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Implementing Fatherhood-Focused Interventions in SUD Treatment

Implementing Fatherhood-Focused Interventions in SUD Treatment

Within residential treatment programs for substance use disorders (SUDs), there are many men who are fathers. Programs often do not focus on fatherhood or parenting as part of residential treatment programs, though there have been some successful outcomes for residential programs for women that incorporate motherhood-focused services (Niccols et al., 2012), including parenting interventions and family work with their children. Mothers have been positive about these coordinated programs, but programs have typically not incorporated parenting programing or family-focused treatment as part of residential treatment programs for men.

Another common co-occurring problem of men in residential substance misuse treatment is use of violence in their intimate relationships (i.e., intimate partner violence, or IPV). Studies suggest approximately 50 percent of men in most residential programs will report some violence in their current or past intimate relationships (Easton, Swan, & Sinha, 2000). Facilities often do not address this issue as part of treatment. Few fathers with SUDs get the level of intervention they need to change their behaviors related to intimate relationships and parenting while in their residential programs. Treatment of substance use problems alone improves their behaviors some, but often men continue to struggle with controlling and expressing their emotions appropriately. Difficulties with emotion regulation and anger can cause conflict with partners and children, which can result in increased stress and relapse to substance use. Given the positive response of mothers to parenting-focused services, there is reason to believe there could be potential helpful impact on fathers as well.

A Coordinated Intervention to Address IPV, Substance Misuse, and Negative Parenting

Fathers for Change is an integrated individual treatment approach for fathers in SUD treatment with a history of IPV, defined as threatened or actual sexual or physical violence against an intimate partner. The outpatient version of Fathers for Change (Stover, 2013) addresses eighteen topics in sixty-minute sessions of individual treatment over approximately eighteen to twenty-four weeks. The intervention combines attachment, family systems, and cognitive behavioral theory and techniques with the following goals:

  • Maintained abstinence from substances
  • Cessation of violence and aggression
  • Decreased child maltreatment risk behaviors (negative parenting)
  • Improved co-parenting

Fathers for Change allows for optional coparent and child participation in up to six of the of the sessions when it is deemed appropriate and safe by treating clinicians. These family sessions are held at the end of the treatment. Fathers for Change has some emerging evidence base in outpatient treatment settings. It has been shown to reduce IPV and improve father-child interactions (Stover, 2015).

Fathers for Change emphasizes the fathering role to increase men’s motivation to remain in treatment. It focuses on reflective functioning, hostile thinking, emotion regulation, and communication skills both with coparents and children. Past studies have found hostility in combination with substance use to be related to violence, and hostility and difficulties managing emotions and feelings are associated with IPV and child maltreatment. Men at risk for IPV often misperceive negativity from others, especially their intimate partners (Holtzworth-Munroe & Hutchinson, 1993) and can respond to minor or ambiguous situations with hostility, physiological reactivity, and emotional arousal. Fathers for Change employs cognitive restructuring and emotion regulation to reduce hostile thinking and poor emotion management to help clients maintain abstinence and reduce IPV and child maltreatment risk.

We felt Fathers for Change may fit well within residential substance use treatment because fathers may be motivated to engage in the program while they do not have competing external demands for their time, like jobs or active parenting/family responsibilities while they are living at the residential facility. We modified the intervention to remove topics that were not universally possible for fathers in the residential treatment setting, such as use of videotaped interactions with their children for interactive parenting guidance. This resulted in a residential treatment version that included fourteen topics of intervention over sixteen weeks. We then designed a study to determine if Fathers for Change was acceptable to men in residential substance use treatment. We wanted to test whether fathers would enroll in and complete the program, find the program helpful and recommend it for other fathers, and show a reduction in hostility and emotion regulation problems following the intervention.

Studying Fathers for Change in Residential Treatment

Fathers living in an eighteen-month residential treatment program, who had at least one biological child under the age of twelve, were currently in contact with their children, and had a history of IPV were invited to participate. Men in the participating facility were primarily Department of Corrections involved and were attending treatment in lieu of incarceration. The research team met with fathers interested in the Fathers for Change program, described study procedures to the men, and completed informed consent procedures. Following informed consent procedures, the study team administered a questionnaire to assess IPV and ensure the participants were eligible for the study. Fathers who endorsed at least one aggression item toward an intimate partner (e.g., hitting, kicking, pushing, shoving) in the last year were eligible to participate in the study. Forty-four fathers met our criteria, consented to participate in the study, and began treatment.

