Family Focused Intervention and Treatment

1. Family Focused Intervention and Treatment James M. Tracy, DDS, CADCII, BRI II Rancho Mirage, CA 92270

2. Change Theory and Intervention • Intervention is a process not an event • The change process applies to the entire family not just the substance abuser • The family is usually more difficult to achieve long lasting change than the addict

3. Apply to families what has been proven to work in PHP’s • Individualized treatment followed by long-term case management has been proven to improve outcomes • I incorporate most elements commonly found in PHP’s monitoring agreement • I provided a long-term family focused case management and monitoring service • Long term accountability for the families combined with long term monitoring for the recovering family member

4. Teaching Points • We now understand that we can improve outcomes by extending the duration of treatment – 90 days or more • Extended treatment combined with long-term monitoring can dramatically improve outcomes • When family member’s focus on their own recovery: • Outcomes improve – Stephanie Brown research • More patients complete treatment • One family week during treatment is rarely enough • Educational oriented programs often do not result in family beginning their own recovery process • Treating The Family is more difficult

5. Family Interventions • Some families require interventions at different times in the recovery process • Some need more than one intervention • To begin the recovery process • During treatment • Immediately post treatment when families return to the old family dynamics

6. 3 Main Models of Family Intervention • Confrontational Intervention Model- What many interventionist do but call it a Johnson Model, but is actually the anti-Johnson Model • Johnson Model – Most common, uses carefrontation, surprise model with focus on the IP • Arise Model – Invitational Model with focus on IP • Systemic Family Intervention – Invitational Model with focus on the family

7. Alcoholic Family System

8. Dis-Ease

9. Systemic Family Intervention • Invitational • Motivational • Family Focused • Respectful • Honest and non-deceptive • Process oriented not an event • Highly effective

10. Systemic Family Intervention Overview • Everyone hears the same information together – becomes easier to come to a common goal • Each person processes how they have been affected by the problem • With entire support system involved, addictive behavior is difficult to sustain. • Support system becomes aware of the effect of enabling behavior. • Each member commits to change.

11. What is the goal of family intervention? • To recognize the effects of addiction on the family • To recognize and change old patterns of behavior • IP is invited to join family in the process of change • Focus is on family health, regardless if the IP goes to treatment – It takes a sophisticated cast of enablers for addictive disease to continue

12. Systemic Family InterventionToday • The invitation process is an important part of the Intervention process • We are having at least 90% of the IP’s attending the intervention workshop • The workshop goes much the same regardless of the IP attending or not attending the workshop

13. Utilize Experiential / Sculpting and Psychodrama Techniques • The most effective treatment approach for families • Most families struggle with traditional talk therapy • “We are going to be doing a lot of stand up therapy instead of sit down therapy” • “When I hear something, I forget” • “When I see something, I remember” • “When I do something, I understand” - Chinese Proverb • “Show me your family” • Experiential approaches seem to break through and effectively address each member’s issues

14. Principles Involved in Effective Invitational Interventions • Invitational Models – Prior Notification • Stages of Grief • Motivational Interviewing • Stages of Change • Developing Elements of a therapeutic relationship • Empathy • Genuineness • Unconditional positive regard • Framing – frame requests in terms of what the person has to gain by agreeing with your suggestions

15. Why is prior notification so important? • Allows the IP to cycle through the early stages of grief and stages of change. • Move from denial and anger to bargaining by the time of intervention • Usually will move from pre-contemplator (no problem) to contemplator (ambivalence)

16. Risk of the surprise model We want to avoid this guy Massive malignant denial Anger + fear = RAGE

17. Families PerceptionPre-Intervention & Pre-Contact The family is connected with pain, anger, and frustration. There is also isolation and loss Focus is on the Addict/Alcoholic The family is saying “I’ve tried everything” “We have to wait until he/she hits bottom” “It’s not the chemicals, it’s……..” “This family is all screwed up. I want out”

18. 1st contact • The catalyst understands the problem is chemical and contacts the interventionist who explains the systemic process. • The catalyst contacts the potential team and arranges for an assessment, either conference call or in person • Entire methodology is explained: assessment, team selection, coaching for invitation and what to expect during the workshop • Explain and re-explain process vs event • Offers HOPE

