Family and Children's
18, No. 1
Using Strategies from Relapse Prevention to Help Families Address Substance Abuse and Neglect
Families struggling to care for their children also often struggle with substance abuse. Indeed, studies say 40-80% of families involved with the child welfare system have substance abuse problems (NCSACW, n.d.).
A Definite Connection
Studies suggest there is a direct association between child neglect and substance abuse (Dunn, et al., 2002). In one study, substance abusing parents were more than three times more likely to neglect their children than other parents, even when researchers controlled for things such as social support, depression, and antisocial personality disorder (Chaffin, et al., 1996). Other studies have shown that substance-abusing parents are likely to provide less supervision, spend less time with their children, and express greater dissatisfaction with their children (sources in Dunn, et al., 2002).
States, Not Traits
It can be helpful to remember that even if they are chronic, substance abuse and child neglect are both states, not traits. In other words, both conditions are fluid, changing over time in response to the family's internal dynamics and the larger environment. Both substance abuse and neglect depend in part on parents' ability to cope with stress and maintain their role as caregiver (Larimer, et al., 1999; Dunn, et al., 2002).
In trying to figure out how to assist families experiencing chronic neglect, it can be helpful to look to the field of substance abuse for models that have been shown to improve people's coping skills and control behaviors that put the user and their children at risk.
One such approach is Relapse Prevention. First implemented in 1977, there has been significant research to support the effectiveness of this method (SAMHSA, 2012).
Relapse Prevention is a cognitive-behavioral approach: the goal is to help people change how they think about and behave in relation to substance use in order to improve their coping skills and minimize the risk of relapse. Cognitive-behavioral approaches have been shown to be particularly effective with substance use disorders (McKellar, et al., 2010).
While Relapse Prevention is a treatment intervention, it has key components child welfare workers can adapt to help families create realistic plans. In fact, these key components are part of what child welfare workers already do every day, though they may not see it as relapse prevention.
- Have co-occurring mental illness (depression, bipolar disorder, PTSD)
- Live with a partner who is still using
- Have frequent exposure to high risk situations
- Have frequent reminders of use (paraphernalia, drug friends, places)
- Want to test their control over drug/alcohol use
- Have inadequate avoidance/refusal skills
- Have inadequate skills to deal with conflict or negative emotions
Source: Peters, 1993
1. Identify and prepare for high risk situations.
A basic tenet of Relapse Prevention is that people abuse drugs and alcohol in the context of a few high risk situations. A key task is to help clients identify their personal triggers: to get them to ask, "What are the situations in which I am most likely to use or be tempted to use?" Often those situations involve negative emotional states, especially those related to interpersonal conflict or social pressure (Marlatt, 1996). When someone has a positive plan for handling a given situation, they are more likely to get through it without using (Larimer, et al., 1999).
Child welfare workers can help parents move in this direction by reviewing recent episodes of drinking or drug use to identify the people, places, emotions, or other characteristics involved. Then, parents can be coached with solution-focused, open-ended questions to plan specific responses for those situations. For example, if spending time with particular friends usually leads to drug use, what can the parent realistically do the next time one of those friends tries to include them in something?
The connection to North Carolina's Principles of Partnership is clear. Parents will be much more willing to explore these situations when the child welfare worker has approached them in a collaborative way, offering to partner in problem-solving.
2. Identify and reinforce successes.
To avoid relapse, people with substance abuse disorders must have two things: a clear plan of action for dealing with high-risk situations, and the confidence to carry out that plan
(Larimer, et al., 1999). Actually, this is true for anyone trying to change behavior: we must have skills needed to make the change and we must believe we can really change.
Child welfare workers ask parents about their successes all the time to encourage and reinforce positive choices and a sense of accomplishment. In the area of substance abuse, this involves asking parents about times when they have not been using, or when they successfully managed a high risk situation without a lapse or relapse. Helping parents make a realistic plan and build their confidence in carrying it out are critical components in maintaining sobriety.
