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1 the american association for marriage and family therapy FamilyTherapy m a g a z i n e november december 2010 addiction Don t miss the AAMFT Institutes for Advanced Clinical Training brochure inside

2 Visit and click on AAMFT Online Store Pioneers of Family Therapy The Pioneers of Family Therapy booklet contains brief biographical information on 25 of the innovators in the family therapy field, along with a Family Therapy Genogram, which documents the time line and history of our profession. Also included in the booklet is a DVD of the 2009 AAMFT Annual Conference plenary session by Bruce Kuehl, PhD, which addresses the founders of the MFT profession.

3 addiction FamilyTherapy November/December Volume 9 Number 6 Features 10 Tips for Selecting and Working with a Substance Abuse Treatment Center Selecting a treatment center is one of the most important decisions a family and their addicted loved one will make in their journey to healing. This article discusses how to assess the level of care needed for an addicted individual, how to evaluate the treatment facility and program, and how to prepare the family for aftercare. Sarah Stuchell, MA 14 Interview with Peter Steinglass, MD Family Therapy Magazine interviewed Dr. Peter Steinglass to get his take on changes he has seen during his career in addiction treatment and the role of family therapists. 15 Interview with C. Everett Bailey, PhD Family Therapy Magazine talks to Clinical Member C. Everett Bailey, PhD, about the nature and characteristics of addiction, prescription medication addiction, and factors that make some people more susceptible to addiction. 16 The Way It Was: Challenging the Myths of Addiction and How Treatment and Research Have Changed The author looks back to the early days of addiction and recovery programs and how treatment models and ideas grew and changed from the 1970s to today, and how the mental health profession has changed along with it. Meri L. Shadley, PhD 20 A Look at Addiction and Ethnicity with a focus on the Chickasaw Nation of Ada, Oklahoma: Substance Abuse Issues, Families, and Life in Indian Country What are the myths about American Indians that shape theory and practice, research and outcomes? Native Americans number approximately 4.4 million citizens in 517 tribes and close to 300 language and tribal groups, with a plethora of unique cultures, histories, and traditions. Waymon R. Hinson, PhD 25 Painkiller Abuse A medical doctor shares her view of prescription medication abuse and addiction and the complexities of comorbidity. Kimberly Dennis, MD Departments 2 President s Message 3 Noteworthy 5 Advocacy Update 29 Practice Strategies: Offering Consultation to Couples and Families in Business 30 Ethical & Legal Matters: Confidentiality in Systemsbased Therapy 32 Clinical Update: Bullying 38 Classifieds 38 Calendar Letters to the Editor We encourage members feedback on issues appearing in the Family Therapy Magazine. Letters should not exceed 250 words in length, and may be edited for grammar, style and clarity. We do not guarantee publication of every letter that is submitted. Letters may be sent to or to Editor, Family Therapy Magazine, 112 South Alfred Street, Alexandria, VA Twenty-five percent of this paper is post-consumer recycled material and preserves trees, saves 7,429 gallons of wastewater flow, conserves 12,387,806 BTUs of energy, prevents 822 lbs of solid waste from being created, and prevents 1,618 lbs net of greenhouse gases. The American Association for Marriage and Family Therapy n o v e m b e r d e c e m b e r

4 p r e s i d e n t s m e s s a g e FamilyTherapy Volume 9, number 6 Executive Editors Michael Bowers Karen Gautney Managing Editor Kimberlee Bryce Legislative Editor Tracy A. Todd Advertising Corey Newman Design and Print Good Printers, Bridgewater, VA Family Therapy Magazine (ISSN ) is published bimonthly (January, March, May, July, September, November) by the American Association for Marriage and Family Therapy, Inc., 112 South Alfred Street, Alexandria, VA Printed in the USA. Periodical mailing from Alexandria and additional entry points by the American Association for Marriage and Family Therapy (AAMFT), Inc. All rights reserved. Written permission for reprinting and duplicating must be obtained through the Copyright Clearance Center at The articles published in the Family Therapy Magazine are not necessarily the views of the association and are not to be interpreted as official AAMFT policy. During a time of increased acrimony and uncertainty, we can be proud to serve in a profession dedicated to our fellow community members and the greater good we can accomplish in the world. As I have shared with you, I believe that most of us chose marriage and family therapy as a career because we love our profession. Our motivation comes from a spot deep within us, a calling, and informs our passion for our field. I know this to be true for myself. My passion for MFT and the AAMFT is a heart issue, and I love this profession and this Association. Whether this period in history is one of the most trying in a generation or a century, there is no question that the people with whom we work every day face challenges in their families, workplaces, and communities with little precedent in most of our lifetimes. It has been rewarding to work with you, my colleagues, who share my belief and confidence in the healing power of relationships, the big idea that relationships matter. 1/2ad:Layout 1 1/16/08 12:52 PM Page 1 Like many professions in these demanding times, we have also faced daunting tasks, and I am proud of the work we have done as an Association to rise to those challenges. I am grateful to each one of you for your contribution to our success. Thank you. As MFTs, we also bear witness to the genuine causes for hope and determination that drive so many with whom we have the privilege to work. The people we see every day are doing incredible things in the lives of their families, friends, neighbors and communities to overcome odds we strive to make more surmountable. And we as an Association are doing our part to plan for the continued viability of our profession to make this work possible now and in the future. We have captured the spirit of optimism and hope, we have worked with you as our members to co-create a vision for a strong future, and we are dedicated in our commitment to sustain a dynamic profession and Association we can be proud to share and pass on. Together we have accomplished great things. - l i n d a s c h w a l l i e, m s Submission of manuscripts: Manuscripts may be submitted electronically to org or mailed to: Editor, Family Therapy Magazine, AAMFT, 112 South Alfred Street, Alexandria, VA Telephone: (703) Concise articles (2000 words or less) are preferred. Authors should allow at least two months for a decision. Advertising deadline for both classified and display advertising is approximately eight weeks before the month of publication. Please call (703) for exact deadline dates or visit All advertising must be prepaid. POSTMASTER: Send address changes to: Family Therapy Magazine 112 South Alfred Street Alexandria, VA Consumer Updates educate the public while marketing your practice The companion piece to the topics found in Clinical Updates for Family Therapists, Vols. 1, 2, and 3; the Consumer Updates are written for the general public and designed to educate consumers and market your services to potential clients. The brochures contain easyto-understand information and resources and discuss the role of marriage and family therapists in treating problems affecting the public. Conveniently packaged in sets of twenty-five by topic, Consumer Updates have space on the back to attach your business card or imprint practice or contact information. $8.75 for members $11.25 for non-members. Order online at or call (703)

