On May 8, 2014, Addiction Professional magazine assembled a group of experts in addiction treatment in Orange, California for a panel discussion titled “Family Dynamics in Addiction Treatment.” CalSouthern’s curriculum director Dr. Bob Weathers—who helped design the university’s Certificate in Addiction Studies program—joined clinical directors from four leading treatment facilities to discuss the critical role that family plays in both addiction and recovery.
In this six-part video series, Dr. Weathers revisits and elaborates upon the issues discussed during what was an extremely compelling, informative and thought-provoking presentation. In part one, he considers how the notion of the family’s role in addiction and recovery has evolved dramatically in recent years, as well as how this changed thinking has impacted treatment.
The Evolving Thinking Regarding Family in Addiction and Recovery
The first question the panel addressed had to do with changes in thinking in the field in terms of integrating and understanding family dynamics with regard to substance abuse treatments. So I’d like to offer a few observations relevant to this, some of which I shared at the presentation.
I’ll share my experience in my own work, particularly working in a residential setting in substance abuse as recently as a dozen years ago. It has since grown into a nationally recognized rehab but at the very beginning we had one patient and I started there as the clinical director a little over a dozen years ago. What we instituted early on at this rehab was a family day and what that meant was that our patients would be admitted for sometimes a 30-day stay, sometimes longer, sometimes a 60-day stay. Somewhere in that stay they would be invited to bring in their families. Some of these patients were local. Many of them were from across the country, the eastern seaboard. They would fly their families in and we’d have what we called “family day.”
The idea was that the families would come and get an idea of what the treatment had been like for their family member. There’d be a family therapy session, maybe a yoga session, they would eat meals with the family member and so on. But that was really it.
Very early on it became clear to me that when the patient had been in this in-patient facility for 60 or more days, when they return home, there are all kinds of problems in terms of re-entry, re-integrating with the family. You can imagine that if somebody has been in the depths of addiction, and these were the patients that we saw, that there are all kinds of trusts that had been broken, violations of the family rules, stealing, lying etc. and the family members at home who have not been at treatment, understandably would build up all kinds of resentments, etc. I felt like we were just scratching the surface with our family day.
Well that’s just a dozen years ago and I think that this still is the norm in many settings. Thankfully, this rehab has evolved a bit in terms of more integration of family, realizing that sending somebody away to a Shangri-La experience, while useful in terms of kind of re-setting the behavior around addiction, it wasn’t sufficient.
Now if I wrap time forward, I was at a presentation here locally here in Orange County. There’s a group that meets once a month called the Men’s Association for Addiction Treatment and the attendees are primarily the directors and CEOs of rehabs like the one worked in. And our featured presenter just in the last month or two was the nation’s number-one interventionist. In fact, he is currently the president of the American Association of Interventionists. Interventionists are the ones that are hired by families to come in and help to steer the family member of concern into some kind of treatment. Generally it’s a sit-down session or sessions with the family where the family really shares the ravages that they’ve experienced and their love and concern for the family member. Oftentimes it’s successful. In fact, most often it’s successful in getting somebody into rehab when they wouldn’t do it on their own.
So this individual’s name is Burr Cook. He’s out of Tennessee. And here’s the story that Burr Cook shared and I want to share it with you in the context of what I just mentioned—my experience a dozen years ago with what was the norm in terms of family treatment.
Burr shared that when he meets with a family—he travels all over the world actually and performs his interventions—he’ll say to the mother and the father, the sister and the brother, he’ll say to them, “If you don’t yourself enter into recovery your son will die.” It’s a very dramatic statement obviously and he backs that up then with the family. He can recount one story after another with a scenario that I just painted earlier which is that family members send their son or daughter off to a rehab in hopes that they’ll come back and be magically cured.
That’s no longer the prevailing wisdom and in fact it’s just the opposite of what’s recommended. The family needs to enter into treatment and that takes various forms. I’m going to spell some of that out in the next few minutes. I want to acknowledge that the one extreme that I first mentioned which is family day I think it represents one end of a continuum and perhaps Burr Cook’s prescription represents the other end.
