Special Difficulties and Particular Situations

Many addicts have children and many children live with their addicted parents. Therefor the therapy-room can not be separated from the world outside. One can not make purely therapeutic considerations.

In Sweden the social services act says that you have to report to child protection agencies when you think that children are at risk and we think that this act should be considered every time you meet addicts who are also parents.

There is no difficulty to decide on reporting when you meet a tired, worn out heroin addict, who is clearly incapable of taking care of her new-born, and it is not particularly difficult either, when you meet a man who drinks every third month, but lives in a stable marriage with a sober wife and well functioning children. Difficulties arise when you work with Sofia who has a three-year-old, uses drugs with varying intensity and shifting interval and then relatively systematically (but maybe not always) leaves her child with her mother. Deciding the limits is often impossible. Is it OK that Anna is drunk once a month? Twice a month? Twice a week (Friday and Saturday evening)? The decisions therapists have to make are often impossible.

What is best for the children? Do I have to report to child protection or can I treat and see if it turns out all right? Can I help the parents/addicts become free of their addiction and at the same time take care of their children in a good enough way?

When we become more skillful as therapists it doesn’t make things any easier. We tend to think and believe even more often that we can help parents into a future where the addiction is no longer a problem, and we know that reporting will risk the cooperation. Will she stay sober so that the children won’t have to be committed, and if I report – will the investigation create more problems than it solves? It’s not uncommon for a therapist to develop a habit of delaying reporting in the hope that changes will come.

The dilemmas that therapists face are real, difficult and painful. Every situation is unique and there are no clear-cut rules.

What is best for the children?

Children have the right to grow up under secure conditions and get the care and stimulation they need for their development. The safety and calm that is required for this can not be provided in a home where one or both parents are addicted.

At the same time we know how important parents are to their children, and we know that children placed in foster homes do not always fare all that well.

What is parental support?

The most important support for new parents has almost always been their own parents. It is of help when parents and relatives trusts in ones competence and at the same time provide encouragement, positive support and practical advice. For relatives of addicts this may be very difficult. They see so much of the ill effects of the addiction and most of the time they are very worried. They often feel as nagging and nagging without any effect. It’s obvious their child and grandchildren needs them but despite this, it is as if they were just banging their head against the wall.

It can be very useful to work with three generations. Many clients need – and want – clear limits for tolerable behavior, even when they protest against what the family is saying. Your support to the family can make the difference that is necessary for relatives to gain enough energy to both pressure and support in an efficient and meaningful way.

What addicts need from the professional network is in many ways the same as that of the family – support, constructive criticism and clear and unambiguous messages. The difference is that the family does this for personal reasons while professionals do it as professionals. The pressure and the support from the family and network are both important and together they can make a difference that makes a difference.

The work of the therapist

It is important that the main focus of treatment is in line with the request and it is the ‘commissioner’ who decides. When Norbert wants to work with his relationship with his wife we try to help him with this, as we think it would be pointless trying to create meaning around behaviors that are exceptions to our idea about alcohol making him a bad parent. When we go with his ideas about problems and goals we also see that several of the goals lead to – or are connected to – more responsible behavior towards the children (see Norbert page *).

If the client's goal has to do with the addiction, the main focus should be on this. If the client aims at being a better parent or husband one should work with this. It is unavoidable though that development of competence within one area leads to development of competence in other areas too. Independently of the complaint or problem, it is almost always possible – and always desirable – to connect progress within one area to progress as a parent.

Helping addicts with children will most often (always?) comprise aspects of the parental role. When we ask for goals we are careful in trying to help parents imagine how their children will notice on their parents when they have reached their goals, and how they think the children will be different then. When parents express that they have no problem in being parents, or that their problem doesn’t interfere with that part of their life, we normally accept this initially, but we always come back to it one way or another.

We always assume that clients wants what’s best for their children, and we also assume that clients don’t want their children to grow up with addicted parents, so we ask how the client will do if things don’t change for the better.

Clients have ideas about what it means to be a parent. Questions inviting clients to think about this are for instance: "If 10 is your idea of a perfect parent, how good are you when you don’t drink or do drugs?"

