Application of Systemic Motivational Therapy to Alcohol Addiction | Karen Kaiser, Ph.D.

The United States is battling a drug epidemic that is destroying the lives of many of its citizens, both those misusing substances, and their families (Maxwell, 2011, Stehr,2015, & Tiger, 2017). One in three people will develop a problem with alcohol at some point in their life, and one in eight will become dependent on alcohol (National Institute on Alcohol Abuse and Alcoholism, 2015). A high number of those who misuse alcohol go on to misuse other substances (National Institute on Alcohol Abuse and Alcoholism, 2008). Those with co-occurring alcohol and other drug use disorders often have more severe dependence-related problems, both with alcohol and other substances (National Institute on Alcohol Abuse and Alcoholism, 2008).

The Biopsychosocial model of addiction is based on principles that multiple biological, psychological, and sociological elements combine to influence or cause addiction (Lewis, 2013). The model proposes that there are biological, psychological, and environmental underpinnings to addiction. Environmental factors include all things around us, including relationships with family members (Lewis, 2013).

The damaging effects of substance misuse falls equally on all family members (Steinglass, 2009). There is evidence for working with the family system to abate the negative impact of substance misuse on each family member. Including family members in treatment significantly increases abstinence from alcohol and illicit drugs (Meyers et al., 1999). This paper proposes the use of Steinglass’ Systemic Motivational Therapy (SMT) model to work with the family system to treat alcohol addiction. SMT was developed to specifically work with families struggling with chronic alcohol misuse (Steinglass, 2009). The model uses a family systems approach with elements of motivational interviewing (Steinglass, 2009). The family, and family interactions are the focus of SMT treatment.

Substance Abuse and the Family
Review of the literature on substance misuse and families reveals the following: 1) Substance misuse effects family members equally although in different areas of life, 2) including family members in treatment facilitates the substance user’s engagement in treatment, 3) families members organize around the substance user’s pattern of addiction, and 4) family members can be successfully taught techniques to help modify the substance user’s behavior (Meyers et al, 1999 & Steinglass, 2009). Steinburg found three distinct phases of behavior within the home regarding family’s style of regulating their environment with the existence of alcohol dependent family members (Steinglass, 1981). Steinglass found variations in the degree of rigidity versus flexibility of behavior and hypothesized that alcoholic family members’ behavior may overwhelm families’ ability to cope (Steinglass, 2009). Therefore, families adjust to individuals changing pattern of substance use.

Families in either stable wet and transitional phases proved to have rigid patterns of behavior; those in the stable dry phase had flexible patterns. The findings provide an initial insight into how families manage a chronic disease process in their home environment (Steinglass, 1981, p. 1).

Application of Systemic Motivational Therapy (SMT)
The therapist’s role in the SMT model is one of clinician-researcher (Steinglass, 2009). The therapist partners with the family, and assumes a neutral, but questioning stance to understand family culture and dynamics. This makes SMT highly appropriate for use with individuals from different cultural backgrounds. The therapist works with families to understand how substance misuse interrelates with family life, explores family beliefs regarding substance use, and identifies family strengths that may be mobilized to address substance use (Steinglass, 2009). Therapist characteristics of positive regard, active listening, empathy, and patient empowerment are central to SMT (Steinglass, 2009).

Therapeutic goals of SMT treatment include assessing the interrelationship between alcohol use/misuse and family life and understanding family-level beliefs and related substance use to help the family mobilize as a group to develop techniques to resolve substance misuse and achieve abstinence (Steinglass, 2009). Understanding the above family dynamics is seen as a crucial part of the family assessment and is vital prior to treatment planning, including recommending potential detox level services (Steinglass, 2009). Working with the family early-on to develop treatment goals will improve treatment success as it will affect substance user engagement.

Together, the family and therapist explore pros and cons of different approaches to treatment, and develop strategies to address substance use (Steinglass, 2009). The therapist helps the family not only realize its strengths and expertise, but helps the family mobilize strengths and expertise to disentangle the family from the web of chronic substance misuse.

The family hypotheses about causes of substance misuse and difficulty within the family (Steinglass, 2009). The family develops “mini-experiments” to address the substance use and formulate outcome criteria to assess success or failure of the strategies used (Steinglass, 2009). Changes in treatment are made according to the success or failure of the mini-experiments. The family takes primary responsibility for developing and implementing treatment strategies in SMT. While the therapist provides clinical expertise, collaboration and support.

Advantages to SMT include its use with various family sizes, including couples, as well as its usefulness with individuals from various cultures. In addition, SMT may be adapted to work with various behavioral health concerns (Steinglass, 2007).

The family is the focus of treatment in SMT. Some would consider this a disadvantage. In fact, SMT does not neglect the individual who is misusing substances. SMT has a holistic focus that includes substance use cessation, and improving social and family interactions. In addition, SMT addresses family ambivalence to substance misuse, as well as the multigenerational passing down and progression of substance use disorders.

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Meyers, R., Miller, W., Hill, D. and Tonigan, J. (1999) Community reinforcement and family training (CRAFT): Engaging unmotivated drug users in treatment. Journal of Substance Abuse, 10: 291–308.
Lewis, T. F. (2013). Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory. Hoboken, NJ: Pearson Learning Solutions.
Steinglass, P. (2009). Systemic-motivational therapy for substance abuse disorders: an integrative model. Journal of Family Therapy, 31(2), 155-174.
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Steinglass, P. (2009). Systemic-motivational therapy for substance abuse disorders: an integrative model. Journal of Family Therapy, 31(2), 155-174.
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