I’ve actually spoken to a number of people who work in the substance abuse treatment industry about that statement who weren’t at that meeting and oftentimes their response is a kind of disbelief because it’s such a radical thing to introduce. So I don’t want to pretend like that’s the norm but that is a way to position the conversation about changes that are going on in the field regarding the treatment of families and addiction.
Let me talk about a couple of things in terms of practical responses. As I mentioned earlier I’ve been involved in developing the curriculum and teaching in our addiction studies certificate program here at CalSouthern. I have a little pamphlet here that spells out a little bit about this program is about. But the piece that I want to mention out of program that’s pertinent is that in all of our individual courses in this entire program, there are assignments as well as textbooks as well as outside readings as well as videos that point to a family system perspective on addiction.
I don’t think you can find one course in the program that doesn’t draw in the necessity of addressing the family. By the way, Burr Cook has a website that’s simply called www.familysystemsintervention.com and his orientation is very much a family systems orientation.
The idea is simple enough. The family systems theory which has really developed just in the last two or three decades to the level it is right now particularly in terms of addiction treatment is that no man, woman, son or daughter is an island. And that for healing to occur it involves not only addressing the addiction but also looking at the ripple effect of that across the family system.
The idea is that if you can pull the so-called identified patient out of the family orbit you can heal them in isolation, let’s say in a very concentrated treatment environment like an in-patient rehab, bring them home to the family system and the family system, of its own kind of necessity is primarily oriented toward maintaining what’s called family homeostasis. And so that son or daughter will be reintroduced to a system that wants to maintain the prior sense of balance or equilibrium. Oftentimes, it’s a very short period that transpires between release from rehab and relapse because there’s so many family variables.
The communications, the stress as I mentioned earlier I think is very understandable, that family members will be really angry and resentful and there’s no way for that not to come out in communications; family systems theory says this. You cannot not communicate. And I think we all know that even if I’m not saying how angry I am at you for what you’ve done to the family, I communicate to you through nonverbal threats or behaviors that must be addressed if there’s going to be a positive outcome from rehab so that the patient can survive.
I just want to put in a word for what we’re doing at CalSouthern. A family system orientation is primary in all of our courses. While I’m thinking of it let me mention that as I’m speaking here in May of 2014. Tomorrow we’re going to have a master lecture presentation here at CalSouthern on the interpersonal neurobiology of addiction. That’s a mouthful.
If I break that down it’s really looking at what I just said and just looking at the impact of relationships. Let’s say family relationships and particularly looking at how our relationships affect our brain functioning. You can't understand addiction if you don’t understand the brain. It’s utilizing that same kind of platform to say that we can't understand relationships also if we don’t understand the brain and vice versa—we can't understand the brain if we don’t understand relationships.
It’s bringing in a convergence of this in the dominant paradigm in the last five to 10 years, interpersonal neurobiology. What’s new is our presenter tomorrow is bringing it to addiction and there’s been relatively little done on this. There’s been some but I’m really looking forward to that presentation. So that gives you another sense of how you can bring in really current perspectives. These perspectives are only available because of the advent of brain scans in the last 10 years. Before, we didn’t have the technology to support this research.
And so this is a new perspective that once again looks at how intrinsic to not only addiction but recovery from addiction the interpersonal environment is, and by looking very specifically in terms of brain functioning. The same brain center that leads us to be addicted can be massively impacted by facilitative versus destructive relationship patterns and so it all converges into a much more powerful intervention these days than what was even imaginable 12 years ago and certainly 20 or 30 years ago when I was in graduate school.
