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Substance Use Disorder Treatment and Family Therapy: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 39.)
Substance Use Disorder Treatment and Family Therapy: Updated 2020 [Internet].
Show detailsKEY MESSAGES
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The key to integrating family-based interventions into substance use disorder (SUD) treatment programs is to create a family-centered culture throughout the organization.
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Cross-training and ongoing supervision are essential for SUD treatment providers to achieve competency in family-based interventions.
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Clinical supervisors overseeing integration efforts should have experience and training in family counseling as well as SUD treatment.
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Provider collaboration supports greater service access and a “no wrong door” approach to treatment by facilitating successful referrals, effective engagement, and meaningful partnerships with community resources.
Helping individuals and families initiate and sustain long-term recovery contributes to the overall health of communities and lowers societal healthcare costs. Many programs already involve families in the SUD treatment process in some way, such as through family psychoeducation groups. Even so, integrating family counseling into SUD treatment may require administrators to make significant investments of time and resources—but the benefits to clients, families, and communities make such investments worthwhile.
As a program administrator, director, or clinical supervisor, you can lead your SUD treatment program in making changes to incorporate family-based interventions into existing services.
Doing so will help:
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Improve long-term recovery outcomes for your program's clients and their families.
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Harness the support of family members as a source of recovery capital for clients with SUDs.
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Improve clients’ family functioning.
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Protect against substance misuse among family members who are children or adolescents.
Including family-based interventions in SUD treatment settings at any level of intensity requires a systematic, continual administrative effort. This chapter provides guidance that will help you initiate and maintain integration efforts by exploring how to:
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Develop a family-centered culture in your organization.
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Incorporate and improve the quality of family counseling and family-based interventions.
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Facilitate workforce development that will support integrated family counseling for SUDs (e.g., providing ongoing staff education about family counseling; hiring new staff members with family and marriage counseling credentials to provide more intensive family counseling).
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Establish or expand collaboration with community-based family therapists and other family-centered social service providers and programs.
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Address programmatic issues related to the integration of family counseling and SUD treatment, such as reimbursement, regulations, and outcomes monitoring.
Developing a Family-Centered Organizational Culture as an Administrator
A family-centered organizational culture fosters SUD treatment practices that promote dignity and respect, refect cultural responsiveness, and focus on family strengths and resources. It creates a welcoming atmosphere and invites family members of all ages into treatment and recovery activities. A family-centered organizational culture also encourages development of program activities that leverage the power of family systems and acknowledge the potential of family members—including those with SUDs—to be positive influences and resources for each other and for other families.
The key to integrating family-based interventions into SUD treatment programs is to create a family-centered culture throughout the organization.
With your clients’ permission, try to involve family members in all aspects of SUD treatment programming. Ideally, clients’ families will have a voice in developing and running activities. Even program evaluations and outcomes research should refect families’ perspectives. By prioritizing the inclusion of families in SUD treatment, you can identify counseling interventions and family-centered program activities that best address the needs of the clients and families you serve.
Engagement
Ensure that all staff members understand how your agency will engage families throughout SUD treatment and family counseling processes and activities. Well-integrated family counseling for SUD treatment refects a family-centered organizational culture across a range of programming, such as:
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Screening and assessment for substance misuse and family issues.
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SUD treatment.
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Family counseling and family-based interventions (e.g., to address intergenerational substance misuse issues).
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Education and engagement (e.g., parent education; web-based psychoeducation about SUDs).
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Community partnerships.
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Home-based counseling and family case management services.
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Process and outcome evaluations.
Promote respectful, nonjudgmental interactions between clients and agency staff at all levels to enhance and maintain engagement. Engagement begins at first contact with clients or family members, so it is essential that your staff members refect a family-centered program culture from the outset.
At an administrative level, you can foster family-based SUD engagement by:
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Informing clients of your services and family-oriented SUD treatment philosophy via brief, easy-to-read materials (e.g., plain jargon-free language; text big enough for older clients and those with vision difficulties to read). Consider having a client/family “bill of rights” in these materials.
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Using family-oriented language in client and family interactions and in all written materials.
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Adapting all client-related materials into diverse languages refecting the cultural/ethnic groups in your community. (See also TIP 60, Using Technology-Based Therapeutic Tools in Behavioral Health Services [Substance Abuse and Mental Health Services Administration (SAMHSA), 2015].)
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Providing free self-assessment tools, such as the Alcohol Use Disorders Identification Test.
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Informing clients at intake or first contact about the benefits of family involvement in treatment and addressing their ambivalence or anxiety about including family members.
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Linking clients and their families with community services that address critical needs, such as housing, employment, or health care.
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Reaching out to families of people with SUDs or mental disorders by offering information about your services in nontraditional settings.
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Providing transportation to your facility for clients and their family members through recovery volunteers, peer recovery support specialists, or case managers.
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Conducting brief interventions over the phone when potential clients or family members call, such as with a motivational interviewing (MI) script that trained support staff can administer (Loveland, 2014).
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Promoting reengagement with clients who have returned to substance use or have had recovery setbacks by welcoming them and their families back into treatment with respect and optimism.
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Keeping demands on family schedules in mind when arranging interviews.
To improve access and engagement, consider an open-access model for initial engagement with clients and family members. In this model, programs set a certain number of hours a day during which clients can walk into one or more access points (e.g., outpatient counseling program or primary care office) without an appointment for an initial intake and admission to available treatment services.
Environment
To foster family-based SUD treatment engagement, create a warm, inviting treatment environment that feels safe and accessible for family members of all ages. Such an environment may have:
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Large counseling rooms or spaces that can accommodate a family or multiple families.
