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Alcohol/Substance Abuse Treatment
The issue of alcoholism has become one of prevalence in the United States. Although portrayed as a social medium and recreational product alcohol can and does have drastic negative effects on an individual and their relationships if not used in moderation. Unfortunately maintaining moderation can be difficult as the drive behind the consumption of alcohol is largely based on altering the individual’s consciousness (Fields, R., 2010). This in of by itself may not develop into abuse or dependency yet creates a high risk environment that is likely to engage with those suffering from mental health disorders such as depression and/or anxiety. In these cases the prevalence of abuse and/or dependence becomes extremely high. In fact the comorbidity of alcoholism/substance abuse and mental health disorders was around 29% nationally in 1990 (Regier D.A, Farmer M. E, Rae D. S, Locke B. Z, Keith S. J, Judd L. L, Goodwin F.K., 1990).
As the development of alcohol/substance abuse is genetically, psychologically and environmentally influenced, the focus of the role that substance abuse has in the family system must go beyond the abusing individual and extend the units of the family as well. Each unit in the family system plays a role in the maintenance or correction of familial boundary imbalance. As the imbalance of ambiguous boundaries among the family units is supported and maintained by the respective individuals therapy involving all family members is crucial to the successful and sustainable recovery of the abusing individual.
For illustrative purposes we will use a case study involving a husband (Harvey), his two teenage children and his wife who are all engaged in Harvey’s prolonged alcohol abuse. The literature above regarding Harvey’s alcohol use and the attempts of his wife to manage it for him are indicative of their being codependency in the relationship. The reported 10 years of consistent alcohol use by Harvey and the subsequent negative effects it has had on his life such as decreased occupational reliability and responsibility, absent parenting and legal troubles present evidence that Harvey may be suffering from Alcohol abuse (Fields R., 2010). Although Harvey has exhibited signs of abuse there is insufficient evidence to postulate that he has become dependent. Dependency on alcohol is signified by adverse physiological reactions to the absence of alcohol in the body. Such symptoms may include but are not limited to, uncontrollable shakes, system shock, severe and consistent mood fluctuations and an over whelming “need” to drink. None of these symptoms are presented with regards to Harvey.
In this example Harvey may be the only abuser in the home yet each individual has a specific role they play in enabling his continued behavior. The wife in particular plays the most influential role of the chief enabler. This is signified by her attempts to manage the collateral damage Harvey’s alcohol abuse has on his occupation, family and his friends. By doing so Harvey’s wife enables him to avoid being accountable for his behaviors and thus is allowed to continue them. Although not represented as to their specific roles in their family system the two children most assuredly are affective and effected with regards to their fathers continued use. Generally speaking the children’s roles are much more passive. The roles of the family hero, scapegoat, mascot and lost child are attempts for the child to manage their emotions in the construct of a family system segregated into individual taking unreasonable responsibility for the hope, responsibility, success and cohesiveness of the family as a whole. For these reasons it is necessary that all units of an imbalanced family system, in particular those involving alcohol/substance abuse, seek counseling individually, in a clinical group setting and as a family unit (Fields, R. 2010). In particular to Harvey it is recommended that he engage in several therapeutic techniques so as to address the many factors involved in alcohol/substance abuse and its perpetuance. Some suggested areas of importance would be cognitive behavioral therapy, behavioral couple’s therapy and group therapy. Alcoholics Anonymous, Transactional Analysis, and Family Systems Therapy are several methods of treatment involving these therapeutic techniques found to be effective in the treatment of individuals and family’s suffering from alcoholism and/or substance addiction.
Alcoholics Anonymous (AA) has been influential in the recovery of individuals suffering from alcohol abuse/dependence for about 80 years. The program is designed to help individuals recovering from alcohol abuse/dependence and to help others reach sobriety. There have been mixed reviews of the program’s effectiveness in increasing or maintaining abstinence and therefore the programs overall effectiveness. However, a study conducted in 2009 established AA as meeting 5 out of 6 criteria for establishing causation as thus be could be considered effective (Branscum, P. 2010). Some of the most apparent benefits to the AA program are its availability, supportive group environment and that it is a free program. One aspect of the program that is particularly advantageous is the individual having what is called a “sponsor”. This individual becomes a mentor for the recovering alcoholic and an integral support system in their recovery. The same program dynamic is also available for family members and spouses of people suffering from alcoholism. Disadvantages to this program are mainly centered on the lack of trained professional oversight in that the program is often administered by individuals in recovery themselves. Although this can have advantages in facilitating rapport, empathy and understanding between members it also creates a potential for recidivism if their sponsor relapses. In retrospect this dynamic could also facilitate the relapse of the sponsor in the face of feelings of failure if their sponsored individual relapses. Another aspect of disadvantage in the use of AA as a recovery method is its inherent fluctuation of individuals attending of their own free-will and those attending by mandate of a court order. Because the two conditions dictate extreme differences in attitude and motivation studies attempting to evaluate the programs effectiveness and evolution are largely hampered by inconsistent results (Branscum, P. 2010). As a result it becomes difficult to evaluate and improve the programs design and effectiveness. Due to consistent advances in assessment and therapeutic techniques the program runs the risk of becoming outdated.