Let me mention a couple of other things of more practicality for our listening audience. I was recently at a conference in Boulder, Colorado that addressed what’s called “integral recovery.” I have a textbook here by John Dupuy. This book just came out last year. It was selected by American Publishers as the number-one book in recovery that was published in all of 2013. The basic idea of Integral Recovery is that it’s a complex kind of holistic perspective but the basic idea is that no one can be 100-percent wrong in their commentary on what makes for the addict and what makes for a successful recovery.
So why don’t we look at integrating medical perspectives with psychological perspectives, spirituality, looking at culture, looking at the effect of family relationships and even looking at socioeconomic factors. Just to spell that last piece out, most addicts if they really hit bottom, are in deep trouble financially, have oftentimes lost jobs, lost homes, or need help in terms of dealing with the criminal justice system. All of these are critical to recovery. No less so than the psychological factors.
My own background is in psychology and we tend to underestimate oftentimes the medical and/or the social structural factors and those are no less important. So integral recovery intends, as in the title, to integrate, to be integral. Integral is actually the term that’s used nowadays. I wrote my bachelor’s thesis all those years ago on holistic approaches to psychology. The term is no longer “holistic,” it’s integral and it just means bringing together different perspectives.
It sounds pretty obvious to me that if you get into the fields of medicine, psychology, social work and so on what you’ll find out there is a lot of “turfdom.” A lot of territorialism where physicians will protect their turf and spiritual healers theirs and psychologist theirs, marriage and family therapist theirs, criminal justice people theirs. This is an attempt to open the conversation. Easier said than done. It really is a work in progress.
I was at this conference in Boulder, Colorado and there was mention made of one of the fathers of integral theory. He’s a psychiatrist here locally at UC Irvine. He’s actually in Europe right now. I’ve spoken to him and we’re going to be meeting when he gets back at the end of May. His name is Roger Walsh.
I have followed Roger Walsh for about 30 years now. I was in conversation with him back in the days of when I was doing my dissertation, and life goes on. He’s one of the grandfathers now of what’s called integral theory which is like I say a holistic approach to mental health. What I want to mention is an article that was published just in the last couple of years in the American Psychologist by Roger Walsh. It’s called Lifestyle and Mental Health.
The significance of this first of all is that American Psychologist is the most conservative publication in psychology. It’s mainstream—every psychologist in the United States, 30,000 or 40,000 psychologists receive this journal as a part of their membership in the American Psychological Association. What Roger Walsh published here won't sound radical for those outside of psychology but if you’re familiar with academic and clinical psychology there tends to be an ignoring of what he’s saying.
His point is simple. Our lifestyles, the things that we do in our day-to-day lives probably have much more impact on our psychological functioning than most of what psychologist spend their time in therapy talking about. I personally don’t disagree with him. He talks about eight different variables. Just to kind of play this out, and I’m going to tie this back into family therapy and changes in family therapy going on nowadays, I’ll mention the eight just because it might be of interest.
If you have curiosity about the article when we’re finished talking you can look it up online. It’s easily available in a PDF file. He talks about eight therapeutic lifestyle changes that all psychologists, all healthcare professionals, ought to be more mindful of than they are. And, by the way, since it’s published in American Psychologist he sites empirical research to support each one of these as being highly correlated with positive mental and physical health so it’s not just based on a theoretical idea. You can't get published in American Psychologist if you don’t back it up with tons of research. It’s very, very exhaustive.
These eight areas, I’ve written them down here. The first one here is exercise. Physical exercise is absolutely critical to mental health. And interestingly, he cites research to suggest that most practitioners of mental health that mention exercise in therapy as well as these other therapeutic lifestyle changes are the ones who themselves value them. So typically one that recommends exercise as a possible topic of conversation at therapy is the one who runs, is the one who plays tennis, the one who exercises. That represents about 10 percent of psychologists and those 10 percent not surprisingly are the ones themselves that exercise. And so you can see the massive blind spot as I see it. He really brings this to bear. He’s very clear minded. He’s not emotional, just very objective about this.
