A Contingency Analysis of Family Treatment and Drug Abuse

2015

Historically, there has been relatively little interchange between family therapists and behavior analysts or therapists, although there are subareas with greater overlap, including teaching parents to use operant approaches with their children (), and teaching couples behavioral skills and communication and problem-solving (). The aim of this chapter is to demonstrate that there is a family treatment approach to drug abuse () that is based on sound behavioral principles and to articulate these principles so that they can be applied to any treatment program wishing to increase family involvement.

The chapter will deal with three major topics: (1) evidence of the power. of the family to influence treatment outcome; (2) engagement of the family in treatment; (3) development of a treatment plan which includes the family.

Much of the material presented relates to the process of initial engagement of the family in treatment and the broad contingencies affecting the degree of family participation. Specific principles will be presented which can dramatically increase the degree of family participation in treatment. Less emphasis is placed upon specific family therapy techniques which have been discussed in detail by Stanton et al. (). This differential emphasis is based on the rationale that a fine-grained analysis of specific therapeutic techniques is premature until a program develops effective methods of involving the family in the program initially and maintaining family involvement.

The family as a determinant of current behavior

Even when the drug user is a young adult, it is highly probable that the family of origin continues to be a powerful determinant of his current behavior. The validity of this statement may not be immediately obvious, since many drug clients are in their 30s, and are often married and have children. Even with married clients, however, the family of origin rather than the family of procreation tends to have primary importance. There is an increasing body of evidence documenting high rates of contact between patients and their families. Vaillant () found that 90% of patients surveyed lived with their parents at age 22 and that this percentage was still 59% at age 30. Similarly, Stanton et al. () found that 82% of young adult male patients in a Veterans Administration program had at least weekly contact with their mothers. Overall, it is clear that efforts to stabilize the patient’s marriage without first involving his parents are likely to fail ().

Potential Detrimental Effects of the Family on Treatment Outcome

Unless it is influenced by the treatment system, the family is likely inadvertently to reinforce drug taking and undermine any treatment program. Virtually any treatment program, regardless of approach, has an extensive anecdotal “folklore” about ways in which family members have subverted treatment. Family members often behave in ways that overtly or covertly encourage drug taking (the “enabling” role is similar to that described in the alcoholism literature). Family members also will frequently undercut the treatment program, especially at a stage when the client is beginning to show progress ().

These observations are not surprising when one sees that substance abuse can have powerful adaptive consequences in maintaining the stability of the family system. The work of Steinglass and Davis () has shown this particularly clearly for alcohol. In their work, each family member typically experiences a positive change in the pattern of marital or family interaction at the moment alcohol is introduced into the system. This may take a variety of forms, such as decreased conflict and tension, increased intimacy or frequency of interaction, or increased emotional expression.

For those unfamiliar with the family therapy literature, it is important to point out that the reactions of family members may often be viewed as maintaining drug-taking behavior whether or not they served a predisposing causal role in the initiation of drug-taking behavior. The family is seen as a relatively stable system which tends to resist change, even those changes which might seem desirable in the long run. Although some families exhibit this “resistive” behavior more dramatically than others, some change-‘ resistant behavior should be expected in any family in which the drug abuse has occurred on a chronic basis for several years.

It is also suspected that family factors may play an important role in the etiology of drug abuse, particularly in determining whether a young person will move from drug experimentation to a pattern of chronic abuse and dependence. In particular, the behavior of the drug abuser may help the family to avoid difficulties in negotiating transitions in the family life cycle, especially the stage of “leaving home” ().

Potential Positive Effects of the Family on Treatment Outcome

Family members can also exert an important positive effect on treatment outcome, even in the absence of specific efforts to involve the family in treatment. Evidence for this conclusion comes from several retrospective surveys. Eldred and Washington () interviewed 158 heroin clients and asked who had been most helpful in their efforts to get off of drugs. The rank order of responses was (1) family of origin, (2) opposite sex partner, (3) Similarly, MACRO Systems researchers interviewed 462 clients and found that the family was seen as second only to treatment (70.9% vs. 79.6%) as an important influence in change (NIDA 1975). Levy (), in a 5-year follow-up of 50 narcotic clients, found that those whose treatment is successful typically have family support.

It is worth noting that similar conclusions have been drawn for alcoholism, although with alcohol it is typically the spouse, not the parents, who is most important. Regardless of the mode of treatment used to deal with alcoholism (AA, inpatient treatment, disulfiram, etc.), family and spouse involvement adds significantly to the probability of success ().

