Therapeutic Alliance and Substance Abuse

Course Objectives

1.  Describe obstacles to forming a therapeutic alliance.

2.  Describe resistance and identify ways to counteract it.

3.  Recognize and describe the need for boundaries in the therapeutic relationship..


Establishing and Maintaining a Therapeuitc Alliance with Substance Abuse Patients: A Cognitive Behavioral ApproachA positive, collaborative therapeutic relationship is an essential component of the cognitive therapy of substance abuse (Beck et al. 1993). To engage substance abuse patients in treatment, therapists will need not only to connect with the patients but also gain their trust. Otherwise, the patients will be less likely to benefit from treatment, and their rates of no-show and dropout are apt to increase.

Therefore, therapists must work diligently to form a working alliance by demonstrating general good will and a respectful desire to help. Further, they must carefully attend to any signs that the patients are losing interest or having adverse emotional reactions, and intervene promptly.

Obstacles to Forming a Therapeutic Alliance

Substance-abusing patients are an especially difficult population with whom to establish a commitment to change. A glance at the troubled family life of a substance abuser is instructive. At the height of his or her use of drugs, a patient often obtains far more gratification from the drugs than from the love and companionship of significant others, friends, and relatives. Therefore, the positive social reinforcement from a supportive therapist may pale in comparison to the high that the patient gets from a line of cocaine or a hit of crack. Thus, the therapist's capacity to act as an agent of change is more limited and fragile than with many other patient populations for whom the therapist’s approval and guidance have greater relative significance. As a result, the therapist will need to build the relationship when the patient is in a period of diminished drug use or abstinence. During this time, the benefits of having meaningful interpersonal relationships should be underscored at the same time as the drawbacks of drug use are being highlighted. The intention of this strategy is to enhance the patient's perceived reasons for remaining drug free, to motivate the patient to strive for relationship preservation, and to communicate the kind of therapeutic support that the patient will value.

Additionally, substance abusers often enter treatment with ambivalence about relinquishing their habits (Carroll et al. 1991a, 1991b; Havassy et al. 1991). Within the framework of Prochaska and colleagues' (1993) stages of change model, one sees that many substance abusers do not enter treatment at the stages of action or maintenance. Instead, they commence therapy with a notion that it might be beneficial to give up the use of drugs, or with a wavering desire to cut back on their use (i.e., the contemplative stage). In extreme cases, such as when patients are remanded by the courts to attend drug abuse rehabilitation sessions, the patients may not acknowledge that they have a problem with drugs or even that they use them at all (the pre-contemplative stage).

From the very start, therapists will need to ascertain their patients' respective levels of commitment to change in order to have the best chance of communicating an empathic understanding and to minimize the risk of pushing an unwanted agenda onto patients whose resistance then will likely increase. It is generally not a good idea to accuse patients of "not really wanting to change," or of "wanting to suffer," or of "being in denial" (Newman 1994a). It is one thing to confront patients in this manner when they are in the protective confines of an inpatient (perhaps group therapy) setting. It is quite another to do this in an individual outpatient setting where the patient can easily leave treatment and never return if he or she takes offense at the therapist's methods. It is far more preferable to acknowledge that the patient has mixed emotions, and then to assess and get to know the part of the patient that likes to use drugs and the other part that would rather be free of them. In this manner, the therapist demonstrates that he or she is not so naive as to believe that the patient's goal is unequivocal and immediate abstinence, but instead to recognize the complexities and difficulties involved in trying to stop using drugs. Further, the therapist avoids the potentially damaging pitfall of communicating in a judgmental un-empathic tone.


The initial interactions between the patient and therapist are extremely important, as substance abuse patients often will be silently sizing up their therapists to determine whether they can be trusted and know what they are doing (Perez 1992). The lack of a positive start to treatment may lead a patient to choose not to return for further sessions, or may foster negative expectancies in the patient that often exacerbate passive resistance or contentious behavior in session.

On the other hand, a positive start to treatment may instill hope in the patient, thus encouraging him or her to stay in treatment and to consider the prospects of therapeutic change more seriously.

The following are some common methods by which therapists can connect with their substance-abusing patients as treatment begins:

1. Speak directly, simply, and honestly.

2. Ask about the patient's thoughts and feelings about being in therapy.

3. Focus on the patient's distress.

4. Acknowledge the patient's ambivalence.

5. Explore the purpose and goals of treatment.

6. Discuss the issue of confidentiality.

7. Avoid judgmental comments.

8. Appeal to the patient's areas of positive self-esteem.

9. Acknowledge that therapy is difficult.

10. Ask open-ended questions, then be a good listener.

Speak Directly, Simply, and Honestly

The development of rapport is hindered when patients cannot understand their therapists due to the therapist’s unbridled use of psychological jargon. Similarly, patients often do not appreciate it when they perceive that their therapists are talking down to them, or are speaking to them in the manner of a teacher addressing a grade school class.

The remedy is to endeavor to speak adult to adult, rather than    authority to subordinate. For example, the cognitive therapist would be ill-advised to speak in the following manner: "I'll be assessing your thought processes so as to spot the kinds of cognitive distortions that lead you to engage in dysfunctional and antisocial activities." Instead, the therapist might say: "If it's okay with you, I'd like to understand your point of view about things. I don't want to assume that I already understand what it's like to live your life. I'm interested in listening to your thoughts so I get the real story." Although the therapist in the second example does not really start teaching the patient about cognitive therapy, he or she establishes some of the groundwork. More important at this early stage, the therapist comes across as being a real person who is understandable. As the patient progresses through succeeding sessions, the therapist will be able to elaborate gradually on the specifics of cognitive therapy, and to teach some of the basic nomenclature. Additionally, it is important for therapists to share their own thoughts and opinions openly (and diplomatically) when patients ask for them, rather than remaining mysterious figures. Substance abusers, either by virtue of their own developmental/personality issues or their experiences with dishonest drug-abusing associates, often have major problems in trusting others. A therapist who makes an earnest effort to respond to questions can provide the patient with evidence that the therapist does not have a hidden agenda. As a qualifier to the above, it is important to note that the therapist should feel free to ask the patient many questions as well, lest the patient put the responsibility for the work of therapy entirely (and inappropriately) on the therapist.

Ask About the Patient's Thoughts and Feelings about Being in Therapy

The therapist shouldn’t assume that the patient is highly motivated for treatment or that he or she is resistant and hostile. The best way to obtain valid data, and at the same time demonstrate that the therapist cares to understand how the patient feels, is to ask the patient directly about his or her experience of coming to the therapist's office.

Such questions can involve asking about the patient’s doubts and concerns, as well as expectations, goals, and hopes for therapy. If the patient expresses misgivings about being in treatment, these negative reactions can be addressed on the spot, thus reducing the risk of early dropout. At the same time, the therapist can utilize this interaction to begin to teach the patient the cognitive therapy model. For example, a patient who expects to be disrespected by the therapist may harbor feelings of anger. By contrast, if the patient expects to be helped, he or she may feel a sense of relief and have a high degree of motivation. This example begins to demonstrate one of the central tenets of cognitive therapy, namely, that the patient's thoughts will influence his or her feelings, intentions, and actions.

Focus on the Patient's Distress

In light of the high rates of dual diagnoses in substance abusers who present for treatment (Castaneda et al. 1989; Evans and Sullivan 1990; Nace et al. 1991; Rounsaville et al. 1991), it is likely that these patients will be suffering from affective disorders, anxiety disorders, or other psychological maladies when they enter treatment. If therapists show an interest in sympathizing with and addressing these emotional problems, in contrast to focusing exclusively on the substance abuse per se, they can demonstrate that they are interested in the entirety of the patient's well-being. In this manner, therapists show that they are interested in getting to know the patient as a person, and not simply as an addict.

Such an approach is especially indicated for substance-abusing patients who also meet diagnostic criteria for antisocial personality disorder (ASPD). These patients typically are unmotivated to change unless they are in emotional distress, in which case there is a desire to participate in therapy to gain relief (Alterman and Cacciola 1991; Woody et al. 1990). By helping these ASPD/depressed drug abusers to improve their mood, therapists may be able to form an interpersonal alliance with patients who otherwise might not bond with a helper. Even when patients do not technically meet criteria for dual diagnoses, they may often experience emotional suffering related to having reached points of crisis in their lives (Kosten et al. 1986; Newman and Wright 1994; Sobell et al. 1988). Therefore, it is quite appropriate for therapists to put such topics as current areas of stress and family problems on the therapeutic agenda. In addition to providing the patients with understanding and empathy, this approach also calls patients' attention to the fact that substance abuse is an important cause of their general malaise in life. This may further motivate patients to consider the cessation of substance abuse as a major goal of treatment.

Acknowledge the Patient's Ambivalence

Anecdotally, some drug-abusing patients report that they doubt (at least early on) that therapists who have not had drug problems themselves can truly understand their patients' plights. However, upon further questioning, it typically becomes apparent that this misconception arises when the patients perceive that their therapists take the view that, "Of course you want to quit using drugs. You have everything to gain and nothing to lose by becoming clean and sober." Patients then conclude that their therapists don't understand the power and allure of drugs such as cocaine. Therefore, it is advisable for therapists to admit that cocaine is a difficult drug to relinquish, and that it would be reasonable and understandable for the patients to have a sense of grief about having to give up the drug (Jennings 1991). By acknowledging and asking about the patients' ambivalence, therapists communicate more accurate empathy, and open up a vital area of discussion that patient’s otherwise might believe it best to conceal.

In fact, one of the standard techniques in the repertoire of the cognitive therapist depends on the therapist's awareness of the patient's mixed emotions and attitudes—the advantages/disadvantages analysis (Beck et al. 1993). Here, therapist and patient explore the pros and cons of both using and not using drugs. Many patients express pleasant surprise that their therapists really are willing to discuss the pros of continuing to abuse drugs. Although the ultimate goal obviously is to strengthen the patients' resolve, know-how, and commitment to be drug free, an exploration of the seductive aspects of drug use can help the formation of a trusting, collaborative therapeutic relationship.

Explore the Purpose and Goals of Treatment

Cognitive therapy contains a significant psycho-educational component (Beck et al. 1979). A long-term goal of treatment is to empower the patient to increase a sense of self-efficacy and to teach the patient to become his or her own therapist. One way to achieve this goal is to make the patient a full partner in charting the course of therapy. This entails discussing the purpose of meeting with the therapist, the goals of treatment, and the types of methods that will be used to achieve these goals. By exploring the purpose and goals of treatment, therapists take some of the mystery out of the process of change, and minimize the chances that mistrustful patients will view their therapists as playing mind games or being on power trips. If the therapist and patient determine that their respective goals are at odds, at least the problem will be on the table, and not a conflict of hidden agendas. They can then agree to find some common ground, and work toward shared goals until the thornier issues can be discussed and explored at greater length. Therapists can stress that the process of change requires teamwork, and that the therapist and patient are not adversaries.

Discuss the Issue of Confidentiality

Because illicit drug use is by definition illegal behavior, patients have learned to be very cautious in what they will divulge about their activities. Thus they often are highly motivated to be dishonest in reporting their substance abuse. Although the vast majority of therapeutic interactions represent privileged communications, drug abusing patients may not understand or trust the extent to which their admissions of drug use will be kept confidential.

To facilitate more open communication and mutual trust, therapists should spell out the nature and limits of confidentiality from the very start. Patients may not be pleased to hear about the limits, but they will appreciate the explanation and the warning. Therapists will need to emphasize that their primary role is to help patients confront their drug use and improve the quality of their lives; therapists do not serve as society's watchdog, or punish, or oppress.

Avoid Judgmental Comments

A longstanding and well-known fact is that it is important for the therapist to communicate a sense of positive regard and respect for the patient (e.g., Bergin and Solomon 1970; Egan 1975; Truax 1963; Truax and Carkhuff 1967; Truax and Mitchell 1971). Nevertheless, it is all too easy for the therapist to fall into the trap of sounding accusatory and judgmental toward a patient who is abusing drugs. If this happens, the formation of a healthy therapeutic relationship is seriously hindered. Further, the patient may become less inclined to view the therapist as an effective professional when the therapist's comments resemble those heard from exasperated relatives.

Instead, therapists need to explain that they wish to ally with their patients in a mutual struggle against the patients' drug use and concomitant life problems. Patients need to be helped to understand that they are not viewed as bad people, but rather as people with a highly troublesome habit with which to deal. Similarly, therapists need to take care not to spew forth judgmental or hostile comments about anybody else. For example, when a therapist treats substance-abusing patient who is involved in a romantic relation-ship with another substance abuser, there is a great temptation for the therapist to criticize the significant other, especially when the significant other sabotages the patient's progress toward abstinence. However, by doing this the therapist runs the risk of triangulating the patient between the loved one and the therapist (in essence, putting the patient in the position of having to take sides). When this happens, patients frequently choose to be loyal to the significant other, which may precipitate a flight from treatment. Even if the therapist makes judgmental comments about impersonal third parties, the patient may wonder whether this is also how the therapist truly feels about the patient when he or she is not around. This will impede the formation and maintenance of a positive therapeutic alliance. It is much more prudent to evaluate the relative merits and drawbacks of the behaviors and attitudes of people, rather than make pat statements about their characters.

Appeal to the Patient's Areas of Positive Self-Esteem

Although substance-abusing patients typically present with a host of problems, including chaotic lifestyles and skills deficits, it is important for therapists to assess their patients' areas of strength and competence. By doing so, therapists show that they have respect for their patients' individual talents and assets. Further, they can appeal to areas in which the patients feel a sense of pride, thereby eliciting greater cooperation in other therapy tasks.

