1 Counseling Family Members of Addicts/Alcoholics: The Stages of Change Model Katherine van Wormer, Ph.D., MSSW ABSTRACT. This article adapts the stages of change model, a model in which specific interventions of harm reduction are directed toward the client's readiness for treatment, as a guiding framework for counseling family members of alcoholics/addicts. Interventions at each stage of the family's readiness for change, from precontemplation to action, are described. KEYWORDS. Alcoholism, families, stages of change, transtheoretical approach The family is a system composed of members in constant and dynamic interaction with each other. Patterns of interaction get established: who interacts with whom, who talks and who listens, who has the authority and who is the controlling force behind the scenes. The family has a pattern, a rhythm that is more than the sum of its parts. Any change in the behavior of one of its members affects not only each of the others but the system as a whole. Addiction, accordingly, is often defined as an illness not just of the Katherine van Wormer, Ph.D., MSSW, is Professor of Social Work, University of Northern Iowa. Address correspondence to: Katherine van Wormer, University of Northern Iowa, 30 Sabin Hall, Cedar Falls, IA Journal of Family Social Work, Vol. 11(2) 2008 Available online at by The Haworth Press. All rights reserved. 202 doi: /
2 Katherine van Wormer 203 individual but of the whole family. Sometimes the misery is so intense that the system barely functions. Families are important in both the etiology of addiction and its recovery (Gruber & Taylor, 2006). In relapse prevention, success in establishing a social support network raises the chances of long-term treatment success. Family therapy, even in only a few sessions, can be invaluable in reducing the feelings of guilt or confusion in significant others. Family counseling, moreover, can be invaluable in preparing the family for changes that are needed to enhance and maintain the addicted person's recovery. That is what this paper is about the change process itself and motivation for change at every level of the treatment process. Paralleling the individual substance user's pathway from experimentation to addiction is the family's progression along a continuum from stability to a loss of control over events relevant to the family, employment, child care, and general family functioning. Changes in the addictive behavior for example, gambling are met by changes in family roles and relationships. The changes may not be direct. One truth aboijt relationships is that there tends to be a lag between the time when a condition, such as addiction (etc.), surfaces and when the reality becomes truly accepted. The situation can become even more complex as individual family members are at different places along the continuum of recognition of the need to take action against a serious problem. To reflect this developmental process and the need to shape treatment interventions accordingly, I have chosen as the most appropriate model, the stages of change model. This model initially was developed by Prochaska and DiClemente (1986) to describe the process of smoking cessation and further developed and modified by Miller (1999) and Miller and Rollnick (2002). Patricia Dunn (2000) finds the stages of change model appropriate for social work because it is compatible with the mission and concepts of the profession, is an integrative model, and is grounded in empirical research. Through building a close therapeutic relationship, the counselor can help the client develop a commitment to change and proceed at his or her own pace. In working with families with substance abuse issues, such patience and empathy are paramount. Yet there is much work to do in families of this sort; the anger and denial can be palpable. Sometimes, the anger and resentment by significant others need to be addressed before a recovering family member is returned to the family setting. Sometimes, of course, the family environment itself is toxic, several of the participants having serious problems with
3 204 JOURNAL OF FAMILY SOCIAL WORK boundary issues or drugs, for example. Here, too, interventions must be directed toward the whole family. To treat the individual in isolation is to ignore the context in which much of that behavior takes place. To know the context, an understanding of the systemic intergenerational nature of addiction is essential. Even more than ordinary illness, addiction is a source of major stress that reverberates through the family system and affects the family's interactions with every other system in the community. The emotional and financial resources of the family may be almost entirely depleted by the stress of the addict's illness. The havoc wreaked on the family by alcohol misuse is even more dramatic and progresses more rapidly when a drug such as methamphetamine (meth) enters the picture. Qualitative data based on interviews