Both prior to the Fathers for Change intervention and following completion, fathers were asked questions from a variety of standardized questionnaires regarding their demographics characteristics (e.g., age, ethnicity, etc.), drug and alcohol use history, expression of anger, emotion regulation skills, and IPV. These included providing answers to true/false statements such as “When I get mad, I say nasty things,” and “When I’m upset, I get angry with myself for feeling that way.” We also administered the Articulated Thoughts in Simulated Situations (Davison, Vogel, & Coffman, 1997) task, which presents scenarios meant to induce anger and jealousy in the fathers. Fathers listen to these situations and are asked to say what they are thinking. Their statements were recorded and coded for hostility and cognitive distortions. Examples of scenarios included partners not answering the phone after several attempts to contact them and fathers coming home from work early to find their female partners spending time with a male friend in their home.

Upon completion of initial assessments conducted by the study team, fathers enrolled in the program and were assigned to trained Fathers for Change clinicians with whom they met with once per week for sixteen weeks. Following the sixteen weeks of treatment, fathers who completed the program were asked to complete follow-up assessments to assess changes in their anger, emotion regulation problems, and hostile thinking.

Additionally, fathers were invited to participate in face-to-face focus groups to provide feedback on the program and discuss the needs of fathers residing in residential treatment facilities. Focus group facilitators asked questions like “What’s the greatest challenge you face as a father?” “What was the most helpful aspect of the program?” “What aspects of the program would you change?” and “What was your favorite part of the program?” Two focus groups were held. Of those eligible to participate, 67 percent of fathers participated in the first focus group session and 78 percent participated in the second focus group.

Finds from the Implementation Study

As we began to examine the data, we referred back to where we thought change would occur. Our four main goals for the study were:

  1. Assess whether fathers would want to participate in Fathers for Change and complete the program
  2. Improve completion rates in the residential facility
  3. Reduce men’s anger and hostility
  4. Improve fathers’ emotion regulation skills

We think that improvement in angry and/or hostile thinking and emotion regulation will help fathers remain abstinent following treatment and reduce IPV and child maltreatment when fathers return to the community. We expected that integrating a coordinated intervention focused on IPV and parenting, in a residential treatment setting, would increase the men’s motivation to remain and complete substance abuse treatment.

As we hoped, fathers readily enrolled in the program and 84 percent of those who enrolled completed all sixteen therapy sessions. This is a very high completion rate considering treatment dropout rates in the same facility are nearly 70 percent on average. Those who did not finish Fathers for Change absconded from the treatment facility—no fathers dropped out of Fathers for Change unless they withdrew from the residential program altogether.

We also found many of the things we hoped we would find in terms of treatment outcomes. Fathers who completed the Fathers for Change treatment had significant reductions in anger, including angry temperament, anger reactions, and anger expression. This indicates a reduction in how often they became angry and improvements in how they expressed anger when they did feel it. This means that many of the fathers were expressing their feelings of anger in a more positive manner.

Next, the fathers also reported improvements in their emotion regulation skills. They felt they understood their emotions better and were more equipped to manage their feelings than before the intervention. In response to the Articulated Thoughts in Simulated Situations, fathers’ reactions to the scenarios included significantly less personalization and negative affect compared to before treatment. They also had less hostility overall and many more references to positive coparenting and an understanding that a positive relationship with the coparent will benefit their children.

Fathers who completed the program showed significant improvements in the areas targeted by Fathers for Change. An increase in anger control strategies was found and suggests that fathers were thinking more about situations and problem solving before reacting in a negative manner. The program focused significantly on communication with coparents and there was an increase in positive coparenting language at postassessment, which suggests that the fathers were willing to communicate with their coparents and likely to provide a better environment for their children in the future.

At the end of the sixteen-week intervention, the fathers were asked to complete a client satisfaction survey. This survey is solely based on evaluating our treatment program rather than evaluating their overall residential treatment at the substance use facility. The fathers were very receptive to the Fathers for Change program and universally reported it motivated them to complete the residential substance abuse treatment program. Fathers were unanimously positive about the overall program stating that they would come back to the program in the future if given the opportunity. They also believed that it helped them identify their hostile triggers and helped a great deal with various aspects of their lives overall. Importantly, the program allowed the fathers to discuss their roles as parents and brainstorm better ways to communicate with their coparents and children. This is an important finding. Helping fathers feel positive about the future and feel equipped to engage in coparenting may facilitate recovery and prevent relapse.

