and their situation. Jack expressed an interest in making some friends, and in having a girlfriend. He recognized that his drinking was a problem and said that he wanted to cut down. Jack's mother expressed extreme anxiety over his mental illness and the effects of alcohol. She felt that Jack was unable to take care of himself and that she needed to monitor him daily. Jack resented what he perceived to be his mother's over-involvement in his life, which led to conflict between them. Despite these problems, they both enjoyed being together. Jack's mother wanted to spend less time managing Jack's illness and more on herself (e.g., taking an exercise class) and with her husband. Jack's stepfather was supportive of his wife's concern for Jack, but he tended to be highly critical, which often inflamed difficult situations. He didn't understand schizophrenia, but was interested in learning more. He wanted Jack to live more independently so that he and his wife could travel more.
The family treatment began with weekly educational sessions. Jack talked openly about his symptoms and his stepfather began to see what the experience was like for Jack. During the educational sessions on substance use, Jack gained a better understanding of how he used substances to escape from feelings of failure but how using actually made things much worse. Jack's mother contacted the local NAMI group and began to attend a group, which she found quite helpful.
In several months, the family was introduced to problem-solving exercises. They worked on several problems in succession over the next eight months. First was getting Jack involved in activities and meeting potential friends. He enrolled in a course at a local community college within a few months. Social skills training with his case manager helped him to make a friend at the college, and he met several sober friends in a dual disorders group.
The second goal was to increase Jack's independence. After several discussions, Jack moved into supervised housing, and several months later he got his own apartment. The family members agreed on how much support the mental health team would provide and on how often Jack's mother would check on him in the new apartment.
The third issue was Jack's drinking, which the family chose not to address until Jack relapsed after a few months of sobriety. Several sessions addressed treatment planning, Jack's involvement in a dual disorders treatment group, understanding the course of recovery, and the family's role in encouraging sobriety without reacting strongly to drinking. Jack again- became committed to reducing his drinking, and the family learned more about accepting his need to learn to control his own behavior. He reduced his drinking dramatically. The parents were extremely proud of the progress that Jack made and were able to understand brief setbacks as part of recovery.
After one year, the family sessions ended. Jack and his parents continued to be regular participants at the monthly multiple-family group meetings. Jack's parents appreciate the support from other families and continue to learn more about dual disorders from other families. They are also helpful to other families that are feeling helpless about their relatives' drinking.
Jack has found a couple of non-drinking friends and a part-time job. He has succeeded in dramatically decreasing his drinking; he currently drinks one or two beers on occasion and has long periods of abstinence. He has been abstinent from marijuana use since beginning the family sessions. Jack's mental illness has been stable for almost two years, and he has not been hospitalized since the beginning of family work. His current goals are to find a better job and a girlfriend. Jack's parents have achieved their goal of having more time for themselves, and have taken several vacations on their own.
THE IMPORTANCE OF FAMILY INTERVENTIONS
Working with the families of dually diagnosed clients is extremely important. Clients often have few friends, small social networks, or drug-abusing friends who encourage self-destructive behaviors. Family members can be their most important social supports. However, these clients and their families typically experience serious tension and conflict around substance abuse, difficult behavior, and symptoms of mental illness. Families may not understand the interactions between substance use, severe mental illness, and behavior. They need practical information about dual disorders and help in developing strategies to meet family goals. Family treatment can reduce stress in the family, increase the family's ability to offer positive supports, and focus everyone on the same goals.
STAGES OF TREATMENT FOR FAMILIES
The concept of stages of treatment described in the previous chapters can also be useful for working with families. At the beginning of treatment, during the engagement stage, the clinician can reach out to families, provide them with practical assistance, and give them information about mental illness and substance abuse to establish a working relationship. This does not appear to have happened with Jack's family because the family initiated contact with the team.
As the family enters the persuasion stage, the clinician provides education about the effects of substances on the course of mental illness and about treatment. Education helps the family become interested in addressing the substance abuse. If needed, clinicians can use motivational interviewing to help family members recognize the impact of substance abuse. Families need to see substance abuse as a barrier to their family member's goals. In Jack's case, the clinician helped the family focus on Jack's goals as well as his parents' goals.
When family members are committed to the same goals of reducing substance use, they enter the active treatment stage. Many different methods can be used to help the client learn to manage his illnesses and pursue goals, depending on the client's motivation to change, the circumstances of the client's substance abuse, and the family's communication and problem-solving skills. When the client has reduced substance use, family work in the relapse prevention stage aims at minimizing vulnerability to relapses of substance abuse and expanding recovery to other areas of functioning. Jack's family was able to make progress in many different areas.
FAMILY INTERVENTIONS
Family interventions for persons with dual disorders can include education, involvement in an individual's treatment plan, family therapy, family support groups, and involvement with organizations that support families such as the Alliance for the Mentally Ill (See Table 1). Families can participate in any or all of these options. Combinations of treatment and support groups can be especially helpful.
Table 1: Family Interventions
- Education
- Involvement in treatment planning
- Family Therapy
- Family Support Groups
- Organizations such as The National Alliance on Mental Illness
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When trying to decide which intervention will be most helpful for a family, assess the family member's areas of interest and motivation for involvement. Try to get families involved in at least one of the interventions listed in Table 1. Any interaction with family is better than none. As with clients, it is critical to treat families with dignity and respect. They have a wealth of knowledge and experience with your client that is invaluable.
