When addressing substance use, it's often helpful to look at the family system as it can have a significant impact on how a teen or young adult succeeds in treatment. Family system simply refers to the roles people play in their families and the patterns of interaction with each other.
Family therapy (also referred to as family counseling) can strengthen the family system by examining the relationships within it and the family interactions — with the goal of helping family members learn to:
Here are two examples of my approach to working with families to help illustrate the benefits of this process. Note: names have been changed.
Devon is young man in his early 20s admitted into treatment with severe alcohol use disorder and severe cocaine use disorder. Devon drank his first beer at 8 years old and would sneak drinks at family parties. By 13, Devon was drinking alcohol and smoking marijuana several nights per week. By the age of 20, he was using cocaine and alcohol daily.
As a family counselor, I began to examine Devon’s family system; the interactions among Devon, his parents and his three sisters. I needed to determine how I could both support his family and determine what changes needed to occur within the system to support Devon’s recovery.
Like many families, Devon’s family knew very little about the disease of addiction. Devon’s parents assumed that this was just a phase that Devon was going through and that he would emerge relatively unscathed on the other side.
It also became clear that Devon had far less structure than his sisters and, as the only son, was given greater leeway. Devon explained that he got away with far more than he should have been able to and any consequences that he received from his parents were light and often short-lived. Devon said that his family didn’t discuss their feelings and avoided having difficult conversations about his drug and alcohol use. As Devon’s substance use progressed, his parents began to feel a great deal of guilt that they had failed him in some way, and caused his addiction.
During family therapy, I educated the family on the disease model of addiction.
This alleviated much of the parents’ guilt and self-blame regarding their son’s addiction. Devon’s family also learned that Devon would need to take ownership of his own recovery. I recommended Devon’s parents attend Al-anon and focus on changes that they needed to make in their own lives. This included learning how to support Devon’s recovery by establishing and maintaining healthy boundaries. They also began to let him experience the consequences of his actions, letting life teach him lessons rather than intervening to minimize the possible impact on his choices.
Devon reported, however, that the most important part of family counseling was an exercise called the knee-to-knee exercise. This is a structured communication exercise that focuses on expression of emotion and “listening to understand” as opposed to “listening to respond.” Family members complete a written exercise that prompts them to express their feelings regarding a wide variety of their loved one’s behaviors. The family members sit in chairs “knee to knee” and then share their feelings while the other family member listens. Family members are not allowed to respond to what they hear. Removing one’s ability to respond increases the likelihood for genuine listening. Devon was able to truly hear, for the first time, how his actions had truly impacted his family. Devon shared that he had no idea that his drug and alcohol use had caused so much pain and fear in his family.
As family therapy concluded, each family member left with a much clearer understanding of the process of recovery, both in their individual lives and the life of Devon.
Robert is also a young man in his early 20s who was admitted into treatment with a primary diagnosis of severe alcohol use disorder and severe cocaine use disorder. Robert shared that he drank his first beer when he was 6 and began to use marijuana, cocaine and alcohol by 12.
Robert is an only child from a well-educated, middle-class family. His father is an attorney and his mother is a successful businesswoman. Robert’s parents are very goal-driven and he frequently had a difficult time living up to their standards of perfection. This caused Robert to feel a great deal of shame. Robert grew up not being able to identify his emotions. Expressions of feelings, other than anger and sometimes sadness, were not allowed within his family (an unspoken rule) and so Robert learned to suppress his feelings.
Robert also shared that it was easy to manipulate his mother with respect to his drug use. Robert’s mother would always take his side, mistakes were never his fault, and he rarely, if ever, suffered consequences for the choices he made. This is an example of co-signing unhealthy behavior and it a hallmark of addictive relationships. It is the normalizing or minimizing of unhealthy behaviors and the removal of responsibility for those behaviors. This prevents the person with the disease of addiction from learning from his or her unhealthy choices.
Robert also had deep-seated resentments toward his father. Robert’s father would often be at a favorite bar instead of attending Robert’s hockey games and Robert could never get the validation that he so desperately craved from his father. This emotional distancing between father and son also reinforced his mother’s unhealthy closeness and the sense that he could “do no wrong” in his her eyes.
There were many goals for family therapy. We had to examine and replace the unspoken family rules within the family system that created problems.
All family members needed to learn how to identify their emotions. Furthermore, an open line of communication, particularly on an emotional level, had to be established. This allowed Robert to express what his emotional needs were and to work through the resentments that he had with his father.
Robert’s mother also had to examine her behaviors; particularly where she was not honoring boundaries and not following through on consequences for her son.
It emerged in counseling that Robert’s grandfather on his mom’s side had the disease of alcoholism and that this fueled her need to soften or block any consequences her son might experience related to his substance use. She was attempting to heal wounds from her childhood in her relationship with Robert.
As the family system began to operate in a healthier manner, Robert began to get his emotional needs met in a way that he never had previously. Robert was also allowed to take ownership of the decisions that he made and to experience the natural consequence of poor decisions without being rescued or shamed. This eventually led to Robert making healthier choices and his recovery from his substance use disorder began to thrive.
Unfortunately, when families are unwilling to engage in this journey with their loved one, the outcomes aren’t usually as positive. The son or daughter with the addiction often becomes the focal point that distracts the family from looking at other problems within the family system.
However, when families are courageous enough to engage in the difficult task of family counseling, the changes can be extensive and beneficial.
Family therapy can not only breathe new life into the family, it can also significantly impact the recovery process for the teen or young adult struggling with the substance use disorder.