Meeting With the Family
The parents are the experts on their children

Everyone is part of larger contexts and the most important of these contexts, at least in the western world, is the family.

Being a social creature means co-existing with other people. One is ones relationships, not an isolated planet. Everyone is someone else’s son or daughter, married to or lives with someone, has children, is friend to someone and is influenced by these people as well as influences them.

We believed for a long time that addicts were outcasts without contact with their families. After having read among, others Stanton and Vaillant we began to understand that addicts have a lot of contact with their parents and siblings, but we were still skeptical – was it really like that in Sweden too?

The therapist (MS): (Telephone): Hi, my name is MS and I work with addicts who wants to quit using drugs. I have been talking with your daughter for an hour and she wants to stop. I have understood that you are a very important person to Angelica and I would need your help. Would it be possible for you to come here Friday at 10 am.

Mother: (Takes a short breath, sighs deeply and answers:) At last someone asks me. Of course I'll come.

Before I (MS) called up mother I had talked for one hour with Angelica 22, who had been using drugs for 8 years. In later years heroin. My mind was set for a long and complicated motivational session and I had prepared myself carefully.

Nothing I thought before the session was correct: Angelica told me openly and in detail about her life and her addiction and she immediately answered yes to my suggestion that her parents and siblings should participate in treatment this time.

I called mother who immediately accepted to participate. The father wasn't available so I asked Angelica to tell him I was going to call him. When I reached him the day after, I introduced myself and before I had the time to say anything else he said: "I know. What time was it on Friday?"

In less than an hour I had agreed with Angelica, her parents and siblings to meet for a session 2 days later. I had also agreed with the social worker (who participated in the session with Angelica) on how we were to co-operate and we were both in disbelief about it all. "This was to easy – there is something fishy about it. It must be coincidence," we said to each other.

Angelica was the first addict we asked if she wanted her family to help her quit doing drugs. To her and her family it was obvious that this was the way it should be done. To addicts, their parents and siblings it is natural and obvious that they should participate in treatment – if they only get a chance.

Addicts are extremely dependent and loyal to their parents and siblings. Some of the addicts we met have been in institutions where they weren't allowed to stay in touch with their parents at least in the beginning of treatment. They are often mad at this and they often stayed in touch secretly anyway. Parents have described how they have been set aside and how they felt questioned and criticized. As the parents and siblings are so important for the client, this is probably a gigantic mistake. The families are the ones who knows the addict best, they know how he functions when it's good and when it's bad. They are always there and they are the lasts to give up.

When Rolle (page *) is in prison his mother spends that time in her country. When he is out of prison, she comes home and they see each other daily, until he goes back to prison. It has been like that for the last 10 years. Rolle and mother are very close and the therapist asks if it would be ok to invite her for a session. Rolle is a little hesitant and wants to make sure it wont be difficult for her. The therapist asks how Rolle would react should he accidentally wrong her and Rolle looks him straight in the eyes and says: "I would kill you."

Rolle was the only addict in the heroin program where we decided we wouldn't invite the parents. The team and the therapist deemed the risks for the therapist to high.

Addict's problems are sometimes conceived of as caused by their parents. Maybe the parents haven't given the tenderness, closeness or care they should have given when the child was small, or they may have beaten, abused or done other bad things to the child without ever taking responsibility for it. When therapists sees parents in this way it is difficult to see them as resources or help in treatment. You would rather not see them at all or at least you don't want to talk treatment with them.

In the heroin program in the middle of the 80's we were influenced by theories that, even if not blaming the parents directly, had the basic idea that the problem was related to the family not functioning well. Our job was to make the families function better and our theory said that the addicts would then stop doing drugs. This view led to us sometimes getting into conflict mostly with parents but also with the addicts.

It took us a long time and a lot of effort to work in a new way, where we could co-operate with addicts and their parents on an equal level and with the understanding that for the addict, loyalty to his parents is more important than loyalty to the therapist – blood is thicker than therapy. For the addict it is immensely important that parents are rehabilitated and acknowledged. Feeling proud of ones parents increases ones own sense of competence.

