SECTION IV
SUPPORTING THE NETWORKGOAL
Participants will learn to support the network by helping to maintain continuity and create a supportive atmosphere.
OBJECTIVES
Upon completion of this section, participants will be able to:
1. Define patient, network member, and therapist roles to facilitate network continuity.2. Understand therapeutic implications for adding and dropping network members.
3, Provide patient and network with a new perspective on addiction that will enhance network support for abstinence.
4.Facilitate open communication among network members, and teach members to support the patient.
TRAINER NOTE
Review goals and objectives for Section IV.
CONTENT
Because the network itself is an instrument for change its constitution and integrity must be protected and its smooth function must be assured. In this chapter we look at the ways to support the network (Galanter, 1993b).
There are two basic ways in which the network is supported:
Keeping the network intact
Creating the right atmosphere* OBJECTIVE 1: KEEPING THE NETWORK INTACT: PATIENT, NETWORK AND THERAPIST ROLES.
In order to maximize the cohesive power of the network, it is necessary to insure its continuity. The therapist, patient and network members all contribute to preserving continuity in important ways.
The Therapist's Role
Every therapy has its very practical side, much of it embodied in the housekeeping issues that characterize the therapist's role. An understanding of this role and the illness it is designed to treat is often as much reflected in these nuts-and-bolts issues as in its over-arching theory. In the case of psychoanalysis, for example, an unresponsive therapist's role in supporting free association may be very important theoretically. On a practical level, however, the analyst who allows protracted silences while waiting for the patient to speak from the couch can make a patient overly anxious and unnecessarily resentful of therapy. Practicalities and creature comforts cannot be dismissed.
In the case of network therapy, the practicalities reflect the way in which the therapist must weave disparate threads from the social group into a supportive tapestry, and how vulnerable that tapestry is to the small tears, if they are allowed to accumulate. This underlines the need for the therapist to define a strategy actively that will secure cohesiveness in the group, and certainly assure its continuity. Here are some important ways in which the therapist secures continuity in the network.
Network sessions are usually held weekly during the first month of treatment, bi-weekly for the next month, and then tapered. After six months they are held once every month or two. More sessions can be scheduled as needed. Individual sessions continue over the course of treatment. Altogether, therefore, the patient has a session of one kind or another either once or twice weekly.
The therapist should always set the time for the next meeting during the network session, as some members will inevitably forget or confuse appointment times unless they are clearly laid out, with no ambiguity.
Members should be discouraged from rearranging the network's appointment times since changes in schedule leave people annoyed, wondering why their own Tuesday night tennis game can't be accommodated if someone else's dinner party was honored.
Some people will complain, and the patient may wonder about all the time spent on arranging meetings. What good does it do to sit around deliberating over Monday at seven or Wednesday at six? The importance of continuity and of getting appointments secured should always be made clear.
The Patient's Role
The importance of the patient's responsibility in care and protection of the network cannot be underestimated. For one thing, avoiding the perception of the network as an instrument of coercion is essential. If it were seen that way, the patient would soon find it irrelevant to curbing temptations and craving, just as his nagging friends and family were beforehand. The patient must see his network as an adjunct to his own efforts to achieve a stable sobriety.
The network must also never suppress a patient's initiative, since recovery is an active process. Addicted people have to maintain vigilance for any problems as soon as they appear on the horizon so as to avoid cues for drinking or taking drugs, and such vigilance is only possible if they adopt an alert and committed stance, and are engaged in a therapeutic process in which their own activity is prized and supported. This is certainly the case in the way self-help is promoted in Alcoholics Anonymous, and a similar feeling of initiative must be supported in network therapy as well. It clearly stands in contrast to conventional insight therapy where a patient often has no formal responsibility other than talking, paying, and being reasonably civil.
The addict's active role in network therapy includes:
the responsibility for assuring that the group's members will be present at appointed sessions.
insuring that misunderstandings or tangled personal relations do not impede effective interaction. In this respect, the patient becomes an active collaborator with the therapist, with a defined role in managing the group.
Some patients, like those with executive experience at work, are effective managers of people, and can readily summon up a network and effectively sustain ongoing attendance. It is useful to rely on their considerable skills and use this occasion to compliment them, and thereby bolster their self-esteem. This feeling of empowerment is particularly valuable early in recovery, when patients' confidence is typically compromised. Other patients are good at engaging and sustaining the network because of their own self-absorption, a narcissistic investment in themselves, and they bask in the pleasure they derive from being the focus of attention in any group, whatever its purpose. To interpret this potential character flaw would no doubt produce injury to their pride; it would be of no value to them at this point, and could potentially undermine the therapeutic alliance. Discussions of network management can therefore be quite useful in the individual sessions, but must always take place within the framework of supporting the patient's self-esteem, particularly while they are emotionally vulnerable.
