Changes in Professionals' Attitudes and Approaches to Parents in the Drug and Alcohol Treatment.

BACKGROUND: Parental involvement with drug and alcohol services remains limited. AIM: to illuminate changes in addiction professionals' subjective attitudes and approaches of parents over time in their career.
METHODS: Overall, twenty seven drug and alcohol professionals participated in the study.
RESULTS: Themes depicting changes on therapists' attitudes, beliefs and experiences of working with the families of their clients are 'Redefining therapeutic role and expectations', 'Increased understanding and acceptance', 'Finding the right distance in relationships', 'Ability to contain feelings and experiences', 'Being selective in collaborations with professionals', 'Empathy for coworkers and increased collaboration'. Therapists described their interaction with families of their clients in their earlier years of practice as a challenging and often overwhelming experience generating intense anger and frustration which sometimes led to acting outs and tempted them to give up their efforts to build an alliance with family members. Nevertheless, experience, clinical supervision and personal growth contributed in being gradually more capable in managing their emotional reactions, setting limits, having less and more realistic expectations from family members and finally providing the latter with the necessary experience of being understood.
CONCLUSIONS: Overall, addiction therapists feel unprepared for meeting the challenging experience of collaborating with families in their earlier years of practice requiring educational support and clinical supervision. Further research is required on addiction professionals-parents alliance and countertransference issues.

1. INTRODUCTION

Despite overwhelming evidence for the effectiveness of family interventions, addiction treatment centers often seem to fail in involving parents in drug and alcohol treatment (1, 2). Even when parents somehow participate in treatment, it seems that they remain on the periphery of the treatment enterprise (3, 4). Furthermore, it appears that family members in contact with drug and alcohol services several times describe feelings of stigma and insignificance which undermine the experience of meaningful and reciprocal relationships and a sense of belonging and trust (5). On the other hand, mental health professionals oftentimes remain reluctant and wary of working with parents of addicted individuals (3, 6). Research into the subjective experience of addiction treatment indicates that collaboration with parents is filled with distressing challenges that can be clustered in two over arching categories: difficulties associated with parental engagement, alliance, and communication issues, and difficulties associated with intra and inter-team collaboration (6).

The present study aims to throw light into the relationship of addiction professionals to parents of addicted adults and to illuminate changes in their attitudes and approaches of working with parents over time in their career. Studying professionals’ subjective experiences of working with parents may hopefully yield useful results as regards parent involvement in drug treatment.

2. PATIENTS AND METHODS

Focus group interviews (7, 8) were utilized to acquire rich, in-depth, detailed descriptions of professionals’ views of their work with parents of their clients over time. Focus groups with twenty seven drug and alcohol professionals (i.e. 68 per cent participation rate) from five in-patient centers of the Drug and Alcohol Treatment Units of the Psychiatric Hospital of Athens. Therapy is multi-focused (i.e. individual, family, group psychotherapy) and employs several art-therapies (i.e. drama, dance, painting etc.). The mean age of therapists was 37 years while the mean time of clinical experience in the addictions was 9 years. Furthermore, the majority of therapists had undergone lengthy psychotherapeutic training (i.e. mainly of psychodynamic or systemic orientation) and personal psychotherapy as well. The focus groups facilitator paid special attention to group dynamics (6).

3. ANALYSIS

Thematic analysis was used to search for themes relating to therapists’ experiences of their interactions with families of addicted clients (8). The process of analysis included open coding, creating categories and abstraction. Two psychologists read independently the transcripts and agreement was sought in thematisation.

4. RESULTS

Almost all participants reported to have experienced changes in their practice and collaboration with parents. Some were associated to the revision of their role and approach to supporting families of addicted people, other changes were related to the development of a deeper understanding, improved ability to contain their personal responses and effectively engage with parents, and still others involved an improved collaboration with coworkers. The analysis of the participants’ accounts revealed the following six sub-themes.

4.1. Redefining therapeutic role and expectations

With practice, participants developed a more realistic view of their limitations and progressively gave up their sense of omnipotence, and redefined their expectations of parents.

