INITIAL CONTACTS WITH THE INDEX PATIENT

INITIAL CONTACTS WITH THE INDEX PATIENT

Unless they enter the treatment program with the expectation that their families will be involved, it is our experience that most addicts are extremely resistant to including other members. This resistance stems to a great extent from the treatment modes that have histori-cally prevailed in the drug-abuse field—mainly the therapeutic com-munity and methadone maintenance methods. In the former, the family is usually seen as an undesirable influence to be shunned, while the latter simply does not take families into account. In any event, many of these clients would attempt to brush us off with a -don't bug me- attitude. They knew, in our case, that continuation on the methadone program could not be made contingent upon family participation, so we were sometimes seen as introducing another hassle in their regimen. In some cases they lied to us about who was in the family, how often they saw family members, or even whether these people were alive or not. Since our experience and our data led us to believe otherwise, we rarely accepted these ploys at face value (al-though we did not get caught in challenging them outright). Rather, we saw them as protective moves. Sometimes it was self-protection, because the addict did not want his cover blown by people who would come in and tell stories about him that differed from his own. Also, the IP appeared to fear that his family might be criticized or blamed by the therapist, and then get on his back for getting them in trouble; he then would not only feel beleaguered but also guilty, disloyal, and traitorous to what was usually a very enmeshed family system. We found it most useful to see his actions as protective of the whole family, especially his parent(s). Since his role in the family was often as one who served to divert fighting among others (Chapter I ), his attempt to buffer the system from potential challengers from outside was both natural and functional.

In Chapter 3 a number of techniques are described for working with the addicted member toward recruiting his family for therapy. Details are given on the structuring of the initial recruiting interview (with the IP, alone)—what points need to be covered, what sequence of topics seems to work best, how to parry or neutralize resistant moves, and so forth. The process usually requires that the therapist obtain as much information as possible about the IP's family and interpersonal system before "showing his cards,'' that is, before stating that he would like the family to come in. Such questions as, ''Do you live with your folks?” -How often do you see them?” "Who else lives at homer and -Who do you spend the most time with in the familyr are appropriate. The therapist also wants to learn how much the family knows about the drug problem before he suggests including them. Using this information, the therapist then can decide who he wants in attendance at the first session.

Principle I: The therapist should decide which family members need to be included, and not leave this decision to the index patient. We have found that when this rule is not followed, the tendency is for only certain family coalitions to show up. The common ones include the IP plus ( I ) a sister, (2) his mother and sister, (3) his mother, or (4) his wife or girlfriend.* Often other members were not even informed that the meeting was to take place. Principle 2: Whenever possible. one or more family member,- should he encouraged to attend the initial or intake interview. This is a variation on the above theme. We discovered, in a few early cases, that if another member was present at the intake interview (before family treatment had ever been mentioned) the amount of time and effort required to get the whole family in for a session was greatly reduced. Sager et al.'26 also noted this phenomenon for non-drug-using families. Whether such an event helped to lessen anxiety or to spread the blame, or whether it was indicative of a less resistant or more -healthy- family, is not known. One way to facilitate this phenomenon is to make it standard procedure for program intake staff to request attendance of family members when they receive a call for an admission interview.

Principle 3: Do not expect the index patient to bring in the family on his own. If we have a cardinal rule, this is it. Innumerable times we got ostensible cooperation from a client, but no results. We got promises and guarantees, but if the task was left to the IP, the family simply did not show. He either would not, or could not, bring them in. In fact, expecting the patient to bring in his family failed so often that we eventually abandoned it entirely.

Principle 4: Obtain permission from the index patient to contact his family, and then get in touch with them, whenever possible, right in the interview. This evolved into our primary goal for the initial interview, as was noted in Chapter 3. An effective technique, em-ployed by others also,m, is to find out where family members are located at the moment, and telephone them directly from the session. This allows the therapist a proper introduction, and does not put the IP in a position of advocating a program about which he himself is

unsure or unconvinced.

A number of other techniques were used during the initial contact period. Since they were applied selectively, rather than to most or all cases, they do not qualify as principles. Whether they were chosen or not depended on the particular context, the idiosyncracies of a certain client or family, and the style of the therapist. Some therapists engaged in heavy, informal personal contact with the addict, such as playing ping pong with him during the "interview,- and the like. Others employed the telephone extensively in making frequent contact with the IP and inviting him to call back whenever he felt the need. In at least one case (seen by Peter Urquhart, Family Counselor) this took an interesting twist. Urquhart had been -chas‑ing" the client by calling fairly constantly (four or five times a week) for several weeks, and getting very little reciprocation. Eventually he cut down to one call a week. The client then became curious as to why the calls had tapered off, and began to contact Urquhart. This paved the way for an agreement to have the family come in.

Less commonly employed was the use of veiled pressure to induce cooperation. Unlike some programs,3] ours did not allow therapists to refuse methadone if a client was adamant about ex-cluding his family.* The client obtained methadone and other treat-ments in the drug program, as desired, during the whole recruitment process. If he objected strongly and persistently enough, the family issue would be dropped. However, in a few cases the therapists tried to get around this by (1) simply "waiting the client out- for a week or so; (2) stating confidently, ''We have found that this treatment works best,- or, -The people who know you best and are best able to help us both lick this problem are your family members-; (3) giving the addict no (ostensible) choice by stating firmly, and without irritation, that this was -the way it is done- and that he had to do it; (4) as a last resort, threatening not to increase his methadone dosage until the family came in. We did not use the last two tactics very often, because we really could not back them up. The particular technique applied to avoid refusal depended on the therapist's sense of where the client was -coming from- and how close he seemed to be to acquiescence.

Overall, when we were unable to succeed at this point it was because the IP either would not permit his family to be contacted, or would not participate in the family evaluation session or treatment himself. Nonetheless, use of the above techniques resulted in the addicts' permission to contact their families in 80% of the cases with which attempts were made.