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

CLINICAL ASPECTS

CLINICAL ASPECTS

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Some of the clinical vignettes presented earlier may appear to have an unusual, or even outlandish, flavor. This is a direct result of the tremendous difficulty encountered in engaging many of these families. They rarely responded to gentle urging or a -kind word.- Often the therapist had to respond very quickly in order to keep from losing a family. It sometimes seemed as if he could not think of something fast enough to turn things around. Frequently the dangers of death or im-prisonment of the addict, balanced against resistance or complacency on the part of the family, put additional pressure on him. Thus he responded with what came to mind, hoping it would work. The mas-sive resistance shown by so many of these families, and the inadequacy of more standard techniques, dictated that the therapists develop new approaches.

Although the recruitment effort might be termed a -pretherapy-exercise, it is (as stated in Principle 8) a clear intervention. This is especially true in cases that require considerable effort to engage,bringing us to a point made by Jay Haley* about the difficult position that our therapists were in. Unlike many clinical situations where the family petitions the treatment program for help, we enjoyed no such luxury. These families neither expected nor, in most cases, wanted to be involved. The majority of them had already seen a drug-treatment program fail with their sons, and they may have been even less impressed this time. Instead, the impetus for their participation usually generated from the therapist. They knew he wanted them in, that he "needed- them in order to perform his job. Often this led to his working hard while they sat back and "played coy.- Thus, in light of these handicaps, the percentage of families actually engaged could probably be considered quite credible.

Problems such as the above can be reduced considerably by program procedures. There are at least 40 drug-treatment programs in the United States in which family participation is mandatory.31 This obviously reduces the amount of time and effort required for re-cruitment. We know of at least one multimodal methadone program that has established this condition, and 75% of its clients bring their families int (although their requirements are less stringent than our own, in that any cluster of family members is acceptable for the first session, and both parents are not necessarily required to participate at the outset). However, even if only 2560 of the families are resistant, the principles set forth herein would appear applicable for this select subgroup.

Treaters who might want to institute family recruitment pro-grams in the future would want to keep in mind the characteristics of our patient population, that is, all the clients were male, between ages 20 and 35, in touch with two parents or parent surrogates, veterans with at least a brief military stint, from the lower socioeconomic classes, nearly equally divided between Blacks and Whites, and living within I hour's drive from the clinic. We also excluded a number of good-prognosis clients who were detoxifying from opiates and there-fore on an immediate path toward nonaddiction. Further, since our clients were outpatients, they may have been more difficult to engage than those in the more -captive- status of inpatients. Many of these factors probably operated to make recruitment more difficult, and some of them might also serve to limit the applicability of our findings to other contexts.

On the other hand, we would posit that most of the principles we have presented can be generalized to other types of -difficult" and -unmotivated- families. Their application seems appropriate with other types of disorders and -tough- cases. We suspect that similar recruitment problems exist, in particular, with symptom groups in which there is a heavy focus on the IP or where there is considerable family -underorganization,- such as is often found with low-income families. We are sensitive to the tendency to pass off our recruitment endeavor as -inapplicable" or -not do-able- simply because other programs have not been engaged in such activities, or because these activities would require the development of additional skills. Another common counterargument is to oversimplify family recruiting as primarily a function of -highly motivated therapists," followed by the disclaimer that one's own therapists are -not as motivated." While we recognize that recruitment is not a simple exercise, the difficulty of the task should not be used as an excuse for failing to make an earnest effort. Clinicians who claim to be interested in helping people should not be too quick to write off a significant number of families who could be reached if properly approached.

Looking to the future, it seems safe to predict that, as family therapy becomes more widespread and accepted within the general populace, the task of engaging families will become easier. The idea of family involvement will seem less alien or irrelevant to the layman. However, it is very doubtful that all resistance will dissipate, any more than it has with individual therapy. Thus we can expect that family therapy will be faced with engagement challenges, at least in certain cases, for some time to come.