Engaging Client’s Family and Friends in Online Counseling

Abstract

This paper describes how online counseling can be used to engage family members in the recovery of clients. The counselor guides the client and the family member separately through the stages of change, helping them commit to joint action. Each participant thinks through his/her concerns and the advantages of getting involved, each makes a specific commitment to working together under the guidance of the counselor. Finally each celebrates, with specific rituals, their decision to work together. Once the client and the family members commit to working together, the counselor guides them through the stages of change as a group. In the pre-contemplation stage, the family members are taught the goals of working together and the procedures to avoid dysfunctional conflict. In the contemplation phase, the client and the family members examine the shared environment and its links to target behavior. In the commitment to action stage, the client and the family members decide on specific changes in their shared environment. In the maintenance phase, the client and the family members analyze if the change has led to improvements. They analyze relapses and make additional cycles of improvement.

On the web, several companies provide online counseling. Growing research shows the benefits of electronic communications (Fein, 1997). The use of e-mail might not only save clients office visit time, but also, some note, e-mail may enable health care providers to better manage their clients out of the office, filling additional available time with more clients (Green, 1996). Some go as far as predicting that online communications will “induce cultural changes in the delivery of care” (Kassirer, 1995).

A number of investigators have examined the impact of online interventions on behavior change (Glasgow & Toobert, 2000; Piette, Weinberger, & McPhee, 2000; Consoli, et al., 1995; Krishna et al., 1997; Alemi & Higley, 1995; Brennan, Moore, & Smyth, 1995; Fitzgerald & Mulford 1985; Alterman & Baughman, 1991; Alemi et al., 1996; Lando et. al., 1997). Interventions that include role-playing (Alemi, Cherry, Meffret, 1989) and electronic social support (Alemi, Stephens, Mosavel, et al., 1996; Gustafson et al., 1992) have been shown to be effective. Online interventions have the advantage of being able to tailor educational messages to individual conditions. Data show that interventions that include tailored messages to clients are more effective than those that do not (Tate, Jackvony, & Wing, 2003; Tate, Wing, & Winett 2001; Robinson, 1989; Campbell et al., 1994; Strecher et. al., 1994; Watkins, Hoffman, Burrows, & Tasker, 1994; Gustafson et al., 1998). In the past decade, numerous studies have shown that online interventions can lower the cost of care and improve the health of clients. For example, Tate, Jackvony, and Wing (2003) showed in randomized clinical studies that e-mail counseling can reduce weight of obese patients over long term (12 months). For another example, Gustafson and colleagues have shown online interventions to be more effective than usual care in improving outcomes for patients with breast cancer (Gustafson, Bosworth, Hawkins et al., 1992) or patients with HIV/AIDS (Gustafson, Boberg, & Bricker et al., 1998). The established effectiveness of online intervention has raised the possibility that it might substitute for and be more effective than face-to-face counseling. But, why should online counseling be more effective? This is a difficult question that has not been adequately answered even at a theoretical level in the literature. No one has articulated a theory about when and under what conditions online counseling would be more effective than face-to-face sessions. Obviously, face-to-face counseling has several advantages over online interactions. After all, face-to-face care includes a counselor most likely to tailor the interaction to clients’ need; in addition, face-to-face care includes a host of visual clues missing in online interventions. Typing online cannot possibly be as fulfilling as voice and visual interaction with a person. Disjointed, short online interactions could not possibly be as effective as the half an hour or hour long continuous interaction. Clearly, more can be done in face-to-face sessions than online. So, it is not surprising that even theoretically, it is hard to imagine conditions under which online counseling could be more effective than face-to-face sessions. But one advantage exists. A key advantage of online counseling is the ease with which family members and friends can be brought into the session, even when they live in different areas. Imagine an adolescent smoker, whose divorced parents need counseling for themselves as well as their teenager. In face-to-face sessions, it is difficult to engage the working parents in regular sessions, but online it is relatively easy to engage both. This paper lays the protocol for engaging family members in care of online clients.

It is important to counsel family members, because they are invariably involved – either as a contributor or as a by stander – to the clients’ behavior. Often, a health problem for one is also a problem for another. Even when problems are not shared across family members, it is important to involve the family. Client and family share a common environment and the client’s resolutions to change cannot be maintained over time without adjustments in the shared environment. Families are like mobiles – all connected to each other in sometimes negative and other times positive tangles of influences. When any one piece is impacted, all the other pieces of the mobile move as well.

