The Family Therapy Treatment Planner: Practice Planner Series by Frank M. Dattilio, Arthur E. Jongsma Jr.

From the Publisher

Saves you hours of painstaking paperwork, while providing optimum latitude in developing customized treatment plans for working with families

Patterned after the bestselling The Complete Adult Psychotherapy Treatment Planner, this invaluable sourcebook brings a proven, well-regarded treatment planning system to the family treatment arena. It contains all the necessary elements for developing focused, formal treatment plans for family relational problems that satisfy all of the demands of HMOs, managed care companies, third-party payers, and state and federal review agencies.

Organized around 38 main presenting problems, from child/parent conflict and alcohol abuse to divorce/separation, depression, jealousy, and more, this timesaving resource also features:

• Over 1,000 well-crafted, clear statements that describe the behavioral manifestations of each relational problem, long-term goals, short-term objectives, and clinically tested treatment options
• A sample treatment plan that can be emulated in writing plans that meet all requirements of third-party payers and accrediting agencies, including the JCAHO and the NCQA
• A quick-reference format that allows you to easily locate treatment plan components by behavioral problem or DSM-IV(TM) diagnosis
• Large workbook-style pages affording plenty of space to record your own customized definitions, goals, objectives, and interventions

Product Details

• Table of Contents
• Read a Sample Chapter

Table of Contents

Read a Sample Chapter

BEHAVIORAL DEFINITIONS

1. Tension develops in the family as a result of one of the family member's excessive time given to outside activities (parent's job or sport, a child's activity, etc.).

2. Family members question the issue of priorities because of the unusual amount of time that is dedicated to the outside activities.

3. Conflict and tension arise over the fact that certain duties and responsibilities are being shifted onto other family members unfairly due to the time absorbed by the external activity.

4. Jealousy and envy brew between family members, sparking arguments.

5. Family members compete over time with the often-absent family member, leading to disagreements (e. g., children arguing over time with parent). 6. A family member's excessive involvement with external activities is due to a mental illness (e. g., bipolar disorder).

LONG-TERM GOALS

1. Eliminate family tension as a result of admitting to the excessive outside activity and giving more time to family matters.

2. Find an acceptable balance between the competing demands of external activities and family responsibilities.

3. Implement a fair and equal system for assignment of chores and responsibilities among family members.

4. Family members strive to spend equal amount of time with each other.

5. Obtain treatment for mental illness in order to restore balance and proper priorities to allocation of time.

SHORT-TERM OBJECTIVES

1. Define the external activity that is contributing to family disharmony. (1, 2, 3, 4)

2. Trace the history of the activity/ family imbalance problem and what contributed to its origin. (5, 6, 7)

3. Each family member lists his/ her time allocation priorities in a rank-ordered fashion. (8, 9)

4. Agree on a list of activity priorities that all members can endorse. (10, 11)

5. Each member identifies the expectations he/ she believes the family holds for him/ her. (12)

6. List the home-based duties, chores, and responsibilities that are assigned to each family member. (13, 14)

7. Agree on an assignment of chores that all find equitable. (15)

8. Each family member acknowledges a responsibility to work on behalf of the family unit, not just self-interest.(16)

9. Agree to argue with each other over activity issue in a respectful, constructive manner. (17, 18, 19)

10. Verbalize feelings and beliefs over the lack of quality time family members spend together. (20, 21)

11. Each family member lists the pros and cons about being close with one another. (22, 23, 24)

12. Implement activities that build family unity and bonding. (24, 25)

13. Identify symptoms of a mental illness in the too-often- absent family member or in his/ her family of origin. (26, 27, 28)

14. Accept referral for psychological treatment of the mentally ill family member. (29, 30, 31)

15. Verbalize acceptance of the presence of a mental illness and the need to obtain treatment for it. (32, 33) evolved (e. g., due to financial need; learned behaviors from family of origin).

THERAPEUTIC INTERVENTIONS

1. Allow each family member to have their say about who is absent too often from the family and for what activity (e. g., dad and work; sibling and sports); discuss any differences in perception.

2. Facilitate the ventilation of feelings as experienced by each family member over the family member's absence.

3. Have each family member take ownership of their feelings and behaviors.

4. Help the family identify the problem and define the specifics (e. g., mom works too much and does not have time for us).

5. Trace how the activity/ family imbalance problem

6. Utilize assessment techniques to help define the problem and its historical roots (e. g., genograms, Family-of-Origin Scale [Hovestadt, Anderson, Piercy, Cochran, and Fine], or Family of Origin Inventory [Stuart]).

7. Solicit each family member's opinion on why the excessive energy is directed outside of the family.

8. Have each family member express their priorities for how time is spent (family time, work, recreation, friends, Internet, etc.). Request that they rank order them according to what each perceives as being most important.

9. Have family members compare their lists of priorities and discuss how and why they are different; also explore how the priorities have come to be so different.

10. Develop a joint family list of priorities by attempting to facilitate agreement between members on what the ranking of priorities in the family should be.

11. Explore issues that may be interfering with the cohesive, rank-ordered list of priorities (e. g., need for attention or fear of not having enough income).

