SECTION II
STARTING THE NETWORKGOAL
Participants will learn how to initiate the first contact with a patient and establish a supportive network.
OBJECTIVES
Upon completion of this section, participants will be able to:
1. Begin setting up the network.
2. Engage the patient and network in initiating a plan for abstinence.
3. Define the network's membership.
4. Convey the guidelines of Network Therapy to the patient and network members.TRAINER NOTE
Review goals and objectives for Section II.
CONTENT
We now consider substance abusers upon entering treatment and the establishment of an initial network. The addictive problem is one over which users have marginal control at best (Miller and Rollnick, 1991; IOM, 1990). Furthermore, because of the covert conditioning process (Marlatt and Gordon, 1985) and the defenses of denial and rationalization (Kaufman, 1994) which have overtaken them, they are unable to provide a balanced picture of the way in which the disorder has impinged on their behavior. Therapists must therefore establish an implicit contract from the outset in which certain controls are introduced. The establishment of such a contract necessitates certain specific departures from traditional insight oriented therapy in which the therapist remains relatively neutral, allowing the patient to define treatment foci.
Recommendations for Starting the Network
1. Begin the process of setting up the network as soon as possible, i.e., at the first contact.
2. Stress abstinence as the clear-cut goal of treatment.
3. Adopt an active therapeutic stance toward the achievement of abstinence, i.e., therapist must advocate this goal and keep members focused on it.
4. Develop an initial plan for abstinence at the outset and involve a network member if feasible.
5. Involve the patient in the selection of an appropriate set of supportive network members. Try to include a range of people of different backgrounds, generations and relationships to the patient. Exclude network members.
6. Spell out the rules of the network to network members clearly.
7. Promote a team atmosphere as much as possible among members.
In treating the substance abuser, the therapist must make clear from the first contact that abstinence is the overriding treatment goal. Stable abstinence is often difficult to achieve early on and, therefore, slips are likely, but the patient must understand that the therapist does not condone slips, "controlled" use, or denial and rationalization that the patient might harbor throughout treatment. The therapist must also actively engage the patient in the process of achieving and maintaining abstinence. Such active engagement must proceed from the outset. Even in the first phone contact, the therapist and patient may develop an initial plan for abstinence and introduce the notion of a network of supports to enact such an initial plan. We will illustrate these ideas with a clinical illustration below.
* OBJECTIVE 1: BEGIN SETTING UP THE NETWORK AS SOON AS POSSIBLE.
Introducing the idea to the patient that his treatment will include involving persons in his immediate social network from the outset is important. To a drug-dependent person, the possibility of losing access to their addictive agent is threatening when they first encounter treatment, and they may deny the full scope of the problem even if they have voluntarily sought help. Therefore, a significant other is essential in both history taking and starting a viable treatment plan. A person close to the patient can often cut through the denial in a way that an unfamiliar therapist cannot, and can therefore be invaluable in dealing with the addiction.
The sooner the idea of the network is broached and implemented, the greater the likelihood that it will take hold. Most patients, though hesitant or resistant at the outset, will accede to the involvement of significant others. Some patients, however, avow that they wish to master the problem on their own. This will often result in patients' wishing to delay the onset of involving others in the network. While a delay may be tolerated for a session or two, there should be no ambiguity at the outset. A network of relatives and\or close friends are expected to be brought in as soon as is feasible but no later then the third session of treatment.
TRAINER NOTE
Discuss the value of role playing in learning Network Therapy. Introduce participants to Appendix A which provides brief descriptions of a patient and network. Have participants volunteer to enact the first scenario as described in Appendix B. Trainer has discretion to interrupt role-play for didactic purposes. Also, we have provided a Network Therapy Ratings Scale in Appendix C. You may use this scale to evaluate trainees aptitudes for Network Therapy based on his/her performance as a therapist in the succeeding role-play exercises. Such ratings, however, are not required but may be implemented at the discretion of the trainer.
EXERCISE
Enact role-play #1 - Building the Network I. Participants can change roles throughout the training in future role-plays.
