Much has been written in recent years about “client-centered” substance use disorder treatment. This approach has represented a major departure from older models of treatment, which tended to be “program-centered.” At the risk of oversimplification, the client-centered approach borrows from the self-determination innovations in the disability and mental health services sector, while the program-centered approach is a legacy of the alcohol/drug social model of the 1950s, '60s and '70s.
At Door to Hope (DTH) in Salinas, Calif., a comprehensive family-centered approach has evolved, taking into account that anywhere from 19 to 53% of individuals in addiction treatment live with children under 18 prior to treatment.1 The development of this approach was influenced heavily by DTH’s origin as a women’s residential treatment program with many clients involved in the child protective services system. Equally important was the development more than a decade ago of a clinic at DTH, MCSTART, that identified and provided intervention services for children exposed to alcohol and drugs in utero.2
The impetus behind the development of MCSTART, which is a collaboration with the Monterey County behavioral health and child welfare systems, grew out of a 1992 study of alcohol- and drug-exposed births that found that nearly 12% of all births in the county hospital were positive for exposure to alcohol or drugs.
In addition to its core services, DTH today offers residential addiction treatment services for women who live with their children during treatment, as well as traditional outpatient services for men and women and specialized residential and in-home treatment for adolescents with co-occurring substance use and mental health disorders.
A natural outgrowth of this history was a realization that the target of treatment efforts was as much the family unit as the individual in treatment. It also was understood that in order for clients to resume parenting responsibilities post-treatment, improvement in parenting behavior would be necessary. Training clients in parenting skills became an essential element in the agency’s treatment protocols.
Not family group or family therapy
In discussing parent skill training it is important not to conflate this activity with two other components of addiction treatment: family groups and family therapy (the former common and the latter less so).
Many treatment programs will include a family group in which one or more loved ones will attend along with the identified client. Usually, the focus of these multi-family sessions involves preparing family and client to resume interactions following treatment. Clients learn that emotional damage does not heal overnight, while significant others are taught to understand triggers, relapse and perhaps the need to attend 12-Step meetings. Issues of codependency, enabling and “recovery” for the family members also may be addressed. Emphasis is placed on how to support the identified client in recovery as well as rebalancing and improving communication with the adults close to the client. These groups are often partially didactic and are facilitated by treatment staff.
Less common in addiction treatment is family therapy, sometimes termed “strategic family therapy” or “family systems therapy.” While a certified alcohol and drug counselor without an advanced degree will often lead a family group, family therapy usually is delivered by a professional with advanced training.
The website of the Mayo Clinic defines family therapy as, “A type of psychological counseling (psychotherapy) done to help family members improve communication and resolve conflicts. Family therapy is usually provided by a psychologist, clinical social worker or therapist. These therapists have graduate or postgraduate degrees and may be credentialed by the American Association for Marriage and Family Therapists (AAMFT).”
Addiction treatment has become increasingly complex. It is not uncommon for a residential treatment regime to include group sessions on:
Post-traumatic stress disorder (PTSD).
Mood management (co-occurring mental health problems).
Some additions to this list, which have been reported in this publication, include:
Sexual health in recovery.
Conversely, parent skills training is not common in addiction treatment settings at present, but the logic for its inclusion is powerful.
Approximately 4 million individuals receive addiction treatment in the United States annually. As noted above, perhaps as many as 50% are active parents of children under 18. We now recognize unequivocally that for many, addiction is transmitted intergenerationally, resulting from a mix of genetics and learned behavior. Families in which one or both parents experience a substance use disorder essentially act as incubators for the transmission of addiction to their children. When these individuals enter treatment, a significant opportunity arises to break that family’s cycle of parent-to-child substance use problems.