A note from Stephanie Galfano, Editor, Counselor and Michael Cartwright, President and CEO, Foundations Associates: It is with pleasure that we introduce a new series of regular articles on co-occurring conditions. Counselor and Foundations Associates, a not-for-profit organization at the forefront in providing integrated treatment and a continuum of care for individuals with co-occurring conditions, are collaborating to bring you the most timely information and practical resources from the top experts on co-occurring conditions.

When a person has a co-occurring condition, they are affected — physically, psychologically, socially, economically, and spiritually — by both an emotional or psychiatric illness and chemical dependency. Although the two conditions are separate and independent, they interact in ways that increase the complexity of diagnosis, treatment, and recovery.

As the awareness of co-occurring conditions grows, so does the prevalence of people being dually diagnosed. In the United States alone, there are over 10 million individuals suffering from co-occurring conditions (Psychiatric Disorders in America: The Epidemiologic Catchment Area Study, Robins & Regier, 1991). Over the last 20 years it has become clear that now 70 percent of people seeking treatment for addictions or psychiatric illness have some sort of co-occurring condition. The importance of learning about co-occurring conditions and their assessment, treatment, strategies for long-term recovery, and resources has never been greater or more relevant.

The new Counselor series on Co-Occurring Conditions reflects of the paramount need to provide comprehensive and effective care for people with co-occurring conditions. The addictions field is aggressively tackling this issue: SAMSHA has set co-occurring conditions as a top priority, and states are facing more consumers who are unable to receive appropriate care through the current divided treatment system. It is clear that mental health professionals require more education about substance use, and addiction professionals require more education on mental health. Research tells us that those who suffer from co-occurring conditions need integrated, not divided, treatment.

The series begins on the following page with “No One is Left Unharmed: Dual Disorders and the Family.” The highly respected authors, Dennis Daley, PhD, and Ricardo Marsili, MDiv, focus on the family’s perspective, and present strategies for counselors on the best ways to help families. We hope this innovative series on co-occurring conditions will provide valuable information and resources to advance the treatment of
co-occurring conditions.

Community studies show that co-occurring substance use and psychiatric disorders are common conditions affecting over 10 million individuals in the United States (Kessler et al., 1994; Robins & Regier, 1991). Numerous studies of clinical populations in addiction or mental health treatment systems also show a high prevalence of co-occurring disorders, and reveal that these disorders are associated with high rates of disability, HIV infection and medical problems, suicidality, violence and homicidality, housing instability and homelessness, treatment utilization, relapse and rehospitalization, and poorer rates of adherence and response to treatment (Cornelius et al., 1996; Daley & Moss, 2002; Daley & Zuckoff, 1999; Mueser, Drake & Noordsy, 1998; Mueser & Fox, 1998; Mueser et al., 2003; Salloum et al., 1996).

These problems impact both the client with the co-occurring disorders and the family. The purpose of this article is to focus on the family’s perspective, and review strategies for counselors to help families. We will first define family, briefly review effects of disorders on the individual and family, and delineate levels of counselor involvement with families. Since there are few studies and reports on co-occurring disorders and the family, this paper is based on an integration of the literature on addiction and the family, psychiatric illness and the family, and our clinical experience with families in adolescent and adult treatment programs.

By the term “family,” we refer to relationships that have an enduring level of emotional involvement. This includes traditional families (e.g., those with one or two parents, adoptive families, foster relationships or stepfamilies), extended families, and elected families (e.g., youth living with peers, gay and lesbian couples or groups; CSAT, 2004).

Effects of disorders on the family
Substance use and psychiatric disorders, alone or in combination, often create a burden on the family system and adversely affect individual members (Beardslee, 2002; CSAT, 2000; Daley & Miller, 2002; Marsh & Dickens, 1998; Mueser, Fox & Mercer, 2002; SAMSHA, 2004). These effects include emotional burden (anger, frustration, anxiety, worry, depression, shame and guilt), economic burden, tension and conflict within the family, abuse or violence, losses, and family breakup. First degree relatives (siblings or children) of an individual with a psychiatric or substance use disorder are more vulnerable to acquiring one of these disorders, and some have a fear of developing a disorder themselves (Karp, 2001; Miklowitz & Goldstein, 1997; Moss et al., 1995; Torrey, 2001).

However, not all families are affected in the same way and not all effects are negative. The actual effects are determined by the type and severity of the co-occurring disorders and other serious problems with the affected family member, behaviors exhibited by this member, support available within and outside the family for its members, and the coping mechanisms of family members.