with former meth addicts reveal that communication and caregiving duties break down to the extent that the well-being of the children and the family as a whole are in dire jeopardy (see Brown & Hohman, 2006). In Iowa, as revealed in media reports, hundreds of parents are losing custody of their children, a trend seen only in recent years as meth has secured its grip statewide (Reiter, 2003; Rood, 1999; van Wormer & Davis, 2008). Perhaps because of the difficulty of working with such chaotic families and the stigma of addiction in general, the family therapy field has devoted little effort to addictions-focused treatment and has tended to refer drug-affiicted members to specialized services or selfhelp groups. And because of the difficulty that substance abuse treatment centers face in working with the whole family, combined with third-party reimbursement disincentives to do so, often little more than lip service is given to family members' needs by these treatment centers. The recent emphasis on the importance of engaging members of social networks in treatment appears to be focused on retention of the alcoholic or addict in treatment or in getting the family to see that the individual take recommended medications rather than to be actively involved in the treatment process as a family (Loughran, 2006). Too often, any family that does not match the traditional mold tends to be invisible, while the importance of the extended family as a vital resource goes unrecognized. Yet, for children and partners in the family system, the need to sort out their feelings and to learn more about the nature of the problem that has so consumed them over the years is crucial for long-term recovery of everyone involved. In contrast to traditional family therapy, the family treatment interventions described in this paper are designed to elicit resilience
4 Katherine van Wormer 205 and healing in family members rather than to uncover the family's presumed role in causing and perpetuating the addiction. I have adapted interventions to parallel the readiness of the family for change, a phase approach. The phase approach views treatment needs in terms of the five basic intervals stretching from precontemplation through the maintenance period. Keep in mind that, in reality, there is no clear-cut division among the stages and that the sequence of the progression is oversimplified here for the sake of explanation. The stages of family needs, moreover, may or may not directly correspond to the alcoholic or addict's stage of recovery. Family members, for example, may be far more ready for change in the direction of sober lifestyle than is the person with the severe problems. 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 taking of steps to do so (action). The focus of this model was on the individual'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 formulation 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 earher in the 1980s adopted this theoretical approach and incorporated
5 206 JOURNAL OF FAMIL Y SOCIAL WORK it in treatment programs (van Wormer & Davis, 2008). The United States, reticent at first and steeped in a tradition of harsh confrontational strategies directed toward clients who had "hit their bottom," has begun now to move in this direction. The dual infiuence of favorable empirical research proving the effectiveness of short-term, motivational treatment and of decisions by insurance companies to reimburse such evidence-based practices has reshaped the treatment industry in the United States (van Wormer & Davis, 2008). The concept of stage-based treatment is central to integrated treatment for addicted clients with mental disorders as well, in that it provides a framework for assessing clients' motivational states and gearing interventions corresponding to the client's degree of readiness (Mueser, Noordsy, Drake, & Fox, 2003). In every stage of the Prochaska and DiClemente model, extending from precontemplation through maintenance or relapse, resolving ambivalence is a central theme of focus (DiClemente, 2006). This approach has been found to be helpful in work with partners with substance abuse problems in regard to resolving ambivalence about change (O'Farrell & Fals-Stewart, 2006). Helping people make decisions that will benefit their lives, similarly, is the overriding goal of motivational enhancement therapy. An important point enunciated by Prochaska and Norcross (2007) is that if one tries to use strategies appropriate to a stage other than the one the client is at, the intervention will be ineffective. If the client is only barely motivated to contemplate giving up a favorite habit and needing some guidance in weighing the pros and cons of change and the counselor pushes for 12 Step involvement, the result most likely would be treatment resistance or noncompliance. Let's consider a family member's typical client statements at each stage of the stages of change continuum (see Table 1). Through a close therapeutic relationship, the counselor can help people develop a commitment to change (Prochaska & Norcross, 2007). Motivational theory states that if the therapist can get the client to do something, anything, to get better, this client will have a chance at success. This is a basic principle of social psychology (van Wormer & Davis, 2008). William Miller (1998) pinpoints the following tasks as predictors of recovery: going to AA meetings, coming to sessions, completing homework assignments, and taking medication (even if a placebo pill). The question, according to Miller, then becomes. How can I help my clients do something to take action on their own behalf? A related principle of social psychology is that in
