THERAPIST FACTORS

THERAPIST FACTORS

There are a number of therapist qualities, some of which are discussed further in Chapters 14 and 15, that appear to contribute to the success of this treatment. The ability to be active is important and is a corner-stone of structural therapy in general. Passive, reflective styles usually do not work well. The therapist must be able to be supportive, concerned, accessible, and enthusiastic. A lack of rigidity is also needed, as drug addicts' families are very skillful and will t rip up" an inflexible therapist. Finally, the more a therapist is able to tap into his own creative and intuitive potential, the more likely he will be able to devise interventions that are both appropriate to the situation and

effective.

In addition, the therapist needs to be skilled in identifying family

and intersystem cycles and sequences. He has to be able to observe what is happening in a family, or within a set of systems, and document it. He also needs to know when to enter the cycle, based in part on the steps within it during which he has the most leverage. For example (as implied earlier), it might not be auspicious for him to try to break a cycle in which, at the moment, the addict is hospitalized to detoxify from heroin—espeically if the therapist has no control over the detoxification process. More prudently, he should wait until the addict returns home and the family system has a more direct influence.

Therapeutic acumen of the above sort is not easy to develop. It requires sharply honed observational skills and the ability to selectively ignore the content of family verbalizations. Attention is best directed toward the consequences of particular acts. Even experienced thera-pists can sometimes become misled by red herring behaviors and overlook the essential elements in a cycle. At the very least, however, this approach requires a different perspective of the addiction process and the people and systems involved in it, plus focus on the sequential, predictable, stable, and functional aspects of interactional behavior.

As mentioned in Chapters 9, 14, and l 6, it is helpful for the therapist to have a support system of other therapists and/or super‑ visors. Sometimes this can be group or peer supervision, perhaps in the form of a team that observes each other's session live. Or, it

might meet regularly or periodically to view tapes or discuss clinical and case management issues, as did the group described in Chapter 16. Not only can the group collaborate in designing interventions, but it can also help to increase each member's strength and leverage with

his own cases. For instance, a therapist who is attempting to induce a crisis within a session is usually under considerable counterpressure from the family to relent or back off. Having one or more colleagues watching through a one-way mirror draws on the greater pool of all their ideas, serves to spread the pressure among them, and helps the therapist to hold more firmly to his position (see Chapter 9). We would advocate that therapists working with addicts' families take the steps necessary to form such a support group whenever possible 

OVERVIEW OF SECTION II

The remaining chapters in this section present some of the clinical material with which our therapy model has been applied. The model provides them with a unifying or common thread.

The four case studies (Chapter 7, 9, 10, and 11) were selected for a number of reasons: (1) they all showed some level of success; (2) they represent a cross-section of several different kinds of cases (in regard to life cycle issues, ethnicity, etc.) treated by therapists with varied credentials and styles; (3) they are useful in making different points about the therapy; (4) the therapists involved were interested in preparing them for publication; (5) for each case we had complete, or near complete, videotape sets of 10 sessions, allowing the material presented to be as complete as necessary*; and (6) we had at least 3 years of posttreatment follow-up information on each.

Chapter 7 presents a case that quite clearly depicts most of the features of the therapy model previously covered. In addition, this family was chosen because it is so explicit. Not only do the family members show the process and patterns so frequently seen in other addicts' families, but they verbalize them as well (such as when the mother states in no uncertain terms that she does not want her son to marry or to leave home). Other families may give indications of similar sympathies, but they may not verbalize them so unhesitatingly.

Chapter 8 discusses the importance of crises in bringing about change. Rather than presenting a single case, the authors survey crises across 39 cases and the relationship between resolution of these crises and treatment outcome.

Chapter 9 gives an example of crisis induction in a case where the father (rather than the mother) is the parent most indulgent of the addict. The therapist forces the issue of the son's imminent death as a way of initiating change.

Chapter 10 shows the intricacies of therapy with the family of a drug pusher. Lengthy excerpts are presented from the entire course of therapy. Chapter 11 

 examines therapy with a family in which the parents have reached retirement. A number of 

conceptual points and general techniques are also covered.

Chapter 12 presents the elements in a process—with accompany-ing clinical material—for detoxifying the addict, in this case in the

family home. The home detoxification paradigm is experimental we have applied it with only a few cases—and permits a peek at the future direction of our work. This chapter also presents some excellent material on the necessary conditions and procedures for the use of tasks in family therapy.

Chapter 13 covers treatment strategies and techniques with families in which the drug abuser is an adolescent. A number of

differences between these cases and families with a young adult drug abuser are discussed. The therapy approach differs in some ways from

the model set forth in the present chapter, being more structural and less strategic in its thrust and operations.