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Child-sized furniture and colorfully painted walls in designated family treatment spaces.
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Free or low-cost child care at the facility, active linkage to childcare providers near the facility, or linkages to financial resources to pay for child care.
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Adaptations to make navigating the facility easier for clients with mobility issues (e.g., older clients).
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Age-appropriate materials (e.g., coloring books to occupy younger children; large-print handouts to provide information for older family members who may have impaired vision).
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Educational programming for family members of all ages, complete with age-appropriate information and educational activities to help them understand the effects of substance misuse on their families.
Incorporating Family Counseling and Family Programming
Integration helps avoid duplication of services, lessen the artificial split between counseling for family problems versus SUDs, and increase treatment efficiency and effectiveness for clients and families. Most SUD treatment agencies serve diverse clients with a range of substance misuse profiles. The array of client needs, multiple family influences, and differences in providers’ training and priorities can compound the challenges of addressing substance misuse. To offset these challenges, professionals—including administrators—in family counseling and SUD treatment should work together. The resources, insights, and strategies each field can bring to programming will enhance treatment.
Understand the various degrees to which family counseling can be incorporated into SUD treatment. There are many ways to provide family-based interventions along the continuum of SUD treatment and recovery support services. You may opt for full integration in your program, offering both family counseling and SUD treatment in the same facility (whether the same or different counselors provide each service). Alternatively, you can build partnerships with other agencies to create a comprehensive referral network for SUD treatment and family counseling services. Exhibit 6.1 provides a framework for levels of integration of family-based interventions in SUD treatment programs.
Encourage open communication about family counseling and family-based interventions, as well as mutual respect between SUD treatment providers and family counselors. Whatever your program's current level of integration, it is essential for you to encourage an organizational culture that values both types of services. SUD treatment providers and family counselors should know when to refer clients and when to consult with counselors or clinical supervisors in the other field. To deliver effective services, providers in each field should coordinate and tailor their approaches so that clients and families who receive family counseling get the most benefit from family-based SUD treatment.
Facilitate cross-training and clear procedures for referral and follow-up. As an administrator, you can foster ongoing communication by creating specific procedures for referral and follow-up with providers from other organizations. You can also invite providers from other agencies to participate in cross-training (Exhibit 6.2) on family-based interventions and SUD treatment.
Understand what makes a fully integrated SUD treatment and family counseling program work. Full integration means that services at all levels refect fully functional operations, policies, procedures, and philosophical approaches to providing family-based SUD interventions. The following paragraphs describe some characteristics of fully integrated programs:
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All staff—from support staff to the executive director—understand the important role of the family as a potentially positive influence on clients in the treatment and recovery process. They have resolved any ambivalence they may have had about making clinical, administrative, and structural changes to integrate family services into the program. They are ready to take action.
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Administrators, program managers, and clinical supervisors reinforce written policies and procedures for including families in program activities. A manual describing how to manage issues specific to family counseling is in place and available to all clinical and nonclinical staff (Exhibit 6.3).
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All clinical staff receive cross-training in and are comfortable with and competent in providing family-based interventions, SUD treatment approaches, and family case management within their licensing and scope of practice. They are knowledgeable about community social services and recovery resources.
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Culturally and linguistically responsive, age-appropriate practices are implemented throughout the organization and inform all policies and procedures. Staff members:
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Have cultural competence training.
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Use treatment strategies that promote dignity and respect for clients.
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Can discuss issues without inhibition or fear of termination.
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Where possible, reflect the cultures and native language of the clients and families the program serves.
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Financing and human resources are adequate to implement and sustain family counseling and family-based interventions and recovery activities.
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Social, individual, and family supports are in place to improve family relationships and involve family members in relapse prevention and recovery maintenance efforts. Established linkages exist with social service agencies to provide assistance with transportation, housing, medical care, food, and childcare services.
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Program infrastructure is robust (e.g., physical space is sufficient and accessible; there are supports for Internet, video, and other multimedia; multilingual program materials are available).
Additional considerations may include policies for nonclients on the treatment premises, security of the building, liability insurance, and service reimbursement.
Supporting Workforce Development
Workforce development plays a key role in delivering quality SUD treatment services to individuals and families affected by substance misuse. Per a family-centered SUD treatment philosophy and mission, workforce development efforts should orient all staff to the importance of engaging family members in the treatment process and providing family-centered services.
Differing philosophies, education, training, and licensing requirements among SUD treatment providers and family counselors can complicate administrative issues in family-centered SUD treatment programs. For example, SUD counselor training focuses mostly on individuals with SUDs, yet family-based SUD interventions require SUD counselors to have training in family-based psychoeducational and counseling approaches. Licensed family and marriage therapists, clinical social workers, mental health counselors, psychiatric nurses, and clinical psychologists may have more education in family systems theory but less in SUD treatment approaches. These providers will not be able to make appropriate referrals for screening, assessment, diagnosis, and treatment of SUDs—unless they also receive the necessary training to conduct these aspects of service themselves.
All clinical staff need training in how substance misuse affects family systems, family dynamics, and initiation and maintenance of family recovery. SUD counselors who provide family-based interventions need family-centered counseling competencies, which often require intensive training to develop. Their clinical supervisors should be trained in family counseling or licensed as marriage and family therapists.
Hiring and Retention
Recruit counselors who are interested in and comfortable with working with families; prioritize candidates with specific education, training, lived experience, or professional history in working with families. SUD treatment counselors have specialized knowledge of addiction and recovery but may be unfamiliar with the theories and techniques of family systems interventions. They may realize the influence a family exerts on one's use of substances, but some may see family issues as a threat to their clients’ recovery, particularly when clients feel overwhelmed and unable to cope with their families’ reactions to treatment and the intense emotions that can be evoked in treatment.