6 Katherine van Wormer 207 TABLE 1. Stage Specific ivlotivationai Statements Stages of change Precontemplation Contemplation Preparation Action Maintenance Family Member Comments We really don't have much to do with this problem; I've had enough of blaming by psychologists and interfering social workers. 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. 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. 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. 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. defending a position aloud, as in a debate, we become committed to it. One would predict, according to motivational enhancement theory, that if the therapist elicits defensive statements in the client, the client would become more committed to the status quo and less willing to change. For this reason, explains Miller, confrontational approaches have a poor track record. Research has shown that people are more likely to grow and change in a positive direction on their own than if they get caught up in a battle of wills. In their seven-part professional training videotape series. Miller, Rollnick, and Moyers (1998) provide guidance in the art and science of motivational enhancement. In this series, the don'ts are as revealing as the do's. According to this therapy team, the don'ts or traps for therapists to avoid are: A premature focus such as on one's addictive behavior The confrontational/denial round between therapist and client The labeling trap forcing the individual to accept a label such as alcoholic or addict (to this I would add chief enabler and codependent) The blaming trap, a fallacy that is especially pronounced in the counseling of couples The question/answer habit, which is characterized by the counselor asking several questions in a row and relying on closed yes or no responses; this exchange paves the way for The expert trap, whereby the client is put down; the opposite of the expert trap is a collaborative exchange of information
7 208 JOURNAL OF FAMILY SOCIAL WORK These precautions relate exceptionally well to work with families, as does the motivational theorists' handling of family member resistance. As he states in the videotape on motivational enhancement. Miller is uncomfortable with the term resistance; his preference is to think of clients as simply cautious in trusting the therapist. To establish such trust and enable the client to elicit the desired selfmotivated statements or insightful statements as, for example, "I think I do have a problem," the skilled therapist relies on open and multifaceted questions, reflective listening, and purposeful summarizing of the client's story. Key to this process is the reframing of the client's story in the direction of decision making. A format such as "I sense that you are saying, on the one hand, that smoking means a lot to you and, on the other hand, that you are beginning to have some health concerns about the damage that the smoking is causing you or may cause you in the future" provides helpful feedback to the reluctant client by reflecting back to him or her what is heard. Keep the precautions in mind, as we will return to them in our discussion of the individual stages. Following the formulation set forth by Miller and Rollnick (1991; 2002), Prochaska and Norcross (2007), and Wallen (1993), major tasks for the addiction counselor at each stage of decision making directly parallel the family member's state of mind. During the initial period, for example, goals are to establish rapport, to ask rather than to tell, and to build trust. Eliciting the person's definition of the situation, the counselor reinforces discrepancies between the client's and others' perceptions of the problem. DEVELOPMENTAL APPROACHES TO FAMILY ILLNESS In traditional substance abuse treatment, the family was often viewed as dysfunctional, lacking healthy communication styles, and so forth. In light of what counselors had come to know of life in an "alcoholic home," often such as the one they themselves had come from, such negative expectations are understandable. Take, for example, the words of one survivor of such family life: Communication in my family was sick. I remember coming home and feeling like I was walking on eggshells every day