For example, Walter (all names have been changed) was a patient who was very mistrustful of authority figures, and his collaboration in the process of therapy at the start of treatment was tenuous at best. Although he seemed to be quite hostile and resistant, he did prove himself to be rather intelligent (in spite of his limited education). When Walter would engage in high-risk behaviors (e.g., drive while intoxicated), the therapist would appeal to the patient's intelligence to get him to reconsider this maladaptive behavior. For example, the therapist would say: "Walt, you and I have discussed how you have survived to this point, mainly due to your smarts. You seem to be someone who thinks fast under pressure. That's why I'm so perplexed that you would risk your safety and freedom by driving drunk. It just doesn't seem to fit. What's your opinion about all of this? I'm interested to hear your views."

Aside from noting the patients' intelligence, therapists can encourage patients to collaborate in the work of therapy by focusing on other attributes such as their survival skills, the love of their friends and family, their spirituality, their integrity, their potential abilities to be positive role models for others, their advanced vocational skills (when sober), and other legitimate personal attributes.

Acknowledge That Therapy Is Difficult

Therapists can help to build rapport with their patients by noting that it takes courage and hard work to participate fully in therapy. This stance can help to counteract patients' beliefs that it is a sign of weakness and incompetence to be in treatment. In essence, the therapist tries to help the patient to take the shame out of being a patient. Additionally, by establishing the baseline notion that therapy will be difficult, the therapist reduces the chance that a patient will bail out of treatment at the first sign of discomfort.

The therapist can liken the pain of going through therapy to the pain of receiving medical treatment for a wound or a broken bone. Although the procedures hurt, they enable the patient to heal and to be strong. The adage, "If it hurts, you know the medicine is working," is appropriate in this regard. By contrast, if the patient comes to learn that he or she actually enjoys and looks forward to therapy sessions, it will seem like a bonus benefit.

Ask Open-Ended Questions, Then Be a Good Listener

One of the defining features of cognitive therapy is the spirit of collaboration that the therapist attempts to foster in working with the patient (Beck et al. 1979). A central method for enhancing an atmosphere of collaboration is to encourage the patient to actively talk and think aloud in the session, and for the therapist to listen carefully and reflect accurately. Additionally, it is important to add structure to this process by asking clinically relevant questions that allow the patient to expound his or her feelings and thoughts.

Open-ended questions serve this purpose well.

A common trap to avoid is lecturing the patients and/or bombarding them with yes/no questions that are reminiscent of interrogation. It is much more collaborative to employ a Socratic style (Overholser 1987, 1988, 1993) in which the therapist gently guides the direction of the session material by punctuating the patients' comments with thoughtful, open-ended questions. The following short dialog serves as an example.

Therapist: I see on your responses to the questionnaires that you haven't used any drugs or alcohol since our last session. What do you think has helped you to do this?

Patient: I don't go past that house no more.

Therapist: The crack house?

Patient: Yeah.

Therapist: What do you say to yourself—how do you manage to keep yourself from going to that house?

Patient: I just remind myself that my life falls apart whenever I start to go there. I just remind myself that I'm kidding myself if I think I can just stop in and say "hi" and shoot the breeze and then just go home. It doesn't work that way. I just have to stay away.

Therapist: So you remember the problems that you had when you used to go there, and how your life changes for the worse when you use drugs.

Patient: That about sums it up. (Frowns)

Therapist: You looked a little sad just then. What went through your mind?

Patient: Ahhh. I don't know. (Pause) It's a lonely feeling.

I got friends who hang out at the house, and I can't see them no more.

Note that in the example above, the therapist gets a lot of useful information from the patient by asking open-ended questions and by carefully listening to the patient's responses. A good rapport seems to be present in the interaction, with the patient implicitly acknowledging that the therapist understands.


It is often difficult to establish rapport and a collaborative working set with substance-abusing patients; moreover, it is very easy to lose that rapport once it is there. Therefore, even when things seem to be going smoothly in the therapeutic relationship, the therapist must be vigilant in consistently doing what is necessary to maintain the positive feelings between therapist and patient.

The following are some general principles that therapists can employ throughout treatment to preserve a productive and healthy therapeutic alliance.

1. Ask patients for feedback about every session.

2. Be attentive. Remember details about the patients from session to session.

3. Use imagery and metaphors that the patients will find personally relevant.

4. Be consistent, dependable, and available.

5. Be trustworthy, even when the patient is not.

6. Remain calm and cool in session, even if the patient is not.

7. Be confident, but be humble.

8. Set limits in a respectful manner.

Ask Patients for Feedback About Every Session

The best cure for a damaged therapeutic relationship is prevention. One of the easiest and most reliable methods for avoiding misunderstandings between the therapist and patient is for the therapist to check on what the patient perceives and feels about the session. This can be done during the course of the session (e.g., "What do you think about what I've been saying so far today?") and/or at the completion of the session (e.g., "How do you feel about today's session? Is there anything I said that rubbed you the wrong way?") If the patient states that he or she is disgruntled, or demonstrates nonverbal reactions that seem to indicate discomfort (e.g., sighing, reticence), the therapist can address this immediately, providing a heavy dose of non-defensive empathy along the way.

For example, one patient misconstrued the therapist's discussion of high-risk situations as an attempt to plant the idea into the patient's head that he was going to succumb to his urges. Once the therapist asked for feedback and ascertained that the patient thought the therapist was trying to sabotage the patient's sobriety, the therapist was able to explain his actual intentions, which were to educate and help the patient. For good measure, the therapist apologized for not being clear.

It is important for the therapist not to assume that everything is okay in the therapeutic relationship just because the patient hasn't openly complained. Patients who have mistrust issues and/or live in dangerous neighborhoods often conceal their negative feelings extremely well. They adopt a "street smile" that hides both their vulnerability and their desire to strike back without warning.

Therefore, the therapist should make an effort to ask for feedback on a regular basis, as both a preventive and a reparative measure.

Be Attentive. Remember Details About the Patients From Session to Session

Although this point may be common sense in theory, it is not always easy to enact in practice. For example, some drug-abusing patients may use slang terms the therapist doesn’t know. If the therapist doesn't ask for clarification, he or she may miss important information. This may further lead the patient to think that the therapist didn't care to understand, rather than that the therapist wasn't able to understand, and the therapeutic rapport may be harmed. To accurately conceptualize the patient's life situation, the therapist must be able to mentally accumulate information about the patient from week to week. In this way, understanding increases. A simple, tried-and-true method to enhance this process is to take thorough, prompt therapy notes about every contact with the patient, and to review these notes religiously before each new session.

Use Imagery and Metaphors That the Patients Will Find Personally Relevant

Once the therapist facilitates the establishment of rapport by speaking "directly, simply, and honestly" (see first item, previous section), he or she can facilitate more sophisticated understanding by using images and metaphors to communicate important but complex points.

For example, a therapist wanted to discuss the patient's tendency to isolate himself from others, including those who purported to love him and to want to help him. The therapist conceptualized the patient's problem in terms of the patient's fear that he would inevitably hurt anyone who got close to him. Further, the patient saw himself as being very attractive and powerful, thus making his efforts to isolate himself from would-be admirers all the more difficult.

The therapist used the following metaphor in order to explain this formulation, while also appealing to the patient's narcissism: "Joe, you're like a shiny new Porsche with no brakes. You're coming down the road looking as cool and swift as you can be, and everyone wants to come up close to you to get a better look. Meanwhile, you know that you have no brakes. Therefore, you're afraid if that people get too close, you're going to run them down, and you're not sure you can live with yourself if that happens, so you drive away from everybody.

Joe, I think we need to get you some brakes. What do you think?"

Then the therapist elicited feedback from the patient, who said he felt both understood and complimented. This facilitated the continued discussion of the important issue above.

Be Consistent, Dependable, and Available

Therapists typically do not earn their drug-abusing patients' trust through sudden, dramatic gestures. Rather, trust is gained through the therapist's consistent professionalism, honesty, and well-meaning actions over a long period of time.

Although drug-abusing patients often may arrive late for sessions, fail to show up at all, and otherwise demonstrate the lack of a serious involvement in the process of treatment, therapists (by contrast) need to demonstrate a steady commitment to helping these patients.

Therefore, it is very important for therapists to arrive on time for their appointments, even in cases when the patients habitually come late. In like manner, it is important for therapists to be available for therapy sessions on as regular a basis as possible (and to make sensible alternative arrangements if necessary), to return their patients' phone calls promptly, and to be reachable in cases of emergency

Another more powerful way that therapists can establish that they are well grounded and dependable centering points in their patients' lives is to unfailingly pursue patients who do not show up for their sessions.

If the therapist establishes a pattern whereby he or she will almost always telephone a patient within hours of their missing a session, the therapist communicates a concern that goes beyond words. Along these same lines, it is advisable for therapists to be willing to continue to treat a drug-abusing patient when he or she returns after a drug lapse or other problematic hiatus from therapy. This strategy provides the most realistic means by which to treat a disorder whose course is often recurrent. Further, it provides a sense of hope for patients who otherwise might believe that they have burned their bridges with all benevolent and helpful others. Therefore, they may be more apt to return to treatment voluntarily and more quickly following future lapses.

Be Trustworthy, Even When the Patient Is Not

As explained above, therapists must demand a higher standard of behavior from themselves than they can expect from their substance abusing patients. Patients who act and think in combative, passive aggressive, and/or mistrustful ways in their everyday life often expect that others will treat them in like fashion. Therefore, it is a corrective experience for patients when they realize that their therapists will continue to demonstrate honesty and concern, even when the patients themselves have been less than friendly or truthful in return.

As difficult as it is to gain the trust of the substance-abusing patient, it can be impaired or lost quickly and with relatively little provocation. Therefore, the therapeutic relationship must be managed in a delicate, pains-taking fashion. In the process of accomplishing this goal, therapists must recognize their own anger when patients lie to them, and must strive to keep such feelings in check. Instead, therapists need to find a diplomatic way to address the "apparent inconsistencies" in what the patients say and do, and to remain nonjudgmental (Beck et al. 1993).

Remain Calm and Cool in Session, Even If the Patient Is Not

When a patient becomes hostile, loud, intransigent, and/or verbally abusive, it does little good for the therapist to respond in kind (Beck et al. 1993). To deescalate a potentially dangerous situation, the therapist must stay calm, non-defensive, and matter-of-fact. It is important at such times for the therapist to express a genuine concern for the patient's well-being and best interests.

When the therapist and patient are at odds, it is extremely helpful for the therapist to call attention to their areas of agreement and collaboration. This helps to remind that patient that a single conflict with the therapist does not mean that the entire therapeutic endeavor is adversarial. Although a certain degree of confrontation between the therapist and the drug-abusing patient is almost inevitable during the course of treatment (Frances and Miller 1991), the therapist can minimize damage to the therapeutic relationship by calmly communicating a tone of respect and concern (Newman 1988).

Be Confident, But Be Humble

One of the most fundamental ways to help patients gain confidence and hope about the process of therapy is for therapists to show confidence in themselves. This involves such behavioral components as clarity of voice, relaxed posture, non-defensiveness, and an energetic optimism.

However, the therapist does not need to go to extremes to demonstrate confidence. In fact, it is actually ill-advised for therapists to portray themselves as omnipotent and/or omniscient. A certain degree of humility is necessary to create and sustain an atmosphere of collaboration and mutual respect.

For example, therapists must be willing to admit that they do not know (or were wrong about) something, if appropriate, rather than try to fake their way through. For example, one patient repeatedly referred to a "Reverend Percy" in his first therapy session. At one point, he asked his therapist, "You're aware of Reverend Percy's work in the community, aren't you?" The therapist, not wanting to seem like he was ignorant about important civic leaders, was tempted to tell a white lie and answer "yes."

Fortunately, the therapist humbly admitted that he hadn't heard of Reverend Percy, but that he was interested in learning more about him. The patient laughed, and stated that it was a good thing that the therapist didn't know Reverend Percy, because "I just made him up!" By showing a willingness to admit that he didn't know something, the therapist passed the patient's rather clever but devious test. Therefore, the therapist preserved his credibility.

Another way therapists can demonstrate humble confidence is to apologize at times. Therapists can do this in response to misunderstandings or minor errors, such as a miscommunication about the exact date and time of a scheduled session, or a harsh sounding comment (e.g., "I'm sorry if my last statement sounded rather hard on you. Really, I'm on your side, but perhaps I got a little carried away just then because I was very concerned about you.").

The therapist communicates confidence by showing that he or she is not afraid to admit to a mistake, and that he or she is still optimistic about the course of therapy.

Set Limits in a Respectful Manner

While it is important that therapists work collaboratively with their substance-abusing patients, they must take care not to become so permissive that patients will know that they can take advantage of their therapists' good will. Limits must be set (Ellis 1985; Ellis et al. 1988; Moorey 1989)—for example, that a therapy session will not be held if the patient is intoxicated.

Therapists should establish ground rules during the first session so there will be no confusion or ambiguity later on. Therapists can set limits without sabotaging the therapeutic relationship if they adopt a respectful tone and emphasize their commitment to help patients with their problems (Newman 1988, 1990).

For example, Beck and colleagues (1993) describe the case of a patient who arrived intoxicated for a therapy session. The therapist asked the patient if he had been drinking, and the patient acknowledged that he had. The therapist thanked the patient for his honesty and then suggested that the session be postponed. When the patient protested, the therapist calmly stated, "We made an agreement that we would meet only when you were sober and able to fully absorb the benefits of the session, and I think we should stick to our agreements." The therapist went further to point out the advantages of the patient's remaining in the waiting room for a couple of hours until it was safe for him to drive home. The patient was a bit disgruntled, but was mollified when the therapist gave him a newspaper to read to keep him occupied.

The lesson to be learned from the above vignette is to set limits, but be neither critical nor controlling. Emphasize that the patient's welfare is the primary concern, and that the therapeutic alliance is still active and strong in spite of the disagreement. Then, follow through.


Therapists who are most adept at accurately understanding their patients have the best chance of establishing and preserving positive alliances with their patients. In this sense, a good case formulation goes a long way toward helping the therapist and patient maximize their collaborative effort.