12. Explore the perceived expectations the family members hold for one another (e. g., dad's belief of what his wife and children expect of him; an oldest child's perception of his family's expectation of him); compare these to actual expectations.

13. Open up a forum for the discussion of what home-based duties and responsibilities have been assigned to individual family members; poll each family member on what they believe would be a fair distribution of duties and responsibilities and why.

14. Bring to the surface any underlying beliefs about how the delegation of chores should be based on income earners versus nonincome earners, adults versus children, and so on.

15. Assist the family in developing a fair method for assigning chores to various family members (e. g., suggest using a lottery drawing to randomize assignment of chores).

16. Confront family members who appear to be attempting to shirk their responsibilities. Discuss the need to take responsibility for their own behavior and to work for the good of the family unit, not just themselves.

17. Explore the issue of jealousy and envy and how this plays into the conflicts between family members over the activity/ family imbalance issue.

18. Focus on specific arguments over time allocation within the family and how these have developed.

19. Suggest some appropriate, more constructive means of expressing disagreement over the activity issue (e. g., using "I" statements rather than "you" statements; staying calm and respectful in tone).

20. Facilitate family members in ventilating their feelings about the lack of time they have with each other or the unequally great amount of time spent with a specific family member.

21. Probe whether certain family members may be avoiding each other or avoiding intimacy by remaining overly involved in the external activities.

22. Ask each family member to list the pros and cons of being a part of a close family unit. Assess whether the family has a problem with being closely knit.

23. Use an assessment inventory to define the nature of relationships within the family (e. g., the Index of Family Relations [IFR] in the Walmyr Assessment Scales Scoring Manual [Hudson]).

24. Discuss the results of the assessment inventory and the implications for family relationships.

25. Suggest ways to build family intimacy, such as social or recreational activities or playing the UnGame (Zakich) together.

26. Investigate whether there is a history of mental health problems in the family of origin of the too-often-absent member.

27. Determine whether the family member who is spending excessive time outside the home may be struggling with a mental health issue (e. g., obsession, addiction, or a more serious psychiatric problem, such as bipolar disorder).

28. Suggest a more in-depth evaluation via referral of the too-often-absent member to another mental health professional (clinical psychologist, psychiatrist, etc.).

29. Discuss the various treatment options for the mentally ill family member (outpatient, inpatient, etc.).

30. Assist the family in identifying methods for supporting the mentally ill family member (intervention, support groups, etc.).

31. Discuss using a buddy system for family members both within and outside of the family (e. g., local chapter of Families of the Mentally Ill or the American Red Cross) to gain support in coping with mental illness in the family.

32. Confront the issue of denial of mental illness on the part of any family member, including the one with the diagnosed illness.

33. Attempt to uncover any enabling process within the family system that may be reinforcing the denial of mental illness.

DIAGNOSTIC SUGGESTIONS

Axis I:

309.24 Adjustment Disorder With Anxiety 309.0 Adjustment Disorder With Depressed Mood

309.28 Adjustment Disorder With Mixed Anxiety and Depressed Mood

309.3 Adjustment Disorder With Disturbance of Conduct

300.4 Dysthymic Disorder 300.02 Generalized Anxiety Disorder

296.2x Major Depressive Episode, Single Episode V61.20 Parent-Child Relational Problem

296.5x Bipolar I Disorder 296.89 Bipolar II Disorder

301.13 Cyclothymic Disorder

Axis II:

301.81 Narcissistic Personality Disorder 301.6 Dependent Personality Disorder

301.9 Personality Disorder NOS

301.5 Histrionic Personality Disorder

BEHAVIORAL DEFINITIONS

1. Parents experience conflicts with adolescent child that begin to interfere with the family's overall functioning.

2. Parents argue with each other over how to respond to the adolescent's disruptive nonconforming behaviors.

3. Family members resent the adolescent-centered conflict, increasing tension in the home.

4. Parents feel a loss of control and the adolescent feels empowered by parent's dilemma, making his/ her own rules and resisting parental intervention.

5. Adolescent acts out in areas of substance abuse, sexuality, school performance, and/ or delinquency.

LONG-TERM GOALS

1. Parents arrive at some level of agreement regarding how to respond to the adolescent.

2. Parents reduce the effects of the adolescent's misbehavior on other family members.

3. Parents learn new methods for working together to achieve harmony and balance in the family.

4. Parents devise and enforce a set of rules and standards that promote peace and harmony in the family.

5. Parents feel empowered to take control of the family and react firmly to adolescent acting out.

SHORT-TERM OBJECTIVES

1. Define the specifics about what needs to change in the adolescent's behavior. (1, 2)

2. Parents clarify philosophy on parenting expectations for the adolescent. (3)

3. Parents and adolescent cooperate with psychological testing to identify specific areas of parent/ child conflict. (4, 5)

4. Identify family, school, or marital factors that may be contributing to the adolescent's undesirable behavior. (6, 7)

5. Parents identify their strengths and weaknesses in parenting style. (8, 9)

6. Parents read books and watch videotapes on parenting adolescents. (10)

8. Parents identify and record the occurrence of a specific desirable behavior of the adolescent's that they would like to see increase in frequency. (14)

