by Rosita Mazzi
(Editor’s Note: In August 2014, social worker Rosita Mazzi visited the United States and spent several days with Linda Grobman, publisher/editor of THE NEW SOCIAL WORKER. During that time, Mazzi presented her research to the Pennsylvania Chapter of NASW and to a group of social work students at Temple University Harrisburg. This is a translation of her research from Italian to English.)
I have been working in the drug addiction service for a decade now and am still here like a survivor! Last year, I started work on a “burning” idea: Begin an initial systematic reflection on the importance of working with the families of the people in treatment.
Background and Objectives
I started with the assumption that the involvement of the parents or other family members in the treatment process could improve treatment outcomes. The kind of addiction that I analyzed is the long-term addiction from “heavy illegal” substances. I studied two years of treatment in a Ser.t (the Italian drug dependency unit).
I tried to standardize and list the main problems treated, with what frequency these problems occur in families being treated, and the therapeutic strategies most commonly used by social workers. I selected 31 cases of drug addicted individuals who were treated over a 2-year period (2012-2013). The sample involved 51 family members treated.
The choice of the variable of this sample was the use of family therapy together with individual treatment, using a specific model of assessment and therapy.
Our research concludes that the level of improvement (where the “better” and “released” categories are compared with “worse” and “abandoned”) is more than 35% with family therapy.
Discussion and Conclusions
The results of this research are extremely stimulating. This small sample, which is important from a qualitative point of view rather than a quantitative point of view, shows that the family is an essential element in treatment for addiction.
Background and Objectives
An average of 300 cases a year are handled by our service. Ninety-five were also followed by social workers, but only a third could take part in the treatment model that is the subject of this research. It is essential to stress from the outset that family involvement in this process of empowerment is not an ethical choice, but derives and results from the basic philosophy of the intervention model and from the tools used in the phase of interpretation and assessment of the dysfunctional dynamics.
I wanted also to present a working model that we social workers at the Scandiano Drug Dependency Unit have been using for several years.
In our service, we treat an average of 300 clients annually, but only 30% of them can involve the family in the change process. We are a staff comprised of one doctor, two psychologists, two social workers, and two nurses. We work together on tailored programs.
Recent discoveries in the fields of psychiatry, medicine, and psychology all head in the direction of a holistic and overall approach. For us, a holistic approach and treatment mean considering all possible individual and relational variables and continually updating the working tools of every profession. We have to adjust the techniques we use to transform the problems and customize each treatment. We are certain that each person is a “unique being.” We are living in a turbulent, constantly changing environment, and as social workers, we also have to update our professional tools and techniques (i.e., the use of the Internet and social networks).
We know that no single “dependency” exists—there are illnesses that respond to medication, but there are also people who have a serious problem with a variety of factors, like drug dependency, which can be resolved through 360 degree changes, both in individuals and their families. As there are limitations on our ability to change the world or society, we have to help people in difficulty to adapt. The person who is integrated produces change in the overall system, breaking the entropy of social systems and innovating them by their very presence.
Data of Research
The individuals treated were mainly male (22 males and 9 females) with an average age of 30 (from 24-45 years of age).
Fifty-one family members were treated, having an average age of 57 (45-71 years of age), and 59% were women. There were five families with just one parent (widows). In other cases, we tried— sometimes unsuccessfully—to involve both parents. However there was only one original single parent family—a widow who had brought up her son alone since birth.
The family model that considers a father and mother as figures that should be present for education and role modeling does not appear to be important in the results of this research, as there are families that have separated, divorced, or recombined that have greater parental cooperation than those statistically considered “stable.”
The family structure (described in the theoretical portion of this article) presents a generational passage at a diachronic level—that is, the fact that the formation of a couple and the birth of children contain the plan to form a new couple and new children. We can presume that difficulties in original attachment ties lead to consequent similar difficulties in building stable relationship ties on the part of children.
Of the 31 patients, 24 (although adults) had not established a new family nucleus. Four had done so, but had returned to their family of origin. Two lived alone and only one case had a family, but without children, and lived in close contact (both in terms of accommodation and work) with their parents.
It is important to remember that all these families have a distorted family relationship, one that is poisoned by dependency, the inability to guarantee separation-individuation because of secrets, the empty nest syndrome, or more general problems of attachment.
