Addiction, families and treatment: A critical realist search for theories that can improve practice

Abstract

The stress–strain-coping-support (SSCS) model and the social-ecological (SE) model were analysed in a search for theories that can serve as a foundation for improving the assistance and support provided to families affected by addiction and alcohol and drug (AOD) problems. The basis for the analyses was a critical realist one, viewing addiction as a multilayered and necessarily laminated phenomenon. The two models approach two different layers of reality: the SSCS model highlights the importance of dealing with mechanisms at the psychological level for affected family members, while the SE model emphasizes the importance of intervening in relationships and systems at the social level of reality. Both models are highlighted as essential for dealing with the complexity of the phenomenon of addiction in families: the SSCS model by providing agency for a neglected group of affected family members and developing a method to address their needs, and the SE model by advocating the relative position of social solutions in the field of AOD treatment and developing a framework for conducting joint sessions and family therapy. Both models and their respective practical guidelines for interventions could work in a complementary way in a clinical setting, as useful tools in different types of case and at different stages of treatment – combining the level and emergence in the interaction between agency and structure – for the betterment of families and individuals.

• Affected family members
• alcohol and drug treatment
• critical realism
• families
• social ecological model
• stress–strain-coping-support model

Acknowledgements

We would like to thank Professor Willy Pedersen for valuable and constructive comments on later drafts of this article.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Notes

¹Step 1: Listen, reassure and explore concerns. Allow family member to describe the situation. Identify relevant stresses. Identify the need for further information. Communicate realistic optimism. Identify the need for future contact. Step 2: Provide relevant, specific and targeted information. Increase knowledge and understanding. Reduce the stress arising from a lack of knowledge or from misconceptions. Step 3: Explore coping responses. Identify current coping responses. Explore the advantages and disadvantages of current coping responses. Explore alternative coping responses. Explore the advantages and disadvantages of alternative ways of coping. Step 4: Discuss social support. Draw a social network diagram. Aim to improve communication within the family. Aim towards a unified and coherent approach. Explore potential new sources of support. Step 5: Discuss and explore further needs. Is there a need for further help? Discuss possible options with family member. Facilitate contact between family member and other sources of specialist help.

²To integrate the social world in service setting different aspect are highlighted: 1. Focusing on the team culture – and the readiness to incorporate a social perspective (Adams, 2008, s. 247). 2. Maximizing the first contact – establishing an expectation of social inclusion, by either developing a service policy that declares that clients will only be seen if they attend with other people in their lives or a representative from a community club, or make a strong recommendation for this (Adams, 2008, s. 248f). 3. Responding to safety issues – assessing the risks and being aware of controlling tactics and counter-reactions in the session (Adams, 2008, s. 249f). 4. Preparing the environment – establishing a family-inclusive service environment, with a venue design and room layout that is welcoming to families (Adams, 2008, s. 251). 5. Social assessment – assessing how the person in the addictive relationship connects to the addictive social system with the participation of intimates (Adams, 2008, s. 252f). 6. Reintegration plans – determining the strengths and capacities within the social system and setting up a framework for achievable steps in a process of social reintegration, where the “case” is the addictive system. The goal in the plan is based on a negotiation outcome of all participants, with an appropriate timeline (Adams, 2008, s. 259f). 7. Facilitative meetings – where expertise is seen as emerging from within the social environments itself. Participation in meetings with several people from an addictive system; meetings with couples, meetings with families, community meetings, multiple family groups, one-to-one sessions and volunteer networks (Adams, 2008, s. 263ff).

³Orford et al. refers to three main ways in which family members cope with addiction: “becoming independent”, “putting up with it” and “standing up to it”. Standing up to it involves an active engagement and effort to pursue change in the family environment (Orford, Velleman, Copello, Templeton, & Ibanga, 2010, p. 54).