When conflicts arise between a therapist and a patient, and/or when unexpressed but problematic ill feelings exist in the therapeutic relationship, the therapist can explore aspects of the case conceptualization to make sense of the interpersonal tensions in session. Oftentimes, this strategy will not only shed light on the reasons for the problems in the therapeutic relationship, but will advance an overall understanding of the patient's life issues. As a result, important material is revealed, the patient feels better understood, and the therapeutic alliance is strengthened.

The following are some general guides for using the case conceptualities in the service of improving the therapeutic relationship.

1. Strive to understand the pain and fear behind the patient's hostility and resistance.

2. Explore the meaning and function of the patient's seemingly oppositional or self-defeating actions.

3. Assess the patient's beliefs about therapy.

4. Assess your own beliefs about the patient.

5. Collaboratively utilize unpleasant feelings in the therapeutic relationship as grist for the mill.

Strive To Understand the Pain and Fear Behind the Patient's

Hostility and Resistance

Although the therapist may believe that change is a good thing, clients may have misgivings. Many patients, especially those with serious, longstanding disorders, cling tenaciously to the status quo in their lives, because to some extent it is familiar and safe (Beck et al. 1990; Layden et al. 1993; Newman 1994a; Young 1990). For many patients, it is frightening and disorienting to change patterns of cognition, affect, and behavior that they have long associated with their very identity. Additionally, many patients believe that significant change is untenable, due to further difficulties that they expect would arise.

For example, Ed and his therapist agreed that prostitutes were a high risk stimulus for him. Whenever he would encounter a prostitute who liked to get high, he was vulnerable to seeking out drugs with which to pay the woman. Then, they would have sex and smoke crack cocaine together. In spite of this understanding, Ed still frequented prostitutes and used drugs. At first, this exasperated the therapist, who thought that Ed was deliberately sabotaging therapy because of an opposition to change. However, when the therapist probed for Ed's fears about giving up this maladaptive pattern, Ed was able to articulate that he felt he had nothing to offer a straight woman. He believed that because he was unemployed and not very handsome, his only means of finding female companionship would be in the context of drug use with a prostitute. In other words, underlying Ed's apparent resistance was a fear of being alone. This understanding helped the therapist to express empathy, and to encourage Ed to actively challenge the belief that he would be alone if he gave up drugs. When patients become overtly angry in session, therapists can cope with this situation best by trying to provide empathy, and by reminding them-selves that no matter how aversive this situation is for therapists, the patients almost always feel worse. This stance helps therapists to decatastrophize the situation, and to keep the therapists' attention squarely on the patients' needs.

For example, one therapist defused a patient's hostile outburst by asking, "Do you feel I've let you down in some way?" Another therapist achieved the same end by saying, "I'm sorry if what I've said or done has upset you. That wasn't my intention. How did what I said hurt your feelings?" Yet another example is the therapist who "normalized" his patient's angry refusal to answer the therapist's questions by stating, "I can see that you're only trying to protect yourself. That's okay. Everybody has the right to do that."

Explore the Meaning and Function of the Patient's Seemingly

Oppositional or Self-Defeating Actions

When substance-abusing patients do not appear optimally connected with the therapist or engaged in the process of therapy, it is useful to explore the factors that seem to make it in the patient’s best interest to oppose the therapist.

Therapists can address this issue head on by noting that there are both advantages and disadvantages to changing one's behavior, and that it might be interesting to look at the pros and cons of attending therapy, as well as the pros and cons of using or abstaining from drugs.

Therapeutic collaboration is facilitated when therapists show that they are willing to look at the cons of change (Grilo 1993). Patients then become more apt to cooperate in the exercise of reviewing the long-term costs involved in not changing. Thus, patient receptivity to change is enhanced. Rita's behavior at the start of therapy was quite contentious. She contradicted or made sarcastic remarks about much of what the therapist would say. After experiencing much frustration and consternation, the therapist finally said: "Rita, given that you frequently disagree with me, my first guess would be that you don't like to meet with me—and yet, you always come to your sessions.

What are you getting out of these sessions? How is therapy meeting your needs, given that we seem to be at odds so often?" Rita didn't know what to make of this at first. Upon further reflection, however, she admitted that she gained a sense of power out of being able to intellectually spar with the therapist. In her view, it would take the fun out of therapy if she agreed with her therapist.

This admission led to a fruitful discussion of power, control, and counter-control in relationships.

Assess the Patient's Beliefs About Therapy

An assessment of how patients idiosyncratically interpret various situations is part and parcel of the process of case conceptualization in cognitive therapy (Persons 1989). One such situation is therapy itself. Some patients expect that therapy will be an adversarial process, especially when they perceive their therapists to be from a more privileged socio-economic background. Here, they may perceive their therapists to be agents of the system who will continue to oppress them. Naturally, this viewpoint is laden with mistrust, and will need to be addressed in order for treatment to proceed in a collaborative and amicable fashion.

Another problematic belief about therapy to which some drug-abusing patients subscribe is that the process should always feel good. This belief ignores the fact that taking part in treatment is hard work, and often involves the discussion of emotionally painful issues. If this belief is not assessed and unaddressed, a patient may bolt from therapy at the first sign of discomfort, perhaps before a positive therapeutic alliance can even be established.

Yet another maladaptive cognitive stance that some patients adopt is that therapists cannot be of any help unless they have gone through the problem of substance abuse in their lives too. Therefore, instead of looking at their therapists as positive role models who have the personal and technical skills to help the patients with their problems, patients may discount the therapists' comments and reject their help because "they just don't understand."

Therapists need to be aware of some of these (and other) dysfunctional presuppositions that drug-abusing patients sometimes have about therapy and therapists. Towards that end, it is extremely useful in the first session for therapists to ask two series of questions, one during the early stages of the session and the other at the end of the session.

The first question is: "What are your thoughts about coming in to meet with me today? I'm not sure whether you feel good or bad about seeing me, and I'm not sure what your expectations or hopes about treatment are. But I'd like to know, if you're willing to share your thoughts with me."

The second question is: "What are your impressions about how things went in today's session? Was there anything that I said that you didn't like or didn't agree with? Was there anything about today's session that was particularly helpful? What should we make sure we continue to talk about in our next session in order to get the most out of being here?"

Assess Your Own Beliefs About the Patient

Therapists are human beings, and therefore are subject to their own dysfunctional beliefs at times. This is most problematic when the therapist's maladaptive beliefs center on their patient’s, and the therapist fails to take stock of these beliefs. Some of the more commonly encountered therapist beliefs (cf. Beck et al. 1993) include:

• "This patient is a loser."

• "This patient is beyond help."

• "This patient will never listen to me."

• "Why can't I reach this patient? What am I doing wrong?”

I'm going to have to give up on working with this patient."

• "You can't be collaborative with this type of patient. If you give them an inch, they'll take a mile. Therefore, I will not budge from my position one iota."

• "This case is more trouble and responsibility than I can bear."

When therapists find themselves having such thoughts, it presents them with an excellent opportunity to use cognitive therapy techniques on themselves (Newman 1994b). This strategy can help therapists moderate their own hopelessness and frustration enough to still be able to provide good will and an earnest effort. The end result is that the therapeutic relationship will continue to have a positive effect on the process of treatment, rather than being a hindrance. Additionally, the therapist will have gained a deeper understanding of the nature of the patient's typical interpersonal difficulties in everyday life.

The following is a sampling of rational response flashcards that therapists can personally develop to help them modify counterproductive beliefs about drugabusing patients (cf. Beck et al. 1993):

• "There have been a number of sessions in which the patient and I have worked very well together. Those were rewarding experiences that I must not forget."

• "Let me try to understand my patient's resistant thoughts and behaviors, rather than simply label her a troublemaker."

• "This power struggle is a great opportunity to get at some really hot interpersonal cognitions!"

• "If I keep my cool, present my point of view calmly, and also show that I'm willing to be flexible within reason, I'll probably get a lot more therapeutic mileage out of this conflict than I will if I become strident or stubborn."

Collaboratively Utilize Unpleasant Feelings in the Therapeutic Relationship as Grist for the Mill

Tension and conflict between a patient and therapist need not be gratuitously disruptive to the process of therapy. In fact, if handled skillfully, such episodes can shed light on the patient's negative beliefs and actions regarding interpersonal relationships (cf. Layden et al. 1993). This information, in turn, can be used to help the patient make important discoveries, and can inspire him or her to experiment with new adaptive behaviors.

For example, a therapist noticed that the patient was looking glum, not making eye contact, and sounding a little sarcastic. To explore the meaning of this behavior, the therapist forthrightly said, "Things seem a little tense between you and me today. Did you notice that?" This led to the patient's becoming uncharacteristically silent; therefore the therapist knew that she had hit home. She added, "Can we talk about it? If something is wrong I'd like to try to work it out, if that's okay with you."

Upon further discussion, the patient stated that the group therapy leader (in another setting, though still part of the patient's treatment package) had said something that "he could only have known if he spoke to you." In other words, the patient thought that his individual therapist was saying things about him behind his back to the group therapy counselor. This, in fact, was not the case at all.

The therapist and patient discussed all the possible alternatives to his mistrustful point of view, including the possibility that the group counselor and individual therapist were independently reaching similar clinical judgments about the patient. The therapist added that she would certainly talk to the patient directly about the prospect of sharing information with the group counselor if the need arose. Then she demonstrated empathy for the patient, stating, "It must have been difficult for you, thinking that I betrayed your trust. I can imagine how disillusioned you must have felt. I'm glad we can set the record straight, because I have enjoyed working with you, and things seemed to be going well until this misunderstanding."

Furthermore, this episode became grist for the mill in that it highlighted one of the patient's characteristic patterns—namely, to jump to conclusions about the ill motives of another person, and then to keep these suspicions to himself. This would then prevent the possibility of talking things out and resolving or clarifying the matter with the other person and the relationship would deteriorate. It was little wonder that the patient felt he had so few friends, and believed that he could never depend on anyone. Because the therapist succeeded in uncovering the nature of the rupture in the therapeutic relationship, the patient-therapist alliance was preserved, and an important aspect of the patient's dysfunction became a clinical topic for the session.


The treatment of substance-abusing patients poses a great set of challenges to therapists. One of the most fundamental and vital of these is the establishment and maintenance of a positive therapeutic relationship. If therapists succeed in communicating a spirit of acceptance, collaboration, respect, good will, and optimism to their drug-abusing patients, the process of treatment will be enhanced. If, by contrast, these goals are not achieved, the likelihood of the patients' demonstrating spotty attendance, poor punctuality, and premature termination will increase, thus diminishing the prospects that therapy will have an appreciable effect.

Therapists can facilitate the formation and maintenance of a positive therapeutic alliance with drug-abusing patients by consistently adhering to principles that are part and parcel of a cognitive therapy approach. Such principles include working with the patient as a team, giving clinical rationales in a clear fashion, eliciting feedback from the patient, exploring the belief systems of the patient, being aware of one's own belief systems and how they may impinge on the therapeutic process, and utilizing the case conceptualization and other strategies that require a thoughtful, empathic, and pragmatic approach.

Chronic Disease Management

Recognizing that substance abuse is a chronic disorder similar to diabetes, hypertension, and asthma led the panel to question the acute care model of service delivery that has characterized substance abuse treatment for the past 50 years (McLellan et al. 2000). Panel members felt strongly that IOT providers—like providers in the rest of the health care system—should rethink the acute care approach to treating substance use disorders. Increasingly, IOT programs are involved in substance abuse treatment beyond the initial 4 to 12 weeks. Much of the discussion in this volume is devoted to continuing care and to finding ways to include case management service providers, families, communities, and mutual-help groups in the ongoing care of individuals with substance use disorders.

Practice-Research Collaboration In the past decade, emphasis on the blending of evidence-based interventions with community-based service delivery has increased. The longstanding divide between practitioners and researchers needed to be bridged. This disparity, described in the Institute of Medicine 1998 report, Bridging the Gap Between Practice and Research, was a major impetus behind the creation of the National Institute on Drug Abuse's (NIDA's) Clinical Trials Network and CSAT's Addiction Technology Transfer Centers and Practice Improvement Centers. Research has resulted in new knowledge about how biochemical processes, learning, spirituality, and environment affect people who abuse substances. These advances may make it easier for clinicians, clients, family members, and the public to understand that substance use disorders are complex illnesses with important biological—as well as social, psychological, and spiritual—dimensions. IOT programs play a central role in translating scientific findings into clinically meaningful information and treatments.

The discussions of treatment and the clinical recommendations in this TIP are informed by the links between practice and research that are becoming the norm in the IOT field.

New Treatment Approaches

A growing interest in evidence-supported interventions has led practitioners to examine long-held assumptions about treatment and the recovery process. Several therapeutic approaches, previously applied primarily in university-based research centers, have begun to emerge as viable and effective interventions that can be implemented successfully in community-based treatment settings. Discussions on cognitive-behavioral interventions, relapse prevention training, motivational enhancement therapy, the use of incentives, and case management approaches have been incorporated into this TIP. Similarly, the TIP describes the benefits of integrating pharmacotherapies into IOT to help manage withdrawal and stabilize people with co-occurring disorders.

Convergence of Systems

Approximately 10 years ago, substance abuse treatment services were viewed widely as specialty services that interacted with a variety of other important stakeholders, such as the mental health, welfare, and criminal justice systems. A profound and important change affecting the delivery of IOT services is the convergence of these previously distinct systems and the substance abuse treatment system. The divisions among services have long been based on administrative convenience and funding streams, not the clinical needs of clients. Programs must be prepared to treat clients who simultaneously may be receiving public welfare, have children in protective services, and be under criminal justice supervision. Each system may place substance abuse treatment requirements on the client, and, as a consequence, these systems can play an important role in supporting the goals of treatment. This TIP addresses the importance of simultaneously working with multiple systems.

