Running Head: TREATING THE FAMILY DISEASE
TREATING THE FAMILY DISEASE: Improved Outcomes
Ron Ohnhaus
HMSV 447
Old Dominion University
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TREATING THE FAMILY
Overview
Does one bad apple spoil the barrel, as an ancient proverb suggests? Science answers
“Yes.” Apples emit a gas that promotes ripening, which causes apples in proximity to spoil more
rapidly than they would apart from one another (Soniak, 2014). Social science studies show the
bad apple metaphor applies to groups of four to eight people, known as the “one-bad-apple
effect” (Kerr et al., 2008, p. 604, 610; Bruce, 2013). Based on the aforementioned studies, if the
bad apple were analogous to an alcoholic or drug addict and the group was his or her family, all
immediate family members might be expected to suffer illness due to just one member’s
alcoholism/addiction. Assuming that all family members become ill by association with one
addict/alcoholic member suggests that all family members would benefit from treatment. This
paper attempts to show the association that exists between individuals with substance use
disorders (SUD’s), their families, and evidence-based; and to evaluate the efficacy of whole
family treatment as compared to treating only the addicted member.
For the purposes of this paper, the terms “alcoholic,” “addict,” “chemically dependent,”
“substance abuse/r,” “alcohol or drug dependence” (AODD), “chronic illness,” and “chronic
disease” are used loosely and somewhat interchangeably to identify the person or illness
associated with “substance use disorder” (SUD), as described by the Diagnostic and Statistical
Manual of Mental Disorders: DSM-5, published in May of 2013. The DSM-5 defines an SUD
by two or more of eleven criteria being present in the assessment of an individual (American
Psychiatric Association, 2013). It is not the intent of this paper to enter into debate or
controversy about whether alcoholism or addiction to other drugs is properly classified as a
“disease.” The validity of the points raised herein does not depend on a precise distinction
between any of these terms.
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TREATING THE FAMILY
The Family Disease Concept
The U.S. government’s National Institute of Health (NIH)/National Institute on Drug
Abuse (NIDA) tells those seeking help for substance abuse disorders that “Like other chronic
diseases, addiction can be managed successfully” and that “Like many diseases, it can take
several attempts at treatment to find the right approach” (NIDA, 2014, p. FAQ). The NIDA
website urges family members and friends of addicts/alcoholics to “assure them that you will
support them in their courageous effort [to overcome addiction]” (2014). NIDA states
"Involvement of a family member or significant other in an individual's treatment program can
strengthen and extend treatment benefits." The combination of these statements indicate that
recovery from substance abuse will be enhanced by the support and involvement of the family,
yet examination of the NIDA website offers little in terms of specific ways to support and be
involved in the treatment process. The site mentions just one resource for friends and families
when it says, “Support groups for family members of people with addictions, like Al-anon and
Alateen, can also be helpful” (NIDA, 2014, p. FAQ).
Al-Anon Family Groups (AFG) originated in the early days of Alcoholics Anonymous
when spouses of alcoholics became acquainted and realized that they had been affected by living
with an alcoholic, and that they needed help to recover from the “devastating effects of
alcoholism” (Al-Anon, 1997, p. xi-xii). The basic text of Alcoholics Anonymous, first published
in 1939 contains the following statement made by a physician: “Years of living with an alcoholic
is almost sure to make any wife or child neurotic. The entire family is, to some extent, ill”
(Alcoholics Anonymous, 2001, p. 122). AFG states that “alcoholism is an enormously powerful
family disease” that can cause family members to “feel trapped in an endless tunnel of suffering”
accompanied by an extreme sense of aloneness (Al-Anon, 1990, p. 1). In their primary volume,
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AFG says that, “Everyone in an alcoholic relationship – friends, co-workers, family members, as
well as the alcoholic – plays a part in the dynamics of the disease” (Al-Anon, 2008, p. 27), and
that unless recovery is undertaken by the non-addicted individuals, “the dynamics of the disease
will continue to dominate [those] relationships” (2008, p. 27). The current Chair of the
American Society of Addictive Medicine Workgroup on Family and Generational Issues, Dr.
