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The Substance Abuser and Multi Family Systems Therapy, Part One

Allan Schwartz, LCSW, Ph.D. Updated: Nov 18th 2011

The Substance Abuser and Multi Family Systems Therapy, Part OneCase:

Bob was a fourty-year-old man with a long history of crack abuse. He was referred for therapy by a long term inpatient and outpatient treatment center where he detoxed from crack and was stabilized to the point that he was no longer drug dependent. He was attending both Alcohol and Narcotics Anonymous sessions several times a week. He had a job and appeared to be doing well when he was referred. There was one major and persistent problem in Bob's life. He was living with his elderly mother ostensibly because, having lost all of his money buying drugs, he could not afford to live anywhere else. His father had died many years before and his older brother and sister were married with children. Within the family, Bob had always been a behavior problem. At least, that appeared to be the problem. Very soon after leaving the drug treatment center and beginning psychotherapy, Bob relapsed. What happened?

One way of answering this question is to look at Bob's family and the way in which all the members interacted. This is not to blame the family but to understand how it works to maintain a steady and predictable method of functioning. In other words, the family is a system. What is a system?


According to the Oxford American Dictionary, "a system is a set of inter-connected parts forming a complex whole. The parts work together as a network and follow a certain set of principles and procedures in which things are done."

According to family psychotherapy, individuals cannot be understood in isolation. Individuals are members of families systems. The family system is made up of interconnected and interdependent individuals. Each member has a role to fulfill, must follow certain family rules and must help maintain a sense of equilibrium or balance in order to ensure cohesivenss and predictability in its members. The rules of the family keep the system going by resisting change, filtering outside influences, and maintaining boundaries, whether healthy or unhealthy in nature.

Our drug addicted patient, Bob, is part of a family system that always helped maintain him in his unhealthy and maladaptive ways of living. In fact, his role was to be the "identified patient." The identified patient has the role of scapegoat. Problems that affect the functioning the system as a whole can be blamed on the scapegoat who then fulfills that assignment. It is better to fulfill a maladaptive role than to be exhiled.

Given his job as the identified patient, Bob's mother continued to predict his failure and expect him to steal her money and abuse drugs. If he came home from work even a little late, he was held under suspicion. The fact that he now contibuted money to the household for the first time in many years didn't make a difference to his mother who complained that it wasn't enough. Seemingly Bob could do nothing right. His mother behaved toward him as though he continued to steal, abuse drugs and live in the streets as a homeless person. She even complained to her older son and daughter who visited the house and they scolded him for his continued bad behavior. Predictably, Bob relapsed and fulfiled his role as scapegoat. It should be said that despite the efforts of the therapist to get him to move out and find his own apartment, Bob insisted that his mother needed him and, so, he could not leave her.

To repeat what was said before, families are not at fault for what happens to their members. Instead, the family is like a machine with interconnected parts that work well or do not.

For this man to have any chance at recovery, it would be necessary to get his mother, sister, brother and any other adult family members involved in treatment. The hardest job that the therapist, patient and family have is to change the system so that everyone can feel and function better.

As a therapist who worked with many families over the years, I can report how frustrating it is to see how the family is unhappy and miserable because they are trapped in this rigid and repetitve system that maintains itself even when individual members can see how malfuncting things are. That is why it is the role of the therapist to not only provide family therapy sessions but to become part of the system so that he can change things from within. This is the most rewarding and the most frustrating part of the work.

In the next blog, we will look at a newer and more powerful type of family therapy used for teenage drug abusers called Multidimensional Family Therapy.

Your comments and questions are encouraged.

Allan N. Schwartz, Phd.


Allan Schwartz, LCSW, Ph.D.

Readers who live in the Boulder, Colorado metro area, or in Southwest Florida may contact Dr. Schwartz for face-to-face consultation. He is also available for psychotherapy through Skype video for those who are not in Florida or Colorado. He can be reached via email at for details.

Reader Comments
Discuss this issue below or in our forums.

defining "family" - Dor Hall - Nov 18th 2011

I speak to my experience. My 'family' in the conventional sense is not involved at all in my mental health treatment. My husband sees my sobriety, but hes not had a direct hand in it. So am I in isolation?

I think not.

I can change myself. And I can hope that by working closely with my doctor and people inside the rooms, those changes I can affect in myself have an impact on others.

I don't fall into any clear definition in the DSM. My psych sees what presents, and we -- WE -- work with it, and growth happens. The program I chose when I chose sobriety is a WE program.

Yes, for all that we fight it, human beings are NOT wired for solitude.

Nothing happens in isolation; things happen in cooperation, but each individual must change his or her own course.

For your consideration ...

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