Multiple Family Group Therapy in

a Drug and Alcohol Rehabilitation

Centre: Residents' Experiences

©2008 By Gabriele Schaefer

(Gabriele Schaefer, Senior Lecturer, School of Social Sciences, Auckland University of Technology, Auckland, New Zealand; Email gabriele.schaefer@aut.ac.nz; Ph. + 64 09-9219999 Ext. 8410. This article was published in ANZJFT, Vol 29 Number 2, 2008, pp 86-96)

This study documents how residents experience Multiple Family Group (MFG) treatment in an 18week residential therapeutic program for people with a severe substance disorder. Individual in-depth interviews with nine residents and three ex-residents of European descent were undertaken, and analysed using a descriptive thematic analysis. Results indicate that, prior to taking part in the program, their relationships with their families were seriously damaged and their situations often appeared complex and hopeless. After attending the MFGs all of the participants of this study experienced a number of positive changes in their relationships with their family members and partners. All interviewees said that they had gained more awareness about their interactions, better communications skills and were able to integrate these skills into their relationships with their families and partners.

Keywords: multifamily therapy groups, substance abuse treatment

Blum (1972), Kaufman (1985), Isaacson (1991), Lewis, Dana and Blevins (2002) and McFarlane (2002) discuss the role of family relationships in the creation and maintenance of drug and alcohol problems and identify a strong connection between disrupted family relationships and alcohol and drug addiction. Based on these findings, more and more therapeutic treatment centres have included family therapy approaches in order to address substance abuse in families (McFarlane, Gingerich, Deakins, Dunne, Horen & Newmark, 2002).

An earlier paper (Schaefer, March 2008) described the ultiple Family Therapy Groups (MFGs) which form part of the treatment at Higher Ground, an 18-week residential facility in Auckland, NZ, for individuals with severe substance abuse disorders. This second paper presents the results of a research study into how residents experience the groups, and what they have learnt from them. The literature and research about MFGs is limited (for a fuller review, see Schaefer 2008) and very little qualitative research critically examines the role of family in the recovery process. This research attempts to gain new insights into what residents experience prior to rehabilitation, and documents their experience of the process of engagement with their families in the MFGs. The study also focuses on how residents integrate new insights into the relationships with their families.

Family Therapy in Substance Abuse Disorders

Family therapy approaches have been established as useful interventions for drug and alcohol abuse (O’Farrell, 1989a, 1989b; Stanton, 1979; Steinglass et al., 1987). In the late 1980s and early 1990s an increasing number of studies focused on family treatment of adolescent substance abuse (Azrin et al., 1994; Friedman, 1989; Henggeler et al., 1991; Joanning et al., 1992; Lewis et al., 1990; Liddle & Dakof, 1994). Each of the cited studies showed that family-based models could engage and retain individual abusers in drug treatment. Drop-out rates ranged from as low as 16% (Henggeler et al., 1991) to a high of 28% (Liddle & Dakof, 1994). Studies which compared family-based treatments to peer-group therapy found that retention rates in the family-based models (family therapy and family education) were significantly better (Joanning et al., 1992; Liddle & Dakof, 1994).

Szapocznik and his colleagues also demonstrated the effectiveness of family therapy in treating adolescent drug use (Szapocznik et al., 1983; 1986; Szapocznik et al., 1988). These researchers reported a change in abstinence rates from 7% at admission to 80% at termination, a result which was also maintained at follow-up, six to 12 months later. Several studies have assessed the extent to which treatment reduced behaviour problems and the psychological distress frequently associated with adolescent drug abuse. Generally, these studies found improvements in the treated group, for example, reduced acting-out behaviours and depression, and improved impulse control. In addition, Azrin et al. (1994) reported substantial improvement in school or work attendance.

Stanton and Todd, and their colleagues (Stanton, 1979; Stanton et al., 1984; Stanton & Todd 1982a) found that structural-strategic family therapy effectively reduced drug use. Their first study, the ‘Addicts and Families Project’ (AFP), demonstrated that family therapy was more effective than standard drug counselling. However, no differences were found between treatment conditions regarding improvement in vocational or educational status.