Some family members are more resilient than others and able to cope well with the stresses associated with a loved one’s illness. Many benefit from support of relatives or friends, which may help offset adverse effects that a disorder can have on a person. Members of some families bond closely together as a result of dealing with the co-occurring disorders.

Treatment of the family
There is considerable evidence that family treatment for a substance use or psychiatric disorder produces positive outcomes, especially in the treatment of adolescents (see CSAT, 2004; NIDA, 2003). Treatment may reduce the emotional burden for family members and enable them to cope more effectively with the member with the disorders (Jacob et al., 1987; Miklowitz & Goldstein, 1997; Mueser, Fox & Mercer, 2002; Mueser & Glynn, 1999; Stanton & Shadish, 1997). However, there is limited literature on treatment of the family in which co-occurring disorders exist, so counselors must rely primarily on the family literature on substance use or psychiatric disorders to inform their clinical practice.

The level of involvement with families may include any of the following:
• Little or no involvement. Families are not contacted at all, or contacted mainly to elicit information about the client’s disorders or functioning.
• Helping the family get treatment for the member with co-occurring disorders. The counselor facilitates treatment entry by helping the family persuade or encourage the affected member to seek treatment. This may be done by phone consultation or one or more meetings with the family. In some instances, this involves helping the family initiate an involuntary commitment to a psychiatric hospital or organize an “intervention” in which the family and significant others work as a group to persuade the member to enter treatment for a substance use disorder (e.g., detoxification, rehabilitation, or outpatient program).
• Providing education. Families are given information about co-occurring disorders or resources where they can receive help (e.g., support groups). Psychoeducation refers to helping families learn strategies on what they can do and cannot do to help the affected member and themselves (e.g., how to deal with a relapse; how to stop enabling behaviors; how to focus on self, etc.).
• Providing support and addressing emotions of family members. The counselor supports and encourages family members to acknowledge and express their feelings so they feel accepted and understood, and their emotional burden is reduced. However, the counselor should keep tension and conflict in families to a minimum, especially in the early phase of treatment.
• Providing ongoing family therapy. A trained family therapist or counselor works with the family to identify areas of the family system to change and negotiate specific changes. Sessions may be held with individual family members, subgroups of the family, or the entire system. The needs of the family are addressed as well as the member with co-occurring disorders. The family system is seen as the primary unit of change.
There will be cases in which families are not accessible or able to participate in treatment. And, there may be instances in which it is not in the best interest of the client to engage the family (e.g., the family member threatens violence, or has a severe psychiatric or addictive disorder than significantly impairs their judgment).

Strategies to help families
In this section, we review strategies for counselors to help families. These are adapted from several sources and involve both systems and clinical interventions (see Clark, 1996; Daley & Moss, 2002; Daley & Sinberg, 2003; Daley & Thase, 2004; Edwards, 1997; Miklowicz & Goldstein, 1997; Mueser & Fox, 2002; Mueser et al., 2000, 2004).

Strategy 1: develop a philosophy regarding family involvement in treatment. Counselors and programs can evaluate their family philosophy and develop or expand services based on staff resources available. Some questions to consider when evaluating a program’s family services include: 1) Does the model of care or philosophy of treatment followed by the agency or counselor take into account the needs of the family? 2) Are families routinely included in assessment and treatment sessions? 3) Are families provided information about co-occurring disorders? 4) Do families have the opportunity to share their concerns, feelings, and worries about their loved one or other family members? 5) Are other family members with serious psychiatric or substance use disorders referred for treatment?

Families can be helped even if a counselor is not trained in family therapy. This can be accomplished by offering psycho-
educational groups to educate families about dual disorders, review strategies to deal with the affected member, and communicate strategies to care for self. Families can also be linked with mutual support groups such as those for families of mentally ill (NAMI) and those for addiction (Al-Anon and Nar-Anon), which can serve as long-term resources.

Historic treatment models have been more “patient or client centered.” Counselors are invited to explore an alternative model and engage in a paradigm shift that encourages a program philosophy to “think family.” This requires counselors to think of the issues, needs, and concerns of family members, not just the client with the disorders. This also requires counselors to value family involvement, and be willing to develop or expand family services.

Strategy 2: Engage the family. This needs to be a priority when clients enter treatment. When the client first calls or is seen in a treatment system, the counselor should attempt to involve the family or significant others. To recruit family members, counselors can ask the client during the phone screening who lives in the home, who knows about the problem, who cares about the problem, and who are people that can influence change. Sessions can be held with these members to develop an understanding of how they perceive the problem and to develop a supportive relationship with them. Counselors need to acknowledge family strengths to effectively join with family members.

