GENERATING CRISES

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

HANDLING CRISES

HANDLING CRISES

In many addicts' families, crises are a way of life. It sometimes seems

as if they would be unhappy if they did not have a periodic crisis to activate them. They appear to swing from one crisis to the next as a way of charting and maintaining their lives, just as Tarzan swings through the jungle from one supportive vine to another. It is therefore not surprising that a family crisis can be anticipated as change starts to occur in therapy and the addict stops or curtails his drug taking. This is probably a necessary feature of change (see Chapter 8). It can be expected to occur 3 or 4 weeks into treatment.* Most commonly, it will revolve around the parents' marital relationship, with them talking about, or taking steps toward, separation or divorce. This puts tremendous pressure on the abuser to become dirty again in order to reunite his family. At such times, the therapist will need to devote considerable time and energy to resolving the crisis in a different way than has occurred in the past. He will have to be accessible and perhaps constantly on call. His goal is to get the parents to hold together in relation to the IP and not let them separate, at least until this storm is weathered. If the transition is handled skillfully, treat-ment is usually on the way to a successful outcome, for succeeding crises will be easier for the family to cope with; a previously recurrent pattern has been broken and real change has occurred.

The therapist wants to contain the crisis within the family, preventing matters from getting out of control and avoiding spillover into other systems. At such times it is best to avoid steps that take the pressure off the family, particularly hospitalization, increasing medi-cations such as methadone, or kicking the IP out of the home precipi-tously. This is partly because the therapist and family rarely have major input or control in these other contexts, including the context of the peer or drug subculture. Their ability to manage or intervene in these social systems is minimal. Equally important, the family of origin is the strongest and most logical support system for dealing with such crises. The IP is one of their own, they have likely had to deal with his crises in the past, and they are usually more motivated to be involved this time. Therefore, it behooves the therapist to mobilize the family around the crisis and put them to work to resolve it.

An additional benefit of generating a crisis is that it brings about a situation in which individuals and systems are more amenable to change.66 Times of crisis are pivotal points at which the system can move radically in either a functional or a dysfunctional direction. The key factor here is that movement is more possible at such times, allowing the therapist maximal influence.