Seeing parents as experts on their child is however not all that easy. It is I as therapist, doctor, teacher, etc who is the expert and the one who knows something. It is difficult but necessary to void oneself of this notion. This doesn't mean that one renounces to ones knowledge, but means that one tries to encounter the addict and his parents with respect and understanding and doesn't dominate them with ones own theories and views. Don't forget that parents in their contact with persons in authority may have gotten the idea: "It's our fault. We did wrong before. We didn't succeed in raising him."

It is thus important to help addicts receive help from their parents and family. Solving problems together, changing situations for the better and writing new stories together containing successes is tremendously importance.

The first session with the family can start in many different ways and in many different constellations. The rest of this chapter deals mostly with ideas on how to meet people you haven't met before. It can be a father, a sister or a friend. When you've done something similar to what we have been talking about before, it will be someone the client wanted to bring in, or has agreed to bring in because you or someone else in the network thought it useful if that person could participate in the rehabilitation-process.

You can assume that he or she who invited the person or persons in question, expect that you will meet these people the way he was met and with which he was satisfied. Otherwise he wouldn't have invited anyone.

With this in mind it is not difficult to bring new people into the work. Think about the original ideas (pages *-*) and note particularly participation. If someone is invited it is because that person is important or can become so. That person needs to feel implicated in the process in one way or another, and needs to share the "earnings" of success.

As always there are many different ways and we will only try to give general ideas by trying to be precise in the description of what we do.

Introduce yourself and ask for names. Make sure you got them correctly. Consider that you yourself may be quite nervous in this situation and that it is easy to forget peoples names. Consider also that those who are there most certainly are more nervous than you are.

Many new people? Note the names in your head or on paper in such a way that you can easily retrieve them. Only very experienced therapists can allow themselves to forget names of people in the room and they seldom do.

Ask the client if it's ok that you recount what you talked about in previous sessions. He will answer yes. Tell shortly about the strengths and resources you've dug out in earlier sessions. A starting point can be the intervention you did in the previous session. End by saying that you've understood that exactly those who are there are very important people in the clients life.

Developing fit

There are many ways to develop fit and create prerequisites for co-operation. They can be used by themselves or in a number of different combinations. Those we use most often are "What are people good at – How was he as a child "or –" Imagine that this will be useful conversation.

Turn to new persons one by one and ask them what the client is good at.

Then turn to the client and ask what that person is good at.

Ask who else would have something to add and what this person believes he or she would say. Ask the client calmly, quietly and curiously if he sees himself like that. If there is strong disagreement only comment: "You see this differently. That is good."

Such comments are very useful when people disagree and seem to work well as long as they are only on the brink of starting to quarrel. When you communicate on this meta-level about disagreement, you don't side with anyone. In principle it is always best not to take a stand except where you have to from ethical, moral or child protection aspects.

Do not try to erase differences. Consider that differences are very useful when you summarize sessions. For instance mother is very positive and will not believe anything bad about her son and she seems to think that everyone should do exactly as he wants. Father is suspicious towards his alleged progress and seems to think that he should be put away to get some real help for his problem. The difference between the parents could be conceived of as a problem but can be defined in the summary as an extraordinary resource in this network. "Mother stands for optimism and father stands for realism – and both are needed."

Another way to get a positive and supportive atmosphere in the room is to start the session by asking: "What was he like as a kid?" "Was he up to mischief?" "Was he kind-hearted, good, well-behaved?" "What was he good at then?" "What is he good at now?"

Ask the client if he remembers and agrees. Ask those present what others, not present, would add if they were there (grandparents etc).

A third way we use to start family-sessions is to focus on what the session can lead to: "Imagine that this will be a useful conversation. What will we have talked about then?"

Another way to ask the same question is: "Imagine that you leave here today and you are satisfied. You think the session has been rewarding and fun. What will we have done here today?"

This type of questions will quickly inform you on what the different persons present thinks are important issues. This will permit you and the family to pick issues quickly and in agreement that are relevant to the different family members.

The question can bring forth many different answers and reactions and it demands an experienced and skilled therapist.

Many people will misunderstand the question and answer what they think should be the result of treatment. The question then becomes a variant of the miracle question and you simply follow the client/family. You get directly to the goals of treatment.

Sometimes you don't get concrete answers or descriptions. You should then insist and show in this way that you are set on co-operating. Sometimes families don't have any ideas at all and this is most often due to strong feelings of hopelessness and resignation. You can then focus on the difficulties they have had and how they coped despite everything (coping-questions).