We define family broadly, to include “any group of persons who are related biologically, legally, or emotionally” (McDaniel, Campbell & Seaburn 1990). Healthy family systems maintain a problem solving orientation (Nichols and Schwartz, 1991) and demonstrate cohesion as a group, adaptability, and good communication skills (Jansen and Harris, 1997). But this is not always the case and engaging family members requires an explicit strategy for dealing with family conflict. A family has a set of rules, often unspoken, that determine how members interact, and roles that members typically play in relation to each other (Satir, 1988).

In this paper we assume that an online counselor is already engaged with a client. Elsewhere we have written about how online counselors can engage an individual patient (Alemi et al., in review). We will not duplicate this material here, but rather focus on how the counselor can leverage his/her relationship with the client to engage family members of the client. Because of the nature of counseling through e-mails (short, frequent, near-daily exchanges with no visual cues) certain therapeutic modalities are not possible. For example, it is beyond the scope of an online counselor to intervene with pathological behaviors. Nor do we think that in the short run online counselors can work on improving family relations. The focus of the intervention described here is limited by the medium used for counseling and by the length of intervention.

Participants

Protocol of care

Before we discuss how we get the client and the family members to participate, it is important to clarify what is it that we want them to do together. We want family members to use “system thinking” to bring about changes in their shared environment to support a target behavior. By system thinking, we mean an analysis of how decisions and behaviors are interrelated. By shared environment, we mean any physical or emotional context within which members of a unit operate. For example, we want family members of diabetes clients to agree to a restricted food list in the household. For another example, we want family members to stop smoking in a household in order to support one members attempt to quit smoking. In all these instances, the family members change an aspect of the environment so that the individual can succeed. The counselor does not presuppose the change that should happen, but family members meet, analyze the situation, and suggest how they want to improve it. Such interaction and change presupposes that the family perceives itself as functioning as a system, where changing one person affects another (Doherty & Campbell, 1988). Furthermore, it requires both the client and the family members to consider the environment itself as an important agent of change (Williams, Frankel, Campbell, & Deci, 2000).

Getting a commitment to action from the client

In order to involve family members in the care of the client, we need to start with asking the client for permission to do so. One can think through this process in several stages involving pre-contemplation, contemplation, commitment to action, and eventual maintenance of action (see Table 1). In the pre-contemplation phase, the counselor assesses the interest of client to involve family members. Here is an e-mail that the counselor might send out:

Table 1.

Key Topics Within Each Stage

	The Counselor’s Questions
Stage	The Client	The Family
Pre-contemplation	Are family members’ aware of what you are trying to do (Email 100)? Do you understand the focus on environmental change (Email 110)? Are you willing to let me guide family members’ involvement (Email 120)?	Are you interested to learn more about participating in the clients’ recovery (Email 300)? Do you have the time (Email 310)? How comfortable are you with maintaining specific boundaries in the family member meetings (Email 320)? Are you willing to help me guide you through this process (Email 330)?
Contemplation	Why haven’t you told other family members (Email 130 and Email 140)? What could go wrong (Email 150)? What benefits may come from involvement of family members (Email 160)?	What could go wrong (Email 340)? What benefits may come from your involvement (Email 350)?
Commitment to action	The decision is up to you. Would you like to involve family members (Email 170)? How and when will you tell family members (Email 180 and Email 190)?	Now is the time to decide, given your concerns as well as your hopes for the better, do you want to continue (Email 360)?
Maintenance	Congratulations for successfully asking for help (Email 200).	Let xxx know that you are willing to help (Email 370) Congratulations for your willingness to show your love but stay focused on what needs to be done (Email 380)

E-mail 100 from counselor to client: You have made significant progress to date. You are committed to the change and are working hard at it. But this is not enough. You also need a positive and supportive environment, which would put you back on course in case you slip. To create such an environment, you need the support of people who share your environment. As you grow in your recovery, you will need the support of your family. Given how far you have come on your own, it is now time to get help from others who live with you. The first question I have is whether they are aware of what you are trying to do and whether they share your objectives?

