Family Therapy in Addiction and Mental Health Treatment

Foreign. I'd like to welcome everybody, today's presentation on family therapy in addiction and mental health treatment. I'm your host, Dr. Donnelly Snipes. If you weren't aware, this is family caregiver month. So I figured we would do something on family therapy. This is based loosely, very loosely, on treatment improvement protocol 39 from the Substance Abuse and Mental Health Services Administration, or samhsa. Basically, what we're going to do is identify why family therapy is important and can be helpful. Explore what a family is, learn how the tendency toward homeostasis often thwarts an individual's ability to change within a system. Explore the family impact of addiction and mental health issues, identify some key risk factors and prevention strategies, and finally, explore a family assessment and goal setting process. So we've got a lot to cover. Why family therapy? Why is this a recommendation? Well, people with addictions and mental health issues are influenced by and influence their environment, including their families and significant others. Go back to Brofen Brenner, socioeconomic, socio, ecological model. I don't know why I can never say that. And you know, he posits and, and that all of our interactions with our environment, with our family affect us, but we also in turn affect our environment. And it is always a reciprocal process. It can be reciprocal in a negative fashion or it can be reciprocal in a positive recovery fashion, but there's always an interaction. So people with addictions, with mood disorders, and with neurocognitive issues such as autism, dementia, schizophrenia, they are individuals that exist in an environment in which they are affecting their family and their family is affecting them. Research has repeatedly demonstrate that addictions and mental health issues are a combination of nature, nature and nurture. So we do want to recognize that even schizophrenia and to a certain extent dementia, they found that there are, I believe it's 13 factors that contribute to the development of dementia that can actually be mitigated. So there are things that we can do in a lot of issues with a lot of mental health conditions that involve nurture. But there is a certain amount of genetics that is involved. In a lot of cases, people have some sort of a predisposition. Now we say that and we want to look at. We recognize that an individual impacts the family and a family impacts the individual. But what is a family? And it shouldn't be or probably isn't a surprise to most of you who are already working in mental health, social work and nursing that families are defined by the individual and don't always include blood relatives. I worked with a lot of people, adolescents who were runaways and they wanted nothing to do with their blood relatives, and their blood relatives often wanted nothing to do with them. Unfortunately, it was kind of heartbreaking, but they had developed and a family in the peers that they connected with, in, in the shelters or whatever situation they happen to be living in. The significant others the identified patient considers important in their lives is who is family? So who is it that this person is going to rely on? Who is it that this person cares about? We need to ask that. And throughout this presentation, I am going to refer to the identified pat. And that's, you know, if the person who has the addiction or the mental health issue in reality, the family, everybody in the family is typically our patient. The family system is our patient. But the identified patient is the one everybody points to and says they have the problem. Families are systems characterized by self regulation and homeostasis. Hopefully you remember this from Family Therapy 101 in graduate school. Each member has a function in maintaining the balance of the family, Maintaining the how things go. Everybody knows kind of what to expect from everyone else. And they, and they, their lives are kind of governed by that. In an addicted family, for example, we have the enabler, the scapegoat, the hero, the lost child and the mascot. Each one of those people and the person with the addiction, each one of these people has a function in the family in order to protect in some way. The person with the addiction, the enabler, is the one who really does a lot of the protecting and trying to hold up the screen and say, there's nothing to see here. Make everything look perfect to the outside and caretake the person with the addiction. Because they don't trust that that person can take care of thems. The scapegoat is often the one that gets blamed for a lot of the family's dysfunction. Because other people in the family are not ready, willing, or able to take responsibility. So they find someone to blame the unruly child who is always getting into trouble. That's causing the distress that is driving dad to drink and that's making mom have to enable everything that's going on. The hero tends to be the person in the family that is super successful. They draw attention away from all the problems. They say, you know, don't look over there at the problems. Look at me. I'm going to be the valedictorian. I'm going to be the captain of the football team or the captain, the cheerleading squad or whatever it is. They are the one that stands out and tries to present that facade of perfection in the family. You know, don't look at that. There's no dysfunction here. The lost child is the one that kind of just disappears into the background. They're not the hero. They're not distracting from anything with good things. They're not the scapegoat. They're not the one that's taking the blame. So nobody looks over at the person with the addiction. They just tend to be lost. They don't really feel like they've got a function. They don't feel like anybody notices them. The enabler is so focused on trying to, you know, make everything look fine and caretake the person with the addiction. And, you know, the hero is too involved in school activities or whatever that they need to succeed at. You know, everybody else has a reason that people are paying attention to them. And the lost child, not so much. The mascot is another character in the addicted family that oftentimes, again, draws attention away from the dysfunction, Away from the. Away from the person with the addiction, Away from the stress. And the mascot is the one that, just like it sounds, Is the one that tends to make people laugh, that tends to try to lighten the moment. You know, the whole family is kind of imploding on itself, and the mascot says, look over here. You know, you can smile. So everybody has their own function in the addicted family, Trying to protect the family name, protect the image, and maybe enable, in some ways, the. The person with the addiction we. We see in families. Think of your own family. Everybody has a role in maintaining the balance. There's the disciplinarian. There's the one that's organized. There's, you know, people have different roles, and they. Everybody reacts based upon those roles. When a person or the situation