Nevertheless, addiction counselors who are enthusiastic about working with families can be as effective as family counselors who are well acquainted with the operation of family systems but may not fully understand the needs and stresses of people with SUDs. Peer recovery support specialists and recovery coaches, including those who have lived experience as a family member of someone with an SUD, can also be valuable members of the clinical team.
Match staff members’ family-centered duties and responsibilities with their educational background, certification or license, training, and scope of practice. Staff members interested in working with families need ongoing training, in-house mentoring, and sufficient resources. For example, addiction counselors may be qualified to provide family intake, family psychoeducation, family recovery support groups, or family consultations, but providing ongoing family counseling may be outside their current scope of licensure and practice. However, with administrative support that facilitates proper training and ongoing supervision, bachelor's- and master's-level addiction counselors can provide evidence-based family interventions like behavioral couples therapy (Rowe, 2012) or manualized approaches like the family education component in the Counselor's Treatment Manual: Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders (Center for Substance Abuse Treatment [CSAT], 2006b, 2006c).
Provide incentives for staff members to further their understanding of and training in family-based counseling for SUDs. SUD treatment providers may need motivation to acquire more intensive training and coaching in family-centered, evidence-based practices that ensure fidelity and quality service. They are more likely to find this motivation in programs that reward ongoing professional development with opportunities to move up the career ladder with commensurate job title changes and salary increases.
Core Competencies
Counselors need specific knowledge, attitudes, and skills to shift from an individual to a family systems focus in their approach. Level of family involvement in treatment falls on a continuum. It may be as simple as providing collateral information to counseling staff during assessment and treatment, or it may be as intensive as attending psychoeducational sessions and participating in family counseling.
Core competencies for working with families differ among professions, but all providers and administrators across the continuum of care should be able to understand the complexity of the clients’ family networks and interactions with their families (Gehart, 2018). How counselors apply that knowledge varies by level of family involvement and complexity of the family-based intervention.
Acknowledge core competencies for family counseling as a framework for training, supervision, performance evaluation, and professional development. Across the continuum of care, SUD treatment providers who offer family-based interventions should understand (CSAT, 2006a; Gerhart, 2018):
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How counselors’ own family histories and issues affect their interactions with and perceptions of the dynamics of families in SUD treatment.
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Systems concepts, theories, and techniques foundational to family-based interventions.
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The diverse cultural factors that influence the characteristics and dynamics of families and couples.
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Risks and benefits of couples- and family-based interventions.
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How, when, and why to involve clients’ families and significant others in treatment and recovery.
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The effects of substance misuse on family communication, roles, and dynamics.
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The characteristics of families, couples, and significant others affected by substance use.
SUD treatment providers who offer family-based interventions should also demonstrate the ability to:
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Show genuine care and concern for clients’ family members and significant others.
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Respect the contributions of significant others to the treatment and recovery process.
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Engage family members and significant others throughout the treatment and recovery process.
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Identify systemic interactions likely to affect recovery (e.g., by recognizing the roles of significant others in clients’ social systems; by knowing the potential signs of domestic violence).
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Determine who should attend family counseling and in what configuration (e.g., individual family members, couples, entire family, extrafamilial recovery supports).
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Identify treatment goals based on both individual and systemic concerns.
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Communicate with families and significant others about confidentiality rules, regulations, and boundaries.
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Obtain consent to treatment from all individuals involved in family-based interventions.
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Apply assessment tools for use with couples, families, and significant others.
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Identify couples’ and families’ strengths, resilience, and resources.
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Recognize issues beyond their own license and scope of practice that require referral for specialized evaluation, assessment, or treatment.
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Apply appropriate models of assessment and intervention for families, couples, and significant others, regardless of their extended, kinship, or tribal family structures.
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Provide culturally appropriate intervention strategies for couples and families.
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Help couples, families, and significant others adopt strategies and behaviors that sustain recovery and maintain healthy relationships.
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Manage session interactions with couples, families, and groups.
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Follow the procedures, processes, and counseling methods of manualized or structured family-based interventions with fidelity and within their scope of practice and license.
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Use family-centered supervision and consultation effectively.
Certification and Licensure
Programs with diverse professional staff have greater depth and richness in clinical teams. Even so, administrators can find it challenging to provide the training, supervision, performance evaluation, and professional development required by different state and national certification and licensing authorities.
Know the certification and licensing requirements of all clinical staff who currently provide or will provide family-based interventions or family counseling in your program. Check with your state licensing board for rules and regulations related to these requirements. Having this knowledge will better enable you to hire clinical staff from diverse educational backgrounds, such as licensed drug and alcohol counselors, marriage and family therapists, clinical social workers, mental health counselors, psychiatric nurses, and other behavioral health service professionals who have training and experience working with families.
Develop training programs that help counselors meet initial or recertification requirements to maintain their licenses. Two examples of licensing and certification authorities you should be familiar with are the American Association for Marriage and Family Therapy (AAMFT) and the International Certification and Reciprocity Consortium (IC&RC).
AAMFT
Fifty states and the District of Columbia require licenses for people practicing as family therapists (AAMFT, n.d.-b). Although the specific educational requirements vary from state to state, all require at least a master's degree. AAMFT's Commission on Accreditation for Marriage and Family Therapy Education requires an educational component on the assessment, diagnosis, and treatment of addiction in their accreditation standards. More information on state licensing and certification requirements is available online (www.aamft.org/Directories/MFT Licensing Boards.aspx?hkey=c0f838ad-2672-4b4e-8b51-b9578fe5c28a).