Other comparative research focused on the differences between family therapy home detoxification treatment and a standard detoxification program, indicating that the rate of detoxification was higher with the whole family involved in treatment (65%) or with part of the family involved in treatment (56%) than when family therapy was refused (12%) or not available (11%) (Stanton et al., 1984). However, replication studies have not shown the same success as the original study. In the Netherlands, Romijn and his colleagues (1992) discovered no significant differences on either drug use or social functioning between the groups receiving family therapy and the control group participating in a standard methadone treatment program. In a recent study of male methadone maintenance patients, McLellan (1993) found that a comprehensive intervention package with a number of treatment components, including family therapy, was more effective than standard care.1

Fukunishi and his colleagues (1994) examined the effect of family group psychotherapy over a six-month period on 14 alcoholic families. They found that it helped the family to be aware of their anxiety and conflict and assisted them to share their feelings with a group. Participation increased family cohesion and allowed anxiety and conflict to be more easily expressed within the family.

Catalano and his team (1999) investigated whether intensive family-focused interventions with methadone-treated parents can reduce parents’ drug use and prevent children’s initiation into drug use. Their findings show that one year after the family skill training, significant positive changes occurred among parents, especially in the areas of family management, parenting skills, decreased parental drug use, and decreased association with deviant peers.

Stanton and Shadish (1997) conducted a systematic review and meta-analysis of outcome studies in drug abuse treatment and family therapy. This review, which included 15 studies comparing family/couple therapy with non-family modalities, such as peer group therapy or individual counselling, showed superior results for family therapy. This did not mean that the non-family modalities were not effective, because the analysis showed that they were. However, the research showed that their results could be improved by the addition of family therapy, or that family therapy presented a more effective alternative.

Multiple Family Group Interventions

In 1975, the family therapist Bowen described the MFG as a specialist family therapy approach that not only brought together the affected family systems, but also combined these with other families and network systems. Central to the effective facilitation of the groups are principles of restoring self-efficacy, vicarious learning, improved communication skills and support (see Kaufman & Kaufman, 1979; 1994; McFarlane, 1982; Asen, 2002). Most publications on MFGs appeared between the 1970s (Alger, 1975; Bergen, 1973; Bowen, 1975; Hendricks, 1971; Kaufman & Kaufman, 1977; Laqueur, 1976; Laqueur et al., 1964; McKamy, 1976) and the mid-eighties (Anton et al., 1981; Clerici et al., 1988; Lovern & Zohn, 1982; Nichols, 1985; Kosten et al., 1986; Zimberg, 1982, McFarlane, 1982). McFarlane (1982), for example, developed a multi-family therapy program in a psychiatric hospital because he was convinced that families might learn from each other by seeing parts of themselves in others. Family members could learn from each other without the need for the facilitators to make issues explicit in a psychological way. Following a gap of some ten years, there has been some recent renewal of interest in MFGs (Boylin et al., 1997; Conner et al., 1998; Henggeler et al., 1991; Kooyman, 1993, McFarlane, 2002; Asen et al., 2001; Asen, 2002; Bishop et al., 2002; Calahan & Robinson, 2002; Eisler, 2005; Scholz et al., 2005; Asen & Schuff, 2006; Lemmens et al., 2005; Lemmens et al., 2005; Lemmens et al., 2007). Most studies that have been conducted in the last seven years demonstrate that MFGs are an effective treatment for various conditions. For a more in-depth discussion on research about MFG’s see Schäfer (ANZJFT, March, 2008).

Multiple Family Groups at Higher Ground

Higher Ground was established in 1989 in Auckland (New Zealand) and provides a 25 bed, four month residential therapeutic community for people with severe dependency on drugs and alcohol. As well as the 12-Step philosophy of Alcoholics Anonymous, the disease model is used in individual as well as in group therapy throughout the treatment. Some of the residents were referred to Higher Ground through the prison system and others were self-referred. Further details of the program can be found in Schäfer, 2008. From 1997, the program has sought ways in which to engage family members of residents more effectively. Consequently, it was decided to run a MFG once a week, inviting every resident’s family members. If they did not have family members attending, residents were encouraged to invite a support person. This support person could be a friend, a sponsor from a 12-Step Fellowship, or a colleague. The MFG focused on developing better communication patterns between family members, generating better boundaries between family members, fostering mutual support, and promoting self-responsibility. These goals were considered consistent with the therapeutic community approach. Between 15 and 25 residents and between nine and 30 family members attended, bringing the total of participants to between 24 and 50 per evening. The groups were split into three smaller groups of between 10 and 25 participants and were usually facilitated by two therapists, who introduced the rules to the group members, and tried to create a safe space in which everyone could share their experiences. Therapists had various therapeutic backgrounds, some were drug and alcohol counsellors, others were family therapists and psychologists. The therapeutic approach was therefore eclectic, including psycho-educational elements (such as giving information about various drugs and the disease model) as well as different therapeutic styles; for example, structural family therapy and narrative family therapy.