changes, though, everyone else has to adapt to maintain the status quo. And I see this a lot. You know, 20 years worked in residential treatment. I would see people, you know, coming into residential and just working their tail off and making a lot of positive changes. And their significant others, Their family would. Was hardly ever seen, and then they would discharge from treatment. And their family still expects that same person that went into treatment and those same behaviors that the person had when they went into treatment to be the same person and same behaviors when they come out of treatment. So they expect the worst, and they expect to react and interact with that person Pretty much in the same way as they did before the person went in. They don't see how they are maintaining or eliciting that old behavior. So part of family therapy in addiction and even in mental health, is helping family members see their part in eliciting or maintaining undesirable behaviors from each other, not just necessarily from the identified patient. When a person tries to change, the system must adapt with them and make necessary changes effectively. If the person is trying to change, then those feelings of anger and hostility and guilt and resentment and you know, any of those other dysphoric feelings, they're going to have to be dealt with. If somebody is, you know, trying to recover from addiction or mental health, whatever, they're trying to make a change, they're trying to start living a happier, healthier life. If they are steeped in an environment where people are just immersed in their own and stuck in their own distress, the person who is in recovery is going to have a hard time staying happy. No matter how strong their boundaries are, if everybody around them, everybody in their family is still suspicious and angry and resentful and all that stuff, until that's processed, that weighs like a boulder and is. Is very challenging cognitively. The family also has to change. If the person with the addiction or mental health issue has started learning about cognitive distortions and optimism and fact based versus emotional reasoning and psychological flexibility and coping skills and distress tolerance and all that stuff we talk about, well, that's wonderful. They have got a whole toolbox full of tools. But if the family still is thinking and acting and perceiving things in the same way, that's going to be challenging. If the family perceives, and we need, this is where we go with the facts here, perceives a behavior as indicating relapse, then you know, that could be problematic. I'll give you an example. When somebody is in recovery, you know, in their addiction, they were addicted to opioids. And so when they were using, they would tend to be groggy and have difficulty paying attention and be sort of disconnected from their family when they were home, well, they're in recovery and all of a sudden they start acting groggy and disconnected from their family. And when they're at home and, you know, not really paying attention to what's going on, does that mean that that person relapsed? Well, there I can think of at least three reasons why the person may be acting that way that have nothing to do with relapsing on opioids or any drug for that matter. You know, early recovery is hard. Early recovery is very, very hard. And it can be exhausting to try to, you know, use all these new tools and, you know, be working and doing, dealing with life on life's terms and Recovering at the same time, it can be exhausting. They may be, maybe they had a really hard day at work, maybe they're starting to get sick, so they're feeling run down. You know, there are a lot of reasons, but the family assumes that the past equates to the present. Then they may jump to some assumptions. There's those cognitive distortions there, jumping to conclusions without all the information. And the person in recovery feels like, you know, I, I can't win. You know, even when I'm doing the next right thing, they expect that I'm not going to. Environmentally, in recovery, people need to make changes if somebody comes out of recovery. And this is especially true for addictions. You know, coming back into an environment that is filled with mood altering drugs, alcohol, nicotine, marijuana, whatever's laying around the house, you know, that is not supportive of recovery. But there are other environmental things that need to change as well. And, and that includes things that may need, need to happen in order for the person in recovery to feel safe, to feel, you know, well, safe in their environment. And interpersonal and relational changes need to happen. You know, a lot of times when people go into recovery or start seeking treatment, there have been breakdowns in the relationship. In, you know, with mental health, the family may feel overwhelmed or resentful or frustrated, and they may have given up on trying to get the person to make positive changes. And it's important to address some of these issues that may be contributing to the distress. And a lot of times I find, and we're going to, I'm getting ahead of myself. A lot of times I find that some of the issues that are maintaining this dysfunctional family environment include really, really poor interpersonal skills, weak boundaries, poor communication skills, inability to say what you need. In addicted families, the, the phrase is don't talk, don't trust, don't feel. So guess what? That's a pretty poor interpersonal setup right there. But even in families where there's not addiction, where there's some other mental health issue, a lot of times communication about from each individual about what they need is often quite lacking. And there's often a lot of hostility when a person tries to change. Continuing to do the same things, reacting the same way and maintaining the same environment will basically bring them back into the status that they were status that they were in before they went into treatment or they will leave. You know, a lot of times going back into a dysfunctional environment is not an option. So the environment either has to change or the person often either relapses. Or leaves. And if we're trying to help the family recover, you know, we don't want them to leave and we don't want them to relapse. So we need to help them see how if they continue with the behaviors that they are exhibiting, that they were exhibiting prior that may be contributing to one another's distress, then they are failing to support recovery and maybe even failing to reinforce new recovery oriented behaviors and promoting feelings of isolation, rejection and helplessness in the identified patient who's like, I have done all this work and I'm trying to do the next right thing and y' all are just, you know, blocking me at every turn. So let's think about a person with an addiction. You know, this is the easiest one to think about. When we think about identified patients and roles and stuff. What are some of the most common problem behaviors that we see the family present with? The, you know, the family comes in and they say, these are the problems that Jim Bob has. This, this