The goals are to establish an alliance with the family and treatment goals. These goals can focus on the needs of the client as well as the needs of family members. Common goals expressed among family members include helping the client initiate abstinence, stabilize psychiatric symptoms, reduce the risk of relapse and re-hospitalization, improve client independence, reduce caregivers’ emotional burden, and learn coping strategies to more effectively deal with the member with co-occurring disorders.

By engaging family members in the treatment process, relational bonds can be strengthened and members can develop an understanding of co-occurring disorders. They can also develop “recovery behaviors” that support the client as well as help them more effectively manage their own feelings and behaviors.

Strategy 3: Educate the family. Families benefit from education on: 1) substance use, psychiatric and co-occurring disorders; 2) the relationships between substance use and psychiatric disorders; 3) types and purposes of treatment (medications, therapy, and psychiatric rehabilitation or dual diagnosis programs) and mutual support programs for clients and families; 4) coping strategies to deal with the client and personal reactions; 5) ways to promote the client’s independence; and 6) working with the mental health or addiction treatment system in getting their needs met.
Education can be provided in sessions with the family or in multiple family groups. Family groups provide a context for family members to learn from others, give and receive support, and share their story about how the disorders have affected them. As a result of the impact of disorders, family members frequently become isolated from their extended family and social supports. A group can help families form bonds with each other and learn what has worked for them.

Strategy 4: Help the family support the recovery of the client and understand relapse. Counselors can help the family support the person in recovery by attending treatment sessions together, inquiring about their loved one’s recovery, encouraging their ongoing involvement in recovery, and initiating discussions of any issue pertinent to the client or family (e.g., recognition of early signs of relapse or concern about any observed behavior). Many disorders are chronic or recurrent conditions, so family members should be aware that setbacks are common.

Members need to understand the difference between minor and major setbacks. Minor setbacks can include reemergence of mild to moderate psychiatric symptoms or lapses into substance use following a period of sobriety. Major setbacks can include reemergence of a higher severity of psychiatric symptoms, a full-blown substance use relapse, or suicidal or violent behavior. The counselor can also help the client and family jointly develop a relapse prevention (RP) plan, which identifies relapse indicators for both disorders and outlines steps the family can take to help the client reduce relapse risk or intervene when early signs of relapse show.

Strategy 5: Reduce the family emotional burden. Family members experience a wide range of emotions such as anger, fear, anxiety, and depression. This burden can be reduced as they learn about specific disorders, get support and help for themselves, identify with other families experiencing similar problems, and share their own feelings and concerns. As families feel empowered by learning information and acquiring new coping skills, their emotional burden often lessens.

During the client's assessment process, the counselor should meet with the family to assess emergent needs and their emotional burden. Sharing their story and experiences in a supportive atmosphere with a counselor is often powerful.

The counselor can determine if there are faith-based or community-based resources the family can use for social support. Facilitating the use of Case Management services and providing access to a 24-hour crisis intervention in the event the dual disordered family member experiences a severe crisis also help families.

Strategy 6: Help the family learn what they can and cannot do to help their loved one with dual disorders. A challenge for family members is to understand and accept that there are limits to what they can do to help the member with the co-occurring disorders. Family members may prevent the affected member from experiencing consequences from their impaired behaviors through “enabling” behaviors. Enabling can be passive and involve acceptance of behaviors such as alcohol or drug use, violence, or failure to function in a responsible manner at home. Or, enabling can be active, in which a family member takes over the impaired member’s responsibilities, bails this member out of trouble, or shields him or her from consequences of their behavior.

The counselor can help family members identify and change enabling behaviors, and understand reasons they enable as well as the problems this creates. Members tend to “react” to one another’s behaviors. When families are in reactionary stages, one member may place a firm boundary on the client, such as no longer giving them money. In response to this limit, another family member may give in to the client’s request for money. It is helpful for counselors to understand enabling in a systems context. Therefore, when family members come together in one room and understand the harmful effects of their behaviors, they can be invited to learn different responses. When one family member agrees to change an enabling behavior and others agree to practice the same behavior, then relational cohesion is increased within the family. This both challenges and supports the ill family member to assume greater responsibility for managing the co-occurring disorders.

The counselor can also encourage family members to attend Al-Anon or Nar-Anon, or NAMI meetings, which can help them develop a system of support with other family members. They can also learn detachment skills, which help them set behavioral limits and decrease their emotional reactions to the client’s behaviors (e.g., they may learn not to take a client’s relapse personally or let this experience have a profound negative effect on their own mood).

