TIPS & TOPICS
Volume 4, No.2
May 2006

In this issue
– SAVVY
– SKILLS
– SOUL
– Until Next Time

Welcome to our fourth year of publishing TIPS and TOPICS. Time has flown by. Thanks for your faithful readership, interest and reactions to the material. I’ll celebrate Volume 4 with a new acronym. A longtime reader shortened TIPS and TOPICS to TNT. I thank him for that; it will shorten my typing time and make it easier to refer to this dynamite newsletter (if I may say so myself).

If you are a new subscriber, remember you can view and download printable copies of all previous editions of TNT. Go to www.DMLMD.com. On the Homepage, click on ‘Tips & Topics.’

SAVVY

This month I talked with several parents very concerned about their adult children with addiction and other issues. All of the parents were supporting them financially and emotionally; all really wanted to do the best thing for their loved ones. When I consider the quality and quantity of family work performed in addiction treatment and mental health systems for that matter, it is disappointing. Much good information on family therapy exists (for free) in the 2004 Treatment Improvement Protocol of the Center for Substance Abuse Treatment (CSAT).

Below is an excerpt from chapter 4 on “Integrated Models for Treating Family Members.”

Tips:

• About the involvement of families in treatment , determine your level of attitudes, knowledge and skills, and that of your agency.

Is there a commitment to improve the level of your involvement with families? What would it take to get closer to a Level 5 agency and team? Are families even on your clinical radar screen?

Levels of Counselor Involvement with Families

Level 1: Counselor has little or no involvement with family

* May contact families for practical and legal reasons, but provides no services to them.
* Counselor views the individual in treatment as the only client.
* May even feel that the client must be protected from family contact.
* Not uncommon for the family of a client to be regarded as a liability for the client.

Level 2: Counselor provides psycho-education and advice

Knowledge base
Counselor’s primary focus is on the client’s substance abuse, but he or she is aware that it affects family relationships and that counseling will change family dynamics.
Examples: Family may increase its blaming of the person who is abusing alcohol or other drugs; substance use problems among other family members may be exposed; family secrets may be revealed.

Relationship to family system
Counselor is open to engaging clients and families in a collaborative way.
* Advising families about how to handle the rehabilitative needs of the client.
* Knowing how to channel communication through one or two key members.
* Identifying gross family dysfunction that interferes with substance abuse treatment.
* Referring the family for specialized family therapy treatment.

Level 3: Counselor addresses family members’ feelings and provides support

Knowledge base
Counselor understands normal family development and family reactions to stress.

Relationship to family system
Counselor is aware of personal feelings in relating to the client and family.

Skills

• Asking questions that elicit family members’ expressions of concern and feelings related to the client’s condition and its effects on the family.
•  Empathically listening to family members’ concerns and feelings and, where appropriate, normalizing them.
• Forming a preliminary assessment of the family’s level of functioning as it relates to the client’s problems.
• Encouraging family members in their efforts to cope with their situation as a family.
• Tailoring substance abuse education to the unique needs, concerns and feelings of the family.
• Identifying family dysfunction and fitting referral recommendations to the unique situation of the family.

Level 4: Counselor provides systematic assessment and planned intervention

Knowledge base
Counselor understands the concept of family systems.

Relationship to family system
Counselor is aware of his or her own participation in systems, including the therapeutic relationship, the treatment system, his or her own family system, and larger community system.

Skills

• Engaging family members, including reluctant ones, in a planned family conference or a series of conferences.
• Structuring a conference with even a poorly communicating family in such a way that all members have a chance to express themselves.
• Systematically assessing the family’s level of functioning.
• Supporting individual members while avoiding coalitions.
• Reframing the family’s definition of its problem in a way that makes problem-solving more achievable.
• Helping family members view their difficulties as requiring new forms of collaborative efforts.
• Helping family members generate alternative, mutually acceptable ways to cope with difficulties.
• Helping the family balance its coping efforts by calibrating various roles so that members can support each other without sacrificing autonomy.
• Identifying family dysfunction beyond the scope of primary care treatment; orchestrating a referral by informing the family and the specialist about what to expect from each other.

Level 5: Family Therapy

Knowledge base
The counselor has received training and supervision to move to this level of expertise. He understands family systems and patterns typical of dysfunctional families and interacts with professionals in other health care systems.

