(p. 447) Fathers Too! Building Parent Interventions for Substance-Abusing Men
For much of the past century, men have consistently outnumbered women in populations of substance-abusing individuals (McMahon, Winkel, Luthar, & Rounsaville, 2005), and researchers (e.g., Anglin, Hser, & McGlothlin, 1987; Hser, Anglin, & Booth, 1987; Hser, Anglin, & McGlothlin, 1987) have repeatedly documented gender differences in precursors to addiction, patterns of use, and related problems. Consistently, one of the more striking differences between men and women entering substance abuse treatment involves their status as parents. In general, substance-abusing women are more likely to be the parent of a minor child (McMahon et al., 2005); they are more likely to express concern about the welfare of their children as they enter substance abuse treatment (Gerstein, Johnson, Larison, Harwood, & Fountain, 1997); and they are more likely to seek treatment with minor children in their care (McMahon et al., 2005). Nevertheless, there are actually more fathers than mothers entering substance abuse treatment, because men consistently outnumber women by a ratio of approximately 2:1 (McMahon et al., 2005), and fathers living away from their children appear to be the largest group of parents seeking treatment for alcohol and drug abuse (McMahon et al., 2005).
Despite clear links between substance abuse and disturbance in the psychosocial development of fathers, mothers, and children, relatively little is known about the adjustment of substance-abusing men as parents (McMahon & Rounsaville, 2002). As responsible fatherhood has become the focus of several public policy initiatives (for reviews, see Cabrera, 2010; Cabrera & Peters 2000; Mincy & Pounce 2002), researchers have, on a limited basis, begun to show that alcohol and drug abuse are clearly associated with compromise of responsible fathering (for a review, see Chapter 8). At this point, there is accumulating evidence that paternal substance abuse is associated with (a) problematic attitudes toward parenting, (b) socially irresponsible production of children, (c) poor co-parenting relationships, (d) less positive parenting behavior, (e) more negative parenting behavior, and (f) relatively poorer father–child relationships (for a review, see Chapter 8).
Although alcohol and drug abuse seem to be associated with compromise of fathering, this research also highlights efforts at responsible fathering that are inconsistent with popular stereotypes of substance-abusing men. At this time, there is accumulating evidence that substance-abusing men are frequently present when their children were born, they often acknowledge paternity, they have often (p. 448) lived with their children, they have often made some attempt to provide financial support, and even if not living in the same household, they frequently have ongoing contact with at least some of their children (McMahon, Winkel, & Rounsaville, 2008; McMahon, Winkel, Suchman, & Rounsaville, 2007).
When carefully considered, this research suggests that parenting may be an important, but largely ignored, issue in the treatment of substance-abusing men (McMahon & Rounsaville, 2002). Very few substance abuse treatments used with men clearly focus on enhancement of parenting with an expectation that improvement in their social role performance will contribute to improvement in the psychosocial adjustment of fathers, mothers, and children. Over the years, researchers (e.g., Kelley & Fals-Stewart, 2002, 2007, 2008; Fals-Stewart & O’Farrell, 2003; O’Farrell, Murphy, Stephan, Fals-Stewart, & Murphy, 2004) have shown that marital intervention can improve substance abuse and family outcomes when delivered to substance-abusing men, they (e.g., Catalano, Haggerty, Fleming, Brewer, & Gainey, 2002) have included fathers in clinical trials of comprehensive interventions for substance-abusing parents, and they (e.g., Lam, Fals-Stewart, & Kelley, 2008, 2009) have begun to develop a marital intervention for substance-abusing fathers living with a sexual partner. However, gender differences in the nature of both substance abuse and parenting argue for comprehensive, gender-specific approaches to parent intervention, and researchers (e.g., Luthar & Suchman, 1999, 2000) have begun to develop parent interventions grounded in a clear understanding of the needs substance-abusing women bring to treatment. Although a number of authors (e.g., O’Neil & Lujan, 2010) have argued that parent intervention for men needs to be grounded in contemporary formulations of male gender, there is not yet an empirically validated, gender-specific intervention designed to address the complex needs of substance-abusing fathers.