Client and Program Diversity

IOT programs serve a greater variety of clients than they did when TIP 8 was published in 1994. The current volume makes a broader and deeper study of how individual differences affect treatment needs. Ten years ago IOT was offered primarily to privately insured clients with mild-to-moderate levels of dysfunction. Since then, IOT programs have adjusted their models to treat adolescents, clients who are homeless or economically disadvantaged, clients with mental disorders, clients involved with the criminal justice system, clients who are disabled, and those with other special needs once considered beyond the scope of IOT programs. Most programs also are responding to the needs of increasingly diverse racial and ethnic client populations. Many IOT programs now incorporate onsite ambulatory detoxification services, medication management, and infectious disease interventions.

Just as the treatment field has yet to settle on a commonly accepted name for itself (e.g., “substance abuse” versus “addiction” versus “substance use disorder” versus “chemical dependence”), there is also no agreed-on term to describe this intensive level of care. Because use of the terms “intensive outpatient treatment” and “intensive outpatient program” (IOP) varies by region, for the sake of consistency, the consensus panel agreed to use the term “intensive outpatient treatment” (“IOT”) to refer to this level of care instead of the equally acceptable term “intensive outpatient program.” Because of the variety of definitions applied by clinicians and researchers to “intensive outpatient treatment,” IOT studies cited in this volume also include day treatment, day hospital treatment, and partial hospitalization programs, in addition to IOT programs.

Outpatient Care vs. Aftercare vs. Continuing Care

The term “aftercare” is avoided throughout this TIP in favor of “continuing care.” Research literature occasionally uses the term “aftercare” when discussing traditional outpatient treatment that follows residential or intensive outpatient treatment. Others use the term “aftercare” when discussing clients' participation in mutual-help groups after formal treatment is completed. In this volume, the term “continuing care” designates the mutual-help groups (including 12-Step and other support groups) available in the community after formal treatment ends. Even during the continuing community care phase or treatment, many clients return to the IOT clinic for occasional followup visits, similar to regular medical checkups for other chronic diseases.

Substance Abuse Treatment vs. Mutual-Help Groups

The distinction between substance abuse treatment programs and mutual-help groups, such as 12-Step support groups, often is misunderstood by managed care organizations and the public. The American Medical Association (1998) has adopted a policy stating that clients with substance use disorders should be treated by qualified professionals and that mutual-help groups should serve as adjuncts to a treatment plan devised within the practice guidelines of the substance abuse treatment field. Likewise, the American Psychiatric Association, American Academy of Addiction Psychiatry, and American Society of Addiction Medicine (ASAM) have issued a joint policy statement that asserts that treatment involves at least the following (American Society of Addiction Medicine 1997):

  • A qualified professional is in charge of treatment.
  • A thorough evaluation is performed to determine the stage and severity of illness and to screen for medical and mental disorders.
  • A treatment plan is developed.
  • The treatment professional or program is accountable for the treatment and for referring the client to additional services, if necessary.
  • The treatment professional or program maintains contact with the client until recovery is completed.

According to the policy statement adopted by these treatment professionals' associations, mutual-help groups are an important component of treatment, but they cannot substitute for substance abuse treatment as outlined above.

What Constitutes IOT?

Although IOT traditionally has consisted of at least 9 hours of treatment per week, usually delivered in three 3-hour sessions, some programs have substantially longer hours and others provide only 6 contact hours per week. The consensus panel agrees that a program that schedules treatment daily, for 6 hours per day, should be considered a partial hospitalization program. But does such a program differ by kind or just by degree from an IOT program? At what point does an IOT service become a partial hospitalization program? Programs in which clients attend sessions 9 hours per week are clearly more intensive than once-a-week outpatient programs. But where does outpatient end and IOT begin? According to ASAM's Patient Placement Criteria, IOT programs provide 9 or more hours of structured programming per week; ASAM does not specify a minimum duration of treatment (Mee-Lee et al. 2001).

This TIP is intended to be equally useful to all IOT programs, regardless of the number of contact hours per week. But for the discussions and guidelines in this TIP to be meaningful, IOT must be delimited. The consensus panel agreed that IOT has the following features:

  • Contact hours per week: 6 to 30
  • Stages: Stepdown and step-up stages of care that vary in intensity and duration
  • Duration: Minimum of 90 days followed by outpatient continuing care
  • Core features and services:
    • Program orientation and intake
    • Comprehensive biopsychosocial assessment
    • Individual treatment planning
    • Group counseling
    • Individual counseling
    • Family counseling
    • Psychoeducational programming
    • Case management
    • Integration of clients into mutual-help and community-based support groups
    • 24-hour crisis coverage
    • Medical treatment
    • Substance use screening and monitoring (urine or breath tests)
    • Vocational and educational services
    • Psychiatric evaluation and psychotherapy
    • Medication management
    • Transition management and discharge planning
  • Enhanced services:
    • Adult education
    • Transportation
    • Housing and food
    • Recreational activities
    • Adjunctive therapies
    • Nicotine cessation treatment
    • Child care
    • Parent skills training

Chapter 2—Principles of Intensive Outpatient Treatment presents 14 guiding principles of IOT and the research that supports them. The principles combine the findings of substance abuse research with the experiences of practiced clinicians. The principles are drawn from NIDA's Principles of Drug Addiction Treatment (National Institute on Drug Abuse 1999), but the chapter focuses on issues that are critical to effective delivery of IOT services.

Chapter 3—Intensive Outpatient Treatment and the Continuum of Care places IOT within a broad substance abuse treatment continuum that includes outpatient treatment and continuing community care. This chapter situates IOT within the framework of ASAM's levels of care and discusses goals, intensity and duration of treatment, treatment setting, and stages for Level I and Level II care. The chapter discusses IOT as both an entry point for substance abuse treatment and a stepdown or step-up level of care for clients and addresses the importance of transitioning clients to continuing community care.

Chapter 4—Services in Intensive Outpatient Treatment Programs describes the core services a program should provide and enhanced services that often are delivered on site or through established links with community-based providers. Core services include group counseling and therapy, individual counseling, psychoeducational programming, pharmacotherapy and medication management, monitoring substance use, case management, 24-hour crisis coverage, induction into community-based support groups, medical treatment, psychiatric screening and therapy, and vocational training and employment services. Enhanced services include adult education, transportation, adjunctive therapies, and parenting classes.

Chapter 5—Treatment Entry and Engagement addresses the complex and critical processes of screening and diagnosis, placement, assessment, and treatment planning. The desired result of these processes is the client's engagement in treatment at the appropriate level of care and the implementation of treatment that addresses his or her needs. This chapter discusses specific steps in the IOT admission process, including engaging and screening the client, assessing barriers to treatment, and attending to crises; it also illustrates them in two case studies.

Chapter 6—Family-Based Services discusses a family systems approach to IOT that acknowledges and supports the important role and influence of family members on treatment outcomes. The chapter includes goals and outcomes of family-based services and strategies for engaging families in treatment. The chapter also describes various types of family services (family education, multifamily groups, family therapy, retreats, support groups) and clinical issues that often arise when including families in treatment, such as unrealistic expectations and sabotage of the client's recovery.

Chapter 7—Clinical Issues, Challenges, and Strategies in Intensive Outpatient Treatment looks at issues and problems that arise in clinical practice and offers solutions grounded in research and clinical experience. The chapter covers client retention, relapse and continued substance use, family members who abuse substances, group work issues, safety and security, client privacy, conflicting mandates, clients who work, and boundary issues.

Chapter 8—Intensive Outpatient Treatment Approaches provides detailed descriptions of established IOT program models and approaches. The chapter describes 12-Step facilitation, cognitive-behavioral, motivational, therapeutic community, Matrix model, and community reinforcement and contingency management approaches. The descriptions address the key aspects, research outcomes, and strengths and challenges of each approach.

Chapter 9—Adapting Intensive Outpatient Treatment for Specific Populations highlights the flexibility and adaptability of the IOT model to meet the diverse needs of specific populations: those involved with the criminal justice system, women, individuals with co-occurring disorders, and adolescents and young adults. The chapter provides a demographic overview of each group and discusses implications for IOT programming as well as clinical issues and strategies to use with each population.

Chapter 10—Addressing Diverse Populations in Intensive Outpatient Treatment examines the importance of cultural competence to substance abuse treatment. Reviewing research that supports the need for individualized treatment, the chapter describes principles for the delivery of culturally competent services and explores topics of special concern: foreign-born clients, women from other cultures, and religious considerations. Sketches of diverse populations include Hispanics/Latinos; African-Americans; Native Americans; Asian Americans and Pacific Islanders; persons with HIV/AIDS; lesbian, gay, and bisexual individuals; persons with physical or cognitive disabilities; rural populations; individuals who are homeless; and older adults. The sketches describe each group's demographic characteristics, statistics on substance use, clinical considerations, and implications for IOT. A chapter appendix contains an extensive list of resources on culturally competent treatment and on treating members of each population.

Group Therapy

The natural propensity of human beings to congregate makes group therapy a powerful therapeutic tool for treating substance abuse, one that is as helpful as individual therapy, and sometimes more successful. One reason for this efficacy is that groups intrinsically have many rewarding benefits—such as reducing isolation and enabling members to witness the recovery of others—and these qualities draw clients into a culture of recovery. Another reason groups work so well is that they are suitable especially for treating problems that commonly accompany substance abuse, such as depression, isolation, and shame.

Although many groups can have therapeutic effects, this TIP concentrates only on groups that have trained leaders and that are designed to promote recovery from substance abuse. Great emphasis is placed on interpersonal process groups, which help clients resolve problems in relating to other people, problems from which they have attempted to flee by means of addictive substances. While this TIP is not intended as a training manual for individuals training to be group therapists, it provides substance abuse counselors with insights and information that can improve their ability to manage the groups they currently lead.

The lives of individuals are shaped, for better or worse, by their experiences in groups. People are born into groups. Throughout life, they join groups. They will influence and be influenced by family, religious, social, and cultural groups that constantly shape behavior, self‐image, and both physical and mental health.

Groups can support individual members in times of pain and trouble, and they can help people grow in ways that are healthy and creative. However, groups also can support deviant behavior or influence an individual to act in ways that are unhealthy or destructive.

Because our need for human contact is biologically determined, we are, from the start, social creatures. This propensity to congregate is a powerful therapeutic tool. Formal therapy groups can be a compelling source of persuasion, stabilization, and support. Groups organized around therapeutic goals can enrich members with insight and guidance; and during times of crisis, groups can comfort and guide people who otherwise might be unhappy or lost. In the hands of a skilled, well‐trained group leader, the potential curative forces inherent in a group can be harnessed and directed to foster healthy attachments, provide positive peer reinforcement, act as a forum for self‐expression, and teach new social skills. In short, group therapy can provide a wide range of therapeutic services, comparable in efficacy to those delivered in individual therapy. In some cases, group therapy can be more beneficial than individual therapy (Scheidlinger 2000; Toseland and Siporin 1986).

Group therapy and addiction treatment are natural allies. One reason is that people who abuse substances often are more likely to remain abstinent and committed to recovery when treatment is provided in groups, apparently because of rewarding and therapeutic forces such as affiliation, confrontation, support, gratification, and identification. This capacity of group therapy to bond patients to treatment is an important asset because the greater the amount, quality, and duration of treatment, the better the client’s prognosis.

The effectiveness of group therapy in the treatment of substance abuse also can be attributed to the nature of addiction and several factors associated with it, including (but not limited to) depression, anxiety, isolation, denial, shame, temporary cognitive impairment, and character pathology (personality disorder, structural deficits, or an uncohesive sense of self). Whether a person abuses substances or not, these problems often respond better to group treatment than to individual therapy (Kanas 1982; Kanas and Barr 1983). Group therapy is also effective because people are fundamentally relational creatures.

Defining Therapeutic Groups in Substance Abuse Treatment

All groups can be therapeutic. Anytime someone becomes emotionally attached to other group members, a group leader, or the group as a whole, the relationship has the potential to influence and change that person. Identifying a group as “therapy” does not imply that other groups are not therapeutic. In preparing this TIP, the consensus panel debated at length what constitutes “group therapy” and what distinguishes therapy groups from other types of groups.

Although many types of groups can have therapeutic elements and effects, the group types included in this TIP are based on the goals and intentions of the groups, as well as the intended audience of the TIP (especially substance abuse treatment counselors and other substance abuse treatment professionals). Thus, this TIP is limited to groups that (1) have trained leaders and (2) intend to produce some type of healing or recovery from substance abuse. This TIP describes (in chapter 2) five models of group therapy currently used in substance abuse treatment:

Psychoeducational groups, which teach about substance abuse. Skills development groups, which hone the skills necessary to break free of addictions.

Cognitive–behavioral groups, which rearrange patterns of thinking and action that lead to addiction. Support groups, which comprise a forum where members can debunk each other’s excuses and support constructive change.

Interpersonal process group psychotherapy (referred to hereafter as “interpersonal process groups” or “therapy groups”), which enable clients to recreate their pasts in the here‐and‐now of group and rethink the relational and other life problems that they have previously fled by means of addictive substances.

Treatment providers routinely use the first four models and various combinations of them. The last is not as widely used, chiefly because of the extensive training required to lead such groups and the long duration of the groups, which demands a high degree of commitment from both providers and clients. All the same, many people enter substance abuse treatment with a long history of failed relationships exacerbated by substance use. In these cases, an extended period of therapy is warranted to resolve the client’s problems with relationships. The reality that extended treatment is not always feasible does not negate its desirability.

This TIP does not discuss multifamily and multi‐couple groups, which are discussed in TIP 39, Substance Abuse Treatment and Family Therapy (Center for Substance Abuse Treatment 2004). Even though multifamily and multicouple groups typically are made up of unrelated groups of families, they focus on family relations as they affect and are affected by a member with a substance use disorder. This TIP concentrates on therapy groups, which have a distinctively different focus.

Also outside the scope of this TIP is the use of peer‐led self‐help groups such as Alcoholics Anonymous (AA) or group activities like social events, religious services, sports, and games. Any or all may have one or more therapeutic effects, but are not specifically designed to achieve that purpose.

