OVERALL
RATIONALE
When a family orientation is to be used in
treatment, it is advantageous for the therapist to present this idea to the
-identified- patient (IP), that is, the addict, at the outset. This avoids
the confusion and possible conflict inherent in forming a therapeutic
relationship with an in-dividual patient, which may compete with a later relationship with
his family. The structuring of the initial
interview with the patient there-fore
becomes crucial in determining whether he and the rest of the family can be
recruited for treatment. If a therapist is aware of the behaviors the patient may use to resist involving
his family—and counters these with
appropriate tactics—chances are increased for successful induction of the
family, whatever the patient's initial re-sponse to this idea.
It is certainly helpful in recruiting families to have
strong pres-sure from the treatment
program for family involvement, but in many programs this pressure is either nonexistent or unenforceable. In
programs such as the methadone maintenance program with which the AFP
was associated—a Veterans Administration (VA) program in which veterans could
not be denied treatment if they refused to involve their families—it is usually
necessary to receive the addict's permission before
contacting the rest of the family."'
At
this point we should state unequivocally that seeing the IP alone at the
outset is always second best to having the whole family present at the initial contact. This is so, even
if the therapist later decides to
engage in individual sessions with the IP. However, given the infrequency with which whole families of drug
abusers appear at intake, the
therapist may use the initial (individual) session to ad-vantage in several ways. First, the individual
meeting can be used to convey to the
addict the message that he is an adult—that although his individuation from his family is a tenuous one, he
has amassed a complexity of
interpersonal skills associated with his habit that need to be respected.
Second, the intake interview provides an opportunity for the addict to admit that his efforts to stand alone
are not working, in view of his habit
and the unspoken family problems around the addiction.
THE INITIAL SESSION SETTING THE
APPOINTMENT
In arranging for the session, the therapist should do as little work
as possible over the telephone (or via
letter). A purpose for the meeting needs to be presented—usually that of
getting the patient's history and setting up
the appropriate treatment schedule for him. In some programs such a meeting is required before treatment
can proceed. The patient should be
informed that this will involve about I hour's time.
The time for the session should be set no later
than 2 or 3 days from the telephone
contact, preferably sooner. This adds to the urgency of the situation, and is a sign to the patient that the
therapist is sensitive to his need
for help. In fact, we have observed that a kind of imprinting process
occurs during the intake period, whereby the patient attaches strongly to the first person (or persons) offering him help; this person appears to have much more
leverage with him than those who deal
with him later. Consequently, a delay of more than 3 days markedly increases the chances of either a
cancellation or a no-show by the
patient.
In the initial
telephone contact, the therapist should also inquire (when appropriate) as to
how the patient expects to travel to
the clinic, and confirm that he is
sure of directions. He should be given the therapist's phone number, and instructed to call if he is going to be
late or if he should get lost.
Finally, the IP is told that it would ease the
therapist's burden if the patient
could bring in another family member—or the whole family—to this session. This
can be framed as -helpful in setting things
up more quickly.- The patient's response gives some indication of how much the
family knows ab.out the drug problem, especially if the patient is reluctant to bring anyone with him.
INTERVIEW
RATIONALE
Since the initial interview is the first major contact between patient and therapist, many transactional rules will be
instituted in the session. The therapist
needs to know which aspects of the interview should be emphasized early and which should be postponed
until later. With the
What is primary in this session is that the
therapist obtain some indication from
the patient that he wants to get out of his drug habit. The indication may be
either stated or implied, and should occur early in the session. This may require prompting by the therapist. Veracity of the statement is not essential at this point,
however. The declaration may be
presented merely as a move in the game of gaining entree to the treatment program or system.
The statement that one wants to be drug-free and
ts acknowledg-ment by the therapist
are important because such an exchange pro-vides a basis for this and for all future sessions. Any work the
therapist intends to do with the
family derives its public rationale from this transaction. Occasionally, a patient will not declare a readiness to break his habit, so the therapist may have to do
some preliminary work in this area. If the patient wants to be
maintained on a prescribed drug, such as
methadone, the therapist may point out that this requires becoming
abstinent from street drugs. If the patient admits he does not feel he can stop using street drugs, the therapist
might discuss with him the pros and
cons of this, working toward an agreement that the use of illegal drugs is in some way detrimental to
his welfare. Once a concession is made by the patient, it is easier to obtain
later agreement on the more global
objective of becoming completely drug-free.
PROTOCOL
The protocol for the remainder of the interview
depends largely on the scope of the
clinician's responsibilities. If he is to act strictly as a therapist, he may focus
immediately on the matter of getting the family recruited. If, on the other hand, his role includes that of drug counselor, the intake strategy may require more
complex structuring. Here, the therapist should be prepared for a
variety of secondary issues that could come
up in the session, including requests for dosage increases, program privileges, and so forth. Since the present chapter is directed at the major issue of getting the pa
tient to recruit his family, drug-counseling
strategy will be dealt with in summary fashion, that is, only where it is directly relevant to the recruiting
task.