Fathers Too! is a semi-structured, gender-specific, individual psychotherapy designed to improve father–child relationships that is currently being developed for men enrolled in substance abuse treatment. Building upon the intrinsic motivation of men to be a better father, the intervention focuses on (a) ways substance use can interfere with self-defined goals to be a more effective parent, and (b) ways fathering can support self-defined goals to establish abstinence. The intervention is based on a developmental-ecological perspective on the parenting of substance-abusing men, and it emphasizes the integration of therapeutic techniques to help men realize their goal to improve their relationship with a specific child.
Although the general approach can be extended to other populations of substance-abusing fathers, Fathers Too! is presently being developed for fathers enrolled in methadone maintenance treatment. Only men who express interest in being a more effective father are considered appropriate. Resident and nonresident fathers with biological children are the target population, but men in a position (p. 449) to function as a father figure for other children are also included. Although men involved in a divorce process or men involved with the child welfare system may be enrolled, men with legal mandates that limit access to their children are not considered appropriate. Men must be stable on a maintenance dose of methadone before they begin the program, and men physiologically dependent on another substance must be detoxified before they are allowed to begin. Men with psychiatric or neurological conditions that, even with treatment, would preclude meaningful participation in a semi-structured individual psychotherapy are not considered appropriate participants.
Fathers Too! is currently being developed for men in methadone maintenance treatment because more than 40 years of research indicates that methadone hydrochloride is a safe, effective, long-term treatment for opioid dependence (for a review, see Strain, 2006). Since methadone was first approved as a maintenance treatment, there has also been agreement that psychosocial intervention must complement medical treatment, and researchers (e.g., McLellan, Arndt, Metzger, Woody, & O’Brien, 1993) have shown that methadone maintenance is most effective when offered with intervention designed to address concurrent medical, psychological, family, vocational, and social problems. At this time, 60 to 90 milligrams of methadone daily, two to three clinic visits weekly, and moderate levels of psychosocial treatment appears to be the most efficacious and cost-effective treatment regimen (Rhoades, Creson, Elk, Schmitz, & Grabowski, 1998; Kraft, Rothbard, Hadley, McLellan, & Asch, 1997).
When offered with a therapeutic dose of methadone, complementary psychosocial interventions clearly improve both psychosocial and substance use outcomes. For example, Woody and colleagues showed that individual psychotherapy can be an effective adjunct to the drug counseling typically offered to methadone-maintained patients (Woody et al., 1983; Woody, McLellan, Luborsky, & O’Brien, 1987, 1995). Moreover, Rounsaville and colleagues argued that, to be effective, psychotherapy should be an integral component of the maintenance program that is made available early in the treatment process (Rounsaville, Glazer, Wilber, Weissman, & Kleber, 1983; Rounsaville & Kleber, 1985). More recently, Fals-Stewart and O’Farrell (2003) showed that marital and substance use outcomes can be improved for opioid-dependent men receiving antagonist treatment when family-oriented intervention is added to treatment-as-usual, and Luthar and Suchman (2000) showed that psychological and parenting outcomes can be improved when parent intervention is added to treatment-as-usual for opioid-dependent women receiving agonist treatment. Despite this, most psychosocial interventions integrated into methadone maintenance treatment target the secondary use of alcohol and other illicit drugs so common within this population (e.g., see Rawson et al., 2002). At this time, there are surprisingly few empirically validated psychosocial interventions that target other problems common among opioid-dependent men.
Although intervention to address interpersonal problems is often deferred until after abstinence is achieved, Fathers Too! is being developed for use with men (p. 450) who have completed an orientation phase of methadone maintenance treatment. This is being done for several reasons. First, even if they are still using alcohol and illicit drugs, substance-abusing men may have ongoing contact with their children. Second, enrollment relatively early in a course of treatment when their distress about their inability to function as a father is likely to be highest may actually facilitate their engagement and make it easier to highlight ways that continued use of alcohol and illicit drugs compromises father–child relationships. Third, Fathers Too! targets men who may be actively using, because, even after they are enrolled in methadone maintenance treatment, use of alcohol and other illicit drugs is very common, and there is a need for creative intervention that targets this secondary use of alcohol and other illicit drugs. Although other approaches to psychosocial treatment target the substance abuse directly (e.g., see Rawson et al., 2002), Fathers Too! attempts to link compromise of fathering with continued use in an effort to promote retention in treatment and accelerate movement toward abstinence. Finally, Fathers Too! targets men who are actively using because, when dealing with secondary substance abuse and interpersonal issues of this nature, there is no evidence that there are advantages associated with waiting for a period of sustained abstinence. In fact, there is some evidence that treatments that address substance use and family problems simultaneously may be more effective than approaches that focus only on the substance use (e.g., see Fals-Stewart & O’Farrell, 2003).