8 Katherine van Wormer 209 because I never knew what the mood would be. I spent a lot of time being tense. We were not allowed to discuss our problems with outsiders or bring outsiders into the home. We were not allowed to have any feelings except laughter. If we were hurt, we could laugh but not cry. I was told exactly how to feel, so to this day I have a hard time describing how I actually feel, (from van Wormer's personal files) During family programming the focus has largely been on negative patterns of interaction and signs of enmeshment or codependency, rather than on their resilience in dealing with family illness. Family members were often advised that their efforts to compensate for the alcoholic or addict's malfunctioning were only making the situation worse, that alcoholics had to "hit their bottom" (van Wormer & Davis, 2008). Fortunately, today professionals schooled in family counseling techniques and a social work's strengths perspective have brought to addictions work a modified and highly useful understanding of family pain and dynamics. And a gradual paradigm shift in thought from family-as-enemy to family-as-treatment-ally is underway. Work with the whole family is now recognized, at least theoretically, as a vital component in addiction treatment (Center for Substance Abuse Treatment [CSAT], 2004), and the family is now commonly viewed as more of a resource than a hindrance on the road to sobriety. Wallen's (1993) Addiction in Human Development offered a developmental perspective to substance abuse family treatment. Because alcoholic families often resist change, as Wallen noted, particular attention must be paid to their life cycle stages as the system adapts to the problem drinking of a family member. Families as well as individuals move through stages of recovery, recovery which affects the balance or equilibrium that has evolved through the underfunctioning of one family member. The final stage of recovery, according to Wallen, involves restoring the system to a balance to maintain sobriety. From systems theory we learn that each family will have its own peculiar style of adaptation: coping through hiding key resources (money), blaming, covering up for the addictive behavior, joining in the addiction, and becoming extremely touchy with outsiders (van Wormer & Davis, 2008). The stress of the addictive pattern
9 210 JOURNAL OF FAMILY SOCIAL WORK (for example, gambling and winning, gambling and entering a losing streak) has a synergistic or multiplying effect throughout the family system and related social networks. The family, awkwardly, may come to serve in a mediating role between the addict and other systems in the environment such as work, school, and extended family members. Gradually, as the illness progresses, the bridges between the alcoholic and his or her social world will be broken. The family may then adapt to social isolation and continual stress of the progressing alcoholism, or members may regroup and form a reconstituted family without the addict. A third alternative, of course, is treatment for the family, either separately or in conjunction with treatment of the alcoholic or addict. Treatment considerations would focus on the deveiopment of new, non-destructive communication patterns and adaptation to changes associated with recovery. Unilateral family counseling, as Miller (2006) indicates, utilizes an approach that is conceptually opposite to Al-Anon. Whereas the focus of Al-Anon is stressing the powerlessness of the family member over the loved one's substance use and on detaching from their chemically dependent partner or relative, the focus in MI is in counseling family members that indeed they can have substantial infiuence in helping the drinker or user make some moves in a positive direction. This is not to say that Al-Anon does not have a role to play in helping family members focus on their own needs but rather that the approaches of MI and Al-Anon are somewhat different. Despite the fact that the partners of alcoholics do not necessarily have a disease, only the symptoms of struggling against someone else's disease, individual and family therapy can be extremely beneficial in the healing process for these survivors. Work in the area of self-esteem can do much to help resolve powerful feelings accompanying years of abuse and unshared pain. Consistent with motivational interviewing and the strengths perspective, use of negative labels such as "chief enabler" and "codependent" should be avoided. Terms such as survivor and family manager might be used instead and the focus placed on survival skills rather than enabling the addictive behavior to persist (van Wormer & Davis, 2008). Taking a cross-cultural perspective. Cable (2000) points out the European-American middle-class bias of the codependency movement with its "one-size-fits-all" prescription for normality. This prescription includes an emphasis on detachment, on taking care of oneself.
