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Engaging the families of substance abusing adolescents in family therapy
Journalof Substance Abuse Treatment, Printed in the USA. All rights reserved.
ORIGINAL
Vol. 2, pp. 91-105,
1985 Copyright
014ts5472/05 53.00 + .al o 1985 Pergamon Press Ltd
CONTRIBUTION
Engaging the Families of Substance Abusing Adolescents in Family Therapy ARTHUR A. WEIDMAN,MSW,
POD,
CAC,
CDC
Jewish Family Service of Greater Springfield, Inc.
Abstract - This
article discusses three major topics: First, the family processes one typically finds in families with a substance abusing adolescent are described. These processes include pseudoseparation and defensive delineation. A case vignette is used to illustrate these processes. Second, an overview of the importance of family therapy in treating substance abusing adolescents is provided. Third, specific principals and techniques for involving families in family therapy are described. This area includes a discmion of such topics as using the initial telephone contact to join with and involve the family, and suggestions for handling some typicalproblems which the therapirt may encounter in the initial interview. These problems or resistance must be handled sensitively if the family is to remain in treatment. This is an important area since involving the families of substance abusing adolescents in treatment can be quite difficult and there is little practical literature available.
THE IMPORTANCE OF FAMILY THERAPY IN THE TREATMENT OF SUBSTANCE ABUSE
INTRODUCTION ADOLESCENTS, ADOLESCENTS,
PARTICULARLY
SUBSTANCE
ABUSING
are a challenging population for therapists. The volitility of adolescents coupled with the severity, intractability, and perilousness of substance abuse contributes to therapists frequently preferring not to treat substance abusing adolescents. In addition, the resistance of many families of substance abusing adolescents to becoming involved in treatment also contributes to therapist reticence about working with these youths and their families. However, the author’s experience has indicated that the resistance of therapists to treating this population in part stems from the therapists’ lack of practical knowledge of how to engage substance abusing adolescents and their families in treatment. Once therapists have a viable framework for understanding substance abuse and specific interventions upon which to draw, they are more willing to work with substance abusing adolescents, and treatment is more successful. This paper describes a framework for understanding adolescent substance abuse. It outlines principles and specific interventions one may use to involve families of substance abusing adolescents in treatment.
One may ask, “why work with the family when only one member is a substance abuser?” There are a number of responses to this question. First, the family is the context within which identity emerges. The family may be seen as a developing system which may facilitate or hinder an individual member’s development. If a family is having difficulty negotiating a particular phase of its development, an individual member may express that difficulty in the form of a symptom or a problem behavior. Problems may be viewed as being maintained by the family and as maintaining family stability. Individual and family problems may be seen as attempts to cope with a developmental issue; however the attempt is not adequate given the family’s limited view of the problem, previous deficits, or scarce resources. The family’s attempt to cope is often well-intentioned, and the resulting dysfunction is often quite unintended. A question that is sometimes useful to pose is, “How does this problem help the family, dyad, or individual maintain stability?” or “To what developmental issue is this problem a response?” Substance abuse may be seen as developing in response to a particular set of family problems and dynamics. One consequence of this view is that in order to understand and treat the etiology and maintaining dynamics of a problem, one will need to work with the family. The specific family
Reprint requests should be sent to Dr. Arthur Weidman, Executive Director, Jewish Family Service of Greater Sprinfield, Inc., It34 Mill Street, Springfield, Massachusetts 01108.
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98 dynamics which are involved in substance abuse will be more fully discussed in the next section. The second reason for working with families is that families are powerful groups of people who exert signficant influence on their members. In treatment, families can either be a tremendous support or an impediment which can undermine and sabotage treatment. From a practical standpoint it is wise to involve families in treatment to engender their support. A recent study (Weidman, 1984a), found a significant difference between two similar treatment facilities in the dropout rate when family therapy was used. In one treatment facility families were involved in family therapy. Within the first week the adolescent was in treatment and continued on a regular basis. This facility had a significantly lower drop-out rate than the similar facility which did not involve families in treatment until the third or later month and did not have family therapy as a required treatment component. There was also a significant relationship between the number of family therapy sessions attended and the drop-out rate in that the more family therapy sessions attended the less likely it was that the youth would drop out of treatment. A third reason for involving the families of drug abusers in family treatment is that family therapy has proven to be an effective tool in the treatment of drug abuse (Kaufman & Kaufman, 1979; Stanton, Todd & Associates, 1982). Stanton (1979) found that structural family therapy, when compared with no treatment and methadone maintenance treatment, substantially increased the percentage of drug free days. He stated, “The practice of treating the drug abuser and his family members separately or concurrently does not appear to be as promising or efficacious as treating them together . . . the point is, if treatment is not constructed to directly intervene in and change the family process surrounding detoxification, such treatment is much less likely to succeed” (p. 143). Stanton, Todd & Associates (1982) found that after one year, drug abusers who had received ten sessions of structural family therapy had a mortality rate of 2% while drug abusers who received no treatment or methadone maintenance treatment had a mortality rate of 10%. Zeigler-Driscoll (1977) found an association between the degree of improvement in the drug abuser’s family and the length of family therapy. It was found that 73% of the families that improved markedly with family therapy had attended five or more sessions. Weidman (1984b) explored the effects of structural family therapy on the level of psychological differentiation of compulsive adolescent substance abusers in residential treatment. It was found that the number of family therapy sessions, independent of length of stay in residential treatment was significantly correlated with an increase in psychological differentiation. Family therapy enabled the drug abuser to separate and individuate from the
Arthur A. Weidman family of origin by disengaging the symbiotic relationship with the maternal figure and strengthening the disengaged relationship with the paternal figure.
THE ROLE OF THE FAMILY IN THE DEVELOPMENT AND MAINTENANCE OF SUBSTANCE ABUSE Compulsive substance abuse may be viewed as a defensive functions, the purpose of which is to maintain family stability. Compulsive substance abuse may be related to a symbiotic relationship between an adolescent and a parent (Alexander & Dibb, 1977; Attardo, 1965; Ziegler-Driscoll, 1977). Viewed in this manner, compulsive substance may be an attempt to cope with the developmental issues of separation and individuation which precede the youth’s leaving home. The drug abuser has never fully achieved separation from the parent and is still in a dependent and symbiotic relationship (Weidman, 1983). The parents of the drug abuser do not encourage the abuser to individuate and separate from the family. Compulsive substance abuse may be seen as a pseudo-separation in which the apparently independent and defiant use of drugs maintains the drug abuser in a dependent position vis-a-vis the family of origin. This substance dependency, which is an exchange of dependency on parents for dependency on drugs, serves to maintain a drug abuser’s dependency on his or her parent(s). An example of pseudo-separation is that of an adolescent who is using drugs and engaged in other anti-social behavior and whose self-destructive, parents still support the youth by giving the youth use of the family car, pocket (read drug) money, money for legal fees, and bail. Frequently the teenager disobeys the parents, steals from the family, may be violent with family members, and is arrested. The dependent and fused nature of the parent-adolescent relationship is shown by the fact that, even with all of the adolescent’s self-destructive acting-out, the parents still try to help by giving the teenager “one more chance.” Were the parents to try to stop the youth’s acting-out by not rescuing the youth, removal from the home and placement in a treatment program or detention center would be the most likely outcome. The parents and the adolescent often experience a profound and unconscious fear of object loss. Since the adolescent and parents are involved in a fused relationship, one often observes a significant depression develop in both parents and adolescent when they are separated. When, with support, parents are able to take a firm and consistent position with the adolescent and get the teenager into treatment, the adolescent typically becomes enraged and depressed. The importance of family processes in the development of compulsive substance abuse is fur-
Family Therapy
ther outlined in the work of Chein, Gerald, Lee and Rosenfeld (1964) who stated, “the overall results of the analysis of our indexes gives strong support to the view that family experiences play an important role in the etiology of addiction” (p. 271). If family processes play a significant role in the development and maintenance of substance abuse, then family therapy should have a significant impact on this problem. The impact of family therapy on the drug abuser’s family may be seen in a number of areas, including disengaging the fused family system and moving the drug abuser from a state of pseudo-separation to a state of relative differentiation, autonomy, and sense of separate identity. An important dynamic operating in the families of chemically dependent teenagers is defensive delineation. Delineations are the view one person has of another as revealed implicitly or explicitly in the behavior of the one person with the other. When the delineation contains evidence of distortion of the other person related to the individual’s defense structure, then the delineation can be termed a defensive delineation. For example, the parents of one teenager saw him as still being a failure despite his one and a half years in a therapeutic community, his getting a high school diploma, and the evaluations of the staff that he was ready to move out on his own. The teenager’s father had never achieved any of his own dreams. The son’s achievements confronted the father with his own failures. Typically, what is found in such cases is a pattern of anxiety in the parents over the adolescent’s potential for individuation and separation. The parental anxiety over the adolescent’s developmental growth is a major cause of parental defensive delineations, wherein the adolescent’s maturation stirs up conflicts and anxieties in the parent who projects onto the adolescent one part of a previously internalized conflict. Externalizing the conflict onto an interpersonal relationship diminishes parental anxiety. A significant component in this process is the conscious or unconscious willingness of the recipient of the projection to accept the projection. The teenager colludes with the parent in providing vicarious gratification for the parent of the unacceptable and unconscious desires. The motivation for the adolescent’s collusion in this process is the gratification received by reducing parental anxiety. Since a relatively fused state exists between the adolescent and parent, what is anxiety reducing for the parent is gratifying for the adolescent. Case Vignette