You may also get quite overwhelming answers with unrealistic expectations like all problems will be solved etc. Joke about it; "it's good to aim at the moon, at least you risk ending in a tree-top". Than deal with it the same way you deal with unrealistic goals when you ask other future-oriented questions.

Sometimes different family members seem to have incompatible ideas. Ask more in detail about concrete examples, listen for how the ideas can be connected to each other. Deepen the descriptions of each person. Often it turns out that family members have more in common than not. Most often family members are prepared to compromise in what needs to be prioritized.

Regularly different ideas will develop that everyone thinks are okay. Make an agenda. You can then take the different points one by one or decide what is reasonable to achieve in today's session. Deal with the problems one by one and create descriptions of how one will know when that problem is solved or on its way to be solved.

Start the next part of the session by saying something like "When I met Nisse I understood that he was really very decided (was pretty decided/ was on his way to make a serious decision) to stop doing drugs/getting straight/putting his life together (use the client's metaphors). What signs have you seen that this is happening (starting to happen)?"

If you feel brave ask: "What has become better?"

The worst that can happen is that they answer: "Nothing is better." You can then ask in a natural way: "Haven't you met lately?" and leave some doubt hanging in the room where the relatives may ask themselves what signs you may have seen that shows that he is starting to change his life.

It is not uncommon for mother or father to start telling that this is not the first time that he has tried to shape up, and this may be an excellent opportunity for you to find out how they saw when he was trying before.

"How did he do then?"

"How did he show that he had the will to change his life?"

"What did they see?"

"What was different?"

"What was different compared to periods when he was in the midst of abusing?"

As usually go for behavioral descriptions. It makes the rest easier.

"Are there any such signs now?"

"Which? What have they seen him do? /heard him say?"

Some families tell that it has always gone up and down. This time is no different from any other time when it was a little bit better. You hear them imply that it is only a question of time before things are back to bad again. Accept this to start with. Draw a sinus curve on a whiteboard, or in the air. Say: "So things are going up and down. What signs are there that this is an up-period?"

"How is he different in this phase?"

"What can become even better?"

"What could be done to help him get a little bit higher this time?"

"What can be helpful for it to stay up a little longer this time?"

Talk about last week and the few last days.

"Has there been any sign that he is trying?"

"What have they seen him do?"

"What have they heard him say?"

Talk to the client about the ways in which the family has been helpful in the past. Ask what they used to do that was supportive of the decision to get off drugs. Ask what they are doing that is helpful. Ask in what ways they are different to him when they now/then see that things are going a little better.

With a clear focus it is easy to get a flow in the session. Make efforts to remember what you asked for and listen carefully to the answers. Don't let go of a question before you have answer, if you are not absolutely sure that the question is impossible. Try putting the question in another way, and if that doesn't work, in a third way. Don't be afraid of thoughtful silence on your part or the family's. Consider that the more you seem to think carefully about what they are saying, following up on their answers and trying to understand what and how they think and mean, the more professional they think you are.

Potential difficulties and some hints

Sometimes families and networks are very occupied with trying to find the reasons for the problem. You will notice it because they will tell you. Ask them about their explanations. They will answer or say it is completely incomprehensible. Listen respectfully. Ask what others may think but don't immerge yourself in the issue and leave it as fast as you can. Try saying: "We can't do anything about what has been."

"Right now it is not about working through the reasons but for him to get out of the hold that the drugs has on him." You can also try saying: "There are many theories about why people start doing drugs (drinking), and no one knows today. Not me either. We know less today about why one starts than how one stops."

Sometimes we explained that there is not one or two reasons that can explain how it has become the way it is. Hundreds or thousands of different things interact and one can spend a lifetime trying to sort out the most important. Right now the most important thing is for him to stop abusing and then Nils can sort it out afterwards if he is still interested.

Sometimes we have said: "We have to put the fire out before finding out why it started."

Some parents will immerse themselves into all the evil the client did. Try to respond in a supporting way but try in your comments to split the problem and the person: "The drugs really made him do terrible things."

Stay calm. Slow down the pace of the session if it's fast or if the atmosphere is tense. With a tense atmosphere it is particularly important to block aggressive interaction between family members.

