INPM's Publications Coordinator
British Columbia, Canada
The idea of treating family members and loved
ones who have been impacted by other people's addictions is a relatively
new concept. Family members only started receiving help with the
creation of Al-anon (originally known as the A.A. Auxilary) in 1951.
Even with the development of Family Systems Therapy in the 1950's
and Behavioral Couples Therapy in the 1960's, loved ones of addicted
individuals did not actually receive specific addictions family
therapy until 1978 with the creation of an adjunct program at the
Lutheran General Hospital in Park Ridge, Illinois. Throughout the
1980's, however, a larger treatment focus for loved ones of people
in addiction emerged. Suddenly, there was an explosion of interest
in the addictions family therapy field. Three models for Addiction
Family Therapy (AFT) developed into a concrete form and these included
the Disease Model, Family Systems Model, and the Cognitive-Behavioral
Model. Currently, these three approaches serve as types of lenses
in which to view the complicated affects of addiction on relationships.
Now twenty years later, a fourth lens-the existential
approach- for studying Addiction Family Therapy (AFT) is created.
With the three previous models, addictions professionals studied
the deficits, interactional patterns, as well as behaviors of both
people in addiction and their loved ones. Thus, addictions professionals
learned to be well-versed in studying addiction as a construct impacting
interpersonal familial dynamics. With an existential focus, however,
clients learn that they are more than their deficits, interactional
patterns, or behaviors. Addiction professionals with an existential
approach view clients holistically as they share methods for transcending
the chaos of addiction cycles and develop ways to find greater meaning
as well as purpose in life. Therefore individuals in recovery and
their loved can use their experiences with addiction as opportunities
for greater emotional growth. In essence, with an existential focus,
people learn how to view addiction as a gift of personal transformation.
In order to fully understand the current existential approach, a
preview of the development of the first three AFT models is necessary.
The Disease Model
The first framework of AFT to arrive in the
field of addictions was the disease model. This approach was a natural
development from the twelve steps of Alcoholics Anonymous combined
with the view that addiction is a disease. Bill W. and Dr. Bob created
Alcoholics Anonymous in 1935 and Jellinek identified addiction as
a chronic as well as progressive disease often characterized by
denial in 1945 (Lemanski, 2001).
By 1951, Al-anon was created as the second
12 step organization. Loved ones of alcoholics could attend support
meetings and learn ways to stop scapegoating or blaming addicted
family members for their problems (Kinney & Leaton, 1995). Therefore,
these people in relationships with alcoholics could use the 12 steps
to realise that they are powerless over other individuals' alcohol
use and learn to set boundaries by taking care of themselves as
they "detach with love" (Kinney & Leaton, 1995).
In 1978, the first form of AFT programming
was created at the Lutheran General Hospital in Illinois that consisted
of Al-anon principles. The program originally included a half day
Saturday session and was led by Al-anon volunteers (White, 1998).
In 1979, a formal AFT treatment program developed that included
three days off site for a residential retreat. Al-anon and A.A.
volunteers could join a nine to twelve month training program to
become Counsellors that taught this three day program. This Lutheran
General Hospital Program was the precursor to the Minnesota Model
which is now used throughout many treatment centres in North America
as well as the world (White, 1998).
In the 1980's, professionals in the addictions
field started to pay attention to the ways that individual family
members and the family as a dynamic system, adapted to the deteriorating
role performance of addicted loved ones (White, 1998). Vernon Johnson
(1990) wrote about enabling and how family members of addicts or
alcoholics may unknowingly support individuals' addictive behaviors
through certain enabling actions such as making excuses or ignoring
the impact of the addiction. Claudia Black and Sharon Wegscheider-Cruse
wrote about the survival roles that children follow in order to
cope with addicted family members. Such roles included the family
hero, mascot, scapegoat, and lost child etc. (Curtis, 1999). There
was also a recognition by professionals that adult children of alcoholics
were patients in their own right, who suffered from a condition
that required treatment as well as support services (White, 1998).
Thus, the support movement of Adult Children Of Alcoholics (ACoA)
was born (White, 1998).
During the 1980's, there was also a recognition
by professionals in the field that addiction was a family disease.
Thus individuals in close relationships with addicts or alcoholics
possibly suffered from a disease of codependency because their feelings
of self-worth and personal identities were enmeshed with people
in addiction. Dr. Timmen Cermak even proposed criteria for making
codependency a medical diagnosis (White, 1998).