5 noteworthy n e w s an d ha p p e n i n g s fr o m th e aa m f t In Memoriam The AAMFT announces the loss of a beloved member and past president. Anthony P. Jurich (Tony), president of the AAMFT from , and his wife, Olivia Collins, were walking on the beach in Mexico when a rogue wave struck them, and the ensuing undertow pulled them away from the shore and below the surface. Both were reached and Olivia was revived by rescuers, but Tony could not be. A news article reporting on the accident has been referenced in a blog on the AAMFT Community (www.aamft.org/community). Tony was in phased retirement from Kansas State University (located in Manhattan, KS) after more than 28 years of teaching and mentoring. Gifts in memory of Tony can be made to the following organizations: The Guerney Marriage and Family Therapy Scholarship for Graduate Students at Kansas State University. Shared Table, El Pueblito United Methodist Church, to feed the hungry people of Taos, New Mexico. Pastor Steve Wired can be reached at The Food Allergy and Anaphylaxis Network, in honor of his nephew and best friend Jake Jurich. Stray Hearts Animal Shelter, to care for the companion animals of Taos County, New Mexico. Letter to the Editor Excellent, excellent article in the last issue on psychogenic non-epileptic attacks. I had been researching this information, but could not afford to buy a number of books on such a specialized topic, nor did my colleagues have such in-depth knowledge. Very much appreciate this a w a r e n e s s da t e s February National Children of Alcoholics Week National Association for Children of Alcoholics February Barbara Massey, MA, Clinical Member, Medford, OR National Eating Disorders Awareness Week National Eating Disorders Association The AAMFT offers a variety of consumer brochures that can be used in your office (with space on the back for your stamp or business card) or used in direct mail marketing for your practice. Visit our online store at to order brochures on Children of Alcoholics and Eating Disorders. Sunflower Casa Project, to support the advocates for children in need of care in Manhattan, KS, and the surrounding area. n o v e m b e r d e c e m b e r

6 New and Recently Published Titles FAMILY THERAPY William J. Doherty and Susan H. McDaniel pages. Paperback. List: $24.95 ISBN ANXIETY IN CHILDBEARING WOMEN Diagnosis and Treatment Amy Wenzel pages. Hardcover. List: $69.95 ISBN DISTINGUISHED BOOk AWARD, SOCIETY FOR THE PSYCHOLOGICAL STUDY OF LESBIAN, GAY, BISEXUAL AND TRANSGENDER ISSUES (APA DIVISION 44) LESBIAN AND GAY PARENTS AND THEIR CHILDREN Research on the Family Life Cycle Abbie E. Goldberg pages. Hardcover. ELUSIVE ALLIANCE Treatment Engagement Strategies With High-Risk Adolescents Edited by David Castro-Blanco and Marc S. Karver pages. Hardcover. List: $69.95 ISBN List: $69.95 ISBN STRENGTHENING COUPLE RELATIONSHIPS FOR OPTIMAL CHILD DEVELOPMENT Lessons From Research and Intervention Edited by Marc S. Schulz, Marsha Kline Pruett, Patricia K. Kerig, and Ross D. Parke pages. Hardcover. List: $79.95 ISBN RISk ASSESSMENT FOR DOMESTICALLY VIOLENT MEN Tools for Criminal Justice, Offender Intervention, and Victim Services N. Zoe Hilton, Grant T. Harris, and Marnie E. Rice pages. Hardcover. GRIEF IN CHILDHOOD Fundamentals of Treatment in Clinical Practice Michelle Y. Pearlman, Karen D Angelo Schwalbe, and Marylène Cloitre pages. Hardcover. List: $69.95 ISBN PLAY THERAPY FOR PRESCHOOL CHILDREN Edited by Charles E. Schaefer pages. Hardcover. List: $69.95 ISBN List: $69.95 ISBN APA LifeTools HOW TO FIND MENTAL HEALTH CARE FOR YOUR CHILD Ellen B. Braaten, PhD pages. Paperback. List: $19.95 ISBN WHEELS DOWN Adjusting to Life After Deployment Bret A. Moore, PsyD, ABPP and Carrie H. Kennedy, PhD, ABPP pages. Paperback. List: $19.95 ISBN f a m i l y t h e r a p y m a g a z i n e

7 advocacy u p d a t e Federal Department of Veterans Affairs (VA) Starts Hiring MFTs After four years of steadfast pressure, lobbying and collaborating with other associations by the AAMFT, the VA has issued qualification standards formally recognizing marriage and family therapists as mental health specialists within that agency s clinical division, the Veterans Health Administration (VHA). At present, VA is uncertain of the process to post new MFT jobs, but expects to use some combination of postings at the websites USAJobs.gov and/ or VA.gov. The AAMFT plans to cross-post VA job openings on the AAMFT Job Connection. We expect that VA will ultimately employ 100 or more MFTs. The AAMFT is pleased that the VA has finally acted to approve these jobs. In addition, at the AAMFT s request, MFTs who hold a doctoral degree without an intervening masters will be eligible for hiring, reversing a puzzling preliminary decision that would have made such MFTs ineligible. (In contrast, counselors who hold doctoral degrees without intervening masters are ineligible.) In 2006, the AAMFT and counseling groups persuaded Congress to change federal law to allow the Department of Veterans Affairs (VA) to hire licensed MFTs and counselors. The VA has a growing need for such practitioners due to the increase in mental health problems among recent military veterans. The AAMFT does plan to formally appeal two aspects of the MFT job description. First, the job description does not specifically include authority to diagnose. Although most state MFT licensure rules include diagnosis, 14 states do not, despite the fact that MFTs in those states do diagnose in practice. Second, only MFTs who are graduates of COAMFTE-accredited programs are eligible, but other types of professionals such as social workers would be eligible for hire as marriage and family therapists, if those other persons meet certain additional requirements. Division Advocacy c a n a d a AAMFT members in Canada are celebrating the accomplishment of one of their major advocacy initiatives. The Canadian Registry received the official bulletin from Medavie Blue Cross inviting Registered Marriage and Family Therapists (RMFTs) in Quebec to register as mental health providers for Veterans Affairs Canada. The current decision affects only Quebec since Quebec is the only province in Canada where marriage and family therapists are regulated. However, an officer with Veterans Affairs Canada has informed the Canadian Registry that once other provinces follow Quebec and adopt provincial regulation of the profession, MFTs from those provinces will be invited to provide mental health services for Veterans Affairs Canada clients. This accomplishment is a result of advocacy meetings in Ottawa over the past 18 months. Congratulations to the Board of the Canadian Registry and all other AAMFT members in Canada on this significant accomplishment. n o v e m b e r d e c e m b e r

