Cathy Patterson-Sterling MA, RCC
Former Director of Family Services
Sunshine Coast Health Center
The idea of treating family members and loved ones who have been impacted by other people's addictions is a relatively new concept. Family members only started receiving help with the creation of Al-anon (originally known as the A.A. Auxilary) in 1951. Even with the development of Family Systems Therapy in the 1950's and Behavioral Couples Therapy in the 1960's, loved ones of addicted individuals did not actually receive specific addictions family therapy until 1978 with the creation of an adjunct program at the Lutheran General Hospital in Park Ridge, Illinois. Throughout the 1980's, however, a larger treatment focus for loved ones of people in addiction emerged. Suddenly, there was an explosion of interest in the addictions family therapy field. Three models for Addiction Family Therapy (AFT) developed into a concrete form and these included the Disease Model, Family Systems Model, and the Cognitive-Behavioral Model. Currently, these three approaches serve as types of lenses in which to view the complicated affects of addiction on relationships.
Now twenty years later, a fourth lens-the existential approach- for studying Addiction Family Therapy (AFT) is created. With the three previous models, addictions professionals studied the deficits, interactional patterns, as well as behaviors of both people in addiction and their loved ones. Thus, addictions professionals learned to be well-versed in studying addiction as a construct impacting interpersonal familial dynamics. With an existential focus, however, clients learn that they are more than their deficits, interactional patterns, or behaviors. Addiction professionals with an existential approach view clients holistically as they share methods for transcending the chaos of addiction cycles and develop ways to find greater meaning as well as purpose in life. Therefore individuals in recovery and their loved can use their experiences with addiction as opportunities for greater emotional growth. In essence, with an existential focus, people learn how to view addiction as a gift of personal transformation. In order to fully understand the current existential approach, a preview of the development of the first three AFT models is necessary.
The Disease Model
The first framework of AFT to arrive in the field of addictions was the disease model. This approach was a natural development from the twelve steps of Alcoholics Anonymous combined with the view that addiction is a disease. Bill W. and Dr. Bob created Alcoholics Anonymous in 1935 and Jellinek identified addiction as a chronic as well as progressive disease often characterized by denial in 1945 (Lemanski, 2001).
By 1951, Al-anon was created as the second 12 step organization. Loved ones of alcoholics could attend support meetings and learn ways to stop scapegoating or blaming addicted family members for their problems (Kinney & Leaton, 1995). Therefore, these people in relationships with alcoholics could use the 12 steps to realise that they are powerless over other individuals' alcohol use and learn to set boundaries by taking care of themselves as they "detach with love" (Kinney & Leaton, 1995).
In 1978, the first form of AFT programming was created at the Lutheran General Hospital in Illinois that consisted of Al-anon principles. The program originally included a half day Saturday session and was led by Al-anon volunteers (White, 1998). In 1979, a formal AFT treatment program developed that included three days off site for a residential retreat. Al-anon and A.A. volunteers could join a nine to twelve month training program to become Counsellors that taught this three day program. This Lutheran General Hospital Program was the precursor to the Minnesota Model which is now used throughout many treatment centres in North America as well as the world (White, 1998).
In the 1980's, professionals in the addictions field started to pay attention to the ways that individual family members and the family as a dynamic system, adapted to the deteriorating role performance of addicted loved ones (White, 1998). Vernon Johnson (1990) wrote about enabling and how family members of addicts or alcoholics may unknowingly support individuals' addictive behaviors through certain enabling actions such as making excuses or ignoring the impact of the addiction. Claudia Black and Sharon Wegscheider-Cruse wrote about the survival roles that children follow in order to cope with addicted family members. Such roles included the family hero, mascot, scapegoat, and lost child etc. (Curtis, 1999). There was also a recognition by professionals that adult children of alcoholics were patients in their own right, who suffered from a condition that required treatment as well as support services (White, 1998). Thus, the support movement of Adult Children Of Alcoholics (ACoA) was born (White, 1998).
During the 1980's, there was also a recognition by professionals in the field that addiction was a family disease. Thus individuals in close relationships with addicts or alcoholics possibly suffered from a disease of codependency because their feelings of self-worth and personal identities were enmeshed with people in addiction. Dr. Timmen Cermak even proposed criteria for making codependency a medical diagnosis (White, 1998).