At the beginning when I was leading the parents’ groups, I was angry with them and with their attitudes toward their daughters. Later on, I understood that my attitude was not helpful to me, to the individual in treatment, and obviously to the parents, so I distanced myself. In my role as a therapist, I now have less expectations of parents…. I am more realistic, in other words, I am acceptant of whatever they can manage. Some can do many things, others very little, yet all can do something (FG2).

When I came here, I sort of adopted a rescuer’s role.… it was a heavy load to try to save the client and the family. I tried really hard to stop adopting such a role (FG1).

4.2. Increased understanding and acceptance

Having been exposed to family tragedies, participants reported to have changed in how they perceived their interactions with parents and addicted children. Some began to identify the family’s strengths, rather than pathology, and interpreted family communication patterns in a more positive light. Participants reported to become more accepting of parents, less judgmental and increasingly able to listen to their story.

…at the beginning I was attending only to the child’s story, while joint family sessions were very distressing to me. With increasing experience, my listening skills improved and I managed to hear more clearly to the person in therapy, and to what parents were sharing with me, in general and with regard to their expectations. In my interactions with them, I am now not as insecure since my attitude has changed, and I facilitate communication by listening to them, rather than being concerned whether they will follow my advice or not (FG1).

According to some participants acceptance involved an ability to ‘roll along’ with the parents’ resistance rather than oppose it, and avoid being forceful, aggressive or blunt when confronting them with their ambivalence.

There is a need for someone to be there to receive the family, to understand and listen to their distress, and this is actually the way we can help them overcome their guilt, curb their resistance, and change… I have noticed that when we do not oppose and accept them, then resistance is curbed to some extent (FG4).

4.3. Finding the right distance in relationships

Some participants reported that at the beginning of their career they were uncomfortable to set limits and tended to withdraw or kept the family at a distance. They avoided contact, did not encourage parental involvement in treatment rejecting their quest for help, and felt unable to deal with it. By contrast, other participants reported to become overinvolved with families, as a result of personal issues stemming from their family of origin. However, with increasing experience, most therapists learned to set boundaries and became less fearful and insecure in their coping with multiple alliances and triangulation. They progressively came to the realization that if they did not manage to form an alliance with parents, the therapeutic success was at risk.

When I began working I was 26 years old, and I had an anxiety as to how parents would see me, I was young and had the same age with their child. Because of my insecurity I used to listen to them for a very long time, I listened to their nagging, anxiety, complaints and had difficulty to set boundaries… I must also say that the first years, I was very angry with them and identified with their children, and believed that with such parents I would have also ended up becoming an addict…. Now, I have more self-confidence both in myself and in my role, and I do not care (what they think of me), I set boundaries with greater ease, I listen to them, and clarify the boundaries of my alliance to their child, (by telling them): ‘I listen to you, but if you have more needs, you have to go to your therapist at the Family Unit’; I can say it with no guilt and no difficulty (F4).

4.4. Ability to contain feelings and experiences

Participants reported to progressively succeed not to become overwhelmed by the parents’ needs, fears, anxieties and expectations to save their child. They also recognized that even though their emotional reactions were occasionally intense, they were more able to contain them and experience them for a shorter duration. Additionally, they perceived their emotional reactions as clues towards comprehending parents’ being in the world. Through this process, they were helped by personal therapy in which they worked on personal unresolved issues which surfaced whenever they were exposed to the family’s emotionally charged dynamics, which inhibited listening to their concerns.

I recall, at the beginning (…) my feelings for the person-in-therapy and for the parents, had an intensity that was not proportionate to the situation. Over the years, with experience, and the changes in my personal life that occurred as a result of assuming additional roles, I think that this intensity is tempered and I feel some kind of enlargement, as if there is a spread of space that can contain more things than the clients and their parents. I am more permissive, more ‘spacious’, in the sense that I can feel more things, at different levels, in the context of a relationship (FG1)

4.5. Being selective in collaborations with professionals

Collaboration issues among individual and group therapists, were extensively discussed especially in focus group 5. There was a lively debate on the value of collaboration among therapists, with discussions on who initiates contact and when. Some participants reported to be selective in their collaborations.

I seek collaboration with specific therapists; there are therapists with whom I have not succeeded to have a good collaboration and I will not contact them (F5).

The close collaboration with therapists who treated the child, helped some participants in their individual or group work with parents, and contributed to the projection of a holistic and comprehensive program of intervention.