EDUCATION
The primary goal of education is to help the family understand the nature of the psychiatric illness and its interactions with substance use. Most families know little about mental illness and even less about substance abuse. Though they want to help their family member, they may not understand the recovery process or know how to nurture recovery. Helping families understand the situation from the client's perspective is a powerful way to enlist their support. Their new understanding helps them learn to work together on shared goals.
Education can be provided verbally, with pamphlets, with books, with videos, and in support groups with speakers. Education alone is helpful for many families, but by itself is not a treatment for a client with dual disorders.
Family education typically covers eight topics: 1) psychiatric diagnosis; 2) medications; 3) the stress-vulnerability model; 4) the role of the family; 5) basic facts about substances of abuse; 6) cues and triggers for and consequences of substance use; 7) treatment of dual disorders; and 8) good communication. Other topics of interest to families include dealing with cravings; managing stress; dealing with high-risk situations; coping with depression; self-help groups (e.g., AA); finding and improving relationships; resolving conflicts; recreational and leisure activities; work; planning for the future; new advances in medication treatment; and money management.
Table 2: Educational Topics for Families
- Psychiatric diagnoses
- Medications
- Stress-vulnerability model
- The role of the family
- Basic facts about alcohol and drugs
- Cues or triggers for and consequences of substance use
- Treatment of dual disorders
- Good communication
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FAMILY THERAPY
Family therapy involves outreach and engagement of the family, education about mental illness and substance abuse, and training in problem-solving techniques for addressing the dual disorders and their impact on the family. An immediate goal of family therapy is to maintain family involvement and to reduce the stress of substance use on them. A long-term goal is to decrease the client's substance abuse, and to help everyone make progress towards personal and shared goals. Jack's story illustrates typical goals.
The focus of problem-solving training is to teach families how to address problems on their own. Family members are taught the following sequence for solving problems: 1) define the problem to everyone's satisfaction; 2) generate possible solutions; 3) evaluate advantages and disadvantages of solutions; 4) select the best solution; 5) plan to implement the selected solution; and 6) meet at a later time to review progress.
When families are still in the persuasion stage, problem-solving is aimed at developing motivation to address substance abuse or to reduce its effects on the family. The clinician looks for ways to prompt family members to consider whether the client's substance use interferes with achieving the goal. Developing a discrepancy between substance use and a desired goal can help a family become motivated to address the problem of substance abuse. For example, a client who wants to work, but does not view his alcohol use as a problem, may experience problems on the job on the day after drinking. Family problem-solving that is focused on improving the client's job performance or getting a better job may lead to a decision to reduce drinking on certain days or to stop drinking altogether.
When families are in the active treatment stage, the problem-solving focuses directly on reducing substance use. This may include anticipating high-risk situations for continued abuse or relapse as well as developing skills and supports for getting needs met without using substances (e.g., finding places to meet people who are not substance users). In relapse prevention, the focus of problem-solving often shifts to other areas that further recovery, such as work, independent living, taking care of health, and developing close relationships.
FAMILY SUPPORT GROUPS
Ongoing multiple-family support groups can be useful for families. Group meetings are led by a clinician that brings in speakers and facilitates family participation. The meetings focus on providing ongoing education to families about dual disorders, facilitating a free exchange that validates others' experiences, motivating families to address the dual disorders, and sharing successful coping strategies. Potential speakers to provide education to a support group include, for example, a doctor from the mental health center to talk about new medications, someone from the social security agency to discuss rules about benefits, an addiction specialist to discuss various aspects of addiction, or a mental health consumer to discuss the concept of recovery.
Al-Anon is a self-help group for family members and support persons of people who have substance use disorders. Families can get information, support, and skills for coping with their relative's substance use problems by attending Al-Anon. To learn more about self-help, see chapter 14.
FAMILY ORGANIZATIONS
The National Alliance on Mental Illness (NAMI) is a grassroots coalition of people and their families coping with mental illness. The organization supports families and advocates for non-discriminatory and equitable funding and policies. The organization supports research into the causes, symptoms, and treatments of mental illness, and public education to eliminate stigma.
In most areas, there is a state NAMI group that sponsors monthly family meetings to provide an opportunity for clients and their families to meet each other and to learn from each other's experience. Usually there are regular educational meetings. The national organization (NAMI) provides numerous educational materials that are extremely helpful to families. The state NAMI groups sponsor family support programs, opportunities for advocacy, and education regarding local issues.
Recommended reading
Among many helpful books on family interventions, we recommend one book that is written for families: Coping with Schizophrenia: A Guide for Families by Kim Mueser and Susan Gingerich (Oakland, New Harbinger Publications, 1994); and a second for clinicians: Behavioral Family Therapy for Psychiatric Disorders by Kim Mueser and Shirley Glynn (Boston, MA, Allyn & Bacon, 1995).
To learn more about Problem Solving Therapy, read Problem Solving Therapy by Thomas D'Zurilla and Arthur Nezu (Springer, 1999).
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