8 advocacy u p d a t e 2010 Division Advocacy Accomplishments Congratulations to many of the AAMFT s divisions for achieving their legislative and other advocacy goals for 2010! The table below lists many of these important advocacy accomplishments. Some advocacy accomplishments may not appear on this table. DivisioN Advocacy Goals Accomplished in 2010 Alaska Connecticut Hawaii Illinois Kansas Louisiana Mid-Atlantic Mississippi Missouri Nebraska New Jersey New Mexico New York North Dakota Oklahoma Quebec Tennessee Utah Virginia Washington West Virginia extension of the existence of the MFT licensure board Amendments to the MFT scope of practice Defeat of legislation that would have eliminated licensure of MFTs MFTs added as qualified examiners who can sign emergency petitions recognition of MFTs by Blue Cross Blue Shield of Kansas Amendments to the MFT educational requirements and the addition of another MFT to the licensure board MFTs grandparented into licensure in Maryland can now serve on the licensure board MFTs can perform services within state government that social workers can perform licensure for MFT associates Medicaid agrees to reopens reimbursement for provisionally licensed MFTs MFT degree now included as a qualifying degree in several state job classifications Adoption of the initial rules for MFTs who serve in the public schools MFT associate supervision hours that were earned at non-profit clinics will be recognized by the licensing agency Adoption of the initial rules for MFTs MFTs in private practice can become Medicaid providers MFTs can now become registered providers for clients in Veterans Affairs Canada Freedom of Choice (vendorship) for MFTs licensure for MFT associates MFTs added as eligible to serve as administrators in the state sex offender treatment program Defeat of legislation that would terminate the MFT advisory board Amendments to the MFT licensure law and adoption of the initial rules for MFTs 6 f a m i l y t h e r a p y m a g a z i n e

9 AAMFT PAC The AAMFT PAC helps in establishing Congressional allies, and member contributions assist with advancing the profession of marriage and family therapy in the United States. The following are PAC contributors from August 1, 2010 through September 30, Thank you! Silver Level Contribution Gehart, Diane R.M. Bronze Level Contribution Maronick, Elaine T. Ziminski, Karen E. Blue Level Contribution Aarssen, Kathleen M. Agulnik, Debra B. Alexander, Andrea L. Alexander, Linda L. Allen, Glenda L. Ambrosia, Linda L. Anderson, Randee S. Archuleta, Kristy L. Armstrong, Kenneth B. Arnold, Amy R. Ashby, Myrna L. Ashley, Carol J. Ashley, Talaria Bacon, Will C. Badenoch, Bonnie L. Badger, Susan C. Bagley, Julia E. Bailey, Deborah C. Bailey, Janet M. Ball, Derek A. Baron- Murray, Edena Becker, Carol Belcher-Belshay, Leni R. Bell, LaCheryl Benard, Donna L. Bennett, Judy S. Bensch, Eric F. Bercik, Jerome Berger, Tracy H. Bernstein, Audrey J. Bernstein, Robin S. Berry, Lori T. Bertani, Mary K. Berube, John D. Billone, Lorena Bingham, Ann B. Bittle, Mary Bizzell, Janette Blair, David M. Blair, Susan B. Blanchard, Danny E. Bliss, Deidre P. Boone, Paula W. Boots, Sabine Bordieri, Regina Born, Randi K. Boyd, Glenn E. Boyland, Kurt P. Bradley, Larry A. Breihan, Robert E Brix, Cassandra M. Brockway, Louise M. Bross, Mary Louise Brown, Chris Brown, E. Glyn Brown, Harry L. Brown, Judith H. Brown, Rachel M. Brown, Stephanie M. Buckner, Ned A. Buhl, M. A. Jane Buhrow, Robert Burch, Matthew J. Burr, Patricia A. Butto, Anthony G. Cahill, Cindy M. Calcagno, Stephanie A. Califano, Robert N. Carlisle, Jeffrey E. Carlson Schamberger, Cynthia J. Carney-Carder, Gail D. Caro, Doris B. Carpenter, Georgia Carter, Marilyn J. Case, Susan L. Cawlfield, Johnny R. Chambers, Jeri P. Chand, Maitri S. P. Charpentier, Claire Chernaik, Laura S. Chernin, Stacey A. Chewning, Dudley G. Churchill, Chiyo M. M. Clements, Debra J. Colberg, Michael D. Collins, Claire M. Colter-Antczak, Leslie S. Columbus, Ulrich C. Connaghan, Kelsey L. W. Corley, M. Deborah Correa, Yolanda Crane, Canaan R. Crippen, Stephen D. Cristo, Jill R. Crites, Dorothea E. Crockett, Juan M. Crook, Amy J. Crownover, Randy L. Cummings, Rose Marie Curd, Michael T. Cutshaw, Jeannette M. Dale, Helga S. Dambara, Joshua Davingman, Stephanie L. Davis, Ann A. Davis, Freddie L. Davis, Genevieve A. Delaney, Mary J. DeMers, Amy E. Desai, Amisha D. Deters-Smith, Gretchen Devlin, Kirsten M. Diaz, Rosa Maria Dietrich, Linnea F. Dimon, Patricia A. Dombrowski, Kathleen A. Donovan, Kelly L. Dornig, Katrina A. Douglass, Marvin E. Drew, Carter Drew, Glenda M. DuBois, Richard L. Dunning, Toni D. Echevarria-Doan, Silvia Eckerman, Heather L. Eiseman, Brenda K. Emmanuel, Donna Ens, Clarence J. Erb, Timothy J. Esmeralda, Aileen A. Falconier, Mariana K. Faragher, Denise J Farley, William T. Farwell, James S. Feder, Rosanne Feldhousen, Elizabeth B. Feldtmose, Patricia C. Ferrigno, Jesseca L. Finley, Robert G. Fishman, Laura R. Fitzgerald, Cynthia S. Fitzgerald, Teresa Flaningam, Ann Marie M. Fleck, Dorothy T. Fledderman, Lisa Marie Foster, David L. Frank, Rhonda R. Freeman, Sheryl J. Friedman, Lisa B. Frith, Martin P. Frost, Harriet B. Fuston, Anita L. Gable, Emily L. George, Jayashree Geraud, Lisa C. Gewirtz, Barbara Gilman, Jonathan M. Giulietti, Rebecca Kronk Gleizer, Jennifer E. Gnatovich, Hallie Gnatovich, Stana M. Goldberg, Lynn Goss, Erin E. Gray, Nancy L. Gray, Robin F. Guedet, Gabrielle Guerrera, Christine A. Guillot, Viki Wall Guiry, Robert W. Gundy, Donna D. Gurnoe, Sam A. Hall, Patrick J. Hammerman, Thomas Hansen, Russell A. Harris, Nicole L. Harris, Stephen D. Harrison, Nikita M. Harrison, Starr Haskin, Katherine J. Hawkins, Angela K. Hayek, Patricia M. Haym, Coreen Heintz, Samantha C. Henderson, B. Janettee Hendricks, Monique Hershman, Linda J. Herzmark, Nicholas Hess, Jenna E. n o v e m b e r d e c e m b e r