4.6. Empathy for coworkers and increased collaboration

Personal growth and self-confidence affected participants’ collaboration with one another.

I seek more frequently the collaboration of my colleagues, by comparison to the past…. It may be due to a sense of competence that I increasingly experience in my work. In other words, by feeling more competent, I am also more able to call up a therapist and ask for his or her help in specific things, as well as offer my help on many more issues (F5).

Some participants expressed their empathy for colleagues who experience difficulties in their relationships with parents.

I think I understand them, I understand the difficulties they face because, okay, we encounter similar difficulties in our collaboration with parents and are exposed to challenging situations (F5).

4.7. Variables contributing to change and personal growth

Variables that were described as facilitating the participants’ change and growth involved: (a) clinical experience, (b) specialized training in addictions, as well as in a theoretical and psychotherapeutic approach, (c) supervision, (d) personal psychotherapy, and (e) becoming a parent, which contributed to an increased sensitivity to the parents’ feelings, responses, and concerns.

In the old days, when I was too young, I tended to identify with the child’s role, and tried very hard to understand why he resorted to drugs; I thought that parents had irrational demands, and sometimes set boundaries that were also irrational. Now, I tend to delve more towards adulthood, probably because I did my personal therapy, and I think that my inner maturity has helped me to attribute new meaning to my role as a therapist. In other words, I can, now, understand better and listen more impartially to both sides (FG1).

Finally, few participants recognized they were in a process of change, without having yet adopted new patterns of interventions with parents. Reflecting on their own responses seemed to help them question some of their practices.

I am undergoing a phase during which I have more concerns and see things that I couldn’t see before. For example, the parents’ guilt. We shouldn’t render them more guilty; recently, this has been a lot in my mind, and has become a concern to me. I try, I am in a process, but haven’t moved forward yet. I try to perceive the situation more holistically (FG2).

5. DISCUSSION

This study attempted to describe changes in professionals’ attitudes and approaches of working with the parents of addicted adults over time in their career. Central processes facilitating their encounter with parents at everyday practice were the management of their own emotional responses as well as the acknowledgement of their own limitations as carers and of parents’ limitations for change.

Regarding professionals’ emotional responses, it appears that high levels of anxiety can also lead them to misconceptions which can be the result of countertransference (10, 11) rather than a pragmatic understanding of family dynamics (6). Such misconceptions and related countertransference reactions may tempt the professional to give up on the family which in turn, increases the likelihood of family’s giving up on the member with addiction problems (12). Thus, professionals’ ongoing attention to their own feelings and containment of their responses is of ultimate importance in preventing destructive misconceptions and countertransference acting-outs (11) which may well induce further guilt feelings to family members facing the traumatic experience of addiction.

Overall, professionals’ meaningful encounter with family members in the present study was facilitated by the former’s gradual awareness of their own limits. Young professionals frequently hold an unconscious belief that they can magically heal the ills of the world through patience and understanding (13, 14). Furthermore, clients’ idealizations may fuel omnipotence and grandiosity in the form of feeling like a savior (15). Nevertheless, sooner or later professionals realize that they fail -even if they may wanted to- to fulfill the expectation of omnipotence they had from the client while acknowledging that a psychotherapeutic relationship is a necessarily limited relationship. Experience, supervision and personal therapy all contribute to their coming in touch with their own feelings of helplessness and mourning their own omnipotent savior fantasies while at the same time acquiring an ability for accepting family member’s limitations for change (11). Thus, change is most often a time consuming and strenuous process, requiring time to accomplish as well as the acknowledgement of the limited nature of human existence. Finally, a therapeutic approach that endorses values of caring and incrementalism on the basis of conflict de-escalation and parents’ limit-setting on their own behavior may contribute in an atmosphere of acceptance and understanding (16). In essence parents should be viewed as victims of stress and strain (17) rather than being burdened with the responsibility of creating or solving the addiction problem.

6. CONCLUSION

The challenge of therapists is not to be driven away physically or emotionally but rather to engage with families in a consistent and constructive exploration of their affects and behaviors. Such engagement requires necessarily therapists’ educational support and supervision as well as a non-pathologising, non-judgmental stance towards families’ ambivalent quest to leave behind them the trauma and loss of the chronic experience of addiction.