Another effective form of therapy is that of Transactional analysis therapy. This type of therapy is designed to help individuals address their interactions with others in an attempt to resolve emotional issues. This is particularly helpful in the recovery of alcoholism in that it helps the recovering individual evaluate their interactions with others and their subsequent responses and behaviors. This can help an individual recognize emotional stimuli that may trigger certain undesired behaviors. By recognizing these triggers the individual can be taught different ways in which to handle these interactions that are more nurturing of a positive self-image (ITAA.org, 2013). The advantage to this type of therapy lies in its proposition of 5 ego-states; the “Critical Parent (CP), Nurturing Parent (NP), Adult (A), Free Child (FC) and the Adapted Child (AC)” (Williams, K. E., 1980). These five ego-states encompass an individual’s behaviors such as criticism,, reflection of personal and social rules and norms, growth, feelings, attitudes and patterns of behavioral adapted to the individuals current reality, feelings, attitudes and patterns of behaviors indicative of the individuals childhood such as, fun, indulgence and spontaneity and conformity and compromise with regards to parental influence (Williams, K. E., 1980). Ascribing the individuals reactions to stimuli based on these 5 ego-states can help an individual recognize the psychological motivations of their behavior. The major advantage to this type of therapeutic treatment is that it helps the individual compartmentalize the reactive aspects of their personality making it easier for the individual to self-modify these behaviors in future interactions. The combination of psycho-analysis and psychotherapy create a more comprehensive approach to motivational and behavior augmentation and present a forum in which the individual is better able to define themselves independently from their external stimuli.
Although transactional analysis can be a very effective method of cognitive therapy one of the major disadvantages is its inherent length and frequency of treatment. Generally the patient would participate in therapy for an hour each day for a length of up to 5 years. This can present a deterrent for individuals in that they may not have such time to devote to it. In addition to this the frequency may become tiresome to the participant and they may feel daunted by the length of time recommended for treatment. However, it is important to note that sustainable change takes time and repetition.
The third therapeutic method presented for recovery is that of family systems therapy. There are many types of family system-based therapeutic methods currently being used. All of these methods have been shown to be effective. Some however exhibit more positive results than others. Generally the most successful family system-based therapies have several commonalities amongst them. They all share a focus on increasing the empowerment, communication and functionality of the individual units of the family and the family as a system. Influences among family members, social groups and the individual’s environment are evaluated to create an action plan for change. This multi-method approach is clearly the exemplification for its effectiveness in treating alcohol/substance abuse (Rowe, L. C, 2012).
In spite of this the program’s effectiveness is largely determined by the willingness of all family units to participate. The more family units involved the more complex and dependent the structure of the family system will be on the units. Much like in any mechanical system; if one piece fails to function properly it affects the entirety of the machine and its functionality. In addition to this, family systems therapy is usually administered in a private setting and can become very expensive and hard to find coverage for under insurance plans.
In addition to these therapeutic constructs Brief Strategic Family Therapy has also been reported by the Substance Abuse and Mental Health Services Administration (SAMHSA) to be extremely effective in restructuring the family system to create a more balanced structure. In particular the program is implemented to help reduce and/or prevent adolescent behavioral problems, drug/alcohol abuse, association with anti-social peers and overall delinquency (SAMHSA, 2013). Although the research and applicability of this method is limited in that it has been primarily applied to Hispanic families and a very small amount of African American Families. This may affect the methods applicability in a cross-cultural context yet the fundamental approach to evaluation of familial, social and environmental structures with sensitivity to the cultural influences should be just as effective among and cultural group.
As a result of the complexity of Harvey’s family system several methods for each family member would be recommended to achieve sustainably effective recovery. For Harvey in particular it would be recommended that he enroll in a controlled rehabilitation facility to effectively and safely stabilize his recovery. This would give Harvey the support and structure to increase the likelihood of him attaining sobriety. During this time Harvey will learn to recognize and modulate his feelings (Fields R., 2010).As he is most likely to relapse from his sobriety at around 120 days it is recommended that Harvey also enroll in a half-way house subsequent to release from the rehabilitation facility. This would help give Harvey the time needed to work through the various stages of recovery presented above and overcome many of the obstacles both psychological and physical need to sustain his sobriety. As the success rates of individuals participating in group therapy of similar symptomology seem to be higher than those not participating, it would also be beneficial for Harvey to explore Alcoholics Anonymous (AA) as a means of social support. The greatest benefit presented by AA is the ability for the recovering individual to change their social environment and influences to that of one indicative of the individual’s recovery.