9. Implement a behavioral contract to increase the frequency of the adolescent's target behavior. (15)

10. Increase the frequency of positive social-or activity-oriented interactions between parents and the adolescent. (16)

11. Establish and implement consequences for negative adolescent behavior (e. g., the use of response cost). (17)

12. Parents identify and make an effort to terminate any undesirable behaviors that they may be modeling for the adolescent. (18, 19)

13. Parents confer with each other frequently to increase mutual support in parenting. (20, 21)

14. Parents use structured dialogue techniques to ensure good parental communication for problem solving. (22)

15. Parents minimize criticism of the other's parenting efforts. (23)

16. Parents discuss disagreements only at times when discussion is likely to be constructive, and not in the presence of the children. (24)

17. Parents identify and replace distorted cognitive beliefs that relate to parenting their teenager. (25, 26)

18. Family members hold family meetings regularly and conform to the rules of interaction. (27, 28)

19. Family members demonstrate empathy and respect for other individuals' points of view by paraphrasing or reflecting speaker's position before responding. (28, 29)

20. Parents list alternatives to their current parenting methods. (30)

21. Parents enact alternative parenting styles and evaluate their effectiveness. (31)

22. Identify and challenge unreasonable beliefs and expectations regarding adolescent behaviors. (32)

23. Parents establish consistent house rules and regulations. (33, 34)

24. Family establishes a regular dinner hour and sets rules regarding how often members will be present. (35, 36)

25. Parents go out alone at least one night per week for socialization and/ or recreation. (37)

1. Open up the forum for family members to share their perception of the adolescent's behavior and discuss feelings about the adolescent's behavior.

2. Assess whether the adolescent's acting-out behavior is transient or is a more stable pattern.

3. Have parents share their philosophy on parenting and what expectations they have for their son or daughter.

4. Use specific questionnaires and inventories to assess specific areas of conflict and how the family may be contributing to the problems (e. g., Adolescent Coping Orientation for Problem Experiences [A-COPE] in Family Assessment Inventories for Research and Practice [McCubbin and Thompson]).

5. Assess the family members' belief system about appropriate versus inappropriate behavior by utilization of interviews and questionnaires (e. g., Family Beliefs Inventory [Roehling and Robin] or Parent-Adolescent Relationship Questionnaire [Robin, Koepke, and Moye]).

6. Explore familial interaction patterns or dynamics that may be exacerbating the conflict between adolescent and parents (underlying conflicts, family-of-origin issues, unrealistic expectations, marital problems, etc.).

7. Explore environmental stressors that may be exacerbating the adolescent's acting out (e. g., family transitions, inconsistent rules, school or social difficulties, peer relationships, or peer pressure).

8. Role-play a parent/ adolescent conflict to assess how parents solve the problem; give parents feedback regarding the strengths and weaknesses of their approach.

9. Teach how the adolescent's strengths can be augmented and his/ her weaknesses diminished.

10. Recommend parents read books on parenting techniques (e. g., Understanding the Adolescent [Orvin]; Parents, Teens, and Boundaries: How to Draw the Line [Bluestein]; Parents and Adolescents: Living Together, vol. 1, The Basics, and vol. 2, Family Problem Solving [Patterson and Forgatch]; or Living with a Work in Progress: A Parents Guide to Surviving Adolescence [Goldberg-Freeman]).

11. Ask parents to develop monitoring for their adolescent, knowing where he/ she is, who he/ she is with, what he/ she is doing, and when he/ she will be home.

12. Assign parents to record their joint monitoring efforts with the adolescent as a homework assignment.

13. Ask parents to discuss their successes at monitoring and to identify events or situations in which monitoring requires improvement.

14. Ask parents to select a behavior of the adolescent's that they would like to see decrease or diminish. Ask them to record its occurrence every day for a week, and notice the behaviors or situations that precede it (antecedents) and follow it (consequences).

15. Have parents decide on an appropriate reward system (e. g., verbal praise, use of the car, allowance) to reinforce the positive target behavior of the adolescent; seek agreement between parents and adolescent for this behavioral contract.

16. Recommend that each parent increase the number of parent-initiated, casual, positive conversations with the adolescent.

17. Develop with parents a response cost/ procedure to use in conjunction with the adolescent's targeted negative behavior; assign implementation and review success.

18. If parents are modeling for the adolescent the behavior they would like to extinguish (e. g., yelling or becoming sarcastic), have parents become aware and contract to change their own behavior before trying to change the same behavior in the adolescent.

19. Teach parents techniques of anger control to better mediate conflict.

20. Ask parents to role-play support for each other regarding their reaction to the adolescent's misbehavior; have the supportive parent ask (in a supportive, non-threatening manner) how the other parent deals with the misbehavior and whether the supportive parent can do anything in the future to help.

21. Have parents contract to support the other's parenting by not interfering during the other's parent/ adolescent interactions or with the other's decisions (i. e., avoid splitting their parental unity).

22. Teach parents communication and problem-solving skills (see Relationship Enhancement [Guerney]) to use with the adolescent as well as each other (e. g., problem definition, brain-storming solutions, evaluation of alternatives, solution enactment, and enactment evaluation).

