- Email: [email protected]
Living again
Journal of Substance Abuse Treatment,
Vol. 9,
0740-5472192 S5.00 + .OO
pp. 71-80, 1992
Copyright 0 1992Pergamon Press Ltd.
Printed in the USA. All rights reserved.
IN THE SPOTLIGHT
Living Again Family Treatment at KIDS of North Jersey
RIVEREDGE,
INTRODUCTION
NEW JERSEY
of drugs and alcohol, eating disorders, or compulsive behaviors in the early teens, sees family participation in treatment as necessary to recovery. The immaturity of most patients requires an intensive family support system after treatment until adult maturity is achieved in the mid-20s. The family is a necessary part of this support system and can be helpful only if family recovery is in full bloom. KIDS requires, as the “price of admission” of the primary patient, the involvement of all members of the residential household, including siblings (even siblings who are part-time residents away at college). Also, extended family members such as grandparents who are part of that household are required to participate in treatment. KIDS approaches family treatment from a multifaceted viewpoint. First, the family is part of the system that maintains the addictive disease of the primary patient. In order for the patient to recover, the family connection to the disease must be broken, and a new recovering support system must be developed for the primary patient. Second, each family member has sustained pain, losses, and developmental dysfunction as a result of coping with the threat to personal survival and identity by the acting-out patient. Treatment helps each family member come to terms with the pain and hurt and then to understand his or her participation in the disease. The recovery process also involves repairing dysfunctional thought, feeling, and behavior patterns. Third, treatment helps each family member to accept the disease and to develop a recovery
THE LATE1970s ANDEARLY 1980s brought alcoholism and drug dependence out of the closet and on center stage as respectable diseases and national causes. At the beginning of Alcoholics Anonymous, wives participated in the group meetings with husbands. Later, they held separate meetings in the same facility leading to the founding of Al-Anon. Early treatment programs viewed family members as the enemy because they seemed to behave in ways that sabotaged the recovery of the alcoholic. Later, treatment programs included family members, usually in a special weekend format helping them understand the patient’s disease and what they could do to support sobriety. More recently, the “adult children of alcoholics” movement has focused on the co-dependency disease as a separate issue from treatment of the primary patient. Family systems therapy has blamed the family and has seen the patient as simply a symptom bearer and scapegoat. Each of these approaches has contributed some important insights into the relationship of family members to chemical dependency and recovery, but at the same time, each has remained partial and incomplete as a treatment strategy. KIDS, as a treatment center dealing with adolescents and young adults, all of whom began their use Requests for reprints should be addressed to Dr. Miller Newton, KIDS of North Jersey, Inc., PO Box 2455, &caucus, NJ 07094. 71
M. Newton
72 lifestyle that brings with it serenity in the here and now. Recovery also stops the transmission of the disease down the family line. This article outlines the conceptual approach of myself and the KIDS program to family treatment. We see recovery as an ongoing process involving five movements. The first movement is to Break Denial; the second is to Unhook From User; the third is to Resolve Issues and Resentments; the fourth is to Develop Detachment, and the fifth is to Develop a Personal Healthful Lifestyle. These movements feed into each other and overlap somewhat, but together they constitute the road from family disease to recovery.
parents. Grandparents “clucking,” friends with raised eyebrows, competitive siblings in the parents’ family of origin system all exist as a threat to a parent who feels defensive and incompetent in the face of a troubled kid. Fourth, if the parent faces and deals with the addiction, it may cost losses to other family members. A sibling may lose friends because of his or her parents’ fear and have to give up activities because of family treatment with the primary patient. Parents may lose promotions, opportunities, and voluntary activities because of family treatment requirements. Help in Breaking Denial
BREAK DENIAL Many professionals and treatment agencies see parent denial about addiction in kids as lack of care, as stupidity, or worse. This viewpoint about parent denial opens the therapeutic relationship as a “we-they” relationship, with parents in the scapegoated enemy role. Having gone through the course of chemical dependency with my own son, I have come to view parent denial in a more positive light. Parent Denial First and foremost, parent denial is about love. Drugs and drug dependence, as well as the ensuing acting out behavior, is very frightening for a parent who cares about his or her child. The parent attacks the problem using the parenting skills learned from his own parents only to find that these fail. As the behavior of the child escalates and the disease progresses, the parent experiences frightening panic about losing the loved child to the insanity of the disease. In the face of this love and care for the child, coupled with the inability to make a dent in the problem, the parent denies the fact of the disease and the drug-use/eating behavior as a defense against the awful reality that the child may be lost forever. Second, an out-of-control child is a living comment on the self-esteem and competence of the parent. After all, anyone with male or female equipment who could have a child, “should be able to manage that child just as one’s parents managed them.” This frightening blow to self-worth, which continues to be acted out day by day in the home and family, is the second reason for denial. The acting-out symptoms are frightening, and the parents’ failure to manage the kid feels like parental inadequacy. Third, facing the fact of an out-of-control child and a potential chemical dependency or eating disorder disease would require treatment, and treatment would require absence of the kid from school, church/synagogue, and family activities. This absence, in turn, signals to important adults in the life of the parents the fact that they have a kid in trouble and have failed as
Many agencies and professionals expect parents to break their own denial in their troubled family situation, in isolation from support and help. This expectation of parents to handle it on their own is the reason why many parents have sought the help of ToughLove, Families Anonymous, and AI-Anon as a way to find out that they are not to blame, that they are okay, and that there is a way to rescue their child from total loss. The first important step in breaking denial is support and identification for the parent. Parents experience most agency contacts as implicit or explicit condemnation of their parenting, “Aha, now how have you screwed up with your kid?” We have pursued an approach that gives an entirely different message, “We understand! We have been through it too. It’s scary and it hurts!” From the first contact with our Intake Coordinator, who is always a mother who has been through it herself, to a visit at an Open Meeting where the prospective parent has a chance to meet other parents and listen to Alcoholics Anonymous/ Overeaters Anonymous type introductions by young people who are very similar to their child, they are offered warm support, understanding, and noncondemnation. They have a chance to identify, to see themselves in the parents and their child in the kids, discovering that they are not alone. Parents are encouraged to get to the bottom of their kid’s problem. They are not initially educated or persuaded that it is drug and alcohol dependence or an eating disorder. Rather, they are given the opportunity to discover the nature of the problem and then to be in charge of decisions about their child’s recovery. They are simply offered help through an assessment to get beyond the blind spots in a parent’s view of the child to real hard data that they can use to solve the problem. The diagnostic assessment is designed to discover information and share it with parents so that they can reach their own conclusion that the problem is severe enough to require help and to understand what kind of help is necessary. Sixty-five percent of the families, who visit the KIDS program and seek an assessment, believe their child has a psychiatric or behavior problem, but 85Vo of the patients in full-time treatment are diag-
KIDS ofNorth Jersey nosed as chemically dependent. The diagnostic assessment process assists the new parents in facing the kid’s problem and in giving it a proper name, drug dependence or an eating disorder. This process uses professional help to get down to the bottom line about a kid’s problem, with support by nondenying parents who help with the assessment process. By giving the parents accurate information about their child’s problem, this process empowers the parents to take first steps toward a solution and recovery. By empowering the parents to act, the assessment breaks the family stalemate, and it initiates parent recovery. Levels in Breaking Denial Parents minimize the behaviors of the kid. They tend to explain it as the “teenies,” that is, normal adolescent rebellious behavior. As they start to face the problem, parents use “do-it-yourself family approaches,” including loving care or strict supervision and discipline. When these approaches fail and a series of crises create pain in the family, parents are forced to admit the uncontrollable problem of the kid and seek outside help. The first level in the process of breaking denial is a parent saying, “My kid has a bad problem, and we need outside help.” The second level is to see the problem for what it is and to utter its name, drug dependence, chemical dependency, alcoholism, overeating, anorexia nervosa, bulimia, or other compulsive behaviors. Often, parents avoid facing the real problem. They would prefer their child to have a “psychiatric problem” because that is illness and not the family’s fault. Reaching the level of calling the kid’s problem.by its actual name is progress in breaking denial. The third level involves understanding it as a disease acquired by the child through use of the substances or unhealthful food practices that passed the point of no return. This third level of understanding the disease assists the parents in getting through the guilt of parental failure about the child’s problem. Mandatory new parent orientation sessions are designed to assist the new parents to get in touch with and share their feelings about their child having a problem and having to be’in treatment. The presentation of the four-stage disease concept (Newton, M. [1981]. Gone way down: Teenage drug-use is a disease. Tampa, FL: American Studies Press) gives the parents a tool to assess the seriousness of their child’s disease, understand its nature, and begin to take themselves off the hook. Accepting Co-dependency Facing the child’s disease, naming it, accepting it, and understanding it are only the beginning of breaking denial, The deeper level of denial involves the family’s re-
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lationship to the disease. Parents can accept parental failure, incompetence, and guilt. Parents even fight each other over who is most at fault. Parents, however, avoid accepting their own co-dependency disease. We deliberately take parents off the hook and put the total responsibility on the patient for the decision to use substances and the loss of control. However, we turn around and put parents and siblings back on the hook with the concept of a reactive disease. “How can you live with a kid doing this crazy stuff and not get crazy yourself trying to cope with it, keep some kind of self-esteem and stay alive? n The concept of reactive disease allows parents to stop the blaming game that most professionals place on families about kid problems, yet at the same time it allows them to face their own habitual and diseased behavior in relationship to a dependent person. We introduce families to this concept in the new parent orientation sessions using a modified version of the family roles as outlined by Sharon Wegscheider in Family trap and Another chance. The roles are Compulsive Dependent Person, Enabler, and Passive Adult for parents and Compulsive Dependent Person, Hero, Scapegoat, Lost Child, Second User, and Mascot for kids. The Compulsive Dependent Person is the first person to bring an addictive disease into the family. It may be either a parent or a child. The Enabler is the adult whose primary role is cleaning up the messes of the Compulsive Dependent Person, either as a parent or spouse. By cleaning up the messes, the Enabler keeps the Compulsive Dependent Person from experiencing the consequences of his or her disease. Another adult role is the Passive Adult, which is characteristically a parent role with a Compulsive Dependent kid. This parent avoids the problem of the Compulsive Dependent kid by work, extracurricular activities, travel, or withdrawal within the home. The family Hero is a super successful kid who attempts to deny the problem of the Compulsive Dependent Person by becoming a super achiever outside the home. Because this achievement is designed to fix the family, it is never enough, for it does not fii the Compulsive Dependent Person, leaving the Hero with a profound sense of inadequacy. The Scapegoat is another type of child who decides not to compete with the Hero for positive attention but copies the Compulsive Dependent Person seeking negative attention by acting out. After all, negative attention is better than no attention at all. The Lost Child, facing all of the compulsive activity in the family, elects to withdraw into the bedroom and into self to avoid the hassle and the “noise” of the troubled family. The Second User is a role we have added to the list. The Second User plays “good kid” and “mother’s helper,” sympathizing with the parent about the Compulsive Dependent kid. This kid focuses attention on the troubled kid in order to hide his or her own involvement with drug use. The Mascot is usually the youngest child in the family who is “oversensitive” to
