PRINCIPLES AND TECHNIQUES

PRINCIPLES AND TECHNIQUES

While engaging families in treatment is a major problem in the addic-tion field, there is almost no literature on how to do this in prac-tice. Aside from an occasional pointer in a few articles,'4, 2". ".."6, [8° the therapist trying to recruit addicts' families—or even difficult nondrug- families—is essentially without published guidelines. This chapter will attempt, at least partially, to fill that void and provide therapists with material aimed at optimizing the recruitment effort.

The material in this section is subdivided into various content areas. Within each of these, one or more principles are set forth, followed by explanation and discussion. The reader may note an air of finality in these principles. This is not altogether unintentional. While every rule has exceptions, these tenets have been arrived at through the pain of multiple failures, so we feel we can state them with a certain degree of confidence.

MEANS AND GOALS FOR TREATMENT

MEANS AND GOALS FOR TREATMENT

The DDTC considered complete abstinence from both illegal drugs and legally prescribed opioids (e.g., methadone) to be a desirable goal of treatment. However, based both upon the literature in the field and their own experience, DDTC staff members were skeptical of this as a realistic goal with most drug addicts, particularly in the short run. Instead, the preference was to approach such a goal gradually, under planned conditions, and with the necessary "supports- intact. The main idea was that the addict should be in a stable situation before abstinence—including detoxification—was attempted, since failure was so prevalent with such attempts.

The AFP staff also suffered no illusions, at the outset, as to the difficulty of this endeavor. In fact, relative to some others in the family field, the AFP standards might not even be considered rigorous—especially at the outset—because detoxification was not necessarily espoused as a goal. Rather than labor under the pretense that -cure" was possible, the idea instead was to see whether significant change could be effected in the extent to which patients stayed off legal and illegal drugs over a given time period—the percentage of -days free,- as described in Chapter 17. There was awareness that we were experi-menting—trying to find out what worked with these families—and that some recognition should be given to the lore that existed in the drug-abuse field up to that time.

On the other hand, the PCGC contingent saw addiction as (primarily) part of a fami ly process in which the addict was only one of a number of actors (Chapter 1). The view was that this process must be interrupted and a new process set in motion, one that did not include addictive behavior. Further, it was held that stopping the drug taking might require that a crisis be induced in the family (see Chapters 6, 8, and 9) as a way to, in a sense, -get them out of a rut.- This contrasted starkly with the notion of a gradual, careful detoxification regimen. The therapy model also dictated that goals be clearly defined and that pressure be put on the addict (within a family context) to get off drugs.

How were these differences resolved? As the work progressed several confluential processes evolved. First, partly to obtain coopera-tion from DDTC staff and partly because it seemed to have merit, the family clinicians did tentatively embrace the DDTC idea of having -all the ducks in line- before detoxification. A reluctance developed toward prematurely rushing headlong into detoxification.

On the other hand, as the family therapists grew more ex-perienced, and the techniques began to be identified and refined, confidence increased to move more rapidly in family treatment. This practice was also dictated by the urgency of having to accomplish something within 10 sessions. Eventually, it became more common-place for a therapist to pose to the family the question, -When is he going to detoxify?" in the first or second session, whereas in early cases therapists tended to sidestep this issue initially. Interestingly, as a treatment paradigm emerged, and some successes were achieved, DDTC personnel grew more amenable to rapid action, moving some-what from their previous cautionary posture. They began to accept that working with the family to pressure the addict against drug taking was a viable and feasible procedure, especially when there were no indi-cations of a possible suicidal reaction. The eventual outcome was a paradigm that drew from the philosophies and practices of both

camps.

MONITORING OF PROGRESS AND PROCEDURES

There were at least two areas in which the AFP had interesting effects on the DDTC. The first of these concerned the monitoring of urine reports. Progress and changes in drug taking were a key part of family therapy. Clear contingencies were established for -dirty- urines given by family (and movie) therapy cases—especially in the two -paid-conditions. The treatment was sharply focused on this behavior. Thus it was essential that the urinalysis results processed at DDTC be obtained and recorded accurately and efficiently. In the early stages of the program, however, it was discovered that the DDTC was going through a -slippage phase'' regarding strict adherence to urine test results: records were sometimes -lost,- patients were able to get away with denying that dirty urines were their own, and (previously firm) established rules preventing clients with dirty urines from obtaining certain privileges, or even remaining in the program, were not being strictly followed. The AFP attention to, and insistance on, (1) clarity and efficiency of urinalysis results, and (2) adherance to program strictures based on urine results highlighted areas where slack had set in. As a result, the DDTC tightened up its urine-monitoring procedure and the total urine-reporting system was improved.*