E-mail 110 from counselor to client: We have been talking about involving your friends and family members who share the same environment with you. My hope is that you will involve people who share the same environment independent of whether they like you or not. The issue is not your relationship with them, but the environment that you share. To change this environment you need their participation. When I talk about the environment, I of course mean the physical place you find yourself (the house and the things inside it). I also mean the mental place around you (e.g., the tension between family members). Do you understand what I mean by environment and can you give me some examples of things in your environment that help or hinder your recovery?

E-mail 120 from counselor to client: You and I have been talking about getting help from your friends and family members. I need to clarify that what we want them to do is not typical. For example, we are not asking them to sit down and talk with you in a free format. Nor are we asking you or them to work on the “relationship.” I will ask them to help in a very specific way. When the time comes, I will ask them to meet on a weekly basis with a specific agenda. Together you will complete a specific task and report back to me. I will then suggest the agenda for the next meeting. The meetings will continue for eight weeks. The meetings are well structured and have to follow a specific pattern. Family members will have direct communications with me. In the end, through these series of meetings you and your family members will come to a decision about a specific change you all want to make in your environment. You can all set out to do the change right away but I ask that you not rush. Let me lay out the task and make sure that all understand and there are no concerns. It may be a lot slower pace than what you like, but I would rather be safe than sorry. Is this ok with you? Are you willing to let me guide their involvement?

In the pre-contemplation phase, the counselor guides the client through the consequences of getting others involved. For example, in case the client has not divulged his/her struggle to change to other family members, the counselor explores the reason for this:

E-mail 130 from counselor to client: I understand that you have not told xxx about your intention to change. Why is that? Can you describe to me the relationship you have with xxx and what types of influences he/she has on you?

The counselor might also explore how the client may reveal his/her struggle to change to the family member:

E-mail 140 from counselor to client: Play along with me for a moment. Suppose you tell xxx about the changes you are working on. First, how and when will you tell? Second, what do you think the likely reaction will be?

In case the client has shared what he/she is working on with other family members, the counselor explores the ambivalence around this issue and helps the client contemplate asking for help:

E-mail 150 from counselor to client: We have been talking about getting help from your friends and family members. Family relationships are often more than they seem. Sometimes helpful people prevent you from making lasting changes and other times people whom you have had a history of conflict help you greatly. Thinking through the people you want to involve in your recovery, could you tell me what could go wrong? How could involving others actually set you back?

E-mail 160 from counselor to client: I understand what your concerns are about involving others in your recovery. I want to set them aside for the time being and think with you about what the advantages might be. One person told me that the real benefit of involving others was that it helped reduce the tension at home. Of course every case is different. What do you think the benefits will be for you?

Once the client has identified family members to participation in his/her recovery, it is important that the family members are provided basic training on computer use and how to send and receive e-mails. They are also provided with information for contacting an Internet Service Provider in the event that problems arise. In addition, if there are significant emotional conflicts between family members, these conflicts need to be addressed in the appropriate therapeutic context and might be beyond the scope of online counseling. A referral to a family-oriented mental health professional is indicated when a client or family reports psychosocial or psychiatric problems that are either chronic (greater than six months), or multiple in nature (Cole-Kelly & Seaburn, 1999, p. 367). A referral is also indicated when dysfunctional relationships directly affect clients’ health and well-being. However, realistically, any family will have some shortcomings compared to the ideal. Even dysfunctional families may be able to work together on a specific guided task without resolving their inherent conflicts. The counselor needs to examine if the level of dysfunction in the family is so large to prevent any productive work. Certainly, improving family relationships is important and perhaps a pivotal point for change. But our experience with bringing about system change shows that help is needed from all individuals who share the environment, whether or not they like each other.

At some point after the deliberation, the counselor has to ask for a specific commitment from the client:

E-mail 170 from counselor to client: I understand your concerns about involving others and the benefits you have listed. One the one hand, you feel [a summary of the list of concerns]. On the other hand, you feel [a summary of the list of advantages]. The decision is up to you. I think you are ready to decide about this. Would you like to involve them?

E-mail 180 from counselor to client: O.K., so you have decided to involve others. How and when will you discuss this issue with them? Who will you start with? At some point, I need to start contacting them and having an independent relationship with them. When should I contact them?

Even after the commitment is given, it is important to work on preparation and on increasing the commitment to action. In addition, it is important to celebrate successful passage of this stage.