10 advocacy u p d a t e Hightower, Tess R. Hill, Claire M. Hiscock, Delreen I. L. Hodgson, Jennifer L. Hoffman, Sheila Hollandsworth, Phyllis W. Homan, Caroline C. Horak, Joseph J. Horne, Rebecca S. Hossfeld, Elizabeth M. Hostikka, Theodore D. Howard, Jamie Hubbard, Darci L. Huffman, Clinton L. Hughes, Rita Hunt, Judith G. Hurley, Tara M. Hutchins, Richard C. Hutton Levenson, Judith V. Ix, Karen D. Jabs, Carol A. Jackson, Rhonda M. JacobsCarter, Sara J. Jaffe, Jaelline J. James-Abra, Karen Jella, Steven H. Johansen, Margaret A. Johns, Paula D. Johnson, James A Johnson, Marie D. Johnson, Mary Margaret E. Johnson, Nancy D. Jones, Rebecca A. Joseph, Erica L. Juarez, Jean M. Kapphahn, Jennifer E. Karam, Tracy L. Karlsberg, Jeri Ann Karstens, Keith A. Kaspzyk, Ronald J. Kassel, Gina M. Kayser, Rachel D. W. Keller, Curt D. Kelley, Carol L. Kelley, Jennifer B. Kellogg, Todd T. Kess Evarts, Barbara E. Khani, Sandi Kilchenman, Lacey A. Kim, Kyung H. Klock-Powell, Kathryn Kornell, Carl W. Kosaka, Megan I. Koslow, Kathryn P. Kovacs, Ruth Kozlay, Jennifer N. Kreofsky, Leslie A. Kries, Carole A. Krimmer, Rachel A. Kurihara, Elizabeth Lai Lachapelle, Elizabeth R. Lam Seto, Jacqueline Siu Yin Lamun, Byron A. Lance, Kim C. Landis, Gary D. Lane, Mary Jane LaPell, David E. LaPlante, Donald E. Law, David D. Lawrence, Ronald W. Leahy, Katherine Learing, Emily Leavy Hoelscher, Maria Lee, Bonnie Leith, Jessica M. LeMay, Leona D. Levendis, Nicki M. Levers, Ashley Lewis, Karen C. Lewis, Patricia Parker Li, Lin Lierman, Diane B. Likcani, Adriatik Lind, Mona-lisa Lindberg, Jennie A. Lindsay, Tiffani J. Little, Jesse K. Littlejohn, Tammy R. Locke, Jacquelyn N. Lopez, Daniel D. Lo-Presti, Bruno F. Lucas, Brenda L. Ludy, Mary L. Luft, Elisabeth Lutz, Stacy David Lyons, Jordan Mahr, Carol A. Malfer, Bridget B. Mallozzi, Paola L. Malone, Patrick T. Manacher, Allegra K. Manley, Marybeth Manlove, Abraham P. Mannle, William L. Marquez, Rafael A. Marr, Christine Marshall, Bethany A. Marshall, Diane L. Marshall-McLean, Shelia C. Mason, Anne E. Mathis, Sandra S. Mathurin, Marie J. Mattox, Crystal J. Maudlin, Karen L. Maynard, Marian L. McAlpine, Julie McBride, Laura McCarthy, Carol S. McCauley, Rachel G. McCleary, Jim McCormack, Margaret G. McCracken, Daniel C. McEachin, Charla McEliece, Constance Jeannette McGlathery, Michael D. McInerney, Cathleen M. McIntyre, Barbara J. Mckenna, Yvonne E. McKinney, Alicia D. McLean, Sasha Coles McTighe, Tim W. Mee, Judith A. Mendonca, Dennis Mennenga, Kayla D. Merlo-White, Nicole L. Miller, Carol A. Miller, Ellen E. Mills, Lilbourne I. Mire, Gloria E. Mitchell, Tim S. Moore, Barbara A. Moreland, Linda Mosley, Martha L. Moss, David M. Moyer, Alfred J. Mudrick, Nicole R. Mueller, Charles M. Mullen, Barbara A. Mulqueen, Dawn P. Munyiri, Grace N. Muras, Heather A. Murphy, Kevin M. Murray, Drew D. Mutter, Kelvin F. Myers, Margaret E. Nagel, Mark A. Nelson, Duane T. Nino, Lizabeth E. Niskey, Jayne E. Noble, Robert J. Norman, Margaret J. Norris, James M. Northey, Sarah S. Oh, Booun Ohlhaver, Charles T. Orosco, Lauretta J. Osterlund, Danie-Marie Owen, Gerry Pacheck, Cory T. Padoko, Sarah Pannett, Sandy Parkey, Rebecca J. Parks, Jeffrey A. Peters, Kathleen H. Peterson, Kent Petkov, Barbara J. Petz, Gerlinde E. Pfeil, Susan M. Phillips, Laura M. Pile, Cara M. Pinson, Danielle D. Piper, Michelle A. Poindexter, Michael J. Posey, Samantha J. Potter, Carol A. Powell, Jerry D. Price, Stephen M. Procello, Richard Prudhomme, Amy L. Pruitt, Vera Gail Purkey, Walter R. Quick, Susan J. Quinn, Michael G. Rainey, Cheryl A. Rausch, Deidra Taylor Rebagliati, Blanca M. Reis, Patricia G. Reynolds, Susan E. Richards, Karen J. Richnofsky, Linda M. Rickel, Annette Urso Riggs, Barbara A. Riley, Pamela J. Rio, Linda M. Rissmiller, Vicki L. Rivera, Donnamarie Roberts, Monica Kim Robinson, La-Quesha S. Rodgers, Kimberly Ann Rodriguez, Iristela Rogers, Tyler A. Rosabal, Babette M. Rossing, Ann Marie Roy, Margaret H. 8 f a m i l y t h e r a p y m a g a z i n e

