Primary Themes and Reframes in
Multiple Family Groups with Substance-Abusing Adolescents
By Gary Sauls and Stephanie Bouis
Duke Addictions Program, Durham, NC
Theoretical Assumptions
Change is constant.
Problems develop when these impede problem solving.
Healthy stress helps unbalance status quo and facilitate change.
Change to one person affects every other and the family as a whole.
Therapist's role is to change functioning so they can find new solutions.
Each family has structure, beliefs and behavioral patterns that affect responses.
Theme: "He's just a bad kid, if only he would..."
By the time families enter treatment, many have become disillusioned; they define the problem as constant behavioral problems associated with the substance abuser. This focus keeps attention off their own relational problems. Families can spend an entire session listing negative behaviors of the identified patient.
Reframe: Present an educational piece on the biological-psychological-social-spiritual aspects of addiction. Set the boundary that this is a medical issue not a moral one. Define the behaviors in medical terms. Compare addiction to other primary diseases which may be easier for some family members to understand. Continually reframe for family members who don't understand.
Theme: "We don't have the problem."
Family members often feel it is not "their problem" and that they don't need help. They will attempt to get you to focus on the identified patient. No matter how skilled or how hard you try, they will continually attempt to pull you back. Again, this may be a defense to keep the focus off of other problems in the family. As long as they can keep the negative focus on the identified patient the family system will not change.
Reframe: Reframe the problem as a systems problem. You may discuss the roles that are acted out in dysfunctional family systems. This gives them an opportunity to see how they fit into the puzzle. Sculpting is an excellent tool to define these roles in an educational way. Once families know these roles you can use them to take the focus off the identified patient and put it where it belongs. Sculpting alone in this setting without the educational piece may not be as helpful. They need a framework for looking at the system that is outside their normal framework. Most family members will identify their role and slowly the focus become family-centered rather than identified patient-centered.
Theme: "She has to want to quit using or treatment won't work."
Family members often believe this common myth, it comes from years of social programming. If families wait until the substance abuser asks, treatment may be too late. Many have died because of this false belief. Many things motivate treatment, rarely is it the self. Most often, external forces such as family, legal, educational, employment, or physical problems precipitate treatment. Family members expect a person who is acting and operating irrationally to make a rational decision. It is true that, ultimately, taking responsibility for one's own recovery process is key in maintaining recovery.
Reframe: Define this as a myth. Use a common metaphor like "You can lead a horse to water, but you can't make him drink" and add "but you can make him thirsty". Discuss the levels of treatment intensity common in the recovery process. Sometimes the recovery process begins with intensive stabilization such as inpatient detoxification or close parental supervision ("lock-down"). Afterwards, he/she can gain insight into how behaviors are affecting others and choose the opportunity to change.
Theme: "I'm happy we won't have to deal with this problem again."
Family members often believe that if they do everything "right" they can put this problem behind them. They look to professionals to "fix' the problem like a car. They want to do their part and then go on with their lives. They become frustrated when they hear this is a life long process that may need sometimes small and sometimes intense interventions in the future. And more importantly, they will have to focus on their part in the "family dance" on an ongoing basis.
Reframe: An educational piece comparing substance abuse to other chronic diseases may be helpful. This should include basic information on recovery maintenance and relapse prevention for substance abuser and family members. Facilitating discussions with other family members who have dealt with this and are actively in a recovery process is very helpful.
Theme: "He's stopped using but he's still causing problems".
Family members often believe adolescents should become "perfect". It is true that most of the day-to-day problems associated with the substance use stop, but normal developmental issues do not and may require attention. Sometimes consequences of substance use, such as legal or school problems, continue. Most professional believe that development is stymied or arrested when chemical use becomes problematic so focusing on these issues is helpful. Safeguarding the identified patient's early recovery process must be the priority to allow time to deal with the wreckage of the past.
Reframe: Set the boundary "that was then, this is now". A lecture on developmental issues can normalize current problems. Take the focus off behaviors that happened prior to treatment and focus on the positive changes. Acknowledge the problems must be solved but not at the expense of recovery.
Theme: "My parents don't really do stuff together, she works a lot."
Often substance abuse has damaged the relationship between parents who have been unable to resolve the problem through discussions and ultimately disengage.
Reframe: Strengthen this boundary by facilitating discussion between parents and with other families. Have parents commit to spending individual time together before the next session. Have other parents share what they do for couples time.
Theme: "I'm going to leave as soon as I turn 18."
Frequently members attempt premature separation as a solution to the problem.
Reframe: It is true that certain things happen when a person turns eighteen. They can be "put out" of their homes. They can buy cigarettes legally. Males must register with selective services. Parents no longer have direct responsibility. It is helpful to discuss growing up in developmental, not chronological, terms. Families benefit from education about these stages which last into the middle 20's. Some learn appreciation for the comforts of home after leaving for a short time. Other families must be assisted with connecting in order to separate.
Theme: "He really can't manage without me."
Families keep the substance user "young". Polarized patterns of over and under-functioning develop that can lead to learned helplessness. Parents can put a cushion between the substance user and the consequences of behavior.
Reframe: Recovering persons can challenge this faulty assumption through personal sharing. Ask the parents, "are you actively participating in his recovery process -- or in his suicide?". Help family members to identify and support to maintain personal limits. Assist members to connect with their own emotions, usually fear, in response to powerlessness. Remind them that feelings are there to provide information, they are not a call for action.
Theme: "I understand her better, she's just like me."
A common expression of boundary dysfunction is enmeshment. Frequently, one parent will over-identify with the substance user. The undesired behavior is sustained by protection and may create tension between the parents. Adolescents use rebellion to develop individuality. Move the family around in the group to exaggerate the splits.
Reframe: Assist family members to shift focus from the fused dyad, solicit the perspective of others. Help parents to connect with their own childhood grief. Encourage boundaries that are mutually supportive without compromising autonomy.
Summary
Psychoeducation in multiple family therapy groups can help inform and normalize these common themes. Before group, discuss with students or co-facilitator if the class will be presented formally at the session beginning or when the themes surface in the discussions. Understanding the themes in other client populations is also helpful. Process with your co-facilitators (before and after the group) why and how the theme was handled.
References:
Edwards, John T., Treating Chemically Dependent Families: A Practical Systems Approach for Professionals, Johnson Institute.
Edwards, John T., 1997. Working With Families Guidelines and Techniques, 4th Edition, Durham, NC: Foundation Place Publishing.
Nichols, Michael P. and Schwarts, Richard C., 1998. Family Therapy, Concepts and Methods, fourth edition, Boston: Allyn and Bacon.