At this point an example may help to illustrate the dynamics which have been described. John was 17 years of age, the only child of parents who have been separated and divorced for over 7 years. They mar-
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ried when Mr. Smith was 19 and Mrs. Smith was 17. Although it was not true, Mrs. Smith had told Mr. Smith she was pregnant so that they would marry. The marriage was beset with problems from the beginning. The parents had frequent arguments in which they screamed and occasionally hit each other. When these fights occurred, Mrs. Smith would get John, who was born a year into the marriage, and hold him between her and Mr. Smith as a shield. This usually stopped the fighting. Mr. Smith is an alcoholic whose father was distant and rigid. When drunk, Mr. Smith would become belligerent. He had many dreams for John, his namesake, dreams that Mr. Smith had been unable to fulfill for himself. Through defensive delineation, Mr. Smith avoided feelings of inadequacy by having John live out these dreams. When John reach puberty and began separating himself from these delineations, he and his father began fighting. The arguments were heated and occasionally physical. The pseudo-separation that John’s behavior represented can be seen in a number of behaviors. John’s use of drugs and alcohol was similar to his father’s alcoholism. John could express hostile feelings only when drunk. John frequently ran from one parent’s home to the other. Mrs. Smith is a very quiet, passive-aggressive woman who rarely experienced angry feelings and frequently experienced guilty feelings. Mrs. Smith’s father was a belligerent alcoholic. Her mother was a masochistic woman whose primary concern was that of placating her husband. Anger was experienced as a dangerous emotion to be avoided at all costs. The defensive delineation that John was an angry, belligerent son protected Mrs. Smith from her own angry feelings and the guilt she experienced about these feelings. The Smith family fiction was that anger was destructive, dangerous, murderous, and not controllable, though, in fact, no one had been seriously hurt physically by the angry outbursts. As a function of this, John, who was the repository of family anger, never actually experienced anger. Instead, he used drugs extensively; he drank nearly every day; he broke into other people’s homes at least thirty times; he stole his mother’s car and had accidents; and he stole from his paternal grandparent’s home. Mrs. Smith reported feeling secretly thrilled by John’s escapades. Although the parents knew that what John was doing was wrong, they both usually gave him one more chance. One might ask, one more chance to do what? Consciously each parent wanted to help John by not reporting him to the authorities. Unconsciously they were giving him one more chance to act out, one more chance to get back at the other parent, one more chance to express anger for the family and not disrupt the family equilibrium. John’s actions served a number of important func-
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tions for the Smith family: (a) He remained in a fused relationship with his mother, acting out the angry feelings that were unacceptable to her; (b) Although overly distant from his father, John was also in a fused-relationship with him. Through projectiveidentification, John was the recipient of his father’s unacceptable failures and became the vehicle for Mr. Smith to raise his own self-esteem. John’s behavior served the function of containing split off and projected negative aspects from his father; (c) John’s actions can be seen as self-destructive in order to atone for the guilt he experienced over not being able to keep his parents together and his unconscious wishes to split them up. (Remember, John was used as a shield to stop Mr. and Mrs. Smith from fighting); (d) John’s behavior served to act out his mother’s hostile feelings against his father. This was achieved by John being a failure at all the things his father had hoped for him; (e) By remaining a focal point and release for guilty and angry feelings, the parents were absolved of responsibility for their own feelings and impulses. Thus, the family fiction that only John had problems was maintained. What should be clear at this point is that adolescent substance abuse is a complex phenomenon involving individual and family dynamics. Therefore, treatment will necessarily involve the family as a frame of reference and focal point for intervention. Successful treatment must address the dynamics of defensive delineations and family fictions which served defensive and regressive functions in maintaining family stability. Treatment must also involve fostering separation and individuation on the part of the adolescent substance abuser. Interventions that facilitate ego-differentiation and interrupt the symbiotic fused relationship between parent and child will be required. ENGAGING THE FAMILY IN TREATMENT This section will describe a few general principles and techniques one may use to engage in treatment the families of substance abusing adolescents. The discussion will focus on the first telephone contact and initial interview with the family. The initial telephone contact and the initial interview are crucial times in the course of treatment. If one does not successfully engage the family at those junctures, there will not be any subsequent treatment. Six general principles will be described which can be used to guide the therapist’s efforts to engage resistant families in treatment. General Principles
First, the therapist should decide which family members need to be included in treatment and not leave
Arthur A. Weidman this decision to the family. This is critical because if the decision is left to the family certain key members, such as a father, grandmother, or an aunt who is living in the home, may be left out. The assessment should provide information about how the symptom functions, how the family maintains the symptom, and what negative consequences might befall the family or a specific member if the symptom were to suddenly disappear. After the therapist has completed an assessment, then treatment goals can be generated and such technical questions as who should come to subsequent treatment sessions may be answered. Second, the therapist can approach the family with a rationale for treatment that is non-judgmental and non-pejorative. It is important to provide support to the parents who often feel responsible for their child’s behavior but who will react with indignation and anger if they are blamed. To accomplish this, the therapist can talk with the parents about what they have been through and the difficulties that they have experienced. The therapist can empathize with the parents, tell them that it is time for the youth’s drug abuse to stop, and that the therapist wants to help them get the problem under control. The primary goal of treatment should be on helping the adolescent overcome the drug problem. The therapist can then join with the parents in helping the child to be the kind of person she or he can be. One way to do this is to talk with the parents about their goals for their child. How would they like her or him to be? What does success mean? The therapist can conclude by stating that working with parents can help them help their child succeed in a new way. Other rationales for family treatment include discussing the fact that substance abuse is a complex, vicious, and potentially life-threatening problem which will require everyone’s help and involvement if the teenager is to be helped. In addition, if the family has already attempted other solutions and forms of treatment, the therapist can suggest that those other attempts may have failed because not everyone who needed to be involved in helping the substance abusing adolescent was included in treatment. Third, if possible try to reframe in positive terms a family member’s resistance to participating in treatment. If the resistance is seen as bad and if the therapist and family are angry or confrontive, a power struggle which can only be destructive may ensure. For instance, a disengaged, disinterested father’s lack of involvement can be reframed as, “not wanting to intrude.” The therapist could then have the family talk about whether the father is intrusive or whether they would like to invite him to become more involved. Fourth, adopt the parents’ goals for the adolescent; these are the primary ones for treatment. Getting off
Family Therapy
drugs, staying out of jail, becoming more responsible, or related issues that the family may want for their teenager should be adopted as treatment goals. Fifth, in attempting to engage the family, it is important to show interest by being flexible in attempts to involve the family in treatment. The therapist must be energetic which may involve frequent telephone calls, home visits, or other attempts to contact and involve the family. The therapist will need to be persistent and be able to tolerate repeated rebukes by the family. Flexibility is crucial, including the ability to change and reschedule appointment times. Finally, the therapist must be absolutely convinced of the value of what is being provided, believing that this will help the family. The therapist’s conviction will be conveyed to the family, and this may help them feel that they want to become involved. Initial Telephone Contact Usually the first contact with the family will be when they telephone the agency. The primary goal for the therapist is to connect with and involve the family so that all household and significant family members will attend the first interview. Secondary goals may include gathering information about the presenting problem and family or completing agency forms. The secondary goals can usually be accomplished by pursuing the primary goal. It is often valuable if the initial telephone contact provides the therapist with enough information to formulate a few hypotheses about the family and the nature or function of the problem. These initial hypotheses can guide the therapist’s line of questioning and behavior during the initial interview. The initial telephone call may also be seen as a screening interview by the family to evaluate the agency and decide whether or not to pursue treatment. There may be some initial resistance by the family to family therapy. It is important that the therapist initially accept the family’s view of the problem and empathize with the caller. The therapist will have more time later when the family is in the therapist’s office to explore other views of the situation. During the initial telephone contact attempts to convince the family that the therapist has a better way of viewing the problem may only engender a useless power struggle. The ultimate outcome may be the family’s refusal to come in for treatment. Five approaches to use on the telephone to involve the whole family in the initial interview are described. First, the therapist can indicate that it is routine to get everyone’s input so that all family members must be seen initially. This may be facilitated by having it be standard procedure for all family members to come to the initial interview. In residential programs family visits can be made contingent on family participation in treatment. For example, in one family