A variety of professionals wrote about codependency.
In fact, Melody Beattie in 1987 "launched a veritable social phenomenon"
with her book Codependent No More (White, 1998). With great enthusiasm,
Sharon Wegscheider-Cruse estimated that 96% of the U.S. population
suffered from codependence (Wilson-Schaef, 1986). The difficulty,
however, was that the definition of codependency became so broad
as to include "anyone who has been affected by the person who has
been afflicted by the disease of chemical dependency" (Wilson-Schaef,
1986). Then this codependency definition eventually included "anyone
who lives in a close association over a prolonged time with anyone
who has a neurotic personality" (Wilson-Schaef, 1986). These estimations
and definitions were actually part of a general hypothesis around
codependency that could not be substantiated. Mellody (2003) even
admitted that there was no scientific validity for the concept of
Little research has been conducted on the overall
effectiveness of the disease model. Laundergan & Williams (1979)
studied Hazelden's 3-5 day residential, psychoeducational program
for spouses and family members of alcoholics. This program was based
on the twelve steps and Al-anon principles. The focus for the spouses
was on detaching from the alcoholic and paying attention to themselves
through self-care in order to improve their own coping styles. Program
evaluation reports showed participants' satisfaction with various
program elements, but there were no controlled studies. There were
some attitude changes by participants, but there was no use of pre
and post treatment measures or scientifically-based methodology
Another research study related to the disease
model was on testing ACoA concepts. In 1986 Werner conducted a longitudinal
study of 49 children born on the island of Kuai, Hawaii. All of
these children came from alcoholic homes. At age 18, 59% of these
children had no psychosocial problems. Therefore there was no conclusive
evidence that these children had any more problems coming from alcoholic
homes (Curtis, 1999). Dunkel (1993) suggests that, in general, there
is no evidence to support that Adult Children Of Alcoholics are
a unique group (Curtis, 1999).
Despite the lack of scientific validity, the
disease model is useful as a framework for managing deficits. Alcoholics
and addicts learn how to care for their disease of addiction through
treatment and follow-up support meetings. Family members and loved
ones of addicted individuals receive validation that they have been
impacted by other people's addictive behaviors. Furthermore, loved
ones who believe they have the disease of codependency can access
adjunct treatment programs, read various written materials, and
join Al-anon or even CODA (Codependency Anonymous) support groups.
Adult Children Of Alcoholics (ACoA's) also receive support around
their experiences of growing up in alcoholic homes.
The Family Systems Model
In the early 1950's Bowen laid the groundwork
for the emerging field of general family therapy. With support of
the Menninger Foundation and the National Institute of Mental Health,
Bowen arranged for mothers to move into cottages on clinic grounds
for several months near their hospitalized children in Topeko, Texas.
Bowen observed the overcloseness as well as overdistance of parents
in order to avoid anxiety. Parents achieved an emotional equilibrium
by keeping their disturbed children needy (Goldenberg & Goldenberg,
2000). Out of this early work, Bowen created the Family Systems
Bowen proposed that families are an emotional
and interactional system. Thus, problems of one family member cannot
be understood apart from those of all other members. Therefore,
the focus is on family interactions and not just the identified
client (Curtis, 1999). Bowen (1976) developed other concepts such
as togetherness and individuation, differentiation of self, the
triangle, family projection process, emotional cut-off, as well
as the multigenerational transmission process.
Other professionals then began viewing the
complex interactional dynamics of families struggling with addictions
through this family systems framework. Ewing & Fox (1968) hypothesized
that alcohol abuse maintained the family emotional homeostasis (Curtis,
1999). If only the alcoholic changes, then the spouse may resist
change. According to this view proposed by Ewing and Fox, the challenge
for therapists is to help the husband and wife interact without
alcohol. Kaufman (1985) revealed four types of alcoholic families
that included the functional family system, neurotic enmeshed family
system, the disintegrated family system, and the absent family system
(Curtis, 1999). Dulfano (1985) described how the parental subsystem
changes as a result of alcoholic behavior and as parents decline
in functioning, children assume more adult-like roles (Curtis, 1999).
In 1987, Steinglass analyzed the characteristics
of the alcoholic family within Bowen's Systems Theory. He examined
how family members create balance around the dysfunction created
by the addiction (Curtis, 1999). Furthermore, Steinglass explored
a way of determining how severely families have been impacted by
addiction, the generational transmission process of addiction, and
the effect of addiction on family developmental or systematic maturation
Even though the dynamics of families impacted
by addiction have been thoroughly examined, only one controlled
outcome study of this approach has been completed (O'Farrell, 2003).
