GENERATING CRISES
As noted, it
is usually not difficult to generate a crisis with an addict's family. Often it can be done through simple
structural moves made within sessions (as, for example, in the case presented
in Chapter 7). In other cases a crisis may have already been
building at the time of intake (see Chapter 4). However, some addicts' families
are too staid and entrenched for this to happen readily. The evidence
presented in Chapter 8 indicates that a
crisis is usually necessary for beneficial change to occur, so the therapist may instead have to intentionally induce a crisis in immovable families of this
type.'°2 As exemplified in Chapter 9,
this may be done by increasing intensity, unbalancing, and essentially pushing a family hard within a
session. The resulting increase in
emotion, with its attendant interactions, can then be managed by the therapist while he is present.
Again, it is not necessary to do this with the majority of addicts'
families—since milder restruc-turing will
suffice to induce a crisis in most cases—but only in those in which no movement or change is taking place.
Home Detoxification
When an addict is detoxified in a hospital, or in
some other setting external to the family, his family members usually deny any
responsi-bility if the attempt fails or is not sustained. They foist
their addicted member on the treatment
system and then abdicate responsibility by stating, in effect, to the detox program, -You undertook it. We had nothing to do with it. If it failed it's your fault,
not ours." Thus staff in the
treatment program, having accepted this yoke, end up feeling responsible, even if the family actively worked to
undercut their efforts either during
or after the detoxification.
We feel this situation is severely flawed and is
exactly the opposite of what it should be. It is the family
that has been rearing and maintaining this addict, not the treatment program. We
believe the family should be the system that shoulders primary responsibility for turning the situation
around. What is needed, then, is a treatment paradigm that helps families to feel
more competent to
change their patterns and to care for their
own. One possible approach is to detoxify
the addict in the home.
Home detoxification is a kind of planned crisis
induction.* It is also a logical
extension of the notion of containing the crisis within the family. In this approach family members essentially
take charge of the detoxification process within their own home. Chapter
12 presents case material and some elements
of a paradigm for carrying it out. The
aim is to have the family help the addict detoxify -cold turkey.- Instead of entering a hospital, or engaging in the
time-honored method of detoxifying
amid friends, the addict undertakes it within his family and home setting. While it is better that the detoxification be from heroin or another illegal opiate rather
than methadone (since symptoms with
the former are more acute and therefore more crisis-like) it can also be done easily from a dosage of, for example, 20 mg of methadone, or even
higher.7'
In planning a home
detoxification, the therapist negotiates with the family when this should
occur. Commonly, a particular weekend is
chosen. A round-the-clock monitoring or "watch- schedule is estab-lished that specifies which members are to spend
which time periods with the addict.
The therapist should also plan to be available 24 hours himself during the period, and to make home
visits when possible.Planning a home detoxification additionally requires that thetherapist anticipate problems ahead of time with the family, such as the addict getting out of the house, a sibling or friend bringing him
drugs, parents relaxing their vigilance, and so forth. The therapist asks them, "What can possibly go wrong?” Once all the foreseeable contingencies are discussed, it may be wise for the therapist to
finalize the planning by making a sort of paradoxical statement, such as, -Well, we've anticipated a lot of things, but we can't think of everything. It's very possible that someone will come up with a problem that we haven't thought of. This is a tough thing to do, and you can expect that at some point something will happen to make it tougher.- With this blanket statement he covers all possible resistance moves by the family. He may also rob such moves of their sting, since they are less unexpected and are also not being condemned by him. It may also be wise for the therapist to negotiate a contract beforehand to undertake the process a second time, in case the first attempt fails; if the family members know they might have to go
through it twice, they are more likely to succeed the first time. On the other hand, since they themselves are now involved in the process, if the attempt fails they are not going to take
subsequent drug use by the addict so
lightly. They will be angry with him and may in this way be able to establish appropriate distance from
him. Thus the therapist can use either success or failure of the first
attempt to his (and their) advantage.
Obviously a successful home detoxification has the family doing just what it should do, and getting credit
for it as well. Con-versely, failure
can serve a disengaging function.*
There are
medical precautions that must be exercised in under-taking a home detox. The
addict should be screened medically to rule out certain conditions that contraindicate a rapid (cold turkey) detoxi-fication, such as untreated coronary artery
disease, uncontrolled dia-betes,
untreated pulmonary tuberculosis, or other severe infection. It is also necessary to have -on-call" medical
backup available to thera-pist and
family throughout the detoxification and to be aware of the closest emergency room service. In fact, knowledge
that these backup systems
are in line may help the family to better weather the crisis
