SECTION I
OVERVIEW OF NETWORK THERAPYGOAL
Participants will learn about the general features of Network Therapy and the rules which govern it.
OBJECTIVES
Upon completion of this section, participants will be oriented about:
1. Identifying who needs Network Therapy
2. Starting a network
3. Knowing how to select network members
4. Understanding the basic Network Therapy agenda
5. Integrating Network Therapy with individualized therapy and self-help groups
6. Knowing how to terminate a networkTRAINER NOTE
Review goals and objectives for Section I.
CONTENT
The purpose of this manual is to describe the Network Therapy (NT) approach to addictions treatment, specify its key ingredients, and differentiate it from other similar approaches to substance abuse treatment. In combination with clinical supervision, it may be used to learn how to systematically conduct NT.
Definition of Network Therapy. Network Therapy is an approach to substance abuse rehabilitation in which selected family members and friends are enlisted to provide ongoing support and to promote attitude and behavior change (Galanter 1993a, 1993b). Network members are part of the therapists working team, not subjects of treatment. With addicted patients, the goal of this approach is the prompt achievement of abstinence with relapse prevention, and the development of a drug-free adaption to daily life. The enlistment of supportive family members and friends can be an invaluable resource both to the patient in his attempt to achieve and maintain abstinence and to the therapist helping him in pursuit of this goal.
This manual is organized in the following manner: Chapter 1 provides a brief overview of NT in which key concepts are defined and basic rules are delineated. Successive chapters expand upon these basic rules. Each begins with a one page summary of "do&'s" and "don'ts" and is followed by detailed descriptions of relevant NT techniques supplemented with clinical illustrations.
* OBJECTIVE 1: WHO NEEDS NETWORK THERAPY?
1. Network therapy is appropriate for people who cannot reliably control their intake of alcohol or drugs once they have taken their first dose; those who have tried to stop and relapsed; those who have not been willing or able to stop.
2. People whose problems are too severe for the network approach include those who cannot stop their drug use even for a day, or comply with outpatient detoxification; and those whose associated problems make cooperation unlikely, such as the homeless or psychotics. Such patients generally need hospitalization.
3. People who can be treated with conventional therapy and without a network include those who have demonstrated the ability to moderate their consumption without problems for extended periods, or who have only had a brief episode of abuse.
* OBJECTIVE 2: START A NETWORK AS SOON AS POSSIBLE AFTER THE PATIENT CONTACTS YOU.
1. It is important to see the alcohol or drug abuser promptly, as the window of opportunity for openness to treatment is generally brief. A week's delay can result in a person's reverting back to drunkenness or losing motivation.
2. If the person is married, engage the spouse early on, preferably at the time of the first phone call. Point out that addiction is a family problem. For most drugs, you can enlist the spouse in assuring that the patient arrives at your office with a day's sobriety.
3. In the initial interview, frame the exchange so that a good case is built for the grave consequences of the patient's addiction, and do this before he can introduce his system of denial. That way you are not putting the spouse or other network members in the awkward position of having contradicting a close relation.4. Then make clear that the patient needs to be abstinent, starting now. (A tapered detoxification may be necessary sometimes, as with depressant pills.)
5. When seeing an alcoholic patient for the first time, start him on disulfiram (Antabuse) as soon as possible, in the office if you can. Have the patient continue taking disulfiram under observation of a network member.
6. Start arranging for a network to be assembled at the first session, generally involving a number of the patient's family or close friends.
7. From the very first meeting you should consider whatever is necessary to assure sobriety till the next meeting, and plan that with the network. Initially, their immediate company, a plan for daily AA attendance, and planned activities may all be necessary.
* OBJECTIVE 3: SELECT NETWORK MEMBERS WITH CARE, AND BE SURE THE NETWORK ATMOSPHERE IS SUPPORTIVE.
1. Include people who are close to the patient, have a longstanding relationship with him or her, and are trusted. Avoid members with substance problems, as they will let you down when you need their unbiased support. Avoid superiors and subordinates at work, as they have an overriding relationship with the patient independent of friendship.