E-mail 190 from counselor to client: Well, I am glad you have decided to proceed. In the long run, you will benefit from their involvement in your recovery. I will be sending an e-mail to them and to you regarding what needs to be done and when it should be done. I suggest that you take the following steps to get things started: (1) talk with each person individually and let them know that I will be sending an e-mail, (2) ask them to sign the informed consent form attached and mail it back to me at the following address xxx xxx, xxx, (3) ask them to direct any questions they have to me so that I can clarify the process, and (4) e-mail me their names and e-mail addresses so that I can get started. Why don’t you start with the first person and let me know if you run into any problem.

E-mail 200 from counselor to client: Congratulations on completing this stage. I understand it was difficult in getting help from others, but anything worth having always is. Asking others for help is not easy and it impresses me that you did it. You need to be strong to do so, and I have come to realize that you really are a strong person. We are making very good progress, and I think in time you will look back on this period as an important turning point for you. Well done so far and I will be in touch shortly about next steps.

Getting a commitment to action from family members

Ideally, the number of recovery family members would be three to five key persons, whom the clients feels play a pivotal role in his/her life. After the client allows the participation of family members in the recovery, it is important to help the family member think through what is being asked from them. The systematic conducting of family meetings takes a great deal of discipline and self-direction, which may not be realistic for some families. It should also be noted that it is understood that the impact the family relationships will play in the client’s recovery will be the primary focus for the recovery team. Continued participation will be contingent on the positive impact each family member plays in the development of an environment conducive to sustained recovery.

Those family members who are truly committed to participating in the recovery of their loved one, will be asked to sign a contract which would outline what will be expected of each recovery family member. This process goes through several stages involving pre-contemplation, contemplation, and commitment to help. The following shows a typical interaction between the counselor and the family members during these stages.

E-mail 300 from counselor to family member: Xxx has suggested that you help in his/her recovery. I am his/her counselor. I know you might want to help but are probably concerned if this is going to lead to any good. I am writing to help you think through these issues and answer any questions you might have. Perhaps it would help if I can provide you with a little more detail (which you will also find in the consent form). Xxx and I have been working in the past months on his/her recovery. Part of the recovery is to have a supportive environment that does not tempt xxx back to his old habits. Changing the environment requires your permission and help. If you agree to help, you would be asked to participate in eight weekly meetings. For each meeting, I will send an agenda out for you to consider. In each meeting you will be expected to work with others to accomplish a specific task. After each meeting, one of the people present is designated to write to me about the results. Based on the results, I will draft the agenda for the next meeting. The goal of the meetings is to bring about specific changes in the environment. I have no prescription for what these changes should be. The decision of what changes should occur depends on you and others in the meeting. All I can help with is the process you should follow to decide on the change. Keep in mind several things that we are not asking you to do. I am not asking you to provide financial, emotional, or any other help. I am not asking you to work on your relationship with xxx. All of these things are important goals but not the ones we will pursue at this time. Are you interested to learn more about this?

E-mail 310 from counselor to family member: I know you are busy and have many other things going on at the same time. I am asking for you to set aside one hour a week to meet with xxx to accomplish specific tasks. You can do more with each other without my guidance but what I want is limited in scope and in time. Are you interested to find out more about this?

E-mail 320 from counselor to family member: I just want to review the purpose of the recovery team and how it will work. The recovery team consists of family and friends who interact with xxx on a daily basis. Your job is not to try to help out in areas he/she should be working on. We are not trying to force xxx into any action. We are not here to provide financial support or to be judgmental. Our job is to solve problems within the environment. We just want to decrease opportunities to use the home environment as an excuse to continue old habits. To accomplish this, each member has to have very clear boundaries where he/she is concerned. You are neither to decide nor force xxx into any action. How comfortable are you with maintaining this boundary in the family member meetings?

E-mail 330 from counselor to family member: Xxx has suggested that you help in his/her recovery. I am his/her counselor. I know you might want to help but are probably concerned if this is going to lead to any good. I am writing to help you think through these issues and answer any questions you might have. Perhaps it would help if I can provide you with a little more detail (which you will also find in the consent form). Xxx and I have been working in the past months on his/her recovery. Part of the recovery is to have a supportive environment that does not tempt xxx back to his old habits. Changing the environment requires your permission and help. If you agree to help, you would be asked to participate in eight weekly meetings. For each meeting, I will send an agenda for you to consider. In each meeting, you are expected to work with others to accomplish a specific task. After each meeting, one of the people present is designated to write to me about the results. Based on the results, I will draft the agenda for the next meeting. The goal of the meetings is to bring about specific changes in the environment. I have no prescription for what these changes should be. The decision of what changes should occur depends on you and others in the meeting. All I can help with is the process you should follow to decide on the change. Keep in mind several things that we are not asking you to do. I am not asking you to provide financial, emotional, or any other help. I am not asking you to work on your relationship with xxx. All of these things are important goals but not the ones we will pursue at this time. Are you willing to help me guide you through this process?