In addition to targeting men early in the treatment process, Fathers Too! targets men with a child from birth to 21 years of age because research indicates that men enter substance abuse treatment with children of all ages (McMahon et al., 2005). Although children differ developmentally, there are common themes in father–child relationships that justify focusing on the nature of these relationships from birth through early adulthood. By focusing on the common dimensions of father–child relationships with attention to ways developmental issues differ for children of different ages, Fathers Too! has the potential to meet the needs of most fathers entering substance abuse treatment.
The primary goal of Fathers Too! is to improve father–child relationships while decreasing the use of alcohol and illicit drugs.
From the beginning, Fathers Too! has been grounded in a developmental-ecological perspective on parenting that conceptualizes fathering as a complex, dynamic process with profound implications for fathers, mothers, and children (for discussion, see Belsky, 1984, 1993; Belsky & Jaffee, 2006; Cicchetti & Lynch, 1995; Cicchetti & Valentino, 2006). Fathers Too! builds on this work by acknowledging the validity of developmental-ecological models of fathering that allow for dynamic modeling of ways substance abuse compromises ability to function effectively as a father and ways inability to function effectively as a father may contribute to the perpetuation (p. 451) of alcohol and illicit drug use. Figure 22.1 outlines the conceptual model that has guided development of the intervention. Constructs double-outlined represent constructs targeted by Fathers Too!
Within a developmental-ecological model of substance abuse and fathering, there are nine broad conclusions grounded in empirical data that must be carefully considered in the development of a parent intervention designed to address the complex needs of substance-abusing fathers.
• Any parent intervention designed to meet the needs of substance-abusing men must acknowledge that patterns of pair-bonding, procreation, and parenting vary with socioeconomic status and ethnic heritage (for reviews, see Garcia Coll & Pachter, 2002; Hoff, Laursen, & Tardif, 2002).
• Any parent intervention designed to meet the needs of substance-abusing men must acknowledge that, when compared with men who have no history of substance abuse, substance-abusing men report greater exposure to childhood adversity known to heighten risk for compromise of parent–child relationships across generations (e.g., see Dube et al., 2003).
• Any intervention designed to meet the needs of substance-abusing fathers must allow for ways traditional ideas about the nature of masculinity influence the parenting behavior of men (for a review, see O’Neil & Lujan, 2010).
(p. 452) • Any intervention designed to meet the need of substance-abusing fathers must acknowledge that parenting behavior and substance abuse are both influenced by personality style (for reviews, see Belsky & Barends, 2002; Verheul, van den Bosch, & Ball, 2009).
• Any intervention designed to meet the needs of substance-abusing fathers must acknowledge that (a) values, attitudes, and beliefs about parenting play an important role in determining actual behavior (for reviews, see Bugental & Happaney, 2002; Holden & Buck, 2002; Siegel & McGillicuddy-De Lisi, 2002) and (b) substance-abusing men often demonstrate values, attitudes, and beliefs about parenting that represent risk for compromise of parent–child relationships and poor developmental outcomes in children (for a review, see Chapter 8).
• Any intervention designed to meet the needs of substance-abusing fathers must acknowledge that situational factors consistently influence the nature of father–child relationships (for a review, see Carlson & McLanahan, 2010). The existing literature suggests that there are seven contextual influences likely to affect the fathering of substance-abusing men: (a) ongoing use of alcohol and illicit drugs, (b) psychological distress, (c) quality of the co-parenting relationship, (d) residence with children, (e) social support for parenting, (f) employment status, and (g) legal history.
• Any intervention designed to meet the needs of substance-abusing fathers must acknowledge that characteristics of the child also influence the quality of parent–child relationships, particularly the age and gender of the child (for a review, see Parke, 2002).
• Any intervention designed to meet the needs of substance-abusing fathers must acknowledge that there is a reciprocal relationship between the psychosocial adjustment of men and participation in family life. The psychosocial adjustment of men influences participation in family life, and participation in family life influences the psychosocial adjustment of men (for a review, see McMahon & Spector, 2007).
