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THEORETICAL FRAMEWORK
Sometimes called a transtheoretical approach because it relies on
several theories of social psychology, the stages of change model
was first proposed by Prochaska and DiClemente (1986) to describe
how smokers who were able to break their nicotine habit successfully
did so. Their concern was with the movement of people from denial
of the need to change (called precontemplation) to the reaching of a
decision to adopt a healthier lifestyle (preparation) and then the tak-
ing of steps to do so (action). The focus of this model was on the indi-
vidual's motivation to change. This framework has played an integral
role in the development of motivational interviewing.
Miller and RoUnick (1991) set forth an empirically based for-
mulation of motivational interviewing (MI) in their groundbreaking
text Motivational Interviewing: Preparing People to Change Addictive
Behavior. The goal of MI is basically harm reduction. The method is
to elicit statements in the individual with substance use or other
destructive behaviors that are in a positive, health-seeking direction
and to reinforce those statements. Miller and RoUnick incorporated
in their model Prochaska and DiClemente's notion that change
involves a psychological progression, that therapist interventions
must be carefully tailored to the client's readiness to change
(Prochaska & Norcross, 2007).
Europeans, immersed in the harm reduction perspective, had ear-
her in the 1980s adopted this theoretical approach and incorporated
206 JOURNAL OF FAMIL Y SOCIAL WORK
Precontemplation We really don't have much to do with this problem; I've had enough
of blaming by psychologists and interfering social workers.
Contemplation The assessment they did on B. was a lot of bunk. Who do these
"experts" think they are? Still, there was one part of it that rang
true.
Preparation I can't take it anymore. My home life is a shambles. B. was doing so
well, but now has had a relapse. Last week you said that there
were some things I could do to help.
Action Sobriety may be healthy, but it sure makes for a dull family life.
Maybe I'll check out one of these Al-Anon groups that you
mentioned. Maybe there are others like me out there I can talk to.
Maintenance It's been a few months; our family is not there yet, but the kids are
getting a lot out of the Al-Ateen group, and I'm beginning to set
some goals for myself.
Precontemplation
Family members of an alcoholic or addict are determined to be
precontemplaters if they are not ready to support the client's process
of change. It is unlikely that members of such a family unit will
approach the treatment center for help on their own. They might
be encouraged to attend a family evening-type program, however,
as when a family member gets in trouble with the law such as through
a drinking while intoxicated (DWI) conviction and follow-up assess-
ment or through a child welfare referral. In any case, rules of the fam-
ily at this stage of recovery are likely to be of the "don't talk, don't
trust, don't feel" variety (Black, 2002) so members are reluctant to
share their family secrets.
In working with a family in which there are addictive problems, the
therapist might start by helping members to identify their family's
goals. He or she asks open-ended questions such as these: "What
brings you here?" "What would you like to happen on our work
together?" "If you change some things, what would they be?"
As required by the court or insurance company, assessment most
often is solely of the individual addict, with input from family mem-
bers being provided, if at all, at a later stage. Zweben (1999) recom-
mends, however, involvement from the start. He assesses the family
members' suitability for such involvement by meeting with the client
with the designated substance abuse with the family members to
assess for two things. The first is whether the significant other has
strong ties to the client, and the second is to determine whether
motivational statements made by the client will be supported by
the significant other.
Although participation of significant others in treatment has been
found to be one of the best predictors of cocaine abstinence, Laudet,
Magura, Frst, Kumar, and Whitney (1999) found the male partners
of cocaine-using women to be far more difficult to engage in family
Katherine van Wormer 213
treatment than the female partners of users. The men's active drug
use and their refusal to focus on this fact are among the reasons
hypothesized for this finding.
Contact with such family members who are reluctant to be
involved is apt to be short-term and superficial. Information-giving
sessions are the least threatening and will give the family time to think
about asking for help. As part of the educational process, family
members can be presented with diagrams of various family styles of
interaction that might or might not apply to them. Grouping reluc-
tant family members with others more eager for help is often helpful.
The challenge to practitioners in a field, the literature and other
teachings of which are guided by a language of damage and defects,
is to adopt a language that corresponds to concepts of strengths and
resilience.
When an alcoholic or addict enters treatment, the inclusion of fam-
ily members from the outset, whether with the addict or in separate
sessions, offers several advantages. Such inclusion provides a means
of observing how family members relate together as a unit, a means
for discovering strengths in the addict's background, and an opport-
unity to provide education into the biological and psychosocial
aspects of addiction. It is never too early, besides, to begin preparing
the family for the changes members will need to make in conjunction
with the addict's recovery. The first session may close with the assign-
ment of tasks designed to get the members of the family to take some
small steps in areas where change is feasible. Getting the family to
take home reading material might be an example of a positive
first step.
The significant other's involvement in treatment may be counter-
productive, as Burke et al. (2002) caution, if he or she is overbur-
dened with anger and resentment. In such a case his or her role
should be limited to being a bystander or witness in the client's indi-
vidual's sessions. Sometimes the family member is actively misusing
substances in the home and is better left behind in that case.
Discovering this fact through meeting with the family is often useful,
however, in the treatment process with the client.