Paralleling the above, a number of areas were uncovered by the AFP in which patients were finding it easy to manipulate the DDTC system. These included ways of getting around program rules, tricks for obtaining permission from staff for higher methadone dosages, methods for triangulating staff members and instigating or exacer-bating conflicts between them, and so forth. Some of these are described in Chapter 16. As they came to light with AFP cases, or within AFP team meetings, they were responded to and corrected by DDTC staff, thus allowing improvement in the overall drug-treatment

program.

RELAXATION AND STRESS REDUCTION

HEALTH BENEFITS OF MODERATE ALCOHOL USE

RELAXATION AND STRESS REDUCTION

It is perfectly clear that heavy drinking, either in one session or across decades, carries with it significant risks to health and safety However, alcohol is not all bad. Used in an informed and moderate way, alcohol can convey some health benefits. For example, the similarity of its actions to those of antianxiety medications such as Valium makes alcohol a potent antianxiety agent for some people. The feeling of relaxation that accom­panies an occasional drink of alcohol can help to reduce stress, and stress reduction is healthy. But remember: people who use alcohol heavily or too regularly as a way of coping with the difficulties in their lives are at con­siderable risk for becoming addicted. Ultimately, the use of alcohol for relaxation and stress reduction is a personal choice that must be made in as informed a way as possible.

PROTECTION AGAINST HEART DISEASE

There is no doubt that chronic heavy drinking damages the heart. How­ever, recent studies show that light (and perhaps moderate) drinkers have a reduced risk for coronary artery disease—a principal cause of heart attacks. Remember, though, that this research is still developing, and it is not possible to arrive at an exact "prescription" of alcohol use for cardio­vascular protection. Still, a growing number of studies suggest that an average of a half to one and a half drinks per day may significantly lower a person's risk for coronary artery disease.

A study from Harvard Medical School further supports these early findings—at least in men. A group of more than 22,000 men who ranged in age from forty to eighty-four were studied over a ten-year period. Com­pared to men who drank less than one alcoholic beverage per week on average, those who drank two to four alcoholic beverages per week were significantly less likely to die of a heart or circulatory disorder. These light-drinking men also suffered fewer cancers over the ten-year period. However, among men who drank two or more drinks per day, the death rate was 51 percent higher. This means that there is a narrow window for the possible health benefits of alcohol for men. Two drinks per week seem to be good; two drinks per day seem to be bad.

For women, however, these findings present a double-edged sword. Moderate alcohol drinking appears to reduce the risk of cardiovascular

disease in women. But studies have also shown that women who drink an average of three to nine drinks per week are significantly more likely to develop breast cancer than women who do not drink. Still, the causes of breast cancer are quite complex and much work remains to determine the exact relationship of alcohol drinking to breast cancer. Women who choose to drink moderately, for whatever reasons, should keep in close touch with the latest information related to breast cancer risks.

DIMINISHED RISK OF DEATH

There have now been several large-scale studies, in both Eastern and Western countries, indicating that light to moderate drinking may diminish the risk of death in middle-aged men. A recent study in China showed that men who drank one to two drinks per day over a six-and-a­half-year period reduced their risk of death by about 20 percent—a find­ing that is consistent with studies in European countries. The protective effect was not limited to death from heart disease—the drinkers were also less likely to die from cancer or other causes. Further, the particular type of alcoholic beverage consumed was inconsequential: Beer drink­ers, wine drinkers, and drinkers of hard liquor shared equally in the benefits, as long as their consumption was not more than an average of two drinks per day. Beyond that level the risk of death was increased by about 30 percent. Alcohol appears to have some similar protective effects in women. But, as just noted, women are also more vulnerable to some of the negative effects of alcohol, so most studies suggest no more than one drink per day for women.

The bottom line seems to be that if you want to get the medicinal effects of alcohol, you have to take it like medicine—a little at a time.