• Finally, any intervention designed to meet the needs of substance-abusing fathers must acknowledge that fathers, mothers, and children stand to benefit from positive father–child relationships. Even when the sexual partnership has ended, mothers receive more emotional, instrumental, and financial support when fathers are involved with their children (e.g., see Carlson & McLanahan, 2010); and even when not living in the same household, children may benefit when fathers are present in a positive way (for a review, see Carlson & Magnuson, 2011).
Fathers Too! is defined by six distinguishing characteristics: (a) a focus on fathering, (b) a relational focus, (c) a focus on self-defined goals, (d) the matching of therapeutic technique to therapeutic task, (e) attention to male gender, and (f) a focus on both fidelity and flexibility. When integrated into a coherent gestalt, these (p. 453) six dimensions distinguish Fathers Too! from other psychosocial interventions that target either substance abuse or problems with parenting.
A Focus on Fathering
As noted above, Fathers Too! focuses on the fathering of substance-abusing men. The intervention is designed to actively engage men around their interest in being a more effective parent and then link that goal with the need to remain in substance abuse treatment, establish abstinence, and avoid relapse. More than anything else, this effort to consistently link effective parenting with sustained abstinence is the characteristic of Fathers Too! that differentiates it from both other substance abuse treatments and other parent interventions. Once men are engaged around their desire to be a more effective parent, the goal is to build positive father–child relationships and decrease the risk for continued substance use by increasing positive parenting behavior and decreasing negative parenting behavior.
A Relational Focus
Fathers Too! is grounded in a relational approach that emphasizes the assessment and treatment of each father in a dynamic process involving fathers, mothers, and children unfolding across generations. As suggested by Suchman, Mayes, Conti, Slade, and Rounsaville (2004), behavioral approaches to parent training have not proven very efficacious when used with substance-abusing mothers. Given the ways chronic substance abuse compromises parent–child relationships, Suchman et al. (2004) have argued that parent intervention designed to better meet the needs of substance-abusing mothers may need to focus more on the emotional quality of the parent–child relationship. Consistent with this, Fathers Too! builds on contemporary ideas about the need for comprehensive, systemic approaches to clinical intervention that acknowledge the complex nature of relational difficulty common among men and women with serious psychopathology that may be related to personality disturbance (for further discussion, see Magnavita, 2005). Rather than focusing on the development of parenting skills designed to promote more effective management of challenging behavior in the child, Fathers Too! focuses on helping men develop more satisfying dyadic (father–mother and father–child) and triadic (father–mother–child) relationships within their family of procreation. The focus is more clearly on the development of the father’s relationships than management of the child’s behavior.
A Focus on Specific Goals
Consistent with other approaches to psychosocial intervention (Miller et al., 1994; Miller & Rollnick, 2002; Weissman et al., 2000), Fathers Too! is characterized by a focus on the definition and pursuit of personal goals. Before beginning treatment, each client is asked to identify specific goals involving (a) their (p. 454) alcohol and drug abuse and (b) their relationship with a child. From the beginning, the focus of the treatment is defined by a mutual understanding of the client’s personal goals.
Matching of Therapeutic Technique to Therapeutic Task
In an effort to match the therapeutic strategy with the focus of the treatment at each step in the behavior change process, a broad range of acceptable therapeutic techniques is used to address the multidimensional nature of parenting behavior. That is, the therapeutic technique is matched to the therapeutic task being pursued within a specific treatment session. Acceptable, proven therapeutic techniques are integrated into a coherent gestalt designed to address the different dimensions of parenting behavior. Consequently, motivational, expressive, cognitive, interpersonal, and behavioral exercises are used at different points in the treatment to (a) provide structure, (b) maintain interest, (c) promote participation, (d) examine different dimensions of parenting behavior, and (e) implement plans for behavior change. This is done because, although some technical approaches focus more exclusively on one specific dimension of a problem like motivation for change (e.g., see Miller et al., 1994, Miller & Rollnick, 2002), other approaches to clinical intervention acknowledge the need for attention to the different dimensions of a problem when working toward lasting behavior change (for further discussion, see Norcross, 2005). Given that substance-abusing men are likely to present with (a) limited motivation, (b) problematic attitudes toward parenting, (c) traditional definitions of gender, (d) feelings of guilt and shame, (e) difficulty in co-parenting relationships, and (f) negative parenting behavior, no single therapeutic approach is likely to adequately address the problems they face as parents.