Advantages of Group Treatment

Treating adult clients in groups has many advantages, as well as some risks. Any treatment modality—group therapy, individual therapy, family therapy, and medication—can yield poor results if applied indiscriminately or administered by an unskilled or improperly trained therapist. The potential drawbacks of group therapy, however, are no greater than for any other form of treatment.

  • Groups provide positive peer support and pressure to abstain from substances of abuse. Unlike AA, and, to some degree, substance abuse treatment program participation, group therapy, from the very beginning, elicits a commitment by all the group members to attend and to recognize that failure to attend, to be on time, and to treat group time as special disappoints the group and reduces its effectiveness. Therefore, both peer support and pressure for abstinence are strong.
  • Groups reduce the sense of isolation that most people who have substance abuse disorders experience. At the same time, groups can enable participants to identify with others who are struggling with the same issues. Although AA and treatment groups of all types provide these opportunities for sharing, for some people the more formal and deliberate nature of participation in process group therapy increases their feelings of security and enhances their ability to share openly.
  • Groups enable people who abuse substances to witness the recovery of others. From this inspiration, people who are addicted to substances gain hope that they, too, can maintain abstinence. Furthermore, an interpersonal process group, which is of long duration, allows a magnified witnessing of both the changes related to recovery as well as group members’ intra‐ and interpersonal changes.
  • Groups help members learn to cope with their substance abuse and other problems by allowing them to see how others deal with similar problems. Groups can accentuate this process and extend it to include changes in how group members relate to bosses, parents, spouses, siblings, children, and people in general.
  • Groups can provide useful information to clients who are new to recovery. For example, clients can learn how to avoid certain triggers for use, the importance of abstinence as a priority, and how to self‐identify as a person recovering from substance abuse. Group experiences can help deepen these insights. For example, self‐identifying as a person recovering from substance abuse can be a complex process that changes significantly during different stages of treatment and recovery and often reveals the set of traits that makes the system of a person’s self as altogether unique.
  • Groups provide feedback concerning the values and abilities of other group members. This information helps members improve their conceptions of self or modify faulty, distorted conceptions. In terms of process groups in particular, as specific themes emerge in a client’s group experience, repetitive feedback from multiple group members and the therapist can chip away at those faulty or distorted conceptions in slightly different ways until they not only are correctable, but also the very process of correction and change is revealed through the examination of the group processes.
  • Groups offer family‐like experiences. Groups can provide the support and nurturance that may have been lacking in group members’ families of origin. The group also gives members the opportunity to practice healthy ways of interacting with their families.
  • Groups encourage, coach, support, and reinforce as members undertake difficult or anxiety‐provoking tasks.
  • Groups offer members the opportunity to learn or relearn the social skills they need to cope with everyday life instead of resorting to substance abuse. Group members can learn by observing others, being coached by others, and practicing skills in a safe and supportive environment.
  • Groups can effectively confront individual members about substance abuse and other harmful behaviors. Such encounters are possible because groups speak with the combined authority of people who have shared common experiences and common problems. Confrontation often plays a part of substance abuse treatment groups because group members tend to deny their problems. Participating in the confrontation of one group member can help others recognize and defeat their own denial.
  • Groups allow a single treatment professional to help a number of clients at the same time. In addition, as a group develops, each group member eventually becomes acculturated to group norms and can act as a quasi‐therapist himself, thereby ratifying and extending the treatment influence of the group leader.
  • Groups can add needed structure and discipline to the lives of people with substance use disorders, who often enter treatment with their lives in chaos. Therapy groups can establish limitations and consequences, which can help members learn to clarify what is their responsibility and what is not.
  • Groups instill hope, a sense that “If he can make it, so can I.” Process groups can expand this hope to dealing with the full range of what people encounter in life, overcome, or cope with.
  • Groups often support and provide encouragement to one another outside the group setting. For interpersonal process groups, though, outside contacts may or may not be disallowed, depending on the particular group contract or agreements.

Modifying Group Therapy To Treat Substance Abuse

Modifying group therapy to make it applicable to and effective with clients who abuse substances requires three improvements. One is specific training and education for therapists so that they fully understand therapeutic group work and the special characteristics of clients with substance use disorders. The importance of understanding the curative process that occurs in groups cannot be underestimated.

Most substance abuse counselors have responded by adapting skills used in individual therapy. Counselors have also sought direction, clinical training, and practical suggestions. Despite individual efforts, however, group therapy often is conducted as individual therapy in a group.

Individual therapy is not equivalent to group therapy. Some principles that work well with individuals are inappropriate for group therapy. Using the wrong approach may lead to several undesirable results. First, the rich potential of groups—self‐understanding, psychological growth, emotional healing, and true intimacy—will be left unfulfilled. Second, group leaders who are unfamiliar with and insensitive to issues that manifest themselves in group therapy may find themselves in a difficult situation. Third, therapists who think they are doing group therapy when they actually are not may observe the poor results and conclude that group therapy is ineffective. Compounding all these difficulties is the fact that group therapy is so ubiquitous. Thus, poorly conceived approaches are being used frequently.

Group therapy also is not equivalent to 12‐Step program practices. Many therapists who lack full qualifications for group work have adapted practices from AA and other 12‐Step programs for use in therapeutic groups. To say that this borrowing is inadvisable is not to say that the principles of AA are inadequate. On the contrary, many people seem to be unable to recover from dependency without AA or a program similar to it. For this reason, most effective treatment programs make attendance at AA or another 12‐Step program a mandatory part of the treatment process. By the same token, AA and other 12‐Step programs are not group therapy. Rather, they are complementary components to the recovery process. Twelve‐Step programs can help keep the individual who abuses substances abstinent while group therapy provides opportunities for these individuals to understand and explore the emotional and interpersonal conflicts that can contribute to substance abuse.

Progress toward optimal group therapy has also been hindered by the misconception that group therapy with clients who have addictions does not require specially qualified leaders. This notion is false. Therapy groups cannot just take care of themselves. Group therapy, properly conducted, is difficult. One reason that it is challenging has to do with the nature of the clients; an addicted population poses unique problems for the group therapy leader. A second reason is the complexity of group therapy; the leader requires a vast amount of specialized knowledge and skills, including a clear understanding of group process and the stages of development of group dynamics. Such mastery only comes with extended training and experience leading groups.

Many groups led by untrained or poorly trained leaders have not fulfilled their potential and may even have had negative effects on a client’s recovery. It matters little whether the inadequately trained group therapist is a person who once abused substances or someone who developed knowledge in a traditional course of academically based training. Where problems exist, they usually relate to one of two deficiencies: a lack of effective group therapy training or use of a group therapy model that is inadequate for clients who are chemically dependent. Additional training and education is needed to produce therapists who are well qualified to lead therapy groups composed primarily of individuals who are chemically dependent.

A second major improvement needed if people who have addictions are to benefit from group therapy is a clear answer to the question, “Why is group therapy so effective for people with addictions?” We already have part of the answer, and it lies in the individual with addiction, a person whose character style often involves a defensive posture commonly referred to as denial. Addiction is, in fact, frequently referred to as a disease of denial.

The individual who is chemically dependent usually comes into treatment with an uncommonly complex set of defenses and character pathology. Any group leader who intends to help people who have addictions benefit from treatment should have a clear understanding of each group member’s defensive process and character dynamics. More than 20 years ago, John Wallace (1978) wrote about this important issue in an informative essay on the defensive style of the individual who is addicted to alcohol. He referred to these character‐related defensive features as the preferred defense system of the individual addicted to alcohol.

A third major modification needed is the adaptation of the group therapy model to the treatment of substance abuse. The principles of group therapy need to be tailored to meet the realities of treating clients with substance use disorders. For the most part, group therapy has been based on a model derived from outpatient therapy for clients whose problems may or may not include substance abuse. The theoretical underpinnings and practical applications of general group therapy are not always applicable to individuals who abuse substances. Substance abuse treatment sometimes is implemented as a grab bag of strategies, approaches, and techniques that were not tailored for people with substance use disorders. Further, the common characteristics and typical dynamics seen in this population have not always been evaluated adequately, and this lapse has inhibited the development of effective methods of treatment for these clients.

This model suitability problem is further complicated by the fact that clients with substance use disorders, and even staff members, often become confused about the different types of group treatment modalities. For instance, in the course of their treatment, clients may engage in AA, Narcotics Anonymous, other 12‐Step groups, discussion groups, educational groups, continuing care groups, and support groups. Given this mix, clients often become confused about the purpose of group therapy, and the treatment staff sometimes underestimates the impact that group therapy can make on an individual’s recovery.

The upshot of these problems has been partial or complete failure; that is, the techniques and strategies that usually work with the general psychiatric population often do not work with people abusing substances. A further negative result is that the clients who have addictions may be unfairly viewed as poor treatment risks—people resistant to treatment and unmotivated to change.

Time also is an important factor in a person’s recovery. What a group leader does in group therapy with clients in an inpatient setting in a hospital during the first few days or weeks of recovery will differ dramatically from what that same group therapist will do with the same recovering person in a continuing care group 6 months into abstinence with the expectation that the person will remain in the group at least another 6 to 12 months.

Approach of This TIP

While this TIP does not provide the training needed to become an interpersonal process group therapist, the point of view, attitudes, and considerations of these group therapists infuse the discussions throughout this TIP. The panel hopes that this TIP will help counselors expand their awareness and comprehension of dynamics that might be going on in their current substance abuse treatment groups. These insights will help counselors become better prepared to manage their groups and their individual members, inform group members’ individual therapists of possible issues that need resolution, record dynamics and issues for use in treatment during later stages of recovery, and improve retention by appropriately acknowledging issues that are outside the scope of the group. The TIP will achieve its purpose to the extent that it assists counselors as they juggle immediate client needs, interactions in groups, tasks leading to recovery, and sheer human complexity.

Substance Abuse Treatment and Family Therapy

This chapter introduces the changing definition of “family,” the concept of family in the United States, and the family as an ecosystem within the larger context of society. The chapter discusses the evolution of family therapy as a component of substance abuse treatment, outlines primary models of family therapy, and explores this approach from a systems perspective. The chapter also presents the stages of change and levels of recovery from substance abuse. Effectiveness and cost benefits of family therapy are briefly discussed.

The family has a central role to play in the treatment of any health problem, including substance abuse. Family work has become a strong and continuing theme of many treatment approaches, but family therapy is not used to its greatest capacity in substance abuse treatment. A primary challenge remains the broadening of the substance abuse treatment focus from the individual to the family.

The two disciplines, family therapy and substance abuse treatment, bring different perspectives to treatment implementation. In substance abuse treatment, for instance, the client is the identified patient (IP)—the person in the family with the presenting substance abuse problem. In family therapy, the goal of treatment is to meet the needs of all family members. Family therapy addresses the interdependent nature of family relationships and how these relationships serve the IP and other family members for good or ill. The focus of family therapy treatment is to intervene in these complex relational patterns and to alter them in ways that bring about productive change for the entire family. Family therapy rests on the systems perspective. As such, changes in one part of the system can and do produce changes in other parts of the system, and these changes can contribute to either problems or solutions.

It is important to understand the complex role that families can play in substance abuse treatment. They can be a source of help to the treatment process, but they also must manage the consequences of the IP’s addictive behavior. Individual family members are concerned about the IP’s substance abuse, but they also have their own goals and issues. Providing services to the whole family can improve treatment effectiveness.

Meeting the challenge of working together will call for mutual understanding, flexibility, and adjustments among the substance abuse treatment provider, family therapist, and family. This shift will require a stronger focus on the systemic interactions of families. Many divergent practices must be reconciled if family therapy is to be used in substance abuse treatment. For example, the substance abuse counselor typically facilitates treatment goals with the client; thus the goals are individualized, focused mainly on the client. This reduces the opportunity to include the family’s perspective in goal setting, which could facilitate the healing process for the family as a whole.

Working out ways for the two disciplines to collaborate also will require a re‐examination of assumptions common in the two fields. Substance abuse counselors often focus on the individual needs of people with substance use disorders, urging them to take care of themselves. This viewpoint neglects to highlight the impact these changes will have on other people in the family system. When the IP is urged to take care of himself, he often is not prepared for the reactions of other family members to the changes he experiences, and often is unprepared to cope with these reactions. On the other hand, many family therapists have hoped that bringing about positive changes in the family system concurrently might improve the substance use disorder. This view tends to minimize the persistent, sometimes overpowering process of addiction.

Both of these views are consistent with their respective fields, and each has explanatory power, but neither is complete. Addiction is a major force in people with substance abuse problems. Yet, people with substance abuse problems also reside within a powerful context that includes the family system. Therefore, in an integrated substance abuse treatment model based on family therapy, both family functioning and individual functioning play important roles in the change process (Liddle and Hogue 2001).

What Is a Family?

There is no single, immutable definition of family. Different cultures and belief systems influence definitions, and because cultures and beliefs change over time, definitions of family by no means are static. While the definition of family may change according to different circumstances, several broad categories encompass most families:

  • Traditional families, including heterosexual couples (two parents and minor children all living under the same roof), single parents, and families including blood relatives, adoptive families, foster relationships, grandparents raising grandchildren, and stepfamilies.
  • Extended families, which include grandparents, uncles, aunts, cousins, and other relatives.
  • Elected families, which are self‐identified and are joined by choice and not by the usual ties of blood, marriage, and law. For many people, the elected family is more important than the biological family. Examples would include
    • Emancipated youth who choose to live among peers
    • Godparents and other non‐biologically related people who have an emotional tie (i.e., fictive kin)
    • Gay and lesbian couples or groups (and minor children all living under the same roof)

The idea of family implies an enduring involvement on an emotional level. Family members may disperse around the world, but still be connected emotionally and able to contribute to the dynamics of family functioning. In family therapy, geographically distant family members can play an important role in substance abuse treatment and need to be brought into the therapeutic process despite geographical distance.

Families must be distinguished from social support groups such as 12‐Step programs—although for some clients these distinctions may be fuzzy. One distinction is the level of commitment that people have for each other and the duration of that commitment. Another distinction is the source of connection. Families are connected by alliance, but also by blood (usually) and powerful emotional ties (almost always). Support groups, by contrast, are held together by a common goal; for example, 12‐Step programs are purpose‐driven and context‐dependent. The same is true of church communities, which may function in some ways like a family; but similar to self‐help programs, churches have a specific purpose.

