The ASAM Principles of Addiction Medicine 5th Edition

63. Family Involvement in Addiction, Treatment, and Recovery

Michael R. Liepman, MD, DFAPA, FASAM, Kathleen A. Gross, MD, Maritza M. Lagos, MD, DABAM, Theodore V. Parran, Jr, MD, FACP, and Kathleen J. Farkas, PhD, LISW, ACSW

CHAPTER OUTLINE

■  DEFINITIONS OF TERMS

■  THE IMPORTANCE OF FAMILY IN ADDICTION

■  FAMILY CONSEQUENCES OF ADDICTION

■  FAMILY ADJUSTMENT TO ADDICTION AND RECOVERY

■  THE PHYSICIAN’S ROLE WITH ADDICTED FAMILIES

■  FAMILY THERAPY FOR ADDICTIONS

■  SUMMARY

Many physicians neither assess nor attend to the impact of chronic illness on a patient’s family, nor do they consider, conversely, the family’s impact on a patient’s illness; this oversight is a grave error, and nowhere has its significance been better elucidated than in the treatment of the chronic illness of addiction. In fact, addiction can be seen as a prototype for all chronic illnesses in terms of its interaction with, and impact on, the family system. It is vital, therefore, to address family issues with every patient having any type of addiction, including not only alcohol or drug use disorders but also the process addictions (e.g., gambling, sex addiction, Internet addiction). Evidence for this includes the following:

■  It is often difficult for the clinician to initially identify an addiction disorder; equally difficult is the task of staying current on the patient’s relapse/recovery status. Family members are often in a position to assist diagnosis and support treatment and recovery; unfortunately, they also may sabotage this process, thereby enabling the addiction to progress.

■  Addiction disorders are very prevalent, and their impact may include significant morbidity and, not uncommonly, mortality among family members of those who are addicted.

■  Addiction disorders overwhelmingly correlate with familial, environmental, and genetic factors and heavily cluster in certain families; therefore, diagnosis of addiction in an individual suggests the likelihood of addiction among that individual’s relatives, a fact that may have significant impact upon that patient’s recovery needs.

■  The incorporation of family education and family therapies into addiction treatment has been shown to have substantial therapeutic value for the addicted patient as well as other family members.

■  A number of simple and straightforward interventions are available to help family members of addicted patients.

For all of these reasons, learning about the family aspects of addiction and the approaches for addressing these issues is useful for physicians and other caregivers.

DEFINITIONS OF TERMS

The term family of origin describes an individual’s parents and siblings, while the term family of procreation is used to indicate the nuclear family, including the individual’s spouse and children. Extended familyrefers to all known living relatives and may include significant others, who are not related genetically, but who are important to the family based on interest, support, and involvement (e.g., nanny or babysitter, neighbor, friend, pastor, employer). Family with addiction or addicted family describes a family in which at least one (and, not infrequently, more than one) member suffers or has suffered from an addiction disorder, while a recovering family refers to a family that has undergone treatment together for all of its addiction disorders and codependence and currently is functioning well and pursuing ongoing recovery support. We do not define recovered family because addiction is a chronic condition that can recur in a family without warning at any time; while there is effective treatment for such families, there is no known cure.

Codependence refers to the tendency of members of a family with addiction to become harmfully overinvolved with the addiction process in a manner that both enables the active addiction to continue and reduces the level of well-being and functionality of the codependent family member. For example, codependent family members, also known as enablers, may find themselves in conflict among one another over the best way to “help” the addicted person while, amid the chaos, the addiction behavior continues unabated. In another example, an addicted person may temporarily stop the addiction behavior but not seriously invest in recovery; although this may transiently reduce strain on the family, and codependent family members may express relief that the addiction behavior has ceased, they then are devastated when the behavior resumes during the next relapse. Family members who do not recognize the need to address their own codependence may have difficulty adjusting to the healthy changes in their loved one and may unwittingly sabotage recovery. They must invest in recovery support for themselves, as they are prone to their own relapses. When codependency is not addressed, the addiction behavior itself may even resurface in another member of the family, such as a child or partner.

Enablers may be either supportive or hostile toward the person with addiction. A supportive enabler tends to provide various kinds of help to rescue the addiction-involved person from the consequences of his or her behavior. Providing bail, offering a place to stay, giving money to pay rent, and lying to the boss about reasons for absences from work are all examples of supportive enabling that prolong active addiction by reducing the impact of addictive behavior consequences; they also diminish the resources and self-esteem of the codependent enabler. This type of enabling helps the addicted person in the short term but harms him/her in the long term as the addiction progresses unrestrained by reality. The hostile enabler, on the other hand, tends to treat the addicted and suffering person with disrespect, anger, and aggression, expressing pent-up resentments about past wrongs and other feelings related to the addiction. This exacerbates the guilt and shame experienced by the addicted person and may serve as an excuse to escape the situation by continuing or resuming addictive behavior (1). Feeling pushed out of the family, the addicted person may seek support from others, either supportive enablers within the family or, worse, other actively addicted persons among their acquaintances at bars or drug houses. Hostile enablers may later regret their actions. Neither kind of enabling seems to help the addicted person to enter and engage with treatment and recovery. Codependency recovery support, such as that provided by Al-Anon and Nar-Anon Family Groups and Adult Children (of alcoholics) Anonymous, teaches individuals to change their focus from the addicted person to healing themselves. They emphasize administering “tough love” to the addicted person, so that he/she must learn to grapple with his/her own consequences in the short run, while leaving the door open to family support for the pursuit of treatment and long-term recovery.

THE IMPORTANCE OF FAMILY IN ADDICTION

At least 25% of the population belongs to a family affected by an addiction disorder in a first-degree relative. The data also suggest that up to 90% of actively addicted individuals live at home with a family or significant other. Given that the lifetime prevalence of addiction disorders is quite high, and that their tendency is to initially manifest in late adolescence or early adulthood, these disorders have a proportionately larger effect during the prime of family life. On the other hand, if physicians tend to overlook addiction in their patients, they are even more likely to miss the diagnosis of addiction in a patient’s family members (2). As a result, the attendant family dysfunction, morbidity, and risk of mortality can go unrecognized, and the underlying cause of many somatic (e.g., headaches, gastrointestinal complaints, insomnia) and emotional (e.g., depression, anxiety, diminished sexual desire and function) complaints may not be identified and addressed (3,4).

Family prodrug attitudes, such as regular and heavy use of intoxicants or reliance on addictive medications, can directly or indirectly encourage or permit the early experimentation with, and repetitive use of, mood-altering substances by children, behaviors that are risk factors for addiction in later life. For example, one of the most influential predictors of childhood experimentation with tobacco is having a parent who smokes. Families that react in an accepting manner to outward displays of intoxication during family rituals (such as parties and other celebrations) transmit to their offspring the idea that being intoxicated is acceptable behavior; families that reject such displays send the opposite message. These messages affect subsequent life decisions, including future use of intoxicants and partner selection (5,6). Families also can play an important role in discouraging existing substance abuse by family members and in encouraging an individual to seek treatment and begin recovery. Close parental relationships have been associated with reduced rates of risky alcohol and drug experimentation in adolescents, leading to lower rates of addiction in young adults (7). Conversely, sheltering a family member from adverse consequences of substance use, thus enabling active use to continue, distorts the normal phenomenon of caring and support into impressively pathologic forms (8). In addition, families often play a direct role in the progression and perpetuation of addiction behaviors; for example, a teen may offer drugs to a younger sibling, or a couple may orient their sexual intimacy around smoking marijuana together. Finally, family problems are widely recognized as an important risk factor for relapse, and continued interpersonal strife within the family system, or continued use of mood-altering drugs by family members within view of a newly recovering person, can precipitate relapse, especially during the early phases of abstinence or recovery.

FAMILY CONSEQUENCES OF ADDICTION

Transmission of Addictions Across Generations and Within Families

Addictions are among the most familial of disorders, with strong genetic determinants and significant environmental contributions. Living in a family with one addicted member can lead to induction of alcohol or other drug abuse in additional family members.

It has been observed that heterosexual women who are married to, or who live with, addicted men are more likely to become addicted themselves (912); conversely, many heavily drinking women who separate from, or divorce, addicted partners subsequently reduce their own drinking or drug use or seek treatment. Among urban African American women, early family discipline and family cohesion are related to abstention and lower rates of drug and alcohol use in adulthood (13).

Children who grow up in a home where alcohol or other drugs are abused, whether in the open or “under wraps,” generally are at increased risk of developing addiction problems themselves. Some of this increase in risk may be related to genetic predisposition (1419). In Type II alcoholism, which is characterized by teen onset, severe prognosis, tendency to become involved with many other drugs, likelihood of attention and learning problems, and deviancy related to thrill seeking and risk taking, the degree of heritability has been estimated at 80% (20,21). Substance abuse prevention research suggests that smoking and drinking alcohol are two early steps in an adolescent’s progression into illicit drug use (22). Exposure to drinking, smoking, and drug use in the home provides behavioral role modeling, tacit approval, and ease of access to drugs, all of which encourage early experimentation. In contrast, children whose parents pursue recovery have been shown to thrive. Moos and Billings (23) found that latency-age sons of recovering alcoholic veterans did better at home and school than did both sons of actively drinking alcoholics and sons of nonalcoholics. Furthermore, children who are exposed to adverse experiences during childhood have substantially greater medical and mental health morbidities, costing health insurance companies and society dearly (24). While this may not always be the case, it is reassuring that treatment and recovery for the addicted person may help the whole family.

Social, Psychological, Physical, and Spiritual Harm

Families can be harmed by the consequences of addictive behavior in ways that include realignment of priorities and deterioration of values, emergence of illness and disability, escalation of violence and other dangers, confrontation with avoidable early losses, and precipitation of addiction among other members. There is mounting evidence that adverse childhood experiences lead to a wide variety of adult adverse health outcomes (2528). Family rituals are among the ways that youngsters learn the values of their ancestors (5,6). However, in some families, use of alcohol and drugs may not always adhere to community legal, cultural, or health-related norms. Observing how parents and relatives cope with stress, recreate, celebrate, or dine together teaches children attitudes and behaviors, including those related to drug and alcohol intake, intoxication, response to others’ use and abuse of substances, and ways of coping with consequences (5,6).