Figure 22.2 illustrates how motivational, expressive, cognitive, interpersonal, and behavioral techniques are integrated during delivery of the intervention to promote movement through a behavior-change process. Early in the treatment, (p. 455) when clients are more likely to be considering change, the emphasis is on the use of motivational and expressive techniques. As treatment continues, cognitive and interpersonal techniques are introduced to facilitate preparation for change. Toward the middle of treatment, the emphasis shifts more clearly to the use of behavioral techniques designed to promote initial change in actual parenting behavior, and toward the end of treatment, motivational techniques are again used to enhance motivation for maintenance of initial change and continued pursuit of treatment goals.
Attention to Male Gender
As a psychosocial intervention for men, Fathers Too! is also grounded in current understanding of male gender. There are four ways this is done. First, research concerning the nature of male gender (for a review, see Levant, 1996) informs thinking about this population of men as men. Next, research documenting gender differences in the nature of substance abuse (e.g., see Anglin et al., 1987; Hser, Anglin, & Booth, 1987; Hser, Anglin, & McGlothlin, 1987) informs thinking about this population of men as substance-abusing men. Third, research concerning the nature of fathering, particularly socially and economically disenfranchised populations of fathers (for reviews, see Carlson & Magnuson, 2011; Carlson & McLanahan, 2010), informs thinking about this population of men as fathers. Finally, the growing literature on men in psychotherapy (e.g., see Brooks, 1998) informs delivery of the intervention to substance-abusing fathers.
Fidelity with Flexibility
Within specific parameters, Fathers Too! allows the clinician to structure the treatment so that it meets the needs of an individual client. Working within the conceptual framework outlined here, the clinician has license to use motivational, expressive, cognitive, interpersonal, and behavioral techniques in a creative, flexible manner to move the client toward realization of his specific treatment goals. A modular approach to the selection and organization of treatment sessions that does not require that all treatment sessions be delivered to each client allows the clinician to tailor the treatment to the needs of a specific client.
Clinicians delivering Fathers Too! are expected to take an active, empathetic, and flexible therapeutic stance in an effort to create a positive helping relationship within which to deliver the intervention. Throughout the treatment, clinicians are expected to (a) provide structure, (b) communicate understanding of targeted problems, (c) convey a sense of acceptance, (d) facilitate discussion, (e) emphasize personal responsibility for change, (e) accept responsibility to be the change agent, and (f) provide support and assistance. Within each session, they take an active, directive stance designed to keep the client remain focused on the realization of his personal goals without being prescriptive. Rather than simply providing information, (p. 456) teaching skills, and prescribing solutions, clinicians are expected to (a) encourage clients to explore their thoughts, feelings, and behavior; (b) promote consideration of alternatives; (c) provide information; (d) help generate plans; and (e) facilitate the development of new skills in ways that allow the client to “own” the work done within the intervention.
Fathers Too! allows for the thoughtful, creative use of motivational, expressive, cognitive, interpersonal, and behavioral techniques to promote behavior change in fathers. Table 22.1 contains a listing of specific techniques drawn from different approaches to clinical intervention that can be used in the delivery of Fathers Too!. Given the multidimensional nature of parenting behavior, no single technical approach is viewed as wholly adequate. The challenge for clinicians is to effectively integrate specific techniques in a way that works for both the clinician and the client. As noted above, clinicians match the therapeutic technique to the stage of treatment and the therapeutic task being pursued within each session to effectively address a specific dimension of parenting behavior. This does not mean, however, that multiple techniques are integrated into each treatment session. In fact, they are not. Instead, a specific therapeutic technique guides delivery of each session or block of sessions.
Table 22.1 Integration of Therapeutic Techniques in Fathers Too!
For example, if the client and the clinician are exploring beliefs about the effective discipline of children, cognitive techniques would be the primary strategy for the treatment session. If the client relates his belief system to childhood experiences within his family of origin, it might be appropriate to acknowledge the continuity in parenting behavior across generations, but it would not be appropriate to abandon exploration of the client’s current belief system to encourage expression of emotion about having been physically abused as a child. Ideally, that would have been done earlier in the treatment during a session that addressed the developmental dimension when encouraging expression of emotion would have been more consistent with both the stage of treatment and the focus of the session.