A variety of professionals wrote about codependency. In fact, Melody Beattie in 1987 "launched a veritable social phenomenon" with her book Codependent No More (White, 1998). With great enthusiasm, Sharon Wegscheider-Cruse estimated that 96% of the U.S. population suffered from codependence (Wilson-Schaef, 1986). The difficulty, however, was that the definition of codependency became so broad as to include "anyone who has been affected by the person who has been afflicted by the disease of chemical dependency" (Wilson-Schaef, 1986). Then this codependency definition eventually included "anyone who lives in a close association over a prolonged time with anyone who has a neurotic personality" (Wilson-Schaef, 1986). These estimations and definitions were actually part of a general hypothesis around codependency that could not be substantiated. Mellody (2003) even admitted that there was no scientific validity for the concept of codependency.
Little research has been conducted on the overall effectiveness of the disease model. Laundergan & Williams (1979) studied Hazelden's 3-5 day residential, psychoeducational program for spouses and family members of alcoholics. This program was based on the twelve steps and Al-anon principles. The focus for the spouses was on detaching from the alcoholic and paying attention to themselves through self-care in order to improve their own coping styles. Program evaluation reports showed participants' satisfaction with various program elements, but there were no controlled studies. There were some attitude changes by participants, but there was no use of pre and post treatment measures or scientifically-based methodology (O'Farrell, 2003).
Another research study related to the disease model was on testing ACoA concepts. In 1986 Werner conducted a longitudinal study of 49 children born on the island of Kuai, Hawaii. All of these children came from alcoholic homes. At age 18, 59% of these children had no psychosocial problems. Therefore there was no conclusive evidence that these children had any more problems coming from alcoholic homes (Curtis, 1999). Dunkel (1993) suggests that, in general, there is no evidence to support that Adult Children Of Alcoholics are a unique group (Curtis, 1999).
Despite the lack of scientific validity, the disease model is useful as a framework for managing deficits. Alcoholics and addicts learn how to care for their disease of addiction through treatment and follow-up support meetings. Family members and loved ones of addicted individuals receive validation that they have been impacted by other people's addictive behaviors. Furthermore, loved ones who believe they have the disease of codependency can access adjunct treatment programs, read various written materials, and join Al-anon or even CODA (Codependency Anonymous) support groups. Adult Children Of Alcoholics (ACoA's) also receive support around their experiences of growing up in alcoholic homes.
The Family Systems Model
In the early 1950's Bowen laid the groundwork for the emerging field of general family therapy. With support of the Menninger Foundation and the National Institute of Mental Health, Bowen arranged for mothers to move into cottages on clinic grounds for several months near their hospitalized children in Topeko, Texas. Bowen observed the overcloseness as well as overdistance of parents in order to avoid anxiety. Parents achieved an emotional equilibrium by keeping their disturbed children needy (Goldenberg & Goldenberg, 2000). Out of this early work, Bowen created the Family Systems Model.
Bowen proposed that families are an emotional and interactional system. Thus, problems of one family member cannot be understood apart from those of all other members. Therefore, the focus is on family interactions and not just the identified client (Curtis, 1999). Bowen (1976) developed other concepts such as togetherness and individuation, differentiation of self, the triangle, family projection process, emotional cut-off, as well as the multigenerational transmission process.
Other professionals then began viewing the complex interactional dynamics of families struggling with addictions through this family systems framework. Ewing & Fox (1968) hypothesized that alcohol abuse maintained the family emotional homeostasis (Curtis, 1999). If only the alcoholic changes, then the spouse may resist change. According to this view proposed by Ewing and Fox, the challenge for therapists is to help the husband and wife interact without alcohol. Kaufman (1985) revealed four types of alcoholic families that included the functional family system, neurotic enmeshed family system, the disintegrated family system, and the absent family system (Curtis, 1999). Dulfano (1985) described how the parental subsystem changes as a result of alcoholic behavior and as parents decline in functioning, children assume more adult-like roles (Curtis, 1999).
In 1987, Steinglass analyzed the characteristics of the alcoholic family within Bowen's Systems Theory. He examined how family members create balance around the dysfunction created by the addiction (Curtis, 1999). Furthermore, Steinglass explored a way of determining how severely families have been impacted by addiction, the generational transmission process of addiction, and the effect of addiction on family developmental or systematic maturation phases.