is how he's destroying our family. Well, depressed mood, anxiety, irritability, anger, self harm withdrawal. And by, by that I mean social withdrawal from the family, addiction and emotional and interpersonal instability. Sort of borderline esque type behaviors. All right, well, yeah, those are really common behaviors to see in families that are not optimally functional and, or families with a person with a mental health. Dis. Mental health issue or a, an addiction. But remember, that behavior is communication. What are these behaviors trying to communicate? You know, this person who is the identified patient is depressed, okay? Depressed means hopeless and helpless. Over what do they feel hopeless and helpless? And why don't they feel empowered? Where is, where is their power being stripped from? They feel anxious. Okay? Anxiety is part of the fight or flight response. A lot of times anxiety stems from feeling unsafe. Is that from trauma? Is that from fear of abandonment? Is that from, you know, fill in the blank, you know, we want to look at. These feelings and behaviors are often clues to underlying dysfunction within the support system. How can these behavioral adaptations have been caused by an unhealthy family dynamics, thinking of adverse childhood experiences or even intergenerational trauma? Someone who is experiences trauma, you know, back in 1950, you know, that would be like my grandmother, you know, if she has difficulty communicating with and connecting with and developing secure attachments with my mother, then my mother, you know, never had secure attachment, never learned how to develop secure attachments and communication skills. She has me and guess what, Bada bing, she doesn't magically know how to develop secure attachments and communication skills or Even realize that, that she has a deficit there. So intergenerationally when there is dysfunction, unfortunately, does that dysfunction is often learned and continued until somebody says, hey, isn't there a better way to do this? So we want to look and see what family dynamics might be contributing to a lack of safety, a sense of hopelessness and helplessness, a sense of, you know, not being heard, not having support, not being loved. And, and you know, how are those things potentially needing to be addressed? In what ways does the family possibly support, encourage or maintain the unhelpful behaviors? And by unhelpful in this case, we're talking about addictive. But also, you know, a lot of people with addictions have co occurring issues. So you know, maybe maintaining the depression and the anger in the identified patient. And the family may be doing that. You know, obviously in 99% of the cases, it's inadvertent. They're not trying to cause somebody else pain or trying to cause somebody else harm. But it is a reward and reinforcement based system. So in what ways is it that the family is maybe maintaining these behaviors? By covering up for the person with the addiction, by enabling them, by continuing to demand that they listen and not pay attention to their. Not pay attention to their own thoughts, wants and needs, but sacrifice for the good of the family. There are a lot of behaviors and families that can communic can contribute to the development of mood and addictive. Move back, can't talk today. Mood and addictive behaviors. How is supporting, encouraging or maintaining the problem behaviors in the identified patient easier or more rewarding than maintaining healthy boundaries? Now in addiction, this is, this is an easy one because when the person with the addiction is confronted about the addiction, there is often conflict. And nobody likes conflict. There's a feeling, a fear on the family's part that the person with the addiction may leave and not come back. And they're afraid that that person will go off and get hurt or whatever. So for their own anxiety, you know, they would rather have Jim Bob here and using than out on the street and not know what's going on with them. How are family members influenced by the addictive behaviors such as denial, blaming, avoiding, justifying and even gaslighting? And in what ways do the dysfunctional behaviors from the addicted family system impact each member, each family member's other social relationships, their mental and physical health? And we're going to go through and talk more about that later. But it's important to have people recognize, you know, what their part is in this, this system and the dysfunction in the system, because most people, whether they intend to or not, probably are playing a part at maintaining that homeostasis. It's not a healthy family, but it's one that they can anticipate. So that is less scary than trying to change. Same sort of thing with mental illness. I'm not going to spend as much time here because we are short on time, But I do want you, you know, maybe after class to reflect. Common behaviors in a person with a mental illness. If they've got depression, a depressed mood, maybe they don't. They won't get out of bed, and they won't shower, and they are cranky all the time, and they, you know, refuse to go to treatment. There are a lot of issues that may come up. What are these behaviors? Trying to communicate. And a lot of times with depression, it's communicating hopelessness and helplessness. How can these behaviors be adaptations caused by unhealthy family dynamics? Um, if that person, for example, is depressed and just, you know, refuses to get out of bed, um, so the enabler brings them food in their room, refuses to, you know, do what they need to do. So the enabler, you know, makes it okay, you know, well, if you're not going to do it, I'll do it for you. Well, that reinforces that behavior. The person has no motivation. You know, they know, well, if I stay here long enough, then the enabler will do it for me. In what ways does the family possibly support, encourage, or maintain the behaviors? And again, that that happens when the family somehow makes that unideal behavior rewarding to the person. If the person does something and there is no negative consequence, or even better yet, there's a positive consequence to it, they're going to do it again. That's behavior modification 101. How are family members influenced by the problem behaviors? And it's important to recognize that even, you know, if we're not talking about addiction, we're talking about clinical depression, the family can be very stressed out by it, very worried by it. And. And we'll go through some of those things in a little bit more detail in a minute. So what are some risk factors for the development of mental health issues or addictions in families? One of the biggest ones is disrupted attachment. If the identified patient is existing in a family in which they do not have secure attachment in. In which they are, you know, feeling insecure, a lot of times. Insecure, unsafe. You know, the two of them could kind of be interchanged as far as words. So if somebody doesn't have secure attachments they're often going to feel unsafe, which contributes to the development of anxiety, depression, anger management issues, addiction. You