Each group session started with an opening round where everybody was given the opportunity to identify the kinds of issues they wanted to work on with their families. Generally, groups focused on the ‘here and now’ dynamic of the clients, and staff coached group members on how to address issues from the past without dwelling on them or blaming each other. The MFG focus was on developing good boundaries and good communication, so that family members could recognise their enabling behaviours towards the resident, and could learn about addiction. The whole session lasted 90 minutes, so each family had only limited time to explore its own issues. Other families were invited to provide their observations and feedback. The staff members debriefed after each MFG and were available to individual participants or family systems.

In the 12 months ending 31 March 2001 a total of 239 family members or support persons and 120 residents attended the MFG. Eighty-two (34%) family members or significant others attended the MFG only once, and 93 (37%) attended between two and five times. 64 (30%) attended between six and 24 times (Higher Ground Statistics, 2002). Stuart Anderson (in personal communication with Robert Steenhuisen, May 2001) pointed out that the majority of residents had family members or support persons regularly supporting them in the MFG. The majority of residents in Higher Ground are European and only 10% are of Maori and Pacific Islander descent.

Methodology

The purpose of my research was to establish whether a process of healing takes place between residents and their families in the MFG context and whether residents are able to integrate their learning from these groups into their daily lives. The Auckland University Human Subjects Ethics Committee approved the study. All names and other identifiers have been changed to ensure confidentiality. At the time of the research I was working as a lecturer at the University but was also facilitating MFGs in Higher Ground on a part-time basis. However, I did not interview residents in my own MFG, and the residents I interviewed were unknown to me before the interview.

During July to August 2001, the staff members facilitating the MFG alerted participants to the research project. Higher Ground also arranged a poster at strategic places on the premises inviting participants to contact the researcher. I approached the ex-residents and invited them to participate, whereas all of the residents let the clinical director know that they wanted to take part in the study.

The Participants

Three woman and nine men who identified themselves as Pakehas, that is, New Zealanders of European descent, participated in this study. It would have been useful to interview Maori and Pacific Island clients about substance abuse, as their family structures often differ from the Western family norm. However, at the time of the research there were no Maori or Pacific Island clients in Higher Ground.

Of the interviewees, three women and six men were residents of Higher Ground and three men were ex-residents. Interviewing ex-residents allowed me to explore whether the MFGs had a long-term impact. All of the ex-residents had graduated from the program several years earlier. In the Results section, the answers of the ex-residents will be presented after the accounts of the residents. The participants’ age ranged from early twenties to early fifties.

Data Collection and Analysis

My associate and I conducted in-depth semi-structured interviews of approximately one hour. With the participants’ permission, the interviews were recorded on audiotape and transcribed. It was my aim to understand the experiences of addiction and the therapeutic processes in the MFG from the participant’s perspective, and to allow flexibility in the interview so that new knowledge could emerge in the interview process (Way, 2001: 114). The interview material discussed here does not claim to be representative of a wider population. Once the interviews had been transcribed, the resulting data was processed via a descriptive thematic analysis technique (see Glesne, 1999). The analysis involved multiple readings of the data and identifying connections, patterns, and themes (Braun & Clarke, 2006: 79). Braun and Clarke (2006) discuss what constitutes the prevalence of a theme, emphasising that there is no right and wrong method for determining prevalence, but that authors need to let the reader know how they analysed their data. In this study prevalence was counted across the entire data set. Each theme is based on accounts from the majority of participants but only one or two extracts are presented that represent it.

