In 1983 we (the authors) read a series of articles and
books on family therapy with addicts. We were particularly impressed by
the work of Stanton and Todd who made a prospective randomized family
therapy study on heroin addicts in Philadelphia 1974-1978. In their
research they showed that structural/strategic family therapy with the
addict and his family of origin was a very effective method.
At the time one of us considered himself to be a
structural family therapist and the other considered himself a strategic
and we had recently begun a fruitful collaboration. Stanton and Todd
worked with a method they called structural/strategic and we decided to
test if it was possible to treat heroin addicts in Sweden with this method.
From the autumn of 1983 till summer 1984 we made a pilot-study where we
treated 6 heroin addicts in five families with structural/strategic family
therapy.
The experiences we made in the pilot-study fitted well
with what we had read in the literature; enmeshed families, bizarre
dysfunctional patterns of interaction, inverted hierarchies, extremely
close contact with one of the parents, many other addicts in the families,
special mythology around death, the problem of addiction fills a function
in the family, the addict sacrifices himself for his relatives,
pseudo-individuation, pseudo-sexuality, when the addict stops doing drugs
someone else gets ill or the parents threaten separation etc.
The pilot-study lead to a larger study "Family
therapy with heroin addicts – an effect- and process-study" (or
"The heroin-program"), financed by the Social Research
Delegation, The Swedish board of health and the commune of Malmö. This
study was done at the clinic of Child and Adolescent Psychiatry at Malmö
General Hospital during the years 1986-1990.
In the heroin program eight therapists worked together
10 hours a week. Four were relatively experienced family therapists from
child psychiatry. Four were less experienced and came from the social
welfare system. Two teams were formed with two experienced and two
inexperienced therapists in each. The idea being that there should always
be at least one experienced therapist behind the one-way-screen even when
an experienced therapist worked with a family.
The purpose was that the experienced should train the less
experienced, that method and worldview would become anchored into the
drug treatment services and research on process
and effect should be conducted.
We hoped that if the method proved successful
there would immediately be trained family therapists available to start
clinical work. In this way the program came to consist of four levels:
treatment, training, anchoring and research.
As for the part of the program dealing with the effect,
the 3-year follow-ups were terminated in the winter of 1993. A clinical
report to the Board of Health was published in 1992.
A more detailed description of the heroin program can
be find in a chapter in a coming anthology by Johan Sundelin and Kjell
Hansson, "Familjeterapi på svenska" (Family Therapy in
Swedish". Research reports from the program are being published in 1994 from the Research unit, Child and Adolescent Psychiatry, Malmö
General Hospital.
Among other things psychotherapeutic theories are
distinguished from each other by how they understand change and what
produces it.
Psychodynamic theory sees change as a result of insight.
Structural family therapy sees change as a result of a changed
organization in the family. Strategic family therapy sees change as the
result of corrected dysfunctional hierarchies and perverse coalitions. The
MRI-school sees change as a result of people stopping the attempted
solutions that have become a problem.
Different models explain each in its own way why people
have problems. The above mentioned have in common that they see a problem
as a symptom caused by some underlying disturbance. This underlying
disturbance is the real problem that has to be changed, cured or corrected
for the symptom to disappear.
To know what has to be done, we therapists explain to
ourselves what we see happen, and at the same time, and within the same
theoretical frame, we explain our own behavior in relation to it. "I
made an interpretation." "I did an enactment." "I did
a lunch-session." "I made a phobia-training."
Just like Cecile is making sense out of her reality
with her story, we therapists create meaning in what we do by explaining
it.
The frame and the metaphors we use will affect our
client's behavior. You don’t have to go any further than to people in
Freudian analysis that dream Freudian dreams, and compare with people in
Jungian analysis dreaming Jungian dreams. What people talk about in the
therapy room and how they talk about it has impact on what they do when
they are at home.
Hence we create meaning in what we see, and we also
create what we see through the meaning we give it.
The basis for several theories about family therapy is
the homeostatic model. The family is described as a self-regulating system
where the symptom, for instance drug abuse, fills a function in the family.
When someone improves – or changes his behaviour in any other way –
this will trigger feedback that will bring the family back to the same
state as before the change.
Clinically this is apparent when the addict detoxes; a
crisis arises somewhere else in the family, and this crisis is an implicit
message to the addict to turn on again. The structure containing, or being
the base of the dysfunctional interactions, must change before the addict
can be reliably abstinent. The families are stuck in their development and
need help to liberate their resources in order to continue a healthy
development, one that doesn’t contain the addiction as an important part
of the interaction. The organization and interaction in the families need
to change.
The descriptive metaphors are (among others)
dysfunctional interactions, overinvolved parents, perverse triangles,
pseudo-individuated teenagers, pathologic dependency and enmeshment.