Even though the dynamics of families impacted by addiction have been thoroughly examined, only one controlled outcome study of this approach has been completed (O'Farrell, 2003). Zweben, Pearlman, & Li (1988) randomly assigned 116 alcohol abusers to eight sessions of conjunct therapy based on a communication-interactional approach in which the presenting problem (alcohol abuse) was viewed from a systemic perspective as having adaptive or functional consequences for these couples. A control group was exposed to a single session of advice counselling. There was no significant group difference on any of the outcome measures even at the eighteen month follow-up period.
There are some major benefits to the Family Systems AFT model even though it has not been scientifically-validated. Counsellors who utilize this approach view families' dynamics, roles, as well as accommodation of the addiction before making generalizations about levels of functioning. Furthermore, with this focus on interactional dynamics, professionals highlight the fact that through the multi-generational transmission process addiction can impact several generations of families.
The Cognitive-Behavioral Model
In the 1960's the approach of behavioral couples therapy emerged. Liberman and Stuart applied step by step intervention procedures and some basic operant conditioning principles to distressed marital relationships. The aim was to have couples make contracts around maximizing their exchanges of positive behaviors (Goldenberg & Goldenberg, 2000). In the 1970's, therapists focused on cognitive aspects by providing proper assessment of intervention efforts and feedback (Goldenberg & Goldenberg, 2000). In the 1980's, couples also started receiving communication and problem-skills training (Goldenberg & Goldenberg, 2000).
An approach called Marital and Family Therapy (MFT) was the main AFT framework to grow out of the Cognitive Behavioral Model. Keller (1974) called Marital and Family Therapy (MFT) "the most notable current advance in the area of psychotherapy of alcoholism" (O'Farrell, 2003). The MFT approach consists of the same operant conditioning principles as behavioral couples therapy. In fact, the major goal of MFT includes altering marital or family patterns to provide an atmosphere that is more conducive to sobriety and to reduce/eliminate abusive drinking while supporting the alcoholic's efforts to change (O'Farrell, 2003). Addictions Family Therapy sessions usually consists of two to four 75-90 minute sessions for assessment purposes, ten to twenty 60-75minute sessions of therapy, and a three to five year follow-up contact period (O'Farrell, 2003). Strategies for MFT include examining exposure to alcohol, behavioral contracting, sobriety trust contracts, antabuse contracts, daily records of urges, building good will through caring days, planning shared recreational as well as leisure activities, core symbols, conflict resolution, communication skills training, and behavior change agreements (O'Farrell, 2003). Marlatt & Gordon (1985) provides a cognitive behavioral approach to AFT with a relapse prevention focus.
Unlike the other two previous models, the cognitive behavioral AFT approach has been well-researched. Fifteen research studies on cognitive behavioral AFT have been completed to date and they include Bowers et al. (1990), Monti et al. (1990), Keane et. al. (1984), Azrin et. al.(1982), Hedberg et al. (1974), Cadogen (1973), O'Farrell & Cutter (1982), O'Farrell et al. (1992), O'Farrell et al. (1993), McCrady et al. (1986), McCrady et al. (1991), McCrady et al. (1979), McCrady et al. (1982), Longabough et al. (1993), and McKay et al. (1993). As supported by research, MFT (the main cognitive behavioral AFT approach) produces better results in the six to twelve month period following treatment for alcohol problems than other methods that do not involve the spouse or family members (O'Farrell, 2003). More research is needed to prove that MFT can be used to maintain behavioral gains and to prevent relapse (O'Farrell, 2003).
Although the cognitive behavioral AFT model has been researched, this approach is not widespread. O'Farrell (2003) states: "…the most popular, most influential and most frequently used methods-family systems and family disease models-have little or no research support for their effectiveness. Conversely, methods that do have the strongest research support for their effectiveness-various behavioral MFT methods-enjoy little popularity and are used infrequently, if at all." (p.217). Thus, cognitive-behavioral AFT is helpful for enhancing positive behavior amongst family members impacted by addiction, however, more time is needed for researchers to demonstrate the long term benefits of this approach. Once this success is achieved then the cognitive-behavioral AFT model may receive more exposure.