For practical purposes, family can be defined according to the individual’s closest emotional connections. In family therapy, clients identify who they think should be included in therapy. The counselor or therapist cannot determine which individuals make up another person’s family. When commencing therapy, the counselor or therapist needs to ask the client, “Who is important to you? What do you consider your family to be?” It is critical to identify people who are important in the person’s life. Anyone who is instrumental in providing support, maintaining the household, providing financial resources, and with whom there is a strong and enduring emotional bond may be considered family for the purposes of therapy (see, for example. No one should be automatically included or excluded.

In some situations, establishing an individual in treatment may require a metaphoric definition of family, such as the family of one’s workplace. As treatment progresses, the idea of family sometimes may be reconfigured, and the notion may change again during continuing care. In other cases, clients will not allow contact with the family, may want the counselor or therapist to see only particular family members, or may exclude some family members.

Brooks and Rice (1997, p. 57) adopt Sargent’s (1983) definition of family as a “group of people with common ties of affection and responsibility who live in proximity to one another.” They expand that definition, though, by pointing out four characteristics of families central to family therapy:

  • Families possess nonsummativity, which means that the family as a whole is greater than—and different from—the sum of its individual members.
  • The behavior of individual members is interrelated through the process of circular causality, which holds that if one family member changes his or her behavior, the others will also change as a consequence, which in turn causes subsequent changes in the member who changed initially. This also demonstrates that it is impossible to know what comes first: substance abuse or behaviors that are called “enabling.”
  • Each family has a pattern of communication traits, which can be verbal or nonverbal, overt or subtle means of expressing emotion, conflict, affection, etc.
  • Families strive to achieve homeostasis, which portrays family systems as self‐regulating with a primary need to maintain balance.
The Concept of Family

In the United States the concept of family has changed during the past two generations. During the latter half of the 20th century in the United States, the proportion of married couples with children shrank—such families made up only 24 percent of all households in 2000 (Fields and Casper 2001). The idea of family has come to signify many familial arrangements, including blended families, divorced single mothers or fathers with children, never‐married women with children, cohabiting heterosexual partners, and gay or lesbian families (Bianchi and Casper 2000).

Some analysts are concerned about indications of increasing stress on families, such as the increasing number of births to single mothers (from 26.6 percent in 1990 to 33 percent in 1999 [U.S. Census Bureau 2001c]). The increase in single‐mother families, which typically have greater per‐person expenses and less earning power, may help to explain why, in the general prosperity of the last half of the 20th century, the percentage of children living in the poorest families almost doubled, rising from 15 to 28 percent (Bianchi and Casper 2000).

Bengtson (2001) asserts that relationships involving three or more generations increasingly are becoming important to individuals and families, that these relationships increasingly are diverse in structure and functions, and that for many Americans, multigenerational bonds are important ties for well‐being and support over the course of their lives.

The Family as an Ecosystem

Substance abuse impairs physical and mental health, and it strains and taxes the agencies that promote physical and mental health. In families with substance abuse, family members often are connected not just to each other but also to any of a number of government agencies, such as social services, criminal justice, or child protective services. The economic toll includes a huge drain on individuals’ employability and other elements of productivity. The social and economic costs are felt in many workplaces and homes.

The ecological perspective on substance abuse views people as nested in various systems. Individuals are nested in families; families are nested in communities. Kaufman (1999) identifies members of the ecosystem of an individual with a substance abuse problem as family, peers (those in recovery as well as those still using), treatment providers, non‐family support sources, the workplace, and the legal system.

The idea of an ecological framework within which substance abuse occurs is consistent with family therapy’s focus on understanding human behavior in terms of other systems in a person’s life. Family therapy approaches human behavior in terms of interactions within and among the subsets of a system. In this view, family members inevitably adapt to the behavior of the person with a substance use disorder. They develop patterns of accommodation and ways of coping with the substance use (e.g., keeping children extraordinarily quiet or not bringing friends home). Family members try to restore homeostasis and maintain family balance. This may be most apparent once abstinence is achieved. For example, when the person abusing substances becomes abstinent, someone else may develop complaints and/or “symptoms.”

Family members may have a stronger desire to move toward overall improved functioning in the family system, thus compelling and even providing leverage for the IP to seek and/or remain in treatment through periods of ambivalence about achieving a sober lifestyle. Alternately, clarifying boundaries between dysfunctional family members—including encouraging IPs to detach from family members who are actively using—can alleviate stress on the IP and create emotional space to focus on the tasks of recovery.

What Is Family Therapy?

Family therapy is a collection of therapeutic approaches that share a belief in family‐level assessment and intervention. A family is a system, and in any system each part is related to all other parts. Consequently, a change in any part of the system will bring about changes in all other parts. Therapy based on this point of view uses the strengths of families to bring about change in a range of diverse problem areas, including substance abuse.

Family therapy in substance abuse treatment has two main purposes. First, it seeks to use the family’s strengths and resources to help find or develop ways to live without substances of abuse. Second, it ameliorates the impact of chemical dependency on both the IP and the family. Frequently, in the process, marshaling the family’s strengths requires the provision of basic support for the family.

In family therapy, the unit of treatment is the family, and/or the individual within the context of the family system. The person abusing substances is regarded as a subsystem within the family unit—the person whose symptoms have severe repercussions throughout the family system. The familial relationships within this subsystem are the points of therapeutic interest and intervention. The therapist facilitates discussions and problemsolving sessions, often with the entire family group or subsets thereof, but sometimes with a single participant, who may or may not be the person with the substance use disorder.

A distinction should be made between family therapy and family‐involved therapy. Family‐involved therapy attempts to educate families about the relationship patterns that typically contribute to the formation and continuation of substance abuse. It differs from family therapy in that the family is not the primary therapeutic grouping, nor is there intervention in the system of family relationships. Most substance abuse treatment centers offer such a family educational approach. It typically is limited to psychoeducation to teach the family about substance abuse, related behaviors, and the behavioral, medical, and psychological consequences of use. Children also need age‐appropriate psychoeducation programs prior to being grouped with other family members in either education or therapy. (For more information see chapter 6, under “Family Education and Participation,” and see also Children’s Program Kit: Supportive Education for Children of Addicted Parents [Substance Abuse and Mental Health Services Administration (SAMHSA) 2003], developed by SAMHSA and the National Association for Children of Alcoholics.)

In addition, programmatic enhancements (such as classes that teach English as a second language) also are not family therapy. Although educational family activities can be therapeutic, they will not correct deeply ingrained, maladaptive relationships.

The following discussions present a brief overview of the evolution of family therapy models and the primary models of family therapy used today as the basis for treatment. Chapter 3 provides more detailed information about these models.

Historical Models of Family Therapy

Marriage and family therapy (MFT) had its origins in the 1950s, adding a systemic focus to previous understandings of the family. Systems theory recognizes that

  • A whole system is more than the sum of its parts.
  • Parts of a system are interconnected.
  • Certain rules determine the functioning of a system.
  • Systems are dynamic, carefully balancing continuity against change.
  • Promoting or guarding against system entropy (i.e., disorder or chaos) is a powerful dynamic in the family system balancing change of the family roles and rules.

The strategic school of family therapy “introduced two of the most powerful insights in all of family therapy: that family members often perpetuate problems by their own actions; and that directives tailored to the needs of a particular family can sometimes bring about sudden and decisive change”.

Based on observations of the relationship between family structure and behavior, along with work with inner‐city children and their families, Minuchin (1974) developed another approach, structural family therapy. Minuchin and Fishman (1981) believed that families use a limited repertoire of self‐perpetuating relational patterns and that family members divide into subsystems with boundaries that regulate family communication and behavior. They sought to shift family boundaries so the boundary between parents and children was clearer. Intervention is aimed at having the parents work more cooperatively together and at reducing the extent to which children assume parental responsibilities within the family.

One major model that emerged during this developmental phase was cognitive–behavioral family and couples therapy. It grew out of the early work in behavioral marital therapy and parenting training, and incorporated concepts developed by Aaron Beck. Beck reasoned that people react according to the ways they think and feel, so changing maladaptive thoughts, attitudes, and beliefs would eliminate dysfunctional patterns and the triggers that set them in motion (Beck 1976). This union of cognitive and behavioral therapies in a family setting was new and useful. The therapist considers not only how people’s thoughts, feelings, and emotions influence their behavior, but also the impact they have on spouses and other family members. Cognitive–behavioral family therapy and behavioral couples therapy are two models that have strong empirical support.

Through the 1980s and 1990s, newer models of MFT were articulated. In response to the problem‐focused strategic and structural family therapies, authors such as de Shazer, Berg, O’Hanlon, and Selkman promulgated solution‐focused family therapy (e.g., Berg and Miller 1992; de Shazer 1988). They asserted that pinpointing the cause of poor functioning is unnecessary and that therapy focused on solutions is sufficient to help families change.

Soon after the introduction of solution‐focused therapy to the MFT landscape, White and Epston’s Narrative Means to Therapeutic Ends 1990 heralded the narrative movement in MFT. This family therapy development has focused on the way people construct meaning and how the construction of meaning affects psychological functioning.

In the early part of the 21st century, MFT seems poised to undergo another change, focused on empirically demonstrating the effectiveness of different approaches to therapy. The few models that have been tested empirically have shown promising results. For example, functional family therapy, multisystemic therapy, multidimensional family therapy, and brief strategic family therapy all have been shown to be highly effective in reducing acting‐out behavior among adolescents and/or in reducing the risk for problem behavior among their younger siblings. Among the couples therapy models known to have reduced marital distress and psychological problems are emotionally focused couples therapy, cognitive–behavioral couples therapy, behavioral couples therapy, integrative couples therapy, and systemic couples therapy. (See chapter 3 for further information.)

Primary Family Therapy Models in Use Today

There are numerous variations on the family therapy theme. Some approaches to family therapy reach out to multiple generations or family groups. Some treat just one person, who may or may not be the IP. Usually, though, family therapy involves a therapist meeting with several family members. An expansive concept of family therapy also might spin off group programs that, for example, could treat the IP’s spouse, children in groups (children do best if they first participate in groups that prepare them for family therapy), or members of a residential treatment setting.

Most family therapy meetings take place in clinics or private practice settings. Home‐based therapy breaks from the traditional clinical setting, reasoning that joining the family where it lives can help overcome shame, stigma, and resistance. It is a return to the practices of social workers who, in the early 20th century, did their work in clients’ homes (Beels 2002). Meeting the family where it lives also provides valuable information about how the family really functions.

Four predominant family therapy models are used as the bases for treatment and specific interventions for substance abuse:

  • The family disease model looks at substance abuse as a disease that affects the entire family. Family members of the people who abuse substances may develop codependence, which causes them to enable the IP’s substance abuse. Limited controlled research evidence is available to support the disease model, but it nonetheless is influential in the treatment community as well as in the general public (McCrady and Epstein 1996).
  • The family systems model is based on the idea that families become organized by their interactions around substance abuse. In adapting to the substance abuse, it is possible for the family to maintain balance, or homeostasis. For example, a man with a substance use disorder may be antagonistic or unable to express feelings unless he is intoxicated. Using the systems approach, a therapist would look for and attempt to change the maladaptive patterns of communication or family role structures that require substance abuse for stability (Steinglass et al. 1987).
  • Cognitive–behavioral approaches are based on the idea that maladaptive behaviors, including substance use and abuse, are reinforced through family interactions. Behaviorally oriented treatment tries to change interactions and target behaviors that trigger substance abuse, to improve communication and problemsolving, and to strengthen coping skills (O’Farrell and Fals‐Stewart 1999).
  • Most recently, multidimensional family therapy (MDFT) has integrated several different techniques with emphasis on the relationships among cognition, affect (emotionality), behavior, and environmental input (Liddle et al. 1992). MDFT is not the only family therapy model to adopt such an approach. Functional family therapy (Alexander and Parsons 1982), multisystemic therapy (Henggeler et al. 1998), and brief strategic family therapy (Szapocznik et al. in press) all adopt similar multidimensional approaches.

Family Therapy in Substance Abuse Treatment

Goals of Family Therapy

The integration of family therapy in substance abuse treatment is still relatively rare. Family therapy in substance abuse treatment helps families become aware of their own needs and provides genuine, enduring healing for people. Family therapy works to shift power to the parental figures in a family and to improve communication. Other goals will vary according to which member of the family is abusing substances. Family therapy can answer questions such as

  • Why should children or adolescents be involved in the treatment of a parent who abuses substances?
  • What impact does a parent abusing substances have on his or her children?
  • How does adolescent substance abuse impact adults?
  • What is the impact of substance abuse on family members who do not abuse substances?

Whether a child or adult is the family member who uses substances, the entire family system needs to change, not just the IP. Family therapy, therefore, helps the family make interpersonal, intrapersonal, and environmental changes affecting the person using alcohol or drugs. It helps the nonusing members to work together more effectively and to define personal goals for therapy beyond a vague notion of improved family functioning. As change takes place, family therapy helps all family members understand what is occurring. This out‐in‐the‐open understanding removes any suspicion that the family is “ganging up” on the person abusing substances.

A major goal of family therapy in substance abuse treatment is prevention––especially keeping substance abuse from moving from one generation to another. Study after study shows that if one person in a family abuses alcohol or drugs, the remaining family members are at increased risk of developing substance abuse problems. The single most potent risk factor of future maladaption, predisposition to substance use, and psychological difficulties is a parent’s substance‐abusing behavior (Johnson and Leff 1999). A “healthy family structure can prevent adolescent substance abuse even in the face of heavy peer pressure to use and abuse drugs” (Kaufman 1990a, p. 51). Further, if the person abusing substances is an adolescent, successful treatment diminishes the likelihood that siblings will abuse substances or commit related offenses (Alexander et al. 2000). Treating adolescent drug abuse also can decrease the likelihood of harmful consequences in adulthood, such as chronic unemployment, continued drug abuse, and criminal behavior.