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stress, disturbance, and conflict in the family. This kid diffuses conflict by clowning, being cute, and joking. Individual acceptance by each parent and sibling of their co-dependency disease is a fundamental part of recovery. Until they accept self-responsibility for the disease and begin to use the Steps of Al-Anon as tools for change and recovery, they will continue to contribute to the child’s disease and to live unhealthily in terms of their own guilt and defensiveness. Family recovery is designed, not only to contribute to the recovery of the child, but to heal the wounds family members have sustained living in a diseased household. Finally, family recovery helps each family member develop health, which permits them to not only enjoy life, but to pass on healthy living to new generations. From Denial to Acceptance Early movement in family therapy can be described in the same concept as First Step work by the patient. The First Step of Alcoholics Anonymous, Overeaters Anonymous, and Al-Anon involves the admission of “powerlessness” over the primary problem, alcohol, food, or the addicted person. For family members, it involves admission of their “powerlessness” over the addicted person and how that “powerlessness” has “made their lives unmanageable.” Families enter in denial, which is also defiance, that is, refusal to face and name the disease. Entry into treatment represents movement from defiance to compliance. “There’s a problem. You say I have to participate in treatment, so I will, just to fix my child.” As the early process of treatment unfolds, family members see the nature of the disease and begin to understand their own diseased behavior as co-dependency, and they move into acceptance. Acceptance is mental, affective, and behavioral acceptance of their own disease as a result of chemical dependency in the family. As one parent stated, “In the beginning I came to meetings for my child, then I started coming for myself.” FAMILY MANIPULATIVE STYLE Another issue comes up during the early days of family treatment. Users con and manipulate to get their way and continue their compulsion. Family members manipulate to try to control the behavior of the user and to make family life more tolerable. Coming into treatment, the nonhonest, nonblunt, manipulative style asserts itself. Parents or siblings do not believe that we are really serious about required participation in treatment. They test the system. One or more family members fail to show up for a required Open Meeting and group session. A parent refuses to write nightly Moral Inventories, a required therapeutic nightly exercise. We have learned to provoke an immediate crisis, demanding that the present family members find and de-
liver the absent family members immediately, or they can take the primary patient and leave treatment that night. In the overwhelming majority of cases, it results in a therapeutic event in which family members face manipulation and dishonesty and agree to follow the commitment they have made pro forma during the admission process. Parents attempt to control the progress of their kid by inappropriately contacting staff members with manipulative issues concerning their child. In Open Meetings, these same parents and siblings attempt to manipulate the progress of their child by lecturing, by threats, and by promises. Often, another family crisis occurs involving a second child with an addictive or compulsive disease. This individual, usually in a Second User role, is discovered during a sibling interview related to the family’s admission to the program. If a diagnostic assessment is indicated from the data on the sibling interview, the family is required to have the second child assessed. At this point, the second reason for parent denial kicks in. “Any family can have one bad kid as long as the other kids are okay.” If a second kid has a problem, then parents see this problem child as an indictment of their parenting. The work to move parents from denial to acceptance with a willingness to seek help for the second child is a sensitive therapeutic task. Failure to follow through on the second compulsive child sabotages treatment of the primary patient and the entire family. Guilt and Shame Family members enter treatment with enormous amounts of guilt and shame based on personal and family identity. The guilt develops as a result of deliberate activities on the part of the primary patient blaming the family and manipulating the use of guilt as a lever for getting away with things. Family members become increasingly desperate to survive in the troubled environment, and in reactive disease, they make mistakes dealing with the patient and each other. Continued attempts to change, improve, and make the family work always fail. These failures develop into a deep shame base for the family as a group and for each individual. Guilt and shame increasingly isolate family members from the extended family and the community, reinforcing shame. The foundation for dealing with guilt and shame is breaking denial about the patient and accepting the fact of the chemical dependency/eating disorder disease as a cause for the troubled behavior. Equally important is the growing acceptance of co-dependency as a reason for their own behavior in an impossible situation with the individual who is addicted. This foundation, which is reaffirmed by staff, by the patient as he or she enters early recovery, and by family peers in the program, assists the family in facing guilt and dealing with shame. Peer support on the part of other fam-
KIDS of North Jersey
ilies at various stages in the continuum of recovery is critically important to families during the early and later stages of treatment. According to one parent, “Other parents get up in meetings and relate their experiences. I find myself saying, “that’s exactly the way I feel. Hey, I did that too!” UNHOOK FROM USER Family members, particularly parents, are overenmeshed with young people with drug dependency and eating disorders. As normal parents, they exercise care and love through taking responsibility for the problems of the young person. Parenting is fixing problems and cleaning up the messes of their kids. The begimring of health is simply to unhook from the young person. KIDS accomplishes this through taking the young person out of the family system and sending the young person home with an oldcomer to live at that young person’s house for a period of time. The physical separation itself produces relief from the incessant controlling and fixing activity of the family. Long before mental and emotional unhooking occurs, the simple distance during the early weeks of treatment produces a relaxation from “walking on eggs” by the entire family. As the family discovers that the user is not going to create 290 a.m. crises and that they can come home without explosions everyday, the feeling of relief steals over the family. The relief is so pleasant in contrast to the anxious, panicky feeling of waiting for “the other shoe to drop” that the family begins to want more in terms of relief and unhooking from enmeshment with the user. This separation creates distance and a cooling off period to allow everybody to take responsibility for themselves, both the compulsive dependent person and the other family members. The physical absence of the addicted individual at fust stabilizes the family where cahn routine and order can replace the crisis-oriented confusion that existed while the patient is the center of the family’s system. Calm and order represented by the absence of the patient in time provokes destabilization. This destabilization has to do with the absence of crisis, that is, the absence of compelling activity around the person with the addiction. New parent “raps,“’ both the content and the affective process, help parents surface their own sense of responsibility for the “failure” of the child and the resulting guilt. The raps help parents understand that the “druggie” or “foodie” is responsible for his or her own choices that led to loss of control. That person also must be responsible for his or her sobriety/abstinence if recovery is to be achieved. The enmeshment also involves incessant activity attempting to control the dependent person or to clean
‘Group Therapy Sessions.
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up the results of his or her disease. This second activity is called enabling. The program is designed to physically stop this activity, to create sufficient distance that the family is suddenly without a dependent person at the center of family activity. The simple absence of the dependent person and the activities of the program, which involve the family members in reframing and reunderstanding what has gone on, stops the incessant activity and creates a void in the family system that is filled by activities related to recovery. This unhooking from incessant activity literally provokes steps toward recovery. At Open Meetings, the Newcomer patient gives Alcoholics Anonymous type introductions, and then, the parents respond later in the meeting. This process begins to reformat family communication. It eliminates the arguing and walking-away dance of codependency. The ritual “love you” response at the end of parent communication to the child and child communication to the parent as well as hugging at the beginning and end of family “talks” not only breaks up prior forms of communication but begins to suggest new possibilities for family communication in the future. Attempt at Control On First Phase, with the patient living away from home, parents and siblings are no longer involved in a day-today basis with incessant acting out and problems. Having unhooked because separated and distant, parents now begin to rehook to the patient related to the treatment process. They attempt to literally control the progress of the patient in facing up to the disease and behaving appropriately in the treatment program. One form of manipulative control is nonverbal communication by parents to their kid in group. Usually, the Enabler or enmeshed parent tries to communicate nonverbally with eyes and lips in the meeting room with the primary patient. Staff and other parents are alert to this sabotaging nonverbal communication and stop it. The failure of this attempt at control is used therapeutically to help parents and siblings accept their “powerlessness” over the dependent person. This acceptance of the First Step of Al-Anon, at a deep internalized level, is the final unhooking that opens the door to co-dependent recovery. Parent Subsystem Boundaries Parents going through the new parent orientation groups, working on acceptance of the disease and backing away from control of the patient are assisted in developing a stronger boundary between the parent subsystem of the family and the child subsystem. Parents discuss with each other and other parents the specific behaviors and problems of their child, they sort out together their parenting through communication in Open Meetings and in “talk” with their child after
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meetings. Siblings are also involved in their raps and with talk after Open Meetings. These activities are designed therapeutically to strengthen the parent system as separate from and in charge of not only the patient child, but other children in the family. A program “no travel” rule during this period of treatment encourages parents to rebuild their relationship with each other as they go through the group sessions together and process their experiences with their compulsive child before treatment. The group sessions and the talk with their child after Open Meeting are designed to reinforce a reconstructed parent relationship. Single parents reinforce the parent subsystem by building relationships with other program parents.
to issues related to his compulsive disease. Later in the meeting, family members speak about their issues and feelings across the room to the patient whose only response is “Love you, Dad!, Love you, Mom!” Staff members, parents, peers, and sibling peers work with family members to tell incidents in this microphone talk without blame and to share their feelings about the incident. This period of separated communication facilitates getting issues out in the open and dealing with feelings that were repressed because of fear of acting out. As shock wave after shock wave subside as a result of emotion-triggering disclosure, it becomes possible to deal with the incidents and resentments in new ways. The public disclosure of problems and behavior is the final blow to family denial.