11 Ruddy, Nancy B. Rutter, Julie M. Ryan, Jane M. Ryan, Shirley A Salek, Ursula M. Salgado, Margie A. Samuels, Diane Sandberg, Cassandra Sanderson, Jessica Sangree, Joan S. Sannazzaro, Joseph R. Sawyer, Gregory S. Sazama, Kathy J. Schaefer, Erin C. Schatten, Florence A. Schlossberg, Phyllis Schneider, Elisabeth Tullis Schroeder, Emily D. Schuermann, Victor A. Schwing, Mary C. Sciutto, L. Allen Scott, Andrea S. Scott, Roxanne I. Seevers, Mary Deger Sexton-Small, Katherine M. Shendge, Manisha S. Sherbin, Candice U. Sherer, Leatrice Mankin Shinefield, Jacqueline Sierra, Vivian M. Silzer, April C. D. Simmons, Deborah S. Sinclair, Janet Slater, William C. Sliwa, Michael J. Smith, David M. Smith, Kimberly M. Smith, Lynne M. Smith-Cohen, Jodi Sosnowski, Danielle N. Spann, Lynda Speth, Pamela B. Spillane-Bramlette, Susan J. Stansbury, Sydney L. Stanton, M. Duncan Stebick, Melissa Steinberg, Jeffry D. Stewart, Sally L. Stoker-Mtume, Norma R. Stout, Paula F. Strassler, Meryl Strausbaugh, Donita M. Stripling-Huna, Emily J. Strzok-Scheidegger, Stephanie M. Studer, Constance L. Sturlaugson, Deanna C. Stutzman, Susan C. Switala, Izabela B. Tatkin, Stanley J. Taus, Stephen D. Tesch, Susan M. Thalasinos, Michael Thomas, Michael M. Thompson, Robert W. Thompson, Thomas N. Thurber, Shawn L. Tietz, Peggy Kruger Tilley, Timothy Top, Sherwyn G. Trabue, Dwight M. Trujillo Arevalo, Alejandra Trusley, Vicki Tufts, Katie J. Van Eron, Kevin J. Van Eron, Valli Van Schaack, Jeanne P. Vande Voort, Richard Vaughn, Emily Sears Vea, Sharon A. Venison, Sarah-Kate Vinton, Melanie M. P. Von Seydewitz, Thomas M. Wahle, Lynn Waks, Beth W. Walatkiewicz, June A. Walker, Xanthippe B. Walters, Cynthia L. Walters, William P. Ward, Naomi T. Ward, Richard L. Watkis, Sharon B. Watson, Jared A. Watts, Sandra L. Weinshel, Margot P. Wenzel, Virginia L. West, Gina N. West, Mark Whelchel, Scott A. White, Richard S. White, Sarah A. Whitney, Martha L. Wilder, Kevin Lee Williamson, Denise C. Wilson, Verne Wingate, Meka T. Winstead, Vicki Wisne, Kathryn M. Wogan, Hilary W. Wolfe, Ronald C. Woods, Kale Wright, Venita W. Young, David W. Yutkewich, Sara Yutkewich, Sara Zacharias, James L. Zaitz, Donna M. Zangari, Mary-Eve C. Zboyan, Sandra C. Zeman, Linda S. Zimmerman, M. Joan There Are Many Reasons CPH and Associates Is The ONLY Provider Of Professional Liability Insurance ENDORSED by AAMFT Incredibly Low Rates Start at: $111-$263 for Licensed MFT s BEFORE discounts $95-$97 for Post Masters/Interns under supervision Save 2 Kinds Of GREEN With Our ONLINE Application SAVE 5% Off Your Professional Liability Premium Just For Purchasing Or Renewing Online. Use Less Paper And Save A Tree! Available Discounts Newly Licensed: 50% off for Professionals licensed for the 1st time within 12 months 25% off for Professionals licensed for the 1st time within 24 months Risk Management: 10% for completing law and/or ethics CEUs Note: a combination of discounts cannot exceed 50% of your Professional Liability premium P F n o v e m b e r d e c e m b e r

12 Tips for Selecting and Working with a Substance Abuse Treatment Center Sarah Stuchell, MA 10 f a m i l y t h e r a p y m a g a z i n e

13 Selecting a substance abuse treatment center is one of the most important decisions a family and their addicted loved one will make in their journey to healing. Selection of a treatment center and treatment itself is usually hard for the addict to do on their own, and treatment can be one of the most frightening and life changing events for everyone involved. When considering a treatment center, it is important to remember that all treatment centers are not created equal, and a one size fits all approach to treatment is not usually successful. The following tips can serve as a guide to help family therapists assist individuals and their family members choose and work with a treatment center. Step One: Assess the Level of Care Needed for the Addicted Loved One There are several levels of care for drug and alcohol treatment. These include medical detoxification ( detox ), inpatient/ residential, and outpatient. One rule of thumb is: the higher the frequency of use, the higher the level of care needed. Detox is the medical treatment of drug/alcohol withdrawal. It is required when the individual is expected to have dangerous, sometimes deadly, withdrawal symptoms upon stopping the drug/alcohol use. Generally speaking, withdrawal from alcohol, Benzodiazepines, and Barbituates can be deadly and require detoxification. Withdrawal from other drugs can be just as painful, but not as lethal, and detox could provide a more comfortable withdrawal process. A medical doctor or addictionologist (MD) will be able to assess whether or not a formal medical detoxification process is required. Some residential treatment facilities provide detox services on site. If the addicted individual is going to require an extensive detox process, you may want to consider a treatment center that offers onsite detox services in conjunction with residential treatment. The medical staff at these facilities can oversee the progress of the patient and make necessary adjustments to the treatment plan during the entire treatment process, creating a seamless and comfortable transition from the very beginning to completion of treatment. Inpatient versus outpatient. Selecting either residential or outpatient is an important decision. Residential treatment allows the family s loved one to live onsite and participate in counseling for 30, 60, or 90 days. Residential treatment is warranted for those who have been abusing drugs or alcohol heavily, are unable to quit on their own, appear to need heavy monitoring, are emotionally distraught (i.e., anxious, depressed, suicidal), have active cravings, are addicted to more than one drug, and appear to be spiraling out of control. Outpatient programs are typically a later-stage option. It may be an option, however, if the individual is able to quit drug use on his or her own without medical risk and the usage is fairly light. In an outpatient program, the patient resides at home, and participates in group and/or individual treatment at scheduled times throughout the week and receives regular drug testing. Length of stay. Deciding upon a length of stay is very important. Most addicted individuals will be resistant to treatment at the outset and will only want to complete the shortest amount of time possible. It is in the best interest of everyone to have the patient complete the longest amount of treatment possible. Studies indicate that treatment success, or the ability to remain sober after treatment, increases with length of treatment. Allowing the individual the time and space to heal and be sober is important in overcoming addiction. Most addicts and alcoholics need a safe place, like a treatment facility, to push through their cravings, overcome their fears, manage their emotions, learn interpersonal skills, and face their shame and guilt without the triggers and reminders in their home environment. n o v e m b e r d e c e m b e r

