THINGS SAID AND THINGS DONE
In conducting the initial session, the therapist
may find that he is getting minimal
resistance to his ideas from the patient. This is surprisingly common. The therapist should think
carefully about the possibilities underlying
this situation, and prepare to deal with any contingency. On the
positive end of a continuum,
compliance could signal a true readiness to
detoxify from drugs; the therapist's guidance is all that has been needed to get things started. Some people do get off
drugs without considerable prodding. Tactics can in this instance be
centered around getting the family organized to assist with the process.
A more difficult situation arises when the
patient is simply -jiving" the therapist,
or stringing him along, with no intention of carrying out the plans he
is agreeing to. Here, the compliance is wholly fictitious. When this
occurs, avoiding entrapment in an undesirable position requires that the
therapist focus his maneuvers and make immediate use of the verbal
compliance. It may be as easy to get the patient into action at this
time as it is to exact promises from him. For example, a parent might be
telephoned on the spot in order to set up an appointment for the family
interview—a technique that Coleman's has also used. Even where a call cannot be worked
out during the session, the therapist can set the conditions at
this time for later contact with the family. This includes
collecting names, addresses, and phone numbers, and instructing the patient to
inform his parents that the therapist will be calling them. As a quid pro quo and
demonstration of good faith or commitment, it may be helpful for the therapist
to give the patient his own phone number in
return.
STRUCTURING THE INTERVIEW
What
happens when things do not go smoothly in the initial session? The therapist should expect some kind of
resistance from most patients, especially longtime users, who know the
usual ins and outs of the drug-treatment
system. Obstacles are easier to handle when the therapist applies a standard structure to this
first interview, seg-menting it to
deal separately with drug history, the patient's interests, and relations with the family. This structure
allows the therapist to begin the
discussion with a topic that the patient expects to discuss, joining with him as his problems and ambitions
are brought out. This precedes talk
about family matters, the domain of central importance here. At the same
time, information is accumulating in a way that will provide the therapist with reasons for suggesting a family approach. He also obtains clues about which paths the
patient's objections to this approach
may take.
Opening: Drugs
First inquiries in the session should concern the
patient's history of drug use and
treatment. Typical queries by the therapist include, "Tell me a little about your habit,'' or, "Have you
ever tried to kick it before? The
therapist should show here that he is properly concerned about the
patient's present condition, which might very well include the first stages of withdrawal.
If the patient concedes that he is in a -bad way,-
or gives a history of prior,
unsuccessful treatment, the therapist can later use these in his arguments for a family approach to the problem. It
works best if the therapist implies
knowledge and authority in the area of drugs, then moves on, since getting
caught up in details is a game that the patient will play as long as the therapist permits.
It
is not unusual for a drug-dependent individual to spend from 1 to 3 hours setting up a situation so that it is
favorable to him, no matter how
small the nature of his request. This is routine behavior in pursuit of a change in medication or other
treatment benefits. He could, for
example, wait around the treatment premises until the staff is obviously rushed before making his request,
hoping to slip it through without being checked. Or it could involve relating a
long and complex story—some addicts
are prodigious storytellers—in a manner meant to inform the therapist that there is no option left but to give the patient what he needs. As soon as the therapist
anticipates that a story is about to unfold he can counter it by cutting the
tale short with a question or
statement that leads the discussion onto another track. This tactic should be repeated until the patient
has been engaged in an appropriate
topic. Incidentally, this is least difficult to accomplish
Personal Interests. Goals
Discussion moves from the area of drug problems
into that of the patient's interests
and future plans. Employment and educational status are the key topics,
since these may be shaped into concrete goals that
are agreeable to everyone who is to be involved in the family therapy. The therapist can start by asking whether
the patient is presently working, and
if so, in what kind of job, with what hours and pay. If the patient is
not working, the therapist can turn to job history. When a patient discusses a job he has enjoyed, his conversation will
change to a more positive note. The therapist can then switch tactics, and encourage him to dwell upon the positive areas.
What the therapist should be
searching for in this discussion is alternatives—kinds of activities that can be shaped into reasonable goals.
The talk becomes less formal, more relaxed, in
this segment. The patient should next
be asked about plans and desires for the future. If he is unclear about
what he wants, the therapist can provide cues, using the job or school information already given, or asking about other matters (-Have you got a girl?" or, -Do you
work out at all, engage in any
sports?-).
Altogether,
the discussion of personal interests should have two results. First, the patient should come away from this session with a
better idea about what he would like to do after he gets off drugs. Second, he
should feel that the therapist is interested in him as an individual, and in helping him to work toward his
goals. Ordinarily, patient goals will
require some assistance from outside. It should be made clear in this
segment of the interview whether help is needed and who is best able to supply it.
Family Matters
Discussion
should move to the patient's family of origin only when the therapist is ready to raise the matter of
involving them in the treatment. Of
first importance is information about (1) the com-position of the family, and (2) the amount of
contact between mem-bers. This will
aid the therapist in deciding who is central in the family, which will vary from patient to patient. Both
parents are important in
The patient's spouse or girlfriend and children may
also be relevant to treating the drug
problem, and should be considered for inclusion.
However, it is our own (Chapters 1, 4, and 6) and others'-'2 "' experience that the family of origin and marital
systems are highly interdependent, and that treatment initially must
include the family of origin. The marital
relationship should be dealt with later, if it is dealt with at all. If spouse and parents do not get
along, the therapist might, for the
present, contract for two separate sessions, with a goal of bringing the two subsystems together later in
treatment.
While the patient is talking about his family, the
therapist should be mapping its configuration in his own mind, deciding which
mem-bers he will want to bring in.
Any family member attending this initial session should be included and called upon here for his opinion about who
in the family knows the patient best. With enough suggestions on the
floor, the therapist will be able to work toward consensus with the patient on the few crucial family members, while
compromising with him about others.
After ascertaining the composition of the family,
but prior to suggesting that they be brought in, the therapist must inquire how much they know about the drug problem. If the
patient says they do not know
anything, he should be made to elaborate on this statement (e.g., -You
mean they don't know you're using now, or that they don't know you've ever used?”). Getting this information
straight is crucial, since the
patient has a legal right to confidentiality, which cannot be violated without his consent. 1[9' i2 If he continues to claim that no one in the family knows he uses drugs, and that he wants it
kept that way, the therapist will have to work on this matter before going any
further in the interview. The best approach is, again, to force him to
elaborate by acting as if this situation
were incredible (-Surely someone must know some thing?”). We feel the therapist can ask
this with some confidence, as we have yet to see an addict over age 20 whose
family was not aware of his drug
involvement at least to some extent. An alternative tactic is to suggest that maybe not bringing the family in to
help before is one reason his prior
attempts to get off drugs have been unsuccessful.
