Clients, Families Experience Parallel Processes in Recovery

Families often are relegated to a peripheral role in traditional addiction treatment for a variety of reasons. However, families who incorporate recovery into their own lives, can maximize an individual’s chances of recovery, said Michael Barnes, PhD, LAC, LPC, chief clinical officer, Foundry Treatment Center Steamboat in Colorado.

On Thursday at the Cape Cod Symposium, Dr Barnes presented a session on how families can organize around a loved one’s addiction to improve outcomes. Recently, he spoke with Addiction Professional about the reasons that family programming isn’t sufficiently supported, the role of systemic motivational interviewing when working with families, and other best practices.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional: Why is family programming still often relegated to a peripheral role in traditional addiction treatment?

Michael Barnes: I think there are several reasons. The first is that as addiction treatment has moved more and more into a medical model, we have to have an identified patient who becomes the subject of treatment, and that the family becomes peripheral or secondary. In any medical environment, families are seen more as support and there for aftercare and those kinds of things.

I think the second reason is insurance. Insurance companies want to know if families are involved in treatment, but they’re not willing to pay for their involvement. They don't see the family as part of the client and they certainly don't pay for that. There are a growing number of programs around the country that are closing their family programs, or at least cutting them way back, because it's just not financially feasible to do it. That’s one of the things that we're trying to combat.

The third reason—and this is really interesting because I live in both worlds, with a PhD in marriage and family therapy, but working as an addiction counselor for 41 years--the 2 disciplines don't understand each other very well. Addiction counselors have very little training in how family systems work. Many are in recovery themselves, and therefore tend to relate more to the struggle of the client than the family in many places. I've heard interventionists bring a client in and say, "I just brought you the healthiest member of this family," and that they tend to see the family as the problem. Family systems thinkers can't fathom why you would take a person out of the family to treat them for an issue, but very clearly the research does not say that if a family member gets sober, that then the family will get healthy. It says just the opposite: if the family can begin to incorporate recovery into their lives, they maximize the person's chances of recovery significantly. This is something we have to get a handle on going forward, and we also need to be able to measure it way better than we're currently measuring outcomes for family programming and all of that.

AP: One topic in your session is systemic motivational interviewing. Can you just explain what that is and how it can help family members move through the process of recovery?

MB: I want to start with a story. I teach at the University of Colorado. I had a student who said, "What's the best way to work with an unmotivated client?" And I said, "I don't know. I've never worked with an unmotivated client. Most of my clients are highly traumatized and they are highly motivated to stay safe." It looks like they're not motivated, but they're really motivated because of the threat and the danger of change is really difficult. They begin to ask: “Is it my need to change? Is it their need to change?" So, I tell that story because what systemic motivational interviewing is, is if we had a client who did not want to participate in our programming and was ambivalent, we would use motivational interviewing to help that person move from pre-contemplative to contemplative to action, etc.

We don't do that with families. We tend to write them off as unmotivated or resistant. Many articles have been written, the most notable by Peter Steinglass, asking how do you move a family from being pre-contemplative? The idea that my loved one is the one with the problem, I'm just here to support them, which is very much that motivation to be safe. The beauty of systemic motivational interviewing is that it allows us to meet the families where they are. Rather than be angry at them for not participating, we are inviting them in.

We do a whole system where we have multiple family programs. If a family decides they don't want to go into the growth-oriented one, then we bring them into one where we just give them information, but it's really a motivational interviewing program to help them talk a little bit about what's going on with their client. But also we talk a little bit about how they're doing in the process and begin to work on the ambivalence that they have about who has the problem and what actually needs to happen.

Several years ago, I worked on a research project where we found that families who have a loved one in the earliest stages of their addiction want a therapist who's really hierarchical, who's going to tell them what to do. But over a relatively short period of living with the addiction, that shifts to wanting a really collaborative therapist, someone who's going to see them as the expert, rather than the therapist seeing themself as the expert. Motivational interviewing is person-centered, it's collaborative. It allows for the joining process with families that say, "We understand the struggles that you've had. We understand that you've been trying to help someone while also trying to keep this family going." That opens the door to asking a number of open-ended questions and two-sided interventions that really allow the family to be in a place of wrestling with their own position, as opposed to us trying to muscle them into a place of doing what we want them to do.

AP: Do you have any recommendations in terms of best practices for incorporating family into traditional addiction treatment to help drive better outcomes?

MB: Yes, the first is that someone from that organization needs to really look at the evidence base for family work with addiction. There is a lot of research out there. It's compelling, particularly in the chronic disease management community. Anyone who wants to do what we are doing, I would really encourage shifting their thinking towards chronic disease management.

So I would compile much of that research and shift my focus from we just need to do this because it's the right thing, to whether it will help our outcomes. When I've tried to do this in the past, people have just blown me off. So when I went back to, OK, what do I think it needs to be? Number one, you need to show that it is successful. Number two, you need to show that it's not a paradigm shift. We're still in a medical model. The other part was that it is an environment where family therapists will also support it.

Clearly, we can cover all those bases. You have to get your facts straight first. Next. the intervention must be as much in service as possible on the relationship between trauma and family system dysfunction. We’re really good at doing trauma work with our clients. My whole research protocol from when I was a professor was all about the secondary trauma of parents and of family members.

I did a research project and had a lot of questions on it, but one of them was: Is living with an actively using family member traumatizing? Seventy-four percent of the family members said they strongly agreed, and 21% said they agreed. We want to tell people to stop enabling, but telling people to stop enabling is like Nancy Reagan telling an addict to just say no unless you're going to teach them why they do it and how they do it, and they reframe it. It’s really a trauma response—when you talk to people about their enablement, you can actually see the sympathetic nervous system start to activate.

So, if the first recommendation is outcomes and research, the second needs to be that the family is actually on a parallel process. Family members need to do the exact same things the clients need to do. They need to learn how to manage their autonomic nervous system. They need to move through a process to acceptance and surrender. They need to accept this is a chronic, progressive, and potentially fatal disease that their loved one is dealing with. What we find in our program is that the parallel process between families and clients is almost precisely the same. Different perspective, but it's the same. Teaching staff, therapists, techs must really understand that if we don't do this with the families, then the person we're treating is going to go home to the same organization as before.

Those are my biggest recommendations at this point, and I think the key needs to be accessing the highest levels of the organization. You have to convince the CEO. If you don't get the CEO on board with really truly understanding and training for support for compassion fatigue, it's never going to happen and turnover rates are going to be horrible. It's just the way it works.

As far as rolling out the family program, you always start by educating the family on their loved one. Explain what a chronic disease is and how the mesolimbic system hijacks the prefrontal cortex.

Then, you educate on trauma as much as you can, so that the family can say, "I see as much of that in me as I see in my son." Once that's the case, I know I've got them. They're now going to be clients. The third thing we talk about is secondary trauma or the impact of addiction on the family, and then healing. Finally,  we work on the question of if you are traumatized, what do you need to change? What do you need to do?

There is a sequence with which families can hear us, but it has to start with their loved one, not them.

Reference

Barnes M. Families that organize around a loved one's addiction: enhancing family engagement, motivation, and readiness for change. Presented at Cape Cod Symposium on Addictive Disorders; September 7-10, 2023; Hyannis, Massachusetts.