An alcohol treatment service has introduced couple and family therapy as an alcohol misuse intervention
Brendan Flynn, MA, DipCPN, DipACC, RMN, RGN,is specialist nurse therapist, couple and family therapy team coordinator and UKCP-registered systemic psychotherapist at Kent and Medway Community Alcohol Service, St Martin’s Hospital, Canterbury.
Flynn, B.(2008) Using couple and family therapy to treat people experiencing alcohol problems. Nursing Times ; 104: 50/51, 40–42.
This article outlines the introduction of systemic psychotherapeutic interventions for couples and families who are experiencing problems with alcohol.
It explains the background to this therapeutic approach and the outcomes for clients. Systemic therapy is now used by the team as an integral part of the mainstream clinical programme within the alcohol treatment service.
Implications for practice
·Systemic therapy improves therapeutic engagement, and our work has shown that working with couples and families is effective.
·Reflecting team processes is also a useful clinical and supervision tool.
·The team’s involvement in consultancy projects indicates that this systemic model is both transferable and adaptable.
·The model has the potential to benefit many and differing client groups with minimal training and peer live supervision.
A multidisciplinary team led by a specialist nurse therapist in Canterbury in Kent has established a psychotherapeutic service
in an adult alcohol treatment setting for couples and families experiencing problems with excessive alcohol use. The service has been running for seven years and has been effective in helping clients make significant and sustained change in drinking and related behaviour.
The Kent and Medway Community Alcohol Service, in keeping with other NHS alcohol treatment services (ATSs), provides a range of tier-2 and 3 treatment interventions to adults with alcohol-related problems.
A treatment paradox appeared to be emerging in that there was growing reluctance within ATSs across the UK to provide couple- and family-based clinical interventions, even though evidence-based research increasingly supports the use of interactional systemic approaches.
Fals-Stewart and Birchler (2001) explored possible reasons why ATSs have historically been resistant to implementing such therapies as part of mainstream treatment. They said two commonly reported reasons are that couple/family treatment modality was seen as ‘too intensive’ and not typically used as an adjunct to other services, but rather as ‘a standalone intervention’.
A further obstacle was the limited resources available to ATSs in the NHS, which created a culture of prioritising drinker-focused treatments over systemic approaches.
Clinicians’ own predispositions also need to be taken into account. Practitioners experiencing anxiety and role insecurity when faced with this client group can be resistant to this style of clinical work, fearing that couples and families will psychologically overwhelm, deskill and demoralise them.
Lack of systemic training and appropriate supervision in this type of work is also a common reason for clinicians to avoid this client group.
It was in this context of a lack of systemic interventions in ATSs across the UK and a growing recognition of the need for this service provision that a systemic couple/family therapy service was established in 2001 in Canterbury. The intention was for the service to complement the existing individual treatment programme.
The client group seen by the team had generally not responded well to other interventions and could be very resistant to change. However, they continued to experience escalating degrees of distress and harm.
Couples and families had one or more member(s) drinking problematically, with coexisting problems such as mental illness, child/adult protection issues, physical, emotional and sexual abuse, violence and other criminal behaviour. Service users were generally aged between 20 and 60 years; children and other relatives involved in therapy could be of any age. Couples
and family members were mainly white European in origin, while team members represented a range of class, cultures, race and ethnic backgrounds.
Clients referred to the team by ATS key workers had generally received help with their drinking and any underlying medical, psychiatric, social or domestic problems had been stabilised. Couples were initially assessed and were then joined in subsequent meetings by children, relatives, friends, colleagues and the referrer.
The frequency of meetings with service users was due to be influenced by the level of clinical need as well as progress made. Meetings could take place every 1–3 weeks, and usually lasted for about 3–4 months. Collaborative reviews of therapy activity took place regularly.
The couple/family therapy team’s clinical ‘mission’ was to engage with, and assist, complex as well as challenging couples,
and families who had enduring alcohol-related problems.
Clients were helped to systemically understand that excessive drinking always occurs in a relationship context and can be influenced by family-of-origin dynamics or as part of a restricted communication process in a current relationship. Systemic family therapy helps couples and families to alter, adapt or introduce new beliefs, behaviours and communications that support and maintain change in drinking patterns. The use of systemic psychotherapy with addictive behaviours is a recognised and effective clinical modality (Stratton, 2006; Copello and Orford, 2002).