The therapist (PA) spends most of the session sitting on the table between Britts' mother and sister. Every time they start talking they start arguing with each other. Every time he lifts his hands with his palms towards them and says: "Stop, wait a second." Every time they fall silent. Every time he tries to return to his chair they start arguing again.

It's of no use to the client that mother and father is arguing with each other, or that a sibling accuses the parents that it is their behavior that has caused the problem. Nor is it of any use to the client to accuse his parents that it is their fault that he is drinking, putting a needle in his arm or bingeing.

Pay no attention to or at least don't immerse yourself into other family members eventual drinking problem or other. This will only constitute another possible explanation for the problem, and you don't have to know why Nils is doing drugs. Even addicted parents can help their children stop, and some of them will stop their abuse in the process of doing it. Observe that it is frequent for young people to seek treatment when their parents just stopped abusing. If this comes forth, accept it, and congratulate the person to the success.

Are you meeting only desperation, exhaustion and anger towards the client? Think of the fact that them being there contradicts anything implying they don't want to help. Their way of experssing themselves is proof of their enormous involvement. Try coping-questions (page *).

When you've gotten this far in the interview, you will have a pretty clear picture of what family members hope for in the future. You may even have a few concrete, behavioral goals that you and the family can use to measure success.

Make sure you have enough of that kind of information by asking them how they will notice when things are going a little bit better. Don't be afraid to examine or point to differences between different goals. Stay calm in front of these differences. Remember that it is usually easy to connect seemingly different goals or help people see that they are dependent or complementary on each other. This is true even if they seem contradictory at first sight.

Sometimes it can be a relief for parents of young people not that interested in stopping drugs, if you calmly and matter-of-fact inform them that you actually never met an addict who didn't desire the positive effects of drugs. Addicts actually don't want to stop using, they just don't want to have the negative effects, or side effects of the drugs.

Björn sighs with relief when the therapist has said this, looks at his mother and says: "I told her the other day that actually I don't want to quit."

The therapist looks at mother, sees that she looks very concerned and comments: "That's a good sign, him daring to be so honest with you now".

She nods and smiles and the therapist adds: "Him telling you now must mean that he somehow knows how impossible it is to have only the positive effects."

Björn nods in confirmation and the therapist sees how mother and son look at each other in mutual understanding.

Are the changes so forth in the direction of the goal?

This is probably one of the most effective strategies existing for anchoring change, as it makes people feel they achieved it by themselves.

It is necessary that you and the family made descriptions of one or several unusual aspects/news in the present situation, or that there were descriptions of new behaviors. If you think that you can ask the question: "Is it as if a piece of the miracle already happened?" and get an affirmative answer; do it. Follow up with: "How did you do it?" or "How did you dare?" to the one responsible for the new behavior.

Examples are for instance a divorced father who invited his heroin addicted son to a fishing trip two weeks earlier, or a wife flushing liquor out for the first time, or an alcoholic stopping a period on the fourth day instead of the seventh. Does the person seem to be offended by you asking about things that should be evident? Explain that you don't see these behaviors as simple, considering that it is not easy to forgive someone who caused a lot of hurt, or do something one hasn't done in a long time.

Every example where someone can be held accountable for change should be commented, and the merit can then be shared through questions bout what, who and how the support came for that change to take place. These are questions that tend to connect people around functional behavioral patterns and make them confident in their own competence. This increases both their self-confidence and their trust in each other.

It is quite common that people don't know how or what they did, when they did something good. We often comment this with: "So it's a mystery how you did it when you succeeded?" When this question is asked with curiosity and amazement, it often leads to a confirmative nod. As mysteries exist to be solved there is always the chance, after an interview with one or several mysteries, that the client and family continue to think about what and how they did something that worked.

"So what is the next step?" or "What do you plan?". If you are in an early stage and there are no signs that things are going better, an alternative may be: "What do you have to do/ what will you do?" Observe that this question should be put to the client and not to the family. The family is not responsible for their child's abuse. If you ask for the family to do something different – the question contains an implicit demand – you are also saying that it is their responsibility to change the situation. It is worthwhile thinking that it is mostly pointless trying to force change upon people, and that you're probably trying to do the same thing to the family as they are trying to do with their addicted child, and with as little result. Do you feel an urge to foster them and tell them what to do? Lean back and tell yourself that you are working to hard and that you are not listening enough to how the family wants to deal with the issue.

