GOALS OF FAMILY TREATMENT

GOALS OF FAMILY TREATMENT

It is best to negotiate the goals for therapy with the family at the very outset of treatment. This is because (1) it provides family members with the sense that treatment will have direction, rather than wander-ing about aimlessly or having as an endpoint the uncovering of personal pain or feelings; (2) it indicates to them that they may get some return for their efforts, that their energies will not be expended fruitlessly; (3) they can take some satisfaction that the therapist at least seems to know what he is doing, thus possibly instilling in them a sense of hope. All of these features serve to both increase the as red herrings by the therapist—as ways of pulling therapy off track and diverting its thrust. Thus the therapist should question their relevance and require that the members who raise them justify their pertinence to the primary goal. (For example, a discussion of the addict's getting a job would only be considered appropriate if it were seen as important in keeping him off drugs.) The general rule is for the therapist to keep sessions focused on drug use until stable im-provement has been achieved.

It is crucial that the therapist form an alliance with both parents or parent surrogates in this stage so that they may take an effective stance toward the addict around the chosen goal. The therapist must keep the parents working together in the early phases, even siding with them against the addict upon occasion. Sometimes therapists, especially young therapists, are uncomfortable in treating a young adult in this manner. For example, such a therapist might feel uneasy suggesting that the parents negotiate a time when their 27-year-old son should be in the house and off the streets in the evening. What one finds, however, is that the IP is often surprisingly cooperative, even though he may protest the fact that he is being treated as a child. This cooperation can be explained as gratitude in many cases. The addict is secretly grateful for the fact that the parents' relationship is being attended to by the therapist. In general, it is very difficult for the addict to significantly improve his situation and remain that way unless there appears to be some tangible evidence that the therapist is addressing the needs of the parental subsystem.

If freedom from drug taking has been maintained for a month or more, it may be possible to shift emphasis to other treatment goals. Two common ones have been mentioned—gainful employment or schooling and getting the addict out of the home. Underlying both topics are issues of separation—either physical separation or separa-tion through increased competence and the resulting independence of functioning. The therapist should be sensitive to the meaning of such separations for the family and restructure therapeutically in such a way that alternative supports are provided for members who are likely to feel the greatest loss.

Similarly, as progress occurs in all the goals relating to the addict, it becomes possible for the therapist to move flexibly toward dealing with other family issues. As is amply demonstrated in suc-ceeding chapters, such a broadening of goals is important at this stage illegal drugs, but it is necessary to get this issue on the docket as early as possible.* Then a process of negotiation can be started as to a date for detoxification and how the family is to prepare for it.

Often questions arise about the feasibility of having the addict become totally drug-free. We have found it critical for the therapist to be committed to this goal and to recognize that as long as the addict is on any drugs, including methadone, he is still labeled as an addict and the basic situation is unchanged (see Chapter I ). It is tempting to think of an addict as similar to a diabetic, implying that he will always need methadone. It is Haley's experience that working from such a

• model with schizophrenics almost never leads to cure.-j- Similarly, the therapist working with an addict is hopelessly hamstrung if he sees his job as helping the family to cope with a handicapped person suffering from an inherently chronic, incurable condition.

It needs to be underscored that the goals are negotiated with the family rather than being foisted upon them by the therapist. Thus the agreed-upon goal must be one that makes sense to them. This process begins by first assessing the priorities and competencies of the client and family, then reaching closure on a realistic and achievable goal. Although the therapist recognizes that the family may be ambivalent about a goal, he seeks to have the goal stated publicly in order to urge the family to action and, in a sense, to call their bluff. If, however, a family is extremely resistant at the outset to the idea of having the IP get off drugs (including methadone), the therapist might be better advised to postpone family treatment and obtain an agreement with them to reconvene when they have decided they do not want an addicted member. Otherwise, the purpose of therapy becomes unclear and the chances for retention of the family in therapy and for any real change are very slight.

Once an agreement has been reached about goals for the IP's drug use, family members may raise other issues or problems. As noted in Chapter 4, some other, crisis-laden issue may even underlie the addict's move to initiate treatment (e.g., he might be about to get married). While these problems may be real, they should be regarded as red herrings by the therapist—as ways of pulling therapy off track and diverting its thrust. Thus the therapist should question their relevance and require that the members who raise them justify their pertinence to the primary goal. (For example, a discussion of the addict's getting a job would only be considered appropriate if it were seen as important in keeping him off drugs.) The general rule is for the therapist to keep sessions focused on drug use until stable im-provement has been achieved.

It is crucial that the therapist form an alliance with both parents or parent surrogates in this stage so that they may take an effective stance toward the addict around the chosen goal. The therapist must keep the parents working together in the early phases, even siding with them against the addict upon occasion. Sometimes therapists, especially young therapists, are uncomfortable in treating a young adult in this manner. For example, such a therapist might feel uneasy suggesting that the parents negotiate a time when their 27-year-old son should be in the house and off the streets in the evening. What one finds, however, is that the IP is often surprisingly cooperative, even though he may protest the fact that he is being treated as a child. This cooperation can be explained as gratitude in many cases. The addict is secretly grateful for the fact that the parents' relationship is being attended to by the therapist. In general, it is very difficult for the addict to significantly improve his situation and remain that way unless there appears to be some tangible evidence that the therapist is addressing the needs of the parental subsystem.

If freedom from drug taking has been maintained for a month or more, it may be possible to shift emphasis to other treatment goals. Two common ones have been mentioned—gainful employment or schooling and getting the addict out of the home. Underlying both topics are issues of separation—either physical separation or separa-tion through increased competence and the resulting independence of functioning. The therapist should be sensitive to the meaning of such separations for the family and restructure therapeutically in such a way that alternative supports are provided for members who are likely to feel the greatest loss.

Similarly, as progress occurs in all the goals relating to the addict, it becomes possible for the therapist to move flexibly toward dealing with other family issues. As is amply demonstrated in suc-ceeding chapters, such a broadening of goals is important at this stage of therapy, whereas it would have been inappropriate in the initial, acute phase of treatment.