Chapter 14 tunes us into a discussion among three of the clinical supervisors about some of the issues and problems in this kind of

work. It deals with some aspects of the therapy that have not received coverage earlier in the volume.

Chapter 15 is a sister chapter to the present one. It was felt that it would be premature to present this material before exposing readers to the clinical matter in Chapters 7 through 14, from which

the material was derived. Chapter 15 also deals with some matters of

controversy, discusses and contrasts case examples, and extends the therapy model to other populations.

Approaches to Wives

Approaches to Wives

In our experience with this population, wives of the clients were perhaps the most willing participants of all family members. For the most part, if the IP would cooperate, his wife was easy to bring in. For whatever reasons, they just did not give us much trouble, and some-times even helped us recruit their husbands' parents.* The only exceptions to this were cases in which the wife and the IP's family of origin were openly antagonistic toward each other. In such instances our research design dictated that we concentrate on involving the family of origin (since they, but not the wife, were required to attend the evaluation session), and bring the wife in after treatment began.

THE NONBLAM1NG MESSAGE

When these families are approached they often feel frightened, de-fensive, and guilty. At some level they know they are to a great extent to blame for the problems of the IP. Thus they are ready to hear blaming from the therapist. They anticipate it, and often attempt to deny or avoid the blame they fear the therapist will place on them by diverting it to external influences such as peers, the neighborhood, or the treatment program. The therapist's task is to get beyond this stumbling block and reduce resistance arising from fear of blame.

Principle 10: The therapist must approach the family with a rationale for treatment that is nonpejorative, nonjudgmental, and which in no way blames them for the problem. This requires skill. Some responsibility is being ascribed to the family by the very fact that they are being asked to become involved. There is an implicit message that the family has not resolved something with one of its members. Consequently, the therapist must approach them in a nonconfronting way, which gets them off the hook, thereby re-ducing resistance and making them more amenable to hearing what he has to say. Our experience is consonant with that of Vaglum's" that family members should not be treated as -patients,- but as "healthy- people who, themselves, are without problems. Under no circumstances should the therapist become involved in a struggle with the family over whether they are the problem or not. Instead, he should allow them to become acquainted with him in order to remove mystery and fear; if they sense that he is both genuinely concerned

and not out to put them on the "hot seat,- they will be more agreeable to his requests.

Vignette 12. In this case the therapist (Jerry I. Kleiman) underscored the parents' martyrdom, talking about all they had been through and how their son never listened to them. He emphasized repeatedly that the son did these things despite "all they had done so far." He empathized with the father's plight—nobody listened to him, people kept secrets from him—and told him it was time for this to stop. He talked to the parents as victims, telling them that there was a need for them to be in control of the situation.

Principle 11: Primary focus should be on helping the index patient rather than the family. This approach stems from the work of Haley, and is described in Chapter 6. It has also been applied by others with these families."' '8" Again, the emphasis is on joining the parents in helping their son to "be the kind of person he can be.- To the extent that the therapist ever takes a blaming stance, it would be in this context. He might join the parents in mildly blaming the IP for the problem. Alternatively, he could state, -No one is to blame.- Or, he might emphasize how difficult it is to get off drugs, and, -Your son needs all the help he can get." The family is then redefined as a group that can help the IP, rather than one that causes his problem. Vignette /3. In this family the therapist (Jerry I. Kleiman) empathized and shared with them. He got them to admit that with all they had done so far, they had not been able to help. He suggested that maybe this was an opportunity for them to teach their son what the world is all about.

Vignette 14. The therapist (Jerry I. Kleiman) talked to the father about his goals for his son. The discussion had a kind of "reparenting" flavor, as the father talked about his lack of success both with his son and in general. Kleiman suggested that perhaps this program would give him a chance to succeed in a new way.

Principle 12: The rationale for family treatment should be pre-sented in such a way that, in order to oppose it, family members would have to state openly that they want the index patient to remain symptomatic. While not necessarily easy to do, succeeding at this task can greatly facilitate the recruiting effort. If nothing else, the family may come in to disprove an implication that they do not want change. It sometimes helps to begin by -ascribing noble intentions- to the family (see Chapter 6): -Of course, your goal is to see him straighten out.- In fact, the therapist ought to operate under the assumption that the family wants to help and desires to see the IP get better. He has to believe that, in the end, the parents really do not want a drug addict for a son. If he implies that they do want an addicted son, he will have a battle on his hands. If he is able to avoid such an altercation, the therapist can instead proceed with establishing his case for family treatment, using strategies of the sort described in other sections.