know, you. We can trace attachment disruption back to a bunch of stuff. So what causes this disruption in attachment? Well, mental illness or addiction in caregivers, that's one of those adverse childhood experiences. If that condition in the caregiver prevented the caregivers from being able to form a secure attachment because they were just emotionally or physically unavailable, then you know what, there's going to be a problem. Sometimes the caregivers may not have mental illness or addiction, but they may lack effective interpersonal skills, including boundaries, in order to form that secure attachment with that child or with other people for that matter. If you remember, the key components of secure attachment are consistency, responsiveness, attention, validation, encouragement and support. Now think about a 16 year old who gives birth to a child. You know, a lot of 16 year olds just do not have the interpersonal skills to develop secure attachment with, with their infants and with their children. So that, not saying that that's true about all 16 year olds, but at 16 you're still, a lot of people are still trying to figure out who they are and figure out how to communicate their thoughts, wants and needs. So that can be a problem. And that's not just 16 year olds. You know, teenagers who give birth, that's anybody who grew up in an environment in which they didn't have secure attachments and they never developed those interpersonal skills that can happen to anybody. Another cause of disrupted attachment include lack of effective skills to nurture a high needs child. High needs children are ones that are very easily triggered by stressors in the environment. They can be very difficult to soothe and they can be very exhausting sometimes. And that can lead to an environment of invalidation of that child. That child has these needs and feels stressed out and gets dysregulated all the time. And the caregivers either don't respond or minimize the, the child's distress. Which we know is one of the key factors for a lot of people in the development of mood disorders and emotional dysregulation issues. What causes high needs though? You know, we're just kind of throwing out high needs there. Well, some people have a genetic predispos, predisposition to emotional dysregulation. They are just wired that way. Other times, fetal exposure to substances or even high levels of cortisol, if the mother was stressed out, really stressed out throughout her pregnancy, those high cortisol levels in the maternal system are. The fetus is also exposed to those and it can contribute to HPA axis dysregulation in, in childhood. Grief or anger at the child can also cause problems with attachment. And you know, recognizing that some children are born with birth defects or disabilities and sometimes the caregivers, not just the birth parent, but you know, everybody in the family may feel grief over the, the fact that the child has a defect or a disability, or be angry about the situation or be angry at themselves, have difficulty dealing with it. There's, there's a lot of stuff. Some families have a child with a birth defect or a disability and they're just, it's, they love the child and there's no issue. But other people have more difficulty coping with that and they have difficulty bonding with the infant because of their guilt, their grief, their anger, their frustration, whatever it is. Unplanned pregnancies, regardless of age can often lead to interpersonal and tangible losses and could cause the birth father to leave. It could cause the person to get excommunicated from their family. It could cause them, you know, maybe they had this whole plan for their life and now they're pregnant and that's not going to be the way their life's going to turn out and they feel angry about the situation. There are a lot of things that can happen, but ultimately when the child comes into the world, if there is not, if the caregivers, and I say that plural, you know, whoever the caregivers, if they have difficulty accepting and providing that unconditional positive regard to that child and meeting that child's needs, then it's going to result in disrupted attachment most of the time. A final issue that can disrupt attachment includes a long ne neonatal intensive care unit stay. When children are in the nicu, especially a level three nicu, if they're very prey or have significant birth defects, they may not be able to be held or touched at all. Others can be, but only for short periods of time. And that lack of skin to skin contact, that lack of being able to take the baby home can contribute disruptions in attachment and oxytocin levels and all kind of kinds of stuff in the caregivers. Not just the birth mother, but the caregivers in general. Family violence and low parental supervision are also risk factors for later development of mood disorders, mental health issues and, and, or addictions. Consequences of addiction and mental health issues on the family? Well, lack of trust, you know, whether it's addiction or mental health issues, the identified patient often has difficulty meeting the expectations of the family. The non symptomatic family members often don't understand, well, why don't you just get up and, you know, push through? Why don't you just fill in the blank? And so it can contribute to a lot of anger and frustration and not trusting. Not trusting one another. There can be anger in. In the form of frustration and feelings of helplessness as they watch the identified patient suffer. I mean, seeing a child or a family member who is just, you know, struggling desperately with clinical depression or generalized anxiety or anything else, it can be agonizing to watch because you want to help, but you don't know what to do, or you. You've tried to help, and they are not receptive of help. There can be resentment at the identified patient for their behaviors and their, quote, refusal to change. Remember, resistance is 95% of the time, at least not a malicious act. It's not the person saying, well, screw you. It's the person saying, yeah, I can't. I just can't. Guilt is another form of anger. It's anger at yourself. And in the family, there can be guilt because they feel responsible for the identified patient's condition. They feel responsible for, you know, not being able to fix the child's depression or anxiety or make the addiction go away. They may feel responsible for the development of the issue, and they also may have some guilt if they feel like they're being abandoned. If they feel like the, know, the. The person with the addiction just up and leaves the family, or the person with depression just, you know, basically shuts the door and shuts everybody out. They may feel guilty because they feel like they did something to cause that person to abandon the family and embarrassment. It happens. Now, this is more common with addiction than other mental health issues. But. But the family sometimes feels very embarrassed about the identified patient's condition, and they try to hide it. They try to minimize it. And that can be very invalidating to the identified patient who's