Family Systems Approach Expands Treatment Focus Beyond Individual With SUD

A family systems approach to treating addiction addresses not only the individual with a substance use disorder (SUD), but also the impact of that disorder on those around the individual who is struggling.

On Saturday at the Rocky Mountain Symposium on Addictive Disorders, James S. DiReda, LICSW, PhD, of Lake Avenue Recovery in Sterling, Massachusetts, presented a session on working with families who are experiencing substance use problems. Dr DiReda explained the family systems approach to addiction treatment and offered intervention strategies and best practices.

Recently, Addiction Professional caught up with Dr DiReda by email to discuss the family systems theory, recovery strategies when working with families, and the importance of showing compassion instead of using “sledgehammer tactics.”

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional: What is the family systems theory for treating addiction?

Dr DiReda: I think using family systems theory is a wonderful way to understand addiction, because systems theory emphasizes that what happens in 1 part of a system affects or impacts the other parts of the system and how it operates as a whole. And for me, it just made sense when I first got exposed to family system theory—and how it applied to addiction—it really made sense to me because when you hold it up to the light, if I’m a family member who’s addicted, then obviously, there are going to be consequences for everyone else involved in that family system or everyone close to me.

It doesn’t even have to be my family. It can be other relationships in my life: girlfriend, social friends, whatever. Addiction changes things. And it sure as heck changes a family system. So understanding family systems, I think, is a great overlay to look at a family where addiction is present, because you can start to see some of the things that I’m going to mention now. A functioning family has open communication and boundaries and space and time to be who you are and still be a part of this family system.

AP: What are the key aspects of a family system?

Dr DiReda: You can develop, grow, individuate, separate, come back, and still be part of the system, and even go on and have your own family. And that family becomes part of your original family system or family of origin. So what we see when addiction takes hold are noticeable changes in everybody in the family system. We focus on what we used to call the identified patient, or the person who’s addicted, and all the emphasis and all the focus gets put on that person. But, I was trained to back up, open the lens, and look at the whole family as a system, not just that one person. Yeah, that one person might be the one that’s making all the noise, or running around exhibiting crazy behavior, or acting out. And everyone else is freaked out by it.

For me, it’s helpful to understand the big picture of who else is involved in this family system and what kind of changes are happening in the relationship, because when we talk about treating the addiction, which we do further down, understanding those aspects is important. When working through some of the damaged or strained relationships, we have to understand how they’re damaged, how they’re strained, what the relationship was prior to, what the relationship is now, in order to try to help mend that damage.

So noticeable changes in everyone is a key aspect. You can look at the family and start to see people behaving differently around one another. The communication changes. They start distancing. And all of those things are noticeable if you’re paying attention, if you’re involved and close, if you know this family and know that 5 years ago, they used to function a certain way. And now all of a sudden they’re functioning in a different way.

It’s sometimes very similar to if somebody developed cancer in a family, prior to the diagnosis they had their way of operating in a certain fashion. But then once the diagnosis was made and the illness really starts to manifest, people behave differently. People behave differently toward the person with the with the cancer, or with the addiction. People behave differently towards one another. People look for safe places to kind of escape to or hide. And that’s where, I think, especially younger kids or younger people sort of find these other roles to become a safe harbor amidst the storm. So, noticing and knowing that stuff, I think, is important as far as being able to address it, and hopefully change it or repair it.

One of the other key aspects is the importance of addressing the family in its entirety, not just singling out and put the spotlight on the person who’s addicted, because that’s pretty common. One child or one person in the family—whether it’s mom or dad, doesn’t have to be a child--one person in the family is addicted. Everyone looks at that person as the one who’s responsible for all the chaos, and problems, and trouble in the family, because they’re addicted and acting out. And so all the emphasis and the onus gets put on that person.

AP: What are some best clinical practices and recovery strategies for working with families impacted by substance use disorder?

Dr DeRida: It’s really important to know family systems, how they operate, and to focus on the family as a system; not just one part of the system is broken or damaged or problematic, and therefore, we just fix that part of the system and the system runs great. That’s naive. I think the whole family suffers and struggles when addiction takes hold. Iif someone in that system is addicted, then others are impacted negatively most times and pay a price.

So, understanding how the whole family is affected and not just the one person that is addicted to drugs and alcohol, I think is probably one of the most important things. And education. When we talk of best clinical practices, education doesn’t sound like it’s a clinical intervention, but for my money, the best way to help people to understand this stuff is to educate them.