In addition to this it is recommended that Harvey engage in individual and family system therapy to address the familial structural inadequacies created by his abuse of alcohol. Issues to be addressed would be Harvey’s development of self-image, perceptions of his environment, behavioral patterns, interpersonal transactions, dependence on his wife and his belief systems. As these are fundamental to his behavioral expression they are at the core of creating sustainable behavior change. Following this it would be recommended that Harvey engage in group family therapy to address the boundary inadequacies and codependent behaviors present in the family structure with regards to his role in maintaining or changing them. By learning to augment aspects of his perceptions and belief systems Harvey will in turn be better able to be adaptive in his familial transactions and therefore be better able to behave adaptively within the family.
Harvey's wife, although not a substance abuser herself, would benefit from both cognitive behavioral therapy and behavioral couples therapy. The main issue present that needs to be addressed for Harvey’s wife is her dependent personality traits. This statistically is most likely a result of experiencing alcoholism/substance abuse from her parental figures in her childhood as most children from a substance abusing family system enter into the same type of relationships in later life. It is recommended that Harvey’s wife engage in local AA groups for the spouses of alcoholics as she may find support and direction in her personal recovery process. In addition to this, codependents anonymous groups can provide a more specialized venue for her exploration of self. Most importantly Harvey’s wife will need to engage in personal therapy to address the personal issues present that have developed to the point of codependent expression. It is also important that his wife understand and accept that his disease is not her fault or responsibility to “fix”. Because of the consumptive nature of substance abuse it is likely that Harvey’s wife has become consumed with maintaining the functionality of the family system and the relationship. In doing so, Harvey’s wife has neglected to take care of herself emotionally and possibly physically as well. Subsequent behavioral couples therapy would be recommended to help establish healthy interactions and communications between Harvey and his wife so they can begin to work together towards in a more proactive and cohesive manner. This in turn will help create a more stable environment with which to facilitate the recovery of their children from the familial imbalance.
Therapy for children suffering in an alcohol/substance abusing home has become multidimensional in that it attempts to address not only the issues presented by living in a home suffering from alcohol/substance but also to reduce the risk of future abuse/dependence of the children. It would be recommended that both children engage in psychotherapy so as to learn to identify and adapt their perceptions and cognitions with relation to their roles and responsibilities in the family structure. The children in an alcohol/substance abusing home are the ones who suffer the most psychological and emotional damage because they are relying on their parents to provide support in these areas as they develop. With one parent absent due to their addiction and the other absent due to their trying to “fix” the situations that arise there is no one to raise the children and provide support but them. In addition to psychotherapy it is recommended that the children enroll in a community substance abuse program. These programs have been shown to be effective in preventing/reducing the prevalence of alcohol/substance abuse in children from alcohol/substance abusing homes (Fields, R., 2010 256). As with both Harvey and his wife it would be recommended that both children engage in behavioral family therapy so as to address the boundary inadequacies present in the family system. This will also give the children an opportunity to confront and discuss their feeling and the effect that their fathers alcohol abuse has had on them. As a result communication will increase and the children will start to gain a sense of control and validity over their feelings and their subsequent behavior. In short the main areas of pertinence for the children are in addressing current and fast trauma and prevention of future alcohol/substance abuse. One method of prevention that ideally will manifest as result of the individual units of the family engaging in therapy will be an increase in the children’s experience of the 40 developmental assets postulated by the Search Institute of Minneapolis. The increased experience of these assets has been shown to reduce the prevalence of substance abuse in adolescence (Fields, R., 2010).
As it is important to understand the circumstances surrounding familial imbalance created by the presence of an alcohol/substance abusing family member to assess and provide effective treatment it is also important to recognize the cultural background of the individuals and family members as well. For example; in Hispanic culture the mother in the family is usually revered as a matriarch and the one who maintains the functionality of the family units and as a system (NCBI, 2013). If Harvey and his wife were of this cultural background this cultural dynamic could manifest a greater difficulty in absolving codependent behaviors in the family, in particular to the wife and her desire to “take care” of issues that arise as a result of the abusing parent. In addition to this the pressures of adjusting and adapting individuals of minority ethnic groups must undergo so as to assimilate into their new social and cultural surroundings have been shown to increase the risk and subsequent abuse of alcohol and illicit drugs (NCBI, 2013). Other aspects for consideration are the socio-economic status of the family, youth involvement in gang activity and access to quality education. As there are many factors that become influential in the development of alcohol/substance abuse among cultural subgroups that are not present elsewhere it is vitally important that therapeutic methods account for and are reflective of these factors.
In summation it is clear that for the recovery of an individual from alcohol/substance abuse to be sustainable their abuse must be addressed in a multidimensional context inclusive of the family unit. Each member of the family is affected by the abusing parent and subsequently develops maladaptive coping strategies and behaviors. Each familial unit must be brought back into balance for the family system to function in a healthy manner. It is also apparent that each member would benefit from individual and family based-system therapy while participating in community based support groups. The combination of these aspects of therapy will increase the likelihood of recovery and decrease the likelihood of relapse and development of future substance abuse of children in the family as well.
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