Reviewing Focus Groups to Find Central Themes

We reviewed focus group responses for recurrent themes reported by the fathers. Our review revealed four central themes from the two focus groups: enjoyment from teaching children through life lessons, difficulties/feelings of guilt due to absence from home, benefits from one-on-one therapy sessions, and tools gained through the intervention.

When asked about their roles as fathers, many of the participants expressed the happiness they felt in guiding and teaching their children. One father even stated, “I think the best thing [about being a father] for me is watching her grow up and I can teach from my mistakes and the things I went through.” Another said, “Personally, what I like most about being a dad is being able to teach my daughter and keep her happy” (Stover, Carlson, & Patel, 2017).

Next, guilt was a very common theme for the participants. Many reported their biggest challenge was being away from their children’s lives. The road to recovery was also listed as a challenge by many participants, but having a normal life with their children again was often motivation for enrolling in treatment and trying to be substance free in the first place. For example, one father stated, “The hardest thing for me is getting through this program and staying on the right path so that I don’t have to be away from my son anymore . . . I know if I don’t get it right I won’t be there, so that’s the hardest part” (Stover et al., 2017). Helping fathers acknowledge and work through their guilt about their absences and the mistakes they made as parents may be a very important piece of recovery that can prevent relapse. Men reported feeling overwhelmed by guilt at times and learning to acknowledge those feelings and cope with them was an important aspect of the Fathers for Change treatment that could be utilized with fathers in residential treatment.

Other fathers mentioned difficulties with trust in their relationships with their children. They let their children down in the past and knew it would take time to regain trust. One father stated, “The biggest challenge for me is the trust thing. He thinks I don’t want him around, so just trying to make him realize it’s nothing he did.” Fathers needed and wanted help reconnecting with their children and talking with their children, with effective language, about their addiction and treatment process. Many said they did not know what to say to their children or how to rebuild the lost trust. Feeling supported with therapist guidance made it easier for them to think about these issues and they were then less overwhelmed by them.

Next, the participants unanimously reported benefitting from individual therapy sessions. Being one-on-one with the study therapists helped the fathers discuss their personal questions about fatherhood, coparenting, and communication. They all stated the positives of individual therapy sessions rather than a group approach. One father said, “I think [the Fathers for Change program] was helpful for me because I never really had much one-on-one time with people. And then that’s someone I could talk to and express feelings about my child, learning how to deal with my emotions towards my child, and getting different perspectives on how to react to problems” (Stover et al., 2017).

Lastly, when we asked participants how the Fathers for Change program was helpful, the majority talked about the communication skills they learned and the self-awareness the program brought to them. Many fathers in residential treatment programs have strained relationships with both their children and their coparents. They also do not always know how to mend their relationships through open conversations. Practicing communication skills with the therapists and having joint sessions with coparents or children were reportedly very helpful. Many of the fathers would have liked more of these sessions. Often family sessions were logistically hard due to coparents and/or children living too far away or being unable to afford transportation to the facility. Finding ways to facilitate family sessions was very important to these men.

Through weekly therapy sessions with our study therapists, the participants were encouraged to have more open communication about their emotions and to articulate their thoughts and feelings. This led the fathers to report a higher sense of self-awareness overall. They made statements like, “Just talking and the ability to talk and take a look at myself. To see what I could’ve done differently and to see what energy I put in things; just self-awareness,” and “The most important part that stood out to me . . . was the emotion coaching. For a long time, back from where I come from, showing emotion is a sensitive side that’s not tolerable. I pushed that onto my kids for a while . . . [Therapy] really showed me . . . how to give that affection back” (Stover et al., 2017).

During the focus groups, we also asked the fathers what they would do to change the program. Many of the fathers agreed that the program should have been longer. They felt more sessions were needed to process their feelings of guilt and to learn new communication and parenting skills. Most of the participants had comments about wanting more sessions and community support after treatment that focused on their family life. They indicated having outpatient aftercare sessions connected to Fathers for Change would be welcomed and helpful as they transitioned into the community and back into more active roles with their children. Several also suggested the idea of the individual sessions followed by a fathers’ support group where they could connect with other fathers also in treatment at the same facility.

Limitations

While this study is the first of its kind to study a coordinated fatherhood and IPV treatment in residential treatment for men, limitations are present in any pilot study such as this. An important caveat in the design of the study is the lack of a treatment comparison group because the study did not utilize a randomized control design. This is an important next step that should be taken in future research studies to measure outcomes of the Fathers for Change program as compared to another intervention. A controlled design will test whether the intervention is effective compared to standard treatment or another treatment type. Long-term benefits are also unknown with the present study, as the fathers were not assessed after being discharged from the treatment facility. Longitudinal data would be valuable for this area of research to determine the long-term benefits related to abstinence, IPV, and parenting of integrating Fathers for Change into residential treatment programs for men. Additionally, fathers who did not complete the program were not assessed at follow-up and did not participate in the focus groups. It is possible that those who dropped out and did not take part in the discussions about the program may have had additional information to add, including negative opinions.