Help from family members is often assumed to be forthcoming. But many family members have reservations. It is important to explore these reservations before they come to undermine the very process that is being set up. The counselor works with the family members to think through various issues that might arise:

E-mail 340 from counselor to family member: Before you decide, lets talk a bit about what might go wrong. I am sure you have helped in the past but found yourself frustrated. Could you list for me what might go wrong this time? What are your concerns?

E-mail 350 from counselor to family member: Here is a summary of why you might not want to help: [The counselor summarizes the concerns]. Let’s now turn the table around. What could come out of these meetings that could actually help you? I mean what good could possibly come to you? I know xxx will benefit but what are the benefits for you?

After working with the family members to think through various issues that might arise, the counselor solicits a decision from the family member.

E-mail 360 from counselor to family member: Here is a summary of what good might come out of doing this: [The counselor summarizes points made by family member]. Now is the time to decide. Given your concerns as well as your hopes for the better, do you want to continue? If you say yes, I would organize the agenda for the first meeting and send it along to you and to xxx.

E-mail 370 from counselor to family member: Great. I appreciate your willingness to help despite reservations that you might have. Let xxx know that you will be helping and I will be writing to both of you shortly.

E-mail 380 from counselor to family member: Congratulations. I appreciate your willingness to help, and I know how hard it is to love a person and yet insist on change. I do not know if you have read the book Tough Love. The key concept of this book is that it is important for family members to express their love for each other without wavering on the requirement for change. This is not easy, as the message you give each other is somewhat contradictory. But everyone needs to respect each other, come to like each other, without loosing sight of the goals for change. I am glad you are willing to give it a try.

Getting a commitment to joint action from clients and family members

Up to now, the counselor has worked with the client and family members to help them come to individual action and commitment. Now it is time to bring about joint action. Getting a group of people, particularly family members who are not on the best of terms, to act requires agreement on a few basic guidelines. A process needs to be in place to reduce conflict and focus the family members on the problem-solving task. These also need to account for variables (children, personal commitments, and personal responsibilities) within the family system, which may interfere with the success of the family members. This process involves pre-contemplation, contemplation, commitment to action, and maintenance phases (see Table 2). Although these stages are generally directed toward the client, they are also evident in the development of family commitment, an effective role in the recovery process. In the pre-contemplation phase, the counselor needs to clarify the basic process and rules for communication (Satir, 1988). What follows is a series of e-mails that the counselor could send out to focus the client and the family members on the group’s ground rules:

Table 2.

Group’s Focus within Each Stage of Change

Stage	The Counselor’s Questions
Pre-contemplation	Do you agree to meeting rules (Email 400 through Email 470)? When is the best time to meet (Email 480)?
Contemplation	How do daily routines affect the target behavior (Email 490)? List possible changes to the environment (Email 500) Evaluate whether the planned change is a systemic change (Email 500)
Commitment to action	Select top 3 systemic changes (Email 510) Plan for simultaneous implementation of changes (Email 520)
Maintenance	Monitor if change has led to improvement (Email 530) Celebrate success (Email 540)

E-mail 400 from counselor to family members: Thank you for agreeing to meet to work on the environment that you live in. I want to lay out what will happen in the next few days. First, through a series of emails, I will layout the planned eight meetings and answer any questions or comments you might have. Next you will set a time and a date for the first meeting and I will forward to you a detailed agenda for the meeting. Once you have had the meeting, one of you will e-mail me a detailed summary of meeting results, with copy to everyone else. I will review this e-mail and send you a new agenda for the next meeting. The process continues until you are ready to act on your environment. Let’s get started. In the next minutes, I will send you the various meeting rules. Please read them and see if you have any questions about them.