I’ve been part of developing a family program as a component of a residential program for people with addictions. And when family members come to our family weekend, they come oftentimes really guarded and jaded, angry, full of resentment about what this person with an addiction did to them and their family. Help them to understand that this is a sickness that makes a person do things they don’t want to do. This is a sickness that makes people do things to hurt others or themselves that they don’t intentionally want to do. It’s something that’s happening behind the scenes that nobody really has control of. Understanding that is a really important aspect, instead of just putting all the focus and all the onus on the person with the addiction.

That sounds a little bit more than a clinical intervention, but I think it’s really important that people understand, and not just the brain chemistry or what happens to an individual from that perspective. But also the recovery part, because I’ve met a lot of smart people who know a lot about addiction, but they don’t know a whole lot about recovery, especially in families. So, helping them to understand what happens to a person who struggles with addiction and then tries to recover is really important, because they are also part of a family system, they’re also a part of that process.

And it’s not like the person with the addiction is going to go somewhere and get fixed, or get a tune up, or get cured, and then come back to their family, and have everything be rosy and bright. That’s sort of naive thinking. The family is involved along the journey every step of the way. Understanding that aspect is really important, and I do that through education. Educating people, I think, is the most important practice that we can do to help people through addiction and recovery. The focus is not just on the person with the addiction. I’ve met family members that get pretty sick and have never used alcohol or drugs, don’t abuse them, and they get really, really sick from proximity to addiction. Help them understand that they also need some support and some treatment. They may not need to go to detox, but going to treatment and somewhere that they can be heard, relate, and connect with others.

So, one of the best clinical practices is to help those families—educate them, support them, and provide places for them where they can go and continue to get that support, regardless of what happens with the person addicted. Because again, sometimes they’ll get better, sometimes they won’t. Sometimes they’ll survive, sometimes they won’t. Family members have to go on.

AP: What are some common mistakes and/or ill-advised strategies when it comes to working with families impacted by substance use disorder?

Dr DiReda: When we look at treatment goals, helping an addicted individual get sober or drug-free, obviously, that’s a goal. But where does that involve the family? Looking at how to keep them connected throughout process and not marginalize or keep them at arm’s length is important because they are a vital part of this process.

One of the things that I’m pretty adamant about is this notion of tough love. People will say things like, “oh, throw them out,” or, “cut them loose.” I think that for someone who’s struggling with an addiction and has alienated everybody in their life, and is full of self-loathing and fear, to cut them off from what might be the last person that they have any connection to in life is very dangerous and very risky. If I cut that person loose, I say, “call me when you get sober,” and I’m one of the last people left that that person feels like they can reach out to who might still love them or support them, I may never hear from that person again.

One of the other mistakes is listening to the various opinion about what you should do, because people don’t know. Even I, as someone who has been doing this for almost 40 years, can’t say that I know every situation, what every response or answer is to every situation.

You have to understand the family. You have to understand the person who’s addicted. You have to understand the dynamics. And you have to understand where the strengths are, and try to build on those instead of just piling on and saying, “Yeah, this person is a no good so-and-so.”

I try to help family members and other treatment professionals understand, even if you’ve been trained in those old methods or interventions, those “sledgehammer tactics,” that they don’t work. You get much more from a loving, compassionate approach than you do from sledgehammer tactics. I’ve done the other things, the sledgehammer tactics. I’ve done the tough love approach without positive results. In fact, with negative results.

I’m an advocate of the loving, compassionate approach. And I know it’s hard—when people are acting out and out of control and at their worst—to be loving and compassionate and understanding. But that goes so much further. And it’s not just with people with addictions. Regardless of what kind of illness or sickness you have, people respond to love, compassion, and understanding. It helps them to heal. That’s what people with addictions are trying to do is to heal from this addiction that has beaten the hell out of them, maybe nearly killed them or tried to kill them. They’re trying to heal from that, and so are the families.

And so, everybody needs to be treated with some love, compassion and understanding. And I learned that from a brilliant therapist named Brian Litzenberger, who taught me that what helps people to heal when they’re struggling, regardless of whether it’s from an addiction or anything else is love, compassion, and understanding. I let that guide me in my work, in my understanding, in my philosophy. And I’m very comfortable with that.

Reference

DiReda JS. Working with families experiencing substance use problems. Presented at: Rocky Mountain Symposium on Addictive Disorders. Aug. 5-7, 2022. Denver, Colorado.