Family Therapy Approaches to Alcoholism

Family Therapy Approaches to Alcoholism
by Elizabeth Fried Ellen, L.I.C.S.W.

Psychiatric Times September 1998 Vol. XV Issue 9

In the past 25 years, a number of treatment modalities have developed that incorporate increasingly sophisticated family therapy perspectives to help alcoholics and their families through the recovery process.
Alcoholism is correlated with a myriad of relational ills, including increased rates of marital and family violence, inadequate parenting, sexual dysfunction, and general domestic discord (Rotunda et al., 1995; Murphy and O’Farrell, 1996; O’Farrell and Murphy, 1995), as well as with increased rates of divorce (O’Farrell, 1992). Alcoholism also takes a heavy financial toll on alcoholics and their families due to employment instability and legal system involvement (Rotunda et al., 1995).

Research and clinical studies have indicated that marital and family problems may not only precipitate abusive drinking, but also can maintain a pattern of excessive drinking once it has developed and derail sobriety in abstinent alcoholics (O’Farrell, 1992). Researchers have noted higher levels of conflict, negativity and competitiveness, and lower-than-average levels of expressiveness, cohesion and conflict-resolution skills in alcoholic families. Researchers did not find significant differences in overall dysfunction between alcoholic families and nonalcoholic but distressed families (Rotunda and O’Farrell, 1997).

“In one form or another, there is general acknowledgment that family issues are very important in alcohol and drug abuse in general,” Peter Steinglass, M.D., told Psychiatric Times. Steinglass, who is the executive director of the Ackerman Institute for Family in New York City, added that the challenge is to translate that awareness into clinical practice. “The question is how to use the family effectively in the treatment venue.”

Traditional attempts at family inclusion largely have segregated treatment for the alcoholic and his or her family (Steinglass, 1994; O’Farrell, 1992; Rotunda and O’Farrell, 1997). Treatment oriented toward a family disease model generally treats alcoholics individually, while treatment for family members often revolves around education about alcoholism and referral to 12-step programs (such as Al-Anon) specifically geared toward family members.

This theoretical approach posits that alcoholism is a progressive disease over which the alcoholic has no control and that sobriety is possible only through strict adherence to 12-step principles. In keeping with this model, family members are taught that they must learn to give up a sense of personal responsibility for the alcoholic family member’s drinking and sobriety, and disengage from active efforts to affect abusive drinking patterns.

Behavioral Couples Therapy

Perhaps the best known model for the use of behavioral couples therapy (BCT) in the treatment of alcoholism is the Counseling for Alcoholics’ Marriages (CALM) Project, a program run by the Harvard Medical School Department of Psychiatry at the Veterans Administration Medical Center in Brockton, Mass., and other Boston-area sites. Begun in 1978, the program has a simple premise; that spouses can reward abstinence by the alcoholic because better communication and greater family cohesion play a major role in the recovery process. The result is a treatment model that simultaneously tackles abusive drinking and marital problems by combining individual, conjoint couples and group couples treatment with a strong behavioral component.

Behavioral interventions include a daily sobriety contract. This involves a daily “trust” discussion in which the alcoholic pledges to remain abstinent for that day and the spouse thanks the alcoholic for this reassurance. For patients taking Antabuse (disulfiram), there is a daily ritual in which alcoholics thank their spouse for watching them take their daily dose of the anti-drinking medication, while the spouse thanks the alcoholic for taking it and records the action on the patient’s calendar.

Timothy O’Farrell, Ph.D., director of the Harvard Families and Addiction Program and head of Project CALM, told Psychiatric Times that the daily sobriety contract and other BCT interventions not only build support for abstinence, but ally the couple in that effort. For example, many spouses of alcoholics-understandably worried about the repercussions of abusive drinking-often try to force the alcoholic to stop drinking. O’Farrell said this approach may be temporarily effective, based on the alcoholic’s desperation to hang on to the relationship, but that it usually fails, often with painful consequences for both sobriety efforts and the couple’s relationship.

“With Antabuse, we do a lot of work to see to it that it’s not set up as a watchdog or policing operation,” said O’Farrell. The intervention is structured in such a way so as to give the alcoholic “credit” for remaining abstinent, while offering his or her spouse much-needed reassurance.

Empirical follow-up studies indicate that successful completion of behavioral marital treatment (including, but not limited to, programs such as Project CALM) resulted in better rates of abstinence and improved marital adjustment than individually based treatment approaches in the 18 to 24 months following program completion (O’Farrell et al., 1998). It was also deemed to be more cost-effective, resulting in a significant drop in alcohol-related health and legal costs (O’Farrell et al., 1996a; O’Farrell et al., 1996b), as well as markedly decreased rates of marital violence (O’Farrell and Murphy, 1995; O’Farrell et al., in press). The later addition of a relapse prevention component further improved abstinence and relational outcomes for BCT participants (Edwards and Steinglass, 1995), especially for those with more severe drinking and marital difficulties (Rotunda and O’Farrell, 1997).

Future Trends

A number of alcoholism specialists have emphasized the need to better match treatment approaches to the alcoholics they serve (Shoham et al., in press; Rotunda and O’Farrell, 1997; Steinglass, 1994; Rotunda et al., 1995) and support efforts to increase collaboration between the research and clinical communities. Increased collaboration, said O’Farrell, could serve both to scientifically validate time-tested alcoholism interventions and speed the application of cutting-edge research to clinical practice (O’Farrell, 1992).

