Efforts to engage young adults with substance use disorders in treatment often focus on the individual and do not consider the role that the family can play in the recovery process. In summarizing the proceedings of a longitudinal meeting on substance use among young adults, this special article outlines three key principles concerning the engagement of broader family units in substance use treatment: (1) care should involve family members (biological, extended, or chosen); (2) these family members should receive counseling on evidence-based approaches that can enhance their loved one’s engagement in care; and (3) family members should receive counseling on evidence-based strategies that can improve their own health. For each principle, we provide an explanation of our guidance to practitioners, supportive evidence, and additional practice considerations.
Engagement strategies that enhance substance use treatment outcomes, even those that are developmentally appropriate, often do not consider the important role that family members (biological, extended, or chosen family) have in promoting risk reduction strategies and supporting the recovery of young adults. Without the right support and information, family members can have unintentional adverse effects on a young adult’s engagement and recovery. Furthermore, substance use recovery programs rarely include components to improve the health of family members affected by a loved one’s substance use disorders (SUDs). Despite consensus that family involvement is critical, most family-based interventions have been studied in families of adolescents who use substances, and few evidence-based approaches are available for families of young adults. Most of the evidence presented in the following article, therefore, is based on data gleaned from adolescents and extrapolated to the young adult population.
The objective of this article is to communicate a series of evidence-informed principles of care pertaining to family members of young adults with SUDs, as derived by an expert panel convened by the Grayken Center for Addiction at Boston Medical Center. The principles pertain to both primary care and specialty addiction settings. The recommendations in this article are not American Academy of Pediatrics policy, and publication herein does not imply endorsement. We outline three principles of care for engaging family members of young adults with SUDs, and we review both supportive evidence and practice considerations. We conclude with potential action steps to leverage the family to help young adults engage in care.
Principles of Care
Principle 1: When Possible, Care Should Involve Family Members
The workgroup concluded that when possible, and with the permission of the young adult (defined as a person aged 18–25), family members should be invited to participate in the patient’s course of treatment. Currently, however, most SUD treatment happens in specialty treatment programs with little family involvement; even when treatment is offered in the primary care setting, limited time during visits makes it difficult to engage family members in safety and treatment planning. As addiction treatment has expanded from almost exclusively behavioral-oriented treatment to include more pharmacologic therapies, there has been even less opportunity to engage family members in care. Care, therefore, continues to be patient-focused and typically does not involve the patient’s social network and family members. In light of these challenges, it is critical to develop strategies to involve family members as key members of the care team, with specific foci on safety and treatment planning.
There are few empirically supported, family-based therapies for young adults with SUDs. Many of these therapies have been studied in younger populations; applying the data to young adults, therefore, requires extrapolation. Three family therapies with a strong evidence base for reducing adolescent substance use are multidimensional family therapy, functional family therapy, and brief strategic family therapy.1,2 Recent evidence suggests that all three models can be distilled into four core practice elements: interactional change, relational reframe, adolescent engagement, and relational emphasis.3 Each element includes specific techniques that a therapist can use to achieve reduction in substance use through improved family functioning. The interactional change element focuses on assessment of family dynamics and communication, so that therapists can provide guidance to family members on how to improve their interactions with their loved one with an SUD. The relational reframe element helps the adolescent or young adult see the clinical problem (substance use) as related to family relational problems. These elements aim to improve family relations to address substance use. In adolescent engagement, the therapist elicits the adolescent’s perspective about the problem and how family therapy can address salient issues. Finally, relational emphasis includes interventions that can improve whole family health and functioning. Studies that include family members of young adults are needed to determine whether family therapy is also effective in this specific age group.
Despite the evidence that family members can play a positive role in care, many obstacles prevent family member involvement. First, few therapists are trained in family therapy for SUDs.3 Most current clinical models of care fail to involve family members routinely as therapeutic allies. Even if a program does offer services that include family members, young adults may choose not to include families as contacts. Federal confidentiality rules and regulations including the Health Insurance Portability and Accountability Act (HIPAA) and 42 Code of Federal Regulations Part 2 preclude providers from contacting families without consent of the young adult. If the young adult initially refuses to consent to family involvement, this decision can be revisited, because social support is an important factor in recovery and treatment adherence. For young adults unable to identify any family member they would like to be involved in treatment, the importance of peer social networks that support risk reduction should be emphasized. It is also important to note that although family members cannot receive information about their loved one without consent, there is nothing that prohibits family members from providing the care team with information about the young adult.
Principle 2: Family Members Should Be Counseled on Evidence-Based Approaches That Can Enhance Their Loved One’s Engagement in Care
The workgroup concluded that family members, using evidence-based communication skills, can increase the likelihood that their loved one will enter care, thus improving SUD outcomes.4 It is important that care teams working with young adults engage the family, provide accurate information about evidence-based treatment approaches, and provide education about the important role the family can plan in their loved one’s recovery. Because evidence-based approaches exist that promote engagement with care, family members should specifically be trained in these behavioral approaches and counseled on techniques to practice these approaches with their loved ones.