Alcohol and drug addiction are classified as behavioral disorders because, although judgment and moral values are key determinants that govern behavior, addiction repetitively and unpredictably impairs judgment and disrupts moral values, resulting in erratic and atypical behaviors. As the addicted person becomes progressively more invested in obtaining and using alcohol or other drugs, his or her values become compromised. Dishonesty, for example, may first surface as “white lies” covering up indiscretions and then progress to stealing, drug dealing, involvement in other illicit behavior to obtain drugs, and sometimes to even more serious criminal activities. Sharing alcohol and other drugs in social situations may lead to early sexual activity, promiscuity, poor choices in sexual partners and in whether or not to have sex, failure to use contraceptive precautions, sexual exploitation or traumatization, the trading of sex for drugs, and prostitution. Sporadic failures to honor religious, civic, and family responsibilities because of intoxication, withdrawal, or preoccupation with obtaining drugs or alcohol may accumulate to such an extent that the individual appears to shirk responsibility altogether.

As their relationship with alcohol and other drugs gradually expands, it crowds out and severely stresses all other major relationships in their lives, particularly family relationships. Individuals in the recovery community often refer to their addiction as having been similar to a major love relationship, with the mood-altering substance in the role of the jealous “significant other.” Any type of psychoactive drug intoxication and its subsequent withdrawal syndrome may interfere with family and work activities. In fact, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, (DSM-5) includes “recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home” as one of its diagnostic criteria for substance abuse. (29). As the addiction progresses through the development of toxicity, tolerance, dependence, withdrawal, and obsession over acquisition and ingestion, the amount of time spent impaired escalates, and the amount of time spent clean and sober diminishes. Over time, an addicted individual may become convinced that he or she cannot live or function without substances. Family members may likewise incorporate addiction-related behavior into their lives (codependence) and become convinced that the situation is hopeless and can never be resolved. Partners may become frustrated and end the relationship, while children may be deprived of healthy parenting.

An individual who abuses alcohol or other drugs has a substantially increased risk of illness or disability. Dangers such as traumatic injury and morbidity due to the psychological and/or physiologic effects of alcohol and other drugs increase the risk of hospitalization, permanent disability, and death (3032). The risk of accidents increases, and family members also may be harmed in these mishaps. Posttraumatic stress disorder (PTSD) may result from episodes of domestic violence, accidents, and episodes with law enforcement or intoxicated companions. The burden on the family increases even further during times when the addicted family member is ill or disabled. Interpersonal verbal, physical, and sexual violence may erupt within families affected by substance use disorders (SUD) to such an extent that addiction clearly is associated with an increased risk of domestic violence. Sexual violence has been associated with substance abuse and addiction, particularly with the use of alcohol and stimulants. The ability of an intoxicated person to remain sensitive to the subtle cues of a willing sexual partner, and to heed warnings, may be diminished; this lack of awareness may result in sexual insensitivity, partner or date rape, or child molestation (33). In particular, when alcohol or sedative–hypnotics are involved, the anxiolytic effects may numb the fear, anxiety, and even the perception of harming loved ones. The amnestic effect of these drugs also may lead to memory blackouts; this process supports denial by preventing recall of hurtful acts that were committed under the influence. Stimulants cause irritability, intensify aggression and expressions of anger, and enhance paranoia, sometimes leading to frank psychosis. Especially in cases where both the victim and the perpetrator of violence are concurrently intoxicated, individuals may lack the ability to de-escalate the conflict before it becomes dangerous.

Active addiction carries with it a sevenfold increase in risk of mortality, and families frequently experience the unexpected death of an addicted family member. While some may consider this a welcome opportunity for the family to rid itself of continuing exposure to danger and unhappiness, it tragically deprives children of their parents and siblings, as well as parents and grandparents of their children and grandchildren, and causes grief over the loss of a valued family member. Family roles must shift to adjust to such a loss. Some members may blame themselves or others in the family for the untimely death of the addicted parent, sibling, child, or spouse. Loss of a role model may affect children, and loss of a spouse and sexual partner may lead to even more instability in the family, sometimes in the form of a new (often addicted) spouse/partner, whose presence as stepparent or transient surrogate may be resented and resisted. Unfortunately, transient surrogate parents, stepparents, stepsiblings, foster parents, and foster siblings may be additional sources of adverse childhood experiences. Loss of a parent or sibling also may occur through institutionalization (incarceration, mental hospital, foster or group home, or nursing home), as the consequence of trauma or emotional disturbance, through running away from home (34), as a result of adolescent pregnancy, or because of premature marriage, divorce, or separation. Addiction may lead to other family structural changes as various members remove themselves from an increasingly dysfunctional family (35).

FAMILY ADJUSTMENT TO ADDICTION AND RECOVERY

Addiction disorders provide a model for understanding the effects of any chronic disease on families and individual family members. Addiction disorders often occur during periods of peak family involvement, are of gradual and insidious onset, involve aberrant behaviors as their earliest symptoms, and feature periods of relapse and remission. As chronic diseases, addiction disorders insidiously alter family “rules, roles, and customs/rituals” (5,6) and often cause family members to overlook the very existence of the disorder.

The early onset, gradual progression, and intermittent, chronic nature of addiction disorders, coupled with the addict’s typical resistance to constructive family influences, often lead to a resigned acceptance of the addiction as an unchangeable trait of family life (8). This is particularly true in families where addiction has persisted for a long time (decades or generations). Such families often have adjusted to the chronic condition of addiction so completely that adjusting to recovery may be stressful; they may do so by developing various self-defeating behaviors called “pathological equilibrium” by Smilkstein in his Cycle of Family Function (36).

Knowledge of the stereotypical defense mechanisms that families develop in response to addiction can be helpful to physicians and addiction treatment professionals. Typical defense mechanisms adopted by families include classic denial that there is a problem, minimization of the magnitude of the problem, projection of the problem (i.e., blaming the problem on others), and rationalization or making excuses for the problem. Through use of these mechanisms, family members attempt to protect themselves and defend the normalcy and worth of their family system. Addicted families tend to employ isolation as a defense to shame, minimizing the amount of potential embarrassment to which they are exposed, while at the same time limiting their exposure to other, potentially healthier family systems (3,37). In fact, families affected by addiction often employ these defenses so effectively that they are not even aware that an addiction disorder is present. If families do not identify addiction as a problem for an individual family member, then they are not able to recognize that addiction also is adversely affecting the family as a system.

All family systems develop typical patterns of interrelating with one another; these patterns have been termed “family rules and family roles” (38). The “rules” of the addiction-affected family have been summarized as follows: Don’t talk (discussion of dysfunctional and painful events in the family often is energetically avoided); Don’t feel ( suppression of emotions is common in addiction-affected families, much as it is in addicted individuals); Don’t trust (the disease of addiction almost inevitably results in repeated episodes of irresponsible and erratic behavior, causing frequent disappointments and negatively impacting others’ ability to trust). Following these rules may well provide some protective effect for individual family members, but it does not encourage the development of healthy, intimate, nurturing relationships. It is important to note that family rules and roles usually take hold early in family life, and members may be largely unaware of their existence.

Stereotypical family roles, first described by Wegscheider-Cruse (39), now are widely acknowledged in popular culture. She postulated that children in families with alcoholism internalize limited and rigid family roles that can stay with them throughout their lives. Her descriptions of those roles (enabler, hero, scapegoat, lost child, mascot) are taught in virtually every treatment program in the United States today. Individuals may move from one role to another over time, and it is striking how often individuals adapt their behaviors to fit the assumed roles. It is important for physicians to be familiar with these roles in order to understand patients’ actions within their family systems (3). For example, spouses and other family members may act as enablers by behaving as though the family’s most important priority is to help the active alcoholic or addict to flourish over the short term, even if at a substantial long-term cost (4042). Enablers typically become overinvolved with the addicted family member and unintentionally align themselves with the addiction, sometimes assisting in defensive activities against those who would apply constructive influences against the addiction (43). Such alignments contribute to the prolongation or chronicity of the addiction disorder.

Cultural factors may influence these interactions. In an elegant ethnographic study that compared Italian American and Irish American Roman Catholic cultures, Bennett and Ames (44) examined the connection between male alcoholism and domestic violence. The Irish American couples reported that the male typically did his drinking in a pub and that any violent behavior seemed limited to those surroundings. Husbands and wives agreed that episodes of domestic violence would not be tolerated in their marital relationship, despite the rules of the Roman Catholic Church concerning divorce. In contrast, the Italian American couples described the male’s drinking as limited to the home, where his violence also erupted. In these couples, husbands and wives agreed that their marriages would continue despite the violence, “until death do us part.”

In the United States, where there are myriad cultures of origin and where marriages often bring together couples from different cultures, families may represent an interactive mixture of cultural rules and beliefs as well as acculturation experiences. In families of mixed cultural backgrounds, it is possible for the “rules” about use of alcohol and drugs, and behaviors associated with such use, to have critical protective elements deleted. In view of the notion advanced by Wolin et al. (5,6) that family rituals are influenced by family cultural beliefs and promote their transmission to future generations, it is important to note the roles that assimilation and acculturation play in the development of these beliefs.

In addition to the influence of culturally transmitted “rules” concerning alcohol and drug use, behavior within individual families affected by addiction has been observed to follow unique, stereotyped sequences that occur differentially in association either with active use of alcohol or other drugs or with abstinence (called “family behavioral loops”; 4547). As in the story of Dr. Jekyll and Mr. Hyde, behavioral transformations within the family are observed that associate with the presence or absence of drinking or drug use. What is remarkable about such transformations is that, as the addicted person changes the character of his or her behavior, so do the other members of the family (48). These behavioral changes of other family members are triggered by conditioned cues indicating the current status of the addicted family member (i.e., either currently sober/ abstinent or in active relapse). Using Family Interaction Mapping to assess families, it has been observed that the patterns are unique to each family but are stereotyped within the family as they repeat over and over again. The characteristics of the intoxicated/relapsed condition provide definite benefits to the family that cannot be found in the sober/abstinent condition; however, the family can be coun-seled or trained to devise ways to replicate this advantage in the sober/abstinent condition, thus eliminating the need for relapses (45).

THE PHYSICIAN’S ROLE WITH ADDICTED FAMILIES

Physicians have a unique opportunity to help families deal effectively with an addiction disorder in a family member. The clinical skills that any concerned physician may employ in dealing with family issues around addiction disorders include the following:

■  Screening for addiction disorders in the family (past and present) and educating the family to recognize addiction in its members

■  Flagging and addressing family consequences of addiction

■  Identifying the benefits of the addiction to the family

■  Helping family members to identify and address their enabling behaviors and codependency issues and to make a family diagnosis of addiction (i.e., to identify the morbidity, pain, and suffering in their own lives as a consequence of the addiction)

■  Working with the family to confront and motivate the addicted member(s) to seek treatment when needed

■  Referring addicted persons for family-oriented addiction treatment

■  Referring family members for the help they need with their codependency and encouraging their participation in the addiction treatment

■  Supporting family members during relapse and recovery

Screening

Most families affected by addiction are missed by the health care team. This is due in part to family denial. Sometimes, addiction is not recognized because the right questions never were asked. Given their high prevalence and significant effect on all family members, addiction disorders should become part of the routine family history. Simply asking all patients if they have a family history of alcohol or drug problems would improve detection considerably. However, the optimal approach makes use of the family version of the CAGE questionnaire or f-CAGE (2). The f-CAGE is a clinical tool that permits screening for symptoms of addiction without requiring that the individuals actually have made the diagnosis themselves, and it markedly improves sensitivity and specificity in screening for family addictions.