E-mail 410 from counselor to family members: The family team should consist of, as much as possible, all the people who are effected by any change in daily routines. This will include people from different generations (parents and children) as well as people who do not get along. The meetings will focus on problem-solving and identifying factors in the environment that enable certain habits to occur and continue. To help facilitate this process, it is important that all members of the family be able to recognize how they contribute to the environment. The meetings are not for airing emotional difficulties, blaming, or providing emotional support. Are these rules clear?

E-mail 430 from counselor to family members: Meetings should begin and end on time. I will provide an agenda. An agenda lists the topics that should be discussed but not conclusions. You make up your own mind; I only suggest what topics you need to discuss. Meetings should not be allowed to exceed specific times; items unresolved at the end of the meeting should be tabled until the next meeting. I know that you almost always see each other and it is natural to continue the discussion. However, setting a separate time and place for the discussion is part of the success of this process. So please stay on the topic, but be prepared to stop when the meeting is over. For all meetings, the first item on the agenda is to select a timekeeper and a reporter. The purpose of the timekeeper is to keep everyone to the time allotted for the topic. The purpose of the reporter is to send me a summary of decisions made in the meeting. Are the roles of agenda, timekeeper, and reporter clear?

E-mail 440 from counselor to family members: Meetings are for joint problem solving. For example, in the first meeting we ask you to list all daily, weekly, and monthly routines in the household that affect or are affected by the habit you want to change. The purpose during the first meeting is to just make a list, not to have a party, share common feelings, or revisit old conflicts. Stay on the task. People naturally want to unload whatever is on their minds. Family members can accept that individuals may come with a need to ventilate about something, but they should be prepared to quickly refocus onto the task at hand. Is it clear what the purpose of the meetings is and what the meeting is not for?

E-mail 450 from counselor to family members: Members of the family should give their undivided attention to each other. Undivided attention means letting the discussant talk. Do not call attention to yourself by laughing uproariously when something funny happens, by rushing to comfort when the discussant feels pain, or by falsely uniting with the person’s concerns (“I know exactly how you feel.”). Undivided attention means that there should be time given for each family member to express his/her views. Is it clear how everyone needs to be attentive during the meetings?

E-mail 460 from counselor to family members: During the meeting, family members should not blame each other. They should not attempt to solve historical relationship problems among themselves. They should focus on the shared environment and how it can be changed to help. They should not give advice (e.g., “Here is what I will do if I were you…”); instead describe what they are willing to do to create a better environment. They should not refer handling the problem to someone else or a book (e.g., “You ought to talk with X about this.” Or, “Have you read X, I think it will help you.”). They should search for solutions in the environment and not in the persons involved. Is it clear how I expect family members to avoid blaming xxx or themselves for things that have gone wrong? The idea is not to identify what has gone wrong but to search for how the environment can be made better. Are you willing to follow this rule?

E-mail 470 from counselor to family members: Any evaluation of ideas should be postponed until all ideas have been listed. Throughout the meeting, family members make a list of the ideas without discussing the pros and cons. After they have made the list, they discuss the merits of the ideas in the list and select one or two. Are you willing to follow this rule? It means that you must postpone reacting to the ideas until a large number have been identified. Does this make sense to you and are you willing to follow this rule in the meeting?

E-mail 480 from counselor al: We are now ready to proceed. Would you discuss among yourselves regarding the best time to meet and xxx send me the meeting time.

The focus of the intervention should remain on making adjustments to the environment, which will bring about the desired outcomes. To accomplish this, the client and the family members should collectively review the environment and see what can be done to change it. This collective review should describe the processes that lead to specific behaviors. An example of this kind of intervention can be found in similar work with diabetics. Whittemore, Chase, Mandle, & Roy (2002, p. 9) provide a successful environmental change for many diabetes clients: “Most participants felt that stocking their shelves only with ‘legal’ foods was critical to success”. This is a clear example of a change that a family could agree upon – buying some foods and avoiding others – to support the needed behavioral change of the diabetic. This may seem simple enough, but removing the favorite family dessert from the household can potentially raise any number of issues or test the resolve of the family members to work together. To help the family members navigate the change, the counselor walks the client and family members through active contemplation before commitment to action. Here are some e-mails that could set the agenda for each meeting and prompt the various discussions.