Relationship to family system
The counselor can handle intense emotions in families and in him- or herself and maintain neutrality despite strong pressure from family members (or other professionals) to take sides.

Skills

• Interviewing families or family members who are difficult to engage.
• Efficiently generating and testing hypotheses about the family’s difficulties and interaction patterns.
• Escalating conflict in the family in order to break a family impasse.
• Temporarily siding with the one family member against another.
• Constructively dealing with a family’s strong resistance to change.
• Negotiating collaborative relationships with professionals from other systems that are working with the family, even when these groups are at odds with one another.

References
The information above was drawn from Treatment Improvement Protocol (2004) TIP 39 produced by SAMHSA (Substance Abuse and Mental Health Services Administration).

Treatment Improvement Protocol (2004) TIP 39: Substance Abuse Treatment and Family Therapy, Chairs: Edward Kaufman and Marianne R.M. Yoshioka, TIP No.39, pp. 80-82.

This material was adapted from Doherty and Baird 1986. Doherty, W.J., and Baird, M.A. Developmental levels in family-centered medical care. Family Medicine 18(3):153-156, 1986

To read more on family work, see the August 2004 edition of TNT. 

SKILLS

You may not yet be able to engage your agency to increase the level of counselor involvement with families. However you can always start to improve family involvement with your own clients.

Tips:

• If a family member calls for the appointment or seems more concerned than the identified client, make sure they are part of the assessment and treatment.

Many clients come from disadvantaged homes where they have burnt their bridges; you can tend to think that family issues are not as relevant. Reconsider the meaning of “family” in a broader sense – i.e. to encompass significant others and supports in the person’s immediate environment. If we think this way, then all of our clients have families to be considered and addressed.

Some clients have more intact families. It is not unusual that parents, siblings, children or other relatives are the ones to seek out information about treatment resources. It is good policy to have both the identified client and the significant family members present right from the beginning at the assessment. This is especially true if the family is supporting the client financially and emotionally, if the client is an adolescent or young adult, or functionally a minor who is being taken care of.

The family usually has many unanswered questions and concerns. Remember they also have many answers to important assessment and evaluation questions. They can provide a perspective based on their many attempts to change the effect of addiction on the family; not to mention the pain and emotional distress from years of trying to cope with addiction illness and its effects on the family.

For a person estranged from blood relatives the equivalent “family” members may be the judge, probation or parole officer, child protection case worker, or case manager. These individuals may also take on the same position and behavior of a family member, and be more concerned about treatment than the identified client. Help may need to begin with a focus on the family, not the identified client. Therapy can focus more on helping families decide how much longer they want to keep subsidizing their child’s substance use and lifestyle with which they disagree. They need help to clarify their needs and limits so that they can convey a clear unified message to their loved one. At this point in time, the family work may actually be the more important work to do- rather than with the identified client yet.

• Individualized treatment is not just for the identified client. Individualized treatment should be for family members and significant others as well.

Families are at various stages of change regarding what to do to promote recovery. They may not realize how their loving care is actually promoting irresponsible and self-destructive behavior. A mother might never have thought of herself as subsidizing her child’s addiction when she does not charge rent or board, or when she gives her son spending money. On the other hand, a sister or brother may be quite aware that what they are doing is not helping their sibling. However they feel at a loss to know how to set a limit without feeling overwhelming guilt; the substance user knows all too well how to play on this guilt to his/her advantage.

The family may be in so much pain themselves they feel stuck on how to have a life of their own, and take care of their own needs. Imagine an adult woman who has grown up as a child of an alcoholic mother. She may have learned that her purpose in life was to take care of her mother and her siblings, give up her own needs to rescue and take care of them. Her own needs for nurturance and support have never been filled. Or in another situation, family members may be so angry and frustrated that they need an understanding ear. Our job is to help them bear the pain, rather than confront them as “enablers” and “co-dependent”.

I remember once being judgmental of a wife and mother who bought alcohol for her end-stage alcoholic husband stricken with liver cirrhosis. But as I listened more to her, she told me the only way she knew to keep her husband from yelling, abusing her and her children was to buy him the liquor to keep him quiet. She could not figure how to extricate herself from the stressful repetitive cycle. What she needed was compassion and guidance, not just an admonition to attend Al-Anon and family psychoeducation once a week.