Strategy 7: Help family members engage in their own recovery. When family members enter into the treatment process, much of their energy is initially focused on understanding co-occurring disorders, stabilizing the crisis at hand and learning strategies to help their loved one. As family members feel safe and less emotionally distraught, they become more receptive to focus on themselves and their own recovery needs. They can then be encouraged to think about what they want to change in themselves. For example, they may need to reconnect with friends or re-engage in activities or hobbies they gave up as their life centered around the member with the disorders. Or, they may want to change how they think about their role in helping support their loved one’s recovery (e.g., they cannot dictate a recovery plan, prevent the client from using substances, or always rescue the client when in trouble).

Families will respond to counselors who are empathic, and help them feel their concerns are important. A positive therapeutic relationship enables the counselors to address other family issues such as marital discord, or substance use or mental health disorders among other family members. There will be cases in which other family members need help themselves (e.g., a spouse with a clinical depression, or a sibling with a substance use disorder).

Strategy 8: Help parents help their children. Counselors can help families by assessing the impact of the disorders on their children. Many studies show that children are affected by a family member’s substance use or psychiatric disorder. For example, compared to sons in families in which the father did not have drug abuse, sons of drug abusers were found to be at higher risk for conduct problems, aggression, impulsivity, inattention, irritability, and heightened motor activity. These sons had lower IQ scores, poorer performance in school, and impairments in the executive functions of the brain — the part of the brain involved in planning and reasoning (Tarter et al., 1995; Moss et al., 1995). Children of opiate addicts have significantly higher rates of school problems, disruptive disorders, anxiety and mood disorders compared to community controls (Nunes et al., 2000). Children of parents with mood disorders were found to be at a significant higher risk for a mood disorder compared to the children in the general population (Miklowitz & Goldstein, 1997). These are just a few example of studies documenting the impact of parental addiction or mental illness on children.

Counselors can help clients help their children by involving them in their treatment and recovery. This can be accomplished by helping the parent:
1) talk with their children about the impact of their disorders on the family and their kids, and maintain an ongoing, open dialogue with the children to address their feelings, questions or concern;
2) educate their children about co-occurring disorders, treatment and recovery;
3) establish normal routines and rituals in the home to increase predictability for the child;
4) take an active interest in the child’s life by monitoring school work and friends, and engaging them in family activities;
5) help children build on their strengths and resiliencies; and
6) facilitate an evaluation for a childwho may have a substance use or psychiatric disorder.

Evident benefits of engaging family
Co-occurring disorders affect the family system as well as individual members. These effects may vary from mild to severe. Children of parents with a substance use or psychiatric disorder are at higher risk for substance use or mental health disorders and academic problems.

Families can play a critical role in helping the member with co-occurring disorder enter treatment. They can support this member by attending sessions and offering to be part of the their treatment as well as recovery.

Families can overcome their emotional burden by participating in treatment and/or self-help programs, and addressing their own feelings, concerns and questions. The evidence in clear: no one is left unharmed by a loved one’s psychiatric, substance use or co-occurring disorder. On the other hand, participation in treatment and support groups provides family members with specific tools to cope with a loved one as well as deal with their own feelings and reactions. For many, treatment offers hope that positive change is possible.

Counselors can help clients and families by engaging family members in treatment, educating them about co-occurring disorders, helping them learn coping skills to deal with a member with co-occurring disorders, and facilitate their own involvement in recovery. Every counselor can help families directly or indirectly if they seriously consider family issues in their work with clients. All counselors who provide care should think more broadly and consider the family system as well as individual members.

Dennis C. Daley, PhD, is Associate Professor of Psychiatry and Social Work, University of Pittsburgh Medical Center, and Chief of Addiction Medicine Services (AMS) at Western Psychiatric Institute and Clinic (WPIC) He is the author of many books, workbooks, papers as well as videos on co-occurring disorders.

Richard Marsili, MDiv, is coordinator of the adolescent dual diagnosis treatment program at Addiction Medicine Services (AMS). He is an experienced family therapist who has developed clinical services for families as well as adolescents.