Edwin, 28, started experimenting with drugs in his
teens and got quickly to heroin. He made one attempt at detox when he
had a child with a woman he stayed with for almost two years. The detox
went well, but as he says himself during the ‘motivation-interview’:
"she couldn’t accept a relapse and after that it was straight
into it again."
For the last six years Edwin has only been off drugs
during a few short arrests and incarcerations.
Although Edwin has an apartment of his own, he spends
most of his time at his parents' home. He eats all his meals there and
he often sleeps there too. Initially we are not allowed to contact his
sister, but when this has been framed as his concern for her, and maybe
also an expression of his mothers concern for her, he accepts that we
invite her in.
At the first family session two days after the
motivation interview Edwin is high. The therapist asks someone to tell
about the previous attempts to help him stop abusing drugs, and mother
immediately starts speaking. When the therapist tries to short-circuit
mother by asking Edwin, he gets confused and looks helplessly at mother
who clearly affronted crosses her arms over her chest and looks to the
floor.
Father is markedly passive, but after a lot of
supportive work and matching, he starts expressing displeasure with his
son's behaviour at home. Edwin is careless, things are never in order,
he does drugs and is negligent, and they argue all the time.
While talking about this he now and then throws a
worried look at mother who looks disdainful but doesn’t comment.
Father is asked to talk to his son about how he would
like things to be at home, but mother now interrupts and says that if he
(the father) weren't nagging so much there wouldn’t be any fighting.
When the therapist purposefully continues to support father, mother
tries to get the sisters support. The sister desperately tries to stay
neutral.
The first session is terminated by the therapists
telling the family that we think we can help them help their son in a
different way from what they have been trying before, but we have to
move carefully and not change to much to fast.
We tell the family that we see a problem around
father and son not being as close as they and the rest of the family
would want them to be. We think that mother is the one who can help them
get closer as she is close to both of them. We suggest that she see to
it that father and son spend a few hours together a couple of times a
week until we meet next time.
This description was done after a session with a family
in 1984. The metaphors deal with the imbalance between mother and father,
the extreme closeness between mother and son and the lack of closeness
between father and son. The structure as highlighted in this session is
the same as was seen in family after family during this period. Blurred
boundaries between subsystems and inverted hierarchy. Similar structures
were also highlighted in our work with families with anorectic members and
many other problems.
The problem as defined in this session is possibly that
father nags to much, or that mother is to kind or to mean, or that Edwin
is not close enough to his father. No one knows how we will know when the
problem is solved. The therapists though "know" that the problem
is solved when the incongruent hierarchy is corrected and when the parents can
cooperate without the child coming between them. For the therapists the
solutions are obvious. The coalition between mother and son must be broken
to give the son a chance to mend for himself. This is not said, and can
not be said to the family, at least in this session.
It is impossible to know what kind of information we
would have gotten from this family had it been interviewed today. What we
know for sure is that we would have met them very differently. We would
have gotten a much clearer picture of what they did well, and not almost
only a picture of their deficites and difficulties.
The clever shrudeness is a state of mind with the
therapist that is built on the assumption that the family has to be
tricked into health. Because of homeostatic mechanisms over which people
have no power, or dysfunctional patterns of interaction, or unconscious
object relations that all have in common that they are explanatory models
or metaphors that therapists use to explain destructive behaviour, family
members must be lured or tricked into doing something different than they
do. The cleverness is to do it in the smoothest way possible.
A metaphor we use today is that the "problem is
the problem". This means that we take what people say about their
problem as a truth and we do not try to change their ideas around this. We
have faith in that their truth is as useful as ours and we no longer know
best.
We saw people as basically resourceful, but we thought
that they were stuck in structures and organizations that prevented them
from using their resources constructively. Resources and hindrances were
thus intimately connected to each other. Today we see people as
resourceful and we see that they are already using their resources
constructively (pre-session change and exceptions). Thus we don’t have
to look for "hidden" or "stuck" resources. It is
enough to listen respectfully, openly and actively to what people say.
In the same way we now see people functioning well
together. We no longer see dysfunctional structures and perverse triangles,
but we see people who interact without the problem being a part of their
life. As we no longer see the problem as caused by some underlying reason,
we can see the problem as an exception to what functions well. In this way
we constantly discover more and more of good function and
"normal" behaviors, that is what the family thinks is good and
normal and here variations are indefinite. We almost always share the
families’ view and we are almost never moralistic about it. Moreover as
we hinted so many times in this book, the differences between the families
world-view and ours are smaller than the similarities.
In this way the metaphors guide our work. The different
metaphors today form the basis for an attitude that is different enough
for us to think and feel it is different. It is this attitude that opens
up for what we call constructive cooperation.
We hope that these metaphors in time will become different and form the
basis for an even more respectful and efficient way to help people in
difficulties. |