Results

Five different themes were identified in the interview topics. The responses of both residents and ex-residents will be summarised in this section.

Theme: Broken Family Relationships

The residents said that they were unable in the past to develop a functional relationship with their family of origin and with partners. They felt many different emotions about their fragmented and dysfunctional relationships. Several participants said that they had committed crimes that further damaged family relationships before they came into Higher Ground. Others had worked as prostitutes in order to support a drug habit, while their children at home were often neglected and abused.

Interviewer: How do you think your parents experienced you while you were in active addiction?

Male resident B: Then? They thought I was crazy. My father thought I was schizophrenic. He didn’t understand what drugs do to you, but he’d read a bit about amphetamines and he realised that on the drugs I was like two different people, and my mother would say to me, she didn’t know who her son was because of how I was acting … The thing my family was most shocked about was my suicide attempt. Everything else was second to that. Because once you’re dead, like my dad said to me, ‘Once you’re dead, you’re dead’, and that’s where my biggest shame was around. I mean being a drug dealer I can live with that. That’s something I did, I chose to do that, but trying to take my own life is something I still have trouble with. How did I get so low?

The majority of the residents had experienced abusive and difficult relationships with their parents and partners in the past. All of them stated that they and their families were in denial about the addiction and rationalised their behaviours to others. As I stated above, some residents had neglected their own children as a result of their past behaviour, and expressed fear that their children might follow in their footsteps because they had witnessed their addictive behaviours for years.

Interviewer: Do you think you treated your children how you have been treated yourself as a child?

Female resident B: Yeah. My kids are only little but they know what a syringe is and they know why I’m going in the bathroom with the syringe. My five-yearold, if he would have found my canisters or dirty syringes in the bathroom — I think to myself, fuck, if that kid had got in there, there is no doubt he’d be trying to do what I do, as little kids do. They mimic what their parents do. And you’re teaching them to lie, because, like, ‘Oh mummy I’m going to school and I’m having an injection like you today’ and I’m like, ‘For god’s sake, whatever you do, do not say anything about that’, you know, ‘Do not tell anyone what I do’.

Ex-residents had had similarly difficult and painful relationships with their families before they came into Higher Ground. One ex-resident experienced loss very early in life when his mother died and he was moved around among several relatives. His father was alcoholic. He was physically and sexually abused and grew up in an impoverished environment. This person left home early and became addicted to drugs. He lost several jobs and before he entered Higher Ground, he was ill and clinically depressed.

Theme: Breaking Through Fear in the MFG

Residents and family members often experienced discomfort because their behaviour or their perspective on life was challenged in the MFG. At the beginning of the group process most residents admitted that they were very fearful. For that reason they said they held back until they got more comfortable with other residents and family members. But despite these initial anxieties, they shared their experiences and were often able to release some of their guilt and shame and build new relationships.

Male resident C: For me, being in the MFG makes me quite nervous. I haven’t been in this sort of environment before. I’m finally having to face issues and things that happened in my past and I find this very, very frightening and very uncomfortable. A lot of shame and guilt that I’ve experienced in my life in the past, I’m having to relive a lot of this in this house and of course I’m ashamed of a lot of these things that I’ve done. But it’s helping me to break the cycle that I’ve been living in. It’s a repetitive cycle and I know that it’s going to help me live a better life in the future.

Ex-residents’ accounts of their experiences in the MFG were similar to those of current residents. One resident explained that it was scary to him that others brought their family members into the group. He was so estranged from his own family that this was a difficult environment for him. Nevertheless, all ex-residents explained that through the MFG they slowly learned to open up emotionally to family members and other participants.

Theme: Residents and Family Members Developing Shared Understandings

Residents talked about the support they received from their family and friends through their participation in the MFG. All of the participants said that they and their family members learned a lot about addiction from other residents and family members. Most of the participants stated that in the MFG they and their family developed shared understandings. Often they were able to identify with patterns in other families present, and through vicarious learning were able to integrate these new insights into their own relationships. In some cases, the residents were able to talk about their addiction and resulting problems with their family members for the very first time.

Interviewer: So if you contrast all these experiences with your family with coming to treatment and what went on in the family group, do you see a difference?