E-mail 490 from counselor to family members: Welcome to the plans for our second meeting. The meeting is scheduled at xx on xx day. The agenda for this meeting is (1) identify the timekeeper and the reporter, (2) list how daily routines (shopping, cooking, washing, socializing, etc.) affect the habit we want to change, (3) discuss the relationship between various events, and (4) evaluate the meeting. For the first half hour, I want you to make a list, without discussing the value of any of the list items. Be as comprehensive as possible. Any repetitive event that affects the habit should be listed, whether the effect is positive or negative. After the first half hour, discuss how the events are interconnected. Do not assign blame to events. Allow ten minutes at the end of this meeting for each person’s evaluation of the meeting and their ability to voice their views. I want you to make a list of what you do every day and with whom you do it. List your daily routines from the time you wake up in the morning until the time you go to sleep at night every day of the week. List weekly and monthly activities. I understand you may feel as if you are under a microscope now, but don’t despair. This step will help you to identify triggers and assist in developing coping skills you can use under different circumstances. Once the family members have a complete list, I want you to tell me what you have learned.

E-mail 500 from counselor to family members: Welcome to the plan for our next meeting. The meeting is scheduled at xx on xx day. The agenda for this meeting is (1) identify the timekeeper and the reporter, (2) make a list of changes you may want to make to the environment so that xxx would be more successful, (3) evaluate which of the solutions listed relate to the whole environment, and (4) evaluate the meeting. When making the list of solutions, allow everyone to work individually and to express their idea without evaluation. After a list has been made (about 15 minutes) devote the remaining time to evaluating the proposed options. A systemic solution does not rely on people’s initiative. It occurs automatically even if people forget about it. It does not rely on motivation, commitment, or memory. It often involves some physical change. It may affect a group of people as opposed to one individual. It reduces the list of options available in the future so decisions are made ahead of time. Evaluate whether the solutions you are implementing are systemic changes or rely mostly on personal effort. Select the top three systemic changes. Allow ten minutes at end of this meeting to ask each person for the evaluation of the meeting their ability to voice their views.

E-mail 510 from counselor to family members: Welcome to the plans for our next meeting. The meeting is scheduled at xx on xx day. The agenda for this meeting is (1) identify the timekeeper and the reporter, (2) discuss the pros and cons of implementing the changes discussed in the last meeting, (3) select the top three changes you want to make, (4) evaluate the meeting. End with setting a date for implementation. Allow ten minutes at end of this meeting to ask each person for the evaluation of the meeting their ability to voice their views.

E-mail 520 from counselor to family members: Here are the plans for our next meeting. The next meeting is scheduled at xx on xx day. The agenda for this meeting is (1) identify the timekeeper and the reporter, (2) simultaneously plan for making the three changes you selected in the last meeting, (3) identify a ritual that would mark the change in the environment, (4) evaluate the meeting. End with setting a date for implementation. Allow ten minutes at end of this meeting to ask each person for the evaluation of the meeting and their ability to voice their views.

E-mail 530 from counselor to family members: Welcome to the plans for our next meeting. The meeting is scheduled at xx on xx day. The agenda for this meeting is (1) identify the timekeeper and the reporter, (2) identify how you would know if the change has led to an improvement, and (3) evaluate the meeting. Discuss how change will be measured, who will measure it, and how the family members will be informed. Again, it is important not to blame anyone if the changes do not bring the intended behaviors. Allow ten minutes at end of this meeting to ask each person for the evaluation of the meeting and their ability to voice their views.

E-mail 540 from counselor to family members: Welcome to the plans for our next meeting. The meeting is scheduled at xx on xx day. The agenda for this meeting is (1) identify the timekeeper and the reporter, (2) identify one or two recent slips, (3) discuss how the environment could have prevented these slips, (4) suggest new changes to the environment, (5) evaluate the suggestions, and (6) evaluate the meeting. Put ten minutes into discussing without blame the circumstances around each slip. Put 15 minutes into discussing how a different environment could have prevented these slips. Put the remaining time in evaluating various changes to the environment. Allow ten minutes at end of this meeting for the evaluation of the meeting regarding their ability to voice their views.

E-mail 540 from counselor to family members: Welcome to the plans for our next meeting. The meeting is scheduled at xx on xx day. The agenda for this meeting is to (1) identify the timekeeper and the reporter, (2) identify what is going well, (3) celebrate success to date, and (4) evaluate the meeting. Put ten minutes into suggesting what is going well. Put the remaining time into praising people who have helped make it a success. Allow ten minutes at end of this meeting to ask each person for the evaluation of the meeting and their ability to voice their views.

