SECTION VI
DIFFERENCES FROM OTHER THERAPIESGOAL
Participants will learn to differentiate Network Therapy from other psychotherapies for substance abuse.
OBJECTIVES
Upon completion of this section, participants will be able to:
1. Understand the seven rules differentiating Network Therapy from individual insight-oriented psychotherapies.
2. Differentiate Network Therapy from structural family therapy.
3, Differentiate Network Therapy from interpersonal group therapy.
4. Identify guidelines for integrating Network Therapy with 12-step activities.TRAINER NOTE
Review goals and objectives for Section VI.
CONTENT
The therapist promotes 12-step involvement but does not interpret the patient's motivation or commitment.
* OBJECTIVE 1: UNDERSTAND THE RULES DIFFERENTIATING NETWORK THERAPY FROM INDIVIDUAL INSIGHT-ORIENTED THERAPIES.
Network vs. Individual Therapy The strategically-oriented approach used in the network carefully targets behaviors and then develops a strategy to change them through direct intervention. Thus, a young adult patient may be encouraged to rely on his mother for help if it is necessary to sustaining his abstinence; the interpretation of his need to rebel may be delayed for months. This is because the mother's strategic utility is more important at this stage than the patient's self-realization.
The non-directive approach to individual therapy, on the other hand, is based largely on subjective and empathic exchange. This latter approach lies at the opposite end of the therapy spectrum, as it plays down the importance of symptoms and diagnoses, and eschews behavioral management as well. The non-directive approach is also based on the assumption that a relatively comfortable alliance between therapist and patient will soon emerge, based on mutual understanding. In actuality, a reliable alliance is unlikely to emerge early in the recovery of addicts, since abstinence must be secured, even though they are ambivalent about accepting this goal. With the addicted person, sadly, these assumptions do not apply, and because of therapists must take a more directive stance. This is essential to avoid being drawn into a process of seduction, in which the inclination to empathize with the patient leads to misconstruing motive and behavior, and to becoming an enabler in the addictive process.
From the perspective of therapy based on mutuality, this should put addiction professionals in a difficult position. They would be compromising one of their most effective means of establishing a therapeutic alliance, namely an empathic, untrammeled exchange with the patient. But the situation is not so bleak, because they do meet individually as well to discuss other issues, ones which are not necessarily related to the immediacies of maintaining abstinence and undoing the denial of illness. Two parallel tracks are therefore developed in the treatment, one in which the network is used strategically to stabilize abstinence, sometimes running contrary to the immediate flow of the patient's desires and feelings, and the second, a more unstructured, empathic exchange. In this latter context trust can be built in developing new goals for a sober life.
Furthermore, it is the network members who may be seen as "enforcers" of abstinence, rather than the therapist himself. One patient was berated by his brother in a network session because of his callousness in ignoring the impact of his alcoholism on his wife. The therapist allowed some of this to be expressed, to let an object lesson get across, while the patient seemed bewildered, but chastened. In the individual session, on the other hand, the patient was encouraged to express his feelings about being scolded, and heard out his feelings of frustration.
It is also important that patients be lent the respect of being accepted as partners in the treatment, but only within constraints defined by the therapist. As addicts, they had previously set their own agenda, one of sustaining addiction, and in that regard autonomy served them poorly. An understanding must therefore be established within specific guidelines that they trade off the options that might allow them to promote addiction, in exchange for respect as collaborators in planning. In this respect, network therapy relies more heavily on active collaboration between therapist and patient than do most other treatments. The patient is expected to assume a role of active partnership in nurturing and organizing the network and assuring its continuity, in anticipating and averting slips, and in establishing goals for later rehabilitation.
The "Rules" of Therapy Given this introduction to the balance of affective expression and behavioral management, we can now consider some specific principles of network therapy and then contrast them with insight-oriented psychotherapy as it is generally practiced.
Network Therapy: The therapist is prepared to set the session's agenda.
Insight Therapy: Patients introduce issues of their own choice.