Male resident B: Oh yeah, I am much closer to my father now and the difference is that they’ve got an understanding of what chemical dependency is all about, through meeting other people here, and they’ve also met other families here that have got similar problems like I’ve got and so it gives them support.

Male resident C: I have a sister who comes in here. We had, no, had burnt the bridges between me and my sister before coming in here and now by sharing and talking with her about what’s happened to me and making her understand what my addiction is all about, I’m finding that we can rebuild our relationship that we’d lost. Listening to other people talk about their stories as well, I find that that really helps me. Because I’ll hear someone else talk about something and it will remind me of a similar situation that happened in my life.

Theme: Families Developing Better Communication and Increased Self-Awareness

In the participants’ view, the process of change happened because the MFG groups facilitated new learning about addiction. The groups supported residents and family members to formulate an effective response to what had happened in the past and how they wanted to relate to each other in the future. In the MFGs, all were coached to implement better communication strategies (for example active listening) and to introduce new behaviours. One resident talked about his parents starting to take on board the importance of setting boundaries with him. In the MFG, he encouraged his parents not to support him if he relapsed. As a result, the majority of residents who were interviewed were able to develop a different and more trusting relationship with their families.

All the ex-residents interviewed were able to remain in recovery after they left their treatment program. Without exception ex-residents agreed that they had developed new and better communication patterns in their relationships with their families. One ex-resident was able to leave his wife after they had tried for a long time unsuccessfully to rescue their relationship. He said that they were able to work through their issues and were now able to have a good co-parenting relationship. He also stated that he is now able to talk about his feelings, own them and not blame others so much.

Interviewer: What have you learned in the MFG?

Male ex-resident I: Yeah. Well I can certainly talk about my feelings now. Yeah. I can certainly own them. To a certain extent not blame but it depends really. It can depend on any given day, where I’m at, as to what I want to own and what I want to dump, control, and, you know, get my own needs met. And being able to take some personal responsibilities for my actions and behaviours and accept consequences. And that’s some of those big decisions such as having split with my wife. We’ve been separated now. And I think that we’ve have been able to have a working relationship, like we’re apart but we can still communicate about the children. And that’s not always been the case, that’s been difficult.

Two residents said that their relationship with their families changed dramatically. Their family responded well to their newly-found openness and willingness to take responsibility for their lives. Two ex-residents said that they experienced more warmth, intimacy and love with their families. One ex-resident was able to stop being the family rescuer by detaching himself from a mother with an eating disorder and a brother who has a severe substance dependency.

But not all insights were relational; ex-residents also developed more self-awareness and self-esteem. One ex-resident spoke about a spiritual reawakening that helped him to overcome the severe anxiety attacks he had experienced in recovery. Two ex-residents spoke about feeling better and stronger about their homosexual orientation than before treatment. All the residents and ex-residents said that they had experienced more awareness of their family patterns and had developed more intimacy with their families.

Theme: Recovery is an Ongoing Process

The majority of the participants in this study reported that, although they had experienced improvements in their relationships with family and friends, they still needed to work on these relationships. Residents mentioned that they needed to engage with their families outside the MFGs in order to test whether they could maintain the changes they had made in the group. This was particularly emphasised by the ex-residents who had had longer ‘trial periods’, giving them the opportunity to integrate their new insights. All ex-residents thought that their progress was not complete and that they were still working on issues, but that they had noticed some definite improvement. For example, one ex-resident was in the process of changing a strong perfectionist pattern that had contributed in the past to feelings of low self-esteem. He is now able to give up the idea that he has to be the best in his profession. Another ex-resident expressed strong regrets about not having invited his father and his brother, who also experiences drug addiction, to participate in the MFG. He was not encouraged by the facilitators to do so, and still has unresolved issues with them. He stressed that it is very important to get family members into the group and make amends to them.

Interviewer: How do you experience the relationship with your family today? Like, with your partner, ex-partner, as well as with your father? You said your mother died.

Ex-resident I: Yeah, no, my mum died before I got clean. So there are regrets about that. My father, my relationship with him is still not good. Um, and that’s my regret, that he knows nothing about recovery, or addiction, and he’s very set in his ways and, you know, I still have a lot of trouble around my father. And in fact so much, that I do not have too much to do with him. My relationship with him is tenuous.