AAMFT also offers a designation as an approved marriage and family therapy supervisor. This designation requires completion of additional training and an examination offered by AAMFT. (See www.aamft.org/AAMFT/Membership/Approved Supervisors/Supervision/Supervision. aspx?hkey=79f01af6-6412-4eb5-9d75-9909aca18b1a for more information.)
IC&RC
IC&RC provides credentials in SUD prevention and counseling in 46 states and the District of Columbia, three branches of the military, some foreign countries, and the Indian Health Service. Each member board determines its own standards for certification or licensing based on IC&RC standards, which include knowledge of substance misuse, counseling, and ethics, as well as assessment, treatment planning, clinical evaluation, and family services. More information is available online (www.internationalcredentialing.org; https://internationalcredentialing.org/memberboards). IC&RC and many member boards also offer a clinical supervisor certification (see https://internationalcredentialing.org/creds/cs).
Professional Development
Involving families in SUD treatment heightens counselors’ responsibilities. For example, counselors need to understand the varied effects of substance misuse on family systems well enough to describe them to clients and family members. They must also incorporate new family-based interventions and activities into their general counseling style and treatment approach. Proper training and consistent clinical supervision are essential to support counselors in handling these additional responsibilities.
Staff Training
Family-based interventions and family counseling require special training and skills uncommon among staff in many SUD treatment programs. Workshops and self-study may increase counselor knowledge, but the key to integrating evidence-based, family-centered counseling approaches into SUD treatment programs is provision of specialized training and ongoing supervision (Olmstead, Abraham, Martino, & Roman, 2012).
Extensive training and supervision in family-based interventions will help counselors develop skills in and maintain fidelity to these counseling approaches. Ideally, training and supervision prepares SUD counselors to work with families by tapping into their existing knowledge of how substance misuse affects families.
Educate staff about family counseling and family issues to increase staff (and therefore client) awareness of the role families can play in SUD treatment, recovery, and relapse. Effective staff education should increase provider knowledge of the family as a unit and the influence of the ecological setting in which substance misuse occurs. Administrative and supervisory staff are the starting point for supporting providers in becoming knowledgeable about family counseling issues and for initiating program changes that integrate or enhance the delivery of such services to clients and their families.
Commit the necessary resources to provide ongoing family-centered training for counselors.
Some strategies to train your program's providers in the delivery of family-based interventions include:
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Gathering input from current counseling staff about training opportunities available from their professional organizations. For example, state branches of the National Association of Social Workers (NASW) often offer low-cost training for members and nonmembers.
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Partnering with local college or university programs that offer courses on family counseling topics.
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Providing internship or field placement opportunities for students in family counseling programs. In some such arrangements, your agency field instructor or supervisor receives free training from the students’ social work, mental health counseling, or marriage and family counseling program.
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Contacting professional organizations like AAMFT, NAADAC (The Association for Addiction Professionals), the American Psychiatric Association, or local branches of NASW for information on members qualified to offer training on family counseling at your organization.
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Vetting all trainers’ educational backgrounds and training experience and making sure their approach is consistent with your program's philosophy and training needs.
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Sending clinical supervisors and experienced counselors to family counseling workshops that offer group discounts; partnering with other agencies to increase group size for better discounts.
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Devoting time, attention, and resources to help staff integrate their family counseling training and get comfortable with how the training may change some of their counseling practices. Ongoing family-centered clinical supervision is crucial to this integration process.
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Creating small learning communities dedicated to advancing competence and professional development in family-based SUD interventions and family counseling among counselors, supervisors, and peer providers in your organization. Provide space for meetings and paid time away from regular clinical duties to participate in these communities and in training opportunities. Invite clinical staff from other programs to participate as well.
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Investigating online training and ongoing consultation resources to reduce program costs for travel and overnight accommodations. (See “Resource Alert: Online Learning Opportunities and Resources.”)
Clinical Supervision
Clinical supervision is a primary resource for counselors for gaining the practical skills and knowledge that will help them become ethical and effective service providers (Boyle & McDowell-Burns, 2016). Training in family-based theory and interventions is a good focus for supervision, which should be ongoing.
Ensure that clinical supervisors have experience and training in family counseling or licensure as marriage and family therapists. These qualifications are essential to help SUD treatment providers gain sufficient competency to provide family counseling. Supervisors should also have a range of knowledge on other issues such as child care, confidentiality and liability concerns related to providing services to children and adolescents, and the documentation and billing related to family counseling sessions.
Direct session observation by supervisors helps counselors develop and maintain competency in common evidence-based SUD interventions (e.g., supervisor in session, behind a one-way mirror, or video recording review; Olmstead et al., 2012). This is especially important for professional development of family counselors, given the higher level of complexity in delivering family-based SUD interventions. Yet one study found that only 2 percent of SUD treatment programs that offered brief strategic family therapy provided supervisor review of audio- or video-recorded family sessions (Olmstead et al., 2012).
Collaborate with other administrators, program managers, and clinical supervisors to integrate live supervision approaches into the training, supervision, and professional development of family counselors. (See “Resource Alert: Clinical Supervision and Professional Development of SUD Treatment Providers” for guidance on conducting live observation supervision.)
Supervisor Competencies
Regardless of the education or professional licensure of the providers clinical supervisors oversee, their supervisory responsibilities in integrated family counseling for SUDs include (Rigazio-DiGilio, 2016):
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Facilitating counselors’ development of self-awareness, cultural and social responsiveness, and theoretical, technical, and cultural competence.
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Monitoring the quality of counselor service provision.
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Assessing counselors’ current areas of competence and those that need development.