* OBJECTIVE 2: THE FIRST CONTACT, INITIATING A PLAN FOR ABSTINENCE.
The engagement of the patient along with a network, particularly at the outset of treatment entails a considerable flexibility in style on the part of the therapist, along with a concomitant persistence in focussing on the essential role of the network. Even the initial exchanges with the patient over the telephone should be considered in this light. The therapist will then do well to engage the cocaine dependent person in an exchange that is sufficient to address two important questions:
1) Can the patient remain cocaine-free between the current phone contact and the initial face-to-face encounter? This is important because considerable attrition takes place prior to actual first appointments. Such attrition is greatly enhanced by on-going drug use. On the other hand, the patient who successfully maintains abstinence is in a better position to be realistic about the advantages of abstinence and to come to treatment as agreed; he has also begun to define a therapeutic alliance based on a commitment to relinquishing his addiction. The therapist will do well to establish a plan for maintaining abstinence from the very outset, that is to say, at the time of the first telephone exchange, if this is feasible.
2) Will the patient be able to bring an initial network member who can assist him in achieving abstinence?
An experience with one patient illustrates how these questions are addressed:
A 29 year old lawyer called, and when asked about his problem, he indicated that his principal reason for coming to treatment was his difficulty with cocaine use of several years duration. A brief exchange revealed his willingness to take steps necessary to deal with his dependency, but a great difficulty in exercising control over his daily use of the drug. Further questioning revealed that his wife was at home with him and that she was eager to see him address this problem. The therapist discussed with him the feasibility of his staying away from the drug until the scheduled appointment two days later, and then asked if it would be possible to clarify this with his wife, too. It seemed that the patient would have difficulty in refraining from taking cocaine in this interim period, and therefore strategically important to initiate assistance from his wife so that the idea of her involvement early on in the treatment could be introduced, and so that she could be of assistance at this juncture. Together over the phone the therapist and couple considered their going out of town for the intervening weekend, which was not feasible, but did agree that they would spend the following night with his parents, as they felt this would bolster his abstinence. Furthermore it was agreed that his wife would be supportive in his endeavor, but that whatever transpired both he and she would appear in the therapist's office at the appointed time.
We accomplish several things in this way. We have tacitly introduced the idea that abstinence is integral to treatment of the patient. The wife is now engaged in providing assistance and support for securing the patient's sober presence at the first appointment. Importantly, we have introduced mutuality and support in dealing with the illness, rather than casting this husband and wife in the roles of felon and victim.
* OBJECTIVE 3: DEFINING THE NETWORK'S MEMBERSHIP.
Once the patient has come in for an appointment, establishing a network is a task undertaken with active collaboration of the patient and therapist. The two, aided by those who join the network initially (usually the spouse), must search for the right balance of members. The therapist must carefully promote the choice of appropriate network members, however, just as the platoon leader selects those who will go into combat with him.
Enlarging the membership of the network beyond the spouse alone offers a valuable range of options, both in terms of the personalities of those selected, and in the logistical options that are generated. Although certain guidelines are followed, the unpredictable nature of the interactions that unfold create a fascinating arena in which professionals can apply their skills. Given a reasonably willing patient, the limitations of this approach are determined largely by the therapist's imaginativeness and facility at building an effective coalition.
Why is the spouse insufficient as a sole constituent of the network? By the time a patient comes for treatment, his spouse has generally been nullified as an effective influence, and he has developed a raft of rationalizations to avoid responding to her distress. He has sealed over his guilt with defensiveness, and may have cast her in the role of a nag, even the cause of his drinking, rather than its victim. Furthermore, the absence of further input from outside the marriage allows the patient to aver at any point that his spouse's observations emerge from some longstanding conflict in the marriage, thereby allowing him to dismiss legitimate issues that she might raise regarding his drinking.