Providing support to families can have a positive impact on engagement in care, even if the loved one is initially not ready for treatment.5–14 The Community Reinforcement and Family Training (CRAFT) model teaches family members to engage loved ones who are not yet ready for behavior change and, importantly, does not rely on the involvement of the individual using alcohol or other drugs. The intervention has three goals: (1) help a loved one move toward treatment, (2) reduce substance use if treatment is not an option, and (3) improve the well-being of the engaged family members.15 The CRAFT model teaches family members skills such as using positive contingencies (rewarding the desired behavior), problem solving, self-care, and communication strategies (eg, avoiding conversations when the loved one is intoxicated).6,15–18 CRAFT increases treatment engagement from 40% to 71% for individuals with alcohol, opioid, and other SUDs and improves anxiety and depression scores among parents.16,19,20 In a study of adults with opioid use disorder discharged from a detoxification program, Brigham et al19 demonstrated that when the family member was a parent, loved ones were significantly less likely to drop out of treatment.
A newer approach, the invitation to change model, draws from CRAFT, motivational interviewing, and acceptance and commitment therapy (an intervention that uses acceptance, mindfulness, and behavior change to address unpleasant feelings and increase psychological flexibility). In this parent-to-parent model, parents with a child with a history of substance use (parent coaches) are trained over 2 days by mental health professionals to deliver a phone-based intervention to other parents seeking advice about how to address their children’s substance use. Coaches provide support to parents, education about addiction, and information on how to access treatment and promote the well-being of families. Although one study has demonstrated feasibility and acceptability of this approach,21 effectiveness has not yet been established.
Currently, it is difficult for family members to receive evidence-based support for a loved one unless the loved one is ready to discuss treatment. Currently, family members rely on support groups such as Al-Anon, Families Anonymous, or national non-profits such as the Partnership for Families. Although these are important resources for families to access, they have not been rigorously studied and cannot replace professional support.
Principle 3: Family Members Should Be Counseled on Resources That Can Improve Their Own Health
It is estimated that ≥20% of the US population has a family member with an SUD,22 and that family members of young adults who use alcohol and other drugs have more physical and mental health conditions, and higher levels of health care utilization, than similar family members not impacted by addiction.23,24 The presence of an SUD in a young adult also has a significant impact on the emotional and physical health of other family members. Therefore, the workgroup felt that it is important that parents and other family members are offered resources and support to address their own health.
The more family members are able to engage in activities to improve their own health, the greater the probability that the health of the entire family system will improve.25 “The Five Step Method” is an intervention developed specifically for primary care settings to reduce stress-related symptoms and improve coping skills of family members affected by addiction. In this model, the five steps (or sessions) are: listening nonjudgmentally, providing relevant information, exploring ways of coping, discussing social support, and establishing the need for further help.26 This method can be delivered in person or with a self-help manual. The Five Step Method has been studied in the United Kingdom and has been shown to decrease stress and improve coping among family members.26,27 The CRAFT intervention, described in Principle 2, has a similar goal of improving family member well-being, regardless of whether the loved one enters treatment or reduces substance use. CRAFT improves overall family functioning independent of whether an adolescent is engaged in treatment.18
Family members may not seek counseling or support due to stigma and shame.28,29 Some healthcare providers may hold stigmatizing beliefs about the family, viewing family members as a barrier, rather than a facilitator, to treatment. An additional challenge is simply identifying family members who could benefit from support services; screening to identify such individuals has not been studied.
Summary and Opportunities for Improvement
Care for young adults with SUDs can be structured so that family members are included regardless of whether the care is outpatient, inpatient, or residential. Even if the young adult chooses not to allow family involvement in care, family members should still have access to accurate information about addiction, treatment, and how to reduce the risks to their own well-being from their loved one’s substance use. Furthermore, given the impact that a loved one’s substance use can have on the physical and mental health of the family and associated health care costs, an explicit focus on improving family member health is warranted. Providers can provide guidance to family members about how they can help support recovery, including support through housing, income, and transportation, as well as through substance use-specific support, such as monitoring for substance use and managing medications. In conclusion, family members can provide valuable support to loved ones with SUDs and should be educated and empowered to do so. Research is needed to improve understanding of the role of the family in treatment of addiction for young adults.
Dr Bagley conducted the literature review, wrote the first draft, reviewed and revised the manuscript, and approved the final manuscript as submitted; Ms Ventura contributed to the literature review, wrote a section of the first draft, and revised and approved the final manuscript; Drs Muench and Lasser provided a significant contribution to the revision of the initial draft and approved of the final manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
The guidelines/recommendations in this article are not American Academy of Pediatrics policy, and publication herein does not imply endorsement.
FUNDING: Dr Bagley was supported by NIH/NIDA (K23DA044324). The funder did not participate in this work.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.