23. Help each parent identify when they are engaging in criticizing the other parent in a nonconstructive manner.

24. Help parents establish a practice of meeting in private so they can discuss parenting decisions and come to a mutual agreement before presenting it to the adolescent.

25. Ask parents to track their thoughts and emotional reactions during problematic situations with their adolescent.

26. Identify and challenge unreasonable beliefs by asking parents to provide evidence for the truth of their beliefs and persuasively illuminating the illogical premise involved (e. g., "If my daughter stays out late, she will become pregnant or a drug addict" can be replaced by "I can make my opinions and the house rules known, but ultimately her behavior is up to her").

27. Have parents initiate regular family meetings for constructive problem solving and evaluation of earlier contracts. Family meetings should be time-limited (starting with 15 minutes) and should observe set ground rules (see page 117 of Parents and Adolescents: Living Together, vol. 2: Family Problem Solving [Patterson and Forgatch]).

28. Family meetings should use respectful communication rules, such as taking turns talking, treating each other with respect, and no lecturing (see page 118 of Parents and Adolescents: Living Together, vol. 2: Family Problem Solving [Patterson and Forgatch]).

29. Reinforce family members' use of communication skills (see Relationship Enhancement [Guerney] and Fighting for Your Marriage [Markman, Stanley, and Blumberg]).

30. Have parents brainstorm alternative styles of parenting that they have learned as a result of their assigned readings, speaking with other parents (through parenting groups, etc.), or previous family therapy sessions. Recommend books such as Tough Love (York, York, and Wachtel).

31. Ask parents to try the alternative parenting style to evaluate its effectiveness. Also, facilitate parents in providing each other with critical feedback afterward as to how well they perceived the alternative to work.

32. Have parents and adolescents list what they each believe is reasonable and unreasonable in adolescent behavior.

33. Have parents establish consistent house rules. Consequences for rule violation and compliance should be specified. Rules can be modified and negotiated in family meetings if necessary.

34. Reinforce the need for parents to follow through on praise for following rules as well as consequences for not following rules.

35. Discuss the feasibility of the family eating meals together; set rules about frequency and attendance.

36. Ask parents to meet with the adolescent (in session or as homework) to discuss and agree to eating dinner together as a family at least once or twice a week.

37. Encourage the parents to have one or two nights per week out alone together, or with adult friends, when children are not the focus of conversation or of the relationship.

DIAGNOSTIC SUGGESTIONS

Axis I:

309.3 Adjustment Disorder With Disturbance of Conduct

309.4 Adjustment Disorder With Mixed Disturbance of Emotions and Conduct

V61.21 Neglect of Child

V61.20 Parent- Child Relational Problem

V61.1 Partner Relational Problem

995.5 Physical Abuse of Child (Victim)

V61.21 Sexual Abuse of Child

995.5 Sexual Abuse of Child (Victim)

313.81 Oppositional Defiant Disorder

312.9 Disruptive Behavior Disorder NOS

312.8 Conduct Disorder, Adolescent Onset Type

314.01 Attention-Deficit/ Hyperactivity Disorder, Combined Type

1. Parents struggle with the issue of infertility and are considering contacting a child adoption agency or making a private adoption arrangement.

2. Parents struggle with a sense of failure and disconnectedness with the adopted child due to the lack of a biological link.

3. Parents struggle with when and if to inform the child that he/ she is adopted, and become overprotective and overindulgent.

4. Adopted child feels different, isolated, and removed from the parents and siblings, and struggles with abandonment issues regarding his/ her biological parents.

5. Parents feel a lack of connection with the adopted child as opposed to biological children.

6. Tension exists between biological and adopted children, with the adopted child sustaining badgering and ridicule from siblings, extended family-of-origin members, and so on.

7. Adopted child questions the whereabouts of their biological parents and make overtures to search for them.

8. Adopted child fantasizes and idealizes the biological parents.

9. Adoptive parents feel a sense of threat, rejection, abandonment, and even betrayal by adopted child's overtures to search for his/ her biological parents and/ or biological siblings.

10. Adopted child successfully locates biological parents and/ or biological siblings and begins to form a bond, creating friction among the adoptive family members.

11. Adopted child encounters a cold and/ or rejecting reception from biological parents and experiences negative emotions as a result.

12. Adoptive parents meet adopted child's biological parents, and tension results for all parties involved.

LONG-TERM GOALS

1. Parents work through their struggles over their inability to conceive and accept this as a dysfunction of their genetic/ biological disposition as opposed to a sense of failure.

2. Parents accept and bond with adopted and biological children equally.

3. Adopted child develops positive feelings regarding adoptive family.

4. Parents educate themselves on the issue of when and if they should inform a child that he/ she is adopted.

5. Adopted and biological children resolve tension between themselves.

6. Parents decide when and if to provide the adopted child with information regarding biological parents, and deal appropriately with any threat that develops as a result of the child's inquiry.

7. Adopted child accepts the outcome of meeting his/ her biological parents regardless of whether their reaction is positive or negative.