"How good are you when you are using drugs?"

"On a scale from 1 to 10; how important is it for you that your children can live with you as a non-addicted parent?"

"What do you think of your chances on a scale from 1 to 10 to be a good parent if you don’t sort out this problem?"

"In what way does the children make this problem easier (or more difficult) to solve?"

When a client isn’t interested in answering these questions or has difficulties imagining what will be different with the children when the addiction is no longer a problem, we are very worried. If this should continue over several sessions and we see no improvement in the client's situation, we leave the context of therapy, clarify our dilemma as persons in authority and start asking questions concerned with social control.

"How will I know that things are improving in such a way that I won’t have to tell the child protection authorities that your children live with a parent who is actively using?"

"What do you think I have to see happen to defend to my boss that I didn’t report?"

"How do I motivate to my boss that I didn’t act to have your children committed, when it was obvious you couldn’t protect them against your husband when he is drunk?"

"What do I need to tell about you handling your and the children’s situation differently so I don’t loose my permit to practice/go to jail/loose my permit?"

If the client can not give satisfactory answers to these questions, nor can she show positive things happening in her life, that could provide us with the facts we need not to report the situation.

When we have to report, the client will thus know that it will be done and it has been made clear why, even if the client doesn’t agree about it being necessary.

It’s important that the therapist is clear about the dilemma of being both a person in authority with certain responsibilities and being a therapist: "I have to follow the law and this situation is no fun nor for me nor for you. You came here to get help and I have to report."

When therapists succeeds with this, it is not uncommon for clients to choose to continue in treatment during the investigation, or choose to come back afterwards.

Finishing comments

When addicts have children we believe it is important that the children are made an important part of treatment, for the sake of both children and parents.

Children have a right to their parents and for our clients it is immensely important to deal with their problem of addiction and at the same time succeed in being parents.

The area is important enough to deserve a book of its own.

In research concerning female heroin addicts it has been found that a large proportion have been sexually abused as children. Some studies have found extremely high proportions of victims of sexual abuse, in other studies somewhat lower figures. Because of these figures there has been a tendency to make a causal link between being sexually abused and abusing drugs, alcohol or food, and because of this the addict has to "work" on the abuse to be able to stop abusing. If this isn’t done the "basic problem" remains unaltered and will cause other problems or the client relapsing into abuse.

There are no doubt that sexual abuse hurts people, but different people handle memories and experiences in different ways, and each individuals support from his environment is unique. The consequences will therefor vary. It is not possible to translate statistic truth onto individuals (at least not in the mental health field).

As we see it there is no linear connection between certain types of experiences and certain types of problems. We believe that difficult experiences is one among many factors that make people more vulnerable and increase the risk that they will develop so called problematic behaviors. We don’t believe these factors can be mapped reliably on the individual level. Nor do we believe that it is necessary to map and "work on" them to help people change what they want to change in their lives. The solution to a problem often has nothing to do with the problem or what caused it.

Treating clients who were victims of sexual abuse impose high demands on therapists. It takes considerable trust in – and respect for – peoples' capacity. It also demands patience and the capacity to endure the pain of other people. When Solveig, 24, tells about her father’s brutal, instrumental raping with bottles and razors that is still ongoing, it also takes a lot of courage to try helping her to report it to the police and finally report it oneself when she didn’t dare.

When a therapist meets a client alone or with the family the assignment is what they say they want help with. This is a question of confidence and respect and is valid even when the therapist strongly suspects that "the real reason" to the problem is sexual abuse.

In the following we want to illustrate meeting clients in three different situations:

· When the therapist believes the client has been sexually abused and thinks it would be valuable to work with it, or at least clarify that it happened.

· Clients' who were sexually abused and don’t want to talk about it. They want to work on the problem that is tormenting them in the present, whether it has to do with the sexual abuse or not.

· Clients who present themselves as victims of sexual abuse and have problems that they themselves think are a result of this.