Usually family members and the client have ideas on what should be the next step. Help them to create concrete measurable steps. Define these as small, small parts of the miracle. This helps them see development.

You should accept that the client is not off drugs in the first session with the family, particularly if it is the first week of treatment. It is good if you put some pressure on him at this stage, in front of people that are emotionally important, but it's not useful if he "looses face". Consider that addicts also do their best and have strong reasons to do what they do. Are you a cautious person? Then ask: "What's your ideas on what you need to do to take the first/next step?"

Follow up with: "In what ways can mother, father, sister, brother etc. be of help?"

No answer? Well, turn to the family and ask them for their ideas on what the client needs to do. Don't expect to much if you get into this situation. The family can lead their child to the water, but they can not force the child to drink. In this situation you will probably get answers turning around "he must want it himself", or "he must get into some treatment program". Try listening for ideas about how they would notice that there was any "will" or any metaphor they choose to use. Ask more about how they will notice (or suspect) that treatment has had any effect, and explore if anyone has any idea about how they can make the client want to "get into treatment".

If you get the feeling that no one wants to do anything to try solving the problem you probably missed something important. It is not likely that the client agreed to invite other people if he doesn't want to change anything. Maybe something important or serious happened in the interval since the family was invited. Try to get hold of the situation as it was before an eventual relapse yesterday or the day before, or any other crisis that might have occurred. Talk about what needs to be done to at least get back to the same point as when the client agreed the family should be invited. In this situation you probably already know or at least have a strong hunch what it's all about.

Even in situations where the family seems to want to talk about all the problems and seems to need to talk about how terrible everything is, it is possible to get to the next or first step. Get hold of the concrete situations the family is talking about and explore how that particular situation would have developed differently after the miracle. "How will a similar situation develop differently after the miracle?" or "What would that particular situation had looked like if there was no problem?"

Scaling questions

In a slow pace and with 3-4 people in the room it can have taken you anything between 30 and 60 minutes to get this far. The longer you spent, the more you are in a hurry now.

If you haven't asked scaling-questions before, you can do it now. Useful ones at this stage can be: "On a scale from 1 to 10, where 10 stands for; you're certain Nisse will stop using drugs, and 0 stands for no chance at all, where are you?" To the client: "Where do you place yourself?"

"On a scale from 1 to 10 where 10 means that you are prepared to do just about anything to solve this problem, and 1 means the contrary (just sitting on your but and wait for a miracle?)"

"Confidence in your/his ability to go one week, or two weeks without drugs (or whatever you think is a reasonable time span before the next session)?"

"Confidence in ability to wake by the alarm and go look for a job?"

For the moment be satisfied with what you've got. Explain that you talked about some things, of course not everything, and that you now need some time to think through what you talked about and summarize how you understand the situation, and also see if you have some idea that you think can be useful. Explain that you usually take a break at this stage to discuss with your team (with yourself) and then you will be back with what you think. You can very well ask them if there is anything important they think you should know, or if they can think of a question that you should have asked and they think you missed. Then ask them to step out to the waiting room, or go out yourself. Reflect for a while with paper and pen to sum up, and then tell the family how you see their situation. The summing up of a family session contains the same elements as the summing up of any other session (pages * - *).

The parents are the experts on their child

The prerequisites for the sixth session with Kajsa could have been better: The therapeutic team thought that Kajsa had been a little to long in the treatment-institution before we had succeeded to set up a meeting with the parents and the contact-persons in the institution.

The contact-persons and Kajsa are in massive conflict, and Kajsa has difficulties sitting in the room with them. The situation in the unit is becoming untenable because of Kajsa's behavior. The contact-persons wants to discuss this with her to help her change her behavior, and avoid having to discharge her from the unit. Kajsa isn't seeing the situation in the same way – she seems offended, questioned and humiliated. She is angry and sulky – and intends to discharge herself from the institution. The parents don't know what happened and seem surprised facing the very tense situation.

In the session are Kajsa, her parents and two contact-persons from the unit and the therapist (SE).

The therapist introduces the context: "We have asked you to come here because we need to co-ordinate what we are doing and find a common goal to help Kajsa moving on." She then asks how the situation is (at this point she is not aware of the conflict between Kajsa and the contact-persons). The contact-persons recount briefly what has happened and wants to continue to sort it out with Kajsa. She doesn't want this and the tension increases in the room. Suddenly she rises and rushes out of the room.

