Improve the client`s parenting
Much has been written in recent years about “client-centered” substance use disorder treatment. This approach has represented a major departure from older models of treatment, which tended to be “program-centered.” At the risk of oversimplification, the client-centered approach borrows from the self-determination innovations in the disability and mental health services sector, while the program-centered approach is a legacy of the alcohol/drug social model of the 1950s, '60s and '70s.
At Door to Hope (DTH) in Salinas, Calif., a comprehensive family-centered approach has evolved, taking into account that anywhere from 19 to 53% of individuals in addiction treatment live with children under 18 prior to treatment.1 The development of this approach was influenced heavily by DTH’s origin as a women’s residential treatment program with many clients involved in the child protective services system. Equally important was the development more than a decade ago of a clinic at DTH, MCSTART, that identified and provided intervention services for children exposed to alcohol and drugs in utero.2
The impetus behind the development of MCSTART, which is a collaboration with the Monterey County behavioral health and child welfare systems, grew out of a 1992 study of alcohol- and drug-exposed births that found that nearly 12% of all births in the county hospital were positive for exposure to alcohol or drugs.
In addition to its core services, DTH today offers residential addiction treatment services for women who live with their children during treatment, as well as traditional outpatient services for men and women and specialized residential and in-home treatment for adolescents with co-occurring substance use and mental health disorders.
A natural outgrowth of this history was a realization that the target of treatment efforts was as much the family unit as the individual in treatment. It also was understood that in order for clients to resume parenting responsibilities post-treatment, improvement in parenting behavior would be necessary. Training clients in parenting skills became an essential element in the agency’s treatment protocols.
Not family group or family therapy
In discussing parent skill training it is important not to conflate this activity with two other components of addiction treatment: family groups and family therapy (the former common and the latter less so).
Many treatment programs will include a family group in which one or more loved ones will attend along with the identified client. Usually, the focus of these multi-family sessions involves preparing family and client to resume interactions following treatment. Clients learn that emotional damage does not heal overnight, while significant others are taught to understand triggers, relapse and perhaps the need to attend 12-Step meetings. Issues of codependency, enabling and “recovery” for the family members also may be addressed. Emphasis is placed on how to support the identified client in recovery as well as rebalancing and improving communication with the adults close to the client. These groups are often partially didactic and are facilitated by treatment staff.
Less common in addiction treatment is family therapy, sometimes termed “strategic family therapy” or “family systems therapy.” While a certified alcohol and drug counselor without an advanced degree will often lead a family group, family therapy usually is delivered by a professional with advanced training.
The website of the Mayo Clinic defines family therapy as, “A type of psychological counseling (psychotherapy) done to help family members improve communication and resolve conflicts. Family therapy is usually provided by a psychologist, clinical social worker or therapist. These therapists have graduate or postgraduate degrees and may be credentialed by the American Association for Marriage and Family Therapists (AAMFT).”
Treatment priorities
Addiction treatment has become increasingly complex. It is not uncommon for a residential treatment regime to include group sessions on:
Post-traumatic stress disorder (PTSD).
Mood management (co-occurring mental health problems).
12-Step participation.
Tobacco cessation.
Relapse prevention.
Relationships.
Vocational rehabilitation.
Spirituality.
Cognitive-behavioral strategies.
Some additions to this list, which have been reported in this publication, include:
Experiential therapy.
Sexual health in recovery.
Advocacy.
Compulsive gambling.
Conversely, parent skills training is not common in addiction treatment settings at present, but the logic for its inclusion is powerful.
Approximately 4 million individuals receive addiction treatment in the United States annually. As noted above, perhaps as many as 50% are active parents of children under 18. We now recognize unequivocally that for many, addiction is transmitted intergenerationally, resulting from a mix of genetics and learned behavior. Families in which one or both parents experience a substance use disorder essentially act as incubators for the transmission of addiction to their children. When these individuals enter treatment, a significant opportunity arises to break that family’s cycle of parent-to-child substance use problems.
Individuals experiencing a substance use disorder often are burdened by feelings of shame because of their alcohol and drug use as well as related behaviors. Different from feelings of guilt (“I did something wrong”), shame is characterized by a belief that something is intrinsically wrong with oneself. While our culture allows for the remediation of guilt through mechanisms such as religious activities or criminal justice restitution, toxic shame is not so easily resolved.