Engaging the family in treatment

Perhaps a more appropriate title for this section would be “active recruiting” of families into treatment because, as will be noted, considerable effort is required to succeed in involving families in treatment. Family recruitment became one of the most important aspects of our project, although we had initially underemphasized its importance and difficulty. Space does not permit a full elaboration of the principles and techniques of effective engagement; the interested reader is referred to publications on this topic. ().

Use of Contingent Reinforcement to Engage Families in Treatment

Without specific attention to the contingencies affecting the behavior of both the client and the family, it is extremely unlikely that the client will give permission to contact family members or that family members will agree to participate in treatment. This results from a combination of factors, all of which need to be specifically addressed.

First, the family therapist initially has few, if any, positive reinforcers under his control. Certainly the “opportunity” to participate in family therapy is not seen as a reward. This is particularly important in the context of a methadone maintenance program, where the most important reinforcers relate to medication. Several steps may be taken to offset this initial difficulty. In the program described here, the family therapist assumed the role of “drug counselor ” to increase his salience and thereby become associated with methadone dispensation, which is-a powerful positive reinforcer for opiate-dependent clients.

Next, efforts were made to increase the primacy of contact with the family therapist, so that the client contacted the family therapist early in the chain of treaters and overall treatment process. Finally, we attempted to have the family therapist placed in charge of the overall treatment, including all important treatment’ decisions. With respect to this final point, we learned that it was important not to pretend to have control over contingencies that would not actually be invoked, such as transferring the client to another program.

A second major factor is the need for the client to receive positive reinforcement from the family therapist before the therapist broaches the subject of family involvement. This usually means paying considerable attention initially to the client’s physical discomfort and to his requests for methadone or other medications, since these issues are paramount from his viewpoint.

A third major factor is that the therapist must act to decrease the client’s anticipation of possible negative outcomes of family involvement. The therapist must convey an attitude about the family that indicates that no one will be blamed. It is crucial to resist the temptation to create an alliance with the patient by implying that his problems may be the fault of the parents. It is also useful for the therapist to agree to “take the rap” for involvement of the family and its outcome. Concretely, this means asking the client for permission to contact the family directly, removing the addict from the awkward position of having to persuade the family that their participation in treatment would be helpful.

Neutralizing the Negative Connotation of Treatment

Initial contact with the family must be conducted with the knowledge that the idea of becoming involved in treatment is likely to have strong negative connotations. Such an attitude on the part of family members is not surprising. It is likely that they have been repeatedly disappointed through a long history of having hopes aroused only to be shattered. Thus, they have ample justification for the assumption that they may be blamed. Particular effort must be made to decrease the atmosphere of blame and to emphasize the potential helpfulness of the parents and other family members. () It is also helpful for the therapist to elicit the goals of the parents in some detail and then to propose a treatment plan that will address these goals. For example, some parents will emphasize employment, while others may emphasize breaking away from undesirable friends and associations. As in all behavioral intervention approaches, effective family therapy using these techniques benefits from individualized determination of steps, goals, and reinforcers in treatment.

In general it is clear that conducting recruitment efforts according to these principles can be quite effective. In a sample of 95 adult male heroin clients, 71% of all eligible families were successfully engaged in treatment. The most frequent barrier was the client’s refusal to allow contact with the family. Of the families for whom permission was obtained, 88% were successfully recruited.

Efficacy of contingent payment for attendance

A recent study () has demonstrated that payment for attendance improves treatment retention and the attendence of family members at sessions. The subject families were lower income and working class families who had a son, the index patient (or “IP”), enrolled in a VA methadone program. The IP had to be opiate dependent for at least 2 years and in regular contact with parents or parent surrogates. The mean age of the IP’s was 25.3 and 25% were married. Each family was randomly assigned to one of three treatment conditions which were adjuncts to the methadone program. These included Paid Family Therapy, Paid Family Movies, and Unpaid Family Therapy. (The family movie group served as a control for the effects of payment and of family involvement.) Ten sessions were scheduled, and in the paid groups every family member age 12 or over received $5 at each session attended. In addition, there were other contingencies, discussed below.

Once families were engaged in treatment, remarkably high rates of treatment compliance were achieved. In the paid family therapy group, all families attended a minimum of four sessions. Equally striking was the finding that 81% attended ten or more sessions as specified by the initial treatment contract.

Comparable figures for unpaid family therapy showed a clear payment effect, although attendance was still much better than might have been expected for such a difficult population. Eight per cent dropped out before treatment began, and 40% attended only one to three sessions. Fifty-two per cent completed at least four sessions, and 40% completed ten or more.

