CLINICAL ASPECTS

CLINICAL ASPECTS

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Some of the clinical vignettes presented earlier may appear to have an unusual, or even outlandish, flavor. This is a direct result of the tremendous difficulty encountered in engaging many of these families. They rarely responded to gentle urging or a -kind word.- Often the therapist had to respond very quickly in order to keep from losing a family. It sometimes seemed as if he could not think of something fast enough to turn things around. Frequently the dangers of death or im-prisonment of the addict, balanced against resistance or complacency on the part of the family, put additional pressure on him. Thus he responded with what came to mind, hoping it would work. The mas-sive resistance shown by so many of these families, and the inadequacy of more standard techniques, dictated that the therapists develop new approaches.

Although the recruitment effort might be termed a -pretherapy-exercise, it is (as stated in Principle 8) a clear intervention. This is especially true in cases that require considerable effort to engage,bringing us to a point made by Jay Haley* about the difficult position that our therapists were in. Unlike many clinical situations where the family petitions the treatment program for help, we enjoyed no such luxury. These families neither expected nor, in most cases, wanted to be involved. The majority of them had already seen a drug-treatment program fail with their sons, and they may have been even less impressed this time. Instead, the impetus for their participation usually generated from the therapist. They knew he wanted them in, that he "needed- them in order to perform his job. Often this led to his working hard while they sat back and "played coy.- Thus, in light of these handicaps, the percentage of families actually engaged could probably be considered quite credible.

Problems such as the above can be reduced considerably by program procedures. There are at least 40 drug-treatment programs in the United States in which family participation is mandatory.31 This obviously reduces the amount of time and effort required for re-cruitment. We know of at least one multimodal methadone program that has established this condition, and 75% of its clients bring their families int (although their requirements are less stringent than our own, in that any cluster of family members is acceptable for the first session, and both parents are not necessarily required to participate at the outset). However, even if only 2560 of the families are resistant, the principles set forth herein would appear applicable for this select subgroup.

Treaters who might want to institute family recruitment pro-grams in the future would want to keep in mind the characteristics of our patient population, that is, all the clients were male, between ages 20 and 35, in touch with two parents or parent surrogates, veterans with at least a brief military stint, from the lower socioeconomic classes, nearly equally divided between Blacks and Whites, and living within I hour's drive from the clinic. We also excluded a number of good-prognosis clients who were detoxifying from opiates and there-fore on an immediate path toward nonaddiction. Further, since our clients were outpatients, they may have been more difficult to engage than those in the more -captive- status of inpatients. Many of these factors probably operated to make recruitment more difficult, and some of them might also serve to limit the applicability of our findings to other contexts.

On the other hand, we would posit that most of the principles we have presented can be generalized to other types of -difficult" and -unmotivated- families. Their application seems appropriate with other types of disorders and -tough- cases. We suspect that similar recruitment problems exist, in particular, with symptom groups in which there is a heavy focus on the IP or where there is considerable family -underorganization,- such as is often found with low-income families. We are sensitive to the tendency to pass off our recruitment endeavor as -inapplicable" or -not do-able- simply because other programs have not been engaged in such activities, or because these activities would require the development of additional skills. Another common counterargument is to oversimplify family recruiting as primarily a function of -highly motivated therapists," followed by the disclaimer that one's own therapists are -not as motivated." While we recognize that recruitment is not a simple exercise, the difficulty of the task should not be used as an excuse for failing to make an earnest effort. Clinicians who claim to be interested in helping people should not be too quick to write off a significant number of families who could be reached if properly approached.

Looking to the future, it seems safe to predict that, as family therapy becomes more widespread and accepted within the general populace, the task of engaging families will become easier. The idea of family involvement will seem less alien or irrelevant to the layman. However, it is very doubtful that all resistance will dissipate, any more than it has with individual therapy. Thus we can expect that family therapy will be faced with engagement challenges, at least in certain cases, for some time to come.