Joseph Troncale, M.D., makes three points in his endorsement of Al-Anon:
1. The whole family needs “recovery from the brokenness that is typical of
alcoholism."
2. When the whole family enters recovery, the addicted person's odds of success in
sobriety are improved.
3. When a family member of an alcoholic chooses not to get help for their
association with alcoholism, they “continue a pattern” of adverse behavior (2014,
p. Professional Perspectives).
Current research consistently affirms the family disease in a number of ways. A study
comparing other chronic illnesses with alcoholism indicates that alcoholism produces an effect in
a family similar to that caused by diabetes and asthma – all three illnesses increase the frequency
of health problems and cost of health care of the non-addicted family members (Ray, Mertens &
Weisner, 2009). This effect was most pronounced in the alcoholic family. A key question posed
by the study is whether the negative effect on the health of the non-addicted family members
would be eliminated concurrent with successful treatment of the alcoholic member (2009,
p.213). If Troncale’s proposition is correct, then one would conclude that successful treatment
of the alcoholic member alone would not correct health problems of the other family members.
Using the bad apple analogy, removing the bad apple from the barrel might seem like a way to
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prevent spoiling the remaining apples, but in all likelihood, by the time the spoilage becomes
visible, advanced ripening of the other apples has already taken place, and removing the visibly
spoiled apple does not reverse this effect, although its removal may slow down the progression
of the problem among the apples that are left. Like the apple barrel, the SUD affected family
harbors illness among its members albeit not always visible to casual observation.
While research is not conclusive on this matter, experiential evidence indicates that the
successful treatment of the alcoholic/addict alone does not cure the associated illnesses of the
non-addicted members, who often continue to “react to alcoholic patterns of behavior” even if
they “haven’t been associated with an alcoholic in many years” (Al-Anon, 2008, p.29). Such
patterns of behavior could even appear in subsequent generations through learned behavior or as
a result of epigenetic transmission (Vassoler & Sadri-Vakili, 2014). While still in its infancy, the
field of epigenetics may provide the answers to many perplexing questions involving learned and
inherited behaviors. Vassoler, Byrnes and Pierce (2014) reviewed studies related to the
preconception effects of drug exposure to adolescent humans and animals on the subsequent
generation. Alcohol, nicotine, cocaine, morphine and marijuana were the subject drugs of the
test. The review included only studies where conception occurred after several weeks of being
drug-free, so as not to allow prenatal exposure to the drugs, and to avoid in-utero exposure of
drugs to the fetus. The results showed several adverse effects in the offspring, including
increased anxiety, depression, developmental abnormalities, impaired memory, attention
disorder, and decreased learning capabilities. This transmission of behavioral and physiological
problems to parent’s offspring may be a partial factor in explaining why some SUD families
exhibit additional health problems in spite of the parent’s successful status in recovery.
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TREATING THE FAMILY
Treatment Outcomes
There are many current studies comparing the results of SUD treatment modalities,
represented by six articles considered in the following summary review. These articles provide a
cross section of geography, culture, gender, age, methodologies and substances in their
assessment of individual SUD treatment as compared to treatment involving the entire family. A
study to examine the cost of treating SUD’s with individual versus family therapy found that
family therapy cost less than individual treatment for SUD and the recidivism rates were lower
(Morgan, Crane, Moore & Eggett, 2013). This result applied to all age groups of SUD diagnosed
individuals. Schaub et al. (2014) showed that Multidimensional Family Therapy (MDFT)
“outperformed individual therapy” in treating adolescents with cannabis use disorder, and
“showed promise as a treatment for…substance use disorders” (p. 3).