“Learning About Myself” During the controlled phase of parent activity in early treatment, parents fail to hear other parents talking about themselves and co-dependency. Just as Al-Anon insists that people unhook from the drunk and focus on themselves, the KIDS program pushes parents and siblings to fill the void in their lives created by the absence of the user to look at themselves. In the words of one parent, “I have learned a lot about myself in the beginning part of the program; I’m still learning everyday.” Unhooking allows family members to look at themselves to learn, to grown, to heal, and to recover. A strong parent and sibling peer group is the necessary medium through which newer family members look at themselves, learn and change. RESOLVE ISSUES AND RESENTMENTS While parents and siblings are involved in the structure of unhooking from the user, a second movement of recovery begins. This movement involves resolving the numerous issues that have occurred because of the patient’s compulsive disease. These issues involve lying, stealing, acting out, violence, embarrassment, and involvement with the criminal justice system, all of which have been deliberately clouded by the user through conning. Other family members hide issues, attempting, out of care, to help the user. Some issues are family secrets, kept by some members from others. When the family arrives at treatment, any issue that comes up triggers a litany or laundry list of past “bitches” and objections with a “there you go again.” This family dance of blaming and closing off is the dominant form of communication in the family system when treatment begins. Rebuilding the family relationship requires two activities. Issues that are outstanding have to be resolved and a new style of communication of dealing with problems and resolving conflicts in the family must be developed. The KIDS program is designed to facilitate resolution of issues. At the first Open Meetings, the patient gives the first of three introductions owning up
Honest Communication The communication techniques of the program block either the patient’s or family member’s chance to react defensively, which would, in turn, trigger the family dance. The family members learn to communicate incidents in factual ways with feelings. Pressure is on the patient for increasing honesty in which misdeeds related to the compulsive disease are disclosed without justification or blame to anyone else. The patient is in fact owning responsibility for the behaviors related to the disease. As this communication style develops, the family dance stops, the intensity of anger and resentment is deflated and there is relief because confused incidents are now cleared up with responsibility placed where it belongs. Parents and siblings have the opportunity in family raps to deal with secrets they keep from each other and the resentment that comes from conflicts over how to deal with the primary patient. Family communication continues at home moving to a more blunt, honest, and self-responsible form of communication. As family health and communication style grow, the family moves into a new stage of communication. Family Talk-Letting
the Past Go
The patients, now in touch with feelings about past behaviors and remorseful about harm done to the family, and family members who have ceased to blame or control the patient through lecture or communication, enter a new stage. The entire family has a IO-min private talk session after each Open Meeting that focuses on resolving past issues. Now, the patient is disclosing the behaviors and the harm done with feelings and making amends to the family. The family members learn not to blame but to share their feelings about the incident to make the incident emotionally whole as a communication issue between patient and family. As these are completed, both the patient and the family are able to let go of the incident, give up the resent-
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ments involved, and literally let incident by incident float away as a matter of the past and the disease. The present is free of intrusion of the diseased past. There are no family secrets. The family can get on with living. “coining
Home”-
A New Start on Family Living
As the patient clears up, through disclosure, his entire past, and as the family members share their feelings of resentment, anger, hurt, and embarrassment, as incidents are completed, closed, and let go, the family is now ready to be reunited on the basis of mutually supported recovery for all. The magic moment comes when the young person earns the right to return home, screams out across the room in the Open Meeting“Coming Home!” then runs and jumps into the family’s arms. This ritual of the returning prodigal sets up the hope of reestablishing the family relationship on a new basis. The new communication style learned during the First Phase of Treatment carries over into living at home together and learning how to resolve conflicts by nonblaming, admission of responsibility, sharing feelings about incidents, and finding solutions. The program staff assists in telephone therapy and in family therapy sessions helping with difficult issues that arise. The patient now makes amends, not only by verbally owning the behavior and saying “sorry”, but by making up to the family for the months and years of harm under the influence of the disease.
triggers memory of incidents related to the compulsive disease and the family’s reaction to it. Having raised the issue, the family continues by dealing with the issue in the framework of the treatment program. The Real Work on Family &gins Usually, the first week at home is “miracle week” where everything is wonderful, new, and different. Then, the miracle ends and some of the old conflicts about living together as a family reemerge, not only between the patient and family members, but between other family members. At that point, family therapy and hard work on family relationships begins. Family recovery, giving up roles, and ending inappropriate alliances occurs and goes on throughout the program. About a week after coming home, the patient begins to bring Newcomers home. Newcomers are other patients who are still working on the First Phase of treatment. Most families would “blow away” the program rules and expectations for family behavior at home after about 1 week. The presence of one or two strangers in the household encourages compliance to keep up “family face” As time progresses, compliance slides into acceptance because the new behavior required by the program is more satisfying than the family’s previous co-dependency behavior. The Couple Relationship
Parent/Sibling Owning Up Parent guilt is helped by the owning up of responsibility for past behaviors by the compulsive patient. Parents now know that it is not their fault but the kid’s fault because he or she has owned it. However, there remain those incidents where parents have acted excessively toward the patient in the past, toward a sibling out of frustration with the patient, or toward their spouse because of an alliance with the troubled kid. The patient, identified as the problem kid in the family, owning up to wrongs and making amends, triggers a process of self-examination and ownership of wrongs on the part of other family members. Self-responsibility for wrongs and amends becomes the way out of guilt and into hopeful and healthful living for all members of the family. The Moral Inventory process, which involves nightly written therapeutic homework for primary patients, parents, and siblings, assists in the owning up process. The beginning of the Moral Inventory involves a “challenge” in which each individual writes about a problem or character defect related to the compulsive disease or the family disease and then uses the Steps to deal with the problem. The Fifth Step requires “admitting up to another person” the nature of the problem and seeking advice and help. This process
Critical for family member’s recovery is the resolution of resentments and issues not only between the patient and the family member, but between parents and other siblings and between the two parents, who are often manipulated by the patient. This disloyalty to the couple relationship in dealing with the troubled kid is often a major problem. Much work is necessary in helping the couple react as a couple and subsystem as opposed to having primary alliances with the troubled kid. This work involves dealing as a couple not only with the child, but also with other children in the family. Second, a new style of communication must be developed that involves blunt, self-responsible communication, no blaming other people, communicating feelings related to behaviors and issues, and learning how to resolve conflict. It takes time to develop a new style of blunt, nonblaming communication. The program encourages practice, not only at home and in raps, but also in family systems therapy sessions. Parents are encouraged to spend time with each other, separate and apart from activities related to the patient, their other children, and treatment activities. This period involves rediscovery of their primary relationship as a couple. Single parents accomplish this task by working on their adult life apart from the children.
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Resolving Parent’s Issues Finally, as the immediate issues and resentments regarding the current family relationship and addictive ilhress and co-dependency issues are resolved, parents, in particuhu, are invited to deal with unresolved issues of their own lives. These issues are of two kinds. First, there are the unresolved issues from the parent’s own family of origin. Second, there are unresolved issues in their own adult lives, either individually or as a couple. Work is done on these issues by family systems therapy, in parent group sessions, and during a Parent Weekend. A Parent Weekend is a special intensive therapy device in which parents spend 2 days (Saturday and Sunday) in the facility following the same group schedule as the adolescent patients in a separate part of the facility. These sessions are directed exclusively to family of origin and parent adult issues and in no way involve the troubled kid. Each parent is required to be involved in one parent weekend sometime after his or her patient kid has entered Second Phase. Dealing With Other Family Problems Clinical staff members at the program have learned to maintain an ongoing list of families with another member who has a compulsive disease. These problems may include habitual lying, overeating, unresolved rage, adult parent alcoholism, sexual disloyalty to a partner, and others. In the course of family treatment, these other compulsive diseases surface or are recognized by family members. We have learned over time that these other major family member problems must be dealt with and resolved for the primary patient to maintain ongoing recovery. If another major disease problem remains, eventually the family will close ranks to deny the fact of that problem, maintain that person’s illness, and resume the bad communication and bad feelings. As the guilt and shame reemerges, the primary patient will almost always decide, “This feels bad anyway, why keep working my sobriety/abstinence program?” The family returns to over emeshment, enabling, and pathologic denial. As a Clinical Staff, we have learned to make every effort and use every device to assist other troubled family members in seeking help for their problems. We use the intervention technique in cases where the individual needs residential treatment to force them into treatment at another appropriate treatment program. The intervention is timed at a point when there is sufficient recovery on the part of the primary patient and other family members that the family will fight to maintain health and ongoing recovery.