The drug addicted individuals in the sample had a medium-high level of education; in fact, 17 out of 30 had a degree or a diploma. Most were well educated. Half managed to hold down a job, while others were in work rehabilitation. Many were unemployed—both because of addiction, and also because of the crisis in the employment market that is affecting Italy.
People who are addicted to drugs often manage to hold down a job. Treatment by our service not only helps them to do this but also has a tool called “Work Bursary,” to rehabilitate those who have lost their jobs as a result of addiction. The parents have a mid- to high level of education—33 parents have degrees or diplomas, and the rest have a junior high school diploma.
This confirms the medium-high social condition of the families treated, as they have good professional and economic situations. In situations in which primary needs are frustrated, willingness to change is greatly compromised.
Types of Substance
- Heroin: 10
- Cocaine: 8
- Hashish Marijuana: 3
- Alcohol: 4
- Alcohol and medication: 2
- Alcohol and cocaine: 4
- Cocaine and heroin: 1
The cases treated have more dependency on heavy drugs and the duration of dependency at the time of family therapy is, on average, six years (a long-term dependency).
We must state that the style of attachment (secure, anxious ambivalent, insecure avodant disoriented disorganized with Bowlby theory) has not been assessed here by specific tests, but through professional evaluation of the accounts of the patient and family.
We noticed a relevance of insecure avoidant or anxious styles of attachment; it demonstrates that dependency and attachment are an inseparable combination.
Internal operating models are produced and can be (also in Bowlby’s opinion) modified with changes in parenting style (the heart of our research). These are compatible with diagnoses of borderline personality disorder or with people who are insecure and dependent, socially anxious, who have difficulty expressing emotions, with a lack of empathy, or with conflictual attitudes that find the panacea to all their problems in the substance on which they are dependent. Above all, they find a recognized pattern of emotional response in the substance, the response produced by the substance that makes drug addiction attractive (i.e., “the effect of the drug makes me live in a familiar and emotionally secure world, one that is predictable and known to me. It is excellent for someone like me who doesn’t know how to deal with people or emotions.”).
Type of Critical Issues
We saw and identified the main family problems. The features of the parents are educational rigidity, communication problems, and relational difficulties. There are in each case medical, psychiatric, educational, psychological, and social repercussions, which converge in our families to generate, structure, and maintain drug addiction. This serious issue then becomes a permanent storm that paradoxically keeps the family within the pathology.
This pathology, whose hardness and stability preserves the suffering, can have negative effects leading to destructiveness or desperation. However the contra-paradox is to think and act in this sense. That is, the family becomes a resource for its own change. The condition that must exist so that this takes place is that the family nucleus, which has so long been enclosed in cold and turbulent solitude, must not be left alone.
Main Family Problems Identified
- Loss = A prolonged inability over the years to talk about deceased spouses or, vice-versa, the tendency to maintain both physical and mental memories intact of that spouse (12 cases).
- Genogram problems = Generational situations and unexpressed problems (e.g., adoptions, suicides, mental illness, alcoholism, incest, and rape) (23 cases).
- Divorces and separations = Situations in which parents have formally or informally separated (17 cases).
- Secrets = These have varying degrees of difficulty in being communicated, but they are personal or family things that have never been said. They are always present in our statistical identification (31 cases).
- Confused family roles = Situations in which parents exchange roles, when a father becomes a mother or vice-versa, or where there is excessive friendship with children, therefore confused family roles (25 cases).
- Absence of a parent: In the case of widows or of parents who have never taken part in their children’s upbringing (25 cases).
- Triangulation of a child in a conflict: A child is used in an inappropriate way as a subject for argument or a tool of communication in marital conflict (18 cases).
- Empty nest syndrome = Parents do not allow children to become independent because they cannot stand the fact that their home (nest) is empty of their presence (27 cases).
- Psychiatric problems in a parent: Where there is a treated or untreated psychiatric disturbance (25 cases)
- Drug addiction problems in parents, previous or (more rarely) current (9 cases).
- Disagreement about upbringing = (21 cases).The drug addicted individual as the black sheep of the family, i.e., the catalyst and guilty party for all family problems (19 cases).
- Adoptive or foster parents, who often in the case of a drug-addicted child tell social services “You gave them to me many years ago, now take them back” (6 cases).
- Parents frustrated by their social role, i.e., those people who have not managed to become something more or other than their own parents and take their frustrations out on their children (15 cases).
- Excessive tolerance of drugs (10 cases).
- An authoritarian education with no dialogue (3 cases).