An added value of using the f-CAGE is that it provides evidence of a family member’s dysfunction and disability, or pain and suffering, stemming from another’s use of alcohol or drugs. This can be especially powerful and useful data in presenting the diagnosis of a family member’s addiction to the person being interviewed. It also is useful in the second task in dealing with addiction in families: helping the family to make a family diagnosis of addiction.

Another tool that can help in this effort is the use of a questionnaire such as the Family Drinking Survey (FDS) (49). The FDS incorporates 32 questions related to the family effects of alcohol or other drugs. The questions are divided into three clinical areas of inquiry: diagnosis of addiction, diagnosis of family addiction (codependency resulting from the significant other’s addiction), and enabling traits on the part of the family. The FDS questions that help make the diagnosis of addiction in a family member, when combined with the results of the f-CAGE, can be extremely useful in convincing the family that they do, in fact, have an addicted member.

The Risk Inventory for Substance Abuse Affected Families is a tool designed to help physicians and other health professionals who work with children and family services (50). The inventory takes about 15 minutes to administer by a trained interviewer. It assesses the dimensions and consequences of substance abuse that make it difficult for parents to adequately and safely care for their children. The scales include the areas of commitment to recovery, patterns of substance abuse, ability to meet children’s needs, parental well-being, and neighborhood safety.

Flagging and Addressing Family Consequences of Addictions

Questions should be asked to identify family pain and suffering resulting from the addicted person’s behavior. The FDS identifies issues of family morbidity, including self-pity, ruined occasions, arguments, anger or depression, worry, fear for safety, insomnia, and other somatic symptoms. Positive responses to the questions permit the physician to make and present the diagnosis of a family illness. Counseling family members about family addiction is more effective when it incorporates their own responses on the FDS, because it can identify specific ways in which their quality of life has been diminished by a family member’s addiction. For example, frequent visits to emergency rooms for injuries and psychosomatic complaints are typical among children of alcoholics and addicts (24,51); emotional factors may play a role in help seeking that does not overtly identify the underlying problem of addiction in the family. As physicians watch patients and their families move through stressful transition points in the family life cycle, it is important to use anticipatory guidance in order to prevent relapse and minimize the initiation of addiction behav-ior in other family members.

Identifying the Benefits of the Addiction to the Family

While there are many negative aspects of addiction, it is the positive side of addiction behavior that underlies much of the observed resistance to recovery. Both the individual with the addiction disorder and the family may perceive (often unconsciously) that the addiction somehow makes their lives better, despite its negative effects. It is this ambivalence toward addiction that makes it difficult to initiate treatment and recovery, triggers relapse, and ultimately causes families to give up on treatment and recovery (8,33,45,52). Understanding the difference in how families behave with active substance use versus abstinence sheds light on family resistance to treatment and recovery (4547).

Helping Family Members to Identify and Address Their Enabling Behaviors and Codependency Issues and to Make a Family Diagnosis of Addiction

The family’s adaptation to addiction behavior enables continuation of the dysfunctional pattern without change. This takes a toll on the addicted individual by permitting the disorder to progress without resistance from the family. It also continues to hurt and demoralize codependent family members, who may feel tricked into conspiring with the disorder, allowing it to resist treatment and recovery.

Working with the Family to Confront and Motivate the Addicted Member(s) to Seek Treatment When Needed

In hospital consultations and in the office, when it becomes apparent that an addiction disorder is active, one may begin by discussing this with the identified patient. Likelihood of change can be enhanced by using motivational interviewing techniques (53). Motivational interviewing offers the opportunity to assess barriers and facilitate change via an array of possible stage-specific goals and outcomes. If resistance is met, widening the net to include family members in the discussion is indicated. Motivational interviewing has been conceptualized to apply to an individual, using stage of readiness to change (43) as a guide for the strategy that is applied. When looking at the situation from a family systems perspective, it will be observed that different members of the family often will be in different stages of readiness to change. Concerns about violations of confidentiality often can be overcome through persuasion, emphasizing that the family is already worried, even without knowing the details. Furthermore, by explaining that their involvement would improve treatment outcome for self and for the other members of the family, the addicted patient is more likely to grant permission for a family meeting.

In hospital inpatient settings, rounding during the family visitation time often can provide an opportunity to frankly and openly discuss the reason for the hospitalization (if it is the addiction disorder) and may naturally lead to dialogue about treatment engagement for the underlying condition. In the office, listening for or asking about family reactions to the addiction behavior and its consequences may lead to the opportunity to invite the partner or other family members in for a conjoint consultation visit to discuss the family’s concerns. In cases where the addicted person is extremely defensive, family members may independently approach the physician with a desire to get help for this person. The physician can listen and seek out additional information about what is going on at home that may not have been shared previously. The physician can then refer the family to a family therapist with skills in addiction treatment or to an interventionist who may help the family to engage their addicted member and themselves in treatment and recovery (41,42,5458).

It should be noted that the traditional assumption, often mentioned by members of Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Al-Anon, that the addicted person must hit rock bottom before accepting treatment and beginning recovery is a suboptimal notion for several reasons: (a) Hitting rock bottom can be very damaging to self and others and, in the worst cases, fatal; in contrast, family members are often the first to notice the addiction because of all the trouble it causes for the family and are therefore in a position to facilitate engagement in treatment before the addicted member hits bottom; (b) it may take a very long time for the individual with an addiction disorder to lose enough to accept entry into treatment, to successfully complete treatment, and then to remain sober; (c) significant others may be lost, having given up on the individual by the time stable and lasting recovery is finally established; (d) although accumulating losses may eventually motivate engagement in recovery, they also diminish the availability of resources (e.g., stable living environment, job-based health care coverage for addiction treatment, license to drive to support meetings, etc.) that might support efforts to begin and sustain recovery; (e) family members who give up on the addicted person often fail to identify and address their own issues; and (f) resentments or termination of relationships may interfere with willingness to volunteer for family treatment when the addicted person does engage in recovery.

Often, it is a crisis or last straw that motivates someone to seek help for their loved one. A Relational Intervention Sequence for Engagement (ARISE) has been developed by Judith Landau et al. (59). This approach is used when someone requests help engaging a person who suffers from an addiction disorder and who resists the notion that it is a problem and/or offered help. Evolved from the Johnson Institute intervention (5558), with the addition of a family systems focus, this approach involves a series of visits with the family (and significant others) and includes the addicted person if he/she is willing to accept the invitation to attend. Level 1 begins with the first caller over the telephone or at the first face-to-face visit at the office or hospital. The approach instills confidence in the first caller that something can be done. On the phone, the family members and, if possible, the addicted person generate a list of who should be invited to participate in the first group meeting; they then develop a strategy to engage these supporters in this task, facilitate an optimal invitation to the addicted person to attend, craft a recovery message, and elicit a commitment from the invitees to attend the first meeting whether or not the addicted person attends. This level of effort is sufficient to engage the addicted person in treatment 55% of the time (59).

If treatment does not begin, Level 2 offers a series of meetings of the support network with or without the addicted person in attendance. Each member of the group is considered a “significant other” of the patient and is coached to describe an iconic experience in which the patient’s drinking, drug use, or process addiction adversely affected that person. Team members are coached to present the feedback in a nonaccusing manner, focusing mostly on how it made him/her feel. They are not to engage in arguing, blaming, name calling, or other disrespectful behavior. If the addicted person is present, he/she is asked (and reminded, if necessary) to listen to all the feedback before responding. Examples of phrases that can be uttered by the team members include the following: “It’s not you, it’s the drinking”; “It hurts me too much to see you continue in this painful disease”; “You did not develop this on purpose, but you’ve got it”; “We care about you, but hate your drinking”; and “I will not argue; this is what you did, this is when you did it, and this is how it made me feel.” There are several common threads in these phrases: (a) exhibiting positive regard toward the individual but negative attitudes toward the addiction behavior; (b) providing data about specific events rather than generalities; (c) validating the disease concept of addiction through statements about the obvious pain of this progressive illness, which damages families, jobs, finances, legal standing, spirituality, and physical health, thus giving the patient permission to become less defensive; and (d) relieving guilt and reducing defensiveness by acknowledging that patients with addiction disorders did not intend to “catch it,” but insisting that they need treatment nonetheless. With the weight of all of this evidence, presented by mutually supportive friends and family members, the “wall of denial” for many patients breaks down sufficiently to encourage the patient to enter a treatment program. By this level, 81% have entered treatment (59).

Level 3 involves meetings at which contingencies that will be executed if the addicted person continues to resist treatment and recovery are crafted by the support group team; 2% of additional cases enter treatment during this level, making the ARISE procedure effective for 83% of cases (59). This approach engages the supporters of the addicted person in resisting further enlistment as enablers and builds a confident, cohesive team to put a firm, healing structure into the life of the addicted person. This team must withstand pleading, lying, threats, empty promises, rationalizations, minimization, tricks, and subterfuge in order to stand firm with its contingencies. Through thick and thin, the team must sustain its commitment to hold the addicted person responsible for his or her behavior, for completing needed treatment, and for sustaining recovery. Even if it is not successful in engaging the index patient (IP) in treatment, a family intervention usually alters the family system surrounding the IP in a positive way by helping family members to free themselves from the secrets, isolation, guilt, and fear engendered by the IP’s addiction.

Referring Addicted Persons for Family-Oriented Treatment

Many addiction treatment programs offer some sort of family-oriented care. Sometimes, it consists of a multifamily psychoeducational group in which information is presented about the disease concept of addiction disorders and recovery. Such groups often feature educational information about genetics and familial transmission of addiction disorders, the impact of growing up in a dysfunctional family with addiction, and how 12-step support groups enhance recovery of the addicted person (Alcoholics Anonymous, Narcotics Anonymous, etc.) as well as significant others (Al-Anon, Adult Children Anonymous, Families Anonymous, etc.). Films showing enactments of family approaches to engagement and treatment may be viewed. Family or couple therapy may be offered to individual families, as indicated, focusing either on recovery only or on broader issues that trouble the family. Single parents whose children are symptomatic or who have been removed by a child protective services agency may be provided parenting education, parent–child therapy, and/or reunification therapy. Families with domestic violence may undergo communication and problem-solving training and/or anger management training. Some programs offer variants of empirically tested cognitive–behavioral treatments designed specifically to promote abstinence while improving family function (6062) [seeFamily Therapy for Addictions]. While most alcohol and drug treatment programs offer family-oriented components, there can be wide variation in attendance policies and degree of family involvement.