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Serving as gatekeepers for a variety of counselor specialties. This requires familiarity with various professional codes of ethics, state licensing requirements, scope of practice boundaries, and state agency licensing requirements (e.g., fulfilling the hours of clinical supervision required by state mental health and SUD treatment departments).
For family counseling supervisors to carry out these responsibilities, they must have the knowledge and skills necessary to (Rigazio-DiGilio, 2016):
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Apply different supervision models, methods, and interventions.
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Attend to ethical, legal, and professional concerns of clinical staff in different areas of practice.
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Manage supervisory relationships.
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Conduct counselor assessments and performance reviews.
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Address cultural diversity and responsiveness issues in counseling and supervisory relationships.
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Maintain a self-reflective stance in supervision.
The Association for Counselor Education and Supervision (ACES) provides specific competency standards for clinical supervisors that apply across a range of educational and professional backgrounds, including family counseling and SUD treatment. Standards include (ACES, 2011):
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Setting goals (e.g., developing specific goals for supervision, in collaboration with the counselor).
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Giving feedback (e.g., balancing feedback that is challenging and supportive).
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Conducting supervision (e.g., providing a safe, supportive, structured supervision context).
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Engaging in the supervisory relationship (e.g., building trust and developing a solid working alliance).
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Using various supervisor models and formats to address counselor needs.
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Attending to cultural diversity and advocacy considerations (e.g., integrating multicultural awareness and responsiveness into your supervision).
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Attending to ethical considerations in the supervisory relationship (e.g., providing counselor with a professional disclosure statement, including information about your professional background, clinical experience, and supervision approach).
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Documenting supervision (e.g., to support counselor development and protect client welfare).
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Evaluating counselor proficiency and performance (e.g., communicating about supervisory evaluation tools and processes).
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Fulfilling educational and work experience requirements for providing competent supervision.
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Engaging in supervision training and supervision of one's own supervision as part of supervisor professional development.
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Initiating supervision, such as by establishing a contract with the counselor (Exhibit 6.4).
As a supervisor, your focus with counselors is on client issues and concerns. Yet the quality of your relationship with the counselor is a primary factor that will determine each counselor's sense of achievement and professional satisfaction, similar to the quality of the counselor's therapeutic relationship influencing the effectiveness of work with clients and family members (Rigazio-DiGilio, 2016). To develop a strong working alliance with family counselors, engage in self-reflection and multilayered self-evaluation (Rigazio-DiGilio, 2016) about:
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Your own cultural, family, and contextual histories and experiences.
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The main theories and models that shaped your education and training in family counseling.
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Ways in which your participation in family, professional, and cultural experiences shape the worldview you bring to every supervision session (see Exhibit 6.5).
Family counseling supervision differs from individual counseling supervision. Instead of only reviewing individual client-counselor interactions in supervision, the supervisor also gives guidance to the counselor on the couple's or family members’ interactions with each other and the counselor's interactions with the couple, a single family system, or multiple family systems. For example, in evaluating a counselor's reflective listening skills, a supervisor might assess the counselor's skill in paraphrasing multiple perspectives and feelings of relatives and summarizing interaction patterns in the couple or family (Lambie, Mullen, Swank, & Blount, 2018). The focus on systems, not individuals, adds complexity to supervision.
Systemic-Developmental Supervision
This model of supervision is widely used in SUD treatment settings. It holds that counselors undergo stages of professional development; it is the clinical supervisor's role to match his or her relational stance and supervision strategies to counselors’ developmental stages. For example, a new counselor might require more structure and encouragement in supervision than an experienced counselor.
Similarly, in the developmental model for supervising family counselors (Carlson & Lambie, 2012), supervisors of beginning family counselors use live observation, model family counseling techniques, and engage in role-plays to facilitate the counselor's development. As the counselor becomes more confident, the supervisor can invite the counselor to develop a family genogram (see Chapter 4) and use it in supervision to help counselors identify transference feelings of family members toward the counselor and countertransference feelings of the counselor linked to the counselor's family of origin.
A genogram depicts a person's family tree through use of symbols. Symbols of different colors or shapes represent individuals in the person's family across several generations. Initially conceptualized by Murray Bowen (Goldenberg, Stanton, & Goldenberg, 2017) as a part of his intergenerational family model, a genogram is more than just a family tree: it is an important counseling tool. Using the information that family members provide, a genogram can visibly demonstrate family patterns, events, and relationships. Across health fields, the genogram offers a map of a family's known health, communication, relationship (e.g., marriage, divorce), vocational, and other psychosocial patterns in each generation. It can aid clinical interviews, psychoeducational sessions, or assessments (e.g., the Family Genogram Interview by Platt & Skowron [2013]).
The genogram is flexible and can be tailored to the needs and current challenges of a family. For example, a counselor may create a genogram and have family members identify those relatives with a history of substance misuse and related health issues. Family members can also use the genogram exercise to identify specific individual strengths and inherent strengths across generations. By illustrating substance use, cultural characteristics, and family dynamics, the genogram can reveal certain influential patterns.
In the context of SUD treatment supervision, a genogram can help supervisors link SUD counselors’ family patterns back to their counseling practice and raise counselor self-awareness of countertransference issues that may result, in part, from these family patterns (Carlson & Lambie, 2012). See also Chapter 4 of this TIP.
The supervisor may also introduce and explore parallel process—that is, how the supervisory relationship mirrors the counseling relationship— and focus on relationship dynamics in the couple's or family's sessions. Supervision of experienced family counselors is more reciprocal, so the supervisor becomes more of a consultant than a teacher. As counselors move through stages, they develop higher levels of self-awareness and differentiation from the supervisor (Carlson & Lambie, 2012).
Exhibit 6.6 lists the stages and samples of supervision strategies in systemic-developmental supervision.