SHORT-TERM OBJECTIVES

1. Identify the negative impact that infertility and its treatment have had on each partner and on the relationship. (1, 2)

2. Parents verbalize an understanding that the inability to conceive is a matter of genetic/ biological factors and not due to personal failure. (3, 4)

3. Parents identify the pros and cons of telling the child of his/ her adoption. (5)

4. Parents agree as to when and what to tell the adopted child regarding his/ her adoptive origins. (6)

5. Adopted child expresses feelings associated with being adopted. (7, 8, 13)

6. Parents accept the responsibility for the child learning of his/ her adoption from a source outside of their immediate adoptive family. (9, 10)

7. Adopted child verbalizes positive feelings toward adoptive family. (11, 12, 13)

8. Parents identify the factors that cause them to experience a lack of connection with the adopted child, as opposed to their biological children. (14, 15, 16)

9. All family members identify the true source of tension between biological children and the adopted child. (17)

10. Parents verbalize acceptance of the child's need to search for his/ her biological parents. (18, 19)

11. Parents and the adopted child verbalize and resolve their fear of rejection and/ or guilt about the adopted child investigating into his/ her biological parents. (20)

12. Parents and the adopted child prepare for the possibility of the adopted child's biological parents having a negative reaction to an inquiry. (21, 22)

13. Parents accept the fact that an adopted child who is of age may choose to reside with or close to his/ her biological parents or siblings after locating them. (23)

THERAPEUTIC INTERVENTIONS

1. Allow the couple to ventilate about the hardship of enduring the infertility process.

2. Explore the stress and strain that infertility has had on the couple's relationship and how it may be precluding their ability to conceive. Recommend Infertility and Identity (Deveraux and Hammerman).

3. Educate the couple on the biological factors of failure to conceive via referral to fertility experts and readings (e. g., The Long-Awaited Stork [Glazer]). Also, help the couple locate an infertility support group in their area, either through their obstetrician/ gynecologist or the American Red Cross directory.

4. Discuss with the parents the notion that giving birth to a child is only a small part of the picture, that parenting is independent of birthing, and that a strong bond can form irrespective of the biological connection.

5. Review with the parents the pros (e. g., not having the child learn from someone else accidentally) and cons (e. g., risking the child's withdrawal from the adoptive family to search for his/ her biological parents) and timing regarding telling the child of his/ her adoption; refer them to readings (e. g., The Adoption Resource Book [Gilman]).

6. Help the parents make an initial decision regarding what and when a child should be told about his/ her adoption. Explain to them that this decision is not carved in stone and can be reevaluated and changed later.

7. Allow the adopted child to vent his/ her feelings regarding adoption in family therapy. Focus on productively processing these feelings.

8. Teach the family members that the adoptive child's emotions (e. g., anger, isolation, acting-out behaviors, and depression) over being adopted are not uncommon.

9. Help the parents process their guilt over not having informed the child of his/ her adoption, which has resulted in the child experiencing anger and rage.

10. Process how the parents arrived at the decision not to inform the child through family therapy sessions, so that the child can better understand their logic.

11. Encourage family activities that will promote the rebonding of the adopted child to parents and siblings (parental nurturing behaviors, games, family outings, one-to-one activities for the child and a parent, etc.).

12. Facilitate contact between the child and older adopted children outside of the immediate family who have accepted being adopted.

13. Recommend that child and parents read books on how it feels to be adopted (e. g., How It Feels to Be Adopted [Krementz]).

14. Assist the parents in identifying possible factors (lack of physical resemblance, absence of time in utero, etc.) that could contribute to differences in bonding with adopted versus biological children.

15. Help the parents to resolve any differences in their feelings for their adopted and biological children and to understand how this is likely to affect the entire family. (If it is identified as a more individual issue, consider referring for individual psychotherapy.)

16. Suggest to the parents that a separate couple's meeting take place between them and the therapist so that the issue of a lack of bonding with the adopted child may be addressed without any of the children present.

17. Address the entire family on the tension between the biological and adopted children. Search for any conflict between the parents to explain why this might exist. Also, help the children mediate their tensions or feuds regarding their differences.

18. Help the parents accept the fact that it is very natural and common for adopted children to be curious about their biological parents.

19. Reinforce with the parents that the adopted child's inquiries are not an overture of rejection, but a quest for his/ her existence and origin.

20. Reassure all family members that their feelings are not unusual and that fear of rejection and guilt are very common.

21. Discuss how the parents and children of the family can support one another in the event that the biological parents reject any inquiry by either the adoptive parents or the adopted child.

22. Use stress inoculation techniques and specific coping skills as advance preparation for any potential negative experiences (brain-storming with all family members their potential reactions to meeting the biological parents and how they feel about it, role-playing the initial meeting with biological parents, etc.).

23. Help the parents and family members to accept the adopted child's decision and his/ her need to rebond with his/ her biological family of origin.