DEVELOP DETACHMENT Having unhooked from the user and resolved issues and resentments from the period of active compulsive
behavior, the family is free to move into the future. The future requires a new stance with reference to self and others in the family relationship. This stance is called “detachment. n Detachment means dealing with each other as autonomous, adult human beings rather than extensions of self. Autonomy as a human being is a status where a person stands on his own and accepts the responsibility for self and actions including any consequences. Detachment or autonomy involves being in touch with oneself as a person separate from roles in the relationship. A mother or father operates as a human being outside of a stereotyped role such as “prime enabler” or “passive adult.” In addition to freedom from the compulsive roles of the co-dependent family, the mother and father are also individual persons separate from their role as parent or spouse. Recovery and health means the freedom to be oneself separate from the expectations of others in the family, to refuse to conform to roles when others in moments of insecurity demand sick behavior from the individual. In addition, detachment and autonomy mean treating other members of the family, including the compulsive patient, as individual persons, free of roles and responsible for one’s own behavior. Changing attitude and behavior toward the compulsive patient is the hardest part of the treatment process because each family member’s co-dependency role has been based on treating the patient as an extension of themselves in terms of control, avoidance, and stereotyped reaction. Detachment and autonomy are worked on by patients in group sessions and by family members in parent and sibling group sessions. Family conferences and, in particular, Parent Weekend are vehicles through which individuals move from role identity to autonomy and individualization in recovery. Enabling and Autonomy Detachment does not mean noninvolvement or no care. Detachment means that acts of care from a parent toward a kid or from a brother toward a sister are free choices or gifts of love. Detachment also means allowing people to experience and be responsible for the consequences of their actions. In the case of a parent in the position of authority, it means ensuring that the individual experience and be responsible for consequences of his behavior. Protecting people from consequences is called enabling. Enabling is diseased behavior in compulsive dependent families. Ensuring that individuals are treated as autonomous persons who are responsible for their behavior and, in turn, the consequences of misbehavior is healthy recovery behavior. Detachment is also tough love. Treating people as responsible human beings is not meanness, but true love because it involves respect and trust in their ability to behave responsibly.
KIDS of North Jersey
Relapse and Progress During the process of developing detachment, there will be moments in which environmental cues, fatigue, and stress trigger return to co-dependency role behavior with the ensuing feeling of guilt and shame. These moments of relapse become part of the content and process of recovery. The Alcoholics Anonymous and Al-Anon slogan, “Progress, not perfection,” is appropriate here. Early in treatment, individual family members fight to hold on to co-dependency role behavior as defenses against threat and shame. As peer pressure in the program and staff action force people to increasing self-responsibility and autonomy, the changing feelings that go with competent autonomy become intrinsically reinforcing. Recovery feels better than sickness. Crisis and Surrender Usually, during the later part of detachment development, a new crisis arises. The primary patient is doing well with the family, school, and self-control. Family members are doing well with autonomy and healthy behavior. At that point, both the patient and family members decide that they are cured, and there is no need for continuing treatment or the discipline of the recovery regimen. They deny their First Step. As old problems, roles, and compulsive behavior emerge, a crisis occurs. Usually, the patient in the family experiences some kind of setback losing privileges/responsibilities and being taken out of school. The family decides that this in unnecessary because the patient seems to be doing fine. This setback may cause problems for planned social activities of parents or siblings such as weddings or vacations. The crisis may involve the family deciding that program rules are unnecessary because the kid is fixed. These events inevitably lead to a serious crisis on the part of the patient who rejects the fact of the disease and may runaway or attempt to return to social use. The counselor, at this point, midwifes a deflation of ego around the crisis, which leads to a new level of acceptance of the chronic disease called “surrender.” The crisis, with the help of therapeutic interpretation, “rubs the noses” of family members in the fact of the chronic disease and the abnormality of this family’s continuing life. As the family members face the crisis and remember the nature of the disease, they surrender to the “powerfulness” of addictive disease. Now, humility is characteristic of their cognitive and affective stance toward the disease. A tentative living “one day at a time” is the ongoing lifestyle of both the patient and the co-dependent family members. DEVELOP A PERSONAL HEALTHY LIFESTYLE Having gone through the process of unhooking from the user, resolving issues and resentments that keep
one’s energy focused in the past, and finally developing healthy detachment, the individual family member is ready and hungry to get on with his or her own life. The program assists parents and siblings in developing an individual healthy lifestyle that is satisfying. This recovery lifestyle is designed to cope with tendencies toward co-dependency.
Recovering Lost Dimensions The parent or sibling engages in two major tasks in building a lifestyle. One task involves going back and picking up lost activities or interests that represent major losses in their lives. The lost activity may be replayed as a therapeutic ritual if it, for instance, is a family event from the past. The activity may be the development of a renewed interest in an old hobby, activity, or a different direction in a career.
A Balanced Lifestyle The other task involves inventorying one’s life activities for health and balance. Is the individual involved in satisfying work activity, a constructive family relationship, satisfying friendships, spiritual activity, physical activity, and mental activity? In some cases, the person is involved in all these areas, but in an imbalanced way, with obsessive activity in one area and diminished activity in others. Using the “first things first” slogan, the staff members help the individual prioritize activities in his or her life and develop a more satisfactory balance in his or her lifestyle.
Character Defects Particular emphasis is continuing work on character defects related to the co-dependency disease. The defects may be nonassertiveness, dishonesty, anxiety, avoidance of conflict, laziness, selfishness, “controlling” behavior, and others. The individual develops a program to compensate for and change these character defects using the Steps and other resources. Often, peers in the family treatment program help as higher power resources in dealing with character defects or developing new activities or interests. The principal tool for facing character defects is the Moral Inventory described earlier in this article. Using the Challenge section and the self-help Steps to face a character defect, the individual then sets goals for changes that will eliminate the character defect. Some character defects are positive qualities turned bad. “Stubborn resistance” is the opposite face of “determination.” Many times the quality side of a character defect can be recovered through the Moral Inventory and Step process. Work on character defects is a recovery task that continues beyond treatment.
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Personal Life and the Family Another area of focus is learning how to balance one’s personal interests and individual life with appropriate care and responsibility in the family. Some parents are over involved in family responsibilities and have diminished and unsatisfying personal lives. Other parents are “passive adults” who avoid family responsibility and involvement. The treatment program helps parents develop an appropriate balance between personal life and family involvement. Siblings also work on appropriate family involvement and appropriate life activities outside of the family for their age. Typical of addictive illness families is to be so turned inward, out of shame, that they have inadequate external involvement. Care, responsibility, and help to others is a necessary antidote to the selfishness that is characteristic of co-dependent family members. The program helps family members develop a caring and serving style. Parents and siblings have the opportunity to help others at the program. They are able to share their experience and relate themselves to new families who are going through struggles about having a compulsive dependent child and being in treatment. Parents are asked to host guest families looking at the program for their child, to lead some of the didactic “raps,” and to assist with intakes. Siblings have the opportunity, not only to host new siblings, but also to be actively involved in holiday celebrations for the kids in group and to put on a talent show as a gift to their patient siblings during the Christmas/Hanukkah season. As part of developing a satisfying personal lifestyle, emphasis continues on the fact of co-dependency being a chronic, noncurable disease. Family members learn that their lifestyle must be a continuing health regimen to cope with and produce recovery in the face of their disease. FAMILY REBUILDING The previous sections describe the five movements of recovery for co-dependent family members. The focus has been on the specific cognition, affectation, and behavior of individual parents and siblings. However, each of the five movements has a clear dimension related to the family system itself. Breaking Denial means ending family delusion and secrets. Broken denial moves the family to honest, open, and reality-based communication as a group. The honest communication about the patient, the disease, and the co-dependency disease offers a chance for family members to relate on a real basis with each other. This openness or transparency is the foundation of healthy family relationships. As family members unhook from the user, they become free to have a family life that is noncompulsive and not centered on a troubled person. Unhooking
from the user means giving up co-dependent roles for survival in the family. As the roles are given up, parents and siblings can become individuals and real persons again in how they relate to each other. The family begins to be a system of persons living together rather than a defense system against a problem. Resolving issues and resentments ends a variety of family dances that drone on in a routine way based on historic grievances. As the garbage of past issues is cleared, family members can begin to build relationships with each other in the present as healthy and recovering persons. The family is free to live in the spontaneous present. Detachment means treating each other in the family as autonomous persons with the right to individual opinions, lifestyles, and responsibility. This movement reestablishes the family as a system of autonomous but related and caring persons. Detachment allows families to grow and develop. As each family member develops a personal healthy lifestyle, the family becomes a rich and complex human system with persons sharing their interest in life. The family dimension of a healthy lifestyle involves maintaining family rituals around holidays and occasions and maintaining common processes such as meals, religious activity, and vacations as a group. CONCLUSION The KIDS program has learned that a blunt directive style of therapy is as necessary for the family treatment program as it is for the patient treatment program. Co-dependency, like chemical dependency, produces a manipulative and deceptive defense system that is analogous to a “hall of mirrors” at a carnival. The antidote to confusion in the maze of denial, justification, excuses, and manipulation is a very directive, blunt, and honest style. Co-dependents, like addicted individuals, have a deep base of shame to their disease. Initial treatment involves a message of care. Continuing relapses and crises in the family call for extraordinary care at times when family members give up on the patient and/or themselves. The willingness of staff to be available at night, on weekends, holidays, and not having a 9 to 5 work day are part of a systemic message of care necessary for the recovery of family members. The care also expresses itself in having a “bag of therapeutic tricks” that is used one after another until the particular crisis or problem is solved. Doctrinaire adherence to a particular therapy system gets in the way of caring therapy for shame-based patients. Miller Newton, pm KIDS of North Jersey, Inc. River Edge, New Jersey
Vol. 9,
0740-5472192 S5.00 + .OO
pp. 71-80, 1992
Copyright 0 1992Pergamon Press Ltd.