A counselor may be in one stage of professional growth as an addiction counselor and another stage in developing competencies for providing family-based interventions. The systemic-developmental model of clinical supervision offers a framework for matching supervision strategies to counselor competency levels in delivering family-based SUD interventions.
Encouraging Collaboration as an Administrator
One of your most important roles as an administrator is to develop ongoing connections between your program and others that provide a range of services to families. Such relationships should encourage family participation in both SUD and family-based services. Yet collaborating with other behavioral health and community-based services involves more than maintaining a list of other agencies where staff can refer clients and family members. If your program does not offer in-house, integrated family counseling services, develop and maintain partnerships with other programs that provide family counseling and family-centered services.
Provider collaboration ensures high-quality referrals, effective outreach, and meaningful partnerships with community resources.
Clinical and nonclinical staff should be familiar with community services and resources for families. Counselors should match the resources of various local programs with a family's needs. They should then provide the family with information, including the pros and cons, of particular programs to facilitate the family's selection of those with resources that will work best for them.
Supporting an informed, family-centered referral process requires a strong community perspective and resource commitment at the administrative level. Such support will allow staff members across the family services spectrum to expand their knowledge of community-based SUD education resources and family services. Staff should know about family-based treatment models and provide information using collateral resources to build trust with family members. Supervisors can help staff adjust to the changes and new information generated by collaboration with other providers.
Partnerships
Partnerships with community-based organizations require intensive collaboration. You will need to identify stakeholders in the community, bring them together, and work toward common goals (Partnership for Drug-Free Kids, 2015). Collaborations with other agencies from which families seek services can help reduce fragmentation, duplication, and isolation of services.
SUD treatment program administrators can be a catalyst for SUD treatment-community partnership with the combined goals of reducing substance misuse and helping families initiate and sustain recovery, achieve improved health and wellness, and become integral members of the community.
Community stakeholders whose goals include prevention and treatment of SUDs with a focus on family-based interventions and recovery may include:
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Other SUD treatment professionals.
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Family counseling professionals.
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School administrators and school personnel.
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Youth and family organizations.
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Family and drug court providers.
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Probation and parole services providers.
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Churches and other faith-based organizations.
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Family and child welfare agencies.
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Eldercare agencies and service providers who work with older adults.
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Primary care providers.
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Family members (including parents, youth, and extended family members).
Family members are clearly key stakeholders in the partnership-building process. Including their perspectives can heighten their commitment as stakeholders, invest them in their own care, and reduce misconceptions about substance misuse and ambivalence about involvement in SUD treatment.
Include consumer voices in the development of family-centered services to anchor your program in the community. Provide a mechanism to gather input from SUD providers, including those who work with families, and other key stakeholders. Doing so can support consumer-led movements that will encourage policy shifts related to community-based SUD treatment and family involvement.
Adequate Resources
Provide adequate resources to monitor and ensure that high-quality referrals, outreach, and partnership components are in place. Examples of such resources include:
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A comprehensive referral system that can facilitate the participation of families and clients in family counseling activities not provided by your program.
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Expanded privacy/disclosure, consent, and referral procedures, which may include multiple release of information forms, active linkage
to other services, and follow-up from your counseling staff.
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Client and family education on benefits and challenges of participating in other programs/services.
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Client and family information on your relationship to other service providers, potential conflicts of interest, and limits of your program's responsibility for the family's treatment at another program.
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Allocation of staff resources for a variety of tasks, including:
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Documenting referrals.
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Monitoring ongoing relationships with other agencies.
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Coordinating information exchange about clients and families in accordance with Health Insurance Portability and Accountability Act (HIPAA) requirements and state law (for more information on HIPAA, see www
.hhs.gov/hipaa).
Develop memorandums of understanding (MOUs) with other agencies to clarify and guide the referral process and interagency coordination of services. Coordination efforts can include active involvement of SUD counseling staff in the therapeutic process and continual contact with the family counselor at the other agency. MOUs can provide a detailed understanding of the other agency's process and procedures, which helps both organizations improve quality and avoid redundancies. For example, if each program screens for mental disorders, coordinated screening processes lessen duplication and client confusion, especially if different screening approaches provide different results. MOUs can also establish each program's responsibilities for on-call services and procedures for responding to family crises.
Monitor and improve referral services by involving families in evaluating the partnership component of your program. A follow-up survey to family members you have referred to another agency may ask:
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Which members of your family are participating in the services of the agency we referred you to?
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On a scale of 1 to 5 (1 being easy and 5 being difficult), how easy was the referral process for you?
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Can you provide examples of what was easy and what was hard about the referral process?
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What can we do to improve the referral process going forward?
Addressing Other Programmatic Considerations
There are other issues you should address in your administrative efforts to integrate family counseling and family-based interventions into your program. These issues include cultural competence, federal and state regulations, consent related to privacy and disclosure, confidentiality, funding, counselor caseloads, treatment outcome evaluations, provider collaboration, and adequate resources for staff.
Organizational Cultural Competence
An organizational culture that is infused with the values of cultural competence and diversity on every level will highlight and implement such values concretely in staffing patterns, language, and cultural issues related to families and substance misuse. Hire staff and build an organizational culture that refects the diversity of the client populations your organization serves. Programmatic cultural responsiveness assessments explore institutional assumptions regarding services for specific racial and ethnic communities. Use this information to reduce bias based on institutional misperceptions. (See “Resource Alert: Developing Organizational Cultural Competence” for a link to more information.)