Zweben, Pearlman, & Li (1988) randomly assigned 116 alcohol abusers
to eight sessions of conjunct therapy based on a communication-interactional
approach in which the presenting problem (alcohol abuse) was viewed
from a systemic perspective as having adaptive or functional consequences
for these couples. A control group was exposed to a single session
of advice counselling. There was no significant group difference
on any of the outcome measures even at the eighteen month follow-up
There are some major benefits to the Family
Systems AFT model even though it has not been scientifically-validated.
Counsellors who utilize this approach view families' dynamics, roles,
as well as accommodation of the addiction before making generalizations
about levels of functioning. Furthermore, with this focus on interactional
dynamics, professionals highlight the fact that through the multi-generational
transmission process addiction can impact several generations of
The Cognitive-Behavioral Model
In the 1960's the approach of behavioral couples
therapy emerged. Liberman and Stuart applied step by step intervention
procedures and some basic operant conditioning principles to distressed
marital relationships. The aim was to have couples make contracts
around maximizing their exchanges of positive behaviors (Goldenberg
& Goldenberg, 2000). In the 1970's, therapists focused on cognitive
aspects by providing proper assessment of intervention efforts and
feedback (Goldenberg & Goldenberg, 2000). In the 1980's, couples
also started receiving communication and problem-skills training
(Goldenberg & Goldenberg, 2000).
An approach called Marital and Family Therapy
(MFT) was the main AFT framework to grow out of the Cognitive Behavioral
Model. Keller (1974) called Marital and Family Therapy (MFT) "the
most notable current advance in the area of psychotherapy of alcoholism"
(O'Farrell, 2003). The MFT approach consists of the same operant
conditioning principles as behavioral couples therapy. In fact,
the major goal of MFT includes altering marital or family patterns
to provide an atmosphere that is more conducive to sobriety and
to reduce/eliminate abusive drinking while supporting the alcoholic's
efforts to change (O'Farrell, 2003). Addictions Family Therapy sessions
usually consists of two to four 75-90 minute sessions for assessment
purposes, ten to twenty 60-75minute sessions of therapy, and a three
to five year follow-up contact period (O'Farrell, 2003). Strategies
for MFT include examining exposure to alcohol, behavioral contracting,
sobriety trust contracts, antabuse contracts, daily records of urges,
building good will through caring days, planning shared recreational
as well as leisure activities, core symbols, conflict resolution,
communication skills training, and behavior change agreements (O'Farrell,
2003). Marlatt & Gordon (1985) provides a cognitive behavioral approach
to AFT with a relapse prevention focus.
Unlike the other two previous models, the cognitive
behavioral AFT approach has been well-researched. Fifteen research
studies on cognitive behavioral AFT have been completed to date
and they include Bowers et al. (1990), Monti et al. (1990), Keane
et. al. (1984), Azrin et. al.(1982), Hedberg et al. (1974), Cadogen
(1973), O'Farrell & Cutter (1982), O'Farrell et al. (1992), O'Farrell
et al. (1993), McCrady et al. (1986), McCrady et al. (1991), McCrady
et al. (1979), McCrady et al. (1982), Longabough et al. (1993),
and McKay et al. (1993). As supported by research, MFT (the main
cognitive behavioral AFT approach) produces better results in the
six to twelve month period following treatment for alcohol problems
than other methods that do not involve the spouse or family members
(O'Farrell, 2003). More research is needed to prove that MFT can
be used to maintain behavioral gains and to prevent relapse (O'Farrell,
Although the cognitive behavioral AFT model
has been researched, this approach is not widespread. O'Farrell
(2003) states: "…the most popular, most influential and most frequently
used methods-family systems and family disease models-have little
or no research support for their effectiveness. Conversely, methods
that do have the strongest research support for their effectiveness-various
behavioral MFT methods-enjoy little popularity and are used infrequently,
if at all." (p.217). Thus, cognitive-behavioral AFT is helpful for
enhancing positive behavior amongst family members impacted by addiction,
however, more time is needed for researchers to demonstrate the
long term benefits of this approach. Once this success is achieved
then the cognitive-behavioral AFT model may receive more exposure.
The Existential Model
The term existential stems from the word existence
(May&Yalom, 2000). Existential philosophers such as Nietzsche, Shopenhauer,
and Kierkagaard from as far back as the 1800's were concerned with
the meaning of existence and how people make sense of their lives.