Implications

The present study was the first to examine implementation of a coordinated IPV and parenting intervention into in a long-term residential substance misuse treatment program for men. Our study suggests the individualized therapy sessions with trained clinicians was very helpful to the fathers. They enjoyed the program and would recommend it to others in their situation. Men wanted even more individual sessions beyond the sixteen provided and wished for aftercare sessions following discharge. This positive feedback, coupled with the significant reductions in hostile thinking, anger expression difficulties, and poor emotion regulation suggest implementation of a program such as Fathers for Change into residential treatment programs can have benefits for fathers. Further studies of integration of such programs into residential substance abuse are warranted and are underway. Dropout rates in residential treatment are high and finding ways to increase motivation and improve outcomes are important. Focus on fatherhood and issues related to relationship violence for men in residential treatment may have substantial benefits for the fathers in treatment as well as their coparents and children.

Acknowledgements: This study was partially funded by the College of Community and Behavioral Sciences Internal Grant Award at the University of South Florida. The authors would like to thank Melanie Bozzay, Dr. Elizabeth Rojas, Dr. Elizabeth Hunt, and Luis Ordaz for providing the study therapies. We further want to thank the clients and staff at Westcare Inc. for their participation and support of this project.

References

  • Davison, G. C., Vogel, R. S., & Coffman, S. G. (1997). Think-aloud approaches to cognitive assessment and the articulated thoughts in simulated situations paradigm. Journal of Consulting & Clinical Psychology, 65(6), 950–8.
  • Easton, C. J., Swan, S., & Sinha, R. (2000). Prevalence of family violence in clients entering substance abuse treatment. Journal of Substance Abuse Treatment, 18(1), 23–8.
  • Holtzworth-Munroe, A., & Hutchinson, G. (1993). Attributing negative intent to wife behavior: the attributions of maritally violent versus nonviolent men. Journal of Abnormal Psychology, 102(2), 206–11.
  • Niccols, A., Milligan, K., Sword, W., Thabane, L., Henderson, J., & Smith, A. (2012). Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes. Harm Reduction Journal, 9. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325166/
  • Stover, C. S. (2013). Fathers for Change: A new approach to working with father with histories of intimate partner violence and substance abuse. Journal of the American Academy of Psychiatry and the Law, 41(1), 65–71.
  • Stover, C. S. (2015). Fathers for Change for intimate partner violence and substance abuse: Initial community pilot. Family Process, 54(4), 600–9.
  • Stover, C. S., Carlson, M., & Patel, S. (2017). Integrating intimate partner violence and parenting intervention into residential substance abuse disorder treatment for fathers. Journal of Substance Abuse Treatment, 81, 35–43.

Carla S. Stover, PhD, is a licensed clinical psychologist and associate professor at the Yale University School of Medicine Child Study Center. Dr. Stover’s research interests are focused on the impact of violence and trauma (particularly family violence) on child development and the advancement of best practice interventions for children and families affected by violence and substance misuse. She has been awarded several grants from the National Institute on Drug Abuse to develop interventions for fathers with histories of intimate partner violence (IPV) and substance misuse.

Melissa Carlson, BS, is a graduate of the University of South Florida majoring in behavioral health care with a concentration in adult community sciences. She has received many scholarships and awards as an undergraduate research student. Carlson is currently coordinating a clinical trial involving parenting and substance abusing fathers. Her research interests in substance abuse interventions and treatment has been fostered by faculty, leading to multiple publications.

Sarika Patel, BA, is a graduate of the University of South Florida majoring in psychology. In her undergraduate career, she presented her own research proposal in the university’s research colloquium and coauthored multiple publications under faculty she worked with. Patel currently works in a research lab conducting a clinical trial on parenting and substance abusing fathers. Her research interests include mental health promotion in underrepresented populations and health psychology.

Raquel Mañalich, BA, is a graduate of the University of South Florida majoring in psychology. She has participated in numerous research studies and has presented research ideas on multiple occasions. Mañalich is currently a research assistant for a clinical trial involving parenting and substance abusing fathers. She has plans to further her education by enrolling in a doctoral clinical psychology program in the near future.

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