The service was coordinated by a specialist nurse therapist who was also a trained systemic psychotherapist. The core team included a principal psychotherapist and school liaison officer who were also trained and experienced systemic psychotherapists. The team also regularly had undergraduate, pre-registration and postgraduate professionals – counsellors, psychologists, psychotherapists, doctors, social workers and nurses – on supervised placements.
The couple/family therapy team used a range of systemic interventions including: assessment; genograms (a pictorial representation of a person’s family relationships and medical history); circular questions; hypothesis formation; and interventive interviewing, which uses linear, strategic, circular and reflexive-style questions to facilitate change in cognitions and/or behaviour.
One particular clinical skill the team had introduced and developed extensively was the use of reflecting teams (Andersen, 1991).
The team was advancing the work of ‘reflecting teams’. This not only gave families constructive, important and varied perspectives on their alcohol-related difficulties but also helped new and less experienced nurses, alcohol workers and other professionals to develop their counselling skills and gain greater confidence from observing and practising with more experienced colleagues. The team comprised 5–6 people: two members were the therapists, who met clients; the remaining members (usually three in number) acted as reflecting observers.
‘Reflecting teams’ embodied a host of principles from the social constructionism paradigm. This paradigm challenges the more traditional forms of social theory and meaning. At the core of social constructionism is the view that there is not a single reality about the world or people’s behaviour, but that meaning is pluralistic and socially co-constructed through language. Bateson (1972) pointed out that we learn about ourselves and our relation to others through comparative reflections. As we compare what we know against a background of other possibilities, the comparison allows us to make distinctions. One way of doing this is for couple/family therapy team members to share their views, stories and perspectives with clients as a template for comparison; the team members’ reflections may become a background for creating clients’ new reflection and understanding of drinking-related difficulties.
Reflecting teams and processes assist clients to view previous problematic behaviours from new perspectives, thereby promoting change and reconstruction of current and future interactions, beliefs and cognitions in relation to excessive alcohol behaviour. It was hoped that, in the context of more collaborative and egalitarian relationships, clients would be more likely to be more receptive than before to new ideas and perspectives and thereby feel supported and motivated to risk making changes in the interactional behaviour that influenced and maintained their drinking problems.
The reflecting process allowed clients to listen without having to justify, defend, explain or set the record straight, while knowing there was an opportunity to speak. This provided an unusual space in which new ideas could surface and a different kind of listening and learning took place.
Reflecting team in action
The use of the reflecting team was explained to clients before meetings were held and written consent was obtained. When therapists met clients, the reflecting team observed the interview from behind a one-way screen in an adjacent room. The reflecting team observers (a maximum of three people) were invited into the room when the therapist and clients agreed that they would like feedback. A conversation took place between team members in the presence of therapists and clients – team members faced each other and did not look directly at clients or therapists. They reflected among themselves clearly so clients could hear what was said. They did this for just a few minutes and then left.
In the remainder of the meeting, therapists invited clients to comment on the team’s reflections or to have a ‘dialogue about the dialogue’ (Andersen, 1991). Feedback from colleagues, service users and evaluation exercises provided several guidelines or principles for the reflecting team. These are listed in Box 1 and served as a structure or template around which the team’s interventions were organised and delivered. These points could be considered as specific to alcohol-related problem reflections but could also be regarded as generic in nature and served as a useful clinical structure for reflecting teams, regardless of the presenting problem or treatment setting.
BOX1. principles of reflections
Possible reflections include:
·Focusing on problem-creating and problem-dissolving discourse;
·Presenting explanations for the problem;
·Putting forward alternative explanations of the problem;
·Introducing possible solutions and hypothetical future scenarios;
·Discussing ways in which family members have constructed views of the problem;
·Exploring family explanations for this problem picture;
·Addressing remarks to other team members or therapists and talking about clients in the third person;
·Framing and connoting narrative and behaviour positively;
·Emphasising ‘both-and’ stories rather than ‘either-or’ ones;
·Offering something different, but not too different; unusual but not too unusual;
·Not looking at clients when talking, leaving them free not to respond to reflections;
·Avoid saying anything that might make clients feel criticised;
·Not saying too much – there’s a limit to what people can absorb.