DIAGNOSTIC SUGGESTIONS

Axis I:

309.0 Adjustment Disorder With Depressed Mood

309.24 Adjustment Disorder With Anxiety

309.28 Adjustment Disorder With Mixed Anxiety and Depressed Mood

309.4 Adjustment Disorder With Mixed Disturbance of Emotions and Conduct

309.3 Adjustment Disorder With Disturbance of Conduct

303.9 Alcohol Dependence 305.00 Alcohol Abuse

300.4 Dysthymic Disorder 296. x Major Depressive Disorder

V61.1 Partner Relational Problem V61.1 Physical Abuse of Adult

V61.20 Parent- Child Relational Problem 995.81 Physical Abuse of Adult (Victim)

309.81 Posttraumatic Stress Disorder

301.6 Dependent Personality Disorder

301.83 Borderline Personality Disorder

301.5 Histrionic Personality Disorder

301.7 Antisocial Personality Disorder

301.4 Obsessive-Compulsive Personality Disorder 301.81 Narcissistic Personality Disorder

BEHAVIORAL DEFINITIONS

1. The regular excessive use of alcohol by one or more members of a family unit leads to interference with functioning at work or school; to ignoring the dangers to health; to vocational, social, or legal problems; and to family and/ or marital conflict.

2. Verbal or physical abuse associated with alcohol abuse leads to serious conflicts between family members.

3. Alcohol abusers make continued failed promises to discontinue use, despite family members' pleas.

4. Violence or threats of violence have occurred, during periods of intoxication as well as during sobriety, which has placed family members at risk.

5. Communication between family members has deteriorated to such a level that familial interaction is greatly reduced, and members simply coexist without any cohesiveness.

6. Non-substance-abusing family members function in a manner that serves to enable the abusers by generating excuses for their drinking.

7. All members engage in denial of the seriousness of the alcohol abuse and the effects that this has had on the family dynamics.

8. Serious financial problems have developed as a result of excessive or frivolous spending, frequent work absences, loss of employment, and so on.

9. Social alienation between family members develops as the substance abuser gravitates toward socializing with other abusers.

10. Children engage in acting-out behaviors as a result of the lack of structure and boundaries in the family.

11. Alcohol-abusing parents overlook children's alcohol use and inadvertently reinforce early substance-abusing patterns in children.

12. Isolation from extended family and friends as alcoholic member has become unavailable or unwelcome by others.

13. Bills are not paid, checks bounce, and there is no follow-through on daily responsibilities.

14. Family experiences shame and humiliation and makes excuses for the alcohol abuser's behavior to save face.

LONG-TERM GOALS

1. Alcohol-abusing family members accept the need for abstinence and become proactive in a recovery program.

2. Alcohol-abusing family members successfully achieve a sustained and consistent reduction in frequency and amount of alcohol consumption, avoiding further negative effects on the family as a whole.

3. Family achieves improved communication and problem solving, and positive family reactions.

4. The non-alcohol-abusing family members unite and become a strong entity to support the alcohol-abusing family members in recovery.

5. Family members engage in 12-step programs such as Alcoholics Anonymous (AA) and Al-Anon, or an alternative program, such as the Sobell method or Solutions-Focused Therapy for Alcoholics.

6. Alcohol abusers terminate any physical, sexual, or verbal abuse.

7. Alcohol abusers develop coping strategies for dealing with the issues related to establishing long-term sobriety (e. g., depression and anxiety, as well as physical problems such as nutritional deficiencies and high blood pressure).

8. Extended family member or some other responsible adult takes over the parental role with the children, preventing the parentizing of the children.

SHORT-TERM OBJECTIVES

1. Identify the untoward effects of the substance abuse on the self-esteem, family life, employment, health, social relations, and personal finances of all family members. (1, 2)

2. Alcohol abuser signs a contract with respect to the controlled and moderate use of all alcohol. (3)

3. Alcohol abuser proves his/ her ability to control alcohol consumption at moderate levels by keeping a record of frequency and quantity of use. (4)

4. Read literature on controlled drinking, the effects of alcohol abuse, and family dynamics of alcohol abuse. (5, 6)

5. All family members sign a contract to be completely free of mood-altering substances during sessions. (7)

6. All family members agree to mandatory attendance at all treatment sessions except in the case of serious physical illness. (7)

7. Alcohol abuser signs a contract for complete abstinence at all times from mood-altering substances and for attendance at AA or group or individual alcohol treatment. (8, 9)

8. All family members sign a behavioral contract that stipulates that no violence or threats will be engaged in toward any other family member. (10, 11)

9. Family members implement cognitive/ behavioral techniques to manage their angry feelings. (12, 13)

10. Violent family member accepts referral for specialized behavioral treatment of explosive disorder. (14)

11. Alcohol abuser identifies attractions to or perceived benefits of the excessive use of alcohol. (15, 16)

12. Alcohol abuser implements alternative stress management actions to achieve the same desirable effects that alcohol has produced in the past. (17, 18)

13. Alcohol abuser implements assertiveness and other social skills as a replacement for alcohol use to cope with social anxiety. (19, 20)

14. All family members agree to engage in several weeks of "caring days" during which each member does something pleasing for the other family members without prompting. (21)

15. Identify opportunities for social interaction with other families, and develop a plan together to initiate contact for activities that do not involve alcohol consumption. (22)

16. Identify alternative social or recreational actions that all family members could engage in and that would be rewarding to all. (22, 23, 24)

17. All family members identify what specific characteristics derail or impede healthy communication between themselves, with an emphasis on the abusing family member's specific behaviors. (25, 26, 27, 28)

18. All family members discuss an incident or conflict using a new mode of communication that is free from any blaming or condescending language. (27, 28, 29)