When the addicted person refuses any involvement in formal treatment, Unilateral Family Therapy (62) or Community Reinforcement and Family Training (CRAFT) (6365) may be used to train concerned significant others (CSOs) to positively reinforce abstinence, reduced substance use, and recovery behaviors while negatively reinforcing continuing substance abuse.

The CRAFT procedure, when tested in a randomized controlled trial with 130 CSOs of alcoholics, found that 64% of their IPs engaged in alcoholism treatment, while the Johnson Institute intervention engaged only 30%, and Al-Anon facilitation, only 13% (64). The strategies involved in Al-Anon facilitation reflect the dominant themes of Al-Anon: Disengage from the alcoholic behavior (stop enabling), abandon hope of influencing the drinking behavior, and take care of yourself. With regard to the CSOs, 89% of CRAFT participants and 95% of those attending Al-Anon completed their assigned sessions; in contrast, only 53% of those using the Johnson Intervention completed their sessions, mostly due to being intimidated by the coercive nature of the family confrontation. Two controlled trials using CRAFT with illicit drug abusers engaged 64% and 67% of IPs, compared to 17% and 29% in the 12-step facilitation condition (65,66). The CSOs in these trials seemed to derive substantial benefit (in pre–post comparisons of levels of depression and anger as well as relationship characteristics such as happiness, cohesion, and conflict) from whatever treatment condition they were assigned, regardless of IP outcomes.

It is important to realize that the addicted IP may suffer from additional mental disorders. It may be necessary to refer the IP to an addiction-trained psychiatrist so the other disorders can also be addressed.

Referring Family Members for the Help They Need

The full range of treatment that individuals or families may require to address the family consequences of addiction and comorbidities in each family member is beyond the scope of this chapter. It is important for the physician to be aware of the broad range of available treatment resources and to be able to help patients engage in the process. Bibliotherapy, or recommending that individuals begin to read materials related to families and addiction, often is a good place to start. Materials from Al-Anon are quite useful, as are a number of self-help books and addiction memoirs that discuss family involvement (6769). For individuals or families who are willing, referral to individual or family counseling or psychoeducational sessions can be extraordinarily helpful. In making such a referral, the physician needs to communicate with the therapist regarding the family illness and the consequences that led to the referral; otherwise, individuals, and even whole families, can participate in counseling for long periods of time without ever disclosing the presence of the underlying addiction disorder. It is as important to assess the therapist’s knowledge, experience, and skill in working with families who suffer from addiction disorders as it is to assess the family’s motivation for change and ability to engage in active treatment. It is helpful also to communicate to both the therapist and the family your commitment to working as a member of the team and to assure them that all medical issues will be addressed properly and promptly during the treatment process.

It is important to recognize that codependent family members also may suffer from other diagnosable mental conditions such as depression, bipolar disorder, anxiety disorder, PTSD, somatization disorder, and substance use disorders. Their ability to respond to addiction or codependency-focused treatment may be hampered by these other disorders unless they too are adequately treated.

Finally, self-help groups for family members, including Al-Anon, Alateen, Alatot, Tough Love, and Families Anonymous, are available in every part of the country. (Contact information generally can be found in the telephone book, on the Internet, or from local addiction treatment professionals.) Most such groups are organized on the principles and steps of AA but focus on the recovery tasks of the individual family member who is experiencing pain from another’s addiction disorder.

Addressing Enabling Behaviors

Another clinical skill for physicians to master is that of helping families identify, and ultimately alter, behaviors that enable the disease of addiction to progress unabated (3). Several questions on the FDS assess family enabling, covering areas such as making excuses for the individual, avoiding situations that may prove embarrassing, trying to limit the family member’s drinking or drug use, joining in the drinking or drug use, and altering schedules or habits to accommodate the family member’s addiction behavior. Presenting information to help them understand how their actions may actually be harming the addicted person by sheltering him or her from appropriate consequences can be very helpful for families. Since they may suffer from the consequences too, it may be challenging to stop enabling. However, it is important to remember that the identification of enabling behaviors is a late step in family treatment and is useful only after families have progressed through the core steps discussed earlier.

FAMILY THERAPY FOR ADDICTIONS

Meta-analyses and reviews of studies on family-oriented treatment approaches have shown superior rates of engagement, positive treatment outcome, and participation in aftercare when compared to individual-oriented care (7073). The evidence from the Stanton and Shadish (73) meta-analysis of 1,571 cases, involving an estimated 3,500 patients and family members, favored family therapy over individual counseling or therapy, peer group therapy, and family psychoeducation. It was effective for both adolescents and adults and can enhance methadone maintenance and other medication-assisted treatments. It also promotes higher treatment retention, which improves outcome.

Approaches for Adults with Addiction Problems

Behavioral couples therapy (BCT), the most extensively researched family approach in the treatment of substance abuse, has been shown effective (7477). In an extensive review of the literature, Epstein and McCrady (74,75) found empirical support for the effectiveness of BCT; however, Fals-Stewart and Birchler (76) have shown that fewer than 30% of the addiction treatment programs surveyed use BCT. This type of therapy has been shown to be effective in a variety of formats. Based on their extensive review of the literature, Thomas and Corcoran (77) report that overall, all treatment conditions showed reduced substance use for up to 2 years after treatment had ended, although drinking tended to increase as time elapsed. There is limited research on drug-using couples, minority groups, and low-income couples. While there are numerous other approaches to family therapy in addiction, much can be said for having empirical evidence of efficacy.

BCT is used with cohabitating partners, one of whom suffers from an addiction disorder. It utilizes a recovery contract to clearly set out the goals of treatment and the conditions that would indicate a relapse. Partners learn to go over the recovery contract together daily, with a trust discussion in which the addicted person verbalizes his/her intent to remain sober and receives verbal reinforcement for doing so. Urges and triggers to use are discussed openly, but arguing about past or future relapses is avoided or deferred to therapy sessions. Medications to assist in maintaining sobriety are taken in the presence of the partner, regular urine drug screens are performed to provide evidence of adherence, and progress is recorded on a calendar. Relapses may be identified by either partner and must be interrupted as soon as possible, in a manner specified in the recovery contract.

Once continuing abstinence is maintained, the focus for the therapy shifts to improving the dyadic relationship. Resentments over past mistakes, disloyalties, dishonesties, and the like must be resolved without triggering a relapse. This involves increasing “positive feeling, goodwill, and commitment to the relationship… and teaching communication skills to resolve conflicts….” (59, p. 206). The positive feelings are enhanced through three strategies: noticing positive behaviors and reinforcing progress (“catch your partner doing something nice”); planning of rewarding, shared experiences (reintroduction of leisure time activities that had been neglected or supplanted by the addiction behaviors and fighting); and Caring Day assignments (encouragement of partners to initiate special acts of caring for one another). Communication is enhanced by the following: developing good listening skills; directly expressing feelings; planning daily times to communicate about feelings, events, and problems without employing aggression or passivity; and using assertive negotiation skills in satisfying desires and needs.

Efficacy of BCT has been supported for alcoholism and for drug abuse by two meta-analyses (70,73). There was a moderate effect size, and a robust advantage was indicated over individual-oriented treatments in the following areas: frequency and duration of abstinence, happiness in relationships, decreased number of separations, reduction of domestic violence, benefits to the children of the couple, improved adherence to recovery medications, and a 5:1 benefit to cost ratio. However, Longabaugh et al. (78) found that patients diagnosed with antisocial personality disorder had better outcomes with individual approaches. The work of Holtzworth-Munroe et al. (79) illustrates the need for individual treatment in cases of intimate partner violence as well. Fichter et al. (80) found that alcoholism relapse was predicted by excessive numbers of critical comments, low warmth, and lack of involvement by significant others. These areas can be addressed by family relationship enhancement training.

Approaches for Families with Troubled Adolescents

Families with adolescents who require substance abuse treatment present special problems, given the complex interplay of adolescent development, substance abuse, and family dynamics. Toumbourou et al. (81) conducted an evaluation of the Behavioral Exchange Systems Training (BEST) program, which is an 8-week parent group that supports and assists parents in coping with their adolescent’s substance use. Parents participating in the BEST program showed reductions in mental health symptoms and increases in satisfaction and assertive parenting behaviors. McGillicuddy et al. (82) developed a coping skills training program for parents of substance-abusing adolescents. This training was associated with improved parental coping, family communication, and parental reports of their own functioning. Prosocial family therapy (PFT) is based on a theory involving the interplay of risk-protection factors and integrates specific parent training with nonspecific family therapy (83). PFT is designed as a preventive intervention for juvenile offenders and their families.

Brief Strategic Family Therapy (BSFT) has been developed to address not only drug use behavior but also the host of other behavioral problems that cluster with drug abuse such as oppositional defiance, underachievement and lack of interest and connection with school, aggression and delinquency, risky sexual behaviors, and disinterest in prosocial behaviors (84). In this approach, the call from the concerned parent immediately leads to scheduling an initial family visit. In a randomized controlled trial with Miami area Hispanic youth, BSFT engaged 93% of families compared to 42% using the usual approach (85). Further, 77% of the BSFT-assigned families remained engaged in treatment for at least eight sessions compared to only 25% of the control families. It is well known that adolescents exposed to unstructured group therapy approaches often actually get worse, as they tend to imitate one another’s pathologic attitudes and behaviors. In contrast, family therapy helps immensely in improving outcome: Cannabis use was reduced by 75%, association with antisocial peers dropped by 58%, and acting-out improved by 42%, all substantially better than the control group therapy condition (8486).

Another type of family therapy for adolescents is Multidimensional Family Therapy (87). It addresses expectancies about using intoxicants, parental addiction, and prevention of family relapse. This model uses both individual and family sessions to address the myriad of issues within the addiction-affected family. In a three-condition random-ized controlled trial, MDFT outperformed adolescent group therapy and family psychoeducation in reducing alcohol and cannabis use (54% vs. 18% and 24%) (88). Another study, comparing MDFT with adolescent group therapy, showed that MDFT was superior in reducing externalizing symptoms and peer delinquency and in improving family cohesion and school behavior (89). These teens showed a 71% decrease in drinking alcohol, compared to an 18% increase in those attending group therapy. One study using MDFT with higher-severity substance-abusing adolescents found better outcomes among those with the most severe drug use and those with psychiatric comorbidity (90).