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the mother and son were enmeshed and actively excluded the father, who was peripherally involved with the family. The mother would appear for family sessions and visits without her husband. When she was told, “If Jim’s father doesn’t show up, you won’t be able to meet with your son,” she became angry, but Jim’s father never missed a session after that. Second, the therapist can suggest that the whole family may only need to be seen, “just this once,” and that later sessions may not need to include everyone. The therapist may explain that seeing the whole family at least once will help him or her gain a more full and complete understanding of their situation and help the therapist be better able to help the family. Third, widen the problem definition by asking how other people react to the problem and how these other people are affected by the problem. Sometimes a parent will say that a non-chemically dependent sibling should not be involved. An effective technique to use is to state that a non-abusing sibling can be used as a model. Fourth, use your past experience and explain that you have found family therapy to be an effective therapeutic technique or indicate that research has shown that involving the family is much more effective than not involving the family. Fifth, often it is only one key family member, such as the father, whom you are told will not come for family therapy. Contact any important family members directly whenever you suspect there will be some resistance to that person coming in. Sometimes, especially if there is disagreement between the parents about how to handle the adolescent, a parent’s resistance to attending an initial interview may represent a power struggle with the other parent rather than resistance to family therapy. Talking directly with the resistant family member may defuse the situation. It is useful to begin by exploring what attempts have been made to involve the resistant family member; then one can suggest other ways to encourage participation. For example, some parents can be motivated to attend an initial interview if their presence is asked for rather than demanded. One can also suggest that since drug abuse is potentially life threatening, the youth may wind up dead if he or she is not helped soon. Some parents can be motivated to come in by pointing out that they are financially liable for their minor. They can be told that if help is not secured soon the youth may become increasingly involved in illegal activities and the family liability for court costs and restitution may be substantial. In other families, it may be that even though the parent or therapist does not have much influence with the resistant family member, another family member such as an aunt, uncle, or grandparent may have influence. In these situations it can be quite effective to work through that influential family member to en-
I02 courage the resistant family member’s participation. The earlier you involve all family members, the easier this will be. Research has shown that if family members are involved later in the treatment process, such as after a few weeks or months of treatment, it is very difficult to later engage these excluded members in treatment (Weidman, 1984a). The excluded members may interpret their not being involved in treatment as a message that they are not important or that they have not been respected. Their later resistance to being involved in treatment may be seen as a reflection of this interpretation. Initial Interview
When the family presents itself for the initial interview it is the therapist’s task to get to know and join with the family, exploring its strengths and competencies as well as its problems, and to test the hypotheses generated after the initial telephone contact. Exploring strengths and competencies is one way to join with the family. Beginning in this manner expands the family’s initially narrow range of focus and limited definition of the problem. Often families are stuck because their view of the problem does not lead to a solution. Helping a family see the problem in a different context and highlighting strengths on which to build may lead to their finding their solution. There are a variety of interventions one may use to involve a family in treatment and develop a working alliance. Generally, these interventions all come under the heading of “joining techniques.” There are four joining techniques, accommodating, confirming, tracking, and normalizing (Minuchin & Fishman, 1981). Accommodating involves using the family’s language and style of speaking. The therapist adjusts his or her way of relating to the family’s style. For example, a family in which the range of affect is constricted or muted would be accommodated to by responding with muted affect. Confirming involves supporting individual and family strengths. The fact that a father has held his job for 15 years or that even with their problems the family is still together are strengths that can be highlighted in an effort to join with the family. Confirming can also involve acknowledging a person’s feelings or even simply describing an interaction. For example, “I notice that when you are asked a question, he answers.” Tracking involves listening and encouraging the discussion by nodding and asking leading questions such as, “and then what happened?” Tracking is a way for the therapist to show interest. Normalizing involves placing an issue or problem in a contact that highlights its normal aspects. Examples of this are: “Many children have nightmares
Arthur A. Weidman at that age,” or “Most newly divorced parents feel overwhelmed; after all you are doing the job of two now.” Specifically, the therapist should talk with each person and stay with that person until the therapist experiences a level of comfort and spontaneity after which time the therapist can move to the next person. One way to begin is by asking, “I would like to get to know you and your family. Could you tell me about yourself?” The therapist may need to be more or less specific depending on the family. As each person describes him or herself, interests, likes, and abilities, the therapist should note and confirm these. In initial interviews there are a number of typical and expected problems that arise. A few of these typical resistances will be described and approaches for handling these problems will be outlined. A family member may rigidly adhere to the idea that either he or she is the problem or that someone else is the problem, but that no one is involved. For example, a family may define the problem as being their substance abusing teenager and not realize that the father’s alcoholism and marital conflicts also play a part in the situation. One can approach this therapeutic difficulty in a number of ways. Encourage each family member to talk about how he or she sees the problem and how the problem affects him or her. The therapist can also expand the family’s view of the problem by asking one family member how the problem affects two other people. For example, “When your sister comes home drunk, how are your mom and dad with each other, do they fight more or less?” The therapist can also expand the family’s view of the problem by asking the person blamed to explain or defend him or herself, “Your folks say that you are the problem, is that so, are you the problem?” When the family cancels or fails to attend the initial interview, therapists frequently feel frustrated and annoyed. It is important to find out why the family failed to attend the session. Sometimes there are legitimate reasons why these events occur. Occasionally a family may explain that they are in a crisis and after the crisis passes they will be able to come in. Since crises are times when a family is unbalanced, it is an ideal time to work with them as it may be easier to engender change. The therapist can begin to connect with the family by defining therapy as aid and an additional resource rather than a stressor. There are occasions when a family is referred by an institution of social control such as a court or child protective service agency, and the family states that there is no problem. In these instances it is particularly important for the therapist to be supportive and to attempt to involve each family member. Beginning with safe and non-threatening topcis such as what family members like to do, interests, school or job situations, and aspirations can provide a way for
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Family Therapy
the family to get to know the therapist and learn to trust him or her. Another approach that can be effective is to gently and without blame confront the family with the facts. For example, one family was referred by the juvenile court and the family adamantly denied that any problems existed. The only problem they could see was that Eric, age 17, was unjustly being harassed by the police. After a lengthy discussion of their likes, hobbies, and interests, the therapist began to talk with the parents about their aspirations for Eric. The parents and Eric wanted him to finish high school and go on to a technical school to learn electronic repair. Eric had an interest in joining the army as another way of learning a skilled trade. At this point the therapist said, “He’s been arrested five times for possession; we’ve got to do something or he’ll wind up in jail. The judge said that next time Eric would be charged as an adult and a felony conviction will ruin his chances of getting into the army or finishing school.” This mobilized the parents to want to work with the therapist. The parents still felt that Eric was being treated unfairly but acknowledged that his future was in jeopardy. This provided the basis for a working alliance and a therapeutic contract. One person dominating the session is another problem which the therapist must address in a skillful and supportive manner. If the therapist senses that it is the person’s anxiety that is driving him or her to dominate the session, providing structure and reassurance are one way of handling this problem. The therapist can explain that everyone needs to be heard in the family. If the person keeps interrupting, the therapist might politely and firmly state that the person will be gotten back to later but that other family members need a chance as well. Another approach is to reframe the interrupter’s behavior as “doing all the work for the family.” Frequently, it is a mother who will be the family spokesman. This person often feels overwhelmed because she feels the complete weight of responsibility for the family. Being in the position of “family switchboard” she may feel harried, overworked, and unappreciated. If this is the case, the therapist can suggest that the mother is working too hard and that she sit back and take it easy while others carry their weight. A frequently occurring problem is a person, typically an adolescent, who will not talk. In deciding how to approach this problem it is important that the therapist assess whether the adolescent is not talking because of fear and anxiety or because of anger and hostility. If the adolescent is scared and anxious two techniques may be useful. The therapist can explain that everyone has an opinion and that the adolescent’s opinion is as important as other people’s opinions. The therapist might say that, “I really need to hear from you.” This support may encourage a fearful