Regulations
Different regulations created by government agencies and third-party payers affect the SUD treatment and family counseling fields. Regulations influence confidentiality, training, and licensing requirements. For example, federal regulations specifically guarantee confidentiality for people who seek SUD assessment and treatment. Your program needs policies and procedures in place that allow clients to give or revoke consent to disclose information to other providers. These policies should be consistent with federal laws and regulations, such as HIPAA 42 CFR Part 2 (SAMHSA, 2019b), and any state laws that apply (www.samhsa.gov/about-us/who-we-are/laws-regulations/confidentiality-regulations-faqs).
A consumer has the right to self-disclose anything he or she wants to disclose about his or her substance use history in group counseling sessions. If family-based group SUD counseling occurs in a HIPAA CFR Part 2 program, as defined by 42 CFR §2.11 and §2.12, then program staff are bound by Part 2 regulations in sharing any information a client self-discloses during such a group.
As an administrator, you should be familiar with laws and regulations in your state that affect confidentiality, training and licensing requirements for counselors, delivery of family counseling services, duty to warn, and mandated reporting requirements for child and elder abuse and neglect.
Privacy and Disclosure
Consent issues require careful consideration by program administrators. All family members receiving services in your program should receive and have the opportunity to sign consent forms acknowledging the organization's policies around confidentiality and the potential risks and benefits of family program activities. Parents or legal guardians can usually sign for children and adolescents (unless the adolescent has reached the age of majority defined by state law or if state law permits minors to consent to SUD treatment or mental health services). Forms asking clients’ permission to share or disclose personal information (e.g., so a provider can discuss a treatment course with family members) should describe in detail, for example, the program or staff responsibilities regarding the reporting of information that is required by law (such as elder abuse, child abuse or neglect, infectious disease, or duty to warn).
Local, state, and federal laws sometimes conflict. Consult with your in-house or local legal services agency to help you reconcile those conflicts.
Inform clients about the limits of confidentiality in family group activities so that all participants understand the benefits and potential risks of family group participation. For example, providers are bound by confidentiality laws, but family therapy group members and others in similar settings may not be. Each family member should receive clear, accurate information about what will happen when they engage in SUD treatment, family counseling, and family program activities. Consent for information-sharing protects clients before, during, and after treatment. Although many laws may not apply to group members, program staff may wish to stress to family group participants the importance of respecting one another's privacy and what is shared in group settings as a facilitator of candid discussion.
Confidentiality
Confidentiality policies should extend to everyone in treatment. Maintaining confidentiality in family and couples counseling is complicated, because many individuals may be involved. Programs need written policies about when family counselors can refrain from disclosing information to family members not present at the time of a client's disclosure and when they are justified in disclosing that information (Mignone, Klostermann, Mahadeo, Papagni, & Jankie, 2017). For example, policies should guide when or if it is okay for a counselor seeing a couple or family to “keep a secret” for a family member who is also in individual counseling from other family members and when that information should be disclosed (e.g., when a family member is suicidal or has relapsed). Duty to warn may apply in some cases, too (www.ncsl.org/research/health/mental-health-professionals-duty-to-warn.aspx)—for instance, if clear and explicit threats are made to other participants, providers, or third parties. At intake, inform all family members involved in treatment, at whatever level, about disclosure policies during the privacy, disclosure, and consent process.
Confidentially issues for family counselors working with adolescents and their families can be complex. Family counseling practices often reflect the idea of restoring parental authority in the family, but adolescents’ developmental stage prompts movement toward independence from parents. You should have clear policies regarding adolescents’ right to and limits of confidentiality based on state and federal laws and professional ethics codes regarding treating adolescents.
In general, all staff (clinical and nonclinical) should adhere to confidentiality laws and organizational policies. Nonclinical staff members may not be bound by confidentiality laws that apply to counselors, but they should be familiar with HIPAA and other applicable privacy laws and the importance of keeping client identifying information (and even clients’ presence in treatment) confidential. For example, family members and clients participating in group activities should not be required to sign a login sheet that other clients can see. One strategy is to create an agency procedure and physical space at reception where clients can discreetly sign in or inform staff of their arrival for a family group activity. These issues become especially complicated when a client identifies as “family” people who are not related by blood or law and wishes to include friends or coworkers in family treatment activities.
The consensus panel recommends that all clients and family members involved in treatment sign consent forms conforming to 42 CFR Part 2 and that program staff discuss confidentiality and its limits with everyone as part of the process by which clients can choose to consent to the sharing or disclosing of certain private/personal information.
The federal regulations at 42 CFR Part 2 (SAMHSA, 2019b) are stricter than many state requirements regarding the privacy of individuals in SUD treatment. Participant patient-identifying information must not be disclosed either to other participants (including family members) or to other service providers without a specific release form that complies with regulations or unless other Part 2 exceptions apply. Program staff may disclose confidential information to other staff members in the same program to provide treatment.
Funding and Reimbursement for Family-Based Interventions
There is considerable evidence to support the clinical effectiveness as well as the cost-effectiveness of family-based interventions in SUD treatment (Akram & Copello, 2013; Morgan & Crane, 2010; Wells, Kristman-Valente, Peavy, & Jackson, 2013). However, like the SUD treatment system, both private and federally funded health insurance still emphasize individual treatment. For example, the average state Medicaid reimbursement of SUD treatment providers for couples or family counseling is less than for individual counseling (Beck, Buche, Page, Rittman, & Gaiser, 2018).
Insurance providers are moving toward reimbursing providers with a wider range of licenses for couples and family counseling services. A survey of all states and the District of Columbia found that Medicaid reimbursed addiction counselors for couples and family counseling at a higher rate when they worked in an SUD treatment program versus private practice (Beck et al., 2018). About 40 state Medicaid programs now have some reimbursement or recognition of licensed marriage and family therapists (AAMFT, n.d.-a). Check your state's Medicaid provider manual for information about recognized licenses and reimbursement codes for family counseling.