14 Step Two: Evaluate the Treatment Facility and Program Tour the facility. Encourage the family and their addicted loved one to tour treatment facilities in order to get a real life experience at the facility. Only a real life experience will help all involved be comfortable in making a decision. Most admission counselors can schedule these tours in which you will be able to walk the grounds, meet staff and therapists, and possibly other clients. Touring will help you get a feel for the center and determine if it is going to be a good fit. The patient will need to be comfortable in order to be open to treatment. Location of the facility. Assess with your client and their family whether or not the addicted individual should go to a treatment center that is in the same city where you and the family are located, or go to another city or state. For many addicts, it is very helpful to leave their hometown because it takes them out of their using environment and reduces the temptation to leave treatment early or engage with their drug dealers. However, distance makes it hard for other family members to participate in treatment, so choosing a treatment center near home may be a better option for those who want a significant amount of family participation. Addicted loved ones may The following chart outlines things to remember as a quick point of reference to share with families: Don t Cash out of your retirement funds or spend all of your life savings on a treatment center Abandon your addicted loved one or enable them to continue to use drugs or alcohol Avoid your own pain and discouragement Be held hostage by an addicted loved one s disease Think that after attending a treatment program your addicted loved one is cured Believe everything your addicted loved one says Believe in a quick fix Blame yourself or your addicted loved one Do Find a treatment center that is affordable to you and within your budget Provide supportive encouragement and treatment opportunities for them to get better Seek therapy for yourself and family members Set limits and boundaries of what you will and will not tolerate or accept from them Prepare for relapse after treatment and create a longer term treatment plan for about 1-2 years post treatment center Watch his or her behavior and dedication to getting well View addiction as a chronic condition that needs to be managed Blame the life-changing destructive substance even be allowed a weekend or day pass in which they can reintegrate in their home environment or with their children, and practice applying the new skills they are learning while in treatment. Cost of treatment. If left untreated, the cost of alcohol or drug abuse will far exceed the cost of treatment. However, the price of treatment is meaningful only in the context of quality and performance. As a good first step, a responsible family member should call the appropriate insurance provider and find out what treatment options and coverage are available. The insurance provider may even be able to provide a few referrals to treatment centers that are in their network. If you and the family decide on a treatment center that is not in the network, ask the center if they can work with the insurance company, or provide a superbill for services, for reimbursement. Be sure the family knows that deciding whether or not they are going to be using insurance should be worked out before beginning treatment. Insurance authorization will be required on the day of admittance, and most facilities will be working closely with a case manager from the insurance company on almost a daily basis to continue to get authorization for treatment services. If your client family cannot afford a private treatment center, they will need to look into a public, subsidized or non-profit facility. A local hospital or clinic should be able to provide a list of available options. You can also research local, state, and federal government programs to see if there is any funding available. State licenses and credentials of facility and staff. Do a background check to make sure the facility is licensed for the services they are providing and that their license is current. See that the treatment team is multi-disciplinary and diverse, including a range of professionals, such as, but not limited to, medical doctors (MDs), addictionologists (MDs), psychiatric nurses, psychologists (PhD/ PsyD), marriage and family therapists (LMFTs), registered nurses (RN), registered dieticians (RD), certified addiction counselors (CAADAC), etc. Some state regulations do not necessarily 12 f a m i l y t h e r a p y m a g a z i n e

15 Quality treatment centers will offer some degree of individual, group, and marital/family therapy. mandate a certain number of licensed or certified staff, if any. Program. The treatment program itself should be diverse and offer a range of activities and treatment modalities. A quality treatment center will incorporate the traditional Alcoholics Anonymous 12-step program with problem-specific and gender-specific treatment modalities. If the addicted individual is struggling with an underlying problem, such as an eating disorder, mood disorder, sexual trauma, marital problems, domestic violence, etc., find a treatment center that specializes in the underlying condition, as well. Gender-specific treatment facilities may be beneficial since women may feel more comfortable opening up around women, and men with other men. Co-ed facilities should provide both gender-specific and co-ed groups, since some problems, such as sexual abuse, may be inappropriate for co-ed group treatment. The program size may also be important to the individual. Whereas some treatment centers are fairly large in size, others offer a smaller, more intimate or private setting. Quality treatment centers will offer some degree of individual, group, and marital/ family therapy. Other holistic treatment centers may provide experiential therapy, such as physical fitness activities, yoga, massage, acupuncture, meditation, hypnosis, etc. Find out how many sessions are included in the treatment price. Some sessions may be purchased for an additional fee. Step Three: Engage with Treatment and Prepare for Aftercare Once in treatment, the family should give their loved one some space and allow them to engage and participate in treatment. Be sure they do not block, disrupt, or change the treatment protocol outlined by your client s treatment team. Any concerns should be discussed with the treatment center. As we know, it is common for those in treatment to be extremely resistant and negative toward the treatment facility and/or program in the beginning. Prepare the family to ignore the frantic phone calls they may receive from their loved one, perhaps begging to be released from treatment. These are all common effects of withdrawal, and treatment centers are usually well-equipped to handle these situations. It is the family members job to become educated about addiction, and to seek help for themselves. They can participate in the family sessions, and in their own individual therapy, and perhaps even attend Al-Anon support groups. As soon as treatment begins, everyone involved should begin to plan for discharge and aftercare. Residential treatment only interrupts the cycle of addiction, and the real work is often done once the loved one returns home. You can facilitate the family working collaboratively with the treatment center to develop an aftercare plan that is well rounded. Treatment centers should offer follow-up programs that help support and monitor recovery. The greater the involvement in longterm care, the greater the probability of sobriety. Tailor-make a structured aftercare plan that includes all the necessary components important for remaining sober: individual therapy, marital/family therapy, eating disorder specialist (whatever the underlying issue), outpatient groups, etc. Prepare for Relapse. Equip the family with information on relapse prevention and their role in assisting their loved one if/when relapse happens. Even though those struggling with addiction may intend to remain sober, most, if not all, find themselves using once again. You might suggest to the family that they draft a relapse contract before they leave the treatment center spelling out the terms of what the addicted loved one will be expected to do should relapse occur. For example, return to inpatient, attend outpatient, increase individual therapy sessions, random drug/alcohol testing, etc. Relapse is considered normal and part of recovery and preparations can be made. Remind the family not to turn a blind eye if they suspect using is occurring. The quicker the relapse is caught, the better. If handled correctly, the relapse can be used in a positive way to facilitate self-awareness and growth. Many addicts successfully learn from their relapses, and get back on track. n Sarah C. Stuchell, MA, is a licensed marriage and family therapist and a Clinical Member of the AAMFT. She is in private practice with office locations in Malibu and Newport Beach, California, and has worked as a consulting therapist to several drug and alcohol rehab centers in Southern California. Stuchell is completing a doctorate in MFT at Loma Linda University, and specializes in substance abuse research and treatment, as well as issues of gender, power and equality. n o v e m b e r d e c e m b e r