19. Families Perception1st Contact with Interventionist • What the family members are saying: • “How can this model get him/her into treatment” • “I’m relieved we don’t have to sneak around” • “You don’t know who your dealing with, he has never listened to anyone but himself” • “If I tell him he’ll run, he’ll freak out!” • “Is it really that bad?” • “We can’t wait, it needs to happen NOW!” • Are focused on the knock down drag out event

20. Assessment • The process is explained in detail with key people, including the Invitation process and coaching, the 2 day workshop and aftercare. • Questions and concerns are addressed • A commitment is made, including date set, and deposit is received • Participants are given instructions, asked not to drink or use during the process and to attend al-anon or AA/NA meetings • Everyone is given a intervention workbook to give an accurate history

21. Families Perception Assessment • “It’s not our problem, I don’t think I’ve been affected” • “I think he is drinking because he is depressed” • What do we do when they refuse to attend? • He’ll never agree to come • “What’s your record; what guarantees are there that this will work?”

22. Invitation Process • Invitation plan is started at the assessment • Decide who will call or meet with the IP first. (usually the chief enabler) • Continually reinforce not to be attached to his/her initial reaction. • A lot of coaching during this process, extremely time consuming • Can be extremely unpredictable and volatile • Usually calms down as workshop nears

23. Beginning the Invitation process creates stress within the Alcoholic family System Breaking the NO TALK rule

24. Families at beginning of Invitation • Terrified to talk to the IP about the problem • Have never talked about how they have been affected or even how they feel • Believe that if he IP’s initial reaction is not favorable that the intervention can not work • Takes about 20 hrs of coaching

25. Family Perception after 1st contact • “He told me the only problem he has is my bitching at him” • “We need to cancel the intervention, he said he won’t come” • “He will meet with you and I, but no one else” • “My sister told me I blew the whole thing, she always criticizes anything I do” • “I’m a wreck, I don’t think I can do it!” • “I thought you were going to call him”

26. Families Perception Day one, The Disease • Family members are feeling hope and trust in the process - “This wasn’t as bad as I was expecting” • The family is saying • “I never realized all this; it makes total sense” • “I now realize how I’ve been affected • “Why didn’t the doctor say anything?” • The IP is saying “yeh, I can see myself in what you discussed” • “I can’t go to treatment, if I leave we’ll go broke”

27. Families Perception Day 2 Enabling and Codependency • The family is clear on new boundaries and their own commitments for treatment • IP is invited to join the family in the process • The family says • “This is the best we’ve ever communicated” • “You predicted everything” • “The bad stuff that I was afraid of never happened” • “I realize that I also have a problem” • “What if I don’t have the time for family week”

28. Families: The Missing Link

29. You Don’t have to Drink to Suffer from Alcoholism • Entire family system is affected • Measured by behavior • Multi-generational legacy • Compulsive behaviors

30. The Pink Cloud • Families feel relief while the alcoholic or addict is in treatment • “It’s the first time I’ve been able to sleep in years.” • “I’m working my program and everything is wonderful” • High relapse rate when the addict/alcoholic returns home • It is common for family members to revert back to old behavior • Old alcoholic family dynamics re-emerge • This can be the all too common result regardless of the duration of treatment

31. Alcoholic Family System Vacuum

32. Trauma of Early Recovery • Addicted Family System must collapse. • Myth - Most expect the problem to be ‘fixed’ when the patient returns home – regardless of what they say • Many families do not survive the disruption and turmoil caused by abstinence. • Early recovery can be very difficult for children • At times the addict cannot return home or they will not remain sober

33. Many families cannot survive the trauma of early recovery

34. How Can Families Survive? • Imperative families utilize outside supports to weather early recovery. • Outside support networks (12-step programs, treatment centers, and therapists) provide a “holding environment” for all family members. • Network becomes a cushion and substitute for the Dysfunctional Family System. • Research recommends additional treatment and unlimited continuing care. (Stephanie Brown)

35. Family Twelve Step Programs • Naronon, AlAnon, CODA, Families Anonymous • How can you expect your loved to do something you are not willing to do? • I.P. and family experience resistance to change. • Regular meeting attendance, get a sponsor, and use them! • Your loved one learned a new language of recovery while in treatment, will you be able to communicate with them?