teenager to begin talking. If the teenager is quite anxious, talk about and ask very concrete and safe questions. This will reassure the teenager. In addition, if the teenager is fearful of betraying family loyalties, this approach will not put the youth in an awkward situation. If the adolescent is angry and hostile, the therapist might try three other approaches. First, solicit the antipathy, encourage the adolescent to verbalize the anger, and listen to and be supportive of the adolescent. The therapist may ask, “Do you often find yourself doing things that you don’t want to do?” This approach can show your support and encourage the teenager to talk about how he or she feels about being in the session against his or her will. Second, if the teenager is adamantly silent, there is no way that the therapist can make the teenager talk. It may be best to avoid a power struggle and give the teenager permission to be silent while suggesting to the teenager that, “if you change your mind let me know.” Finally, the therapist might try moving on to someone else and talking about a topic that may be of interest to the non-talker or a topic in which the teenager may be misrepresented by other family members. If this occurs it is likely that the teenager will jump in to correct what she or he feels is a misrepresentation of the situation. These above problems may occur at other times during the course of treatment. The approaches described can be used at those times as well. Case Vignette A case example may help clarify a few of the previously described principles and techniques. Mrs. Johnson, a divorced mother, telephoned the agency at the insistance of her ex-husband’s attorney. Mr. and Mrs. Johnson had been unable to resolve a number of issues around the custody of their daughters, Jennie, age 13, and Julie, age 16. Mrs. Johnson complained bitterly about her ex-husband, their three year old divorce, and his subsequent remarriage. Mrs. Johnson blamed Mr. Johnson for all the difficulties she was experiencing as a single parent of two teenagers. Mrs. Johnson was not sure why the attorney had suggested that she call the agency and did not initially think that a meeting would accomplish anything. She seemed most interested in denegrating Mr. Johnson. The therapist decided not to directly challenge Mrs. Johnson’s formulation of her difficulties. (The primary goal of the initial telephone call is to connect with and involve the family so that all involved and significant family members will attend the first interview.) The therapist was supportive of Mrs. Johnson by voicing his understanding of how difficult it can be to be a single parent, especially of teenagers. The therapist then asked how Julie and Jennie were adjusting. Mrs. Johnson related that
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Julie was using alcohol and marijuana and that her grades were failing. In addition, Jennie was becoming difficult to handle and had recently been suspended from school for disrupting class. The therapist emphathized with Mrs. Johnson and stated that this was too much for her to handle alone and that he would like to help her get these problems under control. Mrs. Johnson began crying, and at this point the therapist suggested that a family meeting might be helpful. (The therapist widened the initially narrow view of the problem in order to provide a rationale for family treatment that is non-judgemental and non-pejorative.) The therapist stated that it would be best if Mrs. Johnson, the two girls, and Mr. Johnson attended this first evaluation session. (The therapist decides which family members are to be included in treatment.) Mrs. Johnson agreed and said that she would make the arrangements with her ex-husband. The therapist said that he would also telephone Mr. Johnson to confirm the appointment. (Contact an important family member directly, especially if there is disagreement between family members, so that the issue of attending family therapy does not become another power struggle.) After this telephone call the therapist generated a number of hypotheses about the Johnson family to help guide his activity during the initial interview a week later. First, it seemed that although the Johnson’s had legally divorced, Mr. and Mrs. Johnson appeared to still have a large emotional investment in the relationship with each other. The custody dispute and the children’s acting out could be seen as ways for Mr. and Mrs. Johnson to have contact and remain involved with each other. This hypothesis was given support by the ease with which Mrs. Johnson agreed to arrange for her ex-husband’s attending the initial evaluation session even though she had not seen any purpose to a family meeting. In addition, most of the interchanges between Mr. and Mrs. Johnson were mutually blaming and critical of the children’s misbehavior. The second hypothesis was that Mrs. Johnson was depressed and that the conflict with her ex-husband and the children’s acting-out may have served the function of deflecting Mrs. Johnson from her depression. Both hypotheses provided the therapist with a focus for the initial interview and both hypotheses received support during that session. In order to avoid the predictable and unproductive pattern of blame and criticism developing in the initial interview, the therapist began the session by introducing himself and asking each person to do likewise. He used the joining techniques of accommodating and confirming as he reflected on the family’s desire to work together to solve their problems. He then asked each person how the problem affected him or
Arthur A. Weidman her personally. Mr. Johnson talked about feeling left out and helpless as he watched his children get into more difficulty. Mrs. Johnson talked about feeling overwhelmed and helpless. Julie was angry and stated, “I just want to be left alone.” Jennie was reticent while mentioning that no one seemed to care anymore. Mr. Johnson tended to control and dominate the first part of the session. He would alternate between blaming Mrs. Johnson, threatening Julie, and bemoaning his inability to help. The therapist reframed Mr. Johnson’s controlling behavior as his attempt to feel a part of the family. The therapist then suggested to Mr. Johnson that he listen to what the others had to say because this might help him better understand how he could help. This intervention allowed Mr. Johnson to let others become more involved in the session and helped the other family members to see his behavior in a different light. Engaging Julie seemed to be the biggest problem facing the therapist. The therapist’s assessment was that Julie was hostile and angry. He began by asking Julie if she had wanted to come to the session. She said, “No.” The therapist then asked her if she was often in the position of doing things she really did not want to do. At this point Julie became quite angry and talked about having to visit her dad, which she did not want to do. She said, “If he doesn’t want to be a part of our family anymore, I don’t want to see him.” It was evident that Julie was acting as her mother’s surrogate in stating this. Julie went on to talk about her mother’s unfair rules. The therapist suggested, “Maybe we can figure out a way for you to get what you need without hurting yourself” Julie responded, “I’d like that, but they don’t want me to do anything.” At this point the therapist ended the session by summing up a few of the issues he thought were most important. He began by framing and normalizing the problem as family issues. The family was described as struggling to adapt to a new structure which was difficult for everyone. The therapist suggested that the children’s acting-out might be understood as their attempt to pull everyone together. The family accepted these reframings of the problems. The therapist then recommended that the first order of business was to help the children act in a less self-destructive manner; Julie’s drug abuse and Jennie’s poor school performance were serious problems which required immediate attention. The parents agreed to cooperate together in getting their children’s behavior under control. Much of the later treatment would involve actualizing this verbal agreement. Julie and Jennie gave their tacit approval by listening attentively and agreeing to come back for family meetings. In addition, Julie expressed interest in attending a teen group which the therapist had mentioned earlier when he spoke about understanding how kids feel when required by parents to do things
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they did not want to do. The therapist ended the session and subsequent treatment began the following week. SUMMARY Families with a substance abusing adolescent are a difficult and challenging group for therapists. When one views the role of the family in the etiology and maintenance of substance abuse, it becomes clearer that family treatment modalities can be an effective approach to this difficult problem. Adolescent substance abuse may represent a difficulty with a separation-individuation process as it recurs during adolescence. Specifically, through defensive delineation parental conflicts are externalized onto the adolescent who then acts out these conflicts. In an attempt to separate from the family and develop an independent sense of identity, the adolescent may rebel and begin to use drugs or alcohol. However, this behavior is a pseudo-separation in that it keeps the adolescent dependent on the family and thus serves to maintain family homeostasis. It is useful for the therapist to see the function of the symptom as the family’s attempt to solve a problem. This view may enable the therapist to help the family develop a more functional solution to its dilemma rather than overtly or covertly blaming one family member or another. If one is to use family treatment modalities, it is crucial that the therapist know how to engage the family in treatment and how to handle some of the more common resistances one may encounter in the process. Generally, the therapist must be persistent, active and supportive. Beginning treatment with substance abusing adolescents and their families is a difficult, complex, and tenuous phase. Particular care must be taken if the family is to be effectively engaged in treatment. This paper has provided specific tech-
niques that the therapist may use during two crucial stages of the beginning phase of treatment, the first telephone contact and the initial interview. The interventions are designed to accomplish three goals. First, the interventions facilitate the involvement of all relevant family members in treatment. Second, it is important that the therapist avoid futile power struggles with the family. Third, the interventions enable the therapist to side step family resistances to treatment. REFERENCES Alexander, B.K., & Dibb, G.A. (1977). Interpersonal perception in Addict Families, Family Process, 16, 17-28. Attardo, N. (l%S). Psycho-dynamic factors in the mother-child relationship in adolescent drug addiction. Psychotherapeutica Psychosomatica, 13, 249-255. Chien, I., Gerald, D.L., Lee, R.S., & Rosenfeld, E. (1964). The road to H. New York: Basic Books. Kaufman, E., & Kaufmann, P. (1979). The family therapy of alcohol and drug abuse. New York: Gardner Press. Minuchin, S. & Fishman, H.C. (1981). Family therapy techniques. Cambridge, Mass.: Harvard University Press. Stanton, M.D. (1979). Family treatment of drug problems: A review. In R.L. Dupont, A. Goldstein, and J. O’Connell (eds.), Handbook on drug abuse, (pp. 133-150), Washington, D.C.: U.S. Government Printing Office. Stanton, M.D., Todd, T.C. & Associates (1982) The family rherapy of drug abuse and addiction. New York: Guilford. Weidman, A. (1983). The compulsive adolescent substance abuser: Psychological differentiation and family process. Journal of Drug Education, 13, 161-172. Weidman, A. (1984a). Family therapy in a residential therapeutic community for adolescent substance abusers, Manuscript submitted for publication. Weidman, A. (1984b). Psychological differentiation and locus of control among compulsive adolescent substance abusers and their parents. (Doctoral dissertation, University of Maryland 1983). Dissertation Abstracts International, 44, 3948-b. (University microfilms DA8405718). Ziegler-Driscoll. G. (1977). Family research at Eagleville Hospital and Rehabilitation Center. Family Process, 16, 175-191.