In 1949, Victor Frankl examined these concepts and created the modern
form of existential analysis known as logotherapy or meaning-centred
therapy. Frankl drew on his experiences as both a successful psychiatrist
and survivor of three concentration camps during the Nazi Holocaust.
In Man's Search For Meaning, Frankl examined how individuals can
use their experiences of suffering as opportunities to create more
meaning in their lives. Frankl (1984) described "the self-transcendence
of human existence" and how individuals can "transform a personal
tragedy into a triumph" when they create a sense of meaning as well
as purpose in their lives. Furthermore, Frankl explained how people
may become frustrated in their abilities to create meaning in their
lives and that these individuals may experience what he calls an
"existential vacuum". When individuals experience these feelings
of complete meaninglessness (the existential vacuum) they suffer
from depression, aggression, or addiction.
May and Yalom wrote about similar existential
themes related to finding meaning. Wong (1999) expanded Frankl's
concepts by creating an integrative model of logotherapy as well
as a cognitive-behavioral reformulation of logotherapy. Furthermore,
Wong developed the International Network On Personal Meaning (INPM).
Patterson-Sterling (2004) expanded Frankl's
concepts of personal meaning into an AFT Existential Model. With
this existential framework, therapists help families impacted by
addiction understand that these experiences of coping with addiction
are opportunities for greater personal growth. Individuals recovering
from their addictions and their loved ones do not only concentrate
on goals related to physical sobriety. Instead, these people learn
to heal old emotional attitudes and behavioral patterns related
to the addiction cycle. In particular, individuals in recovery learn
to deconstruct their addict constellation of behaviors and loved
ones recognise the importance of changing their old coping styles.
Furthermore, partners and family members as well as individuals
in recovery become aware of rescuing caretaker cycles in order to
create healthy relationship boundaries (Patterson-Sterling, 2004).
Initial stages of healing may be different
for people depending on whether they were in active addiction or
in close relationships with addicted individuals. Thus, recovering
addicts or alcoholics and their loved ones need to be aware of each
other's journeys toward healing so they can understand each other's
personal growth and emotional changes. Once people learn about transcending
the chaos of addiction cycles during these earlier stages, then
they can focus on connecting with a deeper sense of meaning in their
lives (Patterson-Sterling, 2004). Such individuals transform the
pain from their experiences with addiction into opportunities for
personal transformation. As a result, addiction becomes the impetus
for these people to reach out and connect with a larger experience
as they find meaning in their lives.
Frankl describes suffering as the distance
between who people were and what they are yet to become. Thus, addiction
is a gift in which individuals explore the depths of their weaknesses
only to realise the strengths that were never utilized until these
adverse situations (the addiction) occurred. Both individuals recovering
from addictions and their loved ones explore the dark periods of
their lives in order to realize the inner light of strength that
exists from within as they make the necessary changes to find happiness
With an existential focus, people get to become
more than the sum total of their deficits, interactional patterns,
and behaviors. These people maintain their individualities, rather
than being viewed as a one dimensional construct impacted by addiction.
Furthermore, addiction is no longer a shameful deficit or an example
of bad genetic luck. Life is a series of never-ending learning lessons.
Addiction then becomes an opportunity for people to explore the
depths of suffering in order to understand their humanity as well
as their full potential to live life with meaning in purpose. As
darkness needs light, so does mankind often need suffering in order
to grow on deeper emotional levels.
The field of research in Existential AFT is
blossoming. Patterson-Sterling (2004) wrote Rebuilding Relationships
In Recovery: A Guide To Healing Relationships Impacted By Addiction.
In the next several months study groups will form to examine the
concepts of Rebuilding Relationships In Recovery (Triple R Healing
Model) as an eight part AFT workshop series. There will be studies
including a control group as well as pre and post treatment outcomes.
Longitudinal outcome measures of six months, one year, three years,
and five years will be included as well. Furthermore, a network
of Rebuilding Relationships In Recovery (Triple R Healing Model)
support groups are starting. Individuals in recovery and their loved
ones will have opportunities to attend support groups and practice
the existential principles of the Triple R Healing Model together.
In summary, the existential model is an exciting
development in the field of AFT. The challenge will be to expand
the existential approach from a frame of reference or paradigm to
a series of expansive counselling protocols that not only include
AFT, but general addictions counselling treatment as well.