Similarly, the utilization of diverse therapeutic techniques does not mean that clinicians simply choose those they find the most familiar or the easiest to use. For example, it is not appropriate for a clinician with extensive training in motivational intervention to use motivational strategies later in the course of this treatment when the goal is to help a client develop more effective ways of communicating with a teenage daughter. To be delivered in a manner consistent with the conceptual model, that treatment session would have to involve the use of behavioral techniques. Consequently, during the course of a full treatment, clinicians are expected to utilize many, if not most, of the techniques outlined in Table 22.1. Most of these techniques are routinely used in other forms of substance abuse intervention, and they are familiar to many clinicians. The challenge for the clinician who has not done similar work is to apply them creatively to address the parenting issues the client brings to treatment. (p. 457)
Build in Rituals
Rituals can be important in psychotherapy pursued with men (Brooks, 1998). Consequently, Fathers Too! incorporates a simple ritual involving a handshake that is used consistently by both male and female clinicians. At the beginning of each treatment session, the clinician greets the client with a handshake to say “Hello.” At the end of each session, the clinician ends with a handshake to both indicate agreement about the plan for continued treatment and say “Goodbye.” Other simple rituals (e.g., talking over a cup of coffee) can also be integrated into the sessions.
Aggressive confrontation, argument, labeling, lecturing, simple education, excessive use of clinical interpretation, and behavioral contracting are not allowed in the delivery of Fathers Too!. Although participation in 12-Step programs is not discouraged, discussion of 12-Step philosophy and encouragement of enrollment (p. 458) in self-help groups is also not allowed, unless it is somehow directly related to a parenting issue (e.g., having children attend a Nar-Anon group). Use of other approaches to the development of parenting skills (e.g., a filial approach where the clinician works with parent and child together) and use of techniques drawn from other approaches to family intervention (e.g., structural family therapy) are also prohibited.
Outline of the Treatment
Fathers Too! has five critical components. Typically, the intervention comprises 16 to 24 treatment sessions conducted over the course of 16 to 20 weeks. Each intervention consists of (a) a pretreatment assessment, (b) four mandatory evaluative sessions, (c) 12 to 16 treatment sessions, (d) a maximum of four supplementary treatment sessions, and (e) a mandatory termination session. The four evaluative sessions begin the treatment for everyone in the same manner, and the mandatory termination session ends the treatment for everyone in the same manner. The other treatment sessions are drawn from a menu of thematic sessions developed to address problems common within the target population, and they are selected to address the different dimensions of parenting that must be addressed to help each client realize his treatment goals. Up to four supplementary sessions may also be used to facilitate evaluation, communication, or treatment planning with significant others. All sessions are approximately 60 minutes long, but when indicated, supplementary sessions may be longer.
The initial assessment of each client enrolled in Fathers Too! is comprised of a pretreatment assessment and four evaluative sessions. Before seeing his clinician, each father completes a pretreatment evaluation designed to generate information about (a) initial treatment goals, (b) current family system, (c) ongoing substance use, (d) personality disturbance, (e) quality of co-parenting relationships, (f) positive and negative parenting behavior, (g) quality of parenting received from biological parents, and (h) childhood trauma. This pretreatment assessment also includes information about positive and negative parenting collected from the child, and information about the emotional-behavioral adjustment of the child collected from both father and child. A summary of this pretreatment assessment is provided to each clinician when the first treatment session is scheduled. As treatment begins, the clinician uses this information to inform completion of the four evaluative sessions. The four evaluative sessions are listed in Table 22.2. This initial (p. 459) series of treatment sessions culminates with a discussion of the results, refinement of the client’s treatment goals, and development of a treatment plan.
Table 22.2 Mandatory Initial Assessment to Begin Fathers Too!
Thematic Treatment Modules
After the goals of treatment have been defined, the clinician selects the thematic treatment modules needed to help the client realize his goals. The thematic treatment modules that have been defined thus far are listed in Table 22.3. Each module is composed of two to five treatment sessions. Once the most appropriate treatment modules have been chosen, they are ordered for delivery to the client following the developmental-ecological hierarchy outlined in Table 22.4, with examples of thematic sessions that might be used at each step in the treatment process.
Table 22.3 Thematic Treatment Modules within Fathers Too!