16 interview: changes in the field of addiction over the decades Family Therapy Magazine interviewed Dr. Peter Steinglass to get his take on changes he has seen during his career in addiction treatment and the role of family therapists. Dr. Steinglass is president emeritus and director of the Ackerman Center for Substance Abuse and the Family, New York, NY. Coming from a medical background, how did you get involved in the systemic treatment of addiction and working with families? It started back in the heyday of family therapy training and research at Albert Einstein College of Medicine. A cadre movement had emerged at the college, offering a very unique program with a series of systemic-related electives. It was there that Al Sheflin (author of Levels of Schizophrenia, 1981), a prominent researcher, would become a great influence on me. We know much has changed in the field regarding substance abuse and addiction in terms of treatment and approaches to deal with individuals and their families. What are some key changes you ve seen over the years that are perhaps benchmarks or milestones? There were quite a few shifts that occurred along the way. Notions held up to be gold standards in the 1960s and 70s simply did not pan out over time. One such view was tough love, or the confrontational approach. Over time, during the 1980s and into the 90s, researchers started to question the old models and put them to the test in terms of efficacy. It was found, more often than not, these tactics were not very effective, or perhaps made things worse. At this stage, we began to see a shift toward a more collaborative style. It was becoming clear that families needed to be involved to bring about better results. In the 1990s, treatment providers began utilizing motivational interviewing. Another trend to emerge surrounded the question of whether or not abstinence was the only goal and measure of success; or could harm simply be reduced, with continued use, as an alternative. This was mostly geared toward hard drug use. An example is the needle exchange program, which was initiated to curtail the spread of HIV. Another program to emerge was the designated driver initiative, to combat the problem of drunk driving. The addiction treatment field at this point really started to expand into many other areas. Do you find that the general substance abuse and addiction treatment field has become more accepting and inclusive of those who work from a family-based approach? A problem with this is that training tracks for family therapists and the medical community are not integrated. There, unfortunately, exists a gap in training. From outside of family therapy, you may see someone with a very strong systemic component to their background but they tend to offer treatment to the individual parallel to the family. They aren t really practicing family therapy. This is where family therapists could really step in and play a vital role. The addictions field has many opportunities to offer MFTs, and we have overwhelming evidence that suggests working with the whole family greatly raises levels of efficacy. As much as two to even four times better, some studies are showing. The bottom line is that marriage and family therapists are sorely needed and this is a fascinating field. Some mental health professionals have a bias against taking on clients with these issues, but I would urge everyone to take another look, as many new and promising studies are emerging all the time, and the skill set possessed by family therapists is in need. Peter Steinglass, MD, is a graduate of Harvard Medical School and joined the Ackerman Institute in 1990 and is currently president emeritus. In addition to his Ackerman post, he is also clinical professor of psychiatry at the Weill Medical College of Cornell University. His research on alcoholism and on chronic medical illness as they affect family life has provided vital information for the clinical community. Dr. Steinglass has written more than 90 articles, book chapters and books on these subjects. 14 f a m i l y t h e r a p y m a g a z i n e

17 interview: The Nature of Addiction Family Therapy Magazine talks to C. Everett Bailey, PhD, about the nature and characteristics of addiction, prescription medication addiction, and factors that make some people more susceptible to addiction. Dr. Everett is a staff member at Psychological Counseling Services, Ltd. (PCS) in Scottsdale, AZ. How did you get started in the addiction field? Eight years ago I joined Psychological Counseling Services and began working with sexual addiction. My work has focused on addictions and compulsions ever since. We see many debates in the MFT field about how terms are used, like compulsion and addiction. What distinctions do you see in this terminology? The distinction between compulsion and addiction lies in behaviors; in particular, acting on destructive behaviors. You may have the compulsion and act it out, but that doesn t necessarily mean you will develop an addiction. Addiction is broad and all encompassing including thoughts, feelings, and ultimately behaviors. DSM-IV gives us two separate listings: alcohol abuse and dependency. Inappropriate behaviors don t always lead to dependency. You might head that direction, but not quite reach it. What do you see as the reason that prescription medication addiction is now the leading addiction issue in the nation? So many drugs have been developed and they are easy to get. Pills are simple, passive; you don t have to do much but swallow them. But the best treatment we can provide our clients, and research backs this up, is to use medication in conjunction with psychotherapy. That is really the solution for long-term maintenance. Where do you see MFTs fitting into the addiction treatment and research world? Addiction is a relational issue passed down through families, with effects on family relations. At the core of healing addiction is healing relationships. These underlying issues cause disconnects, which need repairing. Family therapists can play a primary role here. Heal the family relationships, heal the addictions. C. Everett Bailey, PhD, LMFT, is with Psychological Counseling Services Ltd. (PCS), in Scottsdale, AZ, specializing in marital therapy and helping couples in the area of compulsive/addictive behaviors. Are some people genetically predisposed to be susceptible to addiction? Though I wouldn t say that anybody is destined for it, some are certainly predisposed by a genetic/chemical component and also influenced by their environment. Life experiences combined with a particular genetic make-up, and perhaps a certain level of trauma, or physical abuse, emotional neglect, etc., can put people at risk. Addiction becomes a way for people to self-medicate and alleviate the pain. And even sexual addiction can be included in this, because chemicals are released in the brain which provide their own sort of high, thus the actions are repeated to get more of that high and eventually an addiction can form. n o v e m b e r d e c e m b e r

18 The Way It Was Challenging the Myths of Addiction and How Treatment and Research Have Changed Meri L. Shadley, PhD Entering the professional world back in the early 1970s, a new counselor found only a few career paths to follow. One could work in mental health centers, social service agencies, probation and parole, or store front programs that were opening up to help with teen runaways, suicide, or the myriad of emerging social problems. Professionals in the fields of psychiatry, psychology, and social work typically assisted the mentally ill or the economically disenfranchised, and para-professionals provided support and assistance to alcoholics. The marriage and family therapy field was in its infancy and the addiction treatment field didn t exist. 16 f a m i l y t h e r a p y m a g a z i n e