There is another problem posed by working with a spouse as sole network member. Undue burden is placed on her whenever a considerable initiative is needed to deal with a slip. The spouse may be unable to shoulder this burden adequately because of her guilt or anger, whereas other network members, when available, can provide relief from the pressure she feels. They may offer emotional support by simply sharing her concern. Sometimes a sympathetic comment, even a glance, from a network member can balance the sense of failure felt by a spouse when the patient has spoken dismissively. It can redefine the slip as a misfortune, rather than as cause for guilt, in a way that the therapist himself may be reluctant to do, for fear of alienating the patient.
The spouse presents only one type of relationship and draws on only one role in which a patient is socialized. With more diverse interactions included in the network, and more varied personalities, the treatment will be more effective.
As much as possible, the therapist seeks to form a team which can operate in a cohesive, task-oriented manner to facilitate the patient's efforts at abstinence. However, it is important that the patient be actively involved with the therapist in negotiating who will best serve as a member of the network since if the patient feels that he is having certain participants forced upon him, it may undermine the entire treatment effort. Parents, siblings, extended family, friends are all potentially helpful network members. Substance abusers should be avoided. Lovers can be included but only if there is sufficient duration and stability in the relationship. Potentially rivaling members should be avoided as much as possible (see example below). Wherever appropriate it is desirable to have members from a generation other than the abuser's and also non-family members. These two groups often add somewhat different perspectives than same generation or immediate family members. A number of these recruitment issues are illustrated in the following clinical example:
A 25 year old graduate student had been abusing cocaine since high school, in part drawing on funds from his affluent parents who lived in a remote city. At two points in the process of establishing his network, the reactions of his live-in girlfriend who worked with the patient and therapist from the outset were particularly important. Both he and she had agreed to bring in his 19 year old sister, a freshman at a nearby college. He then mentioned a "friend" of his, a woman whom he apparently found attractive, even though there was no history of an overt romantic involvement. The expression on his girlfriend's face suggested that she did not like this idea, although she offered no rationale for excluding this potential rival. The idea of having to rely for assistance solely on two women who might see each other as competitors, however, was unappealing. The therapist therefore finessed the idea of the "friend", and moved on to evaluating the patient's uncle. whom he initially preferred to exclude, despite the fact that his girlfriend thought him appropriate. It later turned out that the uncle was perceived as a potentially disapproving representative of the parental generation. The therapist encouraged the patient to accept the uncle as a network member nonetheless, so as to round out the range of relationships within the group and this rationale was spelled out. In matter of fact, the uncle proved to be caring and supportive, particularly after he was helped to understand the addictive process.
TRAINER NOTE
Continue role playing. New trainees may play these roles. It is beneficial to recast roles periodically allowing more participants to be actively engaged in the learning process.
EXERCISE
Enact role-play #2 - Building the Network II (Appendix B)
* OBJECTIVE 4: CONVEYING THE RULES OF THE NETWORK.
The following guidelines should be made clear from the first, so that the network members can collaborate in implementing their respective roles in working with the patient. Above all, they should be conveyed by example. The correction of misapprehensions about these norms should be given a high priority; similarly, violations of these guidelines are discussed as soon as detected, and in a supportive manner.
1. The purpose of the network is to help the patient maintain his abstinence; unrelated benefits for other members are not pursued in network sessions, either by patient, network members, or the therapist.
2. Information relevant to the patient's abstinence or slips into drug use will be promptly reported to the therapist and to the network members.
3. Supportiveness for the patient is primary. Members should help him deal with problems he confronts regarding abstinence but not to be critical of his difficulties in achieving a recovery.
4. If a slip is detected by a network member, he will offer the patient assistance, but will not impose a course of action without consultation with the therapist.
5. The nature of confidentiality is important. The patient's own exchanges with the therapist which are unrelated to drug problems are kept in confidence. Information revealed by network members to the therapist, however, will be brought up in the group if relevant.
SUMMARYIn this section, we have delineated the essential features of starting a network including engagement of the patient and network, initiating a plan for abstinence, defining the network’s membership, and listing the essential guidelines to which patients and network members should adhere. We have also suggested exercises by which trainees may learn how to accomplish these tasks. In the next section, trainees will be instructed in the cognitive-behavioral interventions of the Networks Therapy approach.