That clients' want to talk about and maybe ‘work on’ memories and experiences of sexual abuse, doesn’t necessarily entail a detailed recounting of the sexual abuse. We understand such a demand as an expression of the client wanting to change something in their lives. Thus we see it as a mean, not as a goal per se (compare for instance with clients who wants to be on methadone, page *). We believe that we are helping Veronica continue her life and develop despite the horrible experiences she had, when she tells us that last Saturday she kissed her boyfriend on the mouth and for the first time didn’t feel as if she left her body.

We also assume that when clients wants to talk about the abuse, this is an expression of them already changing. We then wonder what they think about this and we ask:

"What are the signs in your life (goes on in your life) that tells you that you are on track?"

We also ask how the client imagines life will be different when these painful and difficult memories – or lack of memories – no longer causes any problems. We investigate the differences (or help the client creating them) in the clients conceptual framework between the problem and the goal. The answers we then get often deal with being able to stay in the present under stress, being able to hug a friend or dare talking to a stranger. Questions we continue with are often exception-questions and scaling-questions: "Do you remember any situation when you disappeared a little less?"

"Does it ever happen, ever so little, that you enjoy sex, hug a fried, dare talk to a stranger?"

"If 10 means that you’ve finished working through this problem and 0 stands for when it influenced you the most, where are you at now?"

These questions lead on to further questions such as:

"How did you do it to get from 0 to ....?"

"Where did you get the idea to do it like that?"

"Who/what was helpful?"

"With whom was it most helpful to talk?"

"How did you prepare yourself?"

"How did you do to go through with it?"

"What did you feel after you succeeded?"

"What does it make you think about yourself?"

"What do you think it will make other (your mother, your boyfriend) think about you when they’ll know you did (handled) it?"

"When this grows stronger, what will you think about yourself and others that you don’t think now?"

Many times questions such as these lead to the conclusion that the client already "worked through" large parts of his problem and the answers often points clearly to how the client did it. The easiest will obviously then be to ask the client to continue what he or she already started with such success and continue to note more successes in the direction we have marked out together.

Nowadays therapists talk more and more with clients about sexual abuse, even with clients who deny being victims – or who deny that it has any importance in their lives. When clients convey this it is extremely important to acknowledge and respect them. If they have a history of abuse it is more abuse to force them. If they haven’t been abused it is of course nonsense to continue talking about it.

Sometimes a therapist strongly suspects that a client has been sexually abused, but it is nothing the client expressed clearly. Often the client has made some more or less direct hints at it, and the therapist thinks it is necessary for therapy to acknowledge to the client that he has understood. For many clients in this situation the most important and often sufficient is that someone knows that they have been sexually abused.

If it is to be possible to talk about sexual abuse and what will be different when these memories no longer affect the client’s life, it is essential that the client trusts and feels safe with the therapist. Taking up the issue prematurely entails the risk of frightening or offending the client into terminating treatment. The client needs to feel – and the therapist be convinced – that treatment is carried ahead by the issue.

On the other hand if the client makes obvious hints the therapist can not behave as if nothing were the matter. If so he or she does the same thing many others did in the small child’s environment – didn’t see nor hear – and victimizes the client again.

The simplest way to handle this situation is simply to ask the client:

"Have you been sexually abused?" or "Did it happen to you as a child that grown-ups touched you in a way you didn’t want?" or "Others I met with similar problems were sexually abused as children. Is it like that for you too?"

Another way is to tell a story about another client with similar problems without asking the client directly if he or she recognizes himself. This is a way to talk indirectly about what is difficult and at the same time convey that the therapist heard and understood. The client then decides himself when and if he or she wants to talk about the abuse.

A third way particularly for clients who were forced in previous therapies:

Cornelia was committed to an institution for the first time when she was 22, because of her drug-problem. She stayed for a week. Two years later in therapy with us (HK and MS) she recounts that the seven days keeps popping up in her memory. Everyone was talking about her ‘incestuous relationship’ with her father. It was obvious to her that everyone wanted her to talk about how it was to have sex with her father, but:

"I don’t think I ever did. But I really can’t know. Everyone told me that if it happened I repressed it, but I don’t believe it happened.." Her voice becomes plaintive as she continues: "Is it important to talk about it?"

