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Stages of change Families with substance abuse problems constitute a vulnerable population with many complicating psychosocial issues. In the ideal situation, the family voluntarily seeks help; most frequently, when a family member requests substance abuse help for another member there is great variation in client motivations for substance abuse treatment.
Substance abuse treatment can be initiated by the person with a substance use disorder, a family member, or even through mandated treatment by an employer or the legal system.
During the recovery process, individuals typically progress and regress in their movement through the stages. Stages of change have been described in several ways, but one especially helpful concept Prochaska et al.
At this stage, the person abusing substances is not even thinking about changing drug or alcohol use, although others may recognize it as a problem. The person abusing substances is unlikely to appear for treatment without coercion. If the person is referred, active resistance to change is probable. When the IP is in the precontemplation stage, the therapist works to establish rapport and offer support for any positive change.
A person in this stage is ambivalent and undecided, vacillating over whether she really has a problem or needs to change. A desire to change exists simultaneously with resistance to change. A person may seek professional advice to get an objective assessment. Motivational strategies are useful at this stage, but aggressive or premature confrontation may provoke strong resistance and defensive behaviors.
Many contemplators have indefinite plans to take action in the next 6 months or so. The role of the therapist is to encourage ambivalence. Helping the IP to see both the pros and cons of substance use and change helps her to move toward a decision.
Client education is an effective tool for creating ambivalence. In this stage, a person moves to the specific steps to be taken to solve the problem. The person abusing substances has increasing confidence in the decision to change and is ready to take the first steps on the road to the next stage, action.
Most people in this stage are planning to take action within the next month and are making final adjustments before they begin to change their behavior. One or more family members in this stage begin to look for a solution. They may seek guidance and treatment options. The goal may be as simple as creating a written record of every drink during the time between sessions. Specific actions are initiated to bring about change. Action may include overt modification of behavior and surroundings.
This stage is the busiest, and it requires the greatest commitment of time and energy. Commitment to change is still unstable, so support and encouragement remain important in preventing dropout and regression in readiness to change.
At this point the forces for change in a family reach critical proportions. Ultimatums and professional interventions are often necessary. The role of the therapist is to encourage the person and continue providing client education to reinforce the decision to stop substance abuse. This stage requires a set of skills different from those that were needed to initiate change.
Alternative coping and problemsolving strategies must be learned. Problem behaviors need to be replaced with new, healthy behaviors. Emotional triggers of relapse have to be identified and planned for. Gains have been consolidated, but this stage is by no means static or invulnerable.
It lasts as briefly as 6 months or as long as a lifetime. In maintenance the family adjusts to life without the involvement of substances Prochaska et al.
During this stage it is important to maintain contact with the family to review changes and potential obstacles to change. During recovery from substance abuse, relapse and regression to an earlier stage of recovery are common and expected—though not inevitable Prochaska et al.
When setbacks occur, it is important for the person in recovery to avoid getting stuck, discouraged, or demoralized. Clients can learn from the experience of relapse and then commit to a new cycle of action. Treatment should provide comprehensive, multidimensional assessment to explore all reasons for relapse.
Termination entered from the maintenance stage is the exit—the final goal for all who seek freedom from dependence on substances. The individual or family exits the cycle of change, and the danger of relapse becomes less acute.
In the substance abuse field, some dispute the idea that drug or alcohol problems can be terminated and prefer to think of this stage as remission achieved through maintenance strategies.
Confrontation Generally, substance abuse treatment has relied on confrontation more than family therapy has. For a long time, within the substance abuse treatment community it was believed that confronting clients and breaking through their defenses was necessary to overcoming denial. Some preliminary research has suggested that a confrontational approach is sometimes the least effective method for getting certain clients to change substance abuse behavior Miller et al.
Treatment of substance abuse has shifted away from confrontational approaches and moved toward more empathic approaches, such as those favored in family therapy.
Still, family therapists should be aware of how confrontation has been used and is still used in some substance abuse treatment programs. Motivation levels Motivating a person or a family to enter and remain in treatment is a complex task, made all the more complicated by the fact that the IP and the family may have different levels of motivation as may different members of the family.
All the same, group and family loyalty will affect people differently. These loyalties may motivate some to enter treatment, but the same loyalties can deter others.
Clinicians in both substance abuse treatment and family therapy also need to consider the motivation level of the family of a person abusing substances. The family members may have been discouraged by treatment in the past, and they may no longer believe or hope that any treatment will enable their family member to stop abusing substances.
They may also conclude that the treatment system did not respond to their needs. It may even be harder to motivate family members than it is to prompt the person with the substance use disorder. Family members may also fear treatment because there are specific issues in the family such as sexual abuse or illegal activity that they do not wish to reveal or change.
In such cases, the therapist must be clear with family members about his ethical obligations to reveal information if certain topics are raised.