19. Verbalize an understanding of and implement techniques for problem solving. (30, 31)

20. Family members report on their perception of how the family has implemented the use of a problem-solving strategy at home, sharing their individual feelings about it. (32, 33)

21. Alcohol abusers formally apologize to other family members for the pain and suffering they have caused due to their substance abuse. (34, 35)

22. Alcohol abusers identify triggers to episodes of drinking and agree to alternative, nondrinking responses to cope with trigger situations. (36, 37)

23. Family members who are not alcohol abusers acknowledge how they have been primary and secondary enablers of the alcohol abusers. (38, 39)

24. Family members confront each other about behaviors that continue the enabling process. (38, 39, 40)

25. The non-alcohol-abusing family members discuss assertive incidents whereby they have avoided enabling or taking responsibility for the alcohol abusers. (39, 40, 41)

26. Family members identify stressors that are affecting them all, especially those that encourage the alcohol use, and formulate a plan of attack. (42, 43)

27. Identify the genetic, emotional, and environmental factors that have fostered a pattern of alcohol abuse. (44)

28. Children identify the unhealthy role each has assumed in the family due to the dysfunctioning that alcoholism has brought. (45, 46, 47)

23. Family members who are not alcohol abusers acknowledge how they have been primary and secondary enablers of the alcohol abusers. (38, 39)

24. Family members confront each other about behaviors that continue the enabling process. (38, 39, 40)

25. The non-alcohol-abusing family members discuss assertive incidents whereby they have avoided enabling or taking responsibility for the alcohol abusers. (39, 40, 41)

26. Family members identify stressors that are affecting them all, especially those that encourage the alcohol use, and formulate a plan of attack. (42, 43)

27. Identify the genetic, emotional, and environmental factors that have fostered a pattern of alcohol abuse. (44)

28. Children identify the unhealthy role each has assumed in the family due to the dysfunctioning that alcoholism has brought. (45, 46, 47)

THERAPEUTIC INTERVENTIONS

1. Gather family members' perspectives on the negative effects that the alcohol abuse has had on family members and the general family dynamics; also focus on the destructive effects on the substance abuser and the impact that denial has played in this process.

2. Consider using such inventories or rating scales as the Alcohol Beliefs Scale (Connors and Maisto) to evaluate attitudes toward alcohol and the effects of alcohol abuse on quality of the alcohol abuser's and the family's life.

3. Ask the alcohol abuser to sign a contract stipulating the parameters for controlled or social drinking, such as the Sobell method (see Behavioral Treatment of Alcohol Problems [Sobell and Sobell]). Solicit an agreement that should the contract be broken after a designated number of times (e. g., 2), then a complete alcohol abstinence contract will be signed.

4. Develop a daily record form to track the frequency and quantity of alcohol use, using this record to determine the alcohol abuser's ability to consistently control his/ her alcohol intake.

5. Research and assign to the alcohol abuser and to family members the most appropriate reading materials regarding alcohol addiction and its effects, controlled drinking, and the family dynamics of alcoholism (see Behavioral Treatment of Alcohol Problems [Sobell and Sobell], How to Control Your Drinking [Miller and Muñoz], and Alcoholism: Getting the Facts [National Institute on Alcohol Abuse and Alcoholism]).

6. Facilitate a discussion on the materials recommended and have family members compare their reactions to what they read. Highlight the differences in perceptions of family members and explore how they perceive this to contribute to the overall problem.

7. Develop a joint family contract that all members sign, an agreement to attend all sessions unless ill and to be completely free of mood-altering substances (not including legitimate prescription medication).

8. If the controlled-drinking contract is broken, ask the alcohol abuser to sign an agreement of abstinence from all alcohol use, accompanied by an agreement to attend a support group (AA) or group psychotherapy for substance abusers.

9. Refer the alcohol abuser to a psychiatrist specializing in alcohol abuse for evaluation for pharmacotherapy (e. g., Antabuse).

10. Construct a written family contract specifying that no member of the family will engage in aggressive or assaultive threats on any other family member.

11. Develop a refuge plan for the safety of family members if violence does erupt.

12. Teach the use of cognitive behavioral strategies (deep breathing, cognitive restructuring, etc.) for anger control and the implementation of stress inoculation techniques (see Cognitive Behavior Modification [Meichenbaum]).

13. Teach assertiveness and assign family members to read the book Your Perfect Right (Alberti and Emmons).

14. Assess the case for the appropriateness of either individual, couple, or family therapy and for referring the acting-out family member to another provider for individual or group treatment of explosive disorder.

15. Explore those perceived benefits that the alcohol abusers are obtaining by engaging in alcohol use (acceptance by friends and peers; reduction of anxiety, social or otherwise; sleep induction; escape from family tensions; etc.).

16. Trace the alcohol abuser's history and help identify how this behavior has been reinforced at home and in the community.

17. Strategize with the alcohol abuser as to what specific behavioral exercises (meditation, relaxation, social skill or assertiveness training, etc.) can be used to replace alcohol use and/ or intoxication but obtain the benefits sought.

18. Instruct the alcohol abuser on the use and implementation of stress management (deep breathing, progressive muscle relaxation, guided imagery, meditation, etc.).