saying, hey, I'm struggling here. The family may experience anxiety that the identified patient will experience harm in addiction. We're talking overdose, legal charges. You know, there's a lot of harm that can come there. But with depression and anxiety, sometimes the family is worried that, you know, I don't know on any given day, if I'm going to come home and this person is still going to be alive. You know, I am afraid that this person's mental health issues are so significant that, you know, on any given day, they might not be with us anymore. This kind of environment where there is depression, anxiety, stress, grief, anger contributes to pessimism and cognitive distortions, which further enhance the anxiety, stress, depression. There can be isolation. A lot of times the family withdraws because they want to. They don't want other people to know their. Their business. They don't want to put it out there partly because of embarrassment sometimes. So isolation can be huge because in a lot of situations, it is super helpful for family members for loved ones to have support from other family members and loved ones of other people that have a similar issue. Whether it's, you know, from al anon or whether it's, you know, family caregivers of people who have clinical depression, Social withdrawal or lack of time for outside activities can also be a huge burden on the family. If they are caregiving and caretaking and trying to, you know, fix the person with the addiction or the depression or the anxiety, they may feel like they are being bad family members being bad caregivers if they do anything to take care of themselves, so they feel like they have to stay home and focus on that person. On the other end of it, there can be withdrawal from the identified patient. At a certain point. Sometimes families just throw up their hands and go, I don't know what to do anymore. And there can be family conflict over how to deal with the identified patient, or where one family member saying, you know, I need to do this to protect our. Our loved one, and somebody else is saying, you're enabling them. You've got to quit doing that. And then there's a lot of conflict within family members about the best way to help or, well, help is the, I guess, the only word I can find the identified patient. So where do we start? As clinicians, There's a lot of stuff there. Examine behaviors in terms of communication. First. We want families to step back, and instead of seeing a behavior, as, you know, coming out of nowhere, or worse yet, a oppositional move on the part of the identified patient. We want to look at everybody's behaviors and terms and feelings. And in terms of communication, what is this behavior saying? When you get angry, that means you are recognizing you are feeling a threat. What is that threat? What is this behavior saying? When you can't sleep because you are stressed out, what is that behavior saying? That behavior is telling you you're anxious, you feel there's a threat, you feel there's a danger to something. What is that? So start looking at the functional nature of behaviors in everybody, not just the identified patient. The next step is to recognize that resistance means, and I should have put anybody, not just the identified patient, but resistance to change. And because a lot of times the families are also resistant to change, they see that identified patient and they're like, well, if Jim Bob gets better, then everything will be fine. Well, that's generally not the case because that old homeostasis thing. So resistance means that people may not have the skills or ability to make a change. Well, we can help them with that. You know, we can help them identify the skills and tools they need and develop those skills and tools to make that change. They may feel overwhelmed by the prospect of change. There's just so much to be done. They don't know where to start. They just. This is so oppressive. They have no idea where to start unraveling it from. We can sit them down and we can say, all right, let's look at this. Let's figure out where you want to start. I make the analogy with a lot of my clients that treatment and recovery is often like a woven blanket. If you've ever had a blanket or a sweater and one of the strings broke, you know, no matter where you start unraveling that blanket, eventually the whole thing's going to unravel. It doesn't matter if you start in the middle or 2/3 or at the end, eventually you'll be able to unravel that whole blanket. Well, mental health and addiction are like a blanket over your head. They are oppressive. So it doesn't matter where you start pulling that string. Wherever you start pulling, you're going to start making that blanket lighter, you're going to start making that load lighter, and you're going to be able to get more oxygen in, you're going to be able to breathe easier. So let's just pick a place, and then we'll figure out where to go from there. And sometimes people are resistant because they've tried before and failed and think the situation's just too freaking hopeless. And they're just like, why? What's the point? It doesn't work. So it's imperative that we work with them to develop safety, to develop a sense of empowerment and help them set smart goals. Specific, measurable, achievable, relevant, and time limited, very small smart goals so they can start experiencing some successes and that we look back over their prior experiences and frame them in terms of learning. You know, yeah, you didn't stay clean or you didn't stay happy depression free forever, but you stayed clean or depression free for a little while. So let's learn about, in that situation, what worked back then, what helped, and what may have led to the relapse or the resurgence of, of the symptoms, let's use that as information instead of beating yourself up. That gives us more skills, clues, tools that we can look at. Counselor tasks. We want to engage family members, including the reluctant ones. Structure conferences or meetings such that everybody has a chance to express themselves. We want to systematically assess the family's level of functioning and support individual members while making sure to avoid coalitions. We don't want, you know, this team over here ganging up against this team. We want to help the family see problem behaviors as a form of communication and an adaptation to safety, stay safe. They were trying to protect themselves as much as possible. We want to reframe the family's definition of its problem in a way that makes problem solving more achievable. So give everybody tasks and tools to help move towards this ultimate goal of however they define happiness. Help the family members explore new forms of collaborative efforts to cope with problems, such as asking, you know, how is it that I can help you? And encouraging everybody to start articulating you to, to other people, you can help me buy. Instead of doing it on their own or expecting people to mind read, start communicating. Help family members generate alternative, mutually acceptable ways to cope with difficulties and help the family balance coping efforts while