ORIGINAL
Vol. 2, pp. 91-105,
1985 Copyright
014ts5472/05 53.00 + .al o 1985 Pergamon Press Ltd
CONTRIBUTION
Engaging the Families of Substance Abusing Adolescents in Family Therapy ARTHUR A. WEIDMAN,MSW,
POD,
CAC,
CDC
Jewish Family Service of Greater Springfield, Inc.
Abstract - This
article discusses three major topics: First, the family processes one typically finds in families with a substance abusing adolescent are described. These processes include pseudoseparation and defensive delineation. A case vignette is used to illustrate these processes. Second, an overview of the importance of family therapy in treating substance abusing adolescents is provided. Third, specific principals and techniques for involving families in family therapy are described. This area includes a discmion of such topics as using the initial telephone contact to join with and involve the family, and suggestions for handling some typicalproblems which the therapirt may encounter in the initial interview. These problems or resistance must be handled sensitively if the family is to remain in treatment. This is an important area since involving the families of substance abusing adolescents in treatment can be quite difficult and there is little practical literature available.
THE IMPORTANCE OF FAMILY THERAPY IN THE TREATMENT OF SUBSTANCE ABUSE
INTRODUCTION ADOLESCENTS, ADOLESCENTS,
PARTICULARLY
SUBSTANCE
ABUSING
are a challenging population for therapists. The volitility of adolescents coupled with the severity, intractability, and perilousness of substance abuse contributes to therapists frequently preferring not to treat substance abusing adolescents. In addition, the resistance of many families of substance abusing adolescents to becoming involved in treatment also contributes to therapist reticence about working with these youths and their families. However, the author’s experience has indicated that the resistance of therapists to treating this population in part stems from the therapists’ lack of practical knowledge of how to engage substance abusing adolescents and their families in treatment. Once therapists have a viable framework for understanding substance abuse and specific interventions upon which to draw, they are more willing to work with substance abusing adolescents, and treatment is more successful. This paper describes a framework for understanding adolescent substance abuse. It outlines principles and specific interventions one may use to involve families of substance abusing adolescents in treatment.
One may ask, “why work with the family when only one member is a substance abuser?” There are a number of responses to this question. First, the family is the context within which identity emerges. The family may be seen as a developing system which may facilitate or hinder an individual member’s development. If a family is having difficulty negotiating a particular phase of its development, an individual member may express that difficulty in the form of a symptom or a problem behavior. Problems may be viewed as being maintained by the family and as maintaining family stability. Individual and family problems may be seen as attempts to cope with a developmental issue; however the attempt is not adequate given the family’s limited view of the problem, previous deficits, or scarce resources. The family’s attempt to cope is often well-intentioned, and the resulting dysfunction is often quite unintended. A question that is sometimes useful to pose is, “How does this problem help the family, dyad, or individual maintain stability?” or “To what developmental issue is this problem a response?” Substance abuse may be seen as developing in response to a particular set of family problems and dynamics. One consequence of this view is that in order to understand and treat the etiology and maintaining dynamics of a problem, one will need to work with the family. The specific family
Reprint requests should be sent to Dr. Arthur Weidman, Executive Director, Jewish Family Service of Greater Sprinfield, Inc., It34 Mill Street, Springfield, Massachusetts 01108.
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98 dynamics which are involved in substance abuse will be more fully discussed in the next section. The second reason for working with families is that families are powerful groups of people who exert signficant influence on their members. In treatment, families can either be a tremendous support or an impediment which can undermine and sabotage treatment. From a practical standpoint it is wise to involve families in treatment to engender their support. A recent study (Weidman, 1984a), found a significant difference between two similar treatment facilities in the dropout rate when family therapy was used. In one treatment facility families were involved in family therapy. Within the first week the adolescent was in treatment and continued on a regular basis. This facility had a significantly lower drop-out rate than the similar facility which did not involve families in treatment until the third or later month and did not have family therapy as a required treatment component. There was also a significant relationship between the number of family therapy sessions attended and the drop-out rate in that the more family therapy sessions attended the less likely it was that the youth would drop out of treatment. A third reason for involving the families of drug abusers in family treatment is that family therapy has proven to be an effective tool in the treatment of drug abuse (Kaufman & Kaufman, 1979; Stanton, Todd & Associates, 1982). Stanton (1979) found that structural family therapy, when compared with no treatment and methadone maintenance treatment, substantially increased the percentage of drug free days. He stated, “The practice of treating the drug abuser and his family members separately or concurrently does not appear to be as promising or efficacious as treating them together . . . the point is, if treatment is not constructed to directly intervene in and change the family process surrounding detoxification, such treatment is much less likely to succeed” (p. 143). Stanton, Todd & Associates (1982) found that after one year, drug abusers who had received ten sessions of structural family therapy had a mortality rate of 2% while drug abusers who received no treatment or methadone maintenance treatment had a mortality rate of 10%. Zeigler-Driscoll (1977) found an association between the degree of improvement in the drug abuser’s family and the length of family therapy. It was found that 73% of the families that improved markedly with family therapy had attended five or more sessions. Weidman (1984b) explored the effects of structural family therapy on the level of psychological differentiation of compulsive adolescent substance abusers in residential treatment. It was found that the number of family therapy sessions, independent of length of stay in residential treatment was significantly correlated with an increase in psychological differentiation. Family therapy enabled the drug abuser to separate and individuate from the
Arthur A. Weidman family of origin by disengaging the symbiotic relationship with the maternal figure and strengthening the disengaged relationship with the paternal figure.
THE ROLE OF THE FAMILY IN THE DEVELOPMENT AND MAINTENANCE OF SUBSTANCE ABUSE Compulsive substance abuse may be viewed as a defensive functions, the purpose of which is to maintain family stability. Compulsive substance abuse may be related to a symbiotic relationship between an adolescent and a parent (Alexander & Dibb, 1977; Attardo, 1965; Ziegler-Driscoll, 1977). Viewed in this manner, compulsive substance may be an attempt to cope with the developmental issues of separation and individuation which precede the youth’s leaving home. The drug abuser has never fully achieved separation from the parent and is still in a dependent and symbiotic relationship (Weidman, 1983). The parents of the drug abuser do not encourage the abuser to individuate and separate from the family. Compulsive substance abuse may be seen as a pseudo-separation in which the apparently independent and defiant use of drugs maintains the drug abuser in a dependent position vis-a-vis the family of origin. This substance dependency, which is an exchange of dependency on parents for dependency on drugs, serves to maintain a drug abuser’s dependency on his or her parent(s). An example of pseudo-separation is that of an adolescent who is using drugs and engaged in other anti-social behavior and whose self-destructive, parents still support the youth by giving the youth use of the family car, pocket (read drug) money, money for legal fees, and bail. Frequently the teenager disobeys the parents, steals from the family, may be violent with family members, and is arrested. The dependent and fused nature of the parent-adolescent relationship is shown by the fact that, even with all of the adolescent’s self-destructive acting-out, the parents still try to help by giving the teenager “one more chance.” Were the parents to try to stop the youth’s acting-out by not rescuing the youth, removal from the home and placement in a treatment program or detention center would be the most likely outcome. The parents and the adolescent often experience a profound and unconscious fear of object loss. Since the adolescent and parents are involved in a fused relationship, one often observes a significant depression develop in both parents and adolescent when they are separated. When, with support, parents are able to take a firm and consistent position with the adolescent and get the teenager into treatment, the adolescent typically becomes enraged and depressed. The importance of family processes in the development of compulsive substance abuse is fur-
Family Therapy
ther outlined in the work of Chein, Gerald, Lee and Rosenfeld (1964) who stated, “the overall results of the analysis of our indexes gives strong support to the view that family experiences play an important role in the etiology of addiction” (p. 271). If family processes play a significant role in the development and maintenance of substance abuse, then family therapy should have a significant impact on this problem. The impact of family therapy on the drug abuser’s family may be seen in a number of areas, including disengaging the fused family system and moving the drug abuser from a state of pseudo-separation to a state of relative differentiation, autonomy, and sense of separate identity. An important dynamic operating in the families of chemically dependent teenagers is defensive delineation. Delineations are the view one person has of another as revealed implicitly or explicitly in the behavior of the one person with the other. When the delineation contains evidence of distortion of the other person related to the individual’s defense structure, then the delineation can be termed a defensive delineation. For example, the parents of one teenager saw him as still being a failure despite his one and a half years in a therapeutic community, his getting a high school diploma, and the evaluations of the staff that he was ready to move out on his own. The teenager’s father had never achieved any of his own dreams. The son’s achievements confronted the father with his own failures. Typically, what is found in such cases is a pattern of anxiety in the parents over the adolescent’s potential for individuation and separation. The parental anxiety over the adolescent’s developmental growth is a major cause of parental defensive delineations, wherein the adolescent’s maturation stirs up conflicts and anxieties in the parent who projects onto the adolescent one part of a previously internalized conflict. Externalizing the conflict onto an interpersonal relationship diminishes parental anxiety. A significant component in this process is the conscious or unconscious willingness of the recipient of the projection to accept the projection. The teenager colludes with the parent in providing vicarious gratification for the parent of the unacceptable and unconscious desires. The motivation for the adolescent’s collusion in this process is the gratification received by reducing parental anxiety. Since a relatively fused state exists between the adolescent and parent, what is anxiety reducing for the parent is gratifying for the adolescent. Case Vignette