Source: internal feedback and adapted from Prism Practice (2004)
Team members used these points as a foundation for teaching and training around reflecting teams and processes.
The team provided a dedicated clinical service to a marginalised and difficult-to-engage client group. The team’s work has achieved a consistent and sustained level of stability and/or abstinence in clients’ drinking behaviour, as well as significant and meaningful changes in relationships and family dynamics. This has led to improved quality of life for couples and families.
The use of reflecting team interventions is a highly innovative clinical activity within the adult alcohol treatment domain.
Evaluation and anecdotal feedback from service users suggests it is effective in promoting interactional change in drinking behaviour. With this in mind, a team member conducted a research project in 2005 on the reflecting-team process. This unpublished research demonstrated that ‘…the scores show a significant positive outcome for couples receiving therapy’.
Clients said that, as a result of the treatment with a reflecting team:
‘…we feel more confident in managing other problems’;
‘…we talk more about different things’;
‘…it helped us that our problems were understood from different angles.’
A more recent outcome study, commissioned by the team in 2006, confirmed that clients and relatives do find this style of clinical work beneficial and that it improves problem resolution, understanding and communication. This unpublished study demonstrated that 86% of the identified clients made significant changes to their drinking behaviour, and 67% of those with a drinking problem found it beneficial to have their partner who did not drink present at meetings. In addition, 86% of partners who did not drink found it helpful to be involved in the treatment process with their partner who did drink. This collective feedback demonstrates that the postmodernist nature of the reflecting team’s approach helps clients to understand their problems as located in linguistic systems (Anderson and Goolishian, 1988).
Reflecting processes are used as part of ‘live supervision’ activity that enables the team to collectively evaluate, adapt and evolve their clinical experience and practice. This development is integral to the therapy process and is the counselling equivalent of an operating theatre, where the human resourcefulness of the team develops its depth of expertise and team spirit together.
Service users have an equivalent experience of safety and security when they explore and seek alleviation from complex alcohol-related personal difficulties, distress and conflicts. The team believes such a way of working is the future and helps
the mental health staff to gain expertise and confidence.
A planned development for the team is to commission formal empirical research projects to further analyse the clinical interventions and how they correlate with clients’ long-term behavioural changes. Research focusing on the therapeutic attachments created during meetings would be of particular interest to the team.
The experience of developing this service helped the team and the ATS to acknowledge that involving partners, children, relatives and friends can have a positive influence on therapeutic engagement and the outcome of interventions. It is clear that the use of systemic therapy had an established and complementary position alongside individual interventions in the mainstream treatment of excessive drinking and related difficulties in ATSs.
·An estimated 920,000 children in the UK are living in a home where one or both parents misuse alcohol (Alcohol Concern, 2008).
·Some 6.2% of adults in the UK have grown up in a family in which one or both parents drank excessively (Alcohol Concern, 2008).
·Although there is evidence-based research supporting the use of interactional systemic approaches to address alcohol misuse, alcohol treatment services have been reluctant to adopt this model.
Alcohol Concern(2008) Alcohol and the Family . London: Alcohol Concern.
Andersen, T. (1991) The Reflecting Team: Dialogues and Dialogues about Dialogues . New York, NY: Norton.
Anderson, H., Goolishian, H.A.(1988) Human systems as linguistic systems: preliminary and evolving ideas about the implications for clinical theory. Family Process ; 27: 4, 371–393.
Bateson, G.(1972) Steps to an Ecology of Mind . New York, NY: Ballantine.
Copello, A., Orford, J.(2002) Addiction and the family: is it time for services to take notice of the evidence? Addiction ; 97: 1361–1363.
Fals-Stewart, W., Birchler, G.(2001) A national survey of the use of couples therapy in substance misuse treatment. Journal of Substance Misuse Treatment ; 20: 277–283.
Prism Practice(2004) The Reflecting Team Approach . London: Prism Practice.
Stratton, P. (2006) Report on the Evidence Base of Systemic Family Therapy . Warrington: Association for Family Therapy.