calibrating roles. So as the enabler moves to one of supporter, you know, so they become less entrenched in doing everything for everybody, and they become a supporter willing to be there to assist. You know, that's a big move for people and it's going to cause some consternation and resentment since, you know, let's say mom. Mom used to always do this, and now she's not. Now all of a sudden I'm angry because, you know, I'm. That reward's not coming anymore. And so there's going to be a recalibration process where people start taking on their own responsibilities and taking on different responsibilities and learning how to set and maintain boundaries and say, this is. This is where I end and this is where you got to pick up. So we want to explore the reciprocal system and explore how each person's behaviors has impacted everybody else physically, affectively, cognitively, environmentally, and relation relationally. So here I've got the identified patient. We'll call him Sam in the middle. And we want to look at how Sam's relationship with, with his dad impacts him and how he impacts his dad. We want to look at how he impacts his mom and how his mom impacts him. Same thing with his sister. But then we also want to look at how Sam's mom and dad's relationship, you know, maybe they fight all the time. How does that impact Sam? Same thing. Let's look at Sam's sister and the dad, you know, maybe the sister is just the apple of dad's eye and Sam feels very rejected because she and dad are thick as thieves and he feels like an outsider. Okay? And then finally, we want to look at the relationship between Sam's sister and Sam's mom. You know, maybe they're thick as thieves or maybe they, they aren't. But we want to look at how their interactions impact Sam and make him feel in terms of the relationship. And it's important to have every single person go through all of the dynamics on their own. You know, you're going to give them a worksheet to work through, through, to start evaluating how different relationships may impact them and any issues they may need to deal with. So in the reciprocal system with dad, you know, okay, so this is dad's and we just went through it. So I'm not going to spend as much time on these next few slides, but we put dad in the middle and this is dad's sheet that he takes home. He's going to look at his relationship with sister, with mom, with Sam, and think about how each one of those relationships impacts him and how he interacts and impacts them. And then, you know, here it's the relationship between Sam and sister. You know, how do they interact and how does that impact dad? How does the interaction between sister and mom impact dad? You know, maybe he feels like the two of them gang up on him all the time. And how does the interaction between Sam and mom impact dad? If mom's enabling Sam, then that could be. He might, dad might be resentful of that relationship because he sees that is causing conflict in the family unit. But looking at again, not just the relationships, but how it affects the person physically, does it impair their sleep? Does it cause them stomach upset? Set, does it, you know, activate their HPA axis? How does it affect them emotionally? How does it affect their thinking? Does it cause them pessimism and consternation, or does it help them feel more creative? How does it affect the environment, you know, their relationships with that person? Does it, do they feel that that person being around or those relationships are cause a chaotic and negative environment, or does it bring positive energy to the family? And then obviously, relationally, how do all of these relationships interact and affect one another? And it's important to get it from each person's perspective because everybody's Perspective is different. So then after you've gone through all that, identify each person's ultimate vision of personal family, health and happiness. And you can do this in a family session. You know, ultimately, you guys want to get out of here. You want to be a healthy family again. What does that mean? What does that look like? What's going to be there and what is not going to be there anymore. Encourage them to develop that unified vision together so they can talk about, okay, these are the things that are our priority to work on that, you know, we all agree if these six criteria are met, we're going to be way better off than we are now. Great. That gives us something to work backwards from. Based on the assessment, you know, those worksheets that you gave people to take home, and talking to the family and identifying their unified vision, you're going to identify what each person may need to address to achieve that ultimate goal. And sometimes, you know, physically, we want to look at some of the things that increase distress in individuals, that probably increases distress in the family, like sleep problems and autoimmune issues and, you know, poor nutrition. Anything that causes that HPA axis to be out of whack. We want to look at affective, cognitive, environmental, and interpersonal issues like communication skills. But we also need to address people's readiness for change for every single thing we ask them to do. Not just ultimately, everybody's maybe super ready to have this happy, healthy family. But then when we get down to brass tacks and what you actually got to do, motivation may not be there for some things, and that's okay. We need to figure out where we're at. So with in this scenario, has an addiction, goals and readiness for change, sleep and circadian rhythms, you know, they're all out of whack right now because of his addiction. So he's going to need to identify that he's not eating well. So that's another thing that he probably needs to do in order to increase his physical health to enhance his recovery effectively. He has a lot of anger towards his dad, his mom and his sister, and towards himself. There's a lot of self loathing that he needs to process because until he processes that, as long as he's holding on to that anger, that feeling of threat or self rejection or rejection from others, it's going to be really hard to find cohesion in that family unit. He also has depression and he feels overwhelmed because prior treatment attempts have failed. So we do want to work with him on enhancing empowerment. And Sam has poor coping skills. So we need to help him work on those so he can deal with life on life's terms without having to use his cognitive distortions. And in addiction recovery, we call it stinking thinking. They're strong in him. So, you know, that would be an area that we would focus on addressing as well as his negative attitude, you know, feeling like there's no hope, there's no point in this, and, you know, my family hates me, and you know, all those negative, stressful thoughts that he has. So we need to help him work on some cognitive processing. Environmentally. Right now, he has easy access to alcohol and cigarettes, so he needs to change that in his environment. He needs to purge those so he doesn't have easy access. And strong recommendation is to also do a deep clean on his home, or at least