After a commitment to joint action has been made, the counselor continues to guide the client and family members in maintaining the commitment. This is done typically through gathering data, analyzing if the change has led to improvement, and analyzing behavior that occurred previous to relapse. Plan new cycles of joint action to further reduce relapse. The acknowledgement of relapse highlights an important concept – that change is not a linear process, but more often an ongoing cyclic progression (Miller & Rollnick, 1991; Prochaska, DiClemente, & Norcross, 1992).

The other important goal implicit in the family meetings is the need for increased regular interaction between family members. Regular family meetings are instituted as a way to support the ongoing recovery process and to facilitate the needed communication. This will only happen with planning (Satir, 1988). The ground rules for these meetings are intended to encourage all participants to effectively express their task-related issues without breaking down into dysfunctional confrontation and other communication problems.

The counselor can work directly with the client or the family member outside of the context of the family meetings to identify typical dysfunctional family patterns that may be subverting the process (Szapocznik, Kurtines, Santisteban, & Rio, 1990). The counselor may look for:

1. Over involvement among family members;

2. Cutoff, or disengagement between members; and

3. Triangles, or tendencies to communicate indirectly through third parties and form alliances that can either perpetuate enmeshment or disengagement (Moore & Aylmer, 1989).

These communication patterns are found in most families – they are dysfunctional but not pathological. The counselor’s intention is to provide strategies that encourage direct communication, healthy interaction, flexibility of the family system, and focus on the problem solving needed to identify appropriate environmental changes, rather than getting embroiled in interpersonal emotional conflict.

It may be necessary for a professional to remind the client and the family members of some of the following ideas as the process unfolds. Family members should be warned against taking individualized action to help the client. For example, if the client asks for money from the family member, it is important that they do not help.

Family members should not use the meeting time to discuss relationship problems. These problems should be acknowledged but the focus should be shifted to how two people who disagree with each other, can work on something that benefits both of them. The family members should not force the client into any action – even when it is for his/her own good. Each person must decide for themselves how to collaborate in bringing about lasting environmental change. Autonomy and choice are to be supported, as opposed to trying to “control” the client. Family members who are demanding, critical, and inflexible are controlling (Williams et al., 2000). This is not to say that all client decisions should be accepted without judgement. Keep in mind that the family members are making decisions about changing the environment and the environment affects all family members. The family should come to a consensus regarding what changes to pursue. The family needs to neither make excuses for nor take the blame for the client’s failures. While supporting each other is a good idea, it is not why we have asked the family to meet. The family meeting’s sole purpose is to solve problems identified in the environment. Relapse into old behaviors or other failures are opportunities for learning and adjustment in the problem solving process – not times for critical blaming or admonishing others’.

Summary

This project was designed to help family members to get involved in the care of the client. We prefer that family members work on changing the environment and not the client or his/her motivation. The study protocol helps family members to analyze how daily routines are carried out, how the food is eaten, how clothes are washed, how parties are thrown, who does the shopping and what is bought, what the family does around the breakfast table, and so on. The study protocol calls the family members’ attention to the actions that everyone can participate in and not just the client. The family members are guided to seek solutions in the environment and avoid relying on motivational slogans. In short, family members are encouraged to engage in relapse prevention.

For decades, addiction has been referred to as family illness. The literature has firmly established that an addicted family member affects everyone in the family. Yet it is difficult to engage family members in traditional face-to-face treatment. Logistics, negative attitudes, and lack of third party payment prevent family members from becoming involved. Online engagement of family members may be an effective way to overcome these barriers.

Several questions remain about the protocol we have laid out. Our efforts to date have been focused on individual online counseling and family members’ engagement has been haphazard and unplanned. Therefore, aside from anecdotal evidence we have no data on effectiveness of the protocol presented here. Naturally, when family members of different ages are involved, there would be questions about computer skills, willingness to collaborate, and their attitudes towards the client. We have provided several stages of change and it would be interesting to know how many actually get through these stages. We have asked for families to have meetings but they may not follow our advice. Families may continuously engage in improvements. It is interesting and important to know if families actually have meetings. These questions remain unanswered. Finally, we have laid out one possible way of engaging family members in care. There are other ways that could be more effective. So much uncertainty remains about the nature of ideal online family counseling. Nevertheless, at least one milestone has been reached. This paper has provided one protocol that researchers can implement and improve in subsequent studies.