19 Yet, the times they were a changing. As soldiers returned from Viet Nam and the hippie revolution spread across America, the need for a new generation of helpers arose. The federal government became engaged in efforts to combat the increase of youth drug use by infusing monies into cities and states. This funding created new jobs and ultimately an entirely new field. Common to the advent of any new science, the blending of different viewpoints and backgrounds opened up opportunity and conflict. Recovering counselors brought their life experiences and educated counselors brought their psychological theories. The tried-and-true approaches used with alcoholics and the mentally ill, however, did not prove to be as useful with teens, returning vets, or the families struggling with these changed loved ones. This was a new breed of client. The urgency of the crisis clearly required passionate and committed people. Creative innovators blended recovery knowledge with new ideas to determine interventions and therapies. Since these new strategies did not come from established research, funding sources began mandating formal evaluations. The familiar struggle between research and practice left some providers feeling negated and their experiences disavowed. Yet, both the academically trained and those coming from personal experience joined together to prove the usefulness of their approaches. Today, the field of addiction treatment is unique in its ability to effectively blend eager newcomers with ardent, seasoned helpers. The professional counselor and the recovering provider work closely together and share the excitement of new discoveries. The passion of substance abuse counselors remains ablaze. After approximately 40 years of working in the field of substance abuse treatment, it is interesting to note what has changed and what has continued. Although some of the original beliefs remain steadfast, others have become myths. Still, other beliefs have been altered by new information. For example, beliefs such as people must hit bottom before they are ready for treatment, and denial and resistance must be confronted are generally considered myths today, while beliefs such as AA is the only way and addiction issues must be treated first, then other issues have transformed. People must hit bottom before they are ready for treatment. The concept of hitting bottom originated from the recovering community. Along with helping individuals understand how difficult it could be to reach and maintain sobriety, the idea offered an explanation for why treatment did not always work. Unfortunately, it started determining when treatment would be offered. Wanting help became the answer to success and interventions were based around getting a person to acknowledge the need and agree to treatment. This belief was so intertwined with the concept of denial that helpers in the field believed that change could not occur until the person was ready. Today, many people are referred to treatment prior to accepting that they have a problem. Drug courts, DUI schools, and family-based intervention approaches support the idea that a change in behavior is first and foremost. The current therapeutic belief is that behavioral change opens doors to perceptual change. Judith Landau, co-developer of the ARISE intervention model, believes that the initiation of change often comes when the family hits bottom (private conversation, 2010.) By increasing opportunities to develop readiness, and to engage families in the process, motivated change can occur. Due to these enlarged support networks and society s vow to address the issue, more substance abusers enter treatment earlier. n o v e m b e r d e c e m b e r

20 Discoveries about gender and cultural differences demanded varied approaches to meet the needs of differing clients. Denial and resistance must be confronted. The concept of denial also originates from the alcohol recovery community. Viewed as the primary obstruction to sobriety, denial became a central issue for alcoholics to face. Determined counselors and sponsors approached denial with understanding, persistence, and humor (i.e., Denial is not a river in Egypt). The tenacity of drug addiction, however, left many helpers even more frustrated than they had been with alcoholism. Confused by how to dismantle the power of drug abuse upon clients, therapeutic communities and drug treatment programs adopted the idea that denial created resistance and resistance must be intensely confronted. Counselors began to rage at and threaten the drug addict. Unfortunately, the well-intended goal of separating the person from their drug and ultimately rebuilding the addict into a stronger individual frequently failed. With this limited success, professionals sought a theory and methods that might improve results. Prochaska and DeClemente (1982) developed the Transtheoretical Model based upon the belief that there were stages to change and that therapeutic goals aligned with these stages would be more effective. Believing that confrontation increased resistance, Miller and Rollnick (1991) advised that counselors roll with resistance and gently lead towards ambivalence. They created an entirely new methodology where specific interactional techniques were recommended to help motivate clients. Over the last 20 years, research has affirmed the motivational approach and, in fact, this theoretical model is now utilized beyond the addiction treatment field. AA is the only way. The best-known and largest self-help group available to addicted individuals is Alcoholics Anonymous (AA). As a model for numerous other self-help groups, the philosophy and orientation of the 12-step approach brought adamant followers to the drug treatment world. Searching for a theoretical base, the addiction field adopted many beliefs and practices found within 12-step organizations. Some of these include: abstinence is the goal; get clean and sober first, then worry about other issues; don t use medications; the focus should be on the addict/alcoholic; take it one day at a time; 12-step is the pathway to recovery; and, you will always have this disease. While many of these thoughts remain central to the field, zealous adherence is no longer advocated. For example, a single focus on getting clean and sober first can delay appropriately diagnosing co-occurring disorders. In addition, focusing only on the alcoholic/addict often alienates family members from the people they love and the problems that divide them. Today, a comprehensive assessment incorporates medical, social, psychological, familial, and economic concerns along with the issues of substance use and abuse. As various modalities of treatment are incorporated into a continuum of care, it is now clear that postponing family or medical intervention added to some addicted individuals suffering and, in fact, may have deterred them from reaching sobriety. Ongoing research about the biopsycho-social realities of addiction has increased the breadth of professionals now entering the addiction field. Each discipline has established specializations and created divisions within their national organizations. Today, physicians, marriage and family therapists, social workers, nurses, and psychologists work alongside the drug and alcohol counselor. While many in the addiction field continue to recommend the 12-step fellowship, alternative self-help groups, as well as formalized treatments and medical interventions aimed at addressing the newest understanding about brain functioning are also utilized. Addiction issues must be treated first, then other issues. In the middle of the 20th century, expectations ran high. People hoped for the American dream a house, a car, a good job, a successful father, a pretty mother, and well-mannered children. When this dream was interrupted by problems of substance abuse, many families initially hid or ignored the issue. The 1970s and 80s, however, saw a clear effort to stamp out the problem. The focus was to combat the crisis by eliminating the availability of drugs, by directly treating alcoholism and drug addiction, and by teaching children to just say no (Nancy Reagan prevention motto). Centering attention on the culprit drugs and alcohol identified the enemy and provided a logical plan. Concentrate on stopping the addiction, and then worry about other problems. While this approach was successful with some people (particularly male alcoholics), other people continued to relapse. Observations throughout the 1990s and early 2000s clarified the difficulty. Being clean and sober did not improve life for those suffering from multiple demons. Poly-drug users grappled with complex problems. Issues of depression and anxiety sometimes drew people back towards the numbing properties of their drug of choice. And for many substance-abusing women, residue from past trauma and ongoing relationship struggles left them too vulnerable when sobriety provided no sanctuary. Discoveries about gender and cultural differences demanded varied approaches to meet the needs of differing clients. While some clients still benefit from the single focus, most need a dual approach. As issues of co-occurring disorders, past violence, and trauma 18 f a m i l y t h e r a p y m a g a z i n e

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