Although payment did influence attendance, it did not significantly influence treatment outcome, above the contribution of attendance alone. ()

Interestingly, many family members went to considerable lengths to emphasize that the money was not important. These statements do not necessarily imply that payment did not influence their behavior. It does appear likely that considerable cognitive dissonance was created by the possibility that their behavior was motivated by money, especially since life-and-death issues were often at stake. Even if payment is not a realistic possibility, either legal or program pressure may be brought to bear to increase family involvement, as long as effective treatment can be conducted when the family does attend. Clearly, whenever possible, an effort should be made to establish contingencies which rely on positive reinforcement and minimize the evasiveness of the treatment setting for the client and family.

Developing a comprehensive treatment plan which includes the family

The focus of the treatment efforts described is, of course, the interaction between the client and his family. While this would typically be labelled “family therapy,” the designation of “family therapy” often creates unnecessary resistance, since it implies that the family has the problem, not the addict. For this reason, we emphasize the helping role of the family and avoid labelling this as family therapy.

Whether or not formal family treatment is involved, and regardless of the other components in the treatment plan, the family can almost always play a positive role. For example, the family can help to increase compliance with treatment involving a narcotic antagonist or can help to insure attendance and treatment compliance in an outpatient methadone program. Conversely, it is almost invariably a mistake to keep family members in the dark about treatment or to set up covert competition about who can be most helpful to the client. Again it should be noted that general procedural rules are helpful but it is always necessary to individualize the approach and maximize positive reinforcement.

The beginning stages of treatment should be designed to create an initial experience of success. In this regard there are many specific things that the therapist should do. The therapist should ‘create an overall favorable climate and maximize the opportunities for positive reinforcement. The treatment should be time-limited and goal-directed, especially directed toward goals identified by the family. In the present program, an attempt was made to develop explicit goals in three areas, including: drug abuse itself, employment and other productive use of time, and living/social situation. Tasks addressing and directed towards achieving these goals were delineated in small steps, with success a high probability.

There are also issues and problems that the therapist should definitely avoid. These include. leaving treatment open-ended and vague, with only marginal relevance to the drug problem. It is particularly important to avoid conflict between the parents, and it is equally important to discourage a “catharsis” of negative emotions. While many drug-dependent clients have come to expect unpleasant encounters as part of treatment, such an emphasis makes therapy extremely aversive for one or more family members, and the treatment will almost certainly fail.

The parents (often, in these families, the father) should be given a major advisory and decision-making role in all important aspects of the treatment program. In the family treatment program described herein, parents have been encouraged to become involved intimately in the overall treatment program. Naturally, in order to do this effectively, the parents need education, support, and guidance from the therapist. Typical areas in which parents are asked to become involved in discussion and decisionmaking include take-home privileges, decisions about hospitalization, readiness to decrease dosage or terminate methadone, and the credibility of urine reports intended to screen for drug use.

There are several important reasons for involving the parents in spite of the complexities involved. First, explicit involvement of the parents minimizes the client’s opportunities to play the therapist and parents, or parents themselves, against each other. For example, without family involvement, the client is likely to complain to the parents about aspects of the treatment and enlist their support, while concurrently complaining to the therapist about the parents. Second, the participation of the parents in treatment decisions enhances the power of the parents, which enables them to be more helpful. Finally, such participation has a major effect on the degree of commitment and investment that the parents have in the long-range success of the treatment, which helps to ensure that gains made during the program are maintained afterwards.

It has been particularly evident that a behaviorally oriented treatment approach can be useful in keeping treatment focused. Although the treatment program described here is not primarily behavioral in orientation, it successfully incorporates several behavioral elements.

First, in all of the family treatment cases, the therapist provides systematic feedback about current drug use to the parents, based on the result of the latest urine tests. This feedback is very important because it maintains the focus of the treatment on hard data. It is also extremely important that the therapist be present to guide the family in evaluating the feedback in the light of the patient’s overall pattern of success and failure and to help shape the family’s response to this feedback. These data permit the therapist to keep the family focused on what they will actually do, rather than remaining at the level of vague generalities. The therapist may allow the family to accept-the-client’s initial excuses but at the same time point out problems which may arise in the future concerning falsification of urine test reporting and the like.

In the research project, the effects of contingent payment for clean urines in combination with program attendance have been examined. Using this procedure, both the client and the other family members have a financial stake in having everyone attend and having the client maintain abstinence, as reflected by uncontaminated urine samples. () As mentioned earlier, contingent payment has a clear effect on attendance and encourages the family to be present so that treatment can work. There is modest evidence that offering contingent payments to the family as a whole for the success of the client at providing clean urine samples and hence being “drug free” has a positive effect on treatment outcome, although payment alone is consistently less powerful than family therapy.