Discussion

The residents and ex-residents said that they were unable in the past to develop a functional relationship with their family and partners. Drug addiction affected all areas of their lives such as health, finances, intimate relationships and staying within the law. The ‘Broken Family Relationships’ theme resonates with the existing literature about the effects of substance abuse. The affected individual and his or her family suffer family disruption (Kaufman & Kaufman, 1979; Velleman, 1992), family violence (Kaufman, Kantor & Strauss, 1989) loss of employment, financial instability (Liddle, Dakof & Gayle, 1995), marital break down (Kosten et al., 1983) and physical and psychological abuse (Kaufman et al., 1989). Individuals with serious substance abuse disorders often commit drug-related crimes and experience accidents (Brake, 1994; Coleman & Strauss, 1983; Lipsitt & Vandenboss, 1992). In many cases, drug addicted mothers lose custody of their neglected and abused children (Hughes et al., 1995). Participants in this study experienced all of the effects that have been identified.

It is also known that drug problems co-occur with clinical disorders such as antisocial personality disorder; conduct disorders in adolescents, and depression (see Liddle et al., 1995). Certainly, participants admitted that they displayed antisocial behaviour while they were in active addiction, reaching the point of breaking the law through drug dealing and prostitution. They also agreed that they were in denial about their addiction, and that they rationalised their behaviour to their families and friends. Isaacson argued that ‘defence mechanisms serve to protect the individual and the family from confronting the chemical use’ (1991: 21). Denial and rationalisation are defence mechanisms that stop the family system from changing. One aim of the MFG is to break through these defence mechanisms in order to create an opening for change.

Minuchin (1979) described how communication becomes fixed in stereotyped patterns of interaction, which can reduce the degree of openness in a family system. He argued that these families became closed systems where coping mechanisms do not function any more. The participants said that the dynamics in their families became so dysfunctional that it resulted in a breakdown of open communication and mutual caring. Two female participants had lost custody of their children, and one male client had lost access to his children. Several participants had relationships with their spouses and family members that were severely damaged, and several had experienced severe depression and a health breakdown. They all reached a point where their lives had become unmanageable.

Through the support given by the MFGs, the residents, ex-residents and their families benefited in their recovery, in line with the third and fourth theme of the study. The mutual support in the MFGs helped them to address some of their dysfunctional family patterns and break through the denial. Bergen (1973) explained that by bringing families together, their sense of isolation can be relieved and a new sense of hope can be developed. Participants in the MFG concurred with these findings; some of them could break through the paralysis within their family system by learning new communication strategies and behaviours. However, this process did not happen ‘overnight’. Most residents and ex-residents said they felt ‘cautious’, ‘nervous’, and ‘uncomfortable’ at the beginning of their involvement in the MFGs. However, after an initial phase of fear and discomfort, all of the participants started to feel safer within the group context, which allowed them to talk about their experiences with other families.

Bowen (1975) emphasised the need for a clear structure in the MFG after he experimented with a more open format. The clear structure in Higher Ground’s MFGs helped the participants feel safer. Several residents and ex-residents discovered the meaning of ‘intimacy’ when they could let go of the different ‘masks’ that protected them from the hurtful responses of other people. McKamy (1976) stressed that the atmosphere of trust constituted the essence of the MFG. Trusting in the therapeutic process in the MFGs allowed the participants to connect intimately to their own life-stories as well as to other people’s psychological processes. According to Laqueur (1976), the exchange of ideas and experiences between families in the MFG can improve the quality of communication within family systems and can function as a catalyst for change within the system. He explained that the advantage of the MFG over individual family therapy was the exposure to multiple perspectives. This process normalises residents’ and family members’ experiences because they realise they are not alone. This process was also effective for the participants of this study and allowed the development of shared understandings (the second theme) for residents, ex-residents and their family members. The identification with similar family patterns of other families present provided new insights into their own relationships, which several others studies about MFGs have also demonstrated (see Bergen, 1973; Bowen, 1975; McKamy, 1976).