Contemplation
Under one scenario, unilateral therapy, the family attends treat-
ment sessions to work on their problems and feelings surrounding
214 JOURNAL OF FAMILY SOCIAL WORK
Preparation
The theme for this stage of change can be summarized in the
addict's partner or co-addict's attitude of, "I can't take it any more.
I am at the breaking point." Tasks for the counselor during this
period are to help family members clarify their goals and strategies
for effecting change, to offer a list of options and advice if so desired,
and to steer the family toward social support networks. Boosting the
Katherine van Wormer 215
Action
At this point, let us assume the whole family is involved in counsel-
ing, all except for the addicted individual (see Loneck, 1995). All fam-
ily participants are bent on seeing change happen. Family sessions at
this stage are crucial in building sohdarity so that the addict will not
be able to play one family member off against another. The sessions
are crucial also in providing these individuals with the opportunity to
ventilate their feelings, grief, rage, despair, etc., and to learn about
addiction as an illness.
If the addicted family member is not in treatment, the family might
want to consider doing a formal Intervention. The Intervention is a
method of confronting the drinker or drug user for the purpose of get-
ting him or her into treatment (Loneck, 1995). Only a confrontation
that causes a family crisis will bring the substance-abusing member to
the painful realization that his or her substance use has caused pro-
blems and that he or she cannot continue as he or she has been.
Maintenance
More important than the role of family in assessment and treat-
ment is the role of family in early recovery. As the addict's progress
Katherine van Wormer 217
toward health and wholeness becomes more and more a reality, the
family therapist may take on the role of facilitator to aid in the pro-
cess of reconciliation. Members of the family may want to come to
terms with lifelong feelings of rejection; there may or may not be a
desire for forgiveness.
Brown and Lewis (1999) provide a detailed delineation of the
therapeutic tasks and pitfalls involved in the process of recovery.
The Alcoholic Family in Recovery draws on the experiences of mem-
bers of four recovering families to describe the ways recovery has
challenged and changed their relationships. Much of this process,
as Brown and Lewis demonstrate, is painful.
Transition, as Brown and Lewis explain, is characterized by mass-
ive change that affects children and adults at every level. The environ-
ment feels unsafe; the family structure, after years of chaos, is not
strong enough to handle change. In the counseling session, the thera-
pist addresses the family concerns and recovery progress. Individual
members may have issues from the past that they will want addressed
at this time.
As behavioral changes are established in the family, the focus of
sessions shifts toward maintenance of change independent of the
therapist. Now that the problematic substance use has decreased
and other family interactions have improved, other family problems
(such as suppressed anger or an adolescent's substance misuse) may
need to be addressed (Waldron & Slesnick, 1998). Family sessions
at this point can help make the difference between sobriety and fail-
ure to change, and even between keeping the family together and div-
orce. The therapist can help the family anticipate Stressors and
support the addict in avoiding triggers and high-risk events.
A complete "what to do i f contingency plan needs to be set in
motion in case of backtracking. Clients are given numbers to call
and asked to come up with ideas for what to put in a step-by-step
plan for getting the help they need. Harm reduction strategies and
solutions to sustain the change in behavior should be explored in
treatment aftercare counseling. The couple, moreover, often can
benefit from receiving information concerning sexual problems that
arise in the absence of alcohol and drug use; if the issue is sexual
addiction, the posttreatment counseling needs are tremendous.
Together, the family members can benefit greatly with work in the
area of communication, decision making, and in discussing rules and
how the rules will be enforced. Now that progress toward recovery is
218 JOURNAL OF FAMILY SOCIAL WORK
well underway, the stage is set for a shared groping for solutions to
problems that may never have been identified without outside help.
Ideally, the family therapist is a nonparticipant in the immediate,
emotionally charged issues within the family (such as who takes
responsibility over what and the division of labor). The focus of
the therapist is not on the content of the interaction but on the process
itself. The motivational therapist guides a family with a recovering
member toward its own process of recovery. As the newly sober
member regains responsibility within the family, other members have
to adapt accordingly. Acting as a coach or guide, the therapist can
help map the course of this adaptation. The entire family must be
prepared to accept as a member a sober and somewhat changed
person. Every person's role in the family alters in the process of
one individual's change.
CONCLUSION
Family counseling is an exciting dimension of addiction treatment.
Family work with alcoholics and other problematic drug users is an
area especially amenable to the motivational strategies that are cur-
rently gaining popularity in the field of substance abuse counseling.
The potential for such strategies to be successful in engaging family
members to reinforce the work that is done in treatment, however,
is only beginning to be realized. Attending to each person's stage
of adjustment to the problem ensures that interventions are appro-
priate to the individual's current motivational state and avoids setting
up a situation of a battle of wills between treatment provider and
family member.
Because the addiction or other problematic behavior did not arise
in a social vacuum and the addicts did not suffer the consequences of
the behavior alone, attention needs to be directed toward the social
environment. The growth process for the family often requires a per-
iod of chaos that precedes the old state's breaking down before the
formation of a new state can occur. Even if the treatment agency
lacks a full-fiedged family program, individual counselors can usually
invite clients to bring their significant others with them to sessions.
Through the stages of change approach described in this paper,
specific interventions can be tailored toward the family's readiness
to change. By closely attending to family dynamics and reinforcing
Katherine van Wormer 219
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