Chapter 27. Family Therapy
Peter Steinglass
Abstract
In a paper published in the Quarterly Journal of Studies on Alcohol in 1953 , Thelma Whalen claimed to have identified four specific patterns of behavior in wives of alcoholic men that she hypothesized might be causative in the onset and/or perpetuation of their husbands’ abusive drinking. The concept Whalen advanced was that the deep-seated intrapsychic conflicts these women were experiencing were being resolved via their marriage to alcoholic men. Pejorative names were given to these wifely patterns, such as “Suffering Susan,” a name meant to describe a woman who was satisfying a need for self-punishment, or “Punitive Polly,” a name coined to connote a woman who would seek out a man she could dominate to satisfy her own intrapsychic needs. Whalen’s ( 1953) paper reflected a pervasive view held among many clinicians at the time that wives and families of patients with serious psychiatric disorders often had a negative influence in that they either caused or tended to exacerbate the patient’s symptomatology. In the case of alcohol-related disorders, the implication was that increased relapse rates in particular could be attributed to ways in which spouses and families were undermining recovery. Furthermore, Whalen suggested that in many instances spousal psychopathology might be an etiological factor in the onset and perpetuation of chronic alcohol misuse. Whalen’s clinical vignettes purportedly provided examples of this linkage. Similar hypotheses were also prevalent as explanations for chronic opioid addiction. A frequently mentioned hypothesis was that women married to drug-addicted men were attracted to these men out of desire to partner with men they considered weak (Taylor et al. 1966). Once again, the suggestion was that personality disorders in these women led them to select marriages in which they felt they could dominate their opioid-addicted spouses, and perpetuating their husbands’ chronic opioid use served one of their central psychopathological needs. In these hypotheses regarding substance use disorders (SUDs)—both alcohol use disorder (AUD) and opioid use disorder (OUD)—the implication was that psychopathology in these women was somehow responsible for the emergence and maintenance of their spouses’ addictive behaviors. By extension, therapeutic strategies for patients based on these hypotheses called for the separation of users from spouses and families. Marital and/or family therapy was thought to be not only unhelpful but also potentially counterproductive. Subsequently, over the next several decades, others working in the addiction field began noting the profound negative impact that excessive alcohol and drug use had on families (Hurcom et al. 2000). Perhaps the greatest attention was given to the increased incidence of domestic violence associated with these disorders (Chase et al. 2003; Chermack et al. 2008), but the linkage between SUDs and substantially higher rates of sexual abuse (especially of children), legal difficulties and incarceration, financial crises, divorce, work disruptions, and the like all pointed to the profound negative impact of these conditions on family life (Copello et al. 2005). Although no one was arguing that SUDs were the only factors leading to such powerful family events as physical abuse or family breakups, assumptions that there might be a direct link between alcohol and/or drug abuse and increased marital and family problems were unavoidable because of the markedly increased rates of these events in families in which SUDs were also present. Additionally, SUDs have been found to create in families a myriad of emotional responses, including grief, despair, helplessness, hopelessness, and uncertainty about the future. More recently, the growing opioid epidemic in the United States over the past decade has amplified public awareness of the profoundly negative effects of excessive drug use on families, particularly on children and their caregivers, secondary to opioid and heroin overdoses. While many clinicians seemed to be arguing that families were negative influences in the lives of patients with SUDs, the data on the impact of SUDs on family life suggested something quite different—namely, that families have a powerful stake not only in successful SUD treatment but also in treatment approaches that address the needs of all family members, not only those of the substance users. Put another way, clinicians should think of families as natural allies in their efforts to design and implement family-focused interventions for SUD treatment, rather than subverters of the therapeutic process. This change in how families living with SUDs were viewed—from considering them as dysfunctional potential contributors to the onset and/or perpetuation of substance abuse to thinking of them as distressed individuals struggling to cope with the sequelae of an SUD—has paralleled similar shifts in thinking among family therapists about how to approach treatment for families dealing with major psychiatric or chronic medical conditions (Heru 2006; Patterson and Garwick 1994). What makes these newer models significantly different from earlier ideas is that they move away from describing the difficulties apparent in these families as problems residing solely in individual family members. Instead, these models use as their starting point the examination of patterns of interaction directly related to a family’s efforts to cope with a chronic psychiatric or medical disorder. This view, in turn, has ushered in a different perspective on the potential value of family therapy for any chronic psychiatric or medical condition, including a substance use disorder.