Family of Origin Psychotherapy in Addiction Treatment Creates ‘Beneficial Change,’ Expert Says

Bruce Fischer, PhD, LP, LMFT, a member of the Cape Cod Symposium 2024 (CCS) faculty, discusses the use of family genograms and motivational interviewing to identify and address intergenerational trauma and addiction within a family system. Drawing from his CCS session titled "Family of Origin Psychotherapy with Individuals and Families Addressing Addiction(s)," this Q&A delves into managing family resistance and addressing challenges in Family of Origin Psychotherapy within addiction treatment.

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Editor’s note: This interview has been edited for length and clarity.

Meagan Thistle, Psychiatry & Behavioral Health Learning Network: How do you differentiate between when to use family systems-oriented individual therapy versus in-person family therapy when addressing addiction-related issues?

Bruce Fischer, PhD, LP, LMFT: This is a good question with no simple answer; here are several guiding principles. One is to not place clients in a dangerous situation. If the family is highly emotionally or behaviorally dysregulated, family therapy is not indicated. In cases like this, I will work with some of the individuals to help them function in a way that will allow family therapy to be beneficial. 

One key to effective family treatment is the timing and sequencing of interventions. For example, if a family is struggling with helping a person with an addiction stay clean, it doesn’t make sense to look at old issues until they are behaviorally stabilized. Therefore, the focus of the therapy at that time should be on how the family can help them stay clean and address how the other family members can take care of themselves. It may be helpful at that time to at least name the other issues that need to be addressed so it doesn’t appear they are being denied.

Thistle: Can you explain how family genograms are utilized in identifying patterns of intergenerational trauma and addiction within a family system?

Dr Fischer: A genogram is a visual representation of a family history. I see it as a living document that changes as clients learn more about their families. It is beneficial because it helps clients to easily see the patterns that have occurred in the family and how powerful those patterns are in influencing their own thinking, feelings, and behavior. Genograms can also help to reduce shame, as doing a genogram helps to reduce the sense that they are the only one who has these problems. Genograms can also help make sense of family secrets and rules, providing insight into how they impact a family and its functioning.

Thistle: How do you handle situations where family members exhibit resistance to participating in therapy, especially when addressing unresolved addiction issues?

Dr Fischer: I use a variety of techniques to work with family resistance. First, adopting a motivational interviewing approach is useful. I find it helpful to reassure clients that I do not allow people to mistreat one another in family therapy. This can have a significant impact on resistance.

I also strive to create safety by being warm, supportive, and nonjudgemental. Usually, I begin by exploring the patient’s concerns about participating in family therapy. Often, people are concerned about being criticized or shamed. Just naming these concerns helps to reduce resistance.

Beyond that, there are several strategies that can be employed to respond to resistance. Last year at the Cape Cod Symposium, I presented a 3-hour presentation outlining 12 skills for addressing resistance.

Thistle: In your experience, what are the most common challenges that arise in family-of-origin psychotherapy, particularly when dealing with addiction, and how do you address them?

Dr Fischer: One of the most significant challenges for therapists is managing their own countertransference.  Many professionals working in the addiction space have had painful family backgrounds of addiction and mental health problems. Unless they have addressed these issues in their own personal work, they can be easily emotionally and sometimes behaviorally activated when working with these families. When this happens, generally, the therapeutic relationship with the family is damaged, which can derail the therapeutic process.

Another challenge is the lack of training for professionals to do this work. Most addiction professionals have had limited training in family therapy. They may have only taken one family therapy class and generally have had limited supervision in family therapy. This is why I’m teaching this material, so that addiction professionals can better meet the needs of families with addiction concerns.

Thistle: Are there any common misconceptions around this topic that you would like to correct for the audience? Or is there anything else you would like to share?

Dr Fischer: One common misconception is that family therapy requires all family members to be present. I have found if I work with those willing to attend, we can still create beneficial change, and often, in time, the resistant family member is willing to come in. Even if they do not attend, creating change within a family system will ultimately impact the entire system. This is not a new concept. Al-Anon has been doing this for decades!

Bruce Fischer, PhD, LP, LMFT, has been in private practice for 46 years. He provides individual, group, and family therapy and has provided family-of-origin work with hundreds of individuals and families dealing with a variety of alcohol, drug, sex, and work addiction problems. He holds a Ph. in Family Social Science as well as certificates in Chemical Dependency Counseling, Family Therapy and Addiction Counseling, and Chemical Dependency and Family Intimacy (Sex Counseling).

Presently, he is a Senior Research and clinical Psychology faculty member Emeritus at Capella University in Minneapolis. He was previously chair of the Addiction Psychology program and the co-founder, associate Dean, Director of Training, and Director of Continuing Education of the School of Psychology at Capella.