Table 22.4 Developmental-Ecological Hierarchy for Ordering of Thematic Treatment Modules
(p. 460) Consistent with general guidelines for delivery of the intervention, this initial listing of thematic sessions is considered tentative. As the treatment evolves, specific sessions can be dropped, and additional sessions can be added to better address the parenting issues of the client as they unfold over time. Outlines of the treatment sessions were developed to serve as examples of ways specific issues might be addressed in a manner consistent with the treatment protocol. When indicated, clinicians and supervisors can collaborate on modification of specific sessions to better meet the needs of the client, as long as the modification is consistent with general guidelines for delivery of the intervention. Modification to make them more relevant to children of different ages is always considered.
Moreover, this listing of thematic treatment sessions is not exhaustive. If a client presents a treatment issue that cannot be addressed by a specific session or cluster of sessions, the clinician and supervisor collaborate on the development of a thematic session that will address the parenting issue in a manner consistent with the treatment protocol. The treatment manual includes a template to guide development of a new thematic treatment session, and as new thematic sessions are developed, they are added to the treatment manual.
Supplementary Treatment Sessions
Supplementary sessions are used to facilitate communication and treatment planning with a third party. Consultations with (a) father and child, (b) father and mother or other caregiver, (c) father and drug abuse counselor, and (d) father and some other source of social support are all acceptable. Supplementary sessions can also be used to secure consultation with a child and adolescent clinician. For example, there may be need to clarify the extent to which a child may be having serious psychiatric difficulty. Even if trained as a child and adolescent clinician, it would not be appropriate for the client’s clinician to do that evaluation. Similarly, a clinician who is not a child psychologist may want assistance from a child psychologist to help a client understand the results of a special education evaluation completed with his child and plan for the client to participate in the special education planning process.
When a decision is made to conduct a supplementary treatment session, there is always careful planning for that session with the client. When considering the use of a supplemental session, the clinician works with the client to (a) clarify the need for the session, (b) secure agreement that the session will be potentially helpful, (c) define the goal of the session, (d) clarify expectations for each of the participants, and (e) consider ways the session should be structured. Whenever a supplementary session is held, there is also always a review of the meeting during the next scheduled session with the client.
Mandatory Termination Session
When clients complete 16 to 20 weeks of Fathers Too!, there is a mandatory termination session where clinician and client review the course of the client’s treatment, (p. 461) review the extent to which he realized his treatment goals, and identify goals he can continue to pursue.
Structure of Treatment Sessions
Each treatment session is delivered following the structure outlined in Table 22.5. Although the amount of time devoted to each component of the session may be adjusted, each element should occur within each treatment session. As noted, every session begins with a handshake as the clinician greets the client for the session. If not spontaneously initiated by the client, this greeting is initiated by the clinician. After the greeting, the next 10 to 15 minutes of every treatment session are devoted to a brief review of important events that have occurred since the last session from the perspective of the client’s treatment goals. The next five to 10 minutes of each session are then devoted to a review of salient material from the previous treatment session and the outcome of any action plan initiated at the end of that session. The outcome of any action plan is always reviewed to highlight the logical progression of the intervention and the client’s movement toward his treatment goals. The last 30 to 40 minutes of each session are devoted to completion of the evaluative or thematic activity planned for that day.
Table 22.5 Structure of Fathers Too! Treatment Sessions
As each treatment session comes to a close, the clinician briefly introduces the evaluative or thematic activity that will be the focus of the next treatment session. Again, the intention is to highlight the logical progression of the treatment and the relevance of each session to the client’s treatment goals. When the course of a session raises questions about what the focus of the next session should be, the clinician can share the question with the client, and they can collaboratively decide what the focus of the next session should be. Every session then ends with a handshake. If not spontaneously initiated by the client, it is always initiated by the clinician.
Delivery of a parent intervention to substance-abusing men is likely to involve some challenges, both challenges that are common in the delivery of any substance abuse intervention and challenges that are specific to the delivery of a parent intervention. Experience with delivery of the intervention thus far suggests that there are five challenges clinicians need to be prepared to actively address: (a) problems with attendance, (b) other pressing concerns, (c) acute intoxication, (d) recurrent (p. 462) substance use with signs of physical dependence, and (e) potential child abuse or neglect. Within Fathers Too!, an effort is made to anticipate these challenges and respond in a proactive manner within established guidelines for management of the challenge.
