Troubled families and individualised solutions? An ontological, discursive and interactionist analysis of families' involvement in alcohol and other drug treatment

Abstract

The main concern in this article-based thesis is the situation for families in the course of addictive processes and the conditions for support and involvement in treatment, where we ask: how can we understand practices towards families and affected family members (AFMs) in alcohol and other drug (AOD) treatment? Three articles are linked together in their common focus on family- oriented practices. Firstly, on the theoretical level, analysing how two models of families in addiction; the Stress-strain-coping-support (SSCS) model and the social ecological (SE) model, aiming respectively towards AFMs in their own right and towards relationships between family members, relates to the phenomenon of addiction, and which options and actions they provide for families. Secondly, on the institutional level, analysing how theories are applied in practice, and what the conditions are for receiving attention and support as AFMs within AOD-treatment. Thirdly, on the family level, analysing processes of treatment and recovery from the interrelated perspectives of persons with a problematic use of substances and their AFMs, related to the possibilities and options encounters with treatment facilitates. The empirical basis for these analyses was obtained from three different AOD- treatment institutions in Norway. Both clinicians (n=l5), directors (n=3) and representatives from families (n=l6 from l0 families) were interviewed to gain knowledge about families encounters with treatment, and the interactional context in which family-oriented practices are exercised. Concept retrieved from a critical realist, discursive and interactionist research tradition were used as tools underlying the different analysis. A common ground is a sensitivity towards discursive opportunities and possibilities at work in talk and interaction. In Article l both the SSCS model and the SE model are highlighted as essential for dealing with the complexity of the phenomenon of addiction in families. The SSCS model by providing agency for a neglected group of AFMs and developing a method to address their needs, and the SE model by advocating the relative position of social solutions in the field of alcohol and drug (AOD) treatment and developing a framework for conducting joint sessions and family therapy. Both models and their respective practical guidelines for interventions could work complementary in a clinical setting, as useful tools in different types of case and at different stages of treatment-combining the level and emergence in the interaction between agency and structure-for the betterment of families and individuals. In Article 2 it is revealed that family-oriented practices are gaining ground within the field of AOD-treatment, as a "going concern". Still, the relative position of family-orientation in the services, is constrained and shaped by three other going concerns related to : (l) discourse on health and illness, emphasising upon addiction as an individual medical and psychological phenomenon, rather than a relational one; (2) discourse on rights and involvement, emphasising upon the rights and autonomy for the individual patient to define the format of their own treatment; and (3) discourse on management, emphasising upon the relationship between cost and benefit, where family-oriented practices are defined as not being cost-effective. All three discourses are networked together in underpin the "gravity" towards individualised practices. The findings point to a paradox: although family- oriented practices are supported by research, and are (or are in the process of) being implemented in policy guidelines, the conditions of possibilities for preforming family-oriented practices in the services are limited. In Article 3, three main "storylines" were analysed as facilitating different processes of treatment and recovery within families: (l) a "medical" storyline, (2) a storyline of autonomy (for AFMs), and (3) a storyline of connection (in families). These storylines positioned AFMs respectively as outsiders, as individuals (in need of help in their own right), and as part of a family system. The medical storyline is revealed as insufficient for dealing with the problems associated with addiction; it needs to be supplemented by storylines which facilitate processes of reintegration and repositioning within families. The storyline of autonomy and the storyline of connection facilitate processes of unilateral and bilateral repositioning respectively. Within a storyline of autonomy, AFM described the importance of being acknowledged in their life situation, to be "just me", to get knowledge about the situation, to get support. viii Summary ix in take care of oneself, to set boundaries, and make the person using substances responsible for their own drinking or drug taking. Within a storyline of connection, participants described how important it was that AOD treatment provided a safe place for open communication and trust building. They appreciated the assistance in establishing a language to talk about their difficulties, hinder a situation where AFM and PAR is "out of step" with each other, and help in translating and synchronizing mutual processes of change. Overall, the findings of this thesis involve three main contributions to the research literature: l. Examples are provided of how the potential in focusing on family relations and social mechanisms is restricted in the way services are organized and function in the current situation. 2. Examples are provided of how family involvement in treatment and family- oriented practices make sense and give opportunities for families struggling with addiction. 3. Attention is drawn to the relevance of the ontological level of social relations in addiction theorizing and practice. The thesis as a whole offers an analytical critique of the field by contextualizing the barriers in implementing family oriented services. By viewing addiction as a necessarily laminated system, with a layered ontology, all possible layers (e.g biological, psychological and social) of the phenomenon play a potential role, and need to be taken into consideration in the practices of AOD services. The case of AFMs, children and families represents a going concern, but still it is a struggle to incorporate these perspectives in everyday clinical life. The findings of the study suggest a re-articulation of the order-of-discourse and a strategic mobilisation of a social ontology in addiction theorising and in practice. The SE model with its focus on reintegration, encompassing a social ontology, is an interesting "gaze" and overarching framework in this respect that can play a part in such a strategic mobilization. So, that those interventions that are highly recommended therapeutically would also represent organisational and operational sustainability.