Project MATCH, the largest clinical study of alcohol-targeted psychotherapies conducted to date, disproved the theory that patient characteristics can predict which kind of treatment is most effective (Project MATCH, 1997). The eight-year, multisite study, funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), randomly assigned 1,726 alcohol-dependent individuals to one of three treatment programs. Researchers found that 12-step programs, cognitive- behavioral therapy and motivational-enhancement therapy were equally effective. It should be noted, however, that the study focused on the characteristics of individual alcoholics and did not take patterns of marital interaction into account in the matching process.

Results of a five-year study sponsored by the NIAAA at the University of California at Santa Barbara (Shoham et al., in press) have infused the matching debate with a strong family therapy focus. The result is an abundance of promising new information about how a specific interactional style between spouses correlates to their successful completion of two types of family therapy.

Researchers examined the “demand-withdrawal” interaction, a dynamic process in which the spouse of an alcoholic nags, criticizes or otherwise pressures the alcoholic spouse to become sober while the alcoholic spouse withdraws. Research has indicated that a number of factors, ranging from evolutionary biology to gender socialization, may account for the observed preponderance of wives in the demand role, while husbands more often assume the withdrawal role (Shoham et al., in press). This phenomenon is thought to be particularly profound in marriages struggling with alcoholism that are also burdened by concerns over financial security, marital discord and general family well-being (or the lack thereof), said study co-author Varda Shoham, Ph.D.

In the study, 63 couples were randomly assigned to either a cognitive behavior therapy (CBT) program or one that was organized around a family systems (FS) approach (30 in CBT and 33 in FS). While sobriety was the primary and explicit goal of treatment in each group, the CBT approach was more structured and more confrontational, emphasizing the rehearsal of concrete relapse prevention techniques and insisting that sobriety be accomplished at a given point in treatment. The FS approach, on the other hand, examined the interactional aspects of abusive drinking, namely, which family factors precipitated drinking and which aided in its prevention. Resistance to sobriety interventions was not challenged, allowing the therapist to subtly model a way for alcoholics and their spouses to constructively engage in treatment without entrenched, destructive communication patterns as exemplified by high demand-withdrawal interactions.

Study results confirmed research hypotheses that highly structured, confrontational interventions like those characterized by the CBT approach would be less successful in couples with a high degree of demand-withdrawal interaction. Fifty-six percent of couples assigned to the FS group completed all treatment sessions, contrasted with a 14% completion rate among CBT group counterparts.

“The implication is that if you want them [couples] to stay in treatment, don’t do more of the same,” said Shoham, who is also director of the clinical psychology program at the University of Arizona at Tucson. “More of the same would be for the therapist to join on the ‘demand’ side. It is very tricky. We all want them to stop drinking. If pushing was working, they would not be coming for treatment. Something in their pattern isn’t working for them and we have to be careful not to replicate it,” said Shoham.


Edwards M, Steinglass P (1995), Family therapy outcomes for alcoholism. Journal of Marital and Family Therapy 10:475-509.

Murphy C, O’Farrell T (1996), Marital violence among alcoholics. Current Directions in Psychological Science. Cambridge: Cambridge University Press, pp 183-186.

O’Farrell T (1992), Families and alcohol problems: an overview of treatment research. Journal of Family Psychology 5(3&4):339-359.

O’Farrell T, Choquette K, Cutter H (1998), Couples relapse prevention sessions after behavioral marital therapy for male alcoholics: outcomes during the three years after starting treatment. J Stud Alcohol 59(4):357-368.

O’Farrell T, Choquette K, Cutter H et al. (1996a), Cost-benefit and cost-effectiveness analyses of behavioral marital therapy with and without relapse prevention sessions for alcoholics and their spouses. Behavior Therapy 27:7-24.

O’Farrell T, Choquette K, Cutter H et al. (1996b), Cost-benefit and cost-effectiveness analyses of behavioral marital therapy to outpatient alcoholism treatment. J Subst Abuse 8(2):145-66.

O’Farrell T, Murphy C (1995), Marital violence before and after alcoholism treatment. J Consult Clin Psychol 63(2):256-262.

O’Farrell T, Van Hutton V, Murphy C (in press), Domestic violence before and after alcoholism treatment: a two-year longitudinal study. J Stud Alcohol.

Project MATCH Research Group (1997), Matching alcoholism treatments to client homogeneity: Project MATCH posttreatment drinking outcome. J Stud Alcohol 58(1):7-29.

Rotunda R, O’Farrell T (1997), Marital and family therapy of alcohol use disorders: bridging the gap between research and practice. Professional Psychology: Research and Practice 28(3):246-252.

Rotunda R, Scherer D, Imm P (1995), Family systems and alcohol misuse: research on the effects of alcoholism on family functioning and effective family interventions. Professional Psychology: Research and Practice 26(1):95-104.

Shoham V, Rohrbaugh M, Stickle T, Jacob T (in press), Demand-withdraw couple interaction moderates retention in cognitive-behavioral vs. family-systems treatments for alcoholism. Journal of Family Psychology.

Steinglass P (1994), Family Therapy: alcohol. In: Textbook of Substance Abuse, Galanter M, Kleber HD, eds. Washington, D.C.: Psychiatric Press, pp 315-329.

This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider. Please consult your healthcare provider with any questions or concerns you may have regarding your condition.

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