3. Don't let lapses turn into relapses.
In Relapse Prevention, one of the most critical steps is re-framing how people think about relapse. A lapse in sobriety should not be seen as a personal failure that immediately sets off a string of catastrophic consequences and shameful reactions. Instead, a single lapse must be understood as a chance to learn from mistakes and figure out how to do better next time. By reducing the punitive response and the resulting shame, small lapses can be prevented from turning into a complete relapse (Marlatt & Gordon, 1980 & 1985, cited in Larimer, et al., 1999).
Compare it to dieting. Just because you treat yourself to that bowl of ice cream one night doesn't mean you need to give up on dieting and over-indulge all week. In cognitive-behavioral terms, people who view a lapse as a personal failure ("I am a terrible parent and will never be sober") are more likely to progress to full-blown relapse than people who view the lapse as "a failure to cope effectively with a specific high-risk situation" (Larimer, et al., 1999).
In the child welfare world, some visitation plans stipulate that parents will lose visits with their children if they use drugs or alcohol at any time. Unfortunately, this can mean that even if a parent uses a small amount away from their children, they can become so ashamed and depressed that they are more likely to fall into a full relapse. If instead parents are encouraged to share with their social worker that they have had a lapse, the two can work together to figure out what the high risk situation was and how to manage it better next time. An approach that encourages learning and self-awareness is much more useful for long-term outcomes than the avoidance and power struggles involved in trying to hide or prove a single episode of use.
4. Create a more balanced lifestyle.
People with substance abuse disorders often have little genuine pleasure in their lives. They tend to have a lot of things they must do, but not many they want to do (Larimer, et al., 1999). To maintain sobriety, parents must find healthy things they enjoy and ways to take care of themselves in spite of other obligations.
In many ways, most of us share this struggle. Because of their histories and coping skills, parents with substance abuse issues tend to need specific support and coaching to find "healthy addictions" to fill some of the time and replace some of the pleasure that drug or alcohol use provided.
One strategy used by treatment providers can be adapted easily by child welfare workers. Parents can be encouraged to keep a log for just a few days, noting what they do and whether it is a "should" or a "want to." Simply raising their awareness of how they spend their time, and of their power to make different choices, can help adjust the balance between the two.
Since substance abuse is a common factor in situations of chronic neglect, it makes good sense to consider how managing one can help improve the other. Fortunately, many of the specific steps of Relapse Prevention are familiar to child welfare workers. Improving parents' self-awareness and ability to cope with risky situations can help increase both their chances for maintaining sobriety and their opportunities for positive parenting.
References for this and other articles in this issue
- Return of Denial. Becomes unable to recognize and honestly tell others what he or she is thinking or feeling.
- Avoidance and Defensiveness. Doesn't want to think about anything that will cause painful feelings to come back, so avoids anything or anybody that will force an honest look at self. Defensive when asked directly about well-being.
- Crisis Building. Begins experiencing life problems caused by denying feelings, isolating self, and neglecting recovery. Wants to solve the problems and works hard at it, but new problems pop up to replace every problem that is solved.
- Immobilization. Totally unable to initiate action; goes through the motions of living but is controlled by life rather than controlling life.
- Confusion and Overreaction. Can't think clearly, upset with self and those around her, irritable, overreacts to small things.
- Depression. Depression so severe and persistent that it cannot be ignored or hidden from others. Difficulty keeping normal routines. Thoughts of suicide, drinking, or drug use as a way to end the depression.
- Behavioral Loss of Control. Unable to control or regulate behavior and daily schedule. Heavy denial and no full awareness of being out of control. Life becomes chaotic and problems are created in all areas.
- Recognition of Loss Control. Denial breaks and suddenly he recognizes how severe the problems are, how unmanageable life has become, and how little power and control he has to solve the problems. Awareness is extremely painful and frightening. Has become so isolated that it seems that there is no one to turn to for help.
- Option Reduction. Feels trapped by pain and inability to manage life. Seems to be only three ways out--insanity, suicide, or drug use. No longer believes anyone or anything can help.
- Relapse Episode. Begins to use again, struggling to control or regain abstinence. Shame and guilt when the attempt fails. Eventually all control is gone and serious bio-psycho-social problems develop and continue to progress.
Source: Miller & Harris, 2000