THE ADDICTION CYCLE. CRISIS RESOLUTION, AND OUTCOME

THE ADDICTION CYCLE. CRISIS RESOLUTION, AND OUTCOME

We examined the 39 cases to see whether there was the expected relationship between crisis resolution and outcome. The degree of success was measured by the extent to which the addict abstained from legal or illegal opioid use (the addiction cycle) during the 6 months following the end of treatment. In those families where a major crisis did not occur during therapy, we predicted poor outcome, since the addiction cycle had not been challenged. In families where a crisis was manifested by the addict during treatment, and where this crisis was not resolved, treatment was also expected to be unsuccessful.
More positive outcomes were anticipated in cases where the addictive crisis was successfully handled, setting the stage for other family issues to emerge and be resolved. Based upon the typology described earlier, these emerging family problems could take one of four forms, with the particular form expected to be related to outcome.
The expected order of the forms, from best to worst outcome, was
(1 ) family issues were resolved without reaching crisis proportions;
(2) such crises developed and were clearly resolvable by the therapist

which was expected to allow the addict to continue to improve and move toward more autonomy from his family; (3) in families where interparental issues were not resolved, continued improvement on the part of the addict was less likely; to the extent that the addict did improve, such improvement was likely to be offset by physical illness of a parent or the emergence of significant problems in a sibling; (4) in the fourth type of family, the breakdown of the addiction cycle was followed by a chain reaction of violence and even death.

The type of reaction mentioned above, in item 4, was unusual in our sample, occurring in only 4 of 39 cases. When it occurred, the violent reaction was not necessarily precipitated by the therapy, but seemed to be an example of the level of crisis under which some of these families attempted to survive, never seeking professional help.* Exactly what would constitute a helpful intervention in this type of family is beyond the scope of this chapter, but it seems that the development of methods for identifying them prior to treatment would be a fruitful direction for future research.

The topic of interest here is the relationship of crisis occurrence and resolution to outcome. However the family patterns described are, although important, too refined to detect any correlations in our own sample of 39 cases; for example, some "types- had as few as 3 families. Consequently, it was decided to compare outcome based on one distinction: those families where the therapist considered the addictive crisis to be successfully resolved versus those families in which either no crisis occurred or the occurring crisis was not success-fully resolved. A listing of the various categories, and the number of families in each, is presented in Table 2.

Outcome data addressing the primary issue of opioid addiction, in the form of days free of legal opiates (e.g., methadone) and days free of illegal opiates during the first 6 months posttreatment, were available for the IP in 37 of the families; for two families these data were incomplete and thus insufficient for inclusion here (see Chapter 17 for a detailed explanation of the methods for obtaining and calculating outcome data). An outcome was classified as -Good- for a given IP if he was free of that particular class of drugs for more than 80% of the days within the 6-month period. We then examined the distribution of cases across these two dimensions--Good" versus -Not Good- outcome, and crisis resolution versus nonresolution (or no crisis)—separately for both legal opiates and illegal opiates.*

Inspection of these distributions revealed that, for illegal opiates, 18 of 25 families in which crisis resolution was attained had Good outcomes (i.e., 72%), whereas Good outcomes occurred in only 5 of 12 (41.7%) of the families in which either no crisis or no crisis resolution occurred. This difference, using a one-tailedt test for the difference between two proportions, was significant at the .05 level. For use of legal opiates, 17 of the 25 families that resolved the crisis (68%) had Good outcomes, while 5 of 12 (41.7% ) of the families without crisis resolution had Good outcomes—a difference signifi-cant at the .10 level using the same one-tailed test.

These results tend to support the idea that occurrence and resolution of a crisis within the course of therapy are important variables in helping the addict to both get off and remain off opioids, that is, to break the addiction cycle. Certainly this is a topic that merits further investigation with larger samples, more detailed meas-ures, and continuous sampling throughout treannent.

M. DUNCAN STANTON/THOMAS C. TODD

CRISIS RESOLUTION AND THE ADDICTION CYCLE

CRISIS RESOLUTION AND THE ADDICTION CYCLE

THE ATMOSPHERE of perpetual crisis and even life-and-death drama in which the heroin addict and his family live is evident in the following excerpt from an initial session:

The addict arrived drunk, having been fired from his job, and having wrecked his truck on the way to see the therapist for their initial meeting. When the therapist suggested that he contact his father, the addict responded by stating, "He wouldn't come down no way; my father has no interest in me whatsoever. I OD'd one time and my father went out and took out a $50,000 insurance policy on me and after 4 months he got mad because I didn't die, and wanted me to start paying for the insurance policy.-

In Chapter 1, a conceptualization is presented of drug addiction as part of a complicated, homeostatic system of interlocking feedback mechanisms that allows the family to maintain pseudostability. The dramatic events that characterize these families, such as drug overdose, criminal activities, and episodic involvement in treatment programs, are seen as symptomatic of a larger process—the inability of the addict and his family of origin to separate. In these families it is possible to detect a recurring pattern of the crisis process and how the family -solves- such crises: family tension triggers the addict's drug-related behavior; other family members (e.g., parents) then focus attention upon the addict, thereby diverting their energies from the

Appreciation is extended to Maria Rychlicki, MAC, and Susan Carle for assist-ance in preparation of the data presented in the latter part of this chapter. original source of stress. Thus the initial conflictual issue is -resolved,- at least for the time being, through denial accompanied by a shift to another problem.

The course of successful treatment can be described as a shift within the parent-addict triad from an initial structure in which the addict is viewed as responsible for the system's instability, to an eventual position of shared responsibility. In this second structure the parents maintain a clear hierarchical status, permitting the addict to leave the system without drugs and without carrying the burden of future family problems. When treatment is successful in allowing the addict to stop -making problems- for his family, the family is faced with an interpersonal crisis. The therapist's ability to guide the family through this crisis—and prevent it from spilling over into extra-familial systems—will determine the extent to which a new structure within the triad can be maintained, allowing for a lasting change.

It is our experience, and the position taken in this book, that this crisis is predictable in families of drug addicts and that successful treatment is largely dependent on the therapist's ability to anticipate the events and phases through which the family passes, as well as to remain in control of them. The present chapter describes ( I ) the rationale for a crisis-oriented family therapy with drug addicts, (2) the nature of the crisis and its relation to the addiction cycle, and (3) the relation between crisis resolution and outcome in 37 families treated within the Addicts and Families Program (AFP).

M. DUNCAN STANTON/THOMAS C. TODD