At this point an example may help to illustrate the dynamics which have been described. John was 17 years of age, the only child of parents who have been separated and divorced for over 7 years. They mar-
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ried when Mr. Smith was 19 and Mrs. Smith was 17. Although it was not true, Mrs. Smith had told Mr. Smith she was pregnant so that they would marry. The marriage was beset with problems from the beginning. The parents had frequent arguments in which they screamed and occasionally hit each other. When these fights occurred, Mrs. Smith would get John, who was born a year into the marriage, and hold him between her and Mr. Smith as a shield. This usually stopped the fighting. Mr. Smith is an alcoholic whose father was distant and rigid. When drunk, Mr. Smith would become belligerent. He had many dreams for John, his namesake, dreams that Mr. Smith had been unable to fulfill for himself. Through defensive delineation, Mr. Smith avoided feelings of inadequacy by having John live out these dreams. When John reach puberty and began separating himself from these delineations, he and his father began fighting. The arguments were heated and occasionally physical. The pseudo-separation that John’s behavior represented can be seen in a number of behaviors. John’s use of drugs and alcohol was similar to his father’s alcoholism. John could express hostile feelings only when drunk. John frequently ran from one parent’s home to the other. Mrs. Smith is a very quiet, passive-aggressive woman who rarely experienced angry feelings and frequently experienced guilty feelings. Mrs. Smith’s father was a belligerent alcoholic. Her mother was a masochistic woman whose primary concern was that of placating her husband. Anger was experienced as a dangerous emotion to be avoided at all costs. The defensive delineation that John was an angry, belligerent son protected Mrs. Smith from her own angry feelings and the guilt she experienced about these feelings. The Smith family fiction was that anger was destructive, dangerous, murderous, and not controllable, though, in fact, no one had been seriously hurt physically by the angry outbursts. As a function of this, John, who was the repository of family anger, never actually experienced anger. Instead, he used drugs extensively; he drank nearly every day; he broke into other people’s homes at least thirty times; he stole his mother’s car and had accidents; and he stole from his paternal grandparent’s home. Mrs. Smith reported feeling secretly thrilled by John’s escapades. Although the parents knew that what John was doing was wrong, they both usually gave him one more chance. One might ask, one more chance to do what? Consciously each parent wanted to help John by not reporting him to the authorities. Unconsciously they were giving him one more chance to act out, one more chance to get back at the other parent, one more chance to express anger for the family and not disrupt the family equilibrium. John’s actions served a number of important func-
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tions for the Smith family: (a) He remained in a fused relationship with his mother, acting out the angry feelings that were unacceptable to her; (b) Although overly distant from his father, John was also in a fused-relationship with him. Through projectiveidentification, John was the recipient of his father’s unacceptable failures and became the vehicle for Mr. Smith to raise his own self-esteem. John’s behavior served the function of containing split off and projected negative aspects from his father; (c) John’s actions can be seen as self-destructive in order to atone for the guilt he experienced over not being able to keep his parents together and his unconscious wishes to split them up. (Remember, John was used as a shield to stop Mr. and Mrs. Smith from fighting); (d) John’s behavior served to act out his mother’s hostile feelings against his father. This was achieved by John being a failure at all the things his father had hoped for him; (e) By remaining a focal point and release for guilty and angry feelings, the parents were absolved of responsibility for their own feelings and impulses. Thus, the family fiction that only John had problems was maintained. What should be clear at this point is that adolescent substance abuse is a complex phenomenon involving individual and family dynamics. Therefore, treatment will necessarily involve the family as a frame of reference and focal point for intervention. Successful treatment must address the dynamics of defensive delineations and family fictions which served defensive and regressive functions in maintaining family stability. Treatment must also involve fostering separation and individuation on the part of the adolescent substance abuser. Interventions that facilitate ego-differentiation and interrupt the symbiotic fused relationship between parent and child will be required. ENGAGING THE FAMILY IN TREATMENT This section will describe a few general principles and techniques one may use to engage in treatment the families of substance abusing adolescents. The discussion will focus on the first telephone contact and initial interview with the family. The initial telephone contact and the initial interview are crucial times in the course of treatment. If one does not successfully engage the family at those junctures, there will not be any subsequent treatment. Six general principles will be described which can be used to guide the therapist’s efforts to engage resistant families in treatment. General Principles
First, the therapist should decide which family members need to be included in treatment and not leave
Arthur A. Weidman this decision to the family. This is critical because if the decision is left to the family certain key members, such as a father, grandmother, or an aunt who is living in the home, may be left out. The assessment should provide information about how the symptom functions, how the family maintains the symptom, and what negative consequences might befall the family or a specific member if the symptom were to suddenly disappear. After the therapist has completed an assessment, then treatment goals can be generated and such technical questions as who should come to subsequent treatment sessions may be answered. Second, the therapist can approach the family with a rationale for treatment that is non-judgmental and non-pejorative. It is important to provide support to the parents who often feel responsible for their child’s behavior but who will react with indignation and anger if they are blamed. To accomplish this, the therapist can talk with the parents about what they have been through and the difficulties that they have experienced. The therapist can empathize with the parents, tell them that it is time for the youth’s drug abuse to stop, and that the therapist wants to help them get the problem under control. The primary goal of treatment should be on helping the adolescent overcome the drug problem. The therapist can then join with the parents in helping the child to be the kind of person she or he can be. One way to do this is to talk with the parents about their goals for their child. How would they like her or him to be? What does success mean? The therapist can conclude by stating that working with parents can help them help their child succeed in a new way. Other rationales for family treatment include discussing the fact that substance abuse is a complex, vicious, and potentially life-threatening problem which will require everyone’s help and involvement if the teenager is to be helped. In addition, if the family has already attempted other solutions and forms of treatment, the therapist can suggest that those other attempts may have failed because not everyone who needed to be involved in helping the substance abusing adolescent was included in treatment. Third, if possible try to reframe in positive terms a family member’s resistance to participating in treatment. If the resistance is seen as bad and if the therapist and family are angry or confrontive, a power struggle which can only be destructive may ensure. For instance, a disengaged, disinterested father’s lack of involvement can be reframed as, “not wanting to intrude.” The therapist could then have the family talk about whether the father is intrusive or whether they would like to invite him to become more involved. Fourth, adopt the parents’ goals for the adolescent; these are the primary ones for treatment. Getting off
Family Therapy
drugs, staying out of jail, becoming more responsible, or related issues that the family may want for their teenager should be adopted as treatment goals. Fifth, in attempting to engage the family, it is important to show interest by being flexible in attempts to involve the family in treatment. The therapist must be energetic which may involve frequent telephone calls, home visits, or other attempts to contact and involve the family. The therapist will need to be persistent and be able to tolerate repeated rebukes by the family. Flexibility is crucial, including the ability to change and reschedule appointment times. Finally, the therapist must be absolutely convinced of the value of what is being provided, believing that this will help the family. The therapist’s conviction will be conveyed to the family, and this may help them feel that they want to become involved. Initial Telephone Contact Usually the first contact with the family will be when they telephone the agency. The primary goal for the therapist is to connect with and involve the family so that all household and significant family members will attend the first interview. Secondary goals may include gathering information about the presenting problem and family or completing agency forms. The secondary goals can usually be accomplished by pursuing the primary goal. It is often valuable if the initial telephone contact provides the therapist with enough information to formulate a few hypotheses about the family and the nature or function of the problem. These initial hypotheses can guide the therapist’s line of questioning and behavior during the initial interview. The initial telephone call may also be seen as a screening interview by the family to evaluate the agency and decide whether or not to pursue treatment. There may be some initial resistance by the family to family therapy. It is important that the therapist initially accept the family’s view of the problem and empathize with the caller. The therapist will have more time later when the family is in the therapist’s office to explore other views of the situation. During the initial telephone contact attempts to convince the family that the therapist has a better way of viewing the problem may only engender a useless power struggle. The ultimate outcome may be the family’s refusal to come in for treatment. Five approaches to use on the telephone to involve the whole family in the initial interview are described. First, the therapist can indicate that it is routine to get everyone’s input so that all family members must be seen initially. This may be facilitated by having it be standard procedure for all family members to come to the initial interview. In residential programs family visits can be made contingent on family participation in treatment. For example, in one family