Printed in the USA. All rights reserved.
IN THE SPOTLIGHT
Living Again Family Treatment at KIDS of North Jersey
RIVEREDGE,
INTRODUCTION
NEW JERSEY
of drugs and alcohol, eating disorders, or compulsive behaviors in the early teens, sees family participation in treatment as necessary to recovery. The immaturity of most patients requires an intensive family support system after treatment until adult maturity is achieved in the mid-20s. The family is a necessary part of this support system and can be helpful only if family recovery is in full bloom. KIDS requires, as the “price of admission” of the primary patient, the involvement of all members of the residential household, including siblings (even siblings who are part-time residents away at college). Also, extended family members such as grandparents who are part of that household are required to participate in treatment. KIDS approaches family treatment from a multifaceted viewpoint. First, the family is part of the system that maintains the addictive disease of the primary patient. In order for the patient to recover, the family connection to the disease must be broken, and a new recovering support system must be developed for the primary patient. Second, each family member has sustained pain, losses, and developmental dysfunction as a result of coping with the threat to personal survival and identity by the acting-out patient. Treatment helps each family member come to terms with the pain and hurt and then to understand his or her participation in the disease. The recovery process also involves repairing dysfunctional thought, feeling, and behavior patterns. Third, treatment helps each family member to accept the disease and to develop a recovery
THE LATE1970s ANDEARLY 1980s brought alcoholism and drug dependence out of the closet and on center stage as respectable diseases and national causes. At the beginning of Alcoholics Anonymous, wives participated in the group meetings with husbands. Later, they held separate meetings in the same facility leading to the founding of Al-Anon. Early treatment programs viewed family members as the enemy because they seemed to behave in ways that sabotaged the recovery of the alcoholic. Later, treatment programs included family members, usually in a special weekend format helping them understand the patient’s disease and what they could do to support sobriety. More recently, the “adult children of alcoholics” movement has focused on the co-dependency disease as a separate issue from treatment of the primary patient. Family systems therapy has blamed the family and has seen the patient as simply a symptom bearer and scapegoat. Each of these approaches has contributed some important insights into the relationship of family members to chemical dependency and recovery, but at the same time, each has remained partial and incomplete as a treatment strategy. KIDS, as a treatment center dealing with adolescents and young adults, all of whom began their use Requests for reprints should be addressed to Dr. Miller Newton, KIDS of North Jersey, Inc., PO Box 2455, &caucus, NJ 07094. 71
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72 lifestyle that brings with it serenity in the here and now. Recovery also stops the transmission of the disease down the family line. This article outlines the conceptual approach of myself and the KIDS program to family treatment. We see recovery as an ongoing process involving five movements. The first movement is to Break Denial; the second is to Unhook From User; the third is to Resolve Issues and Resentments; the fourth is to Develop Detachment, and the fifth is to Develop a Personal Healthful Lifestyle. These movements feed into each other and overlap somewhat, but together they constitute the road from family disease to recovery.
parents. Grandparents “clucking,” friends with raised eyebrows, competitive siblings in the parents’ family of origin system all exist as a threat to a parent who feels defensive and incompetent in the face of a troubled kid. Fourth, if the parent faces and deals with the addiction, it may cost losses to other family members. A sibling may lose friends because of his or her parents’ fear and have to give up activities because of family treatment with the primary patient. Parents may lose promotions, opportunities, and voluntary activities because of family treatment requirements. Help in Breaking Denial
BREAK DENIAL Many professionals and treatment agencies see parent denial about addiction in kids as lack of care, as stupidity, or worse. This viewpoint about parent denial opens the therapeutic relationship as a “we-they” relationship, with parents in the scapegoated enemy role. Having gone through the course of chemical dependency with my own son, I have come to view parent denial in a more positive light. Parent Denial First and foremost, parent denial is about love. Drugs and drug dependence, as well as the ensuing acting out behavior, is very frightening for a parent who cares about his or her child. The parent attacks the problem using the parenting skills learned from his own parents only to find that these fail. As the behavior of the child escalates and the disease progresses, the parent experiences frightening panic about losing the loved child to the insanity of the disease. In the face of this love and care for the child, coupled with the inability to make a dent in the problem, the parent denies the fact of the disease and the drug-use/eating behavior as a defense against the awful reality that the child may be lost forever. Second, an out-of-control child is a living comment on the self-esteem and competence of the parent. After all, anyone with male or female equipment who could have a child, “should be able to manage that child just as one’s parents managed them.” This frightening blow to self-worth, which continues to be acted out day by day in the home and family, is the second reason for denial. The acting-out symptoms are frightening, and the parents’ failure to manage the kid feels like parental inadequacy. Third, facing the fact of an out-of-control child and a potential chemical dependency or eating disorder disease would require treatment, and treatment would require absence of the kid from school, church/synagogue, and family activities. This absence, in turn, signals to important adults in the life of the parents the fact that they have a kid in trouble and have failed as
Many agencies and professionals expect parents to break their own denial in their troubled family situation, in isolation from support and help. This expectation of parents to handle it on their own is the reason why many parents have sought the help of ToughLove, Families Anonymous, and AI-Anon as a way to find out that they are not to blame, that they are okay, and that there is a way to rescue their child from total loss. The first important step in breaking denial is support and identification for the parent. Parents experience most agency contacts as implicit or explicit condemnation of their parenting, “Aha, now how have you screwed up with your kid?” We have pursued an approach that gives an entirely different message, “We understand! We have been through it too. It’s scary and it hurts!” From the first contact with our Intake Coordinator, who is always a mother who has been through it herself, to a visit at an Open Meeting where the prospective parent has a chance to meet other parents and listen to Alcoholics Anonymous/ Overeaters Anonymous type introductions by young people who are very similar to their child, they are offered warm support, understanding, and noncondemnation. They have a chance to identify, to see themselves in the parents and their child in the kids, discovering that they are not alone. Parents are encouraged to get to the bottom of their kid’s problem. They are not initially educated or persuaded that it is drug and alcohol dependence or an eating disorder. Rather, they are given the opportunity to discover the nature of the problem and then to be in charge of decisions about their child’s recovery. They are simply offered help through an assessment to get beyond the blind spots in a parent’s view of the child to real hard data that they can use to solve the problem. The diagnostic assessment is designed to discover information and share it with parents so that they can reach their own conclusion that the problem is severe enough to require help and to understand what kind of help is necessary. Sixty-five percent of the families, who visit the KIDS program and seek an assessment, believe their child has a psychiatric or behavior problem, but 85Vo of the patients in full-time treatment are diag-
KIDS ofNorth Jersey nosed as chemically dependent. The diagnostic assessment process assists the new parents in facing the kid’s problem and in giving it a proper name, drug dependence or an eating disorder. This process uses professional help to get down to the bottom line about a kid’s problem, with support by nondenying parents who help with the assessment process. By giving the parents accurate information about their child’s problem, this process empowers the parents to take first steps toward a solution and recovery. By empowering the parents to act, the assessment breaks the family stalemate, and it initiates parent recovery. Levels in Breaking Denial Parents minimize the behaviors of the kid. They tend to explain it as the “teenies,” that is, normal adolescent rebellious behavior. As they start to face the problem, parents use “do-it-yourself family approaches,” including loving care or strict supervision and discipline. When these approaches fail and a series of crises create pain in the family, parents are forced to admit the uncontrollable problem of the kid and seek outside help. The first level in the process of breaking denial is a parent saying, “My kid has a bad problem, and we need outside help.” The second level is to see the problem for what it is and to utter its name, drug dependence, chemical dependency, alcoholism, overeating, anorexia nervosa, bulimia, or other compulsive behaviors. Often, parents avoid facing the real problem. They would prefer their child to have a “psychiatric problem” because that is illness and not the family’s fault. Reaching the level of calling the kid’s problem.by its actual name is progress in breaking denial. The third level involves understanding it as a disease acquired by the child through use of the substances or unhealthful food practices that passed the point of no return. This third level of understanding the disease assists the parents in getting through the guilt of parental failure about the child’s problem. Mandatory new parent orientation sessions are designed to assist the new parents to get in touch with and share their feelings about their child having a problem and having to be’in treatment. The presentation of the four-stage disease concept (Newton, M. [1981]. Gone way down: Teenage drug-use is a disease. Tampa, FL: American Studies Press) gives the parents a tool to assess the seriousness of their child’s disease, understand its nature, and begin to take themselves off the hook. Accepting Co-dependency Facing the child’s disease, naming it, accepting it, and understanding it are only the beginning of breaking denial, The deeper level of denial involves the family’s re-
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lationship to the disease. Parents can accept parental failure, incompetence, and guilt. Parents even fight each other over who is most at fault. Parents, however, avoid accepting their own co-dependency disease. We deliberately take parents off the hook and put the total responsibility on the patient for the decision to use substances and the loss of control. However, we turn around and put parents and siblings back on the hook with the concept of a reactive disease. “How can you live with a kid doing this crazy stuff and not get crazy yourself trying to cope with it, keep some kind of self-esteem and stay alive? n The concept of reactive disease allows parents to stop the blaming game that most professionals place on families about kid problems, yet at the same time it allows them to face their own habitual and diseased behavior in relationship to a dependent person. We introduce families to this concept in the new parent orientation sessions using a modified version of the family roles as outlined by Sharon Wegscheider in Family trap and Another chance. The roles are Compulsive Dependent Person, Enabler, and Passive Adult for parents and Compulsive Dependent Person, Hero, Scapegoat, Lost Child, Second User, and Mascot for kids. The Compulsive Dependent Person is the first person to bring an addictive disease into the family. It may be either a parent or a child. The Enabler is the adult whose primary role is cleaning up the messes of the Compulsive Dependent Person, either as a parent or spouse. By cleaning up the messes, the Enabler keeps the Compulsive Dependent Person from experiencing the consequences of his or her disease. Another adult role is the Passive Adult, which is characteristically a parent role with a Compulsive Dependent kid. This parent avoids the problem of the Compulsive Dependent kid by work, extracurricular activities, travel, or withdrawal within the home. The family Hero is a super successful kid who attempts to deny the problem of the Compulsive Dependent Person by becoming a super achiever outside the home. Because this achievement is designed to fix the family, it is never enough, for it does not fii the Compulsive Dependent Person, leaving the Hero with a profound sense of inadequacy. The Scapegoat is another type of child who decides not to compete with the Hero for positive attention but copies the Compulsive Dependent Person seeking negative attention by acting out. After all, negative attention is better than no attention at all. The Lost Child, facing all of the compulsive activity in the family, elects to withdraw into the bedroom and into self to avoid the hassle and the “noise” of the troubled family. The Second User is a role we have added to the list. The Second User plays “good kid” and “mother’s helper,” sympathizing with the parent about the Compulsive Dependent kid. This kid focuses attention on the troubled kid in order to hide his or her own involvement with drug use. The Mascot is usually the youngest child in the family who is “oversensitive” to