Causing harm to a child constitutes perhaps the most vilified behavior in our society. While the neglect and abuse caused by parental substance use disorder may be understood as a result of addiction, the belief that addiction is a form of “willful misconduct,” to use the words of the U.S. Supreme Court, remains pervasive. Parent skills training provides a mechanism to deal directly with toxic shame through concrete remediation activities.
L’Shanna Klein serves as coordinator of the parenting services at Door to Hope. In this role she oversees the parent skills training that is provided in the Nueva Esperanza program as well as the women’s residential service. She says, “We start with an appraisal of parental stress as well as an assessment of the child’s development using the Ages and Stages Questionnaire: Social-Emotional™. This allows us to have a baseline from which services are developed. It’s hands-on and for many of our women this means developing a sense of their child’s perspective. It’s getting down on the floor—and interacting directly with their child in structured activities designed to increase the mother-child bond.”
All staff who provide parent skills training are certified Parents as Teachers™ (PAT) educators who use an evidence-based curriculum designed to increase parent knowledge of early childhood development, improve parenting practices, provide early detection of developmental delays and health issues, prevent child abuse and neglect, and increase children’s school readiness and success.
Klein notes, “Our involvement does not end with graduation from the residential program. We follow up with home visits for up to two years as well as continued involvement in ongoing support groups. As issues emerge in the family’s life, our educators are there to coach, support and suggest referral for additional services. A major goal is a change in the mother’s self-image from 'neglectful' parent to 'successful' parent.”
“Cynthia” is a graduate of Nueva Esperanza who now works in the program. Her story is typical and illustrates the intergenerational transmission of substance use disorders. She describes her own upbringing as “rough,” with two alcoholic parents and four siblings. In middle school she began to lose her way and “failed out” because of alcohol and drug use that included inhalants, marijuana and cocaine. Her use eventually led her to methamphetamine, which she was introduced to by a sibling who told her it was “better than coke.”
After bearing five children and coming to the attention of child protective services, Cynthia entered treatment. Eventually reunified with her children, she credits what she learned to her exposure to PAT. Today, each of her children is thriving and leading a successful life. She explains:
I really didn’t know how to parent at all when I got into treatment. My mother was not a positive role model. Understanding how to soothe an upset child and the little things like interacting at eye level were new concepts for me. Also, being in a treatment program is a bit overwhelming even if you don’t have kids, but with kids it’s hard to concentrate on your own recovery. I’ve learned lots of tools from my PAT teachers. For example, I stopped using “time out” as a form of discipline. Now it’s “time in” where we sit together for a few minutes. This quiets and calms a child, where “time out” pushes the child away and just creates more frustration and anger.
Chris Shannon is Executive Director of Door to Hope. She credits the agency’s focus on families to its historical legacy. She says, “The Door was started by women who believed that the Monterey County community needed a safe place for women to get help with alcohol and drug problems. For the most part the staff and governing board have always had the belief that while drugs tear families apart, treatment and recovery should reunite and rebuild families. Everything that we do starts with the assumption that each client is part of a family, and where possible recovery from addiction is greatly enabled by strengthening that client’s family.”
Importance of assessment
Assessment instruments are the tools by which we begin to construct a treatment plan. Yet many ask for only minimal information about the client’s family life.
For example, the Addiction Severity Index (ASI), one of the most widely used tools, asks, “How many people depend on you for the majority of their food, shelter, etc.?” Later, under “Family/Social Relationships,” there is a question about “usual living arrangements” that allows boxes to be checked that indicate “With sexual partner & children” or “With children.” Clients then are asked to assess whether they are satisfied with these arrangements (three possible responses are available: no, indifferent and yes). Finally, a question asks if the client has a “close reciprocal relationship with any of the following people,” and a box exists for children.
Adding questions about family functioning and parent engagement during the assessment phase of treatment can help treatment professionals craft recovery plans that take into account the importance of remedial parenting skills training.
Clearly, the families of many persons in treatment or early recovery can benefit from the inclusion of parent skills training. In addition, clients benefit by addressing negative emotions associated with their past behavior as parents.
John de Miranda, EdM, LAADC, is Associate Director of Door to Hope in Salinas, Calif. (www.doortohope.org).
References
1. Amelia AA, Mericle AA, Riallo D, et al. Integration of parenting skills education and intervention in addiction treatment. J Addict Med 2013;7:1-7.
2. de Miranda J. County’s efforts give head start to young children. Alc Dr Abuse Weekly 2004 Feb 2.