A brief clinical vignette will illustrate this point. Edna was a perceptive and thoughtful woman who had been relegated to a passive position in her family when she took up heavy drinking as a vocation after she stopped work to raise her son. The only avenue of assertion left her now was to carp at her husband and twelve-year-old boy. When family problems arose, her opinions were regularly discounted. When asked about ameliorating her lot, she said she had no clear idea of how to influence her family, other than to protest their impositions, and this to no avail. Edna's network was initiated with her husband, her widowed father, and a friend, and as it emerged, her role as network manager was important in her own becoming more effective with family and friends.
Edna's husband initially assumed that he would arrange for the meetings, monitor her behavior, and generally take her in hand. His intentions were good, but this would have only served to reproduce the existing pattern in the family, and introduce her feeling of alienation into the treatment. The therapist went to great lengths to explain to Edna that it was her responsibility to deal with attendance at network meetings, and direct her recovery. Rather than balking at the whole idea, she saw this as an opportunity to assert herself, and as a consequence saw in the therapist a potential ally in her achieving a new, more active role for herself. This was underlined in individual sessions by helping her define options for developing a more influential position in the family, based on her continuing abstinence.
Edna's role in securing the attendance of network members served as a laboratory for examining her emerging self-assertion. It helped her understand how she dealt with other people, how she influenced them to adopt her goals, and how she confronted the problems of becoming an initiator with family and friends, a role she had long ceased to play. Since the network was supportive of her abstinence, she had a forum in which her newfound self-assertion was treated with more respect.
The Network's Role
A strong network is premised on open communication. In order for it to operate as a therapeutic instrument, all participants, the therapist included, must be free to contact each other about a drug problem whenever the need arises, even without securing permission from the patient. This should be clear from the outset, as part of a negotiated plan for treatment. The availability of this resource will not only be invaluable when a crisis arises, it will also define the network's influential bond and assure that the network roles are taken seriously.
The patient and network members should be encouraged as well to communicate among themselves and to provide support, whenever they feel it advisable. This means that a network member should expect to be called on by the patient for assistance related to drug problems when needed. Experience shows that this option is not abused, and that the sensitivities inherent in the ongoing social relations are not violated.
There are many situations in which this understanding about open communication later proves invaluable. For example, one patient, an actor, was often on location to tape a television serial, and was not always careful to inform the therapist of when he would next appear for a session, although he did express apologies for his unreliable attendance when he appeared. If not for the fact that his irregularity could reflect a relapse, the therapist would have been prepared to await his return, and resolve related psychological issues as the treatment progressed. On one occasion, the therapist's ability of calling a friend of his, a member of his network, proved important in dealing with a lapse in his attendance. The friend located him and he and other members of the group were able to help the patient cut his slip short.
The network can substitute for the therapist in his absence, by arranging for a patient to meet with its members while the therapist is at a conference or on vacation. But such meetings often will not take place unless they are carefully scheduled beforehand with the details of time and place clearly set. The need for securing these arrangements illustrates the importance of the therapist in formalizing anticipated network activities, transforming the members from a group of well-wishers to a well-honed instrument for change with delegated authority.
In order for the work milieu in the network to be regarded as effective, the therapist's delegation of authority must be authentic. The network must have experience in participating actively in decisions and in arriving at a consensus that is implemented in action; their opinions cannot be solicited after the fact. For this reason, action on many decisions should be reserved for the network, even though they could have been addressed with the patient alone. For example, if urines have been monitored for drugs of abuse, can the frequency of collection be reduced? A patient's peers may have an excellent sense of his own reliability in reporting future slips. Is the patient ready to go back to work? Each network member can give input on the patient's readiness for new responsibilities.
The network can sometimes be a court of last resort, and a very useful one indeed. For example, one patient had to be placed on a regimen of observed urinalyses because his combined addiction to snorting heroin and smoking cocaine represented a very high risk for relapse. He was a rebellious young man used to demanding his own way, and after a two months of monitoring he decided in a pique that he had enough of the urinalyses; they had all been negative, and the procedure was inconvenient for him. The therapist was very uncomfortable with this because his period of risk for relapse was not over by any means. The patient was finally persuaded to wait until the network meeting, which would take place the following week, where he could present his case to the group. After some discussion at the meeting, they agreed with the need for continued monitoring, and then prevailed on him to follow their collective advice. The patient was annoyed, but in the end he could not dismiss their consensus out of hand, and agreed to an extension of the period of observation.
* OBJECTIVE 2: ADDING AND DROPPING MEMBERS.