"Now she behaves as if she was three years old again", one of the contact-persons says in a worn out voice.

Mother goes out after Kajsa but returns after only a few moments, shakes her head and says: "When she's like that it's best to leave her alone. It's no use talking to her now."

"What else helps? How can the personnel know when she is like three years old and what's the best way to deal with her then from your experience? What have you found that is most helpful?" the therapist wonders, and mother describes in detail her experiences in meeting Kajsa when she is angry.

The therapist steers forcefully for the remainder of the session. When the contact-persons describes Kajsa and how and what she did, the therapist systematically turns to the parents and asks if they have seen such behaviors before and the best way to deal with it. The parents, as natural experts on their child are given, and take on the role of consultants to the contact-persons.

The contact-persons describe the conflict in the ward: "Kajsa was so mad I thought she would hit me, but then she turned on her heel and left".

"Yes," says mother, "that is what she usually does". She turns towards father and asks: "Wasn't that when she phoned you?"

"Yes" answers father, "she phoned and said they treated her like...." he pauses briefly, then goes on: "..... bad and she was going to sign herself out. I told her she should think carefully about it in order not to make a mess for herself, and then I talked to you," he says while turning towards his wife, "and you phoned the housemother."

The contact-persons now recounts that Kajsa talked to her father and then went to her room where she didn't want to talk to anyone. Eventually the housemother spoke to her and said the same thing father had said; take it easy, think about it, stay here and sort it out, think ahead.

Everyone agrees that without this joint attitude from parents and staff, Kajsa wouldn't have stayed. Everyone also agrees that the situation in itself is a sign of Kajsa’s progress, as it is the first time in many years that she didn't run away from a conflict but stayed and wanted to sort it out.

What would have happened if the therapist had tried to sort the conflict out by helping everyone to tell their version of what happened? Most probably the conflict would have increased. So what did the therapist do? When we look at the videotape we see that SE is doing only one thing: Again and again and no matter the issue SE turns to the parents and asks for advice and information. She meets the parents as experts on their child, and conducts the conversation in such a way that the team and contact-persons asks and listens to them.

She also helps the contact-persons use the parents as a resource in treatment.

Sonja turns to the staff and asks: "What can the parents do to support the treatment in your unit when Kajsa calls them and complains about you?"

The personnel answer the therapist. Mother listens attentively and nods thoughtfully when they say that best is if mother doesn't say to much, before she has talked to the persons Kajsa is complaining about. She wonders: "Can I call immediately?" and they answer that; "that is exactly what we hope for".

The session is ended with a short conversation with Kajsa, who has been waiting outside. SE presents different options for the next session; joining in the session, following the session behind the one-way screen or not coming at all. In the summary of the session co-operation is emphasized, particularly important with such a special and different addict as Kajsa. In the next session one week later Kajsa attends.

When a therapist has the idea that it is the parents that caused the problem it is practically impossible for him to ask them for advice or encounter them as experts. Instead the therapist will tend to take over, trying to do what the parents failed to do; foster the child. Clients are usually not very fond of this – as others they need to be proud of their parents, and see that their parents are respectfully met.

Talking isn't enough

In the session the family, Bengt and the therapist (ASH) have discussed what Bengt needs to do to take the next step in his rehabilitation. Bengt has been off drugs for some time and has started to orient towards a life with work and without drugs.

At this point everyone agrees that Bengt has to take some concrete steps and it is crystal-clear for everyone what he needs to do. It isn't that clear that he is prepared to take these steps just now – Bengt seems hesitant.

During the summary the therapist asks the family if they want to have the next session before or after the next step Bengt takes in his rehabilitation.

They immediately answer "After the next step".

Bengt mutters: "It's not that simple", but someone immediately retorts:

"You just got to do it!"

Everyone agrees that Bengt has to do something of what constitutes the next step, not just talk about it.

The last question and the family's response to it clearly clarify the client's responsibility for his rehabilitation. It's concrete action that counts. The most important people around Bengt all have a positive expectation on him that he can't come around through his usual maneuvering.

Before the next session, Bengt had done what had been discussed in the session.