- A permissive education where everything (or almost everything) is allowed in order not to upset children (25 cases.)
- The inability to teach children that they must conquer things in life (create their own personality) (25 cases).
So we have tried to demonstrate the hypothesis that asserts that change within the family ensures an important improvement in the case, which is often an improvement in, or recovery from, drug dependency.
One example is how the manipulation strategies are internalized or guilt inducing. That one individual exerts over another, the expectations that one individual has of another (e.g., “you are not like I want you to be,” You should feel guilty,” “you should be like I want you to be,” “if you love me you have to…,” “because you are not the way I want, I’ll try to build you piece by piece,” ) are damaging.
Work with the family must be focused on emotional ties and secrets and if they are dealt with and treated only in relation to the person who carries the symptom, they do not guarantee such a high level of recovery.
Patients are treated mainly from a health and psychological point of view, as well as social rehabilitation (involvement in work and day communities). In some cases, this action takes place at the same time, as the complexity of the dependency and our bio-medical and psychosocial approach to the problem means that treatments are also complex.
We must also remember that all these patients receive more or less in-depth family therapy. This means that to obtain a good level of recovery, the work that social workers do with respect to family relationships, secrets, and attachment must also be coordinated and supported by psychologists and doctors. This makes our approach a successful method in the fight against drug dependency.
Type of Intervention and Therapeutics Strategies
At this point, we should also touch on working instruments for involving families. Our social work service offers these social work instruments:
- Motivational actions
- Individual support interviews and psycho-social support
- Support interviews for family abilities/family-parent therapy
- Action on ties
- Action on separation-individuation
- Action on family secrets
- Communication training
- Parent Training (group therapy)
- Therapeutic day community
- Residential therapeutic community
How Long Does Treatment Last?
In general, it lasts anywhere from three months to two years, with interviews that initially take place once a week, especially during the assessment phase. Interviews then take place fortnightly or monthly. Family therapy is variable and depends on many factors, including the resistance to change, the type of treatment of the child, and the number of relapses.
Our Research Concludes That the Level of Improvement Is More Than 35% With Family Therapy
Conclusions and Discussion
The results of this research are extremely stimulating. This small sample, which is important from a qualitative rather than a quantitative point of view, shows that the family is an essential element in treatment for addiction.
The level of recovery/improvement in dependency was 90.32% of the cases analyzed. Without family involvement, the level of recovery/improvement was 55%.
Various techniques have been used and not all can be described in such a short work. However, we have attempted to give the idea of operational complexity, which absolutely parallels the complexity of drug addiction, which, as we have already stated, is a bio-psycho-social issue.
For our team, family therapy is a winning strategy. Family involvement is not a new feature in our work—it is present in our work with minors, fostering, adoption, and child protection.
Psychologists and doctors also base their individual, clinical interview on family relationships. We must stress that this assumption of the family is a scientific and methodological tool of social service, which becomes an ethical choice as a consequence of methodological selection. It is not a moralistic or a familistic assumption.
This research aims to remind us that it is important to learn and to listen to the whispers and murmurs that the family constantly produces, in order to begin a process of independent healing.
Rogers, O. W. (2013). Beginnings, middles & ends: Sideway stories on the art & soul of social work. Harrisburg, PA: White hat Communications.
Holmes, J. (1994). La teoria dell'attaccamento :John Bowbly e la sua scuola. Cortina ed. Italy.
Jodorowsky, A. (2012). Metagenealogia: la famiglia un tesoro, un tranello. Feltrinelli Italy.
Watzlawick, P. (1989). -il linguaggio del cambiamento :elementi di comunicazione terapeutica. Feltrinelli ed. milano Italy.
Copello, A, & Oxford, J. (2008). Addiction and the familly :it is time for services to take notice of the evidence. in Addiction N°97.
G. Zanusso, A. D'avanzo , A.Michelon, Angeli Milano. (1998, 7). Comportamenti familiari nella tossicodipendenza:strumenti per cambiare.
–Tzu, Lao. (2009). Tao Te Ching A book about the way and the power of the way. U , K ,Le Guin Paperback.
Rosita Mazzi is a social worker specializing in family treatment and drug addiction treatment. She received her first degree in social work from Pisa University in 1984 and her second degree in sociology from Bologna University in 1991. She practices social work in the public health service called Ser.t in Ausl of Reggio Emilia, Italy.