Kaufman and Kaufman (1977) claimed that only enmeshed families would be prepared to become involved in MFGs. Researchers such as Schroeder (1991) observed that some individuals in the twelve-step programs were disengaged from their families and that it was quite hard for their therapists to reconnect them. In this study, some residents and ex-residents were very distant from their families because they were too ashamed to have much contact with them. Despite this apparent ‘disengagement’, the family members were happy to attend the MFG, in contrast to what Kaufman and Kaufman (1977) maintained.

Several residents were indeed ‘enmeshed’ with their families, who enabled them to continue drug taking by either providing the drugs themselves, or by protecting the addicted family members from the consequences of their substance abuse in other ways, such as giving them money. Three residents and ex-residents experienced a process of individuation in the MFG. One ex-resident explained that he was ‘enmeshed’ with his brother who was also abusing drugs. Through the MFG, he was able to recognise that their relationship was too involved and he needed to take care of his own needs rather than rescuing his twin brother. Through the MFG, both brothers were able to engage in different communication strategies. However, the resident’s brother could not cope with the pressure his twin brother put on him, and left the MFG. The enmeshment was broken, but this did not heal the relationship between the brothers. Nevertheless, this ex-resident experienced some individuation and is now able to be ‘an adult’ who is responsible for fulfilling his own needs and setting clear boundaries.

Kosten and his team (1983) noted that drug and alcohol addiction often leads to marital break-up. In two cases in this study, the MFGs actually facilitated the break-up of couple relationships that had been very dysfunctional in the past. The loss of couple relationships is not always destructive, and both of the participants of this study who were in this situation realised that they needed to focus on their recovery by themselves.

Several participants explained that because they had changed, their family systems and intimate partners had changed as well. In several cases, change occurred for family members despite the fact that, living overseas, they had never attended the MFGs. At first glance this seems surprising and unlikely given how deeply disturbed the family dynamics in these families were. However, Minuchin (1979) did point out that if one participant in the system changed, others had to change as well. Bowen (1978, p. ??) is famous for his statement that ‘distance and silence do not fool an emotional system’, which acknowledges that changes in one family member may affect even those who have no contact with him/her.

It is important to mention that the participants of this study did not fully resolve their family problems, which is reflected in the fifth theme. Ex-residents in particular (who had more time to integrate their learning from the MFGs into their daily lives outside residential treatment) emphasised that they still needed to work on family issues such as denial or emotional distance, and personal issues such as low self-esteem and anxiety. They suggested that it is important to bring all family members into the MFG and take advantage of the opportunities for learning that is provided within this therapeutic group.

Conclusion

This study was limited to Higher Ground, and we did not address questions such as the extent to which Maori and Pacific Island people experience the MFGs differently from Pakeha participants. Further investigation into MFGs in New Zealand should include participation of Maori and Pacific Islanders. Such research should also explore how the disease model and the 12-step program impact on resident’s beliefs about their recovery in general and the healing within their family relationships in particular. However, our fifth theme indicates that recovery is an ongoing process.2 In AA, recovery is perceived as a lifelong commitment dependent on each individual’s pace, and it could be that the participants in our study internalised this belief because they received treatment in a residential 12-step program. It would also be interesting to investigate how ex-residents who relapsed and were not able to maintain and improve their relationships with their families, describe their experience of the MFGs, although it would be difficult to recruit them for an interview.

We need more quantitative and qualitative studies of MFGs in different rehabilitation centres, as well as outpatient treatment, addressing different cultural interpretations of family systems. Nevertheless, despite these limitations, this study has shown a glimpse into how residents and ex-residents experience the MFGs and whether they were able to integrate their new insights into their family relationships. All of the cited studies of MFGs (see Kaufman & Kaufman, 1979) clearly indicated the main functions of the MFGs are that families learn from each other and have the opportunity to improve their communication skills with each other — and our study supports these findings.

Endnotes

1 It is important to note, though, that the number of studies is not large, the target populations are not inclusive, and conclusions are drawn from studies with a variety of methodological limitations.

2 I refer here to Schroeder (1991) who argues that family therapy and twelve-step programs complement each other.

Acknowledgments

I wish to acknowledge the assistance I received from Robert Steenhuisen, Stuart Anderson and from George Latham.  I also want to thank the Auckland University of Technology for their financial support for this project.

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