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stress, disturbance, and conflict in the family. This kid diffuses conflict by clowning, being cute, and joking. Individual acceptance by each parent and sibling of their co-dependency disease is a fundamental part of recovery. Until they accept self-responsibility for the disease and begin to use the Steps of Al-Anon as tools for change and recovery, they will continue to contribute to the child’s disease and to live unhealthily in terms of their own guilt and defensiveness. Family recovery is designed, not only to contribute to the recovery of the child, but to heal the wounds family members have sustained living in a diseased household. Finally, family recovery helps each family member develop health, which permits them to not only enjoy life, but to pass on healthy living to new generations. From Denial to Acceptance Early movement in family therapy can be described in the same concept as First Step work by the patient. The First Step of Alcoholics Anonymous, Overeaters Anonymous, and Al-Anon involves the admission of “powerlessness” over the primary problem, alcohol, food, or the addicted person. For family members, it involves admission of their “powerlessness” over the addicted person and how that “powerlessness” has “made their lives unmanageable.” Families enter in denial, which is also defiance, that is, refusal to face and name the disease. Entry into treatment represents movement from defiance to compliance. “There’s a problem. You say I have to participate in treatment, so I will, just to fix my child.” As the early process of treatment unfolds, family members see the nature of the disease and begin to understand their own diseased behavior as co-dependency, and they move into acceptance. Acceptance is mental, affective, and behavioral acceptance of their own disease as a result of chemical dependency in the family. As one parent stated, “In the beginning I came to meetings for my child, then I started coming for myself.” FAMILY MANIPULATIVE STYLE Another issue comes up during the early days of family treatment. Users con and manipulate to get their way and continue their compulsion. Family members manipulate to try to control the behavior of the user and to make family life more tolerable. Coming into treatment, the nonhonest, nonblunt, manipulative style asserts itself. Parents or siblings do not believe that we are really serious about required participation in treatment. They test the system. One or more family members fail to show up for a required Open Meeting and group session. A parent refuses to write nightly Moral Inventories, a required therapeutic nightly exercise. We have learned to provoke an immediate crisis, demanding that the present family members find and de-
liver the absent family members immediately, or they can take the primary patient and leave treatment that night. In the overwhelming majority of cases, it results in a therapeutic event in which family members face manipulation and dishonesty and agree to follow the commitment they have made pro forma during the admission process. Parents attempt to control the progress of their kid by inappropriately contacting staff members with manipulative issues concerning their child. In Open Meetings, these same parents and siblings attempt to manipulate the progress of their child by lecturing, by threats, and by promises. Often, another family crisis occurs involving a second child with an addictive or compulsive disease. This individual, usually in a Second User role, is discovered during a sibling interview related to the family’s admission to the program. If a diagnostic assessment is indicated from the data on the sibling interview, the family is required to have the second child assessed. At this point, the second reason for parent denial kicks in. “Any family can have one bad kid as long as the other kids are okay.” If a second kid has a problem, then parents see this problem child as an indictment of their parenting. The work to move parents from denial to acceptance with a willingness to seek help for the second child is a sensitive therapeutic task. Failure to follow through on the second compulsive child sabotages treatment of the primary patient and the entire family. Guilt and Shame Family members enter treatment with enormous amounts of guilt and shame based on personal and family identity. The guilt develops as a result of deliberate activities on the part of the primary patient blaming the family and manipulating the use of guilt as a lever for getting away with things. Family members become increasingly desperate to survive in the troubled environment, and in reactive disease, they make mistakes dealing with the patient and each other. Continued attempts to change, improve, and make the family work always fail. These failures develop into a deep shame base for the family as a group and for each individual. Guilt and shame increasingly isolate family members from the extended family and the community, reinforcing shame. The foundation for dealing with guilt and shame is breaking denial about the patient and accepting the fact of the chemical dependency/eating disorder disease as a cause for the troubled behavior. Equally important is the growing acceptance of co-dependency as a reason for their own behavior in an impossible situation with the individual who is addicted. This foundation, which is reaffirmed by staff, by the patient as he or she enters early recovery, and by family peers in the program, assists the family in facing guilt and dealing with shame. Peer support on the part of other fam-
KIDS of North Jersey
ilies at various stages in the continuum of recovery is critically important to families during the early and later stages of treatment. According to one parent, “Other parents get up in meetings and relate their experiences. I find myself saying, “that’s exactly the way I feel. Hey, I did that too!” UNHOOK FROM USER Family members, particularly parents, are overenmeshed with young people with drug dependency and eating disorders. As normal parents, they exercise care and love through taking responsibility for the problems of the young person. Parenting is fixing problems and cleaning up the messes of their kids. The begimring of health is simply to unhook from the young person. KIDS accomplishes this through taking the young person out of the family system and sending the young person home with an oldcomer to live at that young person’s house for a period of time. The physical separation itself produces relief from the incessant controlling and fixing activity of the family. Long before mental and emotional unhooking occurs, the simple distance during the early weeks of treatment produces a relaxation from “walking on eggs” by the entire family. As the family discovers that the user is not going to create 290 a.m. crises and that they can come home without explosions everyday, the feeling of relief steals over the family. The relief is so pleasant in contrast to the anxious, panicky feeling of waiting for “the other shoe to drop” that the family begins to want more in terms of relief and unhooking from enmeshment with the user. This separation creates distance and a cooling off period to allow everybody to take responsibility for themselves, both the compulsive dependent person and the other family members. The physical absence of the addicted individual at fust stabilizes the family where cahn routine and order can replace the crisis-oriented confusion that existed while the patient is the center of the family’s system. Calm and order represented by the absence of the patient in time provokes destabilization. This destabilization has to do with the absence of crisis, that is, the absence of compelling activity around the person with the addiction. New parent “raps,“’ both the content and the affective process, help parents surface their own sense of responsibility for the “failure” of the child and the resulting guilt. The raps help parents understand that the “druggie” or “foodie” is responsible for his or her own choices that led to loss of control. That person also must be responsible for his or her sobriety/abstinence if recovery is to be achieved. The enmeshment also involves incessant activity attempting to control the dependent person or to clean
‘Group Therapy Sessions.
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up the results of his or her disease. This second activity is called enabling. The program is designed to physically stop this activity, to create sufficient distance that the family is suddenly without a dependent person at the center of family activity. The simple absence of the dependent person and the activities of the program, which involve the family members in reframing and reunderstanding what has gone on, stops the incessant activity and creates a void in the family system that is filled by activities related to recovery. This unhooking from incessant activity literally provokes steps toward recovery. At Open Meetings, the Newcomer patient gives Alcoholics Anonymous type introductions, and then, the parents respond later in the meeting. This process begins to reformat family communication. It eliminates the arguing and walking-away dance of codependency. The ritual “love you” response at the end of parent communication to the child and child communication to the parent as well as hugging at the beginning and end of family “talks” not only breaks up prior forms of communication but begins to suggest new possibilities for family communication in the future. Attempt at Control On First Phase, with the patient living away from home, parents and siblings are no longer involved in a day-today basis with incessant acting out and problems. Having unhooked because separated and distant, parents now begin to rehook to the patient related to the treatment process. They attempt to literally control the progress of the patient in facing up to the disease and behaving appropriately in the treatment program. One form of manipulative control is nonverbal communication by parents to their kid in group. Usually, the Enabler or enmeshed parent tries to communicate nonverbally with eyes and lips in the meeting room with the primary patient. Staff and other parents are alert to this sabotaging nonverbal communication and stop it. The failure of this attempt at control is used therapeutically to help parents and siblings accept their “powerlessness” over the dependent person. This acceptance of the First Step of Al-Anon, at a deep internalized level, is the final unhooking that opens the door to co-dependent recovery. Parent Subsystem Boundaries Parents going through the new parent orientation groups, working on acceptance of the disease and backing away from control of the patient are assisted in developing a stronger boundary between the parent subsystem of the family and the child subsystem. Parents discuss with each other and other parents the specific behaviors and problems of their child, they sort out together their parenting through communication in Open Meetings and in “talk” with their child after
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meetings. Siblings are also involved in their raps and with talk after Open Meetings. These activities are designed therapeutically to strengthen the parent system as separate from and in charge of not only the patient child, but other children in the family. A program “no travel” rule during this period of treatment encourages parents to rebuild their relationship with each other as they go through the group sessions together and process their experiences with their compulsive child before treatment. The group sessions and the talk with their child after Open Meeting are designed to reinforce a reconstructed parent relationship. Single parents reinforce the parent subsystem by building relationships with other program parents.
to issues related to his compulsive disease. Later in the meeting, family members speak about their issues and feelings across the room to the patient whose only response is “Love you, Dad!, Love you, Mom!” Staff members, parents, peers, and sibling peers work with family members to tell incidents in this microphone talk without blame and to share their feelings about the incident. This period of separated communication facilitates getting issues out in the open and dealing with feelings that were repressed because of fear of acting out. As shock wave after shock wave subside as a result of emotion-triggering disclosure, it becomes possible to deal with the incidents and resentments in new ways. The public disclosure of problems and behavior is the final blow to family denial.