Therapeutic Factors

Because of the variety of family therapy models, the diverse schools of thought in the field, and the different degrees to which family therapy is implemented, multiple therapeutic factors probably account for the effectiveness of family therapy. Among them might be acceptance from the therapist; improved communication; organizing the family structure; determining accountability; and enhancing impetus for change, which increases the family’s motivation to change its patterns of interaction and frees the family to make changes. Family therapy also views substance abuse in its context, not as an isolated problem, and shares some characteristics with 12‐Step programs, which evoke solidarity, self‐confession, support, self‐esteem, awareness, and smooth re‐entry into the community.

Still another reason that family therapy is effective in substance abuse treatment is that it provides a neutral forum in which family members meet to solve problems. Such a rational venue for expression and negotiation often is missing from the family lives of people with a substance problem. Though their lives are unpredictable and chaotic the substance abuse—the cause of the upheaval and a focal organizing element of family life—is not discussed. If the subject comes up, the tone of the exchange is likely to be accusatory and negative.

In the supportive environment of family therapy, this uneasy silence can be broken in ways that feel emotionally safe. As the therapist brokers, mediates, and restructures conflicts among family members, emotionally charged topics are allowed to come into the open. The therapist helps ensure that every family member is accorded a voice. In the safe environment of therapy, pent‐up feelings such as fear and concern can be expressed, identified, and validated. Often family members are surprised to learn that others share their feelings, and new lines of communication open up. Family members gain a broader and more accurate perspective of what they are experiencing, which can be empowering and may provide enough energy to create positive change. Each of these improvements in family life and coping skills is a highly desirable outcome, whether or not the IP’s drug or alcohol problems are immediately resolved. It is clearly a step forward for the family of a person abusing substances to become a stable, functional environment within which abstinence can be sustained.

To achieve this goal, family therapy facilitates changes in maladaptive interactions within the family system. The therapist looks for unhealthy relational structures (such as parent‐child role reversals) and faulty patterns of communication (such as a limited capacity for negotiation). In contrast to the peripheral role that families usually play in other therapeutic approaches, families are deeply involved in whatever changes are effected. In fact, the majority of changes will take place within the family system, subsequently producing change in the individual abusing substances.

Family therapy is highly applicable across many cultures and religions, and is compatible with their bases of connection and identification, belonging and acceptance. Most cultures value families and view them as important. This preeminence suggests how important it is to include families in treatment. It should be acknowledged, however, that a culture’s high regard for families does not always promote improved family functioning. In cultures that revere families, people may conceal substance abuse within the family because disclosure would lead to stigma and shame.

Additionally, the definition, or lack of definition, of the concept of “rehabilitation” varies greatly across cultural lines. Cultures differ in their views of what people need in order to heal. The identities of individuals who have the moral authority to help (for example, an elder or a minister) can differ from culture to culture. Therapists need to engage aspects of the culture or religion that promote healing and to consider the role that drugs and alcohol play in the culture. (Issues of culture and ethnicity are discussed in detail in chapter 5.)

Effectiveness of Family Therapy

While there are limited studies of the effectiveness of family therapy in the treatment of substance abuse, important trends suggest that family therapy approaches should be considered more frequently in substance abuse treatment. Much of the federally funded research into substance abuse treatment has focused on criminal justice issues, co‐occurring disorders, and individual‐specific treatments. One reason is that research with families is difficult and costly. Ambiguities in definitions of family and family therapy also have made research in these areas difficult. As a result, family therapy has not been the focus of much substance abuse research. However, evidence from the research that has been conducted, including that described below, indicates that substance abuse treatment that includes family therapy works better than substance abuse treatments that do not (Stanton et al. 1982). It increases engagement and retention in treatment, reduces the IP’s drug and alcohol use, improves both family and social functioning, and discourages relapse.

Although the effectiveness of family therapy is documented in a growing body of evidence, integrating family therapy into substance abuse treatment does pose some specific challenges:

  • Family therapy is more complex than nonfamily approaches because more people are involved.
  • Family therapy takes special training and skills beyond those typically required in many substance abuse treatment programs.
  • Relatively little research‐based information is available concerning effectiveness with subsets of the general population, such as women, minority groups, or people with serious psychiatric problems (O’Farrell and Fals‐Stewart 1999).

The balance, however, certainly tips in favor of a family therapy in treating substance abuse. Based on effectiveness data and the consensus panel’s collective experience, the consensus panel recommends that substance abuse treatment agencies and providers consider how they might incorporate family approaches, including age‐appropriate educational support services for their clients’ children, into their programs.

Cost Benefits

Only a few studies have assessed the cost benefits of family therapy or have compared the cost of family therapy to other approaches such as group therapy, individual therapy, or 12‐Step programs. A small but growing body of data, however, has demonstrated the cost benefits of family therapy specifically for substance abuse problems. Family therapy also has appeared to be superior in situations that might in some key respect be similar to substance abuse contexts.

For example, Sexton and Alexander’s work with functional family therapy (so called because it focuses its interventions on family relationships that influence and are influenced by, and thus are functions of, positive and negative behaviors) for youth offenders found that family therapy nearly halved the rate of re‐offending—19.8 percent in the treatment group compared to 36 percent in a control group (Sexton and Alexander 2002). The cost of the family therapy ranged from $700 to $1,000 per family for the 2‐year study period. The average cost of detention for that period was at least $6,000 per youth; the cost of a residential treatment program was at least $13,500. In this instance, the cost benefits of family therapy were clear and compelling (Sexton and Alexander 2002).

Other studies look at the offset factor; that is, the relationship between family therapy and the use of medical care or social costs. Fals‐Stewart et al. (1997) examined social costs incurred by clients (for example, the cost of substance abuse treatment or public assistance) and found that behavioral couples therapy was considerably more cost effective than individual therapy for substance abuse, with a reduction of costs of $6,628 for clients in couples therapy, compared to a $1,904 reduction for clients in individual therapy.

Similar results were noted in a study by the National Working Group on Family‐Based Interventions in Chronic Disease, which found that 6 months after a family‐focused intervention, reimbursement for health services was 50 percent less for the treatment group, compared to a control group. While this study looked at chronic diseases such as heart disease, cancer, Alzheimer’s disease, and diabetes, substance abuse also is a chronic disease that is in many ways analogous to these physical conditions (Fisher and Weihs 2000). Both chronic diseases and substance abuse

  • Are long‐standing and progressive
  • Often result from behavioral choices
  • Are treatable, but not curable
  • Have clients inclined to resist treatment
  • Have high probability of relapse

Chronic diseases are costly and emotionally draining. Substance abuse is similar to a chronic disease, with potential for recovery; it even can lead to improvement in family functioning. Other cost benefits result from preventive aspects of treatment. While therapy usually is not considered a primary prevention intervention, family‐based treatment that is oriented toward addressing risk factors may have a significant preventive effect on other family members (Alexander et al. 2000). For example, it may help prevent substance abuse in other family members by correcting maladaptive family dynamics.

Other Considerations

Family therapy for substance abuse treatment demands the management of complicated treatment situations. Obviously, treating a family is more complex than treating an individual, especially when an unwilling IP has been mandated to treatment. Specialized strategies may be necessary to engage the IP into treatment. In addition, the substance abuse almost always is associated with other difficult life problems, which can include mental health issues, cognitive impairment, and socioeconomic constraints, such as lack of a job or home. It can be difficult, too, to work across diverse cultural contexts or discern individual family members’ readiness for change and treatment needs.

These circumstances make meaningful family therapy for substance abuse problems a complex and challenging task for both family therapists and substance abuse treatment providers. Modifications in the treatment approach may be necessary, and the success of treatment will depend, to a large degree, on the creativity, judgment, and cooperation in and between programs in each field.


Clinicians treating families have to weigh many variables and idiopathic situations. Few landmarks may be apparent along the way; for many families, the phases of family therapy are neither discrete nor well defined. This uncertain journey is made less predictable because multiple people are involved. For example, in an adolescent program, a child in treatment might have a parent with alcoholism. As the parent’s substance abuse issues begin to surface, the child is withdrawn from treatment. This is why children need to participate in a group of their own. In a family therapy program, the child’s and the parent’s substance abuse problems would be addressed concomitantly.

Another factor that can complicate any therapy process is external coercion, such as court‐mandated treatment or mandates arising out of child protective services requirements. These situations can affect families in varied ways; treatment providers should approach mandated family therapy with heightened vigilance about the role of coercion in family process. Often in substance abuse treatment, a legal mandate or some other form of coercion makes therapy a requirement. The nature of mandated treatment is likely to have an effect on the dynamics of family therapy. It can place constraints on the therapist and raise distracting issues that have a negative effect on treatment, requiring more care, coordination of services, and case management. The legal and ethical thicket is dense in these circumstances. An exception is when the client is a minor, the courts can mandate treatment and family therapy. Practitioners should avail themselves of all relevant resources (e.g., professional associations, supervision, ethical guidelines, local and State legal and consumer organizations) before venturing to treat families under court order or similar situations. Therapists must form a working alliance with each family member and establish trust with the family so that sensitive information can be disclosed. This requires the therapist to demonstrate that she is on the family’s side therapeutically, but she also needs to disclose to the family any other obligations she has as a result of her position. For example, by agreeing to treat the family under the particular circumstances at hand, the therapist might be obligated to make progress reports to probation or parole agencies.

Co‐occurring problems

Even though an individual with a substance use disorder generally brings a family into treatment, it is possible that more than one person in the family has substance abuse problems, mental illness, problems with domestic violence, or some other major difficulty. Substance abuse, in fact, may be a secondary reason for referral for therapy. Changing the family’s maladaptive patterns of interaction may help to correct psychosocial problems among all family members. For more information about co‐occurring mental and substance use disorders see the forthcoming TIP Substance Abuse Treatment for Persons With Co‐Occurring Disorders (Center for Substance Abuse Treatment [CSAT] in development k).

Biological aspects of addiction

Other important considerations involve the biological and physiological aspects of addiction and recovery. The recovery process varies according to the type of drug, the extent of drug use, and the extent of acute and chronic effects. Recovery also may depend, at least partly, on the extent to which the drugs are intertwined with antisocial behavior and co‐occurring conditions. For the IP, post‐acute withdrawal symptoms also will commonly present and interfere with family therapy for a significant period before gradually subsiding.

The biological aspects of addiction also may affect the type of therapy that can be effective. For example, family therapy may not be as effective for someone whose drug use has caused significant organic brain damage or for a person addicted to cocaine who has become extremely paranoid. Severe psychopathology, however, should not automatically exclude a client from family therapy. Even in these cases, with appropriate individual and psychopharmacological treatment, family therapy may be helpful (O’Farrell and Fals‐Stewart 1999) since other members of the family might need and benefit from family therapy services.

Socioeconomic constraints

The socioeconomic status of a family in treatment can have far‐reaching ramifications. During treatment, poverty has two immediate implications. First, therapy will need to address many survival issues—a therapist cannot explore aspects of family systems or cognitive–behavioral traits if a family is being evicted, is not eating properly, is without financial resources and employment, or is experiencing some other threat to daily life. Second, the reimbursement systems that can be accessed probably will determine how long treatment will continue, irrespective of client needs. Therefore, family therapy treatments for substance abuse must be designed to be relatively brief and to target aspects of the family’s environment that may be maintaining the drug abuse symptomatology (e.g., Robbins et al. in press). In addition, family members should be referred to Al‐Anon, Alateen, and NAR‐Anon to enhance their potential for long‐term recovery.

Cultural competence

Cultural competence is an important feature in family therapy because therapists must work with the structures of families from many cultures. Knowledge of and sensitivity to cultures is involved in determining

  • To what extent is the family’s divergence from mainstream norms a function of pathology or a different cultural background?
  • How is the family arranged—hierarchically? Democratically? Within this structure, what are the communication patterns?
  • How well is this family functioning? That is, to what extent can the family meet its own goals without getting in its own way?
  • What therapeutic goals are appropriate?
  • What are the culture’s prescribed roles for each family member?
  • Who are the appropriately defined “power figures” in the family?

The need for cultural competence does not imply that a therapist must belong to the same cultural group as the client family. It is possible to develop cultural competence and work with groups other than one’s own. A sensitive therapist pays attention, senses cultural nuances, and learns from clients. Even when the therapist is from the same culture as the family in treatment, trust cannot be assumed. It must be built. The expectations regarding the therapist’s role as an agent of change must be clearly discussed in relation to the developing trust with the family and individual members.

Issues related to cultural sensitivity and appropriateness are considered in greater detail in chapter 5 and in the forthcoming TIP Improving Cultural Competence in Substance Abuse Treatment (CSAT in development b).

Stages of change and levels of recovery

The process of recovery is complex and multifaceted. One useful framework for understanding this process involves stages of change (Prochaska et al. 1992), which can be applied to an individual or to the whole family and used as a framework for treatment. The five stages of change are

  1. Precontemplation
  2. Contemplation
  3. Preparation
  4. Action
  5. Maintenance

Individuals typically progress and regress in their movements through these stages (Prochaska et al. 1992). Although these stages can be applied to a whole family, not every family member necessarily will be at the same stage at the same time. The therapist needs to address where each family member is, for these factors play an important role in assessment and treatment matching decisions. For additional information on the stages of change, refer to chapter 3 of this TIP and see also TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT 1999b).

While Prochaska et al. (1992) conceptualized readiness for change, other researchers have modeled the stages of recovery after treatment has begun. One such model of the path through treatment is Kaufman’s (1990b) progressive levels of recovery:

  • Dry abstinence is a time when clients must cope with problems revolving around the cessation of substance use (such as withdrawal, sudden realization of the actual damage intoxication has caused, and the shame that follows).
  • Sobriety, or early recovery, concentrates on maintaining freedom from substances. Bit by bit, the client is helped to substitute health‐sustaining behaviors for relationships and circumstances that precipitate substance use.
  • Advanced recovery shifts from support to examination of underlying personal issues that predispose the client to substance use. Trust and intimacy are re‐established, and the client moves through the termination of therapy.