Multisystemic therapy (MST) for juvenile offenders also has been shown effective in reducing substance use. This approach analyzes the symptomatic behavior in its environmental context, maintains an optimistic positive attitude, and empowers parents and caregivers to influence youth to take progressively more responsibility for their behavior. Treatment may occur at home, in schools, and elsewhere in the youth’s environment. Its efficacy is supported by nine clinical trials, two with substance-abusing juvenile offenders (9193). One goal is to prevent out-of-home placement. Treatment retention of families was an incredible 100% for 2 months and 98% for the full 4 months of the program. Cost of treatment was offset by the saved costs of out-of-home placement and hospitalizations. Clinical benefits were evident at 4- and 14-year follow-ups. In the drug court study, enhancement with MST reduced positive urine drug screens from 70% to 28%.

The Youth Support Project (YSP) also targets juvenile offenders. Many physicians who treat high-risk families struggle with ways to engage them in treatment interventions. YSP was developed especially for high-risk families, those who are difficult to enroll and to retain in addiction treatment (94). Among minority juvenile offenders, the impact of cultural factors on the development of alcohol and drug use disorders and on treatment outcomes is not well understood. The Alcohol Treatment Targeting Adolescents In Need (ATTAIN) study examined the effectiveness of a brief motivational, cognitive–behavioral intervention among Hispanic and African American juvenile offenders. Significant reduction in alcohol and marijuana use was observed with treatment, and specific cultural factors were associated with baseline level of use of both substances and with greater reduction in alcohol use (95).

Approaches for Older Adults

While most substance use disorders begin in adolescence, many continue to struggle with their disorders into the golden years. Some may have overcome their addictions earlier, only to relapse later in life as various illnesses bring them under a doctor’s care with multiple prescribed drugs. Others may actually have their first experience with substance or process addictions later in life as they face stresses such as disabling illness, retirement, partner loss, problems with their offspring, and isolation.

When a person’s youthful addiction has continued into the later years, their social support system usually includes many enablers. Their offspring may have addictions, having grown up in an addiction-friendly environment, while those relatives who may not partake in this behavior may nevertheless be codependent and enabling. On the other hand, some of these older individuals have long ago parted ways with family and have either surrounded themselves with others who abuse substances or live in isolation.

Given the demographic changes in U.S. society and the expected increase in the number of older adults experiencing problems with alcohol and other drugs (96), family therapy approaches for adult children and their substance-using parents will become increasingly important. In 2009, persons reaching age 65 had an average life expectancy of an additional 19.2 years (97), and in 2010, persons 65 years or older represented 13% of the U.S. population (98). In 2009, alcohol and, to a lesser extent, prescription medications and marijuana were more widely abused; the rate of binge drinking among persons aged 65 or older in 2011 was 8.3%, while the rate of heavy drinking was 1.7% (99). Among adults aged 60 or older in 2011, the rate of nonmedical use of prescription-type drugs was similar to the rate of marijuana use (1.2% and 1.1%, respectively) (99).

Among the factors contributing to underrecognition of substance use disorders in older people are failure to identify symptoms, attribution of symptoms to the aging process or disease, ageism, lack of knowledge about screening, and physician discomfort with the topic of substance abuse (100). Elderly individuals commonly use a mix of prescription drugs from multiple sources, possibly combined with tobacco and alcohol; although quite often none of the doses of the medicines they are taking are extraordinary, the interacting combinations may cause episodes of intoxication, memory loss, accidents and falls, impaired driving, and mood instability. Screening tools that were developed for younger populations are often inappropriate for older adults, and some of the DSM-5 criteria for alcohol dependence do not apply to older people (96).

Physicians can play a significant role in screening, assessment, and treatment planning for older families because of the increased number of physician services older people use, the greater extent to which they take prescription medications, and gerontologic health models that stress family involvement. Providers caring for elders, especially the primary medical care provider, will find partnering with family very helpful in assessing the extent of functional impairment as well as in monitoring improvements in function and adherence. If an intervention seems necessary to facilitate entry of the elder into an addiction treatment program, family and significant other involvement will be crucial. Age-appropriate tools, such as the Michigan Alcoholism Screening Test-Geriatric Version, improve accuracy in detection among older adults (101).

Recent reviews of family approaches in the treatment of alcohol-related problems among older adults show this is an understudied area (102), especially in terms of access to family therapy (103) and outcome research, but a few treatment approaches have been evaluated with the older population. The Consensus Panel of the Treatment Improvement Protocols (TIPs) developed by the Substance Abuse and Mental Health Services Administration within the U.S. Department of Health and Human Services recommends that, with this population, the least intensive treatment options should be explored first. Brief intervention is the recommended first step, supplemented or followed by motivational interviewing and, finally, family coercive intervention. For example, the health care provider may gradually modify prescription regimens, consolidating multiple drugs with similar functions into one and, when possible, substituting safer, nonaddictive alternative medications. The process of determining which drugs might be targeted for change may make use of information from state-controlled pharmaceutical monitoring systems, immunoassay drug screens (with GC/MS confirmation), and drug interaction databases. Good communication with family and other providers (e.g., specialists, pharmacists) can help prevent this project from being undermined. A brief intervention may be sufficient to address the problem (104), by either reducing consumption of harmful drugs or stopping use altogether; if not sufficient, it may help move a patient toward more intensive (though costly) specialized treatment.

If participation in a 12-step recovery program is indicated, deep guilt and shame may interfere with acceptance of the diagnosis and referral. A strategy that may help overcome this is to introduce this individual (and partner, if appropriate) to a recovering 12-step volunteer with similar circumstances (along with their partner, if appropriate). This will comprise a service activity for the recovering person, and it will reduce the anxiety and shame of the recovery novice as he or she is gently introduced to others in the supportive recovering community (the fellowship).

Coercive intervention, although sometimes indicated, can be the least effective approach. In a study of families seeking to perform a Johnson Institute intervention with a relative, when the target of the intervention was their elderly parent, many were reluctant to confront them with their concerns because they were reluctant to overturn traditional lines of authority (56). In particular, when the elder also suffers from what is perceived as a coexisting terminal illness, family and caregivers often give up trying to confront them about their SUD.

Despite advances in family interventions, there is a lack of empirical validation of family therapies oriented specifically toward older adults. The TIP Consensus Panel’s recommendations on treatment of the older alcohol abuser emphasize the following: (a) age-specific group treatment that is supportive and nonconfrontational and aims to build or rebuild the patient’s self-esteem, as well as training significant others to substitute supportive positive comments for aggressive negative communications toward the recovering person; (b) a focus on coping with depression, loneliness, and loss (e.g., death of a spouse, retirement) by generating ways to reintegrate the person into the family and community; (c) a focus on rebuilding the client’s social support network, including the family; (d) pace and content of treatment appropriate for the older person; (e) staff members who are interested and experienced in working with older adults; and (f) linkages with medical services, services for the aging, and appropriate institutions for referral into and out of treatment, as well as case management.

Approaches for Active Duty Military and Veterans

Those who have served in the military are at particularly high risk of SUDs. A study of nearly 90,000 Iraq War veterans found that 20% of active duty (AD) and 42% of National Guard and Reserve (NG/R) soldiers screened positive for mental health symptoms 3 to 6 months after returning from Iraq (105). The average age of the sample was 30, 90% were male, and 58% were married. Interpersonal problems were endorsed by 14% AD and 21% NG/R veterans, PTSD by 17% AD and 25% NG/R veterans, depression by 10% and 13%, alcohol abuse by 12% and 15%, suicidal ideation by 0.6% and 1.5%, ideation about interpersonal aggression by 2% and 4%, and fair to poor physical health by 17% and 21%, making an overall rate of endorsement of mental distress by 27% and 36%, respectively (105). They did not report on drug abuse. Only a small number of those who screened positive for alcohol abuse were referred for treatment, and even fewer actually participated in treatment.

Most enter military service at a young age, years before their brains have fully matured. However, the reservists in the study were older and were more likely to be established in employment and family life; 43% had children (106). Some are exposed to battle conditions in which their own lives and those of their compatriots are threatened. They may witness or cause deaths and injuries of soldiers on both sides and of noncombatant civilians including women, children, and the elderly. They may have sustained injuries, both physical and emotional. Under constant stress and exposed to danger, away from home and family, they may develop maladaptive coping strategies, among them the use of various intoxicants to relax, not feel, have fun, reduce pain and anxiety, and stay alert. This type of behavior is often part of the combat culture, condoned or allowed (often without consequences) by the command. Young soldiers may be influenced to join in by peer pressure.

Typically, PTSD is caused by frightening childhood experiences, followed by retraumatization later in life. Family members, particularly the partners of returning soldiers, may find the changes in their partner difficult to understand and cope with. PTSD often causes avoidance of sharing emotions and discussing the traumatic events leading to the PTSD. Yet, it may be triggered by situations of helplessness that may be otherwise unrelated to combat. Spousal bewilderment over what to do in such situations may be a focus of early family treatment. While there are effective treatments for PTSD, the common response of many returning veterans is to isolate and rely on intoxicants to suppress anxiety. Addiction treatment must be combined with addressing the PTSD, and partner involvement in treatment is critical.

Sexual harassment or assault frequently occurs in military settings and is directed toward both women and men. Perpetrators, as well as victims, may have psychological reactions to what has happened. Partner reaction to the victim’s change in interest in sexual activities, and questions about what actually happened and how responsible the victim may have been in attracting the abuse, may be issues salient to the family therapy.

In a cross-sectional study of 242 veteran couples, substance abuse by the intimate partner explained 20% (alcohol) and 13% (drugs) of the variance in the association with veteran substance abuse compared to only 2% each for PTSD, antisocial personality disorder, and depression (107). This underscores the importance of assessing and treating the couple or family together, as the veteran treated individually coming home to the substance-abusing partner would experience cue-triggered craving when watching the partner use intoxicants, easy access to intoxicants in the home, and urges to join in, especially if the substance abuse previously constituted a shared activity leading to mutual satisfaction and intimacy (108). On the other hand, if the newly sober veteran becomes frustrated by being unable to come home to a safe, abstinence-promoting environment because the partner insists on continuing to use intoxicants, conflict may erupt, leading to stress, loss of support, and even violence (109,110). Supportive enabling would be the likely response of the substance-abusing partner, and denial would likely be a prominent attitude at home. The most common outcomes of individual treatment when both partners are substance abusers are either relapse or divorce.