Danzer (2014) makes a strong case for the use of MDFT in treatment of adolescent SUD,
citing a personal case that exemplified results predicted by studies of this evidence-based
method. Danzer cites research showing MDFT’s effectiveness in treating severe adolescent
SUD including favorable reductions in negative behaviors and improvements in co-occurring
psychiatric problems (p. 18). Because MDFT involves working directly with the parents on the
issues that they bring to the family dynamic of SUD in the adolescent, they can change for the
better and these changes contribute significantly to the overall family outcome. Danzer’s blowby-blow account of his use of MDFT with an adolescent and his parents vividly demonstrates the
theoretical principles of this model of family-based therapy.
Klostermann and O'Farrel (2013) point to a body of professional literature that
overwhelmingly shows family-based SUD treatment superior to individual treatment, and they
review the three dominant theoretical models of family SUD treatment – the family disease
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TREATING THE FAMILY
approach, the family systems perspective, and behavioral models (p. 236). All three models
target substance abuse as the undesirable element in the family system, and each stress the need
for abstinence through improved family dynamics that nurture caring and open relationships
between all family members. The differences in theoretical models are mostly found in varying
degrees of emphasis on formal therapy sessions and self-help group attendance, yet all three
include both of these elements. The treatment models based on these theoretical approaches
include MDFT, Behavioral Couples Therapy (BCT), Community Reinforcement and Family
Training (CRAFT), Unilateral Family Therapy (UFT), Multisystemic Family Therapy (MFT),
Solution-Focused Therapy (SFT), and Brief Strategic Family Therapy (BSFT). These treatment
models all show improved outcomes when compared to individual therapies in terms of longer
periods of abstinence, reduced recidivism, less divorce/separation and more satisfying family
relationships (Klostermann & O’Farrel, 2013).
O’Farrel and Clements (2012) explore controlled studies of marital and family therapy
(MFT) when used in cases of SUD. They find that MFT helps the non-addicted family members
cope better, even if the alcoholic/addict continues their substance abuse, and that CRAFT
“promotes treatment entry” more effectively than other methods including Al-Anon referral
(p.122). They also report that BCT is “clearly more effective than individual treatment at
increasing abstinence and improving relationship functioning” (p. 122). Their extensive review
also shows that BCT works well for women, gay and lesbian alcoholics and that it has been
efficacious in reducing intimate partner violence (IPV) among couples exhibiting SUD.
Conclusions
Steinglass (2009) reports that in spite of the overwhelming evidence that family therapies
offer substantially superior outcomes in all aspects of SUD treatment, there remains a dearth of
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family-based programs available to SUD-affected individuals. Barriers to family-based
programs include difficulties scheduling all family members for sessions, resistance of nonaddicted members to get help for themselves, and a lack of trained professionals to administer
family therapies (Klostermann & O’Farrel, 2013). Steinglass proposes a Motivational
Interviewing approach as a bridge between the “divide currently separating the worlds of family
therapy and substance abuse treatment” (p. 171).
All recently reviewed studies agree that a holistic treatment of the family yields a
superior outcome to individual treatment. In addition to the obvious benefits of abstinence, the
non-addicted family members experience improved mental and physical health – an outcome that
is reflected by the experiential evidence of AFG:
Alcoholism is a progressive disease that can be arrested but not cured. Therefore, we who
are affected by another’s alcoholism can best ensure our own continuing serenity if we
learn to depend on ourselves for our own well-being, rather than on another person’s
sobriety. As we become increasingly aware of our behavior, our choices, and the part we
play or have played in the alcoholic situation, we become much better able to make
changes that allow us to create a life we can be proud to live (Al-Anon, 2008, p. 34).
AFG recommends mental health and substance abuse counseling for families in addition to
participation in self-help groups (2008). Treatment outcomes for those that embrace the family
disease concept and utilize family-based therapies are enviable. SUD treatment models should
move toward family-based therapy quickly to maximize successful outcomes of all involved
parties.
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TREATING THE FAMILY
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