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the mother and son were enmeshed and actively excluded the father, who was peripherally involved with the family. The mother would appear for family sessions and visits without her husband. When she was told, “If Jim’s father doesn’t show up, you won’t be able to meet with your son,” she became angry, but Jim’s father never missed a session after that. Second, the therapist can suggest that the whole family may only need to be seen, “just this once,” and that later sessions may not need to include everyone. The therapist may explain that seeing the whole family at least once will help him or her gain a more full and complete understanding of their situation and help the therapist be better able to help the family. Third, widen the problem definition by asking how other people react to the problem and how these other people are affected by the problem. Sometimes a parent will say that a non-chemically dependent sibling should not be involved. An effective technique to use is to state that a non-abusing sibling can be used as a model. Fourth, use your past experience and explain that you have found family therapy to be an effective therapeutic technique or indicate that research has shown that involving the family is much more effective than not involving the family. Fifth, often it is only one key family member, such as the father, whom you are told will not come for family therapy. Contact any important family members directly whenever you suspect there will be some resistance to that person coming in. Sometimes, especially if there is disagreement between the parents about how to handle the adolescent, a parent’s resistance to attending an initial interview may represent a power struggle with the other parent rather than resistance to family therapy. Talking directly with the resistant family member may defuse the situation. It is useful to begin by exploring what attempts have been made to involve the resistant family member; then one can suggest other ways to encourage participation. For example, some parents can be motivated to attend an initial interview if their presence is asked for rather than demanded. One can also suggest that since drug abuse is potentially life threatening, the youth may wind up dead if he or she is not helped soon. Some parents can be motivated to come in by pointing out that they are financially liable for their minor. They can be told that if help is not secured soon the youth may become increasingly involved in illegal activities and the family liability for court costs and restitution may be substantial. In other families, it may be that even though the parent or therapist does not have much influence with the resistant family member, another family member such as an aunt, uncle, or grandparent may have influence. In these situations it can be quite effective to work through that influential family member to en-
I02 courage the resistant family member’s participation. The earlier you involve all family members, the easier this will be. Research has shown that if family members are involved later in the treatment process, such as after a few weeks or months of treatment, it is very difficult to later engage these excluded members in treatment (Weidman, 1984a). The excluded members may interpret their not being involved in treatment as a message that they are not important or that they have not been respected. Their later resistance to being involved in treatment may be seen as a reflection of this interpretation. Initial Interview
When the family presents itself for the initial interview it is the therapist’s task to get to know and join with the family, exploring its strengths and competencies as well as its problems, and to test the hypotheses generated after the initial telephone contact. Exploring strengths and competencies is one way to join with the family. Beginning in this manner expands the family’s initially narrow range of focus and limited definition of the problem. Often families are stuck because their view of the problem does not lead to a solution. Helping a family see the problem in a different context and highlighting strengths on which to build may lead to their finding their solution. There are a variety of interventions one may use to involve a family in treatment and develop a working alliance. Generally, these interventions all come under the heading of “joining techniques.” There are four joining techniques, accommodating, confirming, tracking, and normalizing (Minuchin & Fishman, 1981). Accommodating involves using the family’s language and style of speaking. The therapist adjusts his or her way of relating to the family’s style. For example, a family in which the range of affect is constricted or muted would be accommodated to by responding with muted affect. Confirming involves supporting individual and family strengths. The fact that a father has held his job for 15 years or that even with their problems the family is still together are strengths that can be highlighted in an effort to join with the family. Confirming can also involve acknowledging a person’s feelings or even simply describing an interaction. For example, “I notice that when you are asked a question, he answers.” Tracking involves listening and encouraging the discussion by nodding and asking leading questions such as, “and then what happened?” Tracking is a way for the therapist to show interest. Normalizing involves placing an issue or problem in a contact that highlights its normal aspects. Examples of this are: “Many children have nightmares
Arthur A. Weidman at that age,” or “Most newly divorced parents feel overwhelmed; after all you are doing the job of two now.” Specifically, the therapist should talk with each person and stay with that person until the therapist experiences a level of comfort and spontaneity after which time the therapist can move to the next person. One way to begin is by asking, “I would like to get to know you and your family. Could you tell me about yourself?” The therapist may need to be more or less specific depending on the family. As each person describes him or herself, interests, likes, and abilities, the therapist should note and confirm these. In initial interviews there are a number of typical and expected problems that arise. A few of these typical resistances will be described and approaches for handling these problems will be outlined. A family member may rigidly adhere to the idea that either he or she is the problem or that someone else is the problem, but that no one is involved. For example, a family may define the problem as being their substance abusing teenager and not realize that the father’s alcoholism and marital conflicts also play a part in the situation. One can approach this therapeutic difficulty in a number of ways. Encourage each family member to talk about how he or she sees the problem and how the problem affects him or her. The therapist can also expand the family’s view of the problem by asking one family member how the problem affects two other people. For example, “When your sister comes home drunk, how are your mom and dad with each other, do they fight more or less?” The therapist can also expand the family’s view of the problem by asking the person blamed to explain or defend him or herself, “Your folks say that you are the problem, is that so, are you the problem?” When the family cancels or fails to attend the initial interview, therapists frequently feel frustrated and annoyed. It is important to find out why the family failed to attend the session. Sometimes there are legitimate reasons why these events occur. Occasionally a family may explain that they are in a crisis and after the crisis passes they will be able to come in. Since crises are times when a family is unbalanced, it is an ideal time to work with them as it may be easier to engender change. The therapist can begin to connect with the family by defining therapy as aid and an additional resource rather than a stressor. There are occasions when a family is referred by an institution of social control such as a court or child protective service agency, and the family states that there is no problem. In these instances it is particularly important for the therapist to be supportive and to attempt to involve each family member. Beginning with safe and non-threatening topcis such as what family members like to do, interests, school or job situations, and aspirations can provide a way for
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the family to get to know the therapist and learn to trust him or her. Another approach that can be effective is to gently and without blame confront the family with the facts. For example, one family was referred by the juvenile court and the family adamantly denied that any problems existed. The only problem they could see was that Eric, age 17, was unjustly being harassed by the police. After a lengthy discussion of their likes, hobbies, and interests, the therapist began to talk with the parents about their aspirations for Eric. The parents and Eric wanted him to finish high school and go on to a technical school to learn electronic repair. Eric had an interest in joining the army as another way of learning a skilled trade. At this point the therapist said, “He’s been arrested five times for possession; we’ve got to do something or he’ll wind up in jail. The judge said that next time Eric would be charged as an adult and a felony conviction will ruin his chances of getting into the army or finishing school.” This mobilized the parents to want to work with the therapist. The parents still felt that Eric was being treated unfairly but acknowledged that his future was in jeopardy. This provided the basis for a working alliance and a therapeutic contract. One person dominating the session is another problem which the therapist must address in a skillful and supportive manner. If the therapist senses that it is the person’s anxiety that is driving him or her to dominate the session, providing structure and reassurance are one way of handling this problem. The therapist can explain that everyone needs to be heard in the family. If the person keeps interrupting, the therapist might politely and firmly state that the person will be gotten back to later but that other family members need a chance as well. Another approach is to reframe the interrupter’s behavior as “doing all the work for the family.” Frequently, it is a mother who will be the family spokesman. This person often feels overwhelmed because she feels the complete weight of responsibility for the family. Being in the position of “family switchboard” she may feel harried, overworked, and unappreciated. If this is the case, the therapist can suggest that the mother is working too hard and that she sit back and take it easy while others carry their weight. A frequently occurring problem is a person, typically an adolescent, who will not talk. In deciding how to approach this problem it is important that the therapist assess whether the adolescent is not talking because of fear and anxiety or because of anger and hostility. If the adolescent is scared and anxious two techniques may be useful. The therapist can explain that everyone has an opinion and that the adolescent’s opinion is as important as other people’s opinions. The therapist might say that, “I really need to hear from you.” This support may encourage a fearful