10 Katherine van Wormer 211 THE STAGES OF CHANGE AND FAMILY TREATMENT Within Project MATCH, the widely cited comparative study that validated treatment effectiveness of motivational as well as of other strategies, the success of treatment outcomes was shown to be related to the extent to which the client's social network was supportive of sobriety (U.S. Department of Health and Human Services, 1999). Project MATCH did not provide such treatment but did conduct follow-up studies on subjects in the experiment. Researchers found that emotional support from one's partner was a key factor in long-term recovery. In recognition of this finding, we should perhaps do more than we have in the past to boost this source of support. In their review of the literature, Waldron and Slesnick (1998) and McCrady (2006) concluded that family treatment is an effective undertaking for both adults and adolescents with problem substance use, in that such intervention is associated with higher rates of treatment compliance and retention than is treatment without family involvement. Having a functioning support system is crucial in promoting change efforts and in preventing a lapse to previous problematic behavior. Since family members often develop problems in response to someone else's drinking or other drug use, including early experimentation with psychoactive substances by children, getting the whole family together for counseling should be a standard of addiction prevention (Velleman, 2000). Family sessions offer an opportunity, moreover, to help children in the family understand some of the stresses their non-problem drinking parent has been under, as Velleman suggests. Family therapy interventions, to be effective, need to be geared toward the family's stage of recovery. This stage may or may not parallel the addict's motivation for change or actual changed behavior. The following scheme adapts Prochaska and DiClemente's (1992) and DiClemente (2006)'s stages of change model for therapeutic work with family members. The four motivational interviewing principles are key to this process. These are: expressing empathy, developing awareness of discrepancy between goals and behaviors that obstruct the goals, rolling with resistance instead of arguing with the resisters, and supporting client self-efficacy or confidence in one's ability to
11 272 JOURNAL OF FAMIL Y SOCIAL WORK overcome difficulty (Burke, Vassilev, Kantchelov, & Zweben, 2002; Prochaska & Norcross, 2007). Note the development role of the therapist in each of the following stages. In some ways, as Prochaska and Norcross (2007) indicate, this sequence of stances parallels the changing roles that effective parents play as their children grow through the stages of personal development. The amount of structure provided varies with the stage across the life course as it does in treatment. 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 assessment or through a child welfare referral. In any case, rules of the family 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 members being provided, if at all, at a later stage. Zweben (1999) recommends, 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, Fürst, Kumar, and Whitney (1999) found the male partners of cocaine-using women to be far more difficult to engage in family
12 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 reluctant 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 family 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 opportunity 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 assignment 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 counterproductive, as Burke et al. (2002) caution, if he or she is overburdened 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 individual'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 treatment sessions to work on their problems and feelings surrounding
13 214 JOURNAL OF FAMILY SOCIAL WORK an alcoholic or addict who refuses to get help and who is destroying the lives of those around him or her. As mentioned above, sometimes the results are surprisingly positive, as the family members are taught how to help set the stage for the substance user's turnaround. Even if the strategies are not successful, there is some evidence that the sessions help unite the rest of the family and provide benefits in terms of reduced levels of frustration and depression (Thomas & Corcoran, 2001). During the contemplation stage the family member acknowledges concerns and is considering the possibility of the need for change, for example, in recognizing that the loved one has a serious addiction problem. Psychologically the shift is from a reluctance to acknowledge a problem to anger, anger caused by the suffering related to the drinking, gambling, etc. The therapist typically gets involved in family addictions work when a client requests counseling for help with a marital problem, domestic violence, or behavioral problems in the children. In assessing the client's needs and goals, the role of addiction in the family life becomes apparent. Just as he or she does in working with addicts in early stage treatment, the therapist strives to elicit self-motivational statements of insight and ideas about solutions from the family chents. Reinforcement of clients' capabilities and survival skills are vital to help these persons have the strength to take action toward the desired solution. Possible actions that the family members might be willing to contemplate are to meet with the therapist for several sessions of family counseling to communicate needs and expectations; to work toward getting the addict to get help for the addictive behavior, perhaps through attending self-help group such as AA; or to work on plans for a trial separation. Whether or not the situation improves, family counseling of this sort can be a godsend for the partner and other family members; having a dispassionate but compassionate outsider to talk to can be immensely therapeutic. 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