“Learning About Myself” During the controlled phase of parent activity in early treatment, parents fail to hear other parents talking about themselves and co-dependency. Just as Al-Anon insists that people unhook from the drunk and focus on themselves, the KIDS program pushes parents and siblings to fill the void in their lives created by the absence of the user to look at themselves. In the words of one parent, “I have learned a lot about myself in the beginning part of the program; I’m still learning everyday.” Unhooking allows family members to look at themselves to learn, to grown, to heal, and to recover. A strong parent and sibling peer group is the necessary medium through which newer family members look at themselves, learn and change. RESOLVE ISSUES AND RESENTMENTS While parents and siblings are involved in the structure of unhooking from the user, a second movement of recovery begins. This movement involves resolving the numerous issues that have occurred because of the patient’s compulsive disease. These issues involve lying, stealing, acting out, violence, embarrassment, and involvement with the criminal justice system, all of which have been deliberately clouded by the user through conning. Other family members hide issues, attempting, out of care, to help the user. Some issues are family secrets, kept by some members from others. When the family arrives at treatment, any issue that comes up triggers a litany or laundry list of past “bitches” and objections with a “there you go again.” This family dance of blaming and closing off is the dominant form of communication in the family system when treatment begins. Rebuilding the family relationship requires two activities. Issues that are outstanding have to be resolved and a new style of communication of dealing with problems and resolving conflicts in the family must be developed. The KIDS program is designed to facilitate resolution of issues. At the first Open Meetings, the patient gives the first of three introductions owning up
Honest Communication The communication techniques of the program block either the patient’s or family member’s chance to react defensively, which would, in turn, trigger the family dance. The family members learn to communicate incidents in factual ways with feelings. Pressure is on the patient for increasing honesty in which misdeeds related to the compulsive disease are disclosed without justification or blame to anyone else. The patient is in fact owning responsibility for the behaviors related to the disease. As this communication style develops, the family dance stops, the intensity of anger and resentment is deflated and there is relief because confused incidents are now cleared up with responsibility placed where it belongs. Parents and siblings have the opportunity in family raps to deal with secrets they keep from each other and the resentment that comes from conflicts over how to deal with the primary patient. Family communication continues at home moving to a more blunt, honest, and self-responsible form of communication. As family health and communication style grow, the family moves into a new stage of communication. Family Talk-Letting
the Past Go
The patients, now in touch with feelings about past behaviors and remorseful about harm done to the family, and family members who have ceased to blame or control the patient through lecture or communication, enter a new stage. The entire family has a IO-min private talk session after each Open Meeting that focuses on resolving past issues. Now, the patient is disclosing the behaviors and the harm done with feelings and making amends to the family. The family members learn not to blame but to share their feelings about the incident to make the incident emotionally whole as a communication issue between patient and family. As these are completed, both the patient and the family are able to let go of the incident, give up the resent-
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ments involved, and literally let incident by incident float away as a matter of the past and the disease. The present is free of intrusion of the diseased past. There are no family secrets. The family can get on with living. “coining
Home”-
A New Start on Family Living
As the patient clears up, through disclosure, his entire past, and as the family members share their feelings of resentment, anger, hurt, and embarrassment, as incidents are completed, closed, and let go, the family is now ready to be reunited on the basis of mutually supported recovery for all. The magic moment comes when the young person earns the right to return home, screams out across the room in the Open Meeting“Coming Home!” then runs and jumps into the family’s arms. This ritual of the returning prodigal sets up the hope of reestablishing the family relationship on a new basis. The new communication style learned during the First Phase of Treatment carries over into living at home together and learning how to resolve conflicts by nonblaming, admission of responsibility, sharing feelings about incidents, and finding solutions. The program staff assists in telephone therapy and in family therapy sessions helping with difficult issues that arise. The patient now makes amends, not only by verbally owning the behavior and saying “sorry”, but by making up to the family for the months and years of harm under the influence of the disease.
triggers memory of incidents related to the compulsive disease and the family’s reaction to it. Having raised the issue, the family continues by dealing with the issue in the framework of the treatment program. The Real Work on Family &gins Usually, the first week at home is “miracle week” where everything is wonderful, new, and different. Then, the miracle ends and some of the old conflicts about living together as a family reemerge, not only between the patient and family members, but between other family members. At that point, family therapy and hard work on family relationships begins. Family recovery, giving up roles, and ending inappropriate alliances occurs and goes on throughout the program. About a week after coming home, the patient begins to bring Newcomers home. Newcomers are other patients who are still working on the First Phase of treatment. Most families would “blow away” the program rules and expectations for family behavior at home after about 1 week. The presence of one or two strangers in the household encourages compliance to keep up “family face” As time progresses, compliance slides into acceptance because the new behavior required by the program is more satisfying than the family’s previous co-dependency behavior. The Couple Relationship
Parent/Sibling Owning Up Parent guilt is helped by the owning up of responsibility for past behaviors by the compulsive patient. Parents now know that it is not their fault but the kid’s fault because he or she has owned it. However, there remain those incidents where parents have acted excessively toward the patient in the past, toward a sibling out of frustration with the patient, or toward their spouse because of an alliance with the troubled kid. The patient, identified as the problem kid in the family, owning up to wrongs and making amends, triggers a process of self-examination and ownership of wrongs on the part of other family members. Self-responsibility for wrongs and amends becomes the way out of guilt and into hopeful and healthful living for all members of the family. The Moral Inventory process, which involves nightly written therapeutic homework for primary patients, parents, and siblings, assists in the owning up process. The beginning of the Moral Inventory involves a “challenge” in which each individual writes about a problem or character defect related to the compulsive disease or the family disease and then uses the Steps to deal with the problem. The Fifth Step requires “admitting up to another person” the nature of the problem and seeking advice and help. This process
Critical for family member’s recovery is the resolution of resentments and issues not only between the patient and the family member, but between parents and other siblings and between the two parents, who are often manipulated by the patient. This disloyalty to the couple relationship in dealing with the troubled kid is often a major problem. Much work is necessary in helping the couple react as a couple and subsystem as opposed to having primary alliances with the troubled kid. This work involves dealing as a couple not only with the child, but also with other children in the family. Second, a new style of communication must be developed that involves blunt, self-responsible communication, no blaming other people, communicating feelings related to behaviors and issues, and learning how to resolve conflict. It takes time to develop a new style of blunt, nonblaming communication. The program encourages practice, not only at home and in raps, but also in family systems therapy sessions. Parents are encouraged to spend time with each other, separate and apart from activities related to the patient, their other children, and treatment activities. This period involves rediscovery of their primary relationship as a couple. Single parents accomplish this task by working on their adult life apart from the children.
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Resolving Parent’s Issues Finally, as the immediate issues and resentments regarding the current family relationship and addictive ilhress and co-dependency issues are resolved, parents, in particuhu, are invited to deal with unresolved issues of their own lives. These issues are of two kinds. First, there are the unresolved issues from the parent’s own family of origin. Second, there are unresolved issues in their own adult lives, either individually or as a couple. Work is done on these issues by family systems therapy, in parent group sessions, and during a Parent Weekend. A Parent Weekend is a special intensive therapy device in which parents spend 2 days (Saturday and Sunday) in the facility following the same group schedule as the adolescent patients in a separate part of the facility. These sessions are directed exclusively to family of origin and parent adult issues and in no way involve the troubled kid. Each parent is required to be involved in one parent weekend sometime after his or her patient kid has entered Second Phase. Dealing With Other Family Problems Clinical staff members at the program have learned to maintain an ongoing list of families with another member who has a compulsive disease. These problems may include habitual lying, overeating, unresolved rage, adult parent alcoholism, sexual disloyalty to a partner, and others. In the course of family treatment, these other compulsive diseases surface or are recognized by family members. We have learned over time that these other major family member problems must be dealt with and resolved for the primary patient to maintain ongoing recovery. If another major disease problem remains, eventually the family will close ranks to deny the fact of that problem, maintain that person’s illness, and resume the bad communication and bad feelings. As the guilt and shame reemerges, the primary patient will almost always decide, “This feels bad anyway, why keep working my sobriety/abstinence program?” The family returns to over emeshment, enabling, and pathologic denial. As a Clinical Staff, we have learned to make every effort and use every device to assist other troubled family members in seeking help for their problems. We use the intervention technique in cases where the individual needs residential treatment to force them into treatment at another appropriate treatment program. The intervention is timed at a point when there is sufficient recovery on the part of the primary patient and other family members that the family will fight to maintain health and ongoing recovery.