Some soldiers are sexually unfaithful to their partners back home and may wonder whether their partners have been unfaithful too. Civilian spouses may worry about whether they will ever be reunited with their soldier partners. In addition, raising children alone, with long intervals of time passing between visits, can be rather difficult; aggressive, military style approaches to discipline may engender fearful or rebellious responses in the children.

On return home, with traumatic brain injuries, other physical injuries, chronic pain, disabilities, PTSD, partner relationship problems, difficulty finding a civilian job, and having missed parts of one’s children’s early years, adjustment can be quite challenging. Traumatic brain injuries are associated with increased risk of domestic violence (111).

A recent preventive strategy was employed by the U.S. Department of Defense with the purpose of building resiliency in military families. Families OverComing Under Stress consisted of several modular interventions for families (112):

■  Project TALK (Teens and Adults Learning to Communicate (113))

■  The University of California, Los Angeles (UCLA) Trauma Grief Intervention (114)

■  Family Talk, a cognitive–behavioral approach to communication enhancement and parenting training (115,116)

■  Individual Family Resiliency Training (117)

■  This was integrated with the current Stress Continuum Model that kept health providers and command on the lookout for symptoms of stress and impaired function among soldiers and family members (118).

Multiple family therapy groups can be very helpful in addressing some of these issues (40,119). While PTSD often leads to avoidance of discussing painful memories, especially to intimates who might be frightened by the content of such memories, these groups allow men and women to find peers who understand and support them by virtue of their common experiences. Family involvement in treatment for addictions is very helpful and likely to improve outcome.

Approaches for Pregnant Women

Pregnant women who abuse substances are at particular risk of poor pregnancy outcomes. About 15% of pregnancies are complicated by substance abuse (120). The most commonly used substance is tobacco, but alcohol, cannabis, opioids, sedatives, and stimulants are not uncommon. Alcohol has been implicated in the spectrum of serious tera-tologic effects known as fetal alcohol effects, characterized by serious health problems and mental handicaps. However, there are still many misconceptions, held both by professional and lay people, about alcohol use among pregnant women, and there is a need to involve families in efforts to detect and treat addiction in pregnant and postpartum women (121). Although women planning to become pregnant may try to abstain from drugs and alcohol, and active substance users wanting a healthy baby will try to stop as soon as they become aware they are pregnant, pre-pregnancy patterns of substance use may be continued well into the period of greatest risk of teratogenicity, the first trimester. Pregnancy may first be suspected after the first missed menstrual period but cannot be confirmed by urine pregnancy test until at least 2 to 3 weeks after conception. A history of irregular menses or denial about becoming pregnant may delay awareness further. In the United States, 50% of pregnancies are unplanned, and 25% are unwanted (122,123). When the pregnancy is unexpected and undesired, the mother’s motivation for substance abuse treatment may be adversely affected; an unwed teenager who views pregnancy as a threat to her future, for example, may fantasize about deliberately harming the fetus by continuing her substance use unabated. Indeed, the most severely damaged fetuses will spontaneously abort during the first trimester, but many of those exposed to lesser amounts of intoxicants may survive despite the damage.

Prenatal care typically does not begin until the period of highest-risk of teratogenicity has already passed. Women may have concerns about the impact of their earlier substance use on the fetus, a concern likely shared by the father and grandparents once they become aware of the pregnancy. Friends and family and, sometimes, prenatal caregivers may express hostility and resentment toward the pregnant substance-abusing woman (hostile enabling) for potentially harming her unborn child. If the pregnancy is welcomed, a desire to protect the baby may support adherence to recommendations of abstinence and for seeking additional addiction care. On the other hand, if the pregnancy is unwanted or if the pregnant woman is ambivalent about it (possibly reflecting the differing views of her parents, the father of the baby, and his parents), she may be uncooperative with treatment recommendations and may rely upon drugs to soothe her mixed emotions. The most commonly used substance, tobacco, can be addressed as a part of routine prenatal care; extinguishing tobacco smoking during pregnancy is beneficial to the developing fetus and reduces the risk of substance relapse later. Continued tobacco use during pregnancy is a tip-off that other substance use may be occurring as well. Addressing tobacco use first may be a good way to build a therapeutic alliance as shame/guilt may inhibit disclosure of other drug use. Engaging the family in constructive recovery activity may be helpful in supporting the pregnant female.

Relationship problems, including conflict over whether to terminate the pregnancy, episodes of domestic violence, abandonment by the partner, or failure to provide support, threaten the health of the fetus and increase the risk of complications, such as perinatal mood disorders and elevated perinatal cortisol levels. Guilt, remorse, anxiety, and anger are likely to complicate what might otherwise be a happy time. Since substances are often used as a way to cope with negative feelings, ongoing episodes of substance abuse may further impact pregnancy outcome.

When abstinence is established early in pregnancy, family may be less concerned than if it is not; however, recovery efforts should be strongly encouraged and supported throughout the pregnancy. Involving the family in Al-Anon and family-oriented psychoeducation and treatment can reduce the likelihood of hostile enabling by family, especially if there are slips or relapses during the initial care. For those with poor natural support systems, longer-term residential care in mother–baby recovery group homes may be indicated.

For women who have become dependent upon opioid drugs, the standard of care has become opioid maintenance, especially after the 5th month of the gestation when meco-nium begins to be produced. By starting the pregnant woman on either methadone or buprenorphine maintenance, the craving and urge to use opioids is curbed, and reinforcement from incidents of relapse is blocked. Furthermore, the duration of action of these two medications is long, reducing the likelihood that the mother, and most importantly the fetus, will not experience intermittent episodes of opioid withdrawal and, therefore, meconium release into the amniotic fluid. Two large randomized clinical trials comparing methadone with buprenorphine during pregnancy have shown a high rate of continued participation in recovery, a low rate of relapse, and manageable postnatal withdrawal in the infants (124). Some women and their relatives may resist taking such medications during pregnancy with the fear that it will harm their developing fetus. Instead, they insist on abstinence as the approach to their addiction. However, the odds are against success, and relapses to short-acting opioids that they would choose in a relapse can produce several episodes of withdrawal every day. Thus, convincing them and their family supports of the relative risk of this approach is important. Likewise, other medications that might be offered to manage anxiety, depression or bipolar disorder, or other psychiatric disorders should be selected carefully and the risks explained thoroughly to all who care lest they be convinced to nonadhere with treatment recommendations (125,126).

Immediately postpartum is a time of high risk for relapse, once alcohol and drug use is no longer perceived as harmful to the fetus. It is a very stressful time, especially for inexperienced mothers learning to cope with a needy infant. Domestic violence may increase during this time as the parents become sleep deprived and argue about responsibilities; their new parental roles may supplant their romance. A postpartum mood disorder may develop. Although support from family or others can mitigate the stress to some extent, awareness of these risks can facilitate early recognition and referral for care. Medications to support recovery from substance use disorders, such as methadone or buprenor-phine for opioid dependence and acamprosate, naltrexone, or disulfiram for alcohol dependence, may be helpful. Continued involvement in 12-step recovery support groups and counseling are critical to success in managing stress and maintaining sobriety.

A longitudinal study of 185 parenting adolescents age 17 and under at delivery that gathered data from the last of 10 interviews over 6 years found their alcohol and drug use to be moderately correlated (r = 0.48). Psychological distress was moderately correlated with alcohol (r = 0.23) and drug (r = 0.24) use (i.e., moderate or heavy vs. none or minimal). Both alcohol (r = 0.22) and drug (r = 0.21) use were correlated with negative control. Psychological distress combined with alcohol use predicted greater use of negative strategies to control or discipline the child (e.g., verbal abuse, physical violence). Drug use also was correlated with unrealistic expectations of the children (r = 0.21) and attributions that their children were trying to annoy them by misbehavior (r = 0.30) (127). Unfortunately, this study did not distinguish between moderate and higher levels of substance abuse. Clearly, treatment for maternal stress and substance use problems in teen mothers could improve parenting skills and the future well-being of the child.

SUMMARY

When one encounters a patient suffering from addiction or a family member affected by addiction of the IP, a clinician can provide screening, assessment, diagnosis, advice, motivational enhancement, referral, intervention services, recovery monitoring, and relapse prevention. The family may be the key to recognizing the addiction, and family-oriented approaches enhance engagement in treatment, completion of treatment, and sustained participation in aftercare. There is a great deal at stake, as the family suffers when the addiction is active and the family also may interfere with treatment and recovery, if not helped to work as part of a unified recovery team. The family can get help for its own codependency and consequential issues; this will contribute to better overall family function and satisfaction. A number of very effective family therapy approaches are described that greatly enhance success rates in treating the addicted person as well as in improving overall family function. Family-oriented care for addiction disorders should be available in all communities and at all treatment programs to optimize efficacy and reduce overall costs for care and harm to the community.

REFERENCES

1.O’Farrell TJ, Hooley J, Fals-Stewart W, et al. Expressed emotion and relapse in alcoholic patients. J Consult Clin Psychol 1998;66:744–752.

2.Frank SH, Graham AV, Zyzanski SJ, et al. Use of the family CAGE in screening for alcohol problems in primary care. Arch Fam Med 1992;1:209–216.

3.Graham AV. Family issues in substance abuse. Faculty Development Program in Substance Abuse. Rockville, MD: Center for Substance Abuse Prevention, 1996.

4.McGann KP. Self-reported illnesses in family members of alcoholics. Fam Med 1990;22:103–106.

5.Wolin SJ, Bennett LA, Noonan DL. Family rituals and the recurrence of alcoholism over generations. Am J Psychiatry 1979;136(4B):589–593.

6.Wolin SJ, Bennett LA, Noonan DL, et al. Disrupted family rituals: a factor in the intergenerational transmission of alcoholism. J Stud Alcohol 1980;41:199–214.

7.Padilla-Walker L, Nelson L, Madsen S, et al. The role of perceived parental knowledge on emerging adults’ risk behaviors. J Youth Adolesc 2008;37:847–859.

8.Steinglass P. Family systems and Motivational Interviewing: a systemic-motivational model for treatment of alcoholism and other drug problems. Alcohol Treat Q 2008;26:9–29.

9.Klassen AD, Wilsnack SC, Harris TR, et al. Partnership dissolution and remission of problem drinking in women: findings from a US longitudinal survey. Presented at The Symposium on Alcohol, Family and Significant Others, Social Research Institute of Alcohol Studies and Nordic Council for Alcohol and Drug Research, Helsinki, Finland, March 1991.