Over the past 10 years, the systematic, goal-oriented approach to the development of psychosocial treatments outlined by Rounsaville and his colleagues has been used to conceptualize, manualize, and document the potential efficacy of this individual psychotherapy (e.g., see Carroll, 1996; Carroll et al., 2000; Carroll & Nuro, 2002; Rounsaville, Carroll, & Onken, 2001; Rounsaville, Chevron, & Weissman, 1984; Rounsaville, O’Malley, Foley, & Weissman, 1988). At the time this chapter was prepared, there had been two preliminary evaluations of Fathers Too! In a psychotherapy development study (McMahon, Suchman, Carroll, & Rounsaville, 1999), the psychotherapy was outlined in a treatment manual and procedures were established for selecting and training counselors and rating videotaped treatment sessions for adherence to the treatment protocol and quality of delivery. A pilot study comparing the potential efficacy of Fathers Too! when added to standard methadone maintenance treatment suggested that the fathers who received Fathers Too! as a supplemental treatment demonstrated potentially meaningful declines in secondary substance use and high-risk parenting behavior (McMahon, 2009).
In a second study of potential efficacy (McMahon et al., 2005), Fathers Too! (McMahon, Giannini, & Maccarelli, 2006) was recently compared with individual drug counseling (Mercer & Woody, 1999) when added to treatment-as-usual for men receiving methadone maintenance treatment. Both treatments were also combined with the low-cost approach to contingency management with reinforcement of attendance at treatment (Petry & Martin, 2002). The goal of the project was to explore the comparative efficacy of the two approaches to psychosocial intervention in the context of the best attendance at treatment possible. The results of that comparative study were being evaluated at the time this chapter was prepared.
Although fathers, more than mothers, are likely to be quickly, and inaccurately, labeled the incompetent, indifferent, irresponsible, potentially dangerous parent as they enter substance abuse treatment (McMahon & Giannini, 2003), existing data on the nature of substance abuse and fathering highlight the need for family-oriented intervention designed to minimize the harm associated with paternal substance abuse (for a review, see Chapter 8). As suggested previously (McMahon et al., 2008), the emerging literature indicates that clinicians should be prepared to engage men in a dialogue about parenting issues as they enter substance abuse treatment, because (a) they will all be at risk to become fathers under difficult circumstances, (b) many of them will already be fathers, (c) many of the fathers will demonstrate positive parenting behavior that should be supported as much as possible, and (d) many of the fathers will demonstrate negative parenting behavior (p. 463) that needs to somehow be addressed. Moreover, men enrolled in substance abuse treatment should be engaged in a dialogue about parenting issues because (a) they are interested in parent intervention (McMahon et al., 2007), (b) they can be engaged in family-oriented intervention (Andreas, O’Farrell, & Fals-Stewart, 2006; Fals-Stewart & O’Farrell, 2003; Kelley & Fals-Stewart, 2002), (c) family-oriented intervention can have positive effects on both substance use and family functioning (Fals-Stewart & O’Farrell, 2003), and (d) family-oriented intervention can have a positive effect on the psychosocial adjustment of other family members, even if they do not participate in the treatment (Andreas et al., 2006; Kelley & Fals-Stewart, 2002).
Support for the development of Fathers Too! has been provided by the National Institute on Drug Abuse (Grants P50 DA09241 and R01 DA020619). Some of the material presented in this chapter was taken from Fathers Too! A Parent Intervention for Drug-Abusing Fathers (McMahon, Giannini, & Maccarelli, 2006).
The author would like to offer this chapter in memory of Bruce Rounsaville, M.D., who generously helped him secure the funding needed to develop this parent intervention for substance-abusing fathers. The author would also like to thank Francis Giannini, L.C.S.W., Lisa Maccarelli, Ph.D., Nancy Suchman, Ph.D., Nancy Petry, Ph.D., Kathryn Nuro, Ph.D., and Kathleen Carroll, Ph.D., for their contributions to the development of this intervention.
Correspondence concerning this chapter should be addressed to Thomas McMahon, Ph.D., Yale University School of Medicine, Connecticut Mental Health Center, West Haven Mental Health Clinic, 270 Center Street, West Haven, Connecticut 06516. Electronic mail may be sent to email@example.com.
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