DEVELOP DETACHMENT Having unhooked from the user and resolved issues and resentments from the period of active compulsive
behavior, the family is free to move into the future. The future requires a new stance with reference to self and others in the family relationship. This stance is called “detachment. n Detachment means dealing with each other as autonomous, adult human beings rather than extensions of self. Autonomy as a human being is a status where a person stands on his own and accepts the responsibility for self and actions including any consequences. Detachment or autonomy involves being in touch with oneself as a person separate from roles in the relationship. A mother or father operates as a human being outside of a stereotyped role such as “prime enabler” or “passive adult.” In addition to freedom from the compulsive roles of the co-dependent family, the mother and father are also individual persons separate from their role as parent or spouse. Recovery and health means the freedom to be oneself separate from the expectations of others in the family, to refuse to conform to roles when others in moments of insecurity demand sick behavior from the individual. In addition, detachment and autonomy mean treating other members of the family, including the compulsive patient, as individual persons, free of roles and responsible for one’s own behavior. Changing attitude and behavior toward the compulsive patient is the hardest part of the treatment process because each family member’s co-dependency role has been based on treating the patient as an extension of themselves in terms of control, avoidance, and stereotyped reaction. Detachment and autonomy are worked on by patients in group sessions and by family members in parent and sibling group sessions. Family conferences and, in particular, Parent Weekend are vehicles through which individuals move from role identity to autonomy and individualization in recovery. Enabling and Autonomy Detachment does not mean noninvolvement or no care. Detachment means that acts of care from a parent toward a kid or from a brother toward a sister are free choices or gifts of love. Detachment also means allowing people to experience and be responsible for the consequences of their actions. In the case of a parent in the position of authority, it means ensuring that the individual experience and be responsible for consequences of his behavior. Protecting people from consequences is called enabling. Enabling is diseased behavior in compulsive dependent families. Ensuring that individuals are treated as autonomous persons who are responsible for their behavior and, in turn, the consequences of misbehavior is healthy recovery behavior. Detachment is also tough love. Treating people as responsible human beings is not meanness, but true love because it involves respect and trust in their ability to behave responsibly.
KIDS of North Jersey
Relapse and Progress During the process of developing detachment, there will be moments in which environmental cues, fatigue, and stress trigger return to co-dependency role behavior with the ensuing feeling of guilt and shame. These moments of relapse become part of the content and process of recovery. The Alcoholics Anonymous and Al-Anon slogan, “Progress, not perfection,” is appropriate here. Early in treatment, individual family members fight to hold on to co-dependency role behavior as defenses against threat and shame. As peer pressure in the program and staff action force people to increasing self-responsibility and autonomy, the changing feelings that go with competent autonomy become intrinsically reinforcing. Recovery feels better than sickness. Crisis and Surrender Usually, during the later part of detachment development, a new crisis arises. The primary patient is doing well with the family, school, and self-control. Family members are doing well with autonomy and healthy behavior. At that point, both the patient and family members decide that they are cured, and there is no need for continuing treatment or the discipline of the recovery regimen. They deny their First Step. As old problems, roles, and compulsive behavior emerge, a crisis occurs. Usually, the patient in the family experiences some kind of setback losing privileges/responsibilities and being taken out of school. The family decides that this in unnecessary because the patient seems to be doing fine. This setback may cause problems for planned social activities of parents or siblings such as weddings or vacations. The crisis may involve the family deciding that program rules are unnecessary because the kid is fixed. These events inevitably lead to a serious crisis on the part of the patient who rejects the fact of the disease and may runaway or attempt to return to social use. The counselor, at this point, midwifes a deflation of ego around the crisis, which leads to a new level of acceptance of the chronic disease called “surrender.” The crisis, with the help of therapeutic interpretation, “rubs the noses” of family members in the fact of the chronic disease and the abnormality of this family’s continuing life. As the family members face the crisis and remember the nature of the disease, they surrender to the “powerfulness” of addictive disease. Now, humility is characteristic of their cognitive and affective stance toward the disease. A tentative living “one day at a time” is the ongoing lifestyle of both the patient and the co-dependent family members. DEVELOP A PERSONAL HEALTHY LIFESTYLE Having gone through the process of unhooking from the user, resolving issues and resentments that keep
one’s energy focused in the past, and finally developing healthy detachment, the individual family member is ready and hungry to get on with his or her own life. The program assists parents and siblings in developing an individual healthy lifestyle that is satisfying. This recovery lifestyle is designed to cope with tendencies toward co-dependency.
Recovering Lost Dimensions The parent or sibling engages in two major tasks in building a lifestyle. One task involves going back and picking up lost activities or interests that represent major losses in their lives. The lost activity may be replayed as a therapeutic ritual if it, for instance, is a family event from the past. The activity may be the development of a renewed interest in an old hobby, activity, or a different direction in a career.
A Balanced Lifestyle The other task involves inventorying one’s life activities for health and balance. Is the individual involved in satisfying work activity, a constructive family relationship, satisfying friendships, spiritual activity, physical activity, and mental activity? In some cases, the person is involved in all these areas, but in an imbalanced way, with obsessive activity in one area and diminished activity in others. Using the “first things first” slogan, the staff members help the individual prioritize activities in his or her life and develop a more satisfactory balance in his or her lifestyle.
Character Defects Particular emphasis is continuing work on character defects related to the co-dependency disease. The defects may be nonassertiveness, dishonesty, anxiety, avoidance of conflict, laziness, selfishness, “controlling” behavior, and others. The individual develops a program to compensate for and change these character defects using the Steps and other resources. Often, peers in the family treatment program help as higher power resources in dealing with character defects or developing new activities or interests. The principal tool for facing character defects is the Moral Inventory described earlier in this article. Using the Challenge section and the self-help Steps to face a character defect, the individual then sets goals for changes that will eliminate the character defect. Some character defects are positive qualities turned bad. “Stubborn resistance” is the opposite face of “determination.” Many times the quality side of a character defect can be recovered through the Moral Inventory and Step process. Work on character defects is a recovery task that continues beyond treatment.
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Personal Life and the Family Another area of focus is learning how to balance one’s personal interests and individual life with appropriate care and responsibility in the family. Some parents are over involved in family responsibilities and have diminished and unsatisfying personal lives. Other parents are “passive adults” who avoid family responsibility and involvement. The treatment program helps parents develop an appropriate balance between personal life and family involvement. Siblings also work on appropriate family involvement and appropriate life activities outside of the family for their age. Typical of addictive illness families is to be so turned inward, out of shame, that they have inadequate external involvement. Care, responsibility, and help to others is a necessary antidote to the selfishness that is characteristic of co-dependent family members. The program helps family members develop a caring and serving style. Parents and siblings have the opportunity to help others at the program. They are able to share their experience and relate themselves to new families who are going through struggles about having a compulsive dependent child and being in treatment. Parents are asked to host guest families looking at the program for their child, to lead some of the didactic “raps,” and to assist with intakes. Siblings have the opportunity, not only to host new siblings, but also to be actively involved in holiday celebrations for the kids in group and to put on a talent show as a gift to their patient siblings during the Christmas/Hanukkah season. As part of developing a satisfying personal lifestyle, emphasis continues on the fact of co-dependency being a chronic, noncurable disease. Family members learn that their lifestyle must be a continuing health regimen to cope with and produce recovery in the face of their disease. FAMILY REBUILDING The previous sections describe the five movements of recovery for co-dependent family members. The focus has been on the specific cognition, affectation, and behavior of individual parents and siblings. However, each of the five movements has a clear dimension related to the family system itself. Breaking Denial means ending family delusion and secrets. Broken denial moves the family to honest, open, and reality-based communication as a group. The honest communication about the patient, the disease, and the co-dependency disease offers a chance for family members to relate on a real basis with each other. This openness or transparency is the foundation of healthy family relationships. As family members unhook from the user, they become free to have a family life that is noncompulsive and not centered on a troubled person. Unhooking
from the user means giving up co-dependent roles for survival in the family. As the roles are given up, parents and siblings can become individuals and real persons again in how they relate to each other. The family begins to be a system of persons living together rather than a defense system against a problem. Resolving issues and resentments ends a variety of family dances that drone on in a routine way based on historic grievances. As the garbage of past issues is cleared, family members can begin to build relationships with each other in the present as healthy and recovering persons. The family is free to live in the spontaneous present. Detachment means treating each other in the family as autonomous persons with the right to individual opinions, lifestyles, and responsibility. This movement reestablishes the family as a system of autonomous but related and caring persons. Detachment allows families to grow and develop. As each family member develops a personal healthy lifestyle, the family becomes a rich and complex human system with persons sharing their interest in life. The family dimension of a healthy lifestyle involves maintaining family rituals around holidays and occasions and maintaining common processes such as meals, religious activity, and vacations as a group. CONCLUSION The KIDS program has learned that a blunt directive style of therapy is as necessary for the family treatment program as it is for the patient treatment program. Co-dependency, like chemical dependency, produces a manipulative and deceptive defense system that is analogous to a “hall of mirrors” at a carnival. The antidote to confusion in the maze of denial, justification, excuses, and manipulation is a very directive, blunt, and honest style. Co-dependents, like addicted individuals, have a deep base of shame to their disease. Initial treatment involves a message of care. Continuing relapses and crises in the family call for extraordinary care at times when family members give up on the patient and/or themselves. The willingness of staff to be available at night, on weekends, holidays, and not having a 9 to 5 work day are part of a systemic message of care necessary for the recovery of family members. The care also expresses itself in having a “bag of therapeutic tricks” that is used one after another until the particular crisis or problem is solved. Doctrinaire adherence to a particular therapy system gets in the way of caring therapy for shame-based patients. Miller Newton, pm KIDS of North Jersey, Inc. River Edge, New Jersey