References
Beardslee, W.R. (2002). Out of the Darkened Room: When a Parent is Depressed. New York: Little, Brown and Company.
Center for Substance Abuse Treatment (CSAT, 2000). Substance Abuse Treatment Reduces Family Dysfunction, Improves Productivity. Rockville, MD: CSAT.
Center for Substance Abuse Treatment (2004). Substance Abuse Treatment and Family Therapy. Treatment Improvement Protocol (TIP) Series, No. 39, DHHS Publication No. (SMA) 04-3957. Rockville, MD: SAMSHA.
Daley, D.C., & Zuckoff, A. (1999). Improving Treatment Compliance: Systems and Counseling Strategies for Substance Use and Dual Disorders. Center City, MN: Hazelden.
Daley, D.C., & Miller J. (2002). Addiction in Your Family: Helping Yourself and Your Loved Ones. Holmes Beach, FLA: Learning Publications, Inc.
Daley, D.C., & Moss H.B. (2003). Dual Disorders: Counseling Clients with Chemical Dependency and Mental Illness, 3rd ed. Center City, MN: Hazelden.
Daley, D.C., & Sinberg-Spear, J. (2003). A Family Guide to Coping with Dual Disorders, 3rd Ed. Center City, MN: Hazelden.
Daley, D.C., & Thase, M.E. (2004). Dual Disorders Recovery Counseling: Integrated Treatment for Substance Use and Mental Health Disorders, 3rd Ed. Independence, MO: Independence Press.
Edwards, J. (1997) Working with Families-Guidelines and Techniques. Durham, NC: Foundation Place Publishing.
Jacob, M., Frank, E., Kupfer, D.J., Cornes, C., & Carpenter, L.L. (1987). A psychoeducational workshop for depressed patients, family, and friends: Description and evaluation. Hospital and Community Psychiatry, 38, 968-972.
Karp, D.A. (2001). The Burden of Sympathy: How Families Cope with Mental Illness. NY: Oxford.
Marsh, D.T., & Dickens, R. (1998). How to Cope with Mental Illness in Your Family: A Self-Care Guide for Siblings, Offspring, and Parents. NY: Penguin Putnam Inc.
Miklowitz, D.J., & Goldstein, M.J. (1997). Bipolar Disorder: A Family-Focused Treatment Approach. NY: Guilford Press.
Moss, H.B., Vanyukov, M., Majumder, P., Kirisci, L., & Tarter, R. (1995). Prepubertal sons of substance abusers: influences of parental and familial substance abuse on behavioral disposition, IQ, and school achievement. Addictive Behaviors, 20, 1-14.
Mueser, K.T., & Fox, L. (1998). Stagewise Family Treatment for Dual Disorders Treatment Manual. Concord, NH: Authors.
Mueser, K.T., & Glynn, S.M. (1999). Behavioral Family Therapy for Psychiatric Disorders, 2nd Ed. Oakland, CA: New Harbinger.
Mueser, K.T., & Fox, L. (2002). A family intervention program for dual disorders. Community Mental Health Journal, 38, 253-270.
Mueser, K.T., Fox, L., & Mercer, C. (2002). Family intervention for severe mental illness and substance use disorder. In A. Schaub (Ed.), New Family Interventions and Associated Research in Psychosis (pp. 205-227). Vienna: Springer-Verlag.
National Institute on Drug Abuse (NIDA, 2003). Brief Strategies Family Therapy for Adolescent Drug Abuse. Therapy Manuals for Drug Addiction. Manual 5. Rockville, MD: NIDA.
Nunes, E.V., Weissman, M.M., Goldstein, R., et al. (2000). Psychiatric disorders and impairment in the children of opiate addicts: Prevalences and distribution by ethnicity. American Journal on Addictions, 9, 232-241.
Salloum, I.M., Daley, D.C., Cornelius, J.R., Kirisci L., & Thase, M.E. (1996). Disproportionate lethality in psychiatric patients with concurrent alcohol and cocaine abuse. American Journal of Psychiatry, 153(7):953-955.
Stanton, M.D., & Shadish, W.R. (1997). Outcome, attrition, and family-couples treatments for drug abuse: A meta-analysis and review of the controlled, comparative studies. Psychological Bulletin, 122(2), 170-191.
Tarter, R., Blackson, T., Brigham, J., Moss, H., & Caprara, G. (1995). The association between childhood irritability and liability to substance use in early adolescence: A two-year follow-up study of boys at risk for substance abuse. Drug Alcohol Dependence, 39, 253-261
Torrey, E.F. (2001). Surviving Schizophrenia: A Manual for Families, Consumers and Providers. NY: Harper-Collins.
Torrey, E.F., & Knable, M.B. (2002). Surviving Manic-Depressive Illness: A Manual on Bipolar Disorders for Patietns, Families and Providers. NY: Harper-Collins.
Yapko, M.D. (1999). Hand-Me-Down Blues: How to Stop Depression from Spreading in Families. NY: St. Martin’s Press.

This article is published in Counselor,The Magazine for Addiction Professionals, February 2005, v.6, n.1, pp.37-44

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