the places he spends time when he's home, and his car so they don't reek of alcohol and tobacco, which are triggers for him interpersonally, relationally. He has low self esteem. Okay, so that's a treatment target right there. Abandonment anxiety. We need to help him address his abandonment anxiety and learn how to develop secure attachments, poor boundaries and communication skills. Well, that's probably going to be common in everybody in the family, but we can help him work on those. He may feel that his significant others are, quote, never supportive. So that goes back to those cognitive distortions. But it also goes back to him being able to assertively communicate his thoughts, wants and needs without expecting mind reading. And he currently has no supportive relationships outside of his family, which, since the family is dysfunctional and he feels rejected, he feels very isolated and unsupported. So developing a support system, whether it's in self help groups or wherever, is potentially another target for treatment. For Sam doing this, our goal is to help him get healthier physically, emotionally, cognitively develop stronger interpersonal skills so he can use those in his family. Sam's mom, you know, Sam has an addiction. So what are her issues? Well, physically, she ain't sleeping well because she's up every night worrying about Sam. We need to help her figure out how to get some quality sleep because she is a hot mess right now. She's not eating well because her stomach's always tied up in knots because she's worried about Sam. We need to help her figure out how to improve her nutrition so her body can regulate itself a little bit better affectively. She has a lack of awareness and recognition of her own feelings. She's just oblivious. She's so focused on Sam and enabling that she doesn't even Know what's going on in her. Developing mindfulness is going to be important. She has anger towards Sam because of the addictive behaviors and towards her husband because she doesn't feel like her husband was. Wants to help Sam. So we need to work. Help her work through those issues because as long as she's holding on to that anger, it's going to act as a wall between them and keep the family from becoming cohesive. She also has guilt and unhealthy coping skills. So she needs to work on not drinking, smoking, or raging when she doesn't get her own way. Cognitively. She does have a lot of cognitive distortions, so we need to work with her on cognitive processing. She has a pessimistic attitude, continuing to assume the worst and expect the worst out of Sam. We need to help her see how that attitude impacts Sam and help her start changing her cognitive approach and maybe at least encourage her to consider an optimistic side. Environmentally, alcohol and cigarettes are still available. So again, that needs to be purged. That's a fam. That needs to be part of the family commitment to support. Sam is getting rid of those triggers in the environment. Relationally, you know, she is. Does have some codependency issues. She compromises her own values and integrity to avoid rejection or anger. She's so busy trying to keep everybody happy that she doesn't know what she feels. And she tends to be very hyp. Hypervigilant to any kind of problem. She walks on eggshells all the time, which is exhausting. And it keeps her from feeling happy. It keeps her in a state of anxiety. We want her to start seeing, just like we want Sam to start seeing how when they are in a state of distress, it impacts the family. Even if the family has great boundaries, when one of your loved ones is in distress, it impacts you. She wants to trust Sam again, so that's, you know, a target. But she also doesn't trust that anybody else can take care of themselves. She's afraid to let go of control. She's holding on to the reins of theoretically everything, you know, with white knuckles. And we need to help her get to the point where she can trust the people in her family to make decisions for themselves. We need to help her see how her refusal to let them take responsibility for their own actions is actually harming them. So it's important, again, always to bring it back to that reciprocal interaction. We see how this impacts you. How does it impact your family? Let's look at this intervention. How will it impact you? How will it help you feel better? Well, great. When you start feeling better, how's that going to impact your family? Family approaches recognize the reciprocal impact of every individual and every relationship on the functioning of the whole system. Family systems resist change in favor of homeostasis. So it's important to always assess the health and well being of all members of the family and the physical, affective, cognitive, environmental, and relationship needs of each individual and their readiness for change for every single treatment goal. So if I'm going to ask Sam's mom to start, you know, giving people a chance to do the right thing instead of having to do it for them, you know, how motivated is she to start to be willing to even try that? So we need to look at levels of readiness for change and we need to develop a unified family vision of what health and happiness look like and each person's tasks in helping the family move toward that goal. Alrighty, I made it in at the very last minute. Are there any questions? And, and this goes exactly to what we're talking about. If there's a adult child living in the house who has an addiction and it can cause a lot of disruption in the family, the question is, what is the adult child's motivation? What is the identified patient's motivation to get help versus not, is it easier for them to not get help? And a lot of times we see in well meaning families, you know, they're trying to help this person out and create an environment that, you know, they do everything for the person so they don't have to be worried about anything except for getting better. But the person is, doesn't feel able at that point to get better or doesn't want to because the family's doing everything for them. There's no motivation to actually do the hard work of recovery. So without knowing exactly what's going on in that situation, it's hard to know what the identified patient's motivation is for continuing to use. But a lot of times there are a combination of factors that go back to that resistance. They feel overwhelmed at the prospect of recovery. They may be resigned because they've tried to recover before and failed. Or, you know, like I said, they may just feel like they've they've got a cushy situation going and there's no way in the world that my parents are actually going to follow through with that threat to kick me to the curb. And you know, that's, that's where interventions can be very helpful because the interventionist helps the family identify the, their boundaries and start setting boundaries and encourages them to maintain those boundaries in order to, we call it, raise the bottom for the person with the addiction to encourage them to seek treatment. That's not always the best answer for everybody. It has to be taken on a individualized