teenager to begin talking. If the teenager is quite anxious, talk about and ask very concrete and safe questions. This will reassure the teenager. In addition, if the teenager is fearful of betraying family loyalties, this approach will not put the youth in an awkward situation. If the adolescent is angry and hostile, the therapist might try three other approaches. First, solicit the antipathy, encourage the adolescent to verbalize the anger, and listen to and be supportive of the adolescent. The therapist may ask, “Do you often find yourself doing things that you don’t want to do?” This approach can show your support and encourage the teenager to talk about how he or she feels about being in the session against his or her will. Second, if the teenager is adamantly silent, there is no way that the therapist can make the teenager talk. It may be best to avoid a power struggle and give the teenager permission to be silent while suggesting to the teenager that, “if you change your mind let me know.” Finally, the therapist might try moving on to someone else and talking about a topic that may be of interest to the non-talker or a topic in which the teenager may be misrepresented by other family members. If this occurs it is likely that the teenager will jump in to correct what she or he feels is a misrepresentation of the situation. These above problems may occur at other times during the course of treatment. The approaches described can be used at those times as well. Case Vignette A case example may help clarify a few of the previously described principles and techniques. Mrs. Johnson, a divorced mother, telephoned the agency at the insistance of her ex-husband’s attorney. Mr. and Mrs. Johnson had been unable to resolve a number of issues around the custody of their daughters, Jennie, age 13, and Julie, age 16. Mrs. Johnson complained bitterly about her ex-husband, their three year old divorce, and his subsequent remarriage. Mrs. Johnson blamed Mr. Johnson for all the difficulties she was experiencing as a single parent of two teenagers. Mrs. Johnson was not sure why the attorney had suggested that she call the agency and did not initially think that a meeting would accomplish anything. She seemed most interested in denegrating Mr. Johnson. The therapist decided not to directly challenge Mrs. Johnson’s formulation of her difficulties. (The primary goal of the initial telephone call is to connect with and involve the family so that all involved and significant family members will attend the first interview.) The therapist was supportive of Mrs. Johnson by voicing his understanding of how difficult it can be to be a single parent, especially of teenagers. The therapist then asked how Julie and Jennie were adjusting. Mrs. Johnson related that
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Julie was using alcohol and marijuana and that her grades were failing. In addition, Jennie was becoming difficult to handle and had recently been suspended from school for disrupting class. The therapist emphathized with Mrs. Johnson and stated that this was too much for her to handle alone and that he would like to help her get these problems under control. Mrs. Johnson began crying, and at this point the therapist suggested that a family meeting might be helpful. (The therapist widened the initially narrow view of the problem in order to provide a rationale for family treatment that is non-judgemental and non-pejorative.) The therapist stated that it would be best if Mrs. Johnson, the two girls, and Mr. Johnson attended this first evaluation session. (The therapist decides which family members are to be included in treatment.) Mrs. Johnson agreed and said that she would make the arrangements with her ex-husband. The therapist said that he would also telephone Mr. Johnson to confirm the appointment. (Contact an important family member directly, especially if there is disagreement between family members, so that the issue of attending family therapy does not become another power struggle.) After this telephone call the therapist generated a number of hypotheses about the Johnson family to help guide his activity during the initial interview a week later. First, it seemed that although the Johnson’s had legally divorced, Mr. and Mrs. Johnson appeared to still have a large emotional investment in the relationship with each other. The custody dispute and the children’s acting out could be seen as ways for Mr. and Mrs. Johnson to have contact and remain involved with each other. This hypothesis was given support by the ease with which Mrs. Johnson agreed to arrange for her ex-husband’s attending the initial evaluation session even though she had not seen any purpose to a family meeting. In addition, most of the interchanges between Mr. and Mrs. Johnson were mutually blaming and critical of the children’s misbehavior. The second hypothesis was that Mrs. Johnson was depressed and that the conflict with her ex-husband and the children’s acting-out may have served the function of deflecting Mrs. Johnson from her depression. Both hypotheses provided the therapist with a focus for the initial interview and both hypotheses received support during that session. In order to avoid the predictable and unproductive pattern of blame and criticism developing in the initial interview, the therapist began the session by introducing himself and asking each person to do likewise. He used the joining techniques of accommodating and confirming as he reflected on the family’s desire to work together to solve their problems. He then asked each person how the problem affected him or
Arthur A. Weidman her personally. Mr. Johnson talked about feeling left out and helpless as he watched his children get into more difficulty. Mrs. Johnson talked about feeling overwhelmed and helpless. Julie was angry and stated, “I just want to be left alone.” Jennie was reticent while mentioning that no one seemed to care anymore. Mr. Johnson tended to control and dominate the first part of the session. He would alternate between blaming Mrs. Johnson, threatening Julie, and bemoaning his inability to help. The therapist reframed Mr. Johnson’s controlling behavior as his attempt to feel a part of the family. The therapist then suggested to Mr. Johnson that he listen to what the others had to say because this might help him better understand how he could help. This intervention allowed Mr. Johnson to let others become more involved in the session and helped the other family members to see his behavior in a different light. Engaging Julie seemed to be the biggest problem facing the therapist. The therapist’s assessment was that Julie was hostile and angry. He began by asking Julie if she had wanted to come to the session. She said, “No.” The therapist then asked her if she was often in the position of doing things she really did not want to do. At this point Julie became quite angry and talked about having to visit her dad, which she did not want to do. She said, “If he doesn’t want to be a part of our family anymore, I don’t want to see him.” It was evident that Julie was acting as her mother’s surrogate in stating this. Julie went on to talk about her mother’s unfair rules. The therapist suggested, “Maybe we can figure out a way for you to get what you need without hurting yourself” Julie responded, “I’d like that, but they don’t want me to do anything.” At this point the therapist ended the session by summing up a few of the issues he thought were most important. He began by framing and normalizing the problem as family issues. The family was described as struggling to adapt to a new structure which was difficult for everyone. The therapist suggested that the children’s acting-out might be understood as their attempt to pull everyone together. The family accepted these reframings of the problems. The therapist then recommended that the first order of business was to help the children act in a less self-destructive manner; Julie’s drug abuse and Jennie’s poor school performance were serious problems which required immediate attention. The parents agreed to cooperate together in getting their children’s behavior under control. Much of the later treatment would involve actualizing this verbal agreement. Julie and Jennie gave their tacit approval by listening attentively and agreeing to come back for family meetings. In addition, Julie expressed interest in attending a teen group which the therapist had mentioned earlier when he spoke about understanding how kids feel when required by parents to do things
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they did not want to do. The therapist ended the session and subsequent treatment began the following week. SUMMARY Families with a substance abusing adolescent are a difficult and challenging group for therapists. When one views the role of the family in the etiology and maintenance of substance abuse, it becomes clearer that family treatment modalities can be an effective approach to this difficult problem. Adolescent substance abuse may represent a difficulty with a separation-individuation process as it recurs during adolescence. Specifically, through defensive delineation parental conflicts are externalized onto the adolescent who then acts out these conflicts. In an attempt to separate from the family and develop an independent sense of identity, the adolescent may rebel and begin to use drugs or alcohol. However, this behavior is a pseudo-separation in that it keeps the adolescent dependent on the family and thus serves to maintain family homeostasis. It is useful for the therapist to see the function of the symptom as the family’s attempt to solve a problem. This view may enable the therapist to help the family develop a more functional solution to its dilemma rather than overtly or covertly blaming one family member or another. If one is to use family treatment modalities, it is crucial that the therapist know how to engage the family in treatment and how to handle some of the more common resistances one may encounter in the process. Generally, the therapist must be persistent, active and supportive. Beginning treatment with substance abusing adolescents and their families is a difficult, complex, and tenuous phase. Particular care must be taken if the family is to be effectively engaged in treatment. This paper has provided specific tech-
niques that the therapist may use during two crucial stages of the beginning phase of treatment, the first telephone contact and the initial interview. The interventions are designed to accomplish three goals. First, the interventions facilitate the involvement of all relevant family members in treatment. Second, it is important that the therapist avoid futile power struggles with the family. Third, the interventions enable the therapist to side step family resistances to treatment. REFERENCES Alexander, B.K., & Dibb, G.A. (1977). Interpersonal perception in Addict Families, Family Process, 16, 17-28. Attardo, N. (l%S). Psycho-dynamic factors in the mother-child relationship in adolescent drug addiction. Psychotherapeutica Psychosomatica, 13, 249-255. Chien, I., Gerald, D.L., Lee, R.S., & Rosenfeld, E. (1964). The road to H. New York: Basic Books. Kaufman, E., & Kaufmann, P. (1979). The family therapy of alcohol and drug abuse. New York: Gardner Press. Minuchin, S. & Fishman, H.C. (1981). Family therapy techniques. Cambridge, Mass.: Harvard University Press. Stanton, M.D. (1979). Family treatment of drug problems: A review. In R.L. Dupont, A. Goldstein, and J. O’Connell (eds.), Handbook on drug abuse, (pp. 133-150), Washington, D.C.: U.S. Government Printing Office. Stanton, M.D., Todd, T.C. & Associates (1982) The family rherapy of drug abuse and addiction. New York: Guilford. Weidman, A. (1983). The compulsive adolescent substance abuser: Psychological differentiation and family process. Journal of Drug Education, 13, 161-172. Weidman, A. (1984a). Family therapy in a residential therapeutic community for adolescent substance abusers, Manuscript submitted for publication. Weidman, A. (1984b). Psychological differentiation and locus of control among compulsive adolescent substance abusers and their parents. (Doctoral dissertation, University of Maryland 1983). Dissertation Abstracts International, 44, 3948-b. (University microfilms DA8405718). Ziegler-Driscoll. G. (1977). Family research at Eagleville Hospital and Rehabilitation Center. Family Process, 16, 175-191.