10.Lex BW. Male heroin addicts and their female mates: impact on disorder and recovery. J Subst Abuse 1990;2:147–175.

11.Wilsnack SC, Wilsnack RW. Epidemiology of women’s drinking. J Subst Abuse 1990;3:133–157.

12.Wilsnack SC, Wilsnack RW. Epidemiological research on women’s drinking: recent progress and directions for the 1990s. In: Gomberg ESL, Nirenberg TD, eds. Women and substance abuse. Norwood, NJ: Ablex, 1993:62–99.

13.Doherty E, Green K, Reisinger H. Long-term patterns of drug use among an urban African-American cohort: the role of gender and family. J Urban Health 2008;85:250–267.

14.Cadoret RJ, Troughton E, O’Gorman TW, et al. An adoption study of genetic and environmental factors in drug abuse. Arch Gen Psychiatry 1986;43:1131–1136.

15.Cloninger CR, Sigvardsson S, Bohman M. Childhood personality predicts alcohol abuse in young adults. Alcohol Clin Exp Res 1988;12:494–505.

16.Goodwin DW. Alcoholism and heredity: a review and hypothesis. Arch Gen Psychiatry 1979;36:57–61.

17.Heath AC, Cates R, Martin NG, et al. Genetic contribution to risk of smoking initiation: comparisons across birth cohorts and across cultures. J Subst Abuse 1993;5:221–246.

18.Reich T, Cloninger CR, Van Eerdewegh P, et al. Secular trends in the familial transmission of alcoholism. Alcohol Clin Exp Res 1988;12:458–464.

19.Swan GE, Carmelli D, Rosenman RH, et al. Smoking and alcohol consumption in adult male twins: genetic heritability and shared environmental influences. J Subst Abuse 1990;2:39–50.

20.Cloninger CR. Neurogenetic adaptive mechanisms in alcoholism. Science 1986;236:410–416.

21.Liepman MR, Calles JL, Kizilbash L, et al. Genetic and nongenetic factors influencing substance use by adolescents. Adolesc Med 2002;13:375–401.

22.Kandel D, Faust R. Sequence and stages in patterns of adolescent drug use. Arch Gen Psychiatry 1975;32:923–932.

23.Moos RH, Billings AG. Children of alcoholics during the recovery process: alcoholic and matched control families. Addict Behav 1982;7:155–163.

24.Woodside M, Coughey K, Cohen R. Medical costs of children of alcoholics: pay now or pay later. J Subst Abuse 1993;5:281–287.

25.Dube SR, Felitti VJ, Dong M, et al. The impact of adverse childhood experiences on health problems: evidence from four birth cohorts dating back to 1900. Prev Med 2003;37:268–277.

26.Edwards VJ, Holden GW, Felitti VJ, et al. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. Am J Psychiatry 2003;160:1453–1460.

27.Brown DW, Anda RA, Tiemeier H, et al. Adverse childhood experiences and the risk of premature mortality. Am J Prev Med 2009;37:389–396.

28.Corso PS, Edwards VJ, Fang X, et al. Health-related quality of life among adults who experienced maltreatment during childhood. Am J Public Health 2008;98:1094–1100.

29.American Psychiatric Association. Desk reference to the diagnostic criteria from DSM-5. Washington, DC: Author, 2013:233.

30.Burant D, Liepman MR, Miller MM. Mental health disorders and their impact on treatment of addictions. In: Fleming MD, Barry KL, eds. Addictive disorders. St. Louis, MO: Mosby/Year Book, 1992:315–337.

31.Wartenberg AA, Liepman MR. Medical consequences of addictive behaviors. In: Nirenberg TD, Maisto SA, eds. Developments in the assessment and treatment of addictive behaviors. Norwood, NJ: Ablex, 1987:49–85.

32.Wartenberg AA, Liepman MR. Medical complications of substance abuse. In: Lerner WD, Barr MA, eds. Handbook of hospital-based substance abuse treatment. New York: Pergamon, 1990:45–65.

33.Nirenberg TD, Liepman MR, Begin AM, et al. The sexual relationship of male alcoholics and their female partners during periods of drinking and abstinence. J Stud Alcohol 1990;51:565–568.

34.Casey K. Children of Eve: the shocking story of America’s homeless kids. Hollywood, LA: Covenant House, 1991.

35.Liepman MR, White WT, Nirenberg TD. Children in alcoholic families. In: Lewis DC, Williams CN, eds. Providing care for children of alcoholics: clinical and research perspectives. Pompano Beach, FL: Health Communications, 1986:39–64.

36.Smilkstein G. The cycle of family function: a conceptual model for family medicine. J Fam Pract 1980;11:223–232.

37.Graham AV, Berolzheimer N. Alcohol abuse: a family disease. Prim Care 1993;20:121–130.

38.Baird MA. Care of family members and other affected persons. In: Fleming MF, Barry KL, eds. Addictive disorders. St. Louis, MO: Mosby Year Book, 1992:195–210.

39.Wegscheider-Cruse S. Another chance: hope and health for the alcoholic family. Palo Alto, CA: Science and Behavior Books, 1989.

40.Kaufman E. Substance abuse and family therapy. New York: Harcourt Brace Jovanovich, 1985:221.

41.Liepman MR. Using family influence to motivate alcoholics to enter treatment: the Johnson Institute Intervention approach. In: O’Farrell TJ, ed. Marital and family therapy in alcoholism treatment. New York: Guilford Press, 1993:54–77.

42.Liepman MR, Wolper B, Vazquez J. An ecological approach for motivating women to accept treatment for chemical dependency. In: Reed BG, Mondanaro J, Beschner GM, eds. Treatment services for drug dependent women, Vol. II. Rockville, MD: National Institute on Drug Abuse, 1982:1–61.

43.Prochaska JO, DiClemente CC. Towards a comprehensive model of change. In: Miller WR, Heather N, eds. Treating addictive behaviors: processes of change. New York: Plenum, 1986:3–27.

44.Bennett LA, Ames GM. The American experience with alcohol: contrasting cultural perspectives. New York: Plenum, 1985.

45.Liepman MR, Flachier R, Tareen RS. Family Behavior Loop Mapping: a technique to analyze the grip addictive disorders have on families and to help them to recover. Alcohol Treat Q2008;26:59–80.

46.Liepman MR, Silvia LY, Nirenberg TD. The use of Family Behavior Loop Mapping for substance abuse. Fam Relat 1989;38:282–287.

47.Silvia LY, Liepman MR. Family Behavior Loop Mapping enhances treatment of alcoholism. Fam Community Health 1991;13:72–83.

48.Steinglass P, Davis DI, Berenson D. Observations of conjointly hospitalized “alcoholic couples” during sobriety and intoxication: implications for theory and therapy. Fam Process1977;16:1–16.

49.Lewis JA, Dana RQ, Blevins GA. Substance abuse counseling, 4th ed. Belmont, CA: Brooks/Cole, Cengage Learning, 2011:273.

50.Olsen L, Allen D, Azzi-Lessing L. Assessing risk in families affected by substance abuse. Child Abuse Negl 1996;20:833–842.

51.Burd L, Wilson H. Fetal, infant, and child mortality in the context of alcohol use. Am J Med Genet 2004;127:51–58.

52.Liepman MR, Nirenberg TD, Doolittle RH, et al. Family functioning of male alcoholics and their female partners during periods of drinking and abstinence. Fam Process 1989;28:239–249.

53.Miller WR, Rollnick S. Motivational interviewing, 2nd ed. New York: Guilford Press, 2002.

54.Landau J, Garrett J. Invitational intervention: the ARISE model for engaging reluctant alcohol and other drug abusers in treatment. Alcohol Treat Q 2008;26:147–168.

55.Johnson VE. Intervention: how to help those who don’t want help. Minneapolis, MN: Johnson Institute, 1986.

56.Liepman MR, Nirenberg TD, Begin AM. Evaluation of a program designed to help families and significant others to motivate resistant alcoholics into recovery. Am J Drug Alcohol Abuse1989;15:209–221.

57.Loneck B, Garrett J, Banks S. A comparison of the Johnson Intervention with four other methods of referral to outpatient treatment. Am J Drug Alcohol Abuse 1996;22:233–246.

58.Loneck B, Garrett J, Banks S. The Johnson Intervention and relapse during outpatient treatment. Am J Drug Alcohol Abuse 1996;22:363–375.

59.Landau J, Stanton MD, Brinkman-Sull D, et al. Outcomes with ARISE approach to engaging reluctant drug-and alcohol-dependent individuals in treatment. Am J Drug Alcohol Abuse2004;30:711–748.

60.Monti PM, Abrams DB, Binkoff JA, et al. Communication skills training, communication skills training with family, and cognitive behavioral mood management training for alcoholics. J Stud Alcohol1990;51:263–270.

61.O’Farrell TJ, Fals-Stewart W. Behavioral Couples Therapy for alcoholism and other drug abuse. Alcohol Treat Q 2008;26:195–219.

62.Thomas EJ, Santa CA. Unilateral family therapy for alcohol abuse: a working conception. Am J Fam Ther 1982;10:49–58.

63.Smith JE, Meyers RJ, Austin JL. Working with family members to engage treatment-refusing drinkers: the CRAFT program. Alcohol Treat Q 2008;26:169–193.

64.Kirby KC, Marlowe DB, Festinger DS, et al. Community reinforcement training for family and significant others of drug abusers: a unilateral intervention to increase treatment entry of drug users. Drug Alcohol Depend 1999;56:85–96.

65.Miller WR, Meyers RJ, Tonigan JS. Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members. J Consult Clin Psychol1999;67:688–697.

66.Meyers RJ, Miller WR, Smith JE, et al. A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others. J Consult Clin Psychol2002;70:1182–1185.

67.Montgomery L. The things between us: a memoir. New York: The Free Press, 2006.

68.Moyers WC, Ketchum K. Broken: my story of addiction and redemption. New York: Viking Press, 2006.

69.Beattie M. Codependent no more: how to stop controlling others and start caring for yourself, 2nd ed. Center City, MN: Hazelden, 1992.

70.Edwards ME, Steinglass P. Family therapy treatment outcomes for alcoholism. J Marital Fam Ther 1995;21:475–509.

71.O’Farrell TJ, Fals-Stewart W. Family-involved alcoholism treatment: an update. In: Galanter M, ed. Recent developments in alcoholism, vol. 15: Services research in the era of managed care. New York: Brunner-Routledge, 2001:329–356.

72.Ripley J, Cunion A, Noble N. Alcohol abuse in marriage and family contexts: relational pathways to recovery. Alcohol Treat Q 2006;24:171–184.