36. Where we are today • We’ve known for some time that we need to improve the family’s treatment experience • We haven’t had many answers, except to ignore the problem • We believe that treatment centers as well as interventionist are beginning to develop more effective family treatment, aftercare, family case management and monitoring

37. Couple’s therapy in early recovery • We recommend therapy for most couples after treatment • Should be more educational type therapy to help couples understand that it will take time to develop a new recovering family system • Help couples balance the responsibility of maintaining recovery and incorporate healthy parenting – i.e., better parenting skills • Assist them in seeing early recovery is difficult and that what they are experiencing is normal • They are right where they are supposed to be

38. Developing healthy relationship dynamics in early recovery can be difficult

39. Current recommendations during a Systemic Family Intervention • For the addict • Multidisciplinary Assessment if indicated • Treatment – most commonly at least 90 days • Urine monitoring and case management for 2 years • For the family • 6 month (Minimum) to 2 years family case management • 3 workshop type treatment experiences with in the first 6 months • Family week at treatment center • Codependency or Family of Origin Workshop (As individuals) • Some type of family Intensive – post treatment • Individual Therapy • Couples Counseling – Ideally following a Couples intensive • For Everyone • Family Intensive • Family Reintegration Workshop – Commonly at the end of Residential Treatment

40. Treatment options for Families • Onsite – Retreat Setting • Living Centered Program (LCP) – Experiential based family of origin treatment and codependency • Coupleship Program • Family Intensives • Family Reintegration Program • Caron – Codependency treatment week • The Bridge – 14 to 30 day codependency residential treatment • Meadows – Survivors Weeks • Offers survivors level I & level II • Pinegrove is also offering a number of Family Intensive Programs

41. Intensive Workshops • Individual therapy can be slow and difficult early on • Traditional couple’s therapy can be HELL early on – educational therapy can be useful • Couples are usually able to benefit from more intense therapy after completing an intensive workshop • Workshops can be the equivalent to a year of therapy • All end in resolution, hope, recommendations and treatment plans for future • Always recommend to return home to therapist • Referring therapists report that therapy is more productive after Onsite • Experiential therapy proven to more effective

42. Case Management • Research recommends additional treatment and unlimited continuing care. (Stephanie Brown) • 90 days of Family Case Management-Life Coaching is included as part of my intervention service • Recommend 6 months to 2 years of Family Case Management • Recommend multiple treatment experiences in the first 6 months of family recovery

43. Onsite Family Re-Integration Workshops • Intensive 4 ½ day family experiential workshop designed to: • Improve family dynamic • Plan for a healthier system • Ideal for treatment centers as an additional family week to: • Develop healthy limits and boundaries to reduce enabling • Challenge myth that the patient is ‘fixed’ after treatment and everything will be wonderful • Create a longer range treatment plan which can enhance success • Too frequently, families are doing well while their loved one is in treatment and seem to forget everything when they rejoin after treatment • Are shocked that everything isn’t wonderful

44. Individual Family Reintegration Workshop Designed to help weather the trauma and stresses of early recovery – may be in crisis following treatment or at the end of treatment An intensive 3-4 day workshop to improve family dynamic’s; help develop their plan for successful reintegration of a new, healthier system. Develop a treatment plan for the entire family which could result in more extended treatment. Define what healthy support is and how it can be achieved. Individually tailored for each family to address specific familial issues, including the establishment of healthy communication, limits and boundaries.

45. Aftercare and Case Management • At the end of the initial 3 month agreement families have • Attended Living Centered Program at Onsite or it’s equivalent • Family week at the treatment center • Family Reintegration Workshop at the end of treatment • Engaged in Therapy • Engaged in 12 step program for family, Al-Anon, Naranon, Coda etc • Recommend Case Management for the family for at least 1 year • Recommend Urine monitoring and case management for the patient • As well as a monitoring program designed to be similar to health professionals

46. Urine Testing and Monitoring • Random urine testing • Only 9 % of patients completing treatment have urine testing post treatment • Recent studies support random urine testing dramatically improves outcome’s, Dupont et al. • Doctors and Pilots have a approx. 90% success at the end of 5 years if the following has happened • Adequate treatment • Long term monitoring and case management

47. Family Recovery

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