19. Use modeling and role-playing to teach assertiveness and social skill techniques, helping the alcohol abuser to weigh the pros and cons of using such techniques.

20. Administer measurement scales to assess any progress made as a result of the assertiveness and social skills training (e. g., Assertiveness Self-Report Inventory [Herzberger, Chan, and Katz] and the Social Solving Inventory [D'Zurilla and Nezu]).

21. Instruct family members on the technique of "caring days" (see Helping Couples Change: A Social Learning Approach to Marital Therapy [Stuart]) in which each member does something pleasant for other members (e. g., do a special chore without being asked; pay a nice compliment).

22. Encourage and assist the family in formulating a plan for social activities with other couples or families that do not include alcohol consumption. Suggest church, hobby, and recreational groups or work associates as possible social network opportunities for outreach.

23. Schedule a specific family recreational activity in which each family member is assigned a specific role in making the activity happen, using the Inventory of Rewarding Activities (Birchler) to brainstorm and develop a list of recreational or educational activities that might be enjoyed by the family.

24. Assign the family to choose one social or recreational activity and assess how they fare on the outcome. Have them keep notes on what they enjoy about the activity and what they do not.

25. Have each family member reflect on the manner in which they obstruct the smooth, productive course of communication (cut the others off during conversation, refuse to respond, etc.).

26. Attempt to track and resolve the origins of any miscommunication patterns that have developed (family-of-origin patterns of dysfunctional communicating, foreign language, etc.).

27. While discussing communication skills, review rules for the speaker and for the listener (see Fighting for Your Marriage [Markham, Stanley, and Blumberg]).

28. Use role-playing, empty chair, or psychodrama techniques to have family members work out a conflict, with the emphasis on using nondegrading, assertive methods of communication.

29. Reinforce positive changes toward well-mannered, respectful, empathetic communication between family members.

30. Teach the following five steps of conflict resolution: (1) define the problem (with the help of the therapist, if necessary); (2) generate many solutions, even if some are not practical, allowing for creativity; (3) evaluate the pros and cons of the proposed solutions; (4) obtain agreement on the proposed solution; and (5) implement the solutions (see family applications of problem-solving methods in "Language System and Therapy: An Evolving Idea" [Goolishian and Anderson] or the Family Therapy Sourcebook [Piercy, Sprinkle, and Wetchler]).

31. Promote family discussion of a conflictual issue in the session to view how members deal with an area of conflict, and then model implementation of problem-solving steps.

32. Assign homework regarding the use of problem-solving techniques, using specific problems that are germane to what is currently happening in the family.

33. Review family members' experience with problem solving at home, reinforcing success and redirecting for failures.

34. Recommend that the alcohol abuser formally apologizes for the pain caused to other family members due to his/ her substance abuse.

35. Help family members obtain closure on the ritual of apology so that it minimizes any barriers to the alcohol abuser's future progress.

36. Help the family identify triggers of relapse of alcohol use and instruct them on what can be done to help avoid future relapses.

37. Suggest to the family members that they develop index cards with alternative strategies for coping with alcohol abuse in the face of stimuli that trigger relapse (connecting with sponsors at AA or support groups, using stress inoculation techniques, etc.).

38. Help the non-alcohol-abusing family members identify the behaviors that they engage in (e. g., lying to cover up for the alcohol abuser's irresponsibility, minimizing the seriousness of the alcohol abuser's drinking problem, taking on most of the family responsibilities, tolerating the verbal, emotional, and/ or physical abuse) that support the continuation of the alcohol abuser's abusive drinking.

39. Use role-playing of family scenarios to guide the non-alcohol- abusing family members in not accepting responsibility for the alcohol abuser.

40. Review instances of family interaction at home in which family members have avoided enabling behaviors.

41. Brainstorm ideas among the family members as to how to more constructively respond to situations that previously precipitated enabling behaviors (not making excuses for broken promises or unfulfilled responsibilities, telling the truth regarding intoxication even if it brings painful consequences, reporting physical abuse to police, etc.).

42. Explore and identify stressors facing each member of the family.

43. Assist the family members in devising a strategy for dealing with each of the identified stressors (financial restructuring; job search; apologies to friends, neighbors, or extended family members; tutoring assistance, etc.).

44. Investigate the emotional, social, and genetic factors that facilitate the alcohol abuse and that reinforce the need for abstinence.

45. Teach family members the roles usually adopted by children of alcoholic parents (e. g., the family hero, the scapegoat, the lost child, and the mascot; see Another Chance [Wegscheider-Cruse] and Bradshaw on the Family [Bradshaw]). Help the children identify the role (or roles) each has adopted.

46. Encourage the children to give up their unhealthy role assumptions and express their needs, feelings, and desires directly and assertively.

47. Help the children brain-storm how they can develop alternative behaviors to the healthy ones.

DIAGNOSTIC SUGGESTIONS

Axis I:

303.9 Alcohol Dependence

305.00 Alcohol Abuse

300.4 Dysthymic Disorder

V61.1 Partner Relational Problem

V61.20 Parent- Child Relational Problem

Axis II:

301.6 Dependent Personality Disorder 301.82

Avoidant Personality Disorder