Because cohesiveness among the network's members is the basis for their effective action, it is very important that the group's membership roster be protected, for both symbolic and practical reasons. Symbolically, the image of a stable, mutually trusting membership helps each of the participants to feel secure in their importance to the group, and obliged as well to continue their participation in a constructive way. It sets the tone for members to speak up frankly and to expect that their views will be heard, since they know they all have a long-term investment in the undertaking. It supports their attendance as well, even when they may have their doubts at times about their value to the patient's recovery.
Practically speaking, a working collaboration in the network is very hard to replenish with substitute members, once an understanding among participants has been achieved. The history of the members' mutual involvement in the patient's initial abstinence is not easily recouped by adding someone who did not go through those struggles with the remainder of the group.
For these reasons, one should be reluctant to make changes in the network's constituents. Often this means discouraging the patient from acting on changes in his relationship with another member. On the other hand, it sometimes becomes necessary to drop a member despite these considerations. For example, a lover whose relationship has come to an end almost always moves out of the network. In such cases, the lover may retain membership for a time, during which it becomes clear that a final break is inevitable. Such situations often introduce a note of misery into the sessions.
* OBJECTIVE 3:
PROVIDE PATIENT AND NETWORK WITH A NEW PERSPECTIVE ON ADDICTION. Patients and network members alike enter the treatment setting with a very limited understanding of the nature of addiction, and are inclined to fix blame on the substance abuser for his illness. Network members may themselves also feel responsible for the patient's problem, and become defensive or angry when the patient runs into trouble. All this serves to confound effective participation in the treatment process. Because of this, it is essential to introduce a perspective on addiction that does not cast blame. This can be done in several ways:
1. Focus the network on alcohol/drug dependence as a disease. Such a focus tends to shift the locus of initiative from a lone guilty addict to a collaborating patient and his treatment team.
2. Stress that relapse prevention is a learning process. Whenever the patient has a lapse or near lapse or has difficulty executing a strategy, stress to both the patient and network that this is an opportunity for the group as a team to fine-tune or make adjustments in the approach to abstinence. This may be particularly helpful when one or more network members become angry or blaming toward the patient.
3. Such educative interventions carry a good deal more weight if the therapist can model for the network a relatively calm attitude toward making such adjustments. Comment's such as "Well, we're beginning to get a better handle on how to get sober..." or "We're getting a better sense of the logistics involved.." indicate a reasonable openness to learning from mistakes and tend to minimize blame.
* OBJECTIVE 4: CREATE THE APPROPRIATE ATMOSPHERE.
In addition to a stable membership, the network clearly needs a good working atmosphere to operate effectively. This allows the patient to give up dependence on drugs and put his trust in the security provided by his peers and the therapist. It entails two principal issues :
a new perspective on addiction
a feeling of mutual supportAddicts emerge from their protracted period of drug dependence as traumatized survivors, and because of this, their ability to sustain abstinence depends on providing them with a sense of security that can support a belief in the goal of recovery. Social support within the network is therefore a central factor in the patient's ability to adhere to a plan for treatment.
Because of the need for cohesiveness in the network, it is important to make use of every opportunity to:
1. Enhance communication and keep the network in touch. For example, when one of a patient's network members was away on vacation for three weeks early in the treatment, the therapist arranged for her to participate in a network session over the speaker phone. During that session, her views were solicited over the phone after the participants in the room had each said their piece. She was apparently uncertain about how to participate from the distance of two thousand miles. She made some worthwhile observations, as is typical for telephone participants, who feel the need to justify the elaborate arrangement with a meaningful contribution. Her continuing presence was therefore felt, and the value of maintaining communication was underlined.
2. Avoid interpersonal conflict. The need for assuring a supportive atmosphere also means avoiding the intrusion of extraneous issues that might undermine the established tone of mutual support. Extraneous conflicts that cannot be easily resolved should be addressed with considerable care, preferably circumvented. Not all issues opened up in discussion can be brought to resolution, and they can often compete for attention with the primary goal of helping the patient maintain abstinence. For example, one network member made a good suggestion that, if followed, promised to enhance the patient's effort at achieving abstinence. However, she did so in an anxious, querulous manner that threatened to sidetrack both her and the patient into an argument deflecting attention away from her original suggestion. Here the therapist was able to intervene by stating that she had contributed a good idea and asked the other network members what they thought of it. This sort of intervention supports the network member's role as a team player, minimizes conflict, and re-focuses the team on achieving abstinence. Such an approach should be adopted by the therapist as much as possible in dealing with interpersonal conflict as it emerges in network sessions.
SUMMARY
Section IV has explicated the crucial role of providing support for the network. Network therapist trainees have learned to define participants’ roles clearly, guidelines for adding and dropping network members, ways to facilitate open communication among network members while simultaneously minimizing interpersonal conflict. In the next section, we will focus on methods for securing patient and network compliance to the treatment plan.