MS answers her: "Don’t force yourself to look for it. If it is important it will come out eventually."

Some clients know that they were abused when they were children, and have talked about it in a number of different contexts in more or less useful ways and are utterly fed up with talking about it. When they seek help they are unreserved about them being incest-victims, but they don’t want to talk about these experiences. They want help with their drug-problem, their eating-problem, their sex-life or a number of other things.

Many victims of sexual abuse have already dealt with their memories in their way. A lot of clients do not feel that it is necessary to talk about the abuse. It has already been dealt with. With clients who feel this way it is very important that the therapist doesn’t force himself on the client. If the therapist does insist anyway, it is almost never of any help but becomes another victimization on the client.

When these clients are met respectfully it is our experience that they often will work on problems that are more or less directly related to experiences of sexual abuse. Estrangement – dissociation in stressful situations – sexual difficulties, etc.

Some clients present themselves as a victim of child sexual abuse and that is why they do drugs, binge or have any of a number of different problems. These clients seem to expect and hope that the therapist will help them ‘work through’ their experience or do something that can free them of their problem. They often seem prepared to talk about the abuse.

Sometimes a client comes back to the third or fourth session and tells that the ‘real’ problem is sexual abuse. The client wants, or needs to talk about this to find some peace from it and believes that the addiction problem will be solved in the process.

A client being set to talk about his or her experiences doesn’t automatically mean that the conversation needs to deal with the sexual abuse in itself. We think that it is always wise to start by finding out how the client imagines life will be different, when these previous difficult and painful experiences no longer create problems.

We ask for instance: "What do you think you will do differently in your life, once you are convinced that your father takes on responsibility for what he did to you?"

Independent of the starting point

Meeting all these clients is always built on finding out their ideas about what their problem is and what their goal is. By talking about this in a traditional solution focused therapy, many clients get the help they want.

After a few sessions it will be clear if solution focused therapy isn’t enough. Maybe the client continues to put himself in dangerous situations because of a strong remaining tendency to dissociate. Maybe the client wants help to reach goals that has to do with a different contact with his family. Maybe the experience and memory is so fogged up that both we and the client agree that the client need to remember at least some to feel and live as a whole person.

Going through completely how to do therapy with clients who were sexually abused is beyond the scope of this book. Only a few points are made here.

When clients start talking about the abuse they often get the desire to confront the perpetrator. ‘Meeting the one who caused so much suffering and put it all back on his lap.’ Some clients choose not to bring it up with their families. They know for certain that they will never get the support they need from their family-members, or they know for certain that the family will join together and reject them. Other clients are prepared to take the risk or they may feel that the mendacity is to high a price to pay, and they are prepared to find supportive networks elsewhere than in the family. Other clients simply feel they have nothing to loose.

It is important for clients to stop feeling guilt and shame and put the responsibility for what happened back onto the perpetrator. Confrontations to early can however do more harm than good. The client needs to feel reasonably strong and certain that she can go through a meeting with the feeling that she will be leaving something behind. The possible outcomes of the meeting need to be reviewed in advance and the client needs help to foresee a perpetrator who bluntly denies everything or a mother who says that it was the client's own fault (for instance "the way you dressed!")

One way to prepare is for the client to write a letter to the perpetrator, where the client expresses what he or she wants to tell the perpetrator. No matter if the client meets the perpetrator or not, or if the letter is sent or not, it can be an important symbolic gesture – the responsibility is put where it belongs. The next step can be for the client to write the letter she thinks the perpetrator would write as an answer, and yet another step can be for the client to write the letter she would have wanted to receive from the perpetrator. Such letters can also be written to other people in the clients network.

Other things as important to work with can be strong tendencies to dissociate that can put the client in danger, flashbacks that jeopardize sex, general anxiety and a number of problematic behaviors that clients can develop.

For you who wants to penetrate the subject more thoroughly we recommend "Resolving Sexual Abuse – Solution-focused therapy and Ericksonian hypnosis for adult survivors" by Yvonne Dolan (1991). This is a book that describes the treatment of adults who were sexually abused as children and it is an endless source of inspiration.