The Existential Model
The term existential stems from the word existence (May&Yalom, 2000). Existential philosophers such as Nietzsche, Shopenhauer, and Kierkagaard from as far back as the 1800's were concerned with the meaning of existence and how people make sense of their lives. In 1949, Victor Frankl examined these concepts and created the modern form of existential analysis known as logotherapy or meaning-centred therapy. Frankl drew on his experiences as both a successful psychiatrist and survivor of three concentration camps during the Nazi Holocaust. In Man's Search For Meaning, Frankl examined how individuals can use their experiences of suffering as opportunities to create more meaning in their lives. Frankl (1984) described "the self-transcendence of human existence" and how individuals can "transform a personal tragedy into a triumph" when they create a sense of meaning as well as purpose in their lives. Furthermore, Frankl explained how people may become frustrated in their abilities to create meaning in their lives and that these individuals may experience what he calls an "existential vacuum". When individuals experience these feelings of complete meaninglessness (the existential vacuum) they suffer from depression, aggression, or addiction.
May and Yalom wrote about similar existential themes related to finding meaning. Wong (1999) expanded Frankl's concepts by creating an integrative model of logotherapy as well as a cognitive-behavioral reformulation of logotherapy. Furthermore, Wong developed the International Network On Personal Meaning (INPM).
Patterson-Sterling (2004) expanded Frankl's concepts of personal meaning into an AFT Existential Model. With this existential framework, therapists help families impacted by addiction understand that these experiences of coping with addiction are opportunities for greater personal growth. Individuals recovering from their addictions and their loved ones do not only concentrate on goals related to physical sobriety. Instead, these people learn to heal old emotional attitudes and behavioral patterns related to the addiction cycle. In particular, individuals in recovery learn to deconstruct their addict constellation of behaviors and loved ones recognise the importance of changing their old coping styles. Furthermore, partners and family members as well as individuals in recovery become aware of rescuing caretaker cycles in order to create healthy relationship boundaries (Patterson-Sterling, 2004).
Initial stages of healing may be different for people depending on whether they were in active addiction or in close relationships with addicted individuals. Thus, recovering addicts or alcoholics and their loved ones need to be aware of each other's journeys toward healing so they can understand each other's personal growth and emotional changes. Once people learn about transcending the chaos of addiction cycles during these earlier stages, then they can focus on connecting with a deeper sense of meaning in their lives (Patterson-Sterling, 2004). Such individuals transform the pain from their experiences with addiction into opportunities for personal transformation. As a result, addiction becomes the impetus for these people to reach out and connect with a larger experience as they find meaning in their lives.
Frankl describes suffering as the distance between who people were and what they are yet to become. Thus, addiction is a gift in which individuals explore the depths of their weaknesses only to realise the strengths that were never utilized until these adverse situations (the addiction) occurred. Both individuals recovering from addictions and their loved ones explore the dark periods of their lives in order to realize the inner light of strength that exists from within as they make the necessary changes to find happiness in life.
With an existential focus, people get to become more than the sum total of their deficits, interactional patterns, and behaviors. These people maintain their individualities, rather than being viewed as a one dimensional construct impacted by addiction. Furthermore, addiction is no longer a shameful deficit or an example of bad genetic luck. Life is a series of never-ending learning lessons. Addiction then becomes an opportunity for people to explore the depths of suffering in order to understand their humanity as well as their full potential to live life with meaning in purpose. As darkness needs light, so does mankind often need suffering in order to grow on deeper emotional levels.
The field of research in Existential AFT is blossoming. Patterson-Sterling (2004) wrote Rebuilding Relationships In Recovery: A Guide To Healing Relationships Impacted By Addiction. In the next several months study groups will form to examine the concepts of Rebuilding Relationships In Recovery (Triple R Healing Model) as an eight part AFT workshop series. There will be studies including a control group as well as pre and post treatment outcomes. Longitudinal outcome measures of six months, one year, three years, and five years will be included as well. Furthermore, a network of Rebuilding Relationships In Recovery (Triple R Healing Model) support groups are starting. Individuals in recovery and their loved ones will have opportunities to attend support groups and practice the existential principles of the Triple R Healing Model together.
In summary, the existential model is an exciting development in the field of AFT. The challenge will be to expand the existential approach from a frame of reference or paradigm to a series of expansive counselling protocols that not only include AFT, but general addictions counselling treatment as well.
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