14 Katherine van Wormer 215 partner's confidence at this stage is tremendously important. The therapist can affirm the significant other's efforts to help the client as well as his or her engagement in the family treatment process. One step that might be introduced at this point, though tentatively, is the suggestion of a visit to a relevant support group such as Al- Anon or Nar-Anon; involvement in such a group can be invaluable in helping members gain support from others in a similar situation. Family members should be prepared for the fact that the stress on detachment at the 12-Step meetings has its place when the addiction has gone beyond a certain point, but there are some strategies they can learn that will help support the chent's process of change and that can be tried at this time. These strategies entail providing positive feedback to the person when he or she is sober and withdrawing during the bad times. Even if the strategies are not successful, there is some evidence that the treatment sessions help unite the rest of the family and provide benefits in terms of reduced levels of frustration and depression (Thomas & Corcoran, 2001). Action At this point, let us assume the whole family is involved in counseling, all except for the addicted individual (see Loneck, 1995). All family 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 getting 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 problems and that he or she cannot continue as he or she has been. The first step in organizing an Intervention is to gather two or more persons together who have witnessed the destructive drinking behavior. The people could consist of family members, friends, clergy, coworkers, employers, or a physician. In the second
15 216 JOURNAL OF FAMIL Y SOCIAL WORK Step, each person prepares a detailed written list of specific examples involving alcohol misuse that he or she has personally witnessed. These actual events force the substance user to admit that their concerns are legitimate. Another important aspect of writing the lists and reading them to each other prior to the actual confrontation is that it unites the group. It is important for members to be prepared to talk about their feelings through using feeling statements that help reduce the defensiveness of the challenged person. Should this not work or not be feasible, another action that can be taken is to commit the person to treatment through a legal process. The local prosecutor's office or treatment center can usually provide the details. Going from the point of view of counselor to family member, a young woman (in personal correspondence of January 28, 1999) provides this poignant account of her childhood memory of an Intervention with her father: When I was around 13, we visited a counselor for a rehearsal. The next week my Dad's brothers and sister, close friends who were recovering alcoholics, my Mom, my sister, and I gathered at our house on the farm and Dad came home. I think he was aware what was going on and became extremely emotional, crying with his head down at the table. I remember exactly where I was standing, at the end of the table against the wall with my sister and when it came my tum to read my statement all I could say was, "I want you to go because I love you," and began to sob. I remember going up to my Mom and Dad's room to get his suitcase and Dad couldn't say a word, he just cried and hugged us and got in the car to go. It is one of the saddest memories I experienced in childhood. He was gone for one month and about three months after he returned we sold our farm and he relapsed yet to return to treatment about a year later on his own will; he has been sober ever since. I can honestly say I am very proud of him. Maintenance More important than the role of family in assessment and treatment is the role of family in early recovery. As the addict's progress
16 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 process 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 members 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 massive change that affects children and adults at every level. The environment feels unsafe; the family structure, after years of chaos, is not strong enough to handle change. In the counseling session, the therapist 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 failure to change, and even between keeping the family together and divorce. The therapist can help the family anticipate Stressors and support the addict in avoiding triggers and high-risk events. A complete "what to do if 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
17 218 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 currently 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 appropriate 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 period 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