A promising new approach for changing the consequences to the family of the client’s relapse to drug taking has been the development of a “home detoxification” procedure. The idea of having the addict detoxify at home grew naturally out of work with the clients and their families and was also heavily influenced by Haley (). It is clear that admission of an addicted family member to the hospital for withdrawal is generally a “nonevent” for most families and produces little emotional involvement in its success or failure. In fact, for many families, hospitalization is positively reinforcing, since it relieves stress and reduces anxiety and guilt. It is a socially acceptable means of demonstrating that the problem is being addressed and that it is out of the family’s hands. Given these contingencies, it is not surprising that the typical result is a cycle of repeated hospitalizations and unsuccessful attempts to terminate administration of methadone or other opiates.

Home drug withdrawal attempts to keep the family focused on the therapeutic realities and has aversive components that the family is not eager to repeat. Several principles should be kept in mind when implementing a home drug withdrawal effort: (1) The conditions for the eventual home drug withdrawal must be carefully worked out. (2) It is important to build on the strengths of the family and upon success experiences earlier in therapy. (3) The family must not be allowed to escape from the home detoxification through initial failure. Instead, the possibility of failure must be anticipated and a backup plan developed. (4) While the conditions for success should be carefully managed, it is nevertheless important that the home detoxification experience should require a high level of family involvement. They will therefore experience success as more meaningful and, as noted, will also not care to repeat the experience ().

Ending therapy

One of the major advantages of involving the family in treatment comes at the end of treatment. If family treatment has been successful, the formerly drug dependent client is left with an important natural support system that will continue after treatment is over. This is in marked contrast to other treatment approaches. For example, a frequent problem with methadone maintenance and therapeutic community programs is that successful treatment leads to loss of the reinforcers in the therapeutic support system. That is, success results in diminished contact with all phases of treatment ranging from the conversations with other clients, the dispensing pharmacist, and the drug counsellor to contacts with various medical and mental health professionals.

Although the problem is diminished in family treatment, loss of support or decreased availability of reinforcers may still be a significant issue for the family when therapy ends, since the family loses the therapist as an important source of support. The therapist can utilize three techniques to minimize the disruption of ending therapy. First, throughout therapy, it should be emphasized that credit for success belongs to the family and the drug-dependent client, not the therapist. This will be most meaningful if the therapist clearly identifies how the success was achieved and how the family could handle similar issues in the future. Second, the therapist should promote a model of episodic involvement in treatment. That is, the family should not feel that they have failed if they need to return for a “booster” of a few additional sessions. Indeed, planned followup sessions are often helpful. Third, it is especially important to avoid a dichotomous success-failure perspective that is extremely likely to lead to relapse. The therapist should assist the family in anticipating potential problems and should discourage the notion that the future will be problem free. It is often useful to rehearse strategies for solving problems that may occur.

Evidence of effectiveness

Despite reported widespread use of family therapy in drug abuse treatment agencies (), unfortunately there are few controlled outcome studies. Recently evidence has been obtained from a controlled treatment outcome study that a family treatment therapy program can have a significant impact on heroin abuse. In addition to the initial outcome data (), which were highly positive, there is accumulating evidence that the results are well maintained in a 2- to 3-year followup period. The home drug withdrawal approach is currently being tested and appears to be relatively successful when it is implemented, but it is not always readily initiated.

Results have been obtained for several outcome variables and will only be briefly summarized here. For the best treatment condition (paid family therapy), 67% of the cases showed a successful outcome in abstinence from use of illegal opiates. Successful outcome was defined as free from use of illegal opiates for at least 80% of one time interval. This contrasts with 33% in the non-family treatment condition and 39% in the control Condition. Results for legal opiates (including detoxification from methadone) were similar: paid family therapy, 62% success; non-family treatment, 27% success; control, 28% success. The results for unpaid family therapy were less dramatic, but the differences between paid and unpaid family therapy were not statistically significant. Finally, a dramatic finding was related to the difference in death rates between clients in the family and non-family treatment groups. For non-family treatment clients, there was a 10% death rate, compared to 2% for clients whose families were involved in treatment. This is not only highly significant statistically, but is also of obvious social significance.

In conclusion, it should be evident that behaviorally based family treatment requires both skill and effort in implementation. It should be equally clear that there is no implication that similar results can be obtained with “garden-variety” family therapy. Treatment was highly structured and systematic, although it should be reemphasized that these results were obtained with only 10 sessions. There is little doubt that, given ample training and administrative support, this approach can be implemented in other settings with positive results.

 

Selections from the book: “Behavioral Intervention Techniques in Drug Abuse Treatment”. John Grabowski, Ph.D.; Maxine L. Stitzer, Ph.D., and Jack E. Henningfield, Ph.D., eds. Reports on behavioral contingency management procedures used in research/treatment environments. National Institute on Drug Abuse Research Monograph 46, 1984.