basis because you know, a lot of times with addiction there's also co occurring mental health stuff and we certainly don't want to trigger a psychiatric crisis and have the person in an unsafe situation. So. So there are a lot of caveats when dealing with interventions. And generally in interventions the first ultimatum is that they need to get help or these, these are the ramifications. Not necessarily kicking to the curb. You know, sometimes that is a last ditch resort, but it is between the family and, and the interventionist or the therapist to work through and decide, you know, what needs to happen for the health of the family as well as to motivate the person. It also requires, you don't just say, well if you don't get help, we're going to kick you to the curb. It requires that the family have tangible options. Right here, you know, I have a bed for you in this residential facility. All you've got to do is say yes or you've got to agree to start going to 12 step meetings five nights a week. You know, they have to have a goal. They have to say you need to do X, not just you need to get better or stop using, but you need to show that you're trying by doing X, Y and Z is generally what an intervention will prompt the person to do. Because recovery is, is a long term issue and is very elusive. We want to see movement towards recovery behaviors. In order to help the family members develop trust in the identified patient. You know, the first thing is to keep a journal. The first thing is to keep a journal because a lot of times those cognitive distortions jump in and as soon as they see something, they're like, every time this person does this, it means they've relapsed. Well, you know, first let's keep a journal and see if that's true. And let's look back, you know, it's been Jim Bob's been, or Sam has been clean for six months. So what is the likelihood that this actually is a relapse right now? The part two of that, you know, let's get some facts about, you know, how likely is it that this is actually what the person is actually relapsed or using again. But also look for alternate explanations instead of just assuming that this is what's going on. Let's look for explanations, and then let's communicate. And that is essential in the family therapy process to open those channels of communication with where when people do have concerns, they're able to voice them without getting attacked by the identified patient verbally. And the identified patient is able to hear and respond. So they're able to carry out an assertive conversation without either one feeling threatened or attacked or accused of anything. And it takes time to navigate to be able to have those discussions. But a lot of times, people, especially in addiction recovery, people who are, you know, in their first year, especially in that early recovery period, recognize that they've done a lot to obliterate trust. And they recognize that their behaviors are going to be called into question sometimes. So they're willing to, as long as it's presented appropriately and they're not accused of something in instead, the family member approaches them and says, I have a concern, and they own their concern. So it goes back to the effective communication, owning your stuff kind of situation. But that is the fastest way to develop trust is to, you know, start recognizing that this person is going to, wow, they've gone an entire year without using. I never thought that was possible. Then that starts inspiring hope whenever there's a problem, Trying to first figure out what are some other explanations why this might be happening. So you don't go into the conversation just sure that the person is relapsed, but then have that conversation with that person. In terms of drug use, some families and some people with, with addictions also agree to randomly be drug tested to prove that they're not using for a period of time. You know, they don't probably want to be randomly drug tested for 15 years, but maybe during the first six months or the first year, they agree that if their significant others have concerns that they will do a kalia waved drug test. And those are the ones that, you know, kind of like the pregnancy test. You pee into a cup and it shows. And those are really inexpensive drug tests that people can get for home use. And then they can be verified by having the person go to a lab if there's any question about the results. For a parent who has a teenager who has used drugs but is in remission, how do you draw a fine line between optimistic and believing in the kid versus being hyper vigilant, looking out for signs of relapse and triggers for relapse? It's always good to be aware of triggers, but it's also important to recognize a person's successes. And, you know, I've known people I'm sorry to say I've known people who have been clean and sober for 10, 15 years and then relapsed. Relapse can happen at any time. So nobody is ever completely out of the woods. But it's important to really start looking at the duration of somebody's sobriety because that means they're learning to deal with life on life's terms. But to be aware of, you know, impending triggers or relapse warning signs. Just like when your kid is starting to act a little funky and you wonder, you know, is this person is. Is my child getting sick? You know, and you're like, how are you doing? You know, you see things in your children and you notice them and you ask are, remember, our frontal cortex doesn't finish developing until age 24. That's after college. So in our teenage years, people tend to be more impulsive, have more difficulty with executive problem solving, so they're more at risk of relapse. So it can be helpful to have parents that are, or caregivers, loved ones that are that independent third party that just kind of notices, brings things up and says, you know, I'm concerned about, just like a sponsor does. A sponsor may say, you know, it seems like I've seen these relapse warning signs in you lately. What's going on? You know, that's a good sponsor. Does that bring stuff to your attention out of your blind spots? And that can be helpful for a family member, but it needs to be negotiated in a way with all parties so the teenager doesn't feel like people are ganging up on them or, or watching helicoptering over them and suffocating them. But so the. And so the parent. So the caregiver also feels like they have the ability to at least point things out. And how that happens, you know, again, is very individualized, depending on the family. But it's important that both people are. Are able to state their thoughts, wants and needs, maintain their boundaries, and feel like they've got open communication. All righty, everybody. Thank you for sticking with me for a little while longer and asking such great questions. I will see you on Tuesday. I guess it is Thursday. I'll see you on Tuesday. Next week. Take care. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand ceus for this podcast is@allce.com podcastceus that's allceus.com podcastce ceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week. Go to allce.com sponsor. Thank you.