2. Get a balanced group. Avoid a network composed solely of the parental generation, or of younger people, or people of the opposite sex. Sometimes a nascent network selects itself for a consultation if the patient is reluctant to address his own problem. This is akin to the "intervention" format, where the group will later supportively engage the patient in the network, with your careful guidance.
3. Make sure that the mood of meetings is trusting and free of recrimination. Avoid letting the patient or the network members being made to feel guilty or angry in meetings. Explain issues of conflict in terms of the problems presented by addiction, rather than getting into personality conflicts.
4. The tone should be directive. That is to say, give explicit instructions to support and assure abstinence. A feelings of teamwork should be promoted, with no psychologizing or impugning members' motives.
5. Meeting as frequently as necessary to assure abstinence, perhaps once a week for a month, every other week for the next few months, and once a month by the end of a year.
6. The network should have no agenda other than to support the patient's abstinence, but as abstinence is stabilized, it can help the patient plan for a new drug-free adaptation. It is not there to work on family relations or help other members with their problems, although it may do this indirectly.
* OBJECTIVE 4: THE NETWORK AGENDA: THREE KEY ITEMS
1. Maintaining Abstinence. The patient and the network members should report at the outset of each session any events related to the patient's exposure to alcohol and drugs. The patient and network members should be instructed on the nature of relapse and plan with the therapist how to sustain abstinence. Cues to conditioned drug-seeking should be examined.
2. Supporting the network's integrity. Everyone has a role on this. The patient is expected to make sure that network members keep their meeting appointments, and stay involved. The therapist sets meeting times explicitly and summons the network for any emergency, such as relapse; he does whatever is necessary to secure stability of the membership if the patient is having trouble with this. Network members' responsibility is to attend network sessions, although they may be asked to undertake supportive activity with the patient early on in the treatment, and in times of crisis.
3. Securing future behavior. The therapist should combine any and all modalities necessary to assure the patient's stability, such as a stable, drug-free residence; avoidance of substance abusing friends; attendance at 12-Step meetings; taking medications like disulfiram or blocking agents; observed urinalysis; and ancillary psychiatric care. Written agreements may be handy, such as a mutually acceptable contingency contract with penalties for violation of understandings.
* OBJECTIVE 5: INDIVIDUAL THERAPY
1. The patient is seen in individual therapy once or twice a week, and abstinence is the first priority for individual therapy, as well. Insight and expressiveness are important, but must be subordinate to making sure that abstinence is not threatened.
2. A search for conditioned cues for drug-seeking can be used to understand the potential for relapse, and to investigate areas of conflict. It is important to explore the emotional, circumstantial or substance-related events that bring substance use to mind.
3. Ultimately, individual therapy must be directed at the patient's adopting a new and drug-free lifestyle in which abstinence will be embedded. Long term recovery is only as stable as the patient's new adaptation to family, friends, and work. Group or family therapy might be used instead or as well, but only if abstinence is stressed.
* OBJECTIVE 6: AA AND OTHER SELF-HELP GROUPS
1. Patients should be expected to go to at least several meetings of AA or related groups, with follow-up discussion in therapy to deal with whatever reservations they may have.
2. If patients have reservations about these meetings try to help them understand how to deal with them. Issues like social anxiety should be explored if they make a patient reluctant to participate. Generally, resistance to AA can be related to other areas of inhibition in a person's life, as well as denial of addiction.
3. As with other spiritual involvements, do not probe the patients' motivation or commitment to AA once engaged. Allow them to work out things on their own, but be prepared to listen should they want to talk about it.
* OBJECTIVE 7: ENDING THE NETWORK THERAPY
1. Network sessions can be terminated after the patient has been stably abstinent for at least six months or a year. This should be done after discussion of the patient's readiness for handling sobriety without a network in the group.
2. An understanding is established with the network members that they will contact the therapist at any point in the future if the patient is vulnerable to relapse. They can be summoned by the therapist on his request as well. This should be made clear with the patient and the network before termination of the treatment.
SUMMARY
In this section, we have provided an overview of the key dimensions of Network Therapy. We have provided a basic definition of NT, as well as guidelines for initiating and implementing the NT approach. We have also addressed its integration with individual therapy and self-help programs. In the succeeding sections we will focus on each of these components in detail.