In network therapy, the therapist prioritizes issues for discussion instead of the patient whenever it is necessary. If there is a possibility of that patient having a slip, the therapist makes that issue the first order of business. Similarly, when the network meets, the patient's review of substance-related experiences is always the first item of business. In traditional therapy on the other hand, salient issues emerge as the patient expresses what first comes to mind, and associates to those reflections.
Network Therapy: Displaying feelings can serve as a defense against dealing with addiction.
Insight Therapy: The expression of feelings is a vehicle for resolving symptoms.
For the non-addicted patient, the unleashing of strong feelings is important in understanding the genesis of symptoms. For the addicted person, this may be useful, but it can also be a guise for leading the therapeutic exchange away from important issues of sobriety, rather than toward them. Such expressions are encouraged only if they do not distract the treatment from its principal goal, and an affective display may even be cut short if it is defensive in nature. One patient addicted to minor tranquilizers became tearful in a session over the mistreatment she had experienced at the hands of her boss. The therapist sensed that she might have taken some pills after the event, and asked her directly if she had, even though she had not "finished" her emotional display. It would have been preferable to wait until she had fully expressed her feelings, but the issue had come up late in the session, and it is important that the agenda of drug use not be put off until our next meeting, as that might have allowed for further erosion in her abstinence.
Network Therapy: Insight can serve as a smoke screen to avoid addiction problems.
Insight Therapy: Insight is encouraged and unconscious conflicts are interpreted.
As in managing the patient's feelings, the resolution of unconscious conflict must be regarded with extreme caution early in network therapy. Discussion of conflicts in the session can operate like a prism in the hands of the addicted person, distorting the actual nature of the drug abuse and misleading the patient and therapist into allowing continued substance abuse. Both therapist and patient must be aware of this, so as to avoid the now-caricatured deliberations over childhood experience while the patient continues to drink.
On the other hand, the resolution of unconscious conflict is one of the principal tenets of insight-oriented psychotherapy, since maladaptive behavior is presumed to be tied into these conflicts, and to remainders of early relationships; these longstanding issues are typically introduced by the patient into contemporaneous relationships. As the therapist addresses these conflicts, the theory goes, the patient will benefit in real life behavior, and find relief from distress. For the addict, however, this is a priority that follows after the assurance of abstinence.
Network Therapy: Addiction-related material is always shared with the network.
Insight Therapy: Exchanges in the consulting room are kept confidential.
In network therapy, constraints of confidentiality are not applied to issues associated with drug use, as it is important that members of the network be aware of any circumstances that would aid them in participating in the addiction treatment. The therapist must let the patient know early on that they are all part of a collaborating network, where information is openly exchanged. On the other hand, issues that do not bear on drug use, ones revealed in individual sessions, are kept in confidence by the therapist. This should be made clear in the earliest sessions with the network. The therapist may forget to do this on occasion, and later may be left with a patient who is off on a drinking binge. The therapist may be uncertain about whether or not to reach out to the family for help in such a situation. In such a case, the therapist may not feel that he/she has the prerogative to call the patient's family member because a prior understanding to that effect had not been clearly established. The best time to reach such an agreement would have been when the patient was initially discussing the format of treatment.
This entire perspective stands in contrast to traditional, expressive therapy, where it is important that patients feel comfortable about revealing behaviors that they would not want family or friends to know, including problems with substance abuse. In particular, patients' shame over their perceived failings is not allowed to compromise the capacity to associate freely in the session or to share confidences with the therapist. In the network, in contrast, it is the responsibility of the therapist to assure that the issue of shame is minimized or dispelled by defining a sense of mutuality and collaboration from the outset.
Network Therapy: The actions of the patient and network members are orchestrated in whatever way necessary to assure the patient's abstinence.
Insight Therapy: The therapist does not prescribe behavior.
In insight therapy, symptom relief is said to derive from the resolution of conflict, and the expression of feelings in an interpretative setting. In the network, on the other hand, it is essential that the therapist be able to prescribe behaviors that will avert relapses to drug use. Both the patient and members of the network therefore must be open to embarking on a behavioral regimen to aid in the implementation of the treatment. For example, the patient and network members should be willing to meet together outside the therapy office at a time when the patient is vulnerable, if so suggested by the therapist. In another context, the therapist may instruct the patient to write a doctor who has prescribed sleeping pills, requesting that he stop prescribing. The network should be drawn into supporting this behavioral direction from the therapist.