This TIP approaches stages of change for families by combining Bepko and Krestan’s stages of treatment for families (1985) and Heath and Stanton’s stages of family therapy for substance abuse treatment (1998). Together, the phases of family change are

  • Attainment of sobriety. The family system is unbalanced but healthy change is possible.
  • Adjustment to sobriety. The family works on developing and stabilizing a new system.
  • Long‐term maintenance of sobriety. The family must rebalance and stabilize a new and healthier lifestyle.

Combining these two models provides a simple, straightforward categorization for a family’s progress in recovery regarding attainment of, adjustment to, and long‐term maintenance of sobriety. For additional information on these phases of family change, see chapter 4.

Unanswered research questions

At present, research cannot guide treatment providers about the best specific matches between family therapy and particular family systems or substances of abuse. Research to date suggests that certain family therapy approaches can be effective, but no one approach has been shown to be more effective than others. In addition, even though the right model is an important determinant of appropriate treatment, the exact types of family therapy models that work best with specific addictions have not been determined. However, a growing body of evidence over the past 25 years suggests that children benefit from participating in age‐appropriate support groups. These can be offered by treatment programs, school‐based student assistance programs, or faith‐based communities.

Experience and sound judgment can distinguish many situations in which family therapy alone would or would not be a workable modality. Treatment must be customized to the needs of each family and the person abusing substances. An adolescent who is primarily smoking marijuana, for instance, is a good candidate for family systems work. On the other hand, if a youth is mixing cocaine, amphetamines, alcohol, and other drugs, the client is likely to need more extensive services—detoxification, residential treatment, or intensive outpatient therapy––which can be used in addition to family therapy (Liddle and Hogue 2001).

Safety and Appropriateness of Family Therapy

Only in rare situations is family therapy inadvisable. Occasionally, it will be inappropriate or counterproductive because of reasons such those as mentioned above. Sometimes, though, family therapy is ruled out due to safety issues or legal constraints. Family or couples therapy should not take place unless all participants have a voice and everyone can raise pertinent issues, even if a domineering family member does not want them discussed. Family therapy can be used when there is no evidence of serious domestic or intimate partner violence. Engaging in family therapy without first assessing carefully for violence can lead not only to poor treatment, but also to a risk for increased abuse.

A systems approach presumes that all family members have roughly equal contributions to the process and have equity in terms of power and control. This belief is not substantiated in the research on family violence. Hence, family therapy only should be used when one family member is not being terrorized by another. Resistance from a domineering family member can be addressed and restructured by first allying with this family member and then gradually and gently questioning this person (and the whole family) about the appropriateness of the domineering behavior (Szapocznik et al. 1988). (See also appendix C, Guidelines for Assessing Violence.)

It is the treatment provider’s responsibility to provide a safe, supportive environment for all participants in family therapy. Children benefit by attending support groups specifically for them; it is important to create a safe environment in which they can discuss family violence, abuse, and neglect. Usually, a way can be found to include even the family member who has turned to violence as a way of dealing with problems. That person is a vital part of the family and will be pivotal in understanding the nature of the family violence. For example, Johnson (1995) distinguishes between common couple violence and patriarchal terrorism. The former is characterized by occasional violent outbursts by either spouse and is not likely to escalate. It is usually an intermittent response to conflict, and in therapy can be examined and channeled into more positive expression. Patriarchal terrorism, however, is systematic male violence with the goal of control. It may not be possible or advisable to include a chronically violent partner in the family therapy process.

Child abuse or neglect is another serious consideration. Children in violent homes have more physical, mental, and emotional health problems than do children in nonviolent homes. Children of people with alcohol abuse disorders suffer more injuries and poisonings than do children in the general population. Research has shown that when families exhibit both of these behaviors—substance abuse and child maltreatment—the problems must be treated simultaneously to ensure a child’s safety. It should be noted that the withdrawal experienced by parents who cease using alcohol or drugs presents specific risks. The effects of withdrawal often cause a parent to experience intense emotions, which may increase the likelihood of child maltreatment. During this time, it is especially important that family support resources be made available to the family (Bavolek 1995), and that children know how to find safe adults to help. Any time a counselor suspects child abuse or neglect, laws require immediate reporting to local authorities. For further information, see TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (CSAT 2000b).

Domestic violence is a serious issue among people with substance use disorders, and it must be factored into therapeutic considerations. If, for example, a restraining order prohibits spouses from seeing each other, the treatment provider must work within this limitation, using therapeutic configurations that make sure that a client who is abusive is not in a session with the person he or she has been barred from seeing. Often when there is concomitant family violence, the offender is mandated to complete a Batterer’s Intervention Program before participating in any couple’s work. At the same time, the victim/spouse is engaged in safety planning and sometimes treatment for his or her own issues.

Only the most extreme anger contraindicates family therapy. Kaufman and Pattison (1981) developed the concept of the need for a period of abstinence before sufficient trust can be built to counteract the anger. Including all family members in treatment and providing them a forum for releasing their anger may help to work toward that threshold. Redefining the problem as residing within the family as a whole can help transform the anger into motivation for change. In turn, this motivation can be used to restructure the family’s interactions so that the substance abuse is no longer supported. The therapist’s ability to reframe proposed obstructions by family members is often the key to creating a positive therapeutic direction.

It is up to counselors and therapists to assess the potential for anger and violence and to construct therapy so it can be conducted without endangering any family members. Because of the life‐and‐death nature of this responsibility, the consensus panel includes guidelines for the screening and treatment of people caught up in the cycle of family violence. These recommendations, adapted from TIP 25, Substance Abuse Treatment and Domestic Violence (CSAT 1997b), are presented in appendix C. However, these guidelines are not a substitute for training; counselors and therapists should have training and supervision in handling family violence cases.

If, during the screening interview, it becomes clear that a batterer is endangering a client or a child, the treatment provider should respond to this situation before any other issue and, if necessary, suspend the rest of the screening interview until the safety of the client can be ensured. The provider should refer the client or child to a domestic violence program and possibly to a shelter and legal services, and should take necessary steps to ensure the safety of affected children. Any outcry of anticipated danger needs to be regarded with the utmost seriousness and immediate precautions taken.

Goals of This TIP

General Goals


The integration of family therapy into substance abuse treatment is an important development in the treatment of addictions. Historically, barriers have separated the fields, among them differences in credentialing, treatment models, and cost for higher‐trained family therapists.

This TIP is intended to provide an opportunity for providers from both disciplines to learn from one another. It provides language that will help both fields talk about family therapy and addiction and facilitate a new and more collaborative way of thinking about substance abuse treatment.

In many States and jurisdictions, credentialing requirements are raising standards for substance abuse counselors and family therapists. These changes, which will require further education, provide opportunities for practitioners to expand their horizons as they upgrade their professional skills. This process can further cross‐fertilize the fields by making the practitioners of both fields more familiar with each other’s work.

Coverage for family therapy

The consensus panel hopes that substance abuse treatment and family therapy practitioners will be able to use this TIP to help educate insurers and behavioral managed care organizations about the importance of covering family therapy services for clients with substance use disorders.

Goals for Specific Groups

Substance abuse treatment counselors

This TIP will help substance abuse treatment counselors

  • Understand the impact of substance abuse on families taken as a whole
  • Recognize that family members need treatment in the context of the family as a whole
  • Appreciate the value of family therapy in treatment and integrate their interventions with the greater good of the family

Family therapists and other clinicians

This TIP will help family therapists become more aware of the presence and significance of chemical dependency and work with the substance abuse treatment community so family environments no longer contribute to or maintain substance abuse. It also is hoped that family therapists will come to appreciate models of substance abuse treatment and the context in which they are delivered.

Clinical supervisors

Clinical supervisors in substance abuse treatment programs and in family treatment programs can use this information to become aware of and knowledgeable about the potential connections between substance abuse treatment and family therapy. These supervisors will then be better equipped to incorporate appropriate family approaches into their programs and evaluate the performance of personnel and programs in both disciplines.

Treatment program administrators

Realizing how beneficial family therapy can be as an adjunct to or integrated part of substance abuse treatment, program administrators can use the TIP to train and motivate substance abuse treatment clinicians to include family members in treatment. Likewise, program administrators in family treatment programs can use the TIP to motivate and train family therapists to include the exploration of substance use disorders in family treatment.

Since it is difficult to find counselors who are expert in both fields, it is hoped that substance abuse treatment administrators will develop collaborative relationships with family therapy programs and manage necessary logistical issues. For example, finding adequate space is often an issue. Working hours, too, may have to be shifted, because staff will need to work some evenings to meet with family members.


The consensus panel hopes that family therapists will begin to raise the issue of substance use as a critical issue that can negatively impact families and that substance abuse treatment counselors will use information in this TIP to inform families about what they can expect from treatment. The growing consumer health movement can be part of the education that emboldens families to ask for adequate treatment. The IP and family members should be encouraged to identify

  • Why is treatment being pursued now?
  • What are the costs and benefits of engaging in therapy now?
  • How is “change” defined in the structure of “progress” in therapy?
  • What are the key components of treatment for the family?
Motivation can be understood not as something that one has but rather as something one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy. There are, it turns out, many ways to help people move toward such recognition and action. Miller, 1995

Why do people change? What is motivation? Can individuals' motivation to change their substance-using behavior be modified? Do clinicians have a role in enhancing substance-using clients' motivation for recovery?

Over the past 15 years, considerable research and clinical attention have focused on ways to better motivate substance users to consider, initiate, and continue substance abuse treatment, as well as to stop or reduce their excessive use of alcohol, cigarettes, and drugs, either on their own or with the help of a formal program. A related focus has been on sustaining change and avoiding a recurrence of problem behavior following treatment discharge. This research represents a paradigmatic shift in the addiction field's understanding of the nature of client motivation and the clinician's role in shaping it to promote and maintain positive behavioral change. This shift parallels other recent developments in the addiction field, and the new motivational strategies incorporate or reflect many of these developments. Coupling a new therapeutic style--motivational interviewing--with a transtheoretical stages-of-change model offers a fresh perspective on what clinical strategies may be effective at various points in the recovery process. Motivational interventions resulting from this theoretical construct are promising clinical tools that can be incorporated into all phases of substance abuse treatment as well as many other social and health services settings.

A New Look at Motivation

In substance abuse treatment, clients' motivation to change has often been the focus of clinical interest and frustration. Motivation has been described as a prerequisite for treatment, without which the clinician can do little (Beckman, 1980). Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with, and succeed in treatment (Appelbaum, 1972; Miller, 1985b). Until recently, motivation was viewed as a static trait or disposition that a client either did or did not have. If a client was not motivated for change, this was viewed as the client's fault. In fact, motivation for treatment connoted an agreement or willingness to go along with a clinician's or program's particular prescription for recovery. A client who seemed amenable to clinical advice or accepted the label of "alcoholic" or "drug addict" was considered to be motivated, whereas one who resisted a diagnosis or refused to adhere to the proffered treatment was deemed unmotivated. Furthermore, motivation was often viewed as the client's responsibility, not the clinician's (Miller and Rollnick, 1991). Although there are reasons why this view developed that will be discussed later, this guideline views motivation from a substantially different perspective.

A New Definition

The motivational approaches described in this TIP are based on the following assumptions about the nature of motivation:

  • Motivation is a key to change.

  • Motivation is multidimensional.

  • Motivation is dynamic and fluctuating.

  • Motivation is influenced by social interactions.

  • Motivation can be modified.

  • Motivation is influenced by the clinician's style.

  • The clinician's task is to elicit and enhance motivation.

Motivation is a key to change

The study of motivation is inexorably linked to an understanding of personal change--a concept that has also been scrutinized by modern psychologists and theorists and is the focus of substance abuse treatment. The nature of change and its causes, like motivation, is a complex construct with evolving definitions. Few of us, for example, take a completely deterministic view of change as an inevitable result of biological forces, yet most of us accept the reality that physical growth and maturation do produce change--the baby begins to walk and the adolescent seems to be driven by hormonal changes. We recognize, too, that social norms and roles can change responses, influencing behaviors as diverse as selecting clothes or joining a gang, although few of us want to think of ourselves as simply conforming to what others expect. Certainly, we believe that reasoning and problem-solving as well as emotional commitment can promote change.

The framework for linking individual change to a new view of motivation stems from what has been termed a phenomenological theory of psychology, most familiarly expressed in the writings of Carl Rogers. In this humanistic view, an individual's experience of the core inner self is the most important element for personal change and growth--a process of self-actualization that prompts goal-directed behavior for enhancing this self (Davidson, 1994). In this context, motivation is redefined as purposeful, intentional, and positive--directed toward the best interests of the self. More specifically, motivation is the probability that a person will enter into, continue, and adhere to a specific change strategy (Miller and Rollnick, 1991).

Motivation is multidimensional

Motivation, in this new meaning, has a number of complex components that will be discussed in subsequent chapters of this TIP. It encompasses the internal urges and desires felt by the client, external pressures and goals that influence the client, perceptions about risks and benefits of behaviors to the self, and cognitive appraisals of the situation.

Motivation is dynamic and fluctuating

Research and experience suggest that motivation is a dynamic state that can fluctuate over time and in relation to different situations, rather than a static personal attribute. Motivation can vacillate between conflicting objectives. Motivation also varies in intensity, faltering in response to doubts and increasing as these are resolved and goals are more clearly envisioned. In this sense, motivation can be an ambivalent, equivocating state or a resolute readiness to act--or not to act.


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AUTHOR: Cory F. Newman, Ph.D.Assistant Professor of Psychology, in Psychiatry
University of PennsylvaniaSchool of Medicine and Clinical Director
Center for Cognitive Therapy University City Science Center 3600 Market Street, Suite 754 Philadelphia, PA 19104-2648


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