18 Katherine van Wormer 219 Statements conducive to healthy living, the therapist can help prepare the family to cope with changes in the dynamics of the family associated with sobriety, as well as with the inevitable setbacks and even eventual separation from the addict if this is the family's decision. Through the use of various communications exercises or of listening skills directed at where the family members are in their recognition of a problem and of the need for help, workers can help family members deal with their own feelings of anger, shame, and guilt that may have plagued them for some time. REFERENCES Black, C. (2002). It will never happen to me: Growing up with addiction as youngsters, adolescents, adults. Center City, MN; Hazelden. Brown, J. A., & Hohman, M. (2006). The impact of methamphetamine use on parenting. In S. L. Straussner & C. Fewell (Eds.), Impact of substance abuse on children and families: Research and practice implication (pp ). New York; Guilford. Brown, S., & Lewis, V. (1999). The alcoholic family in recovery: A developmental model. New York; Guilford. Burke, B. L., Vassilev, G., Kantchelov, A., & Zweben, A. (2002). Motivational interviewing with couples. In W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing: Preparing people for change (2nd ed., pp ). New York; Guilford. Cable, L. C. (2000). Kaleidoscope and epic tales; Diverse narratives of adult children of alcoholics. In J. Krestan (Ed.), Bridges to recovery (pp ). New York: Free Press. Center for Substance Abuse Treatment (CSAT). (2004). Substance abuse treatment and family therapy. Treatment Improvement Protocol (TIP) Series, No. 39. Rockville, MD: Substance Abuse and Mental Health Services Administration. DiClemente, C. C. (2006). Addiction and change: How addictions develop and addictive people recover. New York: Guilford Press. Dunn, P. (2000). Dynamics of drug use and abuse. In A. Abbott (Ed.), Alcohol, tobacco and other drugs: Challenging myths, assessing theories, individualizing interventions (pp ). Washington, DC; NASW Press. Gruber, K., & Taylor, M. (2006). A family perspective for substance abuse; Implications from the literature. In S. L. Straussner & C. Fewell (Eds.), Impact of substance abuse on children and families: Research and practice implication (pp. 1-29). New York; Guilford. Laudet, A., Magura, S., Fürst, R. T., Kumar, N., & Whitney, S. (1999). Male partners of substance-abusing women in treatment: An exploratory study. America Journal of Drug and Alcohol Abuse, 25(4),
19 220 JOURNAL OF FAMIL Y SOCIAL WORK Loneck, B. (1995). Getting persons with alcohol and other drug problems into treatment: Teaching the Johnson Intervention in the practice curriculum. Journal of Teaching in Social Work, 2(1-2), Loughran, H. (2006). Alcohol problems, marriage, and treatment: Developing a theoretical timeline. In S. L. Straussner & C. Fewell (Eds.), Impact of substance abuse on children and families: Research and practice implication (pp ). New York: Guilford. McCrady, B. (2006). Family and other close relationships. In W. R. Miller & K. Carroll (Eds.), Rethinking substance abuse: What the science shows (pp ). New York: Guilford Press. Miller, W. R. (1998). Enhancing motivation for change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (2nd ed., pp ). New York: Plenum Press. Miller, W. R. (1999). Enhancing motivation for change in substance abuse treatment: Treatment improvement protocol series 35. Rockville, MD: U.S. Department of Health and Human Services. Miller, W. R. (2006). Motivational factors in addictive behaviors. In W. R. Miller & K. M. Carroll (Eds.), Rethinking substance abuse: What the science shows (pp ). New York: Guilford. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford. Miller, W. R., Rollnick, S., & Moyers, T. B. (1998). Motivational interviewing (6-tape series). University of New Mexico. Mueser, K. T., Noordsy, D. L., Drake, R., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. New York: Guilford. O'Farrell, T., & Fals-Stewart, W. (2006). Behavioral couples therapy for alcoholism and drug abuse. New York: Guilford Press. Prochaska, J. O., & DiClemente, C. C. (1986). The transtheoretical approach. In J. C. Norcross (Ed.), Handbook of eclectic psychotherapy (pp ). New York: Brunner/Mazel. Prochaska, J. O., & Norcross, J. (2007). Systems of psychotherapy: A transtheoretical analysis. Belmont, CA: Thomson. Reiter, B. (2003, November 23). Task force sees firsthand how meth can ruin lives. Dei Moines Register, p. la. Rood, L. (1999, January 4). Families wrecked by meth: Epidemic loss. Des Moines Register, 1 A. Thomas, C, & Corcoran, J. (2001). Empirically based marital and family interventions for alcohol abuse: A review. Research on Social Work Practice, 11(5), U.S. Department of Health and Human Services (1999). Brief interventions and brief therapies for substance abuse. Treatment Improvement Protocol (TIP) Series, No. 34, Rockville, MD: U.S. Government Printing Office.
20 Katherine van Wormer 221 van Wormer, K., & Davis, D. R. (2008). Addiction treatment: A strengths perspective (2nd ed.). Belmont, CA: Thomson. Velleman, R. (2000). The importance of family. In D. B. Cooper (Ed.), Alcohol use (pp ). Oxon, England: Radcliffe Medical Press. Waldron, H. B., & Slesnick, N. (1998). Treating the family. In W. Miller & N. Heather (Eds.), Treating addictive behaviors (pp ). New York: Plenum Press. Wallen, J. (1993). Addiction in human development: Developmental perspectives on addiction and recovery. New York: Haworth. Zweben, A. (1999). Involving a significant other in the change process. Boxed reading. In W. R. Miller (Ed.), Enhancing motivation for change in substance abuse treatment. Treatment Improvement Protocol (TIP) Series 35. Rockville, MD: U.S. Department of Health and Human Services.
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