Network Therapy: Social pressure is an integral part of treatment, often the only means of assuring abstinence.
Insight Psychotherapy: Outside parties are not solicited to influence the patient's behavior.
The bald-faced use of social pressure or guilt inevitably incurs resentment in the patient, and in an outpatient setting, the resulting rebelliousness can understandably be hard to control. But such pressures, applied indirectly, may be necessary to get alcoholics and drug abusers to enter treatment. In ongoing treatment as well, addicts' inability to give up a highly conditioned addictive behavior often necessitates the use of this leverage if stability is to be sustained. In its mildest form, this can mean exploring with the patient in an individual session how loved ones will be compromised if drinking continues. But it can also be done by engaging the family so as to assure that a return to addiction will lead to their implicit withdrawal of support or to the patient's embarrassment. The highly influential bonds that hold members of the network together in their intimate relations carry with them the potential of inflicting great remorse if a patient were to let down his loved ones and friends, disappointing them by his return to drug use. If well orchestrated, this potential remorse can prove to be a major motivation for remaining abstinent, and serve as a deterrent based on the desire to see them content.
For example, an alcoholic woman and her husband entered treatment because the family had pressed her to stop drinking. Knowing that her resentment toward her spouse was undermining her motivation, the therapist arranged that the network include her younger sister, enrolled in college in a remote city, in the next session. This was done by speaker phone. It was clear that the patient did not have the heart to let down her sister who had been hoping for years that she would finally agree to meet with a doctor and address her drinking problem.
Network Therapy: Unconscious anger and conflict is dealt with by encouraging mutuality and support. The motives of people in the network are not interpreted.
Insight Therapy: Interpret transference reactions to aid in addressing the patient's conflict.
The patient would be put in an awkward situation if his psychological defenses were subjected to scrutiny while he is in the company of family members about whom he has mixed feelings. Furthermore, since the interpretation of behavior is of value to a person only in the context of an ongoing therapy, network members themselves are rarely if ever offered interpretations that would put their motivations in question. Their attitudes toward the therapist are left unexposed, and the difficulties they may have in relating to the group are dealt with in a supportive manner. The positive side of their contributions are pointed out, rather than their misgivings and resentments, as such revelations would imply undue criticism.
Thus, a controlling father vying for a dominant role in the group is engaged in a friendly and respectful manner. It is never implied that his demanding behavior might reflect his competitive nature. A self-centered sibling is heard out as well, even though she displays little genuine concern for the patient; her unsympathetic nature might later help the network to confront the addicted patient. We do not look to change the adaptation of the father or sister, only to help them play a constructive role in the immediate situation of the network.
* OBJECTIVE 2: DIFFERENTIATE NETWORK THERAPY FROM STRUCTURAL FAMILY THERAPY.
The network approach to substance abuse treatment utilizes a group of people, often consisting of family members, to assist the patient in achieving and maintaining abstinence. Yet Network therapy diverges in several important respects from family and group therapy as typically practiced.
Network Therapy: Uses the family as a supportive, cohesive team to assist the patient achieving abstinence and avoids restructuring pathological family relationships.
Family Therapy: Actively restructures family relationships to relieve the "symptom" of substance abuse.
One of the most artful contributions of the family therapy movement is the conception of families as social systems whose imbalances can generate psychological symptoms in members seemingly uninvolved in the immediate conflict. This conception of the origin of symptoms can be valuable in understanding the emergence of substance abuse in a given child within a family, but it is not the best way to terminate chronic, longstanding patterns of substance abuse. It is more effective to assemble a task-oriented network whose members are strategically best suited to the behavioral task. The dynamics of the group should be understood, but used tacitly and in a supportive manner. A perceptive manager might do the job of leadership well, even in the absence of an intellectual understanding of family dynamics. As such, we avoid focusing on the patient's family history in the network sessions, since involving family conflicts can be disruptive to the network's primary task of helping maintain the patient's abstinence. Similarly, contemporary conflicts among family members are noted but not explored. The therapist helps network members work together to achieve the goal of abstinence and to minimize the interference of family conflicts. For example, the mother may have some excellent ideas to help her substance abusing son avoid high risk situations. However, she expresses these in a disapproving tone of voice to which the son responds testily. If the communication pattern overtakes the task at hand -- avoiding high risk situations-- the therapist might point out in a calm, more detached tone of voice that the mother has made a good suggestion and invite the network to generate other ideas.
* OBJECTIVE 3: DIFFERENTIATE NETWORK THERAPY FROM INTERPERSONAL GROUP THERAPY.
Network Therapy: Keeps the group task-oriented and avoids interpreting the group transference and the emotional reaction of members to each other.
Group Therapy: Focuses on the interpersonal, emotional forces that emerge in the group especially as they relate to the therapist.
In group therapy, participants enter treatment without established ties among themselves, and their management must therefore draw its strength from the dynamics that later emerge in the group sessions. For example, members may fear losing emotional support if the leader is going on vacation for a few weeks, even though this fear may not be openly stated. There may be unstated feelings of anger when a given member is getting more attention, as when he is the focus of discussion. Such feelings may be more influential in group interactions than the explicit tasks of the group. Typically, the therapist has created an open-ended unstructured atmosphere in which these dynamics can emerge and which are ultimately interpreted.
This approach is of course very different from the one employed in network treatment, on a number of counts. In the first place, the network therapist does not interpret behaviors of the group as a whole with regard to the underlying conflicts they experience. Although attuned to these matters, the therapist actively develops a supportive context that will implicitly relieve conflict within the group, rather than pressing for self-examination. The leader also shies away from interpreting the patient's characteristic motivations in the network sessions, and certainly avoids addressing the personality style of the members. In Bion's terms, the network therapist might be said to focus on the overt task in the therapy session in goal-directed behavior, rather than encouraging individuals to understand their own reactions.
In sum, a network session is quite different from those typical of many models of individual, group, and family therapy, in that it avoids emphasis on emotional expressiveness, interpretation of conflict, and formal restructuring of family and peer relations. Instead, it is freed up to focus on the social supports and behavioral change necessary to protect the patient's abstinence. This straightforward and directive approach does not derive from ignorance of the dynamics inherent in these aforementioned perspectives. It is born instead out of respect for the remarkable tenacity of the behaviors associated with alcohol and drug dependence, and the value of meaningful, coordinated support from family and friends in altering those behaviors.
* OBJECTIVE 4: IDENTIFY GUIDELINES FOR INTEGRATING NETWORK THERAPY WITH 12-STEP ACTIVITIES.
As helpful as the network can be in supporting the patient's efforts at abstinence both inside and outside the network therapy sessions, there are always times when for various reasons network members are unavailable. In addition, many addicted individuals have very few non-substance abusing peers. For these as well as other reasons, involvement in self-help support groups such as AA, CA, or NA often prove to be a valuable adjunct to the network therapy proper. Indeed, with its intense supportiveness and cohesiveness, 12-step groups provide many of the same qualities of the network only within a different context.
Some patients readily accept 12-step involvement as part of their treatment regimen. Others offer greater resistance. Here the network can often be of assistance in facilitating the patient's engagement in AA, CA or NA. A spouse who is encouraged to go to some meetings with a patient, a friend in the network who expresses interest in their content, a network member who reports that AA was useful to his own relative, are all invaluable in moving the person through the initial stages of resistance.
Patients with great ambivalence regarding AA present an intriguing glimpse of how a given personality style can interfere with the process of engagement. Fear of passivity, fear of humiliation, or conflicts about anger and retribution can make affiliation seem like a potential threat. For example, one patient compared AA to a punishing parent, thereby making AA into an object of dread. Working with this conflict in individual sessions and with support from network members, the patient eventually became engaged in AA.
Some Guidelines for Self-Help Involvement in Network Therapy
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, core conflicts or characterological issues 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.
SUMMARYThis final section has provided a didactic overview of how to differentiate the key components of Network Therapy from: a) inside oriented psychotherapy, b) structural family therapy, and c) interpersonal group therapy. It has also provided guidelines for implementing 12-step activities within the context of an ongoing network therapy.