You finish the article and you realize there’s a kind of black hole in psychology and I would also say in medical perspectives. I come from a family of doctors and nurses. All of them have worked in hospitals and I heard these stories my whole life about how it is that the patients they see are patients that are there, more often than not, because of lifestyle decisions, lifestyle commitments or lack of commitments that lead to diabetes and other physical health problems.
Nutrition is another area. I just viewed a video the other day about the impact of excessive sugar on our biology, on our psychology. Again, many of us know this but it’s not brought up typically in therapy.
I like the next two. The next one is some connection to nature. As a therapeutic lifestyle, do we have some way to reengage with nature? There’s all kinds of research to suggest that there are positive mental health benefits of being out in nature in whatever form that might be and it’s virtually never discussed in the context of therapy.
Certainly the next one is: relationships. Being in nurturing helpful relationship, recreation in all forms, stress management. I think there’s a lot of lip service paid to stress management. Certainly a lot of research on stress management and psychology but I’m not sure how often it is brought up. In fact, I am sure after reading Roger Walsh’s article that really talking practically about what might be involved in terms of managing stress is rarely brought up in therapy unless somebody comes in with high anxiety. For example, someone who says “Help me with my stress.”
There are two others that are really also on the margins of psychology. Specifically, spirituality. There’s too much research to ignore the positive effects of spirituality from a mental health perspective as well as physical health, for example, longevity. In terms of spiritual practice, prayer, devotional practice of some kind as well engagement in a spiritual community—all research points toward that being vital in psychology. About 150 years ago, pretty much from Freud, spirituality has been split off from psychology. There’s always research, but it doesn’t get discussed because it doesn’t plot in terms of the psychology paradigms of the day.
And then finally, altruism, self-sacrifice in giving to others is one of the highest correlates for positive mental health and again, it’s rarely discussed. In fact, some of this is pathologized in terms of being codependent. We’ll talk about codependence later, but I find that ironic.
So why I mentioned Roger Walsh and these therapeutic lifestyle changes in the context of talking about family development is that at the same conference, Roger Walsh was being mentioned favorably. The idea is that the entire family needs to practice this. Somebody can go away to rehab and they’re typically exposed to most if not all of these as being instrumental to their recovery. They come home to a family that has little value for these practices. The idea now is to get the family involved.
The term for it in the interval community is simply integral life practice across one’s entire lifespan. It’s no longer okay to relegate that just to the individual, the addict that’s in recovery. The whole family needs to be involved because we’re all inter-connected in terms of our psychologies and our physical health. And so if I’m that is now watching my diet to manage my level of sugar intake because this tends to be associated with my risk for relapse to alcohol, and I come home to a family that features a diet high in carbohydrates and sugar, this is not a helpful environment for me. The family needs to be drawn into this. It’s somewhat radical, as I said earlier relating to Burr Cook. It’s radical because most family members are more than happy to send off their son or daughter to rehab, but they didn’t sign on for this kind of radical change in terms of lifestyle.
More and more of this integral or holistic perspective is insinuating itself into treatment programs. The idea is that it takes a village; it takes a village to heal in recovery. It takes a family to heal in recovery. But this is not the same as blaming the family for the addict’s behavior.
It’s not about blaming anybody and so it can be mistaken for that. It’s just that if we want to create an optimal environment for healing and for recovery, we all need to roll up our sleeves and get involved. I believe this sort of thinking will continue to evolve and be front and center over the next years.
Let me mention just one other piece and that is, in recent months I’ve been doing some supervision here locally. I work at a center that focuses specifically on nutrition. It’s a part of something called “continuing care.” These are clients that have oftentimes been in an in-patient rehab, have moved into sober living and into less and less restrictive treatments. These people are coming in once or twice a week for booster sessions, particularly looking at the role of supplements and helpful diet. And just to mention another way that families are involved is that there are family groups every Saturday where the entire family comes together and talks about not just the nutritional regimen of the patient, but of the entire family. This would have been unheard of 12 years ago.