Some strategies for expanding the types of behavioral health service providers who can be reimbursed for family counseling services and increasing reimbursement rates include:
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Identifying ways to partner with professional associations to encourage reimbursement for family counseling and family-based interventions.
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Developing relationships with key staff at your Single State Agency for substance use disorder treatment services. (See SAMHSA's Directory of Single State Agencies for Substance Abuse Services at www
.samhsa.gov/sites /default/fles/ssa-directory-01212020 .pdf). - •
Partnering with other agencies to seek increased Medicaid reimbursement for family counseling.
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Sharing the evidence that family-based SUD interventions are effective and reduce healthcare costs by improving treatment outcomes and long-term recovery.
Counselor Caseloads
Working with families increases the amount of clinical time and nonclinical work that counselors perform. Family counselors must not only manage more clinical complexity than those doing individual work, but also meet more documentation requirements, collaborate with more referral sources and multiple providers involved with the family, and satisfy greater training and clinical supervision needs. At an administrative level, you will need to adjust counselors’ caseloads to account for these additional work requirements (Association for Family Therapy and Systemic Practice, n.d.).
Incorporate burnout prevention strategies in staff training and supervision activities. Depending on the level of family involvement in your treatment program and the complexity of the family's needs, counselors may experience higher levels of stress. Ensure that counselors are not doing family work beyond their level of professional development—even when no other staff is available. (See the “Clinical Supervision” section of this chapter.) When counselors attempt to function at a level that is beyond their training, their interventions are typically ineffective, and they can begin to feel demoralized. This is likely to affect the family negatively and be a contributing factor to counselor burnout.
Clinical supervisors should monitor the development of counselors doing family work and slowly introduce new family counseling cases into counselors’ caseload when they are ready. Balancing cases involving families with cases involving only individual clients or couples can help lessen counselor stress.
Outcomes
Evaluating client outcomes can improve counselor delivery of family-based services and provide evidence you can share with potential funders on the effectiveness of your program's family-based SUD treatment approach (Boswell, Kraus, Miller, & Lambert, 2013; Moran, 2017). Strong evidence suggests that using a routine outcome monitoring (ROM) system in behavioral health service settings improves clinically significant client outcomes and enhances counselors’ abilities to predict and prevent client deterioration (Boswell et al., 2013). However, ROM measures are not universally applied in treatment programs. Counselors may view ROM requirements as intrusions into their client relationships, feel anxious about use of ROM information to assess their performance, and worry about client privacy; some administrators see ROM as time-consuming and costly (Boswell et al., 2013; Moran, 2017).
Strategies to address concerns related to ROM system implementation include (Boswell et al., 2013):
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Inviting counselor input about which outcome measures to use and what feedback would be most helpful to them to enhance their work with clients and families.
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Being transparent about benefits and potential time burdens that counselors may encounter and how ROM data will be used to evaluate counselor performance.
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Making ROM measures as simple as possible so they are less disruptive to counselors, clients, and family members. For example, use self-report measures that take less than 10 minutes to complete.
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Using electronic or online outcomes assessment, tracking, and feedback systems that are simple for clients and counselors to use and are HIPAA compliant in addressing confidentiality concerns.
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Automating reminders for counselors and support staff to initiate periodic follow-up outcome assessments with clients and family members.
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Incentivizing ROM engagement (e.g., allow time outside regular duties for training on ROM processes and assessment instruments or reimburse fee-for-service counselors for ROM training).
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Identifying one or two “local champions” who are well respected in your organization; have had positive experiences with ROM; are enthusiastic about ROM; and who take responsibility for helping you adopt, integrate, and sustain the ROM system in your program.
Measuring outcomes of family counseling is complex—more so than, for example, measuring whether an individual client has stopped or reduced substance misuse or is attending recovery support groups. Before instituting a ROM process for family-based interventions, consider which family outcomes to assess and which family members to engage in the process. Some questions to ask yourself include:
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Are you interested in knowing how your family-based interventions are affecting the functioning of the entire family or how the family-based interventions are affecting the client's substance use?
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If you treat younger children in your program, will they or one of their parents ill out ROM surveys?
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If children or adolescents fill out outcome assessment instruments as part of ROM, are there different versions of a single instrument? Are instruments designed to be age appropriate?
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Are the ROM instruments you are using culturally responsive and available in multiple languages?
There is no single instrument to address all of these concerns, but the SCORE-15 Index of Family Functioning and Change (Exhibit 6.7) is specifically designed to measure outcomes of family counseling. Consider adding it to other measures of substance misuse outcomes you may already use as part of ROM.
Engage clinical staff in a process that dispels misgivings about the ROM process and encourages buy-in. Doing so will enhance staff members’ motivation to improve the quality of the family-based interventions they provide. Involve them in the planning and implementation process right up front. This will increase their motivation and demonstrate your administrative commitment to transparency.
Where Do We Go From Here?
Administrators must balance the potential for better client and family treatment outcomes with the challenge and costs of program development, the additional training and professional development of counselors from different backgrounds, and nonreimbursable activities like developing partnerships with other organizations.
In your decision-making process, remember that you cannot measure the value of adding family-based interventions to your treatment program only in terms of better substance misuse outcomes for specific clients or enhanced functioning of specific families.
Families, however defined, are the cornerstone of our cultural life and the backbone of society's structure. When you shift SUD treatment programs from a solely individual focus to a family-centered focus, you not only improve individual treatment outcomes but also contribute to SUD prevention efforts and enhance protective factors that can improve the health and wellness of future generations. Remember your agency's mission statement and let that guide you to next steps.
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