Family Therapy in Addictions Work

Introduction

I would like to offer my observations and recommendations based on my work in Singapore between 2005 and 2011 in the field of addictions. To summarize:

• addiction is a “Family Disease”, and family therapy is a must
• counselors who work in addictions should have training in both addictions and in family therapy
• that training should be culturally appropriate
• there needs to be some sort of government approved certification and/or licensure of addiction specialists

My Singapore Experience

I just finished reading a superb article by Timothy Sim on family therapy in Singapore¹.
He captures it all. It brought me back to many issues I struggled with while working in Singapore.
As an addiction specialist practicing in Singapore for nearly six years (2005-2011), I had personally handled nearly 80 cases in addition to supervising hundreds of cases by other therapists. I expected to involve the entire family when working with a person suffering from an addictive disease. Note, I said “expected” since for a variety of reasons, it was almost impossible to work with families during my stay in Singapore. The counselors I supervised did little better, in fact, probably worse.

Before my six-year stint in Singapore, I had presented several workshops on addictions there. However, when I was asked to come and present a workshop on Family Therapy in early 2000, I turned it down because I really had no solid idea about the structure of Singaporean families. I had never treated one. I think the agency who wanted to hire me thought this was a very odd reply.

Cultural Differences

When I actually came to work in Singapore in 2005, I realized how spot on I was. I realized later that many many Western professionals come to Singapore and provide training without having any idea of Singaporean culture. While I had always felt that I might be able to share addiction information which could be applied to any culture with some adjustments, family therapy is quite culture bound.

Even here in the United States family therapy with a Latino family would look quite different than with an African American family. For example, immigration and the specific country of the Latino family is very significant, as well as the concept of “Machismo.” Certainly, one cannot underestimate the cultural trauma inflicted on the African American population as a result of slavery and racial bias. In family therapy, parenting, economics, religion, and power structure all affect family dynamics; all of which reflect the culture of the family.

Addictions counseling has suffered from some of the same cultural problems. Currently certifying addiction specialists is done through an International Agency which is clearly reflective of Western thinking and programs. Thankfully some work is being done to offer a certification for Asian Addiction Counselors spear-headed by Dr. Munidasa Winslow of Promises Pte Ltd, Singapore (http://www.promises.com.sg). The Asia Pacific Certification Board (http://apcb.asia) is in its early and formative stages but offers real hope for certifying Asian addiction specialists.

Need for Family Therapy in Addictions Counseling

In addictions work, family therapy is a must. Addiction is called “The Family Disease.” In general, the addictive behaviour of the addict affects deleteriously the lives of at least 5 other people often in a rather dramatic fashion. Anyone who has worked with an addict or family member is quite aware of this. They also know how almost impossible it is to get family members to come in either to help the addict get treatment through an intervention process or to support a loved one’s recovery once treatment has begun. They tend to think that just fix the addict and all will be well.

I remember talking with a dear Singaporean friend of mine a number of years ago who worked in domestic violence, an area which is clearly a family matter. Even here, the family thought, just stop the offender, and all would be well. She commented on how she began to understand that addictions were often part of the offending behavior, so you needed to address that aspect and even then, when the overt behavior had stopped and the addiction managed, the family needed on-going help but were reluctant to participate.

Unfortunately, even when the overt violence ceased and addictions were managed; emotional violence, control, and dysfunctional family systems remained intact. The family system needs treatment, not just the individual.

Naturally there are many reasons why Singaporean family members refuse to come in. The most obvious is shame, and sometimes guilt. They also truly believe that they have nothing to do with the addiction let alone helping in the recovery process. Without their involvement, recovery is difficult and relapse problems intensify.

I think equally important, is our inability to apply family therapy principles to the various ethnic groups who require counseling care. I am certainly aware that each group and sub-group also have different ways of recovering from an addiction, so it is completely logical that the families need to be addressed specifically within their own cultural understandings.

I was told when I first began to work in Singapore that Singaporeans do not share “private” things about sensitive issues. I have not found this to be true at all. What I have found true is that therapists are afraid to ask. Counselors need to be comfortable asking about sex, money, addictions, and all sorts of complicated relationships. In my experience clients are more than willing to share if they feel safe and comfortable with the therapist. They talk and talk…it is just no one asks. This includes asking the family members.

Training of Professional Counselors

Interestingly, the first line of defense in addictions is often the social worker practicing in a Family Service Center. It strikes me that the first training all such workers should engage in is addictions and family work since they are usually the first counselors to engage when there are problems.

The agencies that treat addictions often don’t see the addict, let alone the family members, until well into the addiction process where the addiction has reached severe and chronic proportions and the family is often in shreds. If family intervention could take place at a much earlier stage, many more would not have to endure the years of endless suffering. We would also go a long way in preventing future addiction problems within the family.

But to do this effectively, a social worker or counselor needs both the addiction training and the family systems training, as well as know when to refer and work collaboratively with other agencies that specialize in addiction treatment. Addictions occur within a system which is also cultural, thus the Western model needs way more than a tweak to work.

Many agencies, especially church affiliates, allow untrained or minimally trained people to counsel. In addictions this can be particularly disastrous as the counselor often becomes the rescuer for the addict who “plays” on the benevolence of the counselor.

Recommendations

Though family therapy has been present in Singapore since the early 1980’s, it continues to struggle with acceptance possibly because so few will actually avail themselves of the process. There is virtually no attempt to document let alone create models and test for best practices with the family therapy and addictions model. Yet, everyone who treats addicts is very aware of what is known as Co-Dependency or Co-Addiction - a model that recognizes both the impact on and the ability to foster the sustaining of addictions in a family system. We also know that addictions affect the children of a parent suffering from an addiction as well as brothers and sisters of an addict, yet again, they are never brought into the treatment process.

I have yet to fully understand why Singapore does not develop its own model of family therapy which is so needed in such a diverse cultural atmosphere. There are a number of highly skilled practitioners who have been trained overseas or who received their training in Singapore under the tutelage of someone from another country. They are in a superb position to develop that model. Many of them offer a uniquely Singaporean approach but never seem to be in the position to train others with their strategies, let alone write about it. I am always a bit struck that Singaporeans seem reluctant to profess their own expertise or accept the expertise of a local professional.

In addition to needing a family therapy model that is reflective of the Singaporean society and addictions training that makes use of such a model, there is a significant need for people to provide adequate supervision and ongoing training. The professional societies in Singapore, and indeed the government, have been slow to create standards of practice and insist on licensing mental health professionals. With concrete measureable standards, one could then be guaranteed of at least minimal professional competency and pay that is reflective of expertise and experience.

Conclusion

In conclusion, I would urge Singaporean Counselors of all disciplines to form a committee to begin to design a family therapy strategy that is more reflective of the Singaporean/Asian culture. Perhaps such a committee might be initiated by the National Council of Social Service (NCSS) with the support of the National University of Singapore.

I would also urge this or another committee to impress upon the various Ministries the urgent need to certify or license counseling practitioners so that the public is assured of professional competency when they seek help.

¹Timothy Sim, Journal of Family Therapy, (2012) 34: 204-224.