For example, the law and ethics require therapists to report child abuse. Moreover, the therapist must not push family members to talk about difficult issues before they are ready to do so. Large agencies and systems may seem untrustworthy and threatening. A family may fear that the system will disrupt it, leading to such consequences as losing custody of a child. Psychoeducational groups are also useful for helping family members understand what to expect from treatment.
Participation in psychoeducational groups often helps to motivate them to become more involved in treatment Wermuth and Scheidt by making them aware of the dynamics of substance abuse and the role the family can play in recovery. Multifamily groups help families see that they can benefit from treatment as others have even if the family member who uses substances does not maintain abstinence Conner et al.
These two frequently used interventions are particularly useful for involving a family early in treatment and motivating it to continue treatment. Cultural barriers to treatment Cultural background can affect attitudes concerning such factors as proper family behavior, family hierarchy, acceptable levels of substance use, and methods of dealing with shame and guilt. Forcing families or individuals to comply with the customs of the dominant culture can create mistrust and reduce the effectiveness of therapy.
To develop effective treatment strategies for diverse populations, the treatment provider must understand the role of culture and cultural backgrounds, recognize the cultural backgrounds of clients, and know enough about their culture to understand its effect on key treatment issues. Integrating Substance Abuse Treatment and Family Therapy The integration of substance abuse treatment and family therapy may be accomplished at several levels see chapter 4 for a full discussion of integrated models of treatment.
Agencies may opt for full integration that would offer both family therapy and substance abuse treatment in the same location with the same or different sets of staff members. As an alternative, agencies might create a partial integration by setting up a system of referral for services. Regardless of the form integration takes, clinicians working in either field need to be aware of the practices and ideas of the other field.
There should be mutual respect and a willingness to communicate between practitioners. They should know when to make a referral and when to seek further consultation with a practitioner from the other field.
Clinicians in each field need to tailor their approaches to be optimally effective for clients who have received or are receiving treatment from a practitioner in the other field. Family Therapy for Substance Abuse Counselors Substance abuse counselors should not practice family therapy unless they have proper training and licensing, but they should be informed about family therapy to discuss it with their clients and know when a referral is indicated.
Substance abuse counselors can also benefit from incorporating family therapy ideas and techniques into their work with individual clients, groups of clients, and family groups. In order to promote integrated treatment, training in family therapy techniques and concepts should be provided to substance abuse counselors.
This section builds on content presented in chapter 1 that explained the potential role of family therapy in substance abuse treatment programs. Chapter 4 discusses the specific integrated family therapy models developed for treating clients with substance use disorders. Traditional Models of Family Therapy The family therapy field is diverse, but certain models have been more influential than others, and models that share certain characteristics can be grouped together.
Phase Difference and Path Difference
Family therapy theories can be roughly divided into two major groups. One includes those that focus primarily on problemsolving, where therapy is generally brief, more concerned with the present situation, and more pragmatic. Within these larger divisions, other categories can be developed based on the assumptions each model makes about the source of family problems, the specific goals of therapy, and the interventions used to induce change.
None was specifically developed, however, for this integration. See Steinglass et al. View of substance abuse Substance abuse stresses the whole family system. Families with members who abuse substances are a highly heterogeneous group.
The 4 Stages of Dating Relationships
Use enactments and rehearsals to enlighten the family system about triggers of substance use, to anticipate problems, and avoid them. Use family restabilization or reorganization to change functioning and organization. See Bepko and Krestan View of substance abuse Focus is on the person who abuses substances and the substance of abuse as a system while also looking at intrapersonal, interpersonal, and gender systems.
Goals of therapy Help everyone in the family achieve appropriate responsibility for self and decrease inappropriate responsibility for others. Three phases of treatment, each with a separate set of goals: Unbalance the system that was balanced around substance abuse in order to promote sobriety.
Rebalance the system in a deep way by going back and working on developmental tasks that were previously missed.
Phase/path difference - The Student Room
Both halves of a couple will notice weaknesses and differences or flaws. Some of those perpetual issues or differences such as free-spending or frugal, neat and orderly or sloppy and disorganized, interested in lots of time together or more involved in outside activities begin to emerge. At this stage of the relationship, couples will take note of the differences and may even begin to complain or attempt to problem-solve.
As intimacy develops between the two people, more self-disclosure emerges, both verbally and nonverbally as couples act in ways that are more like how they are in their daily life. This is when the big question emerges even more strongly: Pushing for an answer; however, may cause real problems in the relationship.
Each person needs to listen to their own inner voice and wisdom.
Chapter 3 Approaches to Therapy - Substance Abuse Treatment and Family Therapy - NCBI Bookshelf
There is no need to rush through this important stage and every reason to go slowly. Open and honest conversations should be happening as couples plan their present and future together.
Questions about children, finances, careers, future goals and lifestyle should be discussed more fully.
Differences are normal and couples will learn about themselves and their relationship as they note how they handle these differences with each other. This is also an important stage for couples to use to evaluate the relationship and their ability to be part of an emotionally intelligent relationship.