SOUL

For 10 years I have been doing fulltime training and consulting; this means a lot of air travel. Summer is approaching in the northern hemisphere. Perhaps you’ll be one of the millions of air travelers taking to the skies on vacation. For you, I offer my Top Ten List of Tips for the Not-So-Frequent-Flier. Not as good as Dave Letterman’s Top Ten, but they’ll be more useful. I must be honest though. These tips don’t emanate purely from my altruistic nature. My eyes roll (I know I should be more patient) when subjected to a novice flier’s “deer in the headlights” behavior at airports and on planes.

Here goes:

1.  Have your Passport or government ID out and ready to show the security agent before you reach the agent. You’ll get nasty looks if you start fumbling through your luggage looking for your ID only when you arrive at the agent – especially if you’ve been standing in the security line for 30 minutes already with ample time to locate your ID.

2.  In the USA, keep hold of your Boarding Pass. Don’t put it in your carry-on bag or purse you put through the security X-ray machine. You’ll need it to show to the agent who shepherds you through the metal detector.

3.  Take out or off all your metal, coins, mobile phones, pens and big buckle belts before you reach X- ray machine belt. If it takes a while to “de-metal” yourself, at least step to the side a little while you take you time to do that. Let others pass and keep the line moving.

4.  In the USA, remove your shoes and put them through the X-ray machine -even if you are sure they contain no metal. Don’t argue with the Transportation Security agents. They have the power to hold you up; you’ll be asked to step to the side for special screening with a hand wand detector. They figure you’ll take off your shoes the next time without arguing.

5.  Take out your video camera and laptop computer; put those on the X-ray belt separately from your bag. And of course, doing it while you are waiting in that long line is better than doing that at the X-ray belt.

6.  Don’t try to carry on 2 big roll-on bags and your small brief case or package. You’ll only have return to Ticketing to check one of the bags. If you have just one roll-on bag with outside pockets stuffed and bulging (the special expanding feature has made your bag two inches fatter) expect to remove some contents from the outside pocket. Your bag will not fit in the overheard bin. You don’t want to have to take out all your dirty laundry in front of everyone on the plane.

7.  It’s nice to be hands-free, wear that backpack, and sling that bag over your shoulder. Be aware that your personal space has now expanded considerably. As you walk through the airplane aisle looking for your seat, be aware your shoulder bag may be slapping each aisle-seated passenger in the face. Your backpack can be a weapon of minor destruction as you swing round suddenly -forgetting your back has a “punching bag” strapped to it.

8.  Sharing is always thoughtful. If you’re carrying a small bag or package that can fit under the seat in front of you, put it there. Leave more space for larger items in the overhead bin. You are sharing that space with maybe six other people. (Note: if you are seated in the bulkhead, yes you get more leg room, but your carry-ons and packages have to be in the overhead bin for take off and landing.) The other sharing thing is the arm-rest. Unless you are in First Class, the arm rest belongs to you and the person seated next to you.

9.  I know the recline button doesn’t convert your airline seat to the same luxurious horizontal position as your expensive recliner chair at home (unless you are in First or Business Class on an international trip). But quite a hassle can be caused if you recline your seat back suddenly – even the few inches it goes. You can smash the laptop screen of the passenger behind you; spill their drink with the jerking movement; send papers flying and other nice things. So recline – but recline slowly. Even check behind you, warning your fellow traveler you are heading for their lap! Oh and by the way- should you be moving from a window or middle seat to the aisle, remember the headrest and upper part of the passenger’s seat in front is not a steel handrail. Grabbing the headrest strongly jerks the person in front as annoyingly as a two year old banging his legs into the back of your seat repeatedly.

And now, No.10 of the Top Ten List of Tips for the Not-So-Frequent-Flier—-

10.  Turn your cell and mobile phone to vibrate, silence, or at least a very low volume. Most passengers are not interested in your latest download ring tone, or some annoying loud alert sound. One trip last holiday season, just before take-off, a couple of women decided to call their friend using the speakerphone feature on their cell phone. I was not interested, at all, in a three-way broadcast of what gifts they got or were about to send to friends.

Happy Travels and welcome to the “Friendly Skies”!!

Until Next Time

Thanks for reading TNT. See you in June.
David