Introducing Family Therapy
This is where the therapist should begin to
discuss his own orientation. The general aim is to set up the situation so the patient can admit
to the value of getting his family's help -this time around.- Depending on the amount and type of resistance encountered, the
therapist can go in one of several
directions. However, before deciding which tack to take, the therapist should first find out where the family
members are at this exact moment,
especially the parents. This is a preventive step that disallows the patient from stating later—should he
be looking for ways to resist—that he
does not know their whereabouts. For example, when the therapist subsequently informs the patient that he wishes to telephone
the father, it will be less easy for the patient to deny knowing Dad's location if he has already told the
therapist that his father is at
work.
Assuming that family members know the patient is
using drugs, the most common type of
-excuse" given for their nonparticipation is that they are unable or unwilling to come in for a
session with the therapist. If the patient indicates that his father or mother
is sick, disabled, working long hours,
or too poor to come in, the therapist should
explain either that he would like to contact them anyway, or that he will need to confirm this by contacting
them. His best move is to find out
from the patient which member( s ) can be reached by telephone at
this moment. Or, the therapist can
ask the patient to make a -bridge-
for him with the parents, by telling them that he will be calling at a specific time later.
When a patient says that his family is unwilling
to help, this may prove to be
genuine. The therapist needs to know, in that event, if it is a result of their being excluded from prior
treatments (which is usually the
case). Again, he needs to talk to them directly to verify this. If he cannot call one of them during the
session, he should set up a later
contact. It is important for this reason to gather several telephone numbers ( home and work numbers of
patient, parents, and siblings), and,
again, to make sure the patient has the therapist's
telephone number.
The
patient may state that his family has known about the problem and was included in dealing with it before.
However, it is unlikely that the kind
of family treatment the therapist has in mind has been attempted previously. It is important for the therapist to learn the details of this earlier family
involvement so he can differentiate
between what has happened before and what is being
When the patient has his mind set on -doing it
alone,- it is worth discussing his
strategy in detail, right in the initial session. While he may be sincere in his desires, his plans
may be hazy or nonexistent. The
therapist can join with him on the importance of -doing it right this time.- The patient should be encouraged to talk about his plans with the therapist.
As the discussion proceeds, the therapist should
take control by asking primary
questions: -How are you going to get off of drugsr -What are you going to do with your time when you
don't have to spend it copping?
"What will you say when your buddies want you to cop with them?" "How many times in your
life are you going to go through this
again?“ If he has not planned for such contingencies as these, the patient is already becoming dependent
on the therapist's guidance, whether
he knows it or not, as the
issues are brought to light.
What the therapist is doing here is gradually
maneuvering the discussion so that the
patient agrees with him
that his parents know and are
concerned about his problems (i.e., -Don't you think they know that you use drugsr or, "Hasn't there
been a cloud there, between you and
them, all the time you've been using?”). Another tack is to note that the family has known and been close to the patient for a long time and it would help the therapist to
get some back-ground or history from
them. Having to explain his denials or support
them with evidence may prove more tiring for the patient than placing the family in the therapist's hands.
From here, work can start on how to
bring the parents in, and what to discuss when they
COMe.
In some cases it may be possible to short-cut the
interview process. For instance, going directly from drugs to family
talk may be possible if the patient offers
that he feels -bad- because his parents have been greatly concerned about his drug problem.
REHEARSING
We have found the technique of contacting one or more family members by telephone during the initial interview with the addict to be highly successful. At times, however, it may seem clinically contraindicated or may not be feasible. Scheduling
problems may inter-fere, it may be putting too much pressure on the addict, or it may be
preferable to let the addict approach his
family first, if only to -prep-them
for a subsequent call from the therapist.
When the latter strategy is employed, it is
useful to rehearse with the addict in the session the task of
contacting family members for the initial family interview. This not only
solidifies the relation-ship between the addict and the therapist, but
also provides the latter with more information about the present family
crisis and how to approach it in the first family interview. The
following segment is from the intake interview of a 24-year-old heroin
addict who lived with his mother and father and had a long
history of drug abuse. His enrollment in the AFP was concurrent with his
mother's loss of employment due to the closing of a store where
she had been a longtime employee. The therapist, Samuel M.
Scott, rehearsed with the addict in how to engage mother, underlining
the crisis of mother's unemployment and associating it with the problem of addiction. This technique gives both the addict and the therapist
an understanding of where the initial
session with the family needs to go.
Rehearsing the recruitment of family members
focuses on the nature of the immediate crisis as well as
enabling the therapist to identify structural characteristics within the family that maintain
the addiction. Usually those members who are
described by the addict as the most
unapproachable are the most important in resolving the crisis at hand. This is particularly obvious where
the addict is overinvolved with
mother, while father maintains a distant role, as in the case above. Mothers in these families are frequently
easy to engage, as they have an investment in being involved in their
sons' problems, although there is usually resistance to involving
mother and father
In other families, it is obvious that the way to
approach difficult members is through
another family member. For example, the best way to reach father may be through
mother. What is critical in this aspect of the interview is that the
therapist have an understanding of which
family members are most involved with the addiction and that an alliance be established with the IP toward
involving these mem-bers in treatment. In cases where this does not happen, the
recruit-ment effort is more difficult
and treatment frequently fails. For example,
one addict stressed that it was very important to him that his uncle be included in the therapy. The AFP
research design dictated that the
initial (nontherapy) research session involve only the nuclear family. It
developed that the crisis in the family was around disagreement between the addict's parents concerning this uncle. The failure of the therapist to include the
uncle in the initial research session
was received by the parents as a message that the therapist was insensitive to
the issues at hand. The family withdrew from treatment and the case foundered.