73.Stanton MD, Shadish WR. Outcome, attrition, and family-couple treatment for drug abuse: a meta-analysis and review of the controlled, comparative studies. Psychol Bull 1997;122:170–191.

74.Epstein, E. McCrady, B. Couple therapy in the treatment of alcohol problems. In Gurman AS, Jacobson NS, eds. Clinical handbook of couple therapy, 3rd ed. New York: Guilford Press, 2002:597–628.

75.Epstein E, McCrady B. Behavioral couples treatment of alcohol and drug use disorders: current status and innovations. Clin Psychol Rev 1998;18:689–711.

76.Fals-Stewart W, Birchler GR. A national survey of the use of couples therapy in substance abuse treatment. J Subst Abuse Treat 2001;20:277–283.

77.Thomas C, Corcoran J. Empirically based marital and family interventions for alcohol abuse: a review. Res Soc Work Pract 2001;11:549–575.

78.Longabaugh R, Rubin A, Malloy P, et al. Drinking outcomes of alcohol abusers diagnosed as antisocial personality disorder. Alcohol Clin Exp Res 1994;18:778–785.

79.Holtzworth-Munroe A, Meehan J, Rehman U, et al. Intimate partner violence: an introduction for couple therapists. In: Gurman AS, Jacobson NS, eds. Clinical handbook of couple therapy, 3rd ed. New York: Guilford Press, 2002:441–465.

80.Fichter MM, Glynn SM, Weyerer S, et al. Family climate and expressed emotion in the course of alcoholism. Fam Process 1997;36:203–221.

81.Toumbourou J, Blyth A, Bamberg J, et al. Early impact of the BEST intervention for parents stressed by adolescent substance abuse. J Commun Appl Soc Psychol 2001;11:291–304.

82.McGillicuddy N, Rychtarik R, Duquette J, et al. Development of a skill training program for parents of substance-abusing adolescents. J Subst Abuse Treat 2001;20:59–68.

83.Blechman E, Vryan K. Prosocial family therapy: a manualized preventive intervention for juvenile offenders. Aggress Violent Behav 2000;5:343–378.

84.Briones E, Robbins MS, Szapocznik J. Brief strategic family therapy: engagement and treatment. Alcohol Treat Q 2008;26:81–103.

85.Szapocznik J, Perez-Vidal A, Brickman A, et al. Engaging adolescent drug abusers and their families into treatment: a strategic structural systems approach. J Consult Clin Psychol1988;56:552–557.

86.Santisteban D, Coatsworth JD, Perez-Vidal A, et al. Efficacy of brief strategic family therapy in modifying hispanic adolescent behavior problems and substance use. J Fam Psychol2003;17:121–133.

87.Rowe CL, Liddle HA. Multidimensional family therapy for adolescent alcohol abusers. Alcohol Treat Q 2008;26:105–123.

88.Liddle HA, Dakof GA, Parker K, et al. Multidimensional family therapy for adolescent substance abuse: results of a randomized clinical trial. Am J Drug Alcohol Abuse 2001;27:651–687.

89.Liddle HA, Rowe CL, Henderson C, et al. Early intervention for adolescent substance abuse: pretreatment and posttreatment outcomes of a randomized controlled trial comparing multidimensional family therapy and peer group treatment. J Psychoactive Drugs 2004;36:2–37.

90.Henderson CE, Dakof GA, Greenbaum PE, et al. Effectiveness of multidimensional family therapy with higher severity substance-abusing adolescents: report from two randomized controlled trials. J Consult Clin Psychol 2010;78:885–897.

91.Henggeler SW, Clingempeel WG, Brondino MJ, et al. Four-year follow-up of multisystemic therapy with substance-abusing and substance-dependent juvenile offenders. J Am Acad Child Adolesc Psychiatry 2002;41:868–874.

92.Henggeler SW, Halliday-Boykins CA, Cunningham PB, et al. Juvenile drug court: enhancing outcomes by integrating evidence-based treatments. J Consult Clin Psychol 2006;74:42–54.

93.Sheidow AJ, Henggeler SW. Multisystemic therapy for alcohol and other drug abuse in delinquent adolescents. Alcohol Treat Q 2008;26:125–145.

94.Dembo R, Cervenka K, Hunter B, et al. Engaging high risk families in community based intervention services. Aggress Violent Behav 1999;4:41–58.

95.Gip AG, Wagner EF, Tubman JG. Culturally sensitive substance abuse intervention for Hispanic and African American adolescents: empirical examples from the alcohol treatment targeting adolescents in need (ATTAIN) project. Addiction 2004;99(s2):140–150.

96.Substance Abuse and Mental Health Services Administration (SAMHSA). Substance abuse among older adults: Treatment Improvement Protocol (TIP). Series Number 26. Rockville, MD: United States Department of Health and Human Services, 2004.

97.National Center for Health Statistics. Health, United States, 2011: with special feature on socioeconomic status and health. Hyattsville, MD: United States Department of Health and Human Services, 2012. Retrieved from http://www.cdc.gov/nchs/data/hus/hus11.pdf. Accessed on Dec. 10, 2013.

98.U.S. Census Bureau, 2011. The older population: 2010. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf. Accessed on Dec. 10, 2013.

99.Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug Use and Health: summary of national findings. NSDUH Series H-44, HHS Publication No. (SMA) 12–4713. Rockville, MD: Author, 2012. Retrieved from http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm#3.1.1. Accessed on Dec. 10, 2013.

100.Blow FC, Bartels SJ, Brockmann LM, et al. Evidence-based practices for preventing substance abuse and mental health problems in older adults. Rockville, MD: Older Americans Substance Abuse and Mental Health Technical Assistance Centre, 2005.

101.Blow F, Brower K, Schulenberg J, et al. The Michigan Alcoholism Screening Test-Geriatric Version (MAST-G): a new elderly-specific screening instrument. Alcohol Clin Exp Res1992;16:372.

102.Stelle C, Scott J. Alcohol abuse by older family members: a family systems analysis of assessment and intervention. Alcohol Treat Q 2007;25:43–63.

103.Lemke S, Moos R. Prognosis of older patients in mixed-age alcoholism treatment programs. J Subst Abuse Treat 2002;22: 33–43.

104.Fleming MF, Manwell LB, Barry KL, et al. Brief physician advice for alcohol problems in older adults: a randomized community-based trial. J Fam Pract 1999;48:378–384.

105.Milliken CS, Auchterlonie JL, Hoge CW. Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. JAMA2007;298:2141–2148. doi: 10.1001.

106.Office of the Deputy Under Secretary of Defense (Military Community and Family Policy), under contract with ICF International. Demographics 2007: Profile of the military communityhttp://www.militaryonesource.com/mos/serviceproviders/2007demographicsprofileofthemilitarycommuni.aspx. Accessed on Dec. 10. 2013.

107.Miller MW, Reardon AF, Wolf EJ, et al. Alcohol and drug abuse among U.S. veterans: comparing associations with intimate partner substance abuse and veteran psychopathology. J Traumatic Stress2013;26:71–76.

108.Fals-Stewart W, Birchler GR, O’Farrell TJ. Drug-abusing patients and their intimate partners: dyadic adjustment, relationship stability, and substance abuse. J Abnorm Psychol1999;108:11–23.

109.Homish GG, Leonard KE. The drinking partnership and marital satisfaction: the longitudinal influence of discrepant drinking. J Consult Clin Psychol 2007;75:43–51.

110.Ostermann J, Sloan FA, Taylor DH. Heavy alcohol use and marital dissolution in the USA. Soc Sci Med 2005;61:2304–2316.

111.Cohen RA, Rosenbaum A, Kane, RL, et al. Neuropsychological correlates of domestic violence. Violence Vict 1999;14:397–411.

112.Beardslee W, Lester P, Klosinski L, et al. Family-centered preventive intervention for military families: implications for implementation science. Prev Sci 2011;12:339–348.

113.Lester P, Rotheram-Borus MJ, Elia C, et al. TALK: teens and adults learning to communicate. In: LeCroy CW, ed. Evidence-based treatment manuals for children and adolescents. New York: Oxford University Press, 2008:170–285.

114.Layne CM, Pynoos RS, Saltzman WR, et al. Trauma/grief-focused psychotherapy: school-based postwar intervention with traumatized Bosnian adolescents. Special issue: Group-based interventions for trauma survivors. Group Dynamics: Theory, Research, and Practice 2001;5:277–290.

115.Beardslee WR, Wright EJ, Gladstone TRG, et al. Long-term effects from a randomized trial of two public health preventive interventions for parental depression. J Fam Psychol2007;21:703–713.

116.D’Angelo EJ, Llerena-Quinn R, Shapiro R, et al. Adaptation of the preventive intervention program for depression for use with predominantly low-income Latino families. Fam Process2009;48:269–291.

117.Lester P, Leskin G, Woodward K, et al. Wartime deployment and military children: applying prevention science to enhance family resilience. In: MacDermid-Wadsworth S, Riggs D, et al., eds. Risk and resilience in U.S. military families. New York: Springer Science+Business Media, 2010:149–173.

118.Lester P, Saltzman WR, Woodward K, et al. Evaluation of a family-centered prevention intervention for military children and families facing wartime deployments. Am J Public Health2012;102(Suppl 1):S48–S54.

119.Kaufman E, Kauffmann P. Family therapy of drug and alcohol abuse. New York: Gardner Press: Distributed by Halsted Press, 1979.

120.Chasnoff IJ, Landress HJ, Barrett ME. The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. N Engl J Med1990;322:1202–1206.

121.Arendt R, Farkas K. Maternal alcohol abuse and fetal alcohol spectrum disorder: a life-span perspective. Alcohol Treat Q 2007;25:3–20.

122.Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006;8:90–96.

123.Mosher WD, Jones J, Joyce CA. Intended and unintended births in the United States: 1982–2010. National Health Statistics Reports #55, 2012.

124.Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review. Addiction. 2012;107(Suppl 1):5–27. doi: 10.1111/j.1360-0443.2012.04035.x.

125.Viguera AC, Whitfield T, Baldessarini RJ, et al.: Risk of recurrence in women with bipolar disorder during pregnancy: prospective study of mood stabilizer discontinuation. Am J Psychiatry 2007;164:1817–1824.

126.Stowe ZN, Newport DJ. The management of bipolar disorder during pregnancy. Medscape Psychiatryhttp://www.medscape.com/viewarticle/565128_4. Accessed December 14, 2007.

127.Spieker SJ, Gillmore MR, Lewis SM. Psychological distress and substance use by adolescent mothers